Airway Management

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Chapter 15 Airway Management

National EMS Education Standard Competencies:

Airway Management, Respiration, and Artificial Ventilation Integrates complex knowledge of anatomy, physiology, and pathophysiology into the assessment to develop and implement a treatment plan with the goal of ensuring a patent airway, adequate mechanical ventilation, and respiration for patients of all ages. National EMS Education Standard Competencies

National EMS Education Standard Competencies:

National EMS Education Standard Competencies Airway Management Airway anatomy Airway assessment Techniques of ensuring a patent airway

National EMS Education Standard Competencies:

National EMS Education Standard Competencies Respiration Anatomy of the respiratory system Physiology and pathophysiology of respiration Pulmonary ventilation Oxygenation Respiration External Internal Cellular

National EMS Education Standard Competencies:

National EMS Education Standard Competencies Respiration Assessment and management of adequate and inadequate respiration Supplemental oxygen therapy

National EMS Education Standard Competencies:

National EMS Education Standard Competencies Artificial Ventilation Assessment and management of adequate and inadequate ventilation Artificial ventilation Minute ventilation Alveolar ventilation Effect of artificial ventilation on cardiac output

Introduction:

Introduction Establishing and maintaining a patent airway and ensuring effective oxygenation and ventilation are vital to patient care. The human body needs a constant supply of oxygen.

Introduction:

Introduction Respiratory system Brings in oxygen Eliminates carbon dioxide Vital organs will not function properly if process is interrupted.

Introduction:

Introduction Failure to manage the airway is a major cause of preventable death in the prehospital setting. Understand the importance of: Early detection of airway problems Rapid and effective intervention Continual reassessment

Introduction:

Introduction Appropriate airway management Open and maintain patent airway. Recognize, treat obstructions. Assess ventilation, oxygenation status. Administer oxygen. Provide ventilatory assistance.

Anatomy of the Upper Airway:

Anatomy of the Upper Airway Upper airway Airway structures above the vocal cords Tongue Must be manipulated Pharynx Extends from nose and mouth to esophagus and trachea Nasopharynx Oropharynx Laryngopharynx

Anatomy of the Upper Airway:

Anatomy of the Upper Airway © Jones & Bartlett Learning.

Larynx:

Larynx Marks where the upper airway ends and lower airway begins Thyroid cartilage Formed by two plates that form the laryngeal prominence (Adam ’ s apple)

Larynx:

Larynx © Jones & Bartlett Learning.

Larynx:

Larynx Cricoid cartilage (cricoid ring) First ring of the trachea Cricothyroid membrane Ligament between the thyroid and cricoid cartilage Site for emergency surgical and nonsurgical access to the airway (cricothyrotomy)

Glottis:

Glottis Space between the vocal cords © Jones & Bartlett Learning.

Trachea:

Trachea Immediately descends into the thoracic cavity Not a straight tube Key to understand when placing an ET tube

Ventilation, Oxygenation, and Respiration:

Ventilation, Oxygenation, and Respiration Respiratory and cardiovascular systems work together. Bring oxygen and nutrients to cells Remove waste

Ventilation:

Ventilation Physical act of moving air into and out of lungs Two phases Inhalation (active, muscular part of breathing) Exhalation (passive process) You must ensure adequate ventilation.

Oxygenation:

Oxygenation Process of loading oxygen molecules onto hemoglobin molecules in the bloodstream Requires adequate fraction of inspired oxygen (F io 2 )

Respiration:

Respiration Respiration: Process of exchanging oxygen and carbon dioxide External Exchange of O 2 and CO 2 between alveoli and blood in pulmonary capillaries Internal Exchange of O 2 and CO 2 between the systemic circulation and the cells

Pathophysiology of Respiration:

Pathophysiology of Respiration Disruption of pulmonary ventilation, oxygenation, and respiration causes immediate effects. Must recognize and correct immediately.

Pathophysiology of Respiration:

Pathophysiology of Respiration Every cell needs a constant supply of oxygen to survive. Perfusion: Circulation of blood in adequate amounts to meet cells ’ needs © Jones & Bartlett Learning.

Hypoxia:

Hypoxia Tissues and cells do not receive enough oxygen. Varying signs and symptoms Early signs: Restlessness, irritability, tachycardia, and anxiety Late signs: Mental status changes, a weak pulse, and cyanosis

Ventilation-Perfusion Ratio and Mismatch:

Ventilation-Perfusion Ratio and Mismatch Air and blood flow must be directed to the same place at the same time. Ventilation and perfusion must be matched. If not, V/Q mismatch results. Blood passes over alveolar membranes without gas exchange. Carbon dioxide is recirculated into bloodstream.

Factors Affecting Ventilation:

Factors Affecting Ventilation Patent airway is critical for the provision of oxygen to tissues. Intrinsic and extrinsic factors can cause an airway obstruction.

Factors Affecting Ventilation:

Factors Affecting Ventilation Intrinsic factors: Infection, allergic reactions, unresponsiveness The tongue is the most common obstruction in an unresponsive patient. Factors may not be directly part of the respiratory system.

Factors Affecting Ventilation:

Factors Affecting Ventilation Extrinsic factors: Trauma and foreign body airway obstruction Trauma requires immediate intervention. Blunt/penetrating trauma and burns can disrupt airflow into the lungs. Trauma to the chest wall can lead to inadequate pulmonary ventilation.

