BASIC AIRWAY MANAGEMENT

Basic Airway Objectives

Upon completion the student will be able to:

Describe the anatomy of the airway and the physiology of respiration. Explain the primary objective of airway maintenance Identify commonly neglected prehospital skills related to the airway Describe assessment of the airway and the respiratory system Describe the modified forms of respiration and list the factors that affect respiratory rate and depth Discuss the methods for measuring oxygen and carbon dioxide in the blood and their prehospital use.

Basic Airway Objectives

1)
2) 3)

4)
5)

Define and explain the implications of partial airway obstruction with good and poor air exchange and complete airway obstruction Describe the common causes of upper airway obstruction, including: The tongue Foreign body aspiration Laryngeal spasm Laryngeal edema Trauma

Basic Airway Objectives

1)
2) 1) 2) 3)

Describe complete airway obstruction maneuvers, including: Heimlich maneuver Removal with magill forceps Describe causes of respiratory distress, including: Upper and lower airway obstruction Inadequate ventilation Impairment of respiratory muscles Explain the risk of infection to EMS providers associated with airway management and ventilation

Basic Airway Objectives

1)
2) 3)

1)

2)

Describe manual airway maneuvers including: Head0tilt/chin-lift maneuver Jaw-thrust maneuver Modified jay-thrust maneuver Discuss the indications, contraindications, advantages, disadvantages, complications, special considerations, equipment, and techniques of the following: Upper airway and tracheobronchial suctioning Nasogastric and orogastric tube insertion

Basic Airway Objectives

3)

4)

Oropharyngeal and nasopharyngeal airway Ventilating a patient by mouth-to-mouth, mouth-to-nose, mouth-to-mask, one/two/three person bag-valve mask, flowrestricted oxygen-powered ventilation device, automatic transport ventilator Compare the ventilation techniques used for an adult patient to those used for pediatric patients, and describe special considerations in airway management and ventilation for the pediatric patient

Basic Airway Objectives

1) 2)

Identify types of oxygen cylinders and pressure regulators, and explain safety considerations of oxygen storage and delivery, including steps for delivering oxygen, from a cylinder and regulator Describe the indications, contraindications, advantages, disadvantages, complication, liter flow range, and concentration of delivered oxygen for the following supplemental oxygen delivery devices: Nasal cannula Simple face mask

Basic Airway Objectives

3)

4)
5)

Partial rebreather mask Nonrebreather mask Venturi mask Describe the use, advantages, and disadvantages of an oxygen humidifier

ADMINISTRATION
Oxygen is the most important drug that we can give a patient. Without it, the bodys cells die and thus the patient dies also.

Room air contains approximately 30% oxygen

ADMINISTRATION

Usually stored in seamless, steel cylinders - color GREEN Sizes and Capacity: * D 350 L * E 600 L * M 3,000 L Pressure: 2,000-2,200 psi

ADMINISTRATION
Pin Index Safety System (PISS) Prevents interchanging different gases and regulators Delivery 1. Demand Valve * Activated manually or by negative pressure

ADMINISTRATION
2.

Flow Meter (Two Types) Pressure Compensated * Small ball in a calibrated tube; affected by gravity, measures actual delivered flow; found in Units mounted on wall. Bourdon Gauge * Not affected by gravity; records a higher reading when an obstruction blocks tubing; used on portable O2 tanks

ADMINISTRATION

Nasal Cannula: 2-6 lpm; 25-50% Basic Mask: 6-10 lpm; 35-60% Partial Rebreather: 10 & higher lpm; 60% Non Rebreather: 10 & higher lpm; 60-95% Demand Valve: 100 lpm; 100% BVM: 0 lpm 21% 15 w/o reservoir 50% 15 w/reservoir up to 95%

MANUAL TECHNIQUES
Head Tilt/Chin Lift Opens most common cause of obstruction, the tongue

MANUAL TECHNIQUES
Modify for suspected spinal injury: 1. Tongue/jaw lift 2. Modified jaw thrust

BODY POSITION

Left or right lateral positioning of a patient aids airway maintenance by allowing fluids/vomitus to drain out Only to be used when spinal injury is NOT suspected If spinal injury is suspected, the patient must be secured solidly to a rigid board so that the body can be turned to the side as a total unit.

