1

MANAGEMENT OF
AIRWAY AND
BREATHING

EMERGENCY MEDICAL TECHNICIAN - BASIC

 Airway Functions
2

 Passage that allows air to move from atmosphere to

alveoli
 Must remain patent (open) at all times
 Anything that blocks airway will cause decrease in
oxygen available to body
 Size of obstruction affects available air exchange
 Airway Anatomy
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 Opening the Airway
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 Techniques
 Head-tilt/Chin-lift
 Jaw Thrust
 Suctioning
 Nasopharyngeal airway (through nose)
 Oropharyngeal airway (through mouth)
 Head-Tilt/Chin-Lift
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 Used when no neck injury is suspected

 Temporary procedure
 Must be replaced with an airway adjunct unless
patient begins adequate spontaneous ventilation
 Head-Tilt/Chin-Lift
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 Technique
 Place one hand on patient’s forehead
 Apply firm, backward pressure with palm causing head
to tilt backward
 Place fingers of other hand under bony part of
patient’s lower jaw near chin
 Lift jaw upward to bring chin forward
 Head-Tilt/Chin-Lift
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 Patients needing head-tilt/chin-lift

 Unresponsive patient without history of trauma
 Cardiac arrest patients without signs of trauma
 Apneic patients without signs of trauma
 Jaw Thrust
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 Used when spinal injury suspected

 Temporary procedure
 Must be replaced with airway adjunct unless
patient begins adequate spontaneous ventilation
 Jaw Thrust
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 Technique
 Place one hand on either side of patient’s head, resting
elbows on surface on which victim is lying
 Grasp angles of patient’s lower jaw, lift with both
hands
 If patient’s lips close, retract lower lips with thumbs
 Jaw Thrust
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 Patients needing jaw thrust

 Unresponsive trauma patient
 Unresponsive patient with undetermined mechanism of
injury
 Suctioning
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 Purpose
 Remove blood, vomit, other liquids, food particles
from airway
 May not be adequate for removing large, solid objects
(teeth, foreign bodies, food)
 Should be performed immediately when gurgling is
heard with spontaneous or artificial ventilation
 Suctioning
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 Suction devices
 Mounted in ambulance
 Portable
 Electrical
 Hand operated

 Should generate 300mm Hg vacuum

 Ensure batteries in units remain properly charged
 Suctioning
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 Rigid Suction Catheter

 Used to suction mouth, oropharynx (back of throat) of
unresponsive patient
 Inserted only as far as you can see
 Take caution not to touch back of airway, particularly
in infants and children (can cause heart rate to drop)
 Suctioning
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 Soft Suction Catheter

 Useful for suctioning nasopharynx (through nose) or
tracheostomy tubes
 Should be inserted only as far as base of tongue or end
of tracheostomy tube
 Suctioning
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 Techniques
 Turn on unit
 Attach catheter
 Insert catheter into oral cavity without suction
 Insert only to base of tongue
 Apply suction, move catheter from side to side
 Suction no longer than 15 seconds in adults, 10 seconds in
children, 5 seconds in infants
 Rinse catheter with saline or water to prevent obstruction
 Nasal Airways
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 Used on responsive patients who need help keeping

tongue out of airway
 Insertion is uncomfortable for responsive patients
sometimes
 When inserting, aim towards back of head, not up
towards top of nose
 Nasal Airways
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 Technique
 Measure from tip of nose to earlobe
 Ensure airway will fit through nostril
 Lubricate with water-soluble lubricant
 Insert with bevel toward base of nostril or septum
 If resistance is met, try other nostril
 Do not use in patients with mid-face trauma or possible
basilar skull fractures
 Nasal Airways
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 Patients needing nasal airway

 Unresponsive patients who are snoring
 Unresponsive patients with gag reflex
 Oral Airways
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 Used on unresponsive patients without gag reflex

 Helps hold tongue away from back of throat

QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
 Oral Airways
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 Technique
 Measure from corner of mouth to earlobe or angle of jaw
 Open patient’s mouth
 In adults insert with tip facing roof of patient’s mouth,
advance until resistance encountered, turn 180o until flange
comes to rest on patient’s teeth
 Or in adults can try and insert right side up, being careful
not to p[ush the tongue back, often easier with a jaw thrust
 In infants and children use tongue depressor to lift tongue,
insert oral airway right side up
 Oral Airways
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 Patients needing oral airway

 Unresponsive, apneic patients (no breathing) with or
without trauma
 Any apneic patient being ventilated with a BVM (bag
valve mask)
 Airway Limitations
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 Nasal/oral airways are not definitive devices

 Manual maneuvers must be used with nasal/oral
airways to ensure airway stays open
 Patients may require frequent suctioning to remove
blood, vomit, other secretions from airway
 Definitive devices such as endotracheal tubes are
required to completely protect the airway
 Laryngeal Mask Airways (LMA)
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 Laryngeal Mask Airways (LMA)
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 Although endotracheal intubation is the definitive way of

controlling the airway, as AMT-basic, you are not qualified to
use it yet. (later EMT course will qualify you to do so)
 LMA’s are excellent for many patients, as they are easy to
place usually, and often work very well for short-term use
 Unfortunately LMA’s DO NOT protect the lungs from
secretions, blood vomit etc.
 LMA’s also do not protect from air getting into the stomach,
therefore use the MINIMUM amount of pressure to ventilate
adequately
 Laryngeal Mask Airways (LMA)
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 Choose the correct size for the patient.