Factors Affecting Ventilation:

Factors Affecting Ventilation Hypoventilation Carbon dioxide production exceeds elimination. Hyperventilation Carbon dioxide elimination exceeds production.

External Factors Affecting Oxygenation and Respiration:

External Factors Affecting Oxygenation and Respiration Factors in ambient air High altitudes: Partial pressure decreases Closed environments: Oxygen decreases Toxic gases displace oxygen in the environment.

Internal Factors Affecting Oxygenation and Respiration:

Internal Factors Affecting Oxygenation and Respiration Conditions that reduce surface area for gas exchange also decrease oxygen supply. Nonfunctional alveoli inhibit diffusion. Fluid in the alveoli inhibits gas exchange. Submersion victims Patients with pulmonary edema Exposure to environmental conditions or occupational hazards

Internal Factors Affecting Oxygenation and Respiration:

Internal Factors Affecting Oxygenation and Respiration Hypoglycemia Oxygen and glucose levels decrease . Infection Increases metabolic needs Disrupts homeostasis Hormonal imbalances May result in ketoacidosis

Circulatory Compromise:

Circulatory Compromise Inadequate perfusion Oxygen demands will not be met. Obstruction of blood flow is typically related to trauma. Inhibits gas exchange at the tissue level

Circulatory Compromise:

Circulatory Compromise Heart conditions reduce blood flow to tissues. Blood loss and anemia reduce the blood ’ s oxygen-carrying ability. Shock: Oxygen is not delivered efficiently. Poor tissue perfusion; anaerobic metabolism

Acid-Base Balance:

Acid-Base Balance Can be disrupted by Hypoventilation Hyperventilation Hypoxia May rapidly lead to deterioration and death

Acid-Base Balance:

Acid-Base Balance Respiratory and renal systems help maintain homeostasis. Tendency toward stability in the body Requires balance between acids and bases Acid in the body can be expelled as carbon dioxide from the lungs.

Acid-Base Balance:

Acid-Base Balance Acidosis can develop if respiratory function is inhibited. Alkalosis can develop if the respiratory rate is too high. Respiratory acidosis/alkalosis Metabolic acidosis/alkalosis

Patient Assessment: Airway Evaluation:

Patient Assessment: Airway Evaluation Quality of care depends on assessment. Assessing the airway F irst determine if patient’s airway is patent. Snoring Vomitus draining from the mouth Gurgling sound heard during breathing Secretions pooling in patient’s mouth indicate depressed or absent gag reflex.

Patient Assessment: Airway Evaluation:

Patient Assessment: Airway Evaluation Adequate breathing Patient is responsive, alert, able to speak. Rate between 12 and 20 breaths/min Adequate depth Regular pattern of inhalation and exhalation Clear and equal breath sounds

Recognizing Inadequate Breathing:

Recognizing Inadequate Breathing Breathing rate of less than 12 breaths/min or more than 20 breaths/min Cyanosis: Indicator of low blood oxygen Preferential positioning Upright sniffing (tripod) position Semi-Fowler (semi-sitting) position

Recognizing Inadequate Breathing:

Recognizing Inadequate Breathing Potential causes: Severe infection Trauma Brainstem insult Noxious or oxygen-poor environment Renal failure Upper and/or lower airway obstruction Respiratory muscle impairment Central nervous system impairment

Recognizing Inadequate Breathing:

Recognizing Inadequate Breathing Airway management steps Open the airway. Clear the airway. Assess breathing. Provide appropriate intervention(s). Evaluation includes: Observation Palpation Auscultation

Inadequate Breathing:

Inadequate Breathing Note the following: Position Orthopnea Chest rise/fall Skin Flared nostrils Pursed lips Retractions Use of accessory muscles Asymmetric chest wall movement Quick breaths, long exhalation Labored breathing

Inadequate Breathing:

Inadequate Breathing Signs Fewer than 12 or more than 20 breaths/min plus dyspnea Irregular rhythm Diminished, absent, or noisy sounds Abdominal breathing Reduced flow Unequal chest expansion Increased effort Shallow breathing Pale, clammy skin Retractions Staccato speech

Inadequate Breathing:

Inadequate Breathing Feel for air movement. Observe chest for symmetry. Note any paradoxical motion. Assess for pulsus paradoxus. Systolic blood pressure drops more than 10 mm Hg during inhalation.

Inadequate Breathing:

Inadequate Breathing Ask about evolution of current problem. Onset, trigger, duration Other symptoms Interventions, previous hospitalization Medications and overall compliance Risk factors

Inadequate Breathing:

Inadequate Breathing Evaluate protective reflexes. Coughing, sneezing, gagging Gag reflex (eyelash reflex) Sighing Hiccupping

Inadequate Breathing:

Inadequate Breathing © Jones & Bartlett Learning.

Assessment of Breath Sounds:

Assessment of Breath Sounds Auscultate breath sounds with stethoscope. Should be clear and equal © Jones & Bartlett Learning.

Assessment of Breath Sounds:

Assessment of Breath Sounds © Jones & Bartlett Learning.

Assessment of Breath Sounds:

Assessment of Breath Sounds Duration: Length of time for inspiratory and expiratory phases Normal I/E ratio is 1:2. Expiration is prolonged with lower airway obstruction. Expiration is short with tachypneic patients.