OROPHARYNGEAL AIRWAY (OP AIRWAY)

Semicircular, disposable and made of hard plastic. Guedel and Berman are the frequent types. Guedel is tubular and has a hollow center. Berman is solid and has channeled sides. Displaces the tongue away from the posterior pharyngeal wall.

OP AIRWAY
Even when in place, it is necessary to maintain manual positioning of the airway by a head-tilt, chin-lift or jaw-thrust maneuver. INDICATIONS Adjunct for airway control, determines presence of gag reflex. Unconscious/unresponsive

OP AIRWAY
INDICATIONS Remove the airway if patient regains a gag reflex May be inserted as a bite block after successful intubation

OP AIRWAY
SIZING Hold the airway next to the side of the patient's face and measuring the length of the airway from the corner of the mouth to the tip of the earlobe, Center of the mouth to the angle of the mandible.

INSERTION
Choose the appropriate size Open the airway Insert the airway: 1. Using a tongue blade. Preferred method in children. 2. Insert upside down and rotate into place. Not to be used in children.

COMPLICATIONS
With intact gag reflex could cause vomiting. Laryngospasm Inappropriate size: 1. To Long: may push the epiglottis closed over the glottic opening, causing complete airway obstruction 2. To Short: May be easily displaced, distal opening may become obstructed by tongue

COMPLICATIONS

May occur from insertion. Improperly placed may push the tongue back into the pharynx and cause obstruction. Aggressive insertion may cause trauma to the upper airway and bleeding. The lumen of the tube is not large enough to allow for suctioning. Suctioning must be performed around the tube.

NASOPHARYNGEAL AIRWAY NP AIRWAY

A curved hollow tube constructed of soft plastic or rubber with a bevel at the distal end and a flange or flare at the proximal end. This airway is less likely to stimulate gagging and vomiting because the the pliable tube moves and flexes as the patient swallows.

NP AIRWAY
It may be used in a patient who is breathing but needs assistance in maintaining a patent airway. 15cm in length. The distal tip sits at the posterior pharynx while the proximal flare is seated on the external nare.

NP AIRWAY

Still requires manual airway maneuvers be maintained during its use.

NP AIRWAY
Indications: 1. When OP is not able to be inserted 2. Airway of choice in spontaneously breathing, but less responsive patient needing airway control. Sizing 1. Proximal end of the tube at the tip of the nose and the distal end at the earlobe

NP AIRWAY

Technique of Insertion * Needs to be lubricated. * Proper size * Advance with bevel toward the septum * If patient is breathing you should feel airflow when placed properly. * If you meet resistance, remove and use other nare.

NP AIRWAY

Complications * Improper size and too long could end up in the esophagus * Too short could be occluded by the tongue * Laryngospasm * Trauma

ESOPHAGEAL OBTURATOR AIRWAY (EOA)

Was widely used, but due to complications and ET training its use has dropped. Recommended in situations when airway control was necessary and not able to intubate. Comprised of a mask and a cuffed esophageal tube with a sealed distal end. 16 air holes allow for ventilation.

EOA

Inflation port to inflate the cuff with a syringe and a pilot balloon to indicate the cuff volume. Placed in the esophagus, to seal and not allow air entry into the esophagus During ventilation, the air is forced through the mask and out of the openings in the proximal end. Air is facilitated in to the glottic opening and hence the trachea.

