and welcome to chapter 11 airway management of the emergency care and transportation of the sick and injured 12th edition after you complete this chapter and the related coursework you will understand the need for proper airway management including recognizing and measuring adequate and inadequate breathing maintaining an open airway providing artificial ventilation students will be able to demonstrate basic competency in applying these concepts to appropriate care through the use of airway adjuncts suction equipment oxygen equipment and delivery systems pulse oximetry continuous positive airway pressure which is cpap and resuscitation devices okay so let's get started the single most important step in caring for any patient is to address life threats and the primary component of this step is to ensure that they are breathing adequately when the ability to breathe is disrupted oxygen delivery to tissues and cells is compromised and oxygen reaches body tissues and cells through two separate but related processes breathing and circulation so this figure on the slide illustrates the upper and lower airways of the human body and we're going to talk about the anatomy first of the respiratory system the respiratory system consists of all the structures that make up the airway and help us breathe or ventilate the airway is divided into that upper and lower airways so the anatomy of the upper airway the upper airway consists of all on atomic airway structures above the vocal cords okay so above the vocal cords so this is the nose mouth oral cavity the pharynx and the larynx the main function of this upper airway is to warm filter and humidify air as it enters the body okay so the first structure we're going to talk about is the pharynx and this is the muscular tube that extends from the nose and mouth to the level of the esophagus and trachea it's composed from top to bottom of the nasopharynx oral pharynx and the lowering geopharynx here's a a good cutaway picture of that fairness so the first one we're going to talk about inside the pharynx is the nasopharynx and it's lined with mucous membranes that filter out dust and particles it warms and humidifies air as it enters the body then there's the oropharynx that is posterior portion of the oral cavity the epiglottis and superior to the larynx helps prevent food and liquid from entering the layer next during swallowing here's another really good picture on the figure of the oral caffeine next we're going in the larynx so this is a complex structure formed by many independent structures made of cartilage it marks where the upper airway in the lower airway begins inside the larynx you have the thyroid cartilage which forms the v-shape it's also known as the adam's apple then you have the cricoid cartilage it's also called the cricoid ring it's the first ring of the trachea next is a cricoid thyroid membrane it's an elastic tissue that connects the thyroid and the cricoid inferiorly then you have the glottis you'll hear it called or term the glottic opening and is it is the area between the vocal cords it's the narrowest part of the adult airway next is the vocal cords and they are white bands of thin muscle tissue they are separated at rest and they produce speech and protect the trachea from the entry of substances like water and vomit then moving right along next we're going to go into the lower airway so from the upper into the lower divided by the larynx the function of the lower airway is to deliver oxygen to the alveoli and the elements of the lower airway so first you have the trachea and that is where air enters the air entry to the lungs it begins directly below the cricoid cartilage it descends anteriorly down the midline of the neck into the thoracic cavity so in the thoracic cavity the trachea divides in or at the corona into the two main stem bronchi which is the right and left and the bronchi are separated by cartilage they distribute oxygen to two lungs on entering the lungs each bronchus divides into ever smaller bronchi which divide into bronchiolis and here's a great uh slide it shows a figure of the trachea in the lungs in the lower airway you can see the trachea the alveoli the main bronchi going into smaller bronchi eye and then into bronchiolize okay from the bronchiolis are they are made of smooth muscle they dilate and constrict as oxygen passes through them so smaller bronchiolis connect to alveoli and at alveoli this is the site of oxygen and carbon dioxide exchange there's millions of thin walled balloon sacs and these alveoli are surrounded by blood vessels which are the pulmonary capillaries oxygen diffuses across the alveoli membrane into those pulmonary capillaries oxygen in the pulmonary capillaries is transported back to the heart and distributed to the rest of the body and carbon dioxide diffuses from the pulmonary capillaries into the alveoli where it is exhaled and removed from the body okay so the heart and the great vessels the vena cava and the aorta are known as the great vessels are also present in the thoracic cavity and are very important for respiration the mediastinum this is an area between the lungs and it contains the heart the great vessels the esophagus the trachea the major bronchi and many nerves okay so that's called the mediastinum the phrenic nerve is also found in the thorax this allows the diaphragm to contract which is necessary for breathing to occur so that's a very important nerve to remember and that is the phrenic nerve all right so let's talk about some physiology of breathing the respiratory and cardiovascular systems work together to ensure that there's a constant supply of oxygen and nutrients and it's delivered to all of the cells of the body it also removes carbon dioxide and waste products from the cell the table on the slide defines ventilation oxygenation and respiration okay that's what we're going to talk about next so the process involved in ventilation oxygenation and respiration first ventilation the that's the physical act of air into the and out of the lungs and it's necessary for oxygenation and respiration to occur the first process of ventilation is inhalation this is the active muscle part of breathing during inhalation the diaphragm and intercostal muscles contract they create a negative pressure in that thorax and it allows air to enter the body and travel to the lungs so ventilation is active the lungs require the movement of the chest and supporting structures to expand and contract during inhalation and exhalation partial pressure that's the amount of gas in the air or dissolved in fluid such as blood so partial pressure of oxygen in the alveoli is 104 millimeters of mercury partial pressure of carbon dioxide in the alveoli is 40 millimeters of mercury deoxygenated arterial blood from the heart has a partial pressure of oxygen that is lower than the partial pressure of carbon dioxide in the pulmonary capillaries the body attempts to equalize the partial pressures which results in oxygen diffusion across the membrane into the blood oxygen and carbon dioxide both diffuse until the partial pressures in the air and blood are equal the mechanism of ventilation can be illustrated by using a bell jar so inhalation and checks chest expansion autonomic you'll see on the left side the bell jar on the right side exhalation and chest contraction autonomic left side and bell jar right side okay so inspiration delivers oxygen to the alveoli not all inspired air reaches the alveoli for gas exchange tidal volume that is defined as a measure of depth of breathing tidal volume for an average adult is about 500 milliliters then there's dead space and that's the portion of inspired air that fails to reach the alveoli okay so next we're going to talk about exhalation we talked about