Assessment of Breath Sounds:

Assessment of Breath Sounds Pitch: Higher or lower than normal (stridor or wheezing) Intensity of sound depends on: Airflow rate Constancy of flow throughout inspiration Patient position Site selected for auscultation

Abnormal Breath Sounds:

Abnormal Breath Sounds Wheezing Continuous, high-pitched Rhonchi Continuous, low-pitched Crackles Discontinuous Stridor Loud, high-pitched, heard during inspiration Pleural friction rub Surfaces of visceral and parietal pleura rub together .

Pulse Oximetry:

Pulse Oximetry Pulse oximeter: Measures oxygen saturation of hemoglobin (Hb) Normal: Sp o 2 of greater than 95% © Jones & Bartlett Learning. © Jones & Bartlett Learning.

Pulse Oximetry:

Pulse Oximetry Used for: Monitoring oxygenation status during intubation attempt or suctioning Identifying deterioration in a patient with trauma or cardiac disease Identifying high-risk patients Assessing vascular status in orthopaedic trauma

Pulse Oximetry:

Pulse Oximetry Erroneous readings may result from: Bright ambient light Patient motion Poor perfusion Nail polish Venous pulsations Abnormal hemoglobin

Pulse Oximetry:

Pulse Oximetry Types of hemoglobin Oxyhemoglobin (Hb o 2 ) Reduced hemoglobin CO-oximeter Determines Hb o 2 saturation (percentage of oxygenated Hb compared with total hemoglobin) The Masimo ® Rad-ST™ Pulse CO-Oximeter™ courtesy of Masimo Corporation (www.masimo.com ).

Peak Expiratory Flow:

Peak Expiratory Flow Measured to evaluate bronchoconstriction Increasing: Patient is responding to treatment. Decreasing: Patient ’ s condition is deteriorating. Perform three times and take the best rate. © Jones & Bartlett Learning.

Arterial Blood Gas Analysis:

Arterial Blood Gas Analysis Blood is analyzed for pH, Pa o 2 , H c o 3 − , base excess, and Sa o 2 . pH, H co 3 − evaluate acid-base status. Pa co 2 indicates effectiveness of ventilation. Pa o 2 and Sa o 2 indicate oxygenation. Table 15-5

End-tidal Carbon Dioxide (etco2) Assessment:

End- t idal Carbon Dioxide ( etco 2 ) Assessment Detects carbon dioxide in exhaled air Adjunct for determining ventilation adequacy Confirms advanced airway placement etco 2 detector types: Colorimetric Digital Digital/waveform

End-tidal Carbon Dioxide (etco2) Assessment:

End-tidal Carbon Dioxide ( etco 2 ) Assessment Colorimetric capnographer Reading after 6 to 8 positive pressure breaths Replace with quantitative device as soon as possible. Courtesy of Marianne Gausche -Hill, MD, FACEP, FAAP.

End-tidal Carbon Dioxide (etco2) Assessment:

End-tidal Carbon Dioxide ( etco 2 ) Assessment Capnometer Numeric reading of exhaled CO 2 Capnographer Graphic representation of exhaled CO 2 Types: Waveform Digital/waveform © Smiths Medical.

End-tidal Carbon Dioxide (etco2) Assessment:

End-tidal Carbon Dioxide ( etco 2 ) Assessment Waveform capnography Provides real-time CO 2 information Displays a graphic waveform Quantitative waveform capnography Recommended for monitoring initial and ongoing placement of an advanced airway device

End-tidal Carbon Dioxide (etco2) Assessment:

End-tidal Carbon Dioxide ( etco 2 ) Assessment Capnography can indicate chest compression effectiveness and detect return of spontaneous circulation. Key features of normal capnographic waveform: Contour Baseline level Rate and rise of the carbon dioxide level

End-tidal Carbon Dioxide (etco2) Assessment:

End-tidal Carbon Dioxide ( etco 2 ) Assessment © 2017 Medtronic. All rights reserved. Used with the permission of Medtronic. © 2017 Medtronic. All rights reserved. Used with the permission of Medtronic.

End-tidal Carbon Dioxide (etco2) Assessment:

End-tidal Carbon Dioxide ( etco 2 ) Assessment Waveform capnography (cont ’ d) Phase I (A-B): Initial stage of exhalation Phase II (B-C): Expiratory upslope Phase III (C-D): Expiratory or alveolar plateau Phase IV (D-E): Inspiratory downstroke © Jones & Bartlett Learning.

End-tidal Carbon Dioxide (etco2) Assessment:

End-tidal Carbon Dioxide ( etco 2 ) Assessment Abnormal capnographic waveforms Hypoventilation Tall waveforms and high etco 2 value Hyperventilation Small waveforms and low etco 2 value Uses of waveform capnography in nonintubated patient: Assess pathologic process that causes pulmonary air trapping Gauge effectiveness of treatment

End-tidal Carbon Dioxide (etco2) Assessment:

End-tidal Carbon Dioxide ( etco 2 ) Assessment © Jones & Bartlett Learning. © Jones & Bartlett Learning. © Jones & Bartlett Learning. © Jones & Bartlett Learning. A. B. C. D.

End-tidal Carbon Dioxide (etco2) Assessment:

End-tidal Carbon Dioxide ( etco 2 ) Assessment Abnormal capnographic waveforms I nadvertent extubation Tubing obstruction © Jones & Bartlett Learning.

End-tidal Carbon Dioxide (etco2) Assessment:

End-tidal Carbon Dioxide ( etco 2 ) Assessment

Airway Management:

Airway Management Air reaches the lungs only through the trachea. In a compromised airway, clearing the airway and maintaining patency are vital. © Jones & Bartlett Learning.