EOA/COMPLICATIONS

Esophageal rupture Laryngospasm Stimulation of vomiting Aspiration of gastric contents during insertion Soft tissue damage from cuff pressure

Inadequate mask seal Unrecognized tracheal intubation Do not leave in place for longer than 2 hours Have suction available when removing Remove when patient resumes breathing

EOA/CONTRAINDICATIONS

Patient is alert, responsive, or has gag reflex Less than 16 years of age Ingested caustic substance

Less than 5 feet tall, greater than 7 feet tall Significant airway bleed

EOA/ADVANTAGES

Insertion does not require visualization and no equipment is necessary Prevents air from entering the stomach Prevents vomitus from traveling up the esophagus

ET may still be inserted with EOA in place Head and neck of a CSpine Injury may be maintained in a neutral in-line position during its insertion

EOA/DISADVANTAGES

Tight mask seal must still be maintained May cause trauma to the esophagus or airway Can be easily misplaced in the trachea

Cannot be left in place for prolonged periods of time Does not isolate the trachea and prevent aspiration of contents from the upper airway Tracheobronchial suctioning cannot be performed.

EOA/INSERTION

Head neutral or flexed forward. Insert the tube (with mask attached) blindly into the mouth and throat Pass the tube gently until the mask seats on the patients face

Cuff Inflation * Do not inflate the cuff until proper placements is confirmed * Auscultate 4 lung fields and the epigastric region

EOA/INSERTION

Cuff Inflation * If accidentally placed in the trachea and the cuff is inflated before checking for proper placement, serious damage to the trachea can result (30-35 ccs of air)

*
* * *

REMOVAL Patient regains gag reflex, position patient on side Stand by with crash suction Remove the mask Deflate the cuff

EOA/REMOVAL

Remove the tube at peak inhalation Get ready to SUCTION

ESOPHAGEAL GASTRIC TUBE AIRWAY (EGTA)

More recent design of the older version of the EOA. Allows for the placement of a nasogastric tube through the lumen of the obturator for decompression of the stomach Ventilation occurs directly into the oropharynx, rather than through the holes of the obturator

EGTA/ESSENTIALS

It is used only in patients who are unresponsive and without protective reflexes It should NOT be used in patients with upper airway or facial trauma where bleeding into the oropharynx is a problem It must NOT be used in any patient with injury to the esophagus, or in children who are below the age of 16

EGTA/ESSENTIALS

Adequate mask seal must be ensured Great attention must be paid to proper placement. One of the great disadvantages of this airway is the fact that correct placement can be determined only by auscultation and observation of chest movement, both may be quite unreliable in the field setting Insertion must be gentle and without force

EGTA/INSERTION

Ventilate and suctioning performed prior to insertion of the airway After lubrication, the airway, with mask attached, is slid into the oropharynx while the tongue and jaw are pulled forward The airway is advanced along the tongue and into the esophagus

EGTA/INSERTION

Following gentle insertion so that the mask now rests easily on the face, the mask is sealed firmly on the face as the jaw is pulled forward to ensure an airway Prior to inflating the cuff, ventilation is attempted as well as auscultation If there is any doubt about placement of the airway remove it and reinsert

PHARYNGOTRACHEAL LUMEN AIRWAY (PTL)

PTL consists of a smaller-diameter long tube inside of a short large-diameter tube. The tube goes either into the trachea or the esophagus, while the shorter tube opens into the lower pharynx Each tube has a cuff, the longer tube seals the esophagus or trachea, the shorter tube seals the oropharynx so that there is no air leak when ventilating

PTL

Insertion is blind, you must determine placement. If longer tube is in trachea you ventilate through it If longer tube is in the esophagus you ventilate through the shorter tube

PTL/ESSENTIALS

Use only in patients who are unresponsive and without gag reflexes Do NOT use in patient with injury to the esophagus or in children under the age of 15 Pay careful attention to placement Insertion must be gentle and without force In the patient regains consciousness, you must remove the PTL (vomiting)

PTL/INSERTION

Ventilate and suction before insertion Prepare the airway Lubricate, and slide the airway into the oropharynx Immediately inflate both cuffs Determine placement Secure

ESOPHAGEAL TRACHEAL COMBITUBE

Similar to the PTL in that it has a double lumen. The two lumens are separated by a partition rather than one being inside of the other. One tube is sealed at the distal end, and there are perforations in the area of the tube that would be in the pharynx.

