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Airway Management Part 1

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Airway Anatomy & Physiology Review. Causes of Respiratory Difficulty & Distress ... Lower Airway Anatomy. Trachea. Bifurcates (divides) at carina. Right, left ... – PowerPoint PPT presentation

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Title: Airway Management Part 1


1
Airway ManagementPart 1
  • EMS Professions
  • Temple College

2
Topics for Discussion
  • Airway Maintenance Objectives
  • Airway Anatomy Physiology Review
  • Causes of Respiratory Difficulty Distress
  • Assessing Respiratory Function
  • Methods of Airway Management
  • Methods of Ventilatory Management
  • Common Out-of-Hospital Equipment Utilized
  • Advanced Methods of Airway Management and
    Ventilation
  • Risks to the Paramedic

3
Objectives of Airway Management Ventilation
  • Primary Objective
  • Ensure optimal ventilation
  • Deliver oxygen to blood
  • Eliminate carbon dioxide (C02) from body
  • Definitions
  • What is airway management?
  • How does it differ from spontaneous, manual or
    assisted ventilations?

4
Objectives of Airway Management Ventilation
  • Why is this so important?
  • Brain death occurs rapidly other tissue follows
  • EMS providers can reduce additional
    injury/disease by good airway, ventilation
    techniques
  • EMS providers often neglect BLS airway,
    ventilation skills

5
Airway Anatomy Review
  • Upper Airway Anatomy
  • Lower Airway Anatomy
  • Lung Capacities/Volumes
  • Pediatric Airway Differences

6
Anatomy of the Upper Airway
7
Upper Airway Anatomy
  • Functions warm, filter, humidify air
  • Nasal cavity and nasopharynx
  • Formed by union of facial bones
  • Nasal floor towards ear not eye
  • Lined with mucous membranes, cilia
  • Tissues are delicate, vascular
  • Adenoids
  • Lymph tissue - filters bacteria
  • Commonly infected

8
Upper Airway Anatomy
  • Oral cavity and oropharynx
  • Teeth
  • Tongue
  • Attached at mandible, hyoid bone
  • Most common airway obstruction cause
  • Palate
  • Roof of mouth
  • Separates oropharynx and nasopharynx
  • Anterior hard palate Posterior soft palate

9
Upper Airway Anatomy
  • Oral cavity and oropharynx
  • Tonsils
  • Lymph tissue - filters bacteria
  • Commonly infected
  • Epiglottis
  • Leaf-like structure
  • Closes during swallowing
  • Prevents aspiration
  • Vallecula
  • Pocket formed by base of tongue, epiglottis

10
Upper Airway Anatomy
11
Upper Airway Anatomy
  • Sinuses
  • cavities formed by cranial bones
  • act as tributaries for fluid to, from eustachian
    tubes, tear ducts
  • trap bacteria, commonly infected

12
Upper Airway Anatomy
  • Larynx
  • Attached to hyoid bone
  • Horseshoe shaped bone
  • Supports trachea
  • Thyroid cartilage
  • Largest laryngeal cartilage
  • Shield-shaped
  • Cartilage anteriorly, smooth muscle posteriorly
  • Adams Apple
  • Glottic opening directly behind

13
Upper Airway Anatomy
  • Larynx
  • Glottic opening
  • Adult airways narrowest point
  • Dependent on muscle tone
  • Contains vocal bands
  • Arytenoid cartilage
  • Posterior attachment of vocal bands

14
Upper Airway Anatomy
  • Larynx
  • Cricoid ring
  • First tracheal ring
  • Completely cartilaginous
  • Compression (Sellick maneuver) occludes esophagus
  • Cricothyroid membrane
  • Membrane between cricoid, thyroid cartilages
  • Site for surgical, needle airway placement

15
Upper Airway Anatomy
  • Larynx and Trachea
  • Associated Structures
  • Thyroid gland
  • below cricoid cartilage
  • lies across trachea, up both sides
  • Carotid arteries
  • branch across, lie closely alongside trachea
  • Jugular veins
  • branch across and lie close to trachea