Positioning the Patient:

Positioning the Patient Move unresponsive patients found in a prone position to a supine position. Log roll and assess for breathing. If the patient is breathing adequately and is not injured, move to recovery position. © Jones & Bartlett Learning. Courtesy of MIEMSS.

Manual Airway Maneuvers:

Manual Airway Maneuvers If an unresponsive patient has a pulse but is not breathing, you must open the airway. Maneuver patient ’ s head to propel the tongue forward and open the airway. © Jones & Bartlett Learning.

Head Tilt–Chin Lift Maneuver:

Head Tilt – Chin Lift Maneuver Indications: Unresponsive No spinal injury Unable to protect airway Contraindications: Responsive Possible spinal injury © Jones & Bartlett Learning.

Head Tilt–Chin Lift Maneuver:

Head Tilt – Chin Lift Maneuver Advantages No equipment Noninvasive Disadvantages Hazardous to spinal injury No protection from aspiration

Head Tilt–Chin Lift Maneuver:

Head Tilt – Chin Lift Maneuver Technique With palm, apply firm backward pressure on patient’s forehead to tilt head back. Place fingertips of other hand under the lower jaw near bony part of chin . Lift chin upward, bringing the entire lower jaw with it, helping to tilt the head back. Lift so teeth are nearly brought together, but avoid closing the mouth completely .

Jaw-Thrust Maneuver:

Jaw-Thrust Maneuver Indications Unresponsive Possible spine injury Unable to protect airway © Jones & Bartlett Learning.

Jaw-Thrust Maneuver:

Jaw-Thrust Maneuver Contraindications Resistance to opening the mouth Advantages Used with spine injury or cervical collar No special equipment required

Jaw-Thrust Maneuver:

Jaw-Thrust Maneuver Disadvantages Cannot maintain if patient becomes responsive or combative Difficult to maintain for an extended time Difficult to use with bag-mask ventilation Thumb must remain in place. Requires second rescuer No protection against aspiration

Jaw-Thrust Maneuver:

Jaw-Thrust Maneuver Technique Place meaty portion of base of your thumbs on the zygomatic arches, and hook the tips of your index fingers under mandible , in the indentation below each ear. Holding patient’s head in a neutral in-line posi­tion, displace the jaw upward and open patient’s mouth with tips of your thumbs .

Tongue-Jaw Lift Maneuver:

Tongue-Jaw Lift Maneuver Used more commonly to open airway for: Suctioning Inserting an oropharyngeal airway Cannot be used to ventilate a patient Does not allow for an adequate mask seal © Jones & Bartlett Learning.

Tongue-Jaw Lift Maneuver:

Tongue-Jaw Lift Maneuver Technique Place hand closest to patient’s head on forehead. With other hand, reach into patient’s mouth and hook first knuckle under the incisors or gum line. While holding patient’s head and maintaining hand on the forehead, lift the jaw straight up.

Suctioning:

Suctioning Removes material from the mouth or throat quickly and efficiently Ventilating with secretions in the mouth will result in upper airway obstruction or aspiration. Next priority after opening airway manually

Suctioning Equipment:

Suctioning Equipment Fixed or portable Hand-operated suctioning units with disposable canisters Mechanical or vacuum-powered suction units © Jones & Bartlett Learning. © Jones & Bartlett Learning. Courtesy of MIEMSS © Jones & Bartlett Learning. Courtesy of MIEMSS

Suctioning Equipment:

Suctioning Equipment

Suctioning Equipment:

Suctioning Equipment The following should be readily accessible: Wide-bore, thick-walled, nonkinking tubing Soft and rigid suction catheters Nonbreakable, disposable collection bottle Supply of water for rinsing the catheters

Suctioning Equipment:

Suctioning Equipment Yankauer catheter Use with adults (pharynx), infants, children. Whistle-tip catheter Can be placed in ET tube Use for nose, back of mouth, when a rigid catheter cannot be used. © Jones & Bartlett Learning. © Jones & Bartlett Learning.

Suctioning Techniques:

Suctioning Techniques Suctioning removes oxygen. Preoxygenate before suctioning. Maximum suctioning time Adult: 15 seconds Child: 10 seconds Infant: 5 seconds

Suctioning Techniques:

Suctioning Techniques Do not stimulate back of throat. After suctioning, continue ventilation and oxygenation. Soft-tip catheters Must lubricate when suctioning the nasopharynx Best when passed through an ET tube Suction during extraction of catheter.

Suctioning Techniques:

Suctioning Techniques Before inserting, measure for proper size. Corner of the mouth to the earlobe Never insert a catheter past the base of the tongue. © Jones & Bartlett Learning. Courtesy of MIEMSS. © Jones & Bartlett Learning. Courtesy of MIEMSS.

Suctioning Techniques:

Suctioning Techniques Technique Measure catheter from corner of mouth to earlobe. Before applying suction, turn patient’s head to the side, open patient’s mouth, and insert tip of catheter to predetermined depth. Do not suction while inserting the catheter. Apply suction in circular motion as you withdraw catheter. Repeat as needed.

Airway Adjuncts:

Airway Adjuncts May be needed to help maintain patency in an unresponsive patient after manually opening and suctioning Not a substitute for proper head positioning

Oropharyngeal (Oral) Airway:

Oropharyngeal (Oral) Airway Curved, hard plastic device Fits over back of the tongue Should be inserted in unresponsive patients who have no gag reflex © Jones & Bartlett Learning.