inhalation and that is an active process exhalation however is a passive process and that means that it does not require muscular effort the diaphragm and the intercostal muscles relax which decreases the size of the thorax and the smaller thorax compresses the air in the lungs into a smaller space and when that happens the air pressure in the thorax is higher in the in that space than it is in the outside so air is pushed out through the trachea regulation of ventilation involves a complex series of receptors and feedback loops that sense gas concentrations in the body fluids and send messages to the respiratory center in the brain to adjust the rate and depth of ventilation the body's need for oxygen is constantly changing and failure to meet the need may result in hypoxia a condition in which the tissues and cells of the body cannot get enough oxygen so if this is not corrected patients may die quickly so let's talk about hypoxic drive now this hypoxic drive differs from the primary control of breathing in that it uses oxygen to control breathing typically it's seen in patients with end-stage copd and some believe that administering high levels of oxygen will increase the amount of oxygen dissolved in the plasma and negatively affect the body's drive to breathe oxygenation so let's talk about oxygenation next that's the process of loading oxygen molecules onto hemoglobin in the bloodstream it's uh it's required for internal respiration to take place oxygenation does not guarantee that internal respiration is taking place and so ventilation without oxygenation can occur in places where oxygen levels in the breathing air may dip be depleted such as mines or confined spacious or high altitudes and so i like to think of it like this you're breathing normally but you don't have the amount of oxygen in the environment and so you're not getting that oxygen delivery to into the bloodstream okay and then respiration and that's the actual exchange of oxygen and carbon dioxide in the alveoli and in the tissues of the body so cells take energy from nutrients through a series of chemical processes known as metabolism metabolism is cellular respiration each cell combines nutrients and oxygen which produces energy and waste products mainly water and carbon dioxide are the waste products all right so let's talk about external respiration and this is pulmonary respiration so this is the process of breathing fresh air into the respiratory system and exchanging carbon dioxide and oxygen between the alveoli and the blood in the pulmonary capillaries surfactant reduces surface tension within the alveoli and keeps the it keeps them expanded and it makes it easier for gas exchange to occur next we have internal respiration so we just talked about external now it's internal this is what's going on inside the body and so internal respiration that's the exchange of oxygen and carbon dioxide between the systemic circulatory system in the cells of the body so internally oxygen passes from the blood into the capillaries to the tissues carbon dioxide and cells cell waste pass from the cells into the capillaries where they are then transported via the venous system back to the lungs all cells need a constant supply of oxygen to survive and when there is inadequate oxygen cells convert glucose into energy through an aerobic metabolism without adequate oxygen anaerobic metabolism takes place which cannot meet the metabolic demands of the cell all right so let's talk about some patho pathophysiology of the respiratory system and there are factors of the nervous system which have input in in the respiratory system so you have these chemoreceptors and the chemoreceptors monitor levels of oxygen carbon dioxide hydrogen ions and the ph of this cerebral fluid and provide feedback constantly to the respiratory centers when serum carbon dioxide or hydrogen ions levels increase the chemoreceptors in the nervous system stimulate the medulla to increase the respiratory rate and so respiratory rate increases because carbon dioxide and hydrogen levels are increased so stimulation from the pons affects the rate and depth of respirations okay so the next factor that we have that affects the respiratory system is the ventilation and a perfusion ratio or mismatch so when ventilation and perfusion has to be directed at the same place at the same time and failure to match ventilation and perfusion is a cause of most abnormal abnormalities of oxygen and carbon dioxide exchange so this is when ventilation is compromised but perfusion continues so blood passes over of the some of the alveoli membranes without gas exchange taking place this results in lack of oxygen diffusing across that membrane and carbon dioxide is also not able to diffuse out therefore it recirculates in the bloodstream so when perfusion across the avalon membrane is disrupted exchange of gases is prevented so effect factors that affect pulmonary ventilation and so we discuss intrinsic factors and so what this is is intrinsic so this is the body the body affecting that airway obstruction and you could have infections or allergic reactions or how about unresponsiveness and this is when that tongue blocks the passage of the um of the gas exchange then you have extrinsic factors so extrinsic something outside the the body and these factors could be um to cause the airway obstruction you could have trauma that's an example um then you have factors that affect respiration so you actually have the the um the factors that are affecting it you could again have external factors and that could be not enough uh the atmosphere pressure or partial pressure of the oxygen in that environment so that's something like say we're in a cave or we're up in denver and then you can have internal factors and this is such as conditions that reduce the surface area for gas exchange and it decreases the body's oxygen supply and so this is going to lead to an adequate tissue perfusion so that could be something like pneumonia pulmonary edema or copd so the next factor that could affect the respiratory system is we have the circulatory compromise and so this is when there's an obstruction of blood flow to individual cells and tissues and it can cause it could be related to trauma so you could have a simple or tension pneumo and um open pneumo which is a sucking test wound a hemothorax or a hemo pneumothorax and talk a lot about those in the respiratory emergencies chapter other causes of circulatory compromise could you could have blood loss or anemia hypovolemic shock or vasodilatory shock okay so now we're going to talk about patient assessment of the respiratory system so patient assessment so wear a mask and protective eye wear that includes eye shields whenever airway management involves suctioning or air slicing generating procedures so that's you'll see it written as agp an aerosize generating procedure air slice generating procedures include cpr nebulizer treatments endotracheal innovation and continuous positive airway pressure next patient assessment wise one of the most important things is you need to recognize adequate breathing so signs of normal breathing for adults is 12 to 20 breaths a minute normal breathing you're going to have a regular pattern of inhalation and exhalation you're going to have bilateral so both sides clear and equal lung sounds you're going to have regular and equal chest rise and fall and it needs to be at an adequate depth this is also known as the tidal volume so abnormal breathing so signs of abnormal breathing it could be fewer than 12 breaths a minute more than 20 breaths a minute in the presence of shortness of breath and shortness of breath is also known as dipsnia you could have an irregular rhythm or diminished or absent or noisy auscultated breath sounds