16
Upper Airway Anatomy
17
Upper Airway Anatomy
  • Pediatric vs Adult Upper Airway
  • Larger tongue in comparison to size of mouth
  • Floppy epiglottis
  • Delicate teeth, gums
  • More superior larynx
  • Funnel shaped larynx due to undeveloped cricoid
    cartilage
  • Narrowest point at cricoid ring before 8 years
    old

18
Upper Airway Anatomy
From CPEM, TRIPP, 1998
19
Upper Airway Anatomy
20
Glottic Opening
21
Lower Airway Anatomy
  • Function
  • Exchange O2 , CO2 with blood
  • Location
  • From glottic opening to alveolar-capillary
    membrane

22
Lower Airway Anatomy
  • Trachea
  • Bifurcates (divides) at carina
  • Right, left mainstem bronchi
  • Right mainstem bronchus shorter, straighter
  • Lined with mucous cells, beta-2 receptors

23
Lower Airway Anatomy
  • Bronchi
  • Branch into secondary, tertiary bronchi that
    branch into bronchioles
  • Bronchioles
  • No cartilage in walls
  • Small smooth muscle tubes
  • Branch into alveolar ducts that end at alveolar
    sacs

24
Lower Airway Anatomy
  • Alveoli
  • Balloon-like clusters
  • Site of gas exchange
  • Lined with surfactant
  • Decreases surface tension ? eases expansion
  • ? surfactant ? atelectasis (focal collapse of
    alveoli0

25
Lower Airway Anatomy
  • Lungs
  • Right lung 3 lobes Left lung 2 lobes
  • Parenchymal tissue
  • Pleura
  • Visceral
  • Parietal
  • Pleural space

26
Lower Airway Anatomy
27
Lower Airway Anatomy
  • Occlusion of bronchioles
  • Smooth muscle contraction (bronchospasm
  • Mucus plugs
  • Inflammatory edema
  • Foreign bodies

28
Lung Volumes/Capacities
  • Typical adult male total lung capacity 6 liters
  • Tidal Volume (VT)
  • Gas volume inhaled or exhaled during single
    ventilatory cycle
  • Usually 5-7 cc/kg (typically 500 cc)

29
Lung Volumes/Capacities
  • Dead Space Air (VD)
  • Air unavailable for gas exchange

30
Lung Volumes/Capacities
  • Dead Space Air (VD)
  • Anatomic dead space (150cc)
  • Trachea
  • Bronchi
  • Physiologic dead space
  • Shunting
  • Pathological dead space
  • Formed by factors like disease or obstruction
  • Examples COPD

31
Lung Volumes/Capacities
  • Alveolar Air (alveolar volume) VA
  • Air reaching alveoli for gas exchange
  • Usually 350 cc

32
Lung Volumes/Capacities
  • Minute Volume Vmin(minute ventilation)
  • Amount of gas moved in, out of respiratory tract
    per minute
  • Tidal volume X RR
  • Alveolar Minute Volume
  • Amount of gas moved in, out of alveoli per minute
  • (tidal volume - dead space volume) X RR

33
Lung Volumes/Capacities
  • Functional Reserve Capacity (FRC)
  • After optimal inspiration, amount of air that can
    be forced from lungs in single exhalation

34
Lung Volumes/Capacities
  • Inspiratory Reserve Volume (IRV)
  • Amount of gas that can be inspired in addition to
    tidal volume
  • Expiratory Reserve Volume (ERV)
  • Amount of gas that can be expired after passive
    (relaxed) expiration

35
Lung Volumes/Capacities
36
Ventilation
  • Movement of air in, out of lungs
  • Control via
  • Respiratory center in medulla
  • Apneustic, pneumotaxic centers in pons