Oropharyngeal (Oral) Airway:

Oropharyngeal (Oral) Airway © Jones & Bartlett Learning. © Jones & Bartlett Learning. © Jones & Bartlett Learning. © Jones & Bartlett Learning. © Jones & Bartlett Learning.

Oropharyngeal (Oral) Airway:

Oropharyngeal (Oral) Airway Indications Unresponsive patients who have no gag reflex Contraindications Responsive patients Patients with a gag reflex Advantages Noninvasive and easily placed Prevents blockage by the tongue Disadvantages No prevention of aspiration

Oropharyngeal (Oral) Airway:

Oropharyngeal (Oral) Airway Technique Select correct size of oral airway. Insert in one of two ways: Open patient’s mouth, hold airway upside down with other hand, and insert the airway with tip facing hard palate. Advance the oral airway until it reaches the soft palate and then rotate it 180º, until flange rests on patient’s lips .

Oropharyngeal (Oral) Airway:

Oropharyngeal (Oral) Airway Insert in one of two ways (cont.): Use a tongue blade to depress tongue , ensuring tongue remains forward. Insert oral airway, with tip pointing down, and follow curvature of tongue until flange rests on the patient’s lips.

Nasopharyngeal (Nasal) Airway:

Nasopharyngeal (Nasal) Airway Soft, rubber tube inserted through nose Better tolerated Do not use with trauma to the nose or skull fracture. Lubricate the airway and insert gently. © Jones & Bartlett Learning.

Nasopharyngeal (Nasal) Airway:

Nasopharyngeal (Nasal) Airway Indications Unresponsive Altered mental status with an intact gag reflex Contraindications Patient intolerance Facial fracture or skull fracture Advantages Suctioned through Patent airway Tolerated by responsive patients Can be placed “b lindly” No requirement for the mouth to be open

Nasopharyngeal (Nasal) Airway:

Nasopharyngeal (Nasal) Airway Disadvantages Improper technique may result in severe bleeding. Does not protect from aspiration

Nasopharyngeal (Nasal) Airway:

Nasopharyngeal (Nasal) Airway Technique Measure distance from tip of nostril to earlobe or angle of jaw. Insert prelubricated airway into larger nostril, with bevel facing the septum, until flange rests on patient’s nostril.

Nasopharyngeal (Nasal) Airway:

Nasopharyngeal (Nasal) Airway © Jones & Bartlett Learning. © Jones & Bartlett Learning.

Causes of Airway Obstruction:

Causes of Airway Obstruction Foreign body Tongue Laryngeal edema Laryngeal spasm Trauma Aspiration Infection or severe allergic reaction

Causes of Airway Obstruction:

Causes of Airway Obstruction Tongue With altered LOC, tongue can fall backward, closing off the airway. Partial obstruction: Snoring respirations Complete obstruction: No respirations Simple to correct with manual maneuver

Causes of Airway Obstruction:

Causes of Airway Obstruction Foreign body Typical victim: Middle-aged or older, dentures, alcohol Signs may include: Choking Gagging Stridor Dyspnea Aphonia or dysphonia

Laryngeal Spasm and Edema:

Laryngeal Spasm and Edema Laryngeal spasm Spasmodic closure of vocal cords Completely occludes airway Causes include: Intubation trauma Extubation Laryngeal edema Glottic opening narrows or totally closes Causes include: Epiglottitis Anaphylaxis Inhalation injury

Laryngeal Spasm and Edema:

Laryngeal Spasm and Edema May be relieved by: Aggressive ventilation Forceful upward jaw pull May be relieved by muscle relaxants May recur; transport patient to hospital for evaluation

Laryngeal Injury:

Laryngeal Injury Fracture of the larynx increases airway resistance by decreasing airway size. Penetrating and crush injuries to the larynx can compromise the airway.

Aspiration:

Aspiration Increases mortality Can obstruct the airway Destroys bronchiolar tissue Introduces pathogens into the lungs Decreases patient ’ s ability to ventilate Have suction readily available

Recognition of an Airway Obstruction:

Recognition of an Airway Obstruction Mild obstruction Patient is responsive, able to exchange air. Usually has noisy respirations and coughing Should be left alone Closely monitor the patient ’ s condition. Be prepared to intervene.

Recognition of an Airway Obstruction:

Recognition of an Airway Obstruction Severe obstruction Inability to breathe, talk, or cough May grasp at throat, turn cyanotic, make frantic movements Cough is weak, ineffective, or absent. Weak inspiratory stridor and cyanosis

Emergency Medical Care for Foreign Body Airway Obstruction:

Emergency Medical Care for Foreign Body Airway Obstruction Begin treatment immediately if choking is confirmed by a responsive patient. If large pieces of foreign body are found, sweep them out of the mouth with your finger. Insert your finger along the inside of the cheek and into the throat. Try to hook the foreign body to dislodge it. Suction as needed.

Emergency Medical Care for Foreign Body Airway Obstruction:

Emergency Medical Care for Foreign Body Airway Obstruction Abdominal thrust (Heimlich) maneuver Creates an artificial cough, expelling the object Perform until the object is expelled or the patient becomes unresponsive.

Emergency Medical Care for Foreign Body Airway Obstruction:

Emergency Medical Care for Foreign Body Airway Obstruction If patient becomes unresponsive, position supine, begin chest compressions. 30 chest compressions 15 with two rescuers or infant/child Open airway, remove any visible object. Attempt rescue breath, look for chest rise

Emergency Medical Care for Foreign Body Airway Obstruction:

Emergency Medical Care for Foreign Body Airway Obstruction If techniques do not work, proceed with direct laryngoscopy. If you see the foreign body, remove it with Magill forceps. © Jones & Bartlett Learning.