 Normal Indonesian adult male: size 3
 Normal Indonesian adult female: size 2
 Large adult male: size 4
 Children sizes depend on age: size 1/2 to 1 1/2
 To place LMA, cover with small amount of water soluble lubricant, open airway
(jaw thrust or head tilt as appropriate; scissor hand technique helps), and insert LMA
similarly to oral airway
 Can insert with curved side up, then when reach resistance turn 180 degrees and push into
place
 Can insert with right side down (like a C that follows the mouth to neck) until meet
resistance
 Do not push when resistance is met
 Make sure you get good ventilation once inserted correctly
 LMA is usually inflated 3/4 of the way to have a good seal
 Adequate Breathing
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 Normal Rate
 Adult: 12 to 20/minute
 Child: 15 to 30/minute
 Infant: 25 to 50/minute
 Regular Rhythm
 Adequate Quality
 Movement of air at mouth, nose
 Chest expansion adequate, symmetrical (equal)
 Breath sounds present, equal
 Minimum effort of breathing
 Adequate tidal volume (depth)
 Inadequate Breathing
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 Abnormal Rate
 Adult: <12 to >20/minute
 Child: <15 to >30/minute
 Infant: <25 to >50/minute
 Irregular Rhythm
 Inadequate Quality
 Absent or reduced at mouth, nose
 Chest expansion inadequate or asymmetrical (unequal)
 Breath sounds diminished, unequal, noisy, absent
 Increased effort of breathing, use of accessory muscles
 Inadequate (shallow) tidal volume
 Inadequate Breathing
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 Skin changes
 Pale, cool, clammy: Early sign
 Cyanosis: Late, unreliable sign
 Retractions of soft tissues above clavicles, between
ribs, below rib cage
 Flaring of nostrils
 “Seesaw” breathing in infants
 Ventilation Techniques
(In order of preference)
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1. Mouth-to-mask with supplemental oxygen

2. Two-person bag-valve mask with oxygen
reservoir and supplemental oxygen
3. Flow restricted, oxygen-powered ventilation
device (manually-triggered ventilator)
4. One-person bag-valve mask with oxygen
reservoir and supplemental oxygen
 Ventilation Techniques
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 Mouth-to-Mouth (safety risk!, so almost never

done)
 Open airway
 Pinch nose closed or seal nose with cheek
 Take deep breath
 Seal lips around patient’s mouth to create airtight seal
 Blow into patient’s mouth slowly over 2 seconds until
patient’s chest rises
 Ventilation Techniques
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 Mouth-to-Mask
 Connect mask to oxygen at 15 liters per minute
 Kneel directly above patient’s head
 Apply mask to patient’s face
 Place thumbs along sides of mask, index fingers of both
hands under patient’s mandible
 Lift jaw into mask, tilt head if neck injury not suspected
 Blow into one-way valve slowly over 2 seconds until
patient’s chest rises
 Ventilation Techniques
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 Bag-valve mask (BVM)

 Self-inflating bag
 One-way valve
 Face mask
 Oxygen reservoir

Must be connected to oxygen to perform

most effectively
 Ventilation Techniques
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 BVM Issues
 Provides less volume than mouth-to-mask
 Single rescuer may have difficulty maintaining air-
tight seal
 Two rescuers using device are more effective
 Position yourself at top of patient’s head for best
performance
 Oral or nasal airway should be inserted
 Ventilation Techniques
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 BVM Technique (Two Rescuer)

 Open airway, insert oral or nasal airway
 Position thumbs over top half of mask, index and middle
fingers over bottom half
 Place apex of mask over bridge of nose, lower mask over
mouth/upper chin
 Use ring and little fingers to bring jaw up to mask
 Have assistant squeeze bag with two hands until chest rises
 Ventilate every 5 seconds for adults, every 3 seconds for
infants and children
 Ventilation Techniques
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 BVM Technique (One Rescuer)

 Open airway, insert oral or nasal airway
 Form a “C” around ventilation port with thumb, index
finger
 Use middle, ring, little fingers under jaw to maintain
chin lift, complete seal
 Squeeze bag with other hand until chest rises
 Ventilate every 5 seconds for adults, every 3 seconds
for infants and children
 Ventilation Techniques
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 BVM Technique (Suspected Trauma)