auscultated is when you're listening through stethoscope or listening to the breath sounds and reduce flow of expired air at the nose or mouth that could be a sign of abnormal breathing also unequal or inadequate expansion of the chest and this will result in reduced tidal volume so increase effort of breathing using accessory muscles and we'll talk about accessory muscles in a later chapter so the shallow depth that could reduce tidal volume as well and skin that is pale cyanotic cyanotic is blue cool or moist and moist you'll also hear it written as clammy skin and skin pulling in or around the ribs or above the clavicles during inspiration and that's also known as retractions a patient may appear to be breathing after the heart has stopped and so these occasional gasping breasts are called agonal gasps then you also have a pattern it's called cheyenne stokes respirations and they are often seen in patients with a stroke or head injury and this is because breathing with con this is an inc breathing with an increasing rate and depth of respirations followed by apnea a toxic respirations have an irregular or unidentifiable pattern and it may follow serious head injuries and then patients experiencing a metabolic or toxic disorder may display other abnormal respiratory patterns such as cushmal respirations and so couchsmall respirations those are deep rapid respirations and it's commonly seen in patients with metabolic acidosis so when the sugar is super high patients with inadequate breathing need to be treated immediately okay so how do we treat these inadequate breathing patients and so emergency medical care of it is we're going to do airway management supplemental oxygen and perhaps ventilatory support so assessment of respiration even though the patient may be ventilating appropriately the actual exchange of oxygen and carbon dioxide at the tissue level may still be compromised by several factors and so as we mentioned earlier it can be compromised by high altitudes poisonous gas gases such as carbon monoxide or enclosed spaces like perhaps cave um or some type of place where their oxygen is depleted at the patient's level of consciousness and skin color are excellent indicators of respirations when assessing patients consider proper oxygenation which can be assessed by a pulse ox so pulse oximetry and oxygen saturation spo2 is a measure of the percentage of hemoglobin molecules that are bound in arterial blood and so this seems pretty um pretty hard but all it is is the pulse ox it reads the reads the percentage of hemoglobin that is saturated and this sp02 should be greater than 94 when breathing room air in conditions such as a stroke or heart attack oxygen is applied when the spo2 is less than 94. pulse ox can take as long as 60 seconds to reflect changes in a patient's oxygen status the patient can develop respiratory insufficiency while well before the pulse ox values begin to decline so pulse ox is considered a routine vital sign and can be used as part of a patient assessment okay so end tidal co2 and that's the measurement of um of the maximal concentration of co2 at the end of an exhaled breath and a low co2 or carbon dioxide level could indicate hyperventilation or decrease co2 return to the lungs or reduce co2 produced at the cellular level a high co2 or high carbon dioxide level may indicate that the patient is retaining co2 and or apnea not breathing very well entitled co2 is measured using cabinometry and capnography devices so chemonometry refers to the use of a device that provides a digital metric reading of the end title carbon dioxide level encapnography produce provides both a numeric reading and a graph from breadth of breath so a normal range is from 35 to 45 millimeters mercury and this can be used in spontaneously breathing patients with an adequate airway using a special nasal cannula okay so next we're going to talk about very important step and that is opening the airway so emergency medical care begins with ensuring an open airway and rapidly assessing whether the unconscious patient has a patent airway and pulse and is breathing adequately so we need to position the patient in the supine position supine position unconscious patient should be moved as a unit because of the potential for a spinal injury into the supine position if they're not already in it and so in an unconscious patient the most common airway obstruction i cannot stress this enough is the patient's tongue and it's because it falls back into the throat when the muscles of the throat and tongue are relaxed so the most common area obstruction is the patient's tongue all right so opening this airway so you're going to open the airway with the head tilt chin lift maneuver and this will open the airway in most patients for patients who have not sustained or are not suspected of having any spinal cord trauma this simple maneuver is sometimes all that you need for the patient to resume breathing and so ten tilt chin lift maneuver is used when there is no spinal cervical spine injury suspected so what we're going to do is with the patient's supine you're going to position yourself beside the patient's head you're going to place the heel of one hand on the patient's forehead and apply firm backward pressure with the palm you're gonna place the fingertips of the other hand under the patient's jaw and lift the chin upward with the entire lower jaw helping to tilt the head back okay and so when there is spinal cord injury suspected we're going to use this method called the jaw thrust maneuver and the jaw thrust maneuver we're going to follow these steps so we're going to kneel above the patient's head we're going to place the fingers behind the angles of the lower jaw move the jaw upward using your thumbs and to help position the lower jaw and that is for the jaw thrust maneuver that is for cervical spine injury suspected okay so next we're going to talk about opening the mouth and even though you may have opened uh the airway with the head tilt chin lift or the jaw thrust maneuver the patient's mouth may still be closed and so to open the mouth we're going to place the tips of our index finger and thumb on the patient's teeth open the mouth by pushing your thumb on the lower teeth and the index finger on the upper teeth the pushing motion will cause the index finger and the thumb to cross over each other this is why it's called the cross finger technique so the photos on this slide it shows you how to perform that jaw thrust maneuver it shows you uh to kneel at the patient's head place your fingers behind the angles of the jaw move the jaw upward use your thumbs to help position the lower jaw and the completed maneuver should look like the second photo okay so next we're going to talk about suctioning and suctioning you must keep the airway clear to ventilate the patient properly if the airway is not clear you will just force fluids or secretions into the lungs and this is going to result in a thing called aspiration so if you hear gurgling the patient needs suctioning suctioning equipment so there's a couple different kinds there's the portable suction and this is a hand operated it could also be a fixed which that means mounted and equipment and so a portable suction unit must provide enough vacuum pressure and flow to allow you to suction the mouth and nose effectively so hand operated suction units with disposable chambers are reliable effective and relatively inexpensive a fixed suction unit should generate airflow of more than 40 liters per minute with a vacuum of more than 300 millimeters of mercury when the tubing is clamped so a portable or fixed unit should be fitted with the following it should have a wide bore thick walled non-kinking tubing plastic or rigid pharyngeal suction tips these are called