37
Ventilation
  • Inspiration
  • Stimulus from respiratory center of brain
    (medulla)
  • Transmitted via phrenic nerve to diaphragm,
    spinal cord/intercostal nerves to intercostal
    muscles
  • Diaphragm contracts, flattens
  • Intercostal muscles contract ribs move up and
    out
  • Air spaces in lungs stretch, increase in size
  • ? intrapulmonic pressure (pressure gradient)
  • Air flows into airways, alveoli inflate until
    pressure equalizes

38
Ventilation
  • Expiration
  • Stretch receptors in lungs signal respiratory
    center via vagus nerve to inhibit inspiration
    (Hering-Breuer reflex)
  • Natural elasticity of lungs pulls diaphragm,
    chest wall to resting position
  • Pulmonary air spaces decrease in size
  • Intrapulmonary pressure rises
  • Air flows out until pressure equalizes

39
Ventilation
40
Ventilation
41
Ventilation
  • Respiratory Drive
  • Chemoreceptors in medulla
  • Stimulated ? PaCO2 or ? pH
  • PaCO2 is normal neuroregulatory control of
    ventilations
  • Hypoxic Drive
  • Chemoreceptors in aortic arch, carotid bodies
  • Stimulated by ? PaO2
  • Back-up regulatory control

42
Ventilation
  • Other stimulants or depressants
  • Body temp fever? hypothermia?
  • Drugs/meds increase or decrease
  • Pain increases, but occasionally decreases
  • Emotion increases
  • Acidosis increases
  • Sleep decreases

43
Gas Measurements
  • Total Pressure
  • Combined pressure of all atmospheric gases
  • 760 mm Hg (torr) at sea level
  • Partial Pressure
  • Pressure exerted by each gas in a mixture

44
Gas Measurements
  • Partial Pressures
  • Atmospheric
  • Nitrogen 597.0 torr (78.62) Oxygen 159.0 torr
    (20.84) Carbon Dioxide 0.3 torr (0.04) Water
    3.7 torr (0.5)
  • Alveolar
  • Nitrogen 569.0 torr (74.9) Oxygen 104.0 torr
    (13.7) CO2 40.0 torr (5.2) Water 47.0 torr
    (6.2)

45
Respiration
  • Ventilation vs. Respiration
  • Exchange of gases between living organism,
    environment
  • External Respiration
  • Exchange between lungs, blood cells
  • Internal Respiration
  • Exchange between blood cells, tissues

46
Respiration
  • How are O2, CO2 transported?
  • Diffusion
  • Movement of gases along a concentration gradient
  • Gases dissolve in water, pass through alveolar
    membrane from areas of higher concentration to
    areas of lower concentration
  • FiO2
  • oxygen in inspired air expressed as a decimal
  • FiO2 of room air 0.21

47
Respiration
  • Blood Oxygen Content
  • dissolved O2 crosses capillary membrane, binds
    to Hgb of RBC
  • Transport O2 bound to hemoglobin (?97) or
    dissolved in plasma
  • O2 Saturation
  • of hemoglobin saturated with oxygen (usually
    carries gt96 of total)
  • O2 content divided by O2 carrying capacity

48
Respiration
  • Oxygen saturation affected by
  • Low Hgb (anemia, hemorrhage)
  • Inadequate oxygen availability at alveoli
  • Poor diffusion across pulmonary membrane
    (pneumonia, pulmonary edema, COPD)
  • Ventilation/Perfusion (V/Q) mismatch
  • Blood moves past collapsed alveoli (shunting)
  • Alveoli intact but blood flow impaired

49
Respiration
  • Blood Carbon Dioxide Content
  • Byproduct of work (cellular respiration)
  • Transported as bicarbonate (HCO3- ion)
  • ? 20-30 bound to hemoglobin
  • Pressure gradient causes CO2 diffusion into
    alveoli from blood
  • Increased level hypercarbia