Supplemental Oxygen Therapy:

Supplemental Oxygen Therapy Administer to any patient with potential hypoxia. Indications Respiratory distress Suspected or documented hypoxemia Oxygen-delivery method Appropriate for the patient’s ventilatory status Reassess frequently. Adjust based on clinical condition and breathing adequacy.

Oxygen Sources:

Oxygen Sources Oxygen cylinders Stores pure oxygen Check label and test date. Various sizes Oxygen delivery is measured in L/min. © Jones & Bartlett Learning.

Oxygen Sources:

Oxygen Sources Oxygen cylinders (cont ’ d) Replace cylinder when pressure falls to 200 psi or lower. Using the pressure and flow rate, you can calculate how long the supply will last.

Safety Reminders:

Safety Reminders Keep combustible materials away. No smoking Store in a cool, ventilated area. Use only with a properly fitting regulator valve. Close all valves when not in use. Secure cylinders. Position yourself to the cylinder ’ s side. Have the cylinder hydrostat tested every 10 years.

Oxygen Regulators and Flowmeters:

Oxygen Regulators and Flowmeters High-pressure regulators deliver gas under high pressure. Pressure is approximately 2,000 psi. Therapy regulator controls flow to patient. Reduces to 50 psi

Oxygen Regulators and Flowmeters:

Oxygen Regulators and Flowmeters Flowmeters allow oxygen to be adjusted. Pressure-compensated flowmeter Bourdon-gauge flowmeter © American Academy of Orthopaedic Surgeons. © Jones & Bartlett Learning.

Preparing an Oxygen Cylinder for Use:

Preparing an Oxygen Cylinder for Use Before administering oxygen, prepare cylinder and therapy regulator. Procedure Inspect cylinder then “crack”. Attach regulator/flowmeter to valve stem. Place regulator collar. Open cylinder and read pressure on regulator gauge. Select flow rate.

Preparing an Oxygen Cylinder for Use:

Preparing an Oxygen Cylinder for Use © Jones & Bartlett Learning. © Jones & Bartlett Learning.

Nonrebreathing Mask:

Nonrebreathing Mask Preferred in prehospital setting 90% to 100% oxygen Mask, reservoir bag Indications Spontaneously breathing patients Contraindications Apnea and poor respiratory effort © Jones & Bartlett Learning. Courtesy of MIEMSS.

Nasal Cannula:

Nasal Cannula Two small prongs 24% to 44% oxygen Best for patients who need long-term therapy Ineffective with: Apnea Poor respiratory effort Severe hypoxia Mouth breathing © Jones & Bartlett Learning. Courtesy of MIEMSS.

Oxygen Delivery Devices:

Oxygen Delivery Devices

Partial Rebreathing Mask:

Partial Rebreathing Mask Lacks one-way valve Residual exhaled air is rebreathed Flow rates of 6 to 10 L/min 35% to 60% oxygen © Jones & Bartlett Learning. Courtesy of MIEMSS.

Venturi Mask:

Venturi Mask Draws room air into the mask along with oxygen Can deliver 24%, 28%, 35%, or 40% oxygen © Jones & Bartlett Learning. Courtesy of MIEMSS.

Tracheostomy Masks:

Tracheostomy Masks Cover the stoma and have a strap that goes around the neck To improvise, place a face mask over the stoma. © Jones & Bartlett Learning.

Oxygen Humidifier:

Oxygen Humidifier Bottle of sterile water moisturizes oxygen Keep upright; only practical with fixed unit on ambulance. Can be source of infection © Jones & Bartlett Learning.

Ventilatory Support:

Ventilatory Support Patient who is not breathing needs artificial ventilation and 100% supplemental oxygen. Indications include signs of: Altered mental status Inadequate minute volume

Normal Ventilation Versus Positive Pressure Ventilation:

Normal Ventilation Versus Positive Pressure Ventilation Normal ventilation Diaphragm contracts. Negative pressure in chest cavity draws in air. Positive pressure ventilation Generated by a device Forces air into the chest cavity from the external environment

Normal Ventilation Versus Positive Pressure Ventilation:

Normal Ventilation Versus Positive Pressure Ventilation

Normal Ventilation Versus Positive Pressure Ventilation:

Normal Ventilation Versus Positive Pressure Ventilation With positive pressure ventilation, more air is needed to achieve the same effects of normal breathing. Increases overall intrathoracic pressure Blood flow is decreased.

Normal Ventilation Versus Positive Pressure Ventilation:

Normal Ventilation Versus Positive Pressure Ventilation Cardiac output is a function of stroke volume multiplied by the pulse rate. Normally, when a person breathes, air enters the trachea. Ventilations that are too forceful can cause gastric distention.

Assisted Ventilation:

Assisted Ventilation Place the mask over the patient ’ s nose and mouth. Squeeze the bag each time the patient inhales. After 5 to 10 breaths, slowly adjust the rate. Adjust the rate and tidal volume to maintain adequate minute volume.

Artificial Ventilation:

Artificial Ventilation Begin artificial ventilation immediately if patient is not breathing. Methods include: Mouth-to-mask technique One-, two-, or three-person bag-mask device technique

Mouth-to-Mask Ventilation:

Mouth-to-Mask Ventilation Plastic barrier placed in patient’s face One-way valve to prevent the backflow of secretions Can use both hands © American Academy of Orthopaedic Surgeons.