 Open airway, insert oral or nasal airway
 Have assistant hold patient’s head or use your knees to prevent
movement
 Position thumbs over top half of mask, index and middle fingers over
bottom half
 Place apex of mask over bridge of nose, lower mask over mouth/upper
chin
 Use ring and little fingers to bring jaw up to mask without tilting head
or neck
 Have assistant squeeze bag with two hands until chest rises
 Ventilate every 5 seconds for adults, every 3 seconds for infants and
children continue to hold jaw up without moving head or neck
 Ventilation Techniques
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 If chest does not rise, reevaluate

 If abdomen rises, reposition head or jaw
 If air escapes under mask, reposition fingers and mask
 Check for obstruction
 If chest still does not rise and fall use another method
of ventilation
 Ventilation Techniques
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 Flow Restricted, Oxygen-Powered Ventilation Devices

(Manually-Triggered Ventilator)
 Peak flow of 100% oxygen at maximum of 40 lpm
 Pressure relief valve that opens at 60 cm H2O
 Audible alarm that sounds when relief valve pressure is exceeded
 Trigger so both hands remain on mask to maintain seal

Do NOT use on children or infants!!!

 Ventilation Techniques
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 Manually-Triggered Ventilator
 Open airway, insert oral or nasal airway
 Position thumbs over top half of mask, index/middle
fingers over bottom half
 Place apex of mask over bridge of nose, lower mask over
mouth and chin
 Use ring/little fingers to bring jaw up to mask
 Trigger device until chest rises
 Repeat every 5 seconds
 Ventilation Techniques
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 Manually-Triggered Ventilator (Suspected Trauma)

 Open airway, insert oral or nasal airway
 Have assistant hold head manually or use knees to prevent movement
 Position thumbs over top half of mask, index/middle fingers over
bottom half
 Place apex of mask over bridge of nose, lower mask over mouth and
chin
 Use ring/little fingers to bring jaw up to mask without tilting head and
neck
 Trigger device until chest rises
 Repeat every 5 seconds
 Assisting Patients Who Are Breathing
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 Who needs assistance?

 A patient who is not breathing
 A patient who has reduced respiratory rate and tidal
volume
 A patient whose breathing rate is increased, but whose
tidal volume is inadequate
 Assisting Patients Who Are Breathing
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 Patients with rapid, shallow breathing

 Explain procedure to patient
 Place mask over patient’s mouth and nose
 Initially assist ventilations at rate at which patient is
breathing. Squeeze bag as patient inhales
 Slowly adjust rate and tidal volume until adequate
ventilations are achieved
 Assisting Patients Who Are Breathing
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 Patients with slow, shallow breathing

 Place bag over patient’s mouth and nose
 Squeeze bag each time patient inhales
 Adjust rate and tidal volume until adequate
ventilations are achieved
 Special Considerations
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 Stoma or tracheostomy tube

 Attach BVM to tube, or use infant/child mask to make
seal over stoma
 Seal mouth/nose if air is escaping when ventilating at
stoma
 If unable to ventilate
 Suction stoma or tracheostomy tube
 Seal stoma, attempt to ventilate through mouth/nose
 Special Considerations
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 Infants and children

 Place infant’s head in neutral position
 Extend child’s head slightly past neutral
 Avoid excessive hyperextension
 Avoid excessive ventilation, just make chest rise
 Gastric distension is more common in children
 Do not use BVMs with pop-off valves
 Special Considerations
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 Dentures
 Leave in place unless obviously loose
 Remove if loose
 Be prepared to remove if displacement occurs
 Oxygen
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 Oxygen cylinder sizes

 D cylinder 350 liters
 E cylinder 625 liters
 M cylinder 3,000 liters
 G cylinder 5,300 liters
 H cylinder 6,900 liters
 Contents under pressure
 Should be positioned to prevent falling, blows to
valve-gauge assembly
 Oxygen
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 Operating procedures
 Remove protective seal
 Quickly open, then shut valve
 Check if tank is full, or has adeqaute amount of oxygen/pressure for
trip. Make sure back-up is available
 Attach regulator-flow meter to tank
 Select proper size of oxygen mask for patient
 Attach oxygen mask to flow-meter
 Open flow-meter to desired setting
 Apply device to patient
 When complete, remove device from patient, turn off device, remove
all pressure from regulator
 Oxygen
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 Non-rebreather mask (NRB mask)

 Preferred method of giving oxygen to prehospital
patients
 Up to 90% oxygen can be delivered
 Non-rebreather bag must be full before mask is placed
on patient
 Flow rate should be adjusted so when patient inhales,
bag does not collapse (~15 lpm)
 Oxygen
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 Nasal cannula
 Rarely best method for giving adequate oxygen in
emergency care settings
 Should be used only if patient will not tolerate non-
rebreather mask in spite of coaching
 Usually use 6 lpm or less oxygen flow
 Oxygen
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 Concerns about giving too much oxygen to patients

with COPD, infants, and children are NOT valid
during short-term emergency administration
 Patients with COPD, infants, and children who
require oxygen should be given high concentration
oxygen.