tonsil tips and also you could hear them called yankar tips the best kind of catheter for infants and children and the large diameter plastic tips are rigid and they don't collapse non-rigid plastic catheters these are also called french or whistle tip catheters they are used to suction the nose and liquid secretions in the back of the mouth and in situations when you cannot use a rigid catheter the portable fixed unit should be non-breakable with a disposable collection bottle and the water supply you should also have water supply for rinsing the tips before inserting any catheter measure the proper size and we use the same technique for measuring for an oropharyngeal so techniques for suctioning is what we're going to talk about next and you want to inspect your suction equipment regularly the steps to operate the suction unit is you're going to check the unit for proper assembly of course of all its parts turn the section unit and test test to see that the vacuum pressure goes up to more than 300 millimeters of mercury select the attachment and appropriate suction catheter to the tubing never suction the mouth or nose for more than 15 seconds for an adult 10 seconds for a child or 5 seconds for an infant suctioning can result in hypoxia so we're also going to rinse the catheter and tubing with water to prevent clogging we're going to repeat suctioning only after the patients have been adequately ventilated or re-oxygenated and do not touch the back of the airway with the suction catheter it can result in activating the gag reflex and so to properly suction the patient we're going to take a look at skill drill 11-3 in your book sometimes a patient may have secretions or vomit that cannot be suctioned quickly and easily and some units cannot remove objects such as teeth foreign bodies and food when this is the case you need to remove the catheter from the patient's mouth immediately log roll them onto the side and clear the mouth with carefully with a glove finger if the patient who requires assisted ventilation produces frothy secretions as quickly as they you can suction them suction the airway for 15 seconds less of course and infants and children then ventilate for two minutes continue this alternating pattern of suctioning and ventilations until all the secretions have been cleared from the airway okay so we talked about suctioning next we're going to talk about airway adjuncts and so basic airway adjuncts prevent obstruction obstruction of the upper airway by the tongue and allows for passage of oxygen and oxygenation to the lungs so the oral pharyngeal airways you're going to hear this called an op airway this keeps the tongue from blocking the upper airway and it also makes it easier to suction the oral pharynx so an indication of the opas or oropharyngeal airway is you have to have an unresponsive patient without a gag reflex in an apnic patient being ventilated with a bvm so contraindications of course are conscious patients or any patients conscious or unconscious who have that gag reflex an oral airway that is too large it can push the tongue back to the pharynx and block the airway and an oral airway that is too small could block the airway directly like any foreign body obstruction so to insert the airway properly you will see the skill drill 11-14 in your book and if you encounter difficulty inserting the oral airway an alternative method is to use an insertion of a 90 degree rotation and uh we're going to take a look at that or you could take a look at that on skill drill in your book 11-5 and that's that 90 degree rotation okay so after the oral pharyngeal airway adjunct the next object we're going to talk about is the np and this is the nasopharyngeal airway and this is used with patients who have that intact category flex but is unable to mean his or her own airway spontaneously and so indications of the npa is a semi-conscious or unconscious patient with an intact gag reflex so these are the gag reflexes that are intact patients who otherwise will not tolerate an opa airway okay so contraindications of the opa or npa i apologize so the npa is a severe head injury with blood draining from the nose also a contraindication of the mpa is a fractured nasal bone a history of that so to insert the airway correctly we're going to see skill drill 11-6 in your book all right so the next step or the next thing we're going to talk about with maintaining the airway is this recovery position this recovery position is is very important it is used to help maintain an airway in an unconscious patient who is not injured and is breathing on his or her own with a normal respiratory rate in an adequate tidal volume so this is an unconscious patient who is not injured okay the recovery position the patient is rolled onto his or her left or right side okay so next we talked about airway adjuncts opening the airways a recovery position next we're going to talk about supplemental oxygen so always give supplemental oxygen to patients who are hypoxic and this is because not enough oxygen is being supplied to those tissues and cells of the body some tissues and organs such as the heart central nervous system lungs kidneys and liver they need a constant supply of oxygen to function normally so we're never going to withhold oxygen from any patient who might benefit from it especially if you must assist the ventilations so next we're going to talk about the supplemental oxygen equipment so this equipment first of all we're going to the first equipment we're going to talk about is the oxygen cylinders and so the oxygen that you will give the patients it's usually supplies in a compressed green gap compressed gas it's a green still or aluminum cylinders so what you want to do is you want to check the cylinder is labeled for medical oxygen so we're going to look at the letters and numbers stamped into the metal on the collar of the cylinder we want to check the month and year that's stamped and this indicates when the cylinder was tested so aluminum cylinders are tested every five years and composite cylinders are tested every three most often the d or jumbo d cylinder size is what we're going to use the length of time you can use the oxygen cylinder depends on the pressure in the cylinder and the flow rate liquid oxygen is becoming more commonly used alternative to compressed gas oxygen you'll see that in hospitals all right so when we talk about supplemental oxygen there are some safety considerations and so we want to handle those gas cylinders carefully because the containers are under pressure and we want to make sure that the correct pressure regulator is firmly attached before we transport the cylinder a puncture or hole in the tank can turn into a deadly missile so secure the cylinders with mounting brackets when they are stored in the ambulance oxygen cylinders that are used during transport should be positioned correctly and secured next on these oxygen cylinders there's this pin indexing system on the neck and so what that does is each of these cylinders they have their the pin indexing system is specific to the gas type that is inside the bottle and this is through a pattern or a given number of pins and it's following accepted national standards so this pin indexing system prevents say an oxygen regulator being accidentally connected to an incorrect gas cylinder so when preparing and to administer the oxygen check that the pin holes on the cylinder exactly match the corresponding pins on the regulator so for large cylinders the safety system is the american standard safety system oxygen cylinders are equipped with threaded gas outlet valves and inside and outside these thread sizes vary on the gas and cylinder and this prism presents accidental attachment of a regulator to the wrong cylinder