50
Respiration
51
Inspired Air PO2 160 PCO2 0.3
Alveoli PO2 100 PCO2 40
PO2 40 PCO2 46 - Pulmonary circulation - PO2
100 PCO2 40
Heart
Oxygenated
Deoxygenated
PO2 40 PCO2 46 - Systemic circulation - PO2
100 PCO2 40
Tissue cell PO2 lt40 PCO2 gt46
52
Diagnostic Testing
  • Pulse Oximetry
  • Peak Expiratory Flow Testing
  • Pulmonary Function Testing
  • End-Tidal CO2 Monitoring
  • Laboratory Testing of Blood
  • Arterial
  • Venous

53
Causes of Hypoxemia
  • Lower partial pressure of atmospheric O2
  • Inadequate hemoglobin level in blood
  • Hemoglobin bound by other gas (CO)
  • ? pulmonary alveolar membrane distance
  • Reduced surface area for gas exchange
  • Decreased mechanical effort

54
Causes of Airway/Ventilatory Compromise
  • Airway Obstruction
  • Tongue
  • Foreign body obstruction
  • Anaphylaxis/angioedema
  • Upper airway burn
  • Maxillofacial/laryngeal/trachebronchial trauma
  • Epiglottitis
  • Croup

55
Obstruction
  • Tongue
  • Most common cause
  • Snoring respirations
  • Corrected by positioning

56
Foreign Body
  • Partial or Full
  • Symptoms include
  • Choking
  • Gagging
  • Stridor
  • Dyspnea
  • Aphonia
  • Dysphonia

57
Laryngeal Spasm
  • Spasmatic closure of vocal cords
  • Frequently caused by
  • Overly aggressive technique during intubation
  • Immediately upon extubation

58
Laryngeal Edema
  • Causes
  • Angioedema
  • Anaphylaxis
  • Upper airway burns
  • Epiglottitis
  • Croup
  • Trauma

59
Aspiration
  • Significantly increases mortality
  • Obstructs Airway
  • Destroys bronchial tissue
  • Introduces pathogens
  • Decreases ability to ventilate
  • Frequently occult

60
Obstructive Airway Disease
  • Obstructive airway disease
  • Asthma
  • Emphysema
  • Chronic Bronchitis

61
Gas Exchange Surface
  • Pulmonary edema
  • Left-sided heart failure
  • Toxic inhalation
  • Near drowning
  • Pneumonia
  • Pulmonary embolism
  • Blood clots
  • Amniotic fluid
  • Fat embolism

62
Causes of Airway/Ventilatory Compromise
  • Thoracic Bellows
  • Chest trauma
  • Fib fractures
  • Flail chest
  • Pneumothorax
  • Hemothorax
  • Sucking chest wound
  • Diaphragmatic hernia

63
Causes of Airway/Ventilatory Compromise
  • Thoracic Bellows
  • Pleural effusion
  • Spinal cord trauma
  • Morbid obesity (Pickwickian Syndrome)
  • Neurological/neuromuscular disease
  • Poliomyelitis
  • Myasthenia gravis
  • Muscular dystrophy
  • Gullian-Barre syndrome

64
Causes of Airway/Ventilatory Compromise
  • Control System
  • Head trauma
  • Cerebrovascular accident
  • Depressant drug toxicity
  • Narcotics
  • Sedative-Hypnotics
  • Ethanol

65
Assessment of Airway/Ventilatory Compromise
  • Respiratory Distress/Dyspnea Possible Life
    Threat
  • Assess/Manage Simultaneously
  • Priorities
  • Airway
  • Breathing
  • Circulation
  • Disability

66
Assessment of Airway/Ventilatory Compromise
  • Airway
  • Listen to patient talk/breathe
  • Noisy breathing Obstructed breathing
  • But, all obstructed breathing is not noisy
  • Adventitious sounds
  • Snoring Tongue
  • Stridor Tight Upper Airway

67
Assessment of Airway/Ventilatory Compromise
  • Breathing
  • Look
  • Symmetry of Chest Expansion
  • Signs of Increased Effort
  • Skin Color
  • Listen
  • Mouth and Nose
  • Lung Fields
  • Feel
  • Mouth and Nose
  • Symmetry of Expansion

