Management of Airway and Breathing

Emergency Medical Technician Basic

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Airway Functions
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
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Opening the Airway

Techniques
Head-tilt/Chin-lift Jaw Thrust Suctioning Nasopharyngeal airway Oropharyngeal airway

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Head-Tilt/Chin-Lift
Used when no neck injury is suspected Temporary procedure Must be replaced with an airway adjunct unless patient begins adequate spontaneous ventilation

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Head-Tilt/Chin-Lift
Technique
Place one hand on patients forehead Apply firm, backward pressure with palm causing head to tilt backward Place fingers of other hand under bony part of patients lower jaw near chin Lift jaw upward to bring chin forward

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Head-Tilt/Chin-Lift
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

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Jaw Thrust
Used when spinal injury suspected Temporary procedure Must be replaced with airway adjunct unless patient begins adequate spontaneous ventilation

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Jaw Thrust
Technique
Place one hand on either side of patients head, resting elbows on surface on which victim is lying Grasp angles of patients lower jaw, lift with both hands If patients lips close, retract lower lips with thumbs
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Jaw Thrust
Patients needing jaw thrust
Unresponsive trauma patient Unresponsive patient with undetermined mechanism of injury

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Suctioning
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
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Suctioning
Suction devices
Mounted in ambulance Portable
Electrical Hand operated

Should generate 300mm Hg vacuum Ensure batteries in units remain properly charged
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Suctioning
Rigid Suction Catheter
Used to suction mouth, oropharynx 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)

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Suctioning
Soft Suction Catheter
Useful for suctioning nasopharynx or tracheostomy tubes Should be inserted only as far as base of tongue or end of tracheostomy tube

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Suctioning
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
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Nasal Airways
Used on responsive patients who need help keeping tongue out of airway Insertion is uncomfortable for responsive patients

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Nasal Airways
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

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Nasal Airways
Patients needing nasal airway
Unresponsive patients who are snoring Unresponsive patients with gag reflex

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Oral Airways
Used on unresponsive patients without gag reflex Helps hold tongue away from back of throat

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Oral Airways
Technique
Measure from corner of mouth to earlobe or angle of jaw Open patients mouth In adults insert with tip facing roof of patients mouth, advance until resistance encountered, turn 180o until flange comes to rest on patients teeth In infants and children use tongue depressor to lift tongue, insert oral airway right side up

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Oral Airways
Patients needing oral airway
Unresponsive, apneic patients with or without trauma Any apneic patient being ventilated with a BVM

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Airway Limitations
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

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Adequate Breathing
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)
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Inadequate Breathing
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 Indequate (shallow) tidal volume
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Inadequate Breathing
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

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Ventilation Techniques (In order of preference)

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

Must be connected to oxygen to perform most effectively

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Ventilation Techniques
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 patients head for best performance Oral or nasal airway should be inserted
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Ventilation Techniques
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
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Ventilation Techniques
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
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Ventilation Techniques
BVM Technique (Suspected Trauma)
Open airway, insert oral or nasal airway Have assistant hold patients 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
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Ventilation Techniques
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

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Ventilation Techniques
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!!!

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Ventilation Techniques
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
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Ventilation Techniques
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

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Assisting Patients Who Are Breathing

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

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Assisting Patients Who Are Breathing

Patients with rapid, shallow breathing
Explain procedure to patient Place mask over patients 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
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Assisting Patients Who Are Breathing

Patients with slow, shallow breathing
Place bag over patients mouth and nose Squeeze bag each time patient inhales Adjust rate and tidal volume until adequate ventilations are achieved

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Special Considerations
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
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Special Considerations
Infants and children
Place infants head in neutral position Extend childs 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
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Special Considerations
Dentures
Leave in place unless obviously loose Remove if loose Be prepared to remove if displacement occurs

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Oxygen
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
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Oxygen
Operating procedures
Remove protective seal Quickly open, then shut valve Attach regulator-flow meter to tank Select proper size of oxygen mask for patient Attach oxygen mask to flowmeter Open flow meter to desired setting Apply device to patient When complete, remove device from patient, turn off device, remove all pressure from regulator
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Oxygen
Non-rebreather 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 adjused so when patient inhales, bag does not collapse (~15 lpm)
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Oxygen
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

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Oxygen
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.
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