all right so the next part of this oxygen that we're going to talk about the oxygen is the pressure regulators and so what a pressure regulator does is it reduces the cylinder pressure um to a useful range for the patient so it's usually between 40 to 70 pounds per square inch or psi after the pressure is reduced to a workable level the final attachment for delivering the gas is one of the following so the regulators are either a quick connect female fitting that will accept a quick connect male plug from the pressure hose or regulator or it's a flow meter that will permit the regulator release of gas measured in liters per minute okay so there's either a quick connect female or a flow meter so the next we're going to talk about those flow meters and what a flow meter does is it's usually permanently attached to the pressure regulator on that emergency equipment and so you have a pressure compensated flow meter and incorporates a float ball within the tapered calibrated tube and it's affected by gravity and it must be always be upright so you're going to see these on a fixed position usually in the hospitals or inside the ambulances fixed to the wall next um type of gauge you're going to have is that borgdon gauge flow meter and this is a gauge that's calibrated to record the flow rate and you could use this in any position so on on the bottle say when the bottle is placed in the bag that's that borgdon flow meter so procedures for operating and administering oxygen so you're going to place the oxygen cylinder into service and administer medical oxygen to the patient through the skill drill on 11-7 and there's also hazards of supplemental oxygen so hazards of supplemental oxygen include combustion so oxygen it doesn't burn or explode but it speeds up the combustion process and so we want to keep any possible source of fire away from an area while oxygen is in use especially cigarettes so make sure the area is adequately ventilated especially in industrial settings and never use an oxygen accelerator standing never leave it standing in the standing position all right so oxygen toxicity and this is not all patients require high flow oxygen excessive supplemental oxygen can be detrimental it can have the detrimental effect on patients with certain diseases or illnesses and this is a chronic obstructive pulmonary disease or cerebral vascular accidents or cvas and myocardial infarction so mis oxygen toxicity refers to damage of cellular tissue due to excessive oxygen levels in the blood increased cellular oxygen levels contribute to the production of oxygen free radicals and this can lead to tissue damage and cellular death in some patients the international liaison committee on resuscitation guidelines and this is published by the american heart association recognize that there may be negative effects of oxygen toxicity and recommends the oxygen be administered to patients experiencing signs of an mi or of a myocardial infarction when they have signs of heart failure are short of breath or the room oxygen saturation is less than 94 and so patients experiencing signs of shock should be placed on oxygen hypoxia is much worse than oxygen toxicity so when in doubt or if unable to measure oxygen saturation reliably supplemental oxygen should be administered when the pulse ox is available tailor oxygen therapy to the patient's needs and administer the amount of oxygen necessary to maintain oxygen saturation at or above 94 percent and so that's very important very important need to know thing okay and so the american heart association says that they recommend oxygen be administered i'm just gonna read it again because it's important two patients experiencing signs of an mi when they have signs of heart failure shortness of breath or their room air saturation is less than 94 all right so oxygen delivery equipment that's what we're going to talk about next and these are um in general oxygen delivery equipment is used in the field it should be limited to non-rebreathing masks bag valve devices and nasal cannulas the first one we're going to talk about is that a non-rebreather so a non-re-breather mask it combines a mask with a reservoir bag system so oxygen fills this reservoir attached to the mask by a one-way valve exhaled gas escapes through this flapper valve port at the cheek areas of the mask and it prevents the patient from rebreathing exhaled gases you want to make sure that the reservoir bag is full before you place it on the patient and adjust the flow rate so that the bag does not collapse when the patient exhales so usually between 10 to 15 liters if the bag does collapse increase the flow rate so when oxygen therapy is discontinued make sure you remove the mass from the patient's face uh and these are available in adult pediatric and infant sizes all right after the non-rebreather we're gonna now we're gonna talk about the nasal cannula and this can deliver oxygen through smooth two small tube-like prongs that fit into the patient's nostrils it can provide 24 to 44 percent inspired oxygen when the flow meter is set at six or one to six liters for patient comfort flow rates above six are not recommended and this is used when patients have mild hypoxia and a patient who breathes through the mouth or it has some type of nasal obstruction they won't get any benefit from this so some emo systems provide humidified oxygen during extended transports because humidified oxygen may be associated with an increased generation of air sliced droplets of fluid compatible with transmitting diseases so just know that humidified oxygen can be associated with increased air slice droplets then you have partial re-breathing mask and there these are similar to non-rebreathers except there's a one-way valve between the mask and the reservoir and the patients re-breathe a small amount of their exhaled air that's a partial rebreathing mask okay next we need to talk about venturi mask and this has a number of attachments and they can vary the percentage of oxygen when a constant flow rate is maintained from the regulator so a medium flow rate delivers about 24 to 40 percent it depends on the manufacturer and so that's a good picture of the venturi mask it's on figure 11-41 then you have a trach mask so the tracheostomy mask this is for patients with tracheostomies and they do not breathe through their mouth or nose and so um you could see a figure on 11-42 tracheostomy masks cover just the trach hole and have a strap that goes around the patient's neck and these may be available in emergency setting or they may not be so in in which case if they are not available you should improvise by placing a face mask over the stoma that was a picture of the placing the face mask over the stoma all right next we're going to talk about assisted or artificial ventilation so basic airway and ventilation techniques are extremely effective when we administer oxygen appropriately so when we have to the signs and symptoms of inadequate ventilation are altered mental status inadequate minute volume in excessive accessory muscle use and fatigue so when we see this we need to assist a patient with their ventilations and we do this with a bag valve mask and so what we're going to do is we're going to explain the procedure to the patient if they are conscious if they're conscious we're going to place the mask over the patient's mouth and nose and we're going to squeeze the bag each time the patient breathes maintaining the same rate as the patient this is if the patient is conscious and breathing after the initial five to ten breaths we are going to slowly adjust the rate and deliver the appropriate title volume we're going to adjust the rate and tidal volume to maintain an adequate minute volume so artificial ventilation so once we determine