68
Assessment of Airway/Ventilatory Compromise
  • Breathing
  • Tachypnea
  • Bradypnea
  • Signs of distress
  • Nasal flaring
  • Tracheal tugging
  • Retractions
  • Accessory muscle use
  • Tripod positioning
  • Cyanosis

69
Assessment of Airway/Ventilatory Compromise
  • Circulation
  • Dont let respiratory failure distract you!!!
  • Tachycardia Early hypoxia in adults
  • Bradycardia Early hypoxia in infants, children
    Late hypoxia in adults

70
Assessment of Airway/Ventilatory Compromise
  • Disability
  • Restlessness, anxiety, combativeness hypoxia
    until proven otherwise
  • Drowsiness, lethargy hypercarbia until proven
    otherwise
  • When the fighting stops, a patient isnt always
    getting better

71
Assessment of Airway/Ventilatory Compromise
  • Focused Exam
  • Respiratory Patterns
  • Cheyne-Stokes diffuse cerebral cortex injury
  • Kussmaul acidosis
  • Biots (cluster) increased ICP pons, upper
    medulla injury
  • Central Neurogenic Hyperventilation increased
    ICP mid-brain injury
  • Agonal brain anoxia

72
Assessment of Airway/Ventilatory Compromise
  • Focused Exam
  • Neck
  • Trachea mid-line?
  • Jugular vein distension?
  • Subcutaneous emphysema?
  • Accessory muscle use?/hypertrophy?

73
Assessment of Airway/Ventilatory Compromise
  • Focused Exam
  • Chest
  • Barrel chest?
  • Deformity, discoloration, asymmetry?
  • Flail segment, paradoxical movement?
  • Adventitious breath sounds?
  • Third heart sound?
  • Subcutaneous emphysema?
  • Fremitus?
  • Dullness, hyperresonance to percussion?

74
Assessment of Airway/Ventilatory Compromise
  • Focused Exam
  • Extremities
  • Edema?
  • Nail bed color?
  • Clubbing?

75
Assessment of Airway/Ventilatory Compromise
  • Mechanical Ventilation
  • Increased resistance
  • Changing compliance

76
Assessment of Airway/Ventilatory Compromise
  • Pulsus Paradoxus
  • Systolic BP drops gt 10 mm Hg w/inspiration
  • May detect change in pulse quality
  • COPD, asthma, pericardial tamponade

77
Assessment of Airway/Ventilatory Compromise
  • History
  • Onset gradual or sudden?
  • What makes it worse, better?
  • How long?
  • Cough? Productive? Of what?
  • Pain? What kind?
  • Fever?

78
Assessment of Airway/Ventilatory Compromise
  • Past History
  • Hypertension, AMI, diabetes
  • Chronic cough, smoking, recurrent colds
  • Allergies, acute/seasonal SOB
  • Lower extremity trauma, recent surgery,
    immobilization
  • Interventions
  • Past admission? Ever admitted to ICU?
  • Medications? Frequency of prn medication use?
  • Ever intubated before?

79
BLS Airway/Ventilation Methods
  • Supplemental Oxygen
  • Increased FiO2 increases available oxygen
  • Objective Maximize hemoglobin saturation

80
Oxygen Equipment
  • Oxygen source
  • Compressed gas
  • Tank size
  • D 400L
  • E 660L
  • M 3450 L
  • Liquid oxygen

81
Oxygen Equipment
  • Regulators
  • High Pressure
  • Cylinder to cylinder
  • Low Pressure
  • Cylinder to patient
  • Humidifier

82
Delivery Devices
  • Nasal cannula
  • Simple face mask
  • Partial rebreather mask
  • Non-rebreather mask
  • Venturi mask
  • Small volume nebulizer

83
Nasal Cannula
  • Optimal delivery 40 at 6 LPM
  • Indication
  • Low FiO2
  • Long term therapy
  • Contraindications
  • Apnea
  • Mouth breathing
  • Need for High FiO2