Mouth-to-Mask Ventilation:

Mouth-to-Mask Ventilation Technique Open airway with the head tilt – chin lift or jaw-thrust maneuver. Insert an oral or nasal airway. Connect one-way valve to face mask and place the mask on patient’s face. Hold the mask in position.

Mouth-to-Mask Ventilation:

Mouth-to-Mask Ventilation Technique (cont’d) Grasp patient’s lower jaw with the next three fingers on each hand. Place thumbs on dome of mask and make an airtight seal. Exhale over a period of 1 second to produce visible chest rise. Remove your mouth from the one-way valve and allow the patient to passively exhale.

Mouth-to-Mask Ventilation:

Mouth-to-Mask Ventilation © Jones & Bartlett Learning. Courtesy of MIEMSS. © Jones & Bartlett Learning. Courtesy of MIEMSS.

Mouth-to-Mask Ventilation:

Mouth-to-Mask Ventilation Determining effectiveness Watch patient’s chest rise and fall and feel for resistance of the patient’s lungs. You should hear and feel air escape as patient passively exhales.

Mouth-to-Mask Ventilation:

Mouth-to-Mask Ventilation Provide correct number of breaths per minute for patient’s age.

Bag-Mask Device:

Bag-Mask Device Can deliver nearly 100% oxygen Can provide adequate tidal volume when used by an experienced paramedic Depends on mask seal integrity © American Academy of Orthopaedic Surgeons.

Bag-Mask Device:

Bag-Mask Device Components Disposable, self-inflating bag No pop-off valve or capability to disable Nonrebreathing outlet valve Oxygen reservoir One-way, no-jam inlet valve system Transparent face mask

Bag-Mask Device:

Bag-Mask Device Total amount of gas in an adult bag-mask device is usually 1,200 to 1,600 mL. Volume of air to deliver is based on visible chest rise. Deliver each breath over a period of 1 second at the appropriate rate.

Bag-Mask Device:

Bag-Mask Device Technique Kneel above patient ’ s head. Maintain neck in a hyperextended position. Open the mouth, suction as needed. Insert an oral or nasal airway. Connect to supplemental oxygen. Place the mask on the patient ’ s face. Bring the lower jaw up to the mask. Connect the bag to the mask.

Bag-Mask Device:

Bag-Mask Device Technique (cont.) Hold the mask in place while your partner squeezes the bag until the chest visibly rises. Squeeze every 5 to 6 seconds for adults, 3 to 5 seconds for infants and children. © Jones & Bartlett Learning. Courtesy of MIEMSS.

Bag-Mask Device:

Bag-Mask Device Technique (cont.) If alone, hold your index finger over the lower part of the mask and your thumb over the upper part. Observe for gastric distention, changes in compliance, and changes in status. © Jones & Bartlett Learning.

Bag-Mask Device:

Bag-Mask Device Squeeze bag as patient inhales. Slowly adjust rate and tidal volume. If patient is hyperventilating, first assist at the rate at which the patient is breathing. Then slowly adjust rate and tidal volume.

Bag-Mask Device:

Bag-Mask Device Ventilations not adequate if: Chest does not rise and fall Rate of ventilation is too slow or too fast Pulse rate does not improve

Bag-Mask Device:

Bag-Mask Device If the chest does not rise and fall: Reposition the head or insert an airway. If the stomach seems to be rising and falling, reposition the head. If too much air is escaping, reposition the mask. If chest still does not rise and fall, check for an airway obstruction.

Automatic Transport Ventilators:

Automatic Transport Ventilators Steps for using: Attach to wall-mounted oxygen source. Set tidal volume and ventilatory rate. Connect to fitting on ET tube or airway device. Auscultate breath sounds and observe chest rise. Courtesy of Impact Instrumentation, Inc.

Automatic Transport Ventilators:

Automatic Transport Ventilators Have bag-mask device available in case ATV malfunctions. Most models have adjustments for respiratory rate and tidal volume. Deliver a preset volume at a preset rate.

Automatic Transport Ventilators:

Automatic Transport Ventilators Generally consumes 5 L/min of oxygen Pressure-relief valve can lead to: Hypoventilation Increased airway resistance Airway obstruction

Continuous Positive Airway Pressure:

Continuous Positive Airway Pressure Noninvasive means of providing ventilatory support for patients with respiratory distress Increases pressure in the lungs Opens collapsed alveoli Pushes oxygen across alveolar membrane Forces interstitial fluid back into circulation

Continuous Positive Airway Pressure:

Continuous Positive Airway Pressure Typically delivered through a face mask secured with a strapping system. Pressure relief valve determines amount of pressure delivered to the patient.

Indications for CPAP:

Indications for CPAP Guidelines: Patient is alert and able to follow commands. Obvious signs of respiratory distress from an underlying disease or after submersion Rapid breathing (more than 26 breaths/min) that affects overall minute volume Pulse oximetry of less than 90%

Contraindications to CPAP:

Contraindications to CPAP Unable to follow verbal commands Respiratory arrest or agonal respirations Unable to speak Hypoventilation Hypotension Pneumothorax or chest trauma Closed head injury Facial trauma Cardiogenic shock Tracheostomy GI bleeding , nausea, or vomiting Recent GI surgery Unable to sit up Unable to fit CPAP system C annot tolerate mask

Application of CPAP:

Application of CPAP Generally composed of: Generator Mask Circuit that contains corrugated tubing Bacteria filter One-way valve

Application of CPAP:

Application of CPAP Patient exhales against a resistance (positive end-expiratory pressure [PEEP]) Controlled manually or predetermined 5 to 10 cm H 2 O is general therapeutic range.