that the patient's not breathing we are going to begin artificial ventilation immediately and there are two methods so we're going to use the mouth to mass technique or the one or two person bag valve mass so normal ventilation versus positive pressure ventilation so artificial ventilations are necessary for life but they are not the same as normal breathing with normal breathing the diaphragm contracts and the negative pressure is generated in the chest cavity which sucks air into the chest but with positive pressure ventilation it's generated by a device and it forces air into that cavity with positive pressure ventilation what we're doing is we are increasing inner thoracic pressure and it causes compression of the vena cava so the vena cava and it could reduce blood return to the heart this produces uh reduces the amount of blood that's pumped by the heart so more volume is required to have the same effect as normal breathing and which pushes the air walls out of normal autonomic shape and so air is forced into the stomach it could cause gastric distension and could result in vomiting and aspiration so gastric distension is when you have air in the belly the emt must regulate the rate of volume and volume of artificial ventilations to prevent this drop in cardiac output and so when we want when we're doing the ventilation rates um for and this is for a person who is not breathing but still has a pulse okay so not breathing but has a pulse the adult rate is one breath every six seconds a child is one breath every two to three seconds and the infant is one breath every two to three seconds and so these these are ventilation rates for people or patients who are not breathing but they do have a pulse next we're going to talk about the mouth to mask or mouth to mask ventilation so a mouth to mouth or mouth mask so this is a barrier device and it's routinely used in mouth-to-mouth ventilations a mask with an oxygen inlet provides oxygen during a mouth to mass ventilation so that's those are two different devices and the most the one that we use is a bag valve mask and this provides less tidal volume than the mouth to mass ventilation but it delivers as much concentration of oxygen with the flow of 15 liters as the mask to face seal so bag mass devices the components of them are you have a disposable self-inflating mass no pop off valve or if one is present you should be able to disable it you have an inline a viral filter an outlet valve that is a true valve for re-breathing and you could also have an oxygen reservoir that allows for the delivery of high concentrated oxygen and that's the bag that you see in the back of this photo a one-way or no jam inlet valve system that provides an oxygen flow rate of the maximum of 15 liters with a standard of about 22 liters for face mask and endotracheal a transparent face mask and the ability to perform under extreme environmental conditions the valve the volume of air is based on observing the chest rise and fall and so the bag mass technique you're going to take a look at it so this is a two when you use the one person bvm technique it's on skill drill 11-8 in your book all right so gastric distension and gastric distension occurs when artificial ventilation fills the stomach with air it's most likely to occur when you ventilate the patient too forcefully or too rapidly with that bag mass device or the air is obstructed as a result of the foreign body or improper head position so give slow gentle breaths during your artificial ventilation and the breath should be over one second to prevent or eliminate this distension ensure that the patient's air is properly positioned so that patient's airway needs to be properly positioned so ventilate the patient at the appropriate rate and ventilate the patient at the appropriate volume if gastric distension makes it impossible to ventilate the patient with an advanced life support provider it is not available or if an advanced life support provider is not available to perform decompression administer or consider applying pressure over the upper abdomen this is the last resort if you um and so if vomiting occurs as a result turn the patient's entire body to the side you want to suction or wipe out the mouth with your gloved hand then return the patient to the supine position and continue the rescue breathing all right so passive ventilation passive ventilation this is sometimes called passive oxygenation or ethnic oxygenation and it's when the air movement into and out of the chest cavity occurs passively as a result of compressing the chest and so when the chest is compressed air is forced out of the thorax as the chest recoils following that compression the negative pressure is created within the chest which results in a vacuum so air is sucked into that cavity the chest cavity similar to what occurs with the muscle contraction during an active inhalation passive ventilation can be enhanced by inserting an op airway and providing supplemental oxygen all right so next we're going to talk about an automatic transport vent and it's you'll see it written atv or resuscitator so the atv is a ventilation device and it's attached to a control box and allows the variables of ventilation to be set it frees an emt to perform tasks such as maintaining the mass seal or ensuring continued airway patency so it's consists a constant reassessment of the patient is necessary right the next thing we're going to talk about is a continuous positive airway pressure and this is a cpap device you'll hear it as a cpap device it's a non-invasive vent support for patients who have respiratory distress so many people diagnosed with obstructive sleep apnea wear a cpap unit at night to maintain their airway while they sleep and cpap in pre-hospital environment has proven to be an excellent adjunct in the treatment of respiratory distress associated with copd acute pulmonary and acute bronchiospasm so cpap is becoming a widely used emt tool at the emt level so what it does is cpap just like it sounds it increases the pressure in the lungs it opens those collapse alveoli and pushes the oxygen across that alveolar membrane and forces interstitial fluid back into pulmonary circulation the therapy is typically delivered through a face mask held to the head with strapping system a good seal with minimal leakage between the face and the mask is essential many cpap systems use oxygen as the driving force to deliver the positive vent pressure to the patient and patients benefit the most from cpap during exhalation so use caution with patients with potentially low blood pressure because cpap causes a drop in the cardiac output all right so why you would use this and that's the indication why you would use the cpap devices so you have to the patient has to be alert and able to follow commands if they go unconscious you have to immediately remove it so the patient is displays obvious signs of moderate to severe respiratory distress from a condition such as pulmonary edema or copd respiratory distress occurs after the submersion incidence so the patient is breathing rapidly such such that the effects uh overall it affects the overall minute volume and the pulse ox reading is usually it has usually less than ninety percent all right contra indications country indications are when you should not use it so um if the patient's in respiratory arrest of course uh or agonal respirations if the patient is hypoventilating the patient cannot speak if the patient's unresponsive or otherwise unable to follow verbal commands you should not use it if the patient cannot protect his own airway and you should not use it if the patient is hypotensive you should not use it if they have any type of signs or symptoms like a pneumo thorax or chest trauma or of course if they