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BASIC AIRWAY MANAGEMENT

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Describe the anatomy of the airway and the physiology of respiration. Explain the primary objective of ... moves and flexes as the patient swallows. NP AIRWAY ... – PowerPoint PPT presentation

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Title: BASIC AIRWAY MANAGEMENT


1
BASIC AIRWAY MANAGEMENT
2
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.

3
Basic AirwayObjectives
  • 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

4
Basic AirwayObjectives
  • 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

5
Basic AirwayObjectives
  • 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

6
Basic AirwayObjectives
  • Oropharyngeal and nasopharyngeal airway
  • Ventilating a patient by mouth-to-mouth,
    mouth-to-nose, mouth-to-mask, one/two/three
    person bag-valve mask, flow-restricted
    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

7
Basic AirwayObjectives
  • 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

8
Basic AirwayObjectives
  • Partial rebreather mask
  • Nonrebreather mask
  • Venturi mask
  • Describe the use, advantages, and disadvantages
    of an oxygen humidifier

9
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

10
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

11
ADMINISTRATION
  • Pin Index Safety System (PISS)
  • Prevents interchanging different gases and
    regulators
  • Delivery
  • 1. Demand Valve
  • Activated manually or by negative
  • pressure

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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

14
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

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

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

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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.

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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.

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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

32
OP AIRWAY
  • INDICATIONS
  • Remove the airway if patient regains a gag reflex
  • May be inserted as a bite block after successful
    intubation

33
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.

34
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.

35
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

36
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.

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NASOPHARYNGEAL AIRWAYNP 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.

41
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.

42
NP AIRWAY
  • Still requires manual airway maneuvers be
    maintained during its use.

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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

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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.

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

49
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.

50
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.

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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

53
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

54
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 C-Spine Injury may be
    maintained in a neutral in-line position during
    its insertion

55
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.

56
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

57
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

58
EOA/REMOVAL
  • Remove the tube at peak inhalation
  • Get ready to SUCTION

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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

61
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

62
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

63
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

64
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

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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

67
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

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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)

70
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

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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.

73
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.

74
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

75
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

76
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

77
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

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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

80
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.

81
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

82
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

83
LMA/WARNINGS
  • If the patient regains consciousness, you must
    remove it.

84
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.

85
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

86
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.

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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

91
SUCTIONINGGENERAL 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)

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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

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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

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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
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