COMBITUBE

When the long tube is in the esophagus, the patient is ventilated through this short tube The long tube is open at the distal end, and it has a cuff that is blown up to seal the esophagus or the trachea If the long tube goes into the esophagus, the cuff is inflated and the patient is ventilated through the short tube.

COMBITUBE

If the long tube goes into the trachea, the cuff is inflated and the patient is ventilated through the long tube. The Combitube is somewhat quicker and easier to insert than the PTL

COMBITUBE/ESSENTIALS

Use only in patients who are unresponsive and without protective gag reflex Do not use in any patient with injury to the esophagus and children below 15 Pay attention to placement Insert gently and without force Remove once patient regains consciousness

COMBITUBE/TECHNIQUE

Insert the tube blindly, watching for the two black rings on the tube for measuring the depth of insertion. These rings should be positioned between the teeth and the lips Use the large syringe to inflate the pharyngeal cuff with 100 cc of air Use the small syringe to fill the distal cuff with 10-15 cc of air

COMBITUBE/INSERTION

The long tube will usually go into the esophagus. Ventilate through the esophageal connector. Longer of the tubes and marked 1. Check placement, if not placed properly: Ventilate through the shorter tracheal connector which is marked 2

LARYNGEAL MASK AIRWAY (LMA)

Developed as an alternative to the face mask for achieving and maintaining control of the airway during routine anesthetic procedures in the operating room. Found to be useful in the emergency situation when intubation is not possible and you cant ventilate with a BVM May prevent doing a surgical procedure to open the airway

LMA

Not designed to seal the esophagus and was not originally meant for emergency use. It is not equal to the ET and should only be used when efforts to intubate the trachea have been unsuccessful and ventilation is compromised.

LMA/WARNINGS

Use only in patients who are unresponsive and without protective reflexes. Do not use in any patient with injury to the esophagus Lubricate only the posterior surface of the LMA to avoid blockage of the aperture or aspiration of the lubricant Patients should be adequately monitored

LMA/WARNINGS

Never force the device to avoid trauma to the airway Never overinflate the cuff. May cause malposition, loss of seal, or trauma. If airway problems persist, it should be removed and reinserted. Does not prevent aspiration if the patient vomits

LMA/WARNINGS

If the patient regains consciousness, you must remove it.

LMA/INSERTION

Ventilate with mouth-to-mask or BVM, and suction Remove the valve tab and check the integrity of the LMA cuff by inflating with maximum volume Cuff should be tightly deflated using the enclosed syringe so that it forms a flat oval disk with the rim facing away from the aperture.

LMA/INSERTION

Lubricate the posterior surface Preoxygenate the patient If no danger of spinal injury, position the patient with the neck flexed and the head extended, otherwise neutral position. Hold the LMA like a pen and insert. Use the index finger to guide the LMA, pressing upwards and backwards toward the ears

LMA/INSERTION

Without holdings the tube, inflate the cuff with just enough air to obtain a seal. The tube will bob when properly placed. Connect the LMA to the BVM and check position.

SUCTIONING

Often a neglected skill. Very important skill that must accompany airway maintenance Can be used to open an airway or to maintain an airway All suctioning should be considered sterile

SUCTIONING GENERAL RULES

Hyperventilate the patient, or apply oxygen in a high-concentration to those who are spontaneously breathing and monitor ECG Use only sterile devices

Be gentle Lubricate all suction catheters and tips Maximum of 10 seconds of suction time Suction on withdrawal of catheter, rotating slowly (ET)

SUCTIONING
NASO, OROPHARYNX Use either the soft, flexible catheter or the tonsil tip catheter The tonsil tip is preferred for oropharyngeal suctioning Another consideration is the V-Vac Suction Device Flexible catheter preferred for naso

SUCTIONING
ET TUBE Sterility is especially important since you have by-passed the bodys natural protective elements Use only soft flexible catheters Be GENTLE Observe the monitor for arrhythmias

SUCTIONING
CRASH SUCTIONING For those times when the patient suddenly vomits, it can be very catastrophic for the patient Involves increasing the bore of the suction device Remember: Since CRASH suctioning removes large amounts of fluids, it also removes large amount of air