have a tracheostomy you can't use it if they have active gastro bleeding gastrointestinal bleeding or vomiting patients if they have any facial trauma or if they're in cardiogenic shock you can't use it if the patient cannot set up right see you cannot use it if the cpap system it cannot or you cannot properly fit it to the patient and if the patient cannot tolerate a mask do not use cpap all right so cpap is uh fun to put on and uh the components of the unit are you'll have a generator to provide the pressure you're gonna have a mask of course you're gonna have the tubing that connects the two there should be a bacterial filter and also a one-way valve and so the cpap generator what happens is it creates resistance throughout the pulmonary cycle and or the respiratory cycle and the resistance creates a back pressure into the airways and that pushes open the smaller airway structures such as the bronchioles and the alveoli as the patient exhales the amount of pressure can be determined by adjusting the valve within the cpap system or a separate valve can be attached and so a pressure of 7 to 10 is generally an acceptable therapeutic range most cpap units are powered by oxygen so it's important you have to have a full cylinder when you're using the cpap and so to use cpap you could visit the skill drill on 11-9 so chapter 11-9 in your book complications of cpac so some patients may find cpap claustrophobic and resist the application of that mask and so when this happens you need to coach patients through the process rather than forcing the mask on them due to high volume of pressure generated by cpap there is also the risk of a pneumothorax and so a hole in the lung high pressure in the chest can lower the patient's blood pressure that's a complication and also if the patient shows signs of deterioration you need to remove that cpap and begin positive pressure ventilation using a bvm attached to high flow oxygen all right so the next thing we're going to talk about in this airway chapter is special consideration and so special consideration of the airways includes stomas and tracheostomy tubes and so with this the patients they have had a laryngectomy and they have a permanent tracheal stoma which is an opening in the neck that connects the trachea directly to the skin this is known as a tracheostomy if the patient has a tracheostomy tube we ventilate it through the tube with a bvm the standard 15 to 22 millimeter adapter on the bvm will fit onto the tube of a tracheal stoma we want to use 100 oxygen attached directly to the bvm if the patient has a stoma but no tube we can use an infant or a child mask with the bvm to make the seal over the stoma so seal the patient's mouth and nose with one hand to prevent the leak of air through the upper airway and ventilate through the stoma so release the seal of the patient's mouth and nose for exhalation this allows the air to exhale through the upper airway if you cannot ventilate a patient with a stoma try suctioning the stoma with a with the mouth of a french or soft-tipped catheter and seal the stoma while giving mouth-to-mouth ventilation all right so the next thing we're going to talk about with the airway is a special consideration is a foreign body airway obstruction so if an obstruction completely keyword is completely blocks the airway this is a true emergency it's going to result in death if not treated immediately in a child sudden foreign airway body obstruction usually occurs during a meal sorry in an adult in a child it can occur when eating in a child they could be playing with small toys or crawling around the house so uh varies in a child with the adult it's usually during the meal so by far as we mentioned earlier the most common airway obstruction in an unconscious patient is that tongue and that is because once again it relaxes back and falls into the back of the throat so causes other causes of airway obstruction that do not involve foreign bodies so this is not involving foreign bodies could be swelling from infection or allergic reactions acute such as anaphylaxis with these repeated attempts to clear the airway could be dangerous these patients they need specific emergency medical care and rapid transport to the hospital is crucial right okay and so another airway obstruction could be trauma and this could be related to tissue damage from that injury so you need to recognize this airway obstruction and so when you have a mild airway obstruction so there's different levels that we're going to talk about next mild airway obstruction this is when the patients can still exchange air but they have varying degrees of the respiratory distress so take great care to prevent this mild airway obstruction to becoming the severe airway obstruction so the patient may have noisy breathing they may be able to cough but with air exchange the patient can uh cough forcefully although you may hear wheezing between coughs wheezing between coughs that's the production of a whistling sound during respiration so as long as a patient can breathe cough forcefully or talk you should not interfere with the patient's efforts to try and expel that foreign body and so continually reassess the patient's condition so when you have this mild airway obstruction the key term the key thing is they're still able to exchange a lit some error and so what you want to be is the cheerleader and you just encourage them and continually reassess with poor air exchange the patient is weak and effective cough and may have increased difficulty breathing and this could be strider or cyanosis strider indicates that mild airway upper upper strider's upper treat immediately as if there is a severe airway obstruction and then of course the severe airway obstruction so this is a patient who cannot breathe or talk and with these patients you want to um they also might be clutching or grasping at their throat when they grasp out their throat that's that universal distress sign and they may also be turning cyanotic and they could have extreme difficulty breathing so there is a little or no airway movement with the severe upper obstructions and if the patient is found unresponsive does not appear to be breathing and does not have a pulse we want to begin cpr with high quality chest compressions when you open the airway and attempt the two ventilations following chest compressions it will be obvious if the airway is blocked so if there is no chest rise or fall after several attempts to ventilate or if you feel resistance when ventilating consider the possibility of that airway obstruction all right so next we're going to talk about the amer uh the emergency care for uh the foreign body airway obstruction so perform that head tilt chin lift maneuver to clear the tongue if spinal trauma of course we're going to use that jaw thrust maneuver so when large pieces of vomited food mucus dentures or blood is in the mouth sweep the mouse should be swept forward and out of the mouth with your glove finger so one available suction uh to maintain the airway all right so abdominal thrusts are the most effective method of dislodging and or forcing an object out of the airway of a conscious patient abdominal thrust or for conscious patients so what happens is residual air always present in the lungs is that you're compressing it upward to expel that object so we're using the abdominal thrust until the object dislodges or until the patient becomes unconscious and so what happens is abdominal thrust conscious patient now for the unconscious patient with the foreign airway obstruction we're going to reassess to confirm apnea and the inability to ventilate so when this patient is unresponsive we're going to begin chest compressions as we would for cpr following 30 compressions and then two breaths so at