84
Venturi Mask
  • Specific O2 Concentrations
  • 24
  • 28
  • 35
  • 40

85
Simple Face Mask
  • Range 40-60 at 10 LPM
  • Volumes greater that 10 LPM does not increase O2
    delivery
  • Indications
  • Moderate FiO2
  • Contraindications
  • Apnea
  • Need for High FiO2

86
Non-Rebreather Mask
  • Range 80-95 at 15 LPM
  • Indications
  • Delivery of high FiO2
  • Contraindications
  • Apnea
  • Poor respiratory effort

87
Partial Rebreather
  • Range 40 60
  • Indications
  • Moderate FiO2
  • Contraindications
  • Apnea
  • Need for High FiO2

88
BLS Airway/Ventilation Methods
  • Airway Maneuvers
  • Head-tilt/Chin-lift
  • Jaw thrust
  • Sellicks maneuver
  • Other Types
  • Tracheostomy with tube
  • Tracheostomy with stoma
  • Airway Devices
  • Oropharyngeal airway
  • Nasopharyngeal airway

89
BLS Airway/Ventilation Methods
  • Mouth-to-Mouth
  • Mouth-to-Nose
  • Mouth-to-Mask
  • One-person BVM
  • Two-person BVM
  • Three-person BVM
  • Flow-restricted, gas powered ventilator
  • Transport ventilator

90
BLS Airway/Ventilation Methods
  • Mouth to Mouth
  • Mouth to Nose
  • Mouth to Mask

91
BLS Airway/Ventilation Methods
  • One-Person BVM
  • Difficult to master
  • Mask seal often inadequate
  • May result in inadequate tidal volume
  • Gastric distention risk
  • Ventilate only until see chest rise

92
BLS Airway/Ventilation Methods
  • Two-person BVM
  • Most efficient method
  • Useful in C-spine injury
  • improved mask seal, tidal volume
  • Three-person BVM
  • Less utilized
  • Used when difficulty with mask seal
  • Crowded

93
BLS Airway/Ventilation Methods
  • Flow-restricted, gas-powered ventilator
  • Cardiac sphincter opens at 30 cm H2O
  • High volume/high concentration
  • Not recommended for children, poor pulmonary
    compliance, or poor tidal volume
  • Oxygen delivered on inspiratory effort
  • May cause barotrauma

94
BLS Airway/Ventilation Methods
  • Automatic transport ventilators
  • Not like real ventilator
  • Usually only controls volume, rate
  • Useful during prolonged ventilation times
  • Not useful in obstructed airway, increased airway
    resistance
  • Frees personnel
  • Cannot respond to changes in airway resistance,
    lung compliance

95
BLS Airway/Ventilation Methods
  • Pediatric considerations
  • Mask seal force may obstruct airway
  • Best if used with jaw thrust
  • BVM sizes neonate, infant450 ml
  • Children gt 8 y.o. require adult BVM
  • Just enough volume to see chest rise
  • Squeeze - Release - Release

96
BLS Airway/Ventilation Methods
  • Stoma patients
  • Expose stoma
  • Pocket mask
  • BVM
  • Seal around stoma site
  • Seal mouth, nose if air leak is evident

97
BLS Airway/Ventilation Methods
  • Airway obstruction techniques
  • Positioning
  • Finger sweep with caution
  • Suctioning
  • Oral airway/nasal airway (tongue)
  • Heimlich maneuver
  • Chest thrusts
  • Chest thrust/back blows for infants
  • Direct laryngoscopy

98
BLS Airway/Ventilation Methods
  • Suctioning
  • Manual or powered devices
  • Suction catheters
  • Rigid
  • Soft

99
BLS Airway/Ventilation Methods
  • Gastric Distention
  • Common when ventilating without intubation
  • Complications
  • Pressure on diaphragm
  • Resistance to BVM ventilation
  • Vomiting, aspiration
  • Increase BVM ventilation time
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