the completion of the 30 compressions pull the jaw open and look at the back of the oral pharynx to see if you could see any foreign objects if you see an object remove it with your glove finger or suction so never perform blind sweep to the back of the oropharynx because it could push the object further down the airway and it could make that obstruction worse so once the object is removed or if the object was seen attempt eventually if you are still unable to ventilate we're repeating the process of the 30 compressions to the two breasts all right so dental appliances and they could become a cause of airway obstructions so perhaps a crown or a bridge or some pieces of braces so we're going to manually remove the appliance before we provide ventilations leaving well fitting dentures in place makes bdm or bag valve mask easier so if it's well fitting we're going to leave it and this is because it provides a structure and it could help to provide a good face to mass seal if they're well fitting but loose dentures of course that interfere with the process should be removed if possible place to dislodge dentures in a container and transport them to the hospital with the patient all right so next another special consideration is facial bleeding and so airway problems can be particularly challenging in patients with this serious facial injuries the blood supply to the face is very rich so it results in severe tissue swelling and bleeding and this could be into the airway so you want to control bleeding with direct pressure and suction as necessary okay so now we're going to talk a little bit about assisting with a advanced life support procedures all right so when a critical patient needs an advanced airway intervention the paramedic will perform the skill but the emt is going to play an essential role in helping set up for the procedure and performing bls airway and ventilation maneuvers and helping monitor the patient so we're going to assist with the placement of this advanced airway okay so we're going to do the endotracheal innovation we're going to assist with that and the first step is pre-oxygenation which often includes bag valve mass ventilation and so we're going to when we're doing the bdm we're going to include an opr and np and ensure a proper seal ventilation rate a proper ventilation a volume of ventilation and allow for the time for the patient to exhale so bro next we're going to maintain a high flow nasal cannula on the patient during the pre-oxygenation phase and leave the nasal cannula in place during the innovation attempt this is called pre-oxygenation so for the equipment setup the personal protective equipment includes face mask and an eye shield we're going to have suction unit with rigid tonsil tip or non-rigid whistle tip catheters we need a laryngoscope handle and blade magnel forceps the et tube there is going to be a stylet or a tube introducer um so this is the the gum elastic bougie we need water soluble lubricant a 10 ml syringe confirmation device commercial et tube securing device we have to have alternate airway management devices such as a supraglottic or a craig kit available and then performing the procedure so remember six typical steps by using the b magic mnemonic okay so we want to the b magic so b is to perform the b bag valve mass preoxygenation e we're evaluating airway difficulties m we're going to manipulate the patient a is attempt the first pass innovation g is used as supraglottic airway if unable to innovate and c is to confirm success and the correct uh any issues so monitor the signs for a potential compensation so absence of end tidal absence of or decreasing spo2 or increasing resistance when we're ventilating so other physical signs of poor ventilation and perfusion and improper positioning or dislodgement of the et2 we're going to monitor for okay so this has concluded the airway management lecture next we're just going to go through some of the questions at the end of the review the review questions at the end of every chapter in the book okay so breathing is controlled by the area in the do you remember where that was controlled breathing is controlled by the pons and the medulla and they are the respiratory centers in the brain stem so b all right the emt should assess the patient's title volume by how are we assessing the tidal volume hey we're looking for that chest rise and fall and so we're um the volume of air that is moved in and out of the lungs in a single breath and we're looking for through the chest resin fall okay so in a healthy individual how are we breathing what's our stimulus and this is going to be increased levels of carbon dioxide in the blood okay so carbon dioxide is that waste product as that waste product increases in the blood it's going to stimulate the brain stem to change the breathing okay so it's c c under the control rising carbon dioxide levels are going to stimulate us to breathe all right number four signs of adequate breathing and an adult include all of the following except so accept all right so we know that the one on here that is not normal uh adequate breathing is going to be that shallow chest rise shallow chest rise all right during insertion of an op airway into an unconscious patient she begins to vomit what are we going to do in the very very very first thing very first thing that you want to do is whenever you begin the vomit you want to immediately turn the patient you would think that you would want to remove that op no we're going to remove we're going to turn that patient on to the side okay in which of the following patients would an np airway be contra indicated so this is when we're not going to use it so all right so probably i would think it would be a patient who fell 20 feet and landed on his or her head very good so severe head injuries or facial injuries we do not want to use them and this is because there could be some type of fracture we do not want to insert that np right into their brain okay so number seven you're delivering oxygen to a patient with a nasal cannula for leaders when he begins to complain of burning in the nose what should we do and this is because it's dry and over a prolonged period of time it could dry those mucous membranes and so humidified oxygen will be much better of course and so the correct answer is we could hook it up to humidified oxygen all right a patient's found unconscious after falling from the third floor window his respirations are slow and irregular what should we do okay it doesn't say anything about something in his uh airway so we don't need the suction we're not doing a non-rebreather we need to bag for them so we're gonna assist bagging this patient it says slow and irregular okay so d slow and irregular respirations we're going to back for them all right and so when ventilating an apnic adult with a bvm you should squeeze the bag and we know we're going to do the visible chest rise that's it we don't want a gastric distension all right so we're going to do ventilate the patient at a if 10 breaths per minute one every six seconds and we're only doing it until visible chest is noted chest rise all right and then finally number 10 you and your partner are ventilating an aptnic patient when you notice that the stomach is getting bigger and it's becoming distended what should we do okay we need to decrease the ventilation rate but use more volume nope increase the rate no we're going to reposition the head so you want to first reposition the head maybe perhaps and this could be because um the head is not in the correct positioning and air is just entering down into the esophagus so b was the correct answer we're going to reposition the head okay so this concludes the lecture for airway management thank you for listening and have a good day