Application of CPAP:

Application of CPAP Some units use a continuous flow of oxygen; others use oxygen on demand. Some newer units allow you to adjust Fio 2 . Continuously monitor available oxygen.

Complications of CPAP:

Complications of CPAP Patients may feel claustrophobic and resist. High volume of pressure can cause a pneumothorax. Increased pressure in the chest cavity can result in hypotension. Air may enter the stomach.

Gastric Distension:

Gastric Distension Inflation of the stomach with air Likely to occur when: Excessive pressure is used to inflate the lungs Ventilations are performed too fast or too forcefully Airway is partially obstructed during ventilation attempts

Gastric Distension:

Gastric Distension Harmful for at least two reasons Promotes regurgitation, can lead to aspiration Pushes diaphragm up, limits lung expansion Signs include: Increased diameter Distended abdomen Increased resistance to bag-mask ventilations

Gastric Distension:

Gastric Distension If signs are noted: Reassess and reposition the airway. Observe chest for adequate rise and fall. Limit ventilation times to 1 second or the time needed to produce adequate chest rise.

Invasive Gastric Decompression:

Invasive Gastric Decompression Involves inserting a gastric tube into the stomach and suctioning the contents Should be considered: For any patient who will need positive pressure ventilation for an extended period When gastric distention interferes with ventilations

Invasive Gastric Decompression:

Invasive Gastric Decompression Nasogastric tube Insert through nose Decompresses stomach Decreases pressure Limits risk of regurgitation © Jones & Bartlett Learning.

Invasive Gastric Decompression:

Invasive Gastric Decompression Nasogastric tube (cont ’ d) Relatively well tolerated Contraindicated with severe facial injuries Use OG route instead.

Invasive Gastric Decompression:

Invasive Gastric Decompression Orogastric tube Inserted through the mouth No risk of nasal bleeding Safer in patients with severe facial trauma Can use larger tubes © Jones & Bartlett Learning.

Orogastric Tube:

Orogastric Tube Orogastric tube (cont ’ d) Less comfortable for responsive patients Preferred for patients who are unresponsive without a gag reflex

Laryngectomy:

Laryngectomy Surgical removal of the larynx Tracheostomy creates a stoma. Total laryngectomy: Breathe through stoma Cannot ventilate by mouth-to-mask technique Partial laryngectomy: Breathe through stoma and nose or mouth

Suctioning of a Stoma:

Suctioning of a Stoma May become occluded with mucous plugs Suction with extreme care. Limit suctioning to 10 seconds.

Ventilation of Stoma Patients:

Ventilation of Stoma Patients Head tilt – chin lift and jaw-thrust not required. If no tracheostomy tube, use: Mouth-to-stoma technique Bag-mask device Use an infant- or child-sized mask to make an adequate seal.

Ventilation of Stoma Patients:

Ventilation of Stoma Patients Two rescuers are needed with a bag-mask device. One to seal the nose and mouth The other to squeeze the bag-mask device

Tracheostomy Tubes:

Tracheostomy Tubes Plastic tube placed within the stoma Patients may receive oxygen via: Tubing designed to fit over the tube Placing an oxygen mask over the tube © Jones & Bartlett Learning.

Tracheostomy Tubes:

Tracheostomy Tubes Patients who experience sudden dyspnea often have thick secretions in the tube. Suction as you would through a stoma. When tube is dislodged, stenosis may occur.

Dental Appliances:

Dental Appliances Different forms Dentures (upper, lower, or both) Bridges Individual teeth Braces (in the younger population)

Dental Appliances:

Dental Appliances Determine whether appliance is loose or fits. If it fits well, leave in place. Remove if loose. Take care if airway obstruction is caused by a bridge (can lacerate pharynx or larynx). Generally best to remove before intubating

Facial Trauma:

Facial Trauma Severe swelling and bleeding in the airway may be present. Control with direct pressure. Suction as needed. © Eddie M. Sperling.

Facial Trauma:

Facial Trauma Inadequate breathing and severe oropharyngeal bleeding may be present. Suction airway for 15 seconds (less in infants and children), then ventilate for 2 minutes. Alternate until secretions have been cleared.

Facial Trauma:

Facial Trauma Suspect cervical spine injury. Endotracheal intubation of a trauma patient is most effectively performed by two paramedics. If you are unable to effectively ventilate or intubate, perform a cricothyrotomy.

Advanced Airway Management:

Advanced Airway Management One of the most common mistakes with respiratory or cardiac arrest is to use advanced techniques too early. Establish and maintain a patent airway with basic techniques first.

Advanced Airway Management:

Advanced Airway Management Primary reasons: Failure to maintain a patent airway Failure to adequately oxygenate and ventilate Involves insertion of advanced airway devices

Predicting the Difficult Airway:

Predicting the Difficult Airway Anatomic findings: Congenital abnormalities Recent surgery Trauma Infection Neoplastic diseases Use LEMON mnemonic

LEMON:

LEMON Look externally. The following can make intubation difficult: Short, thick necks Morbid obesity Dental conditions

LEMON:

LEMON Evaluate 3-3-2. 3 — Mouth width of more than 3 fingers is best. 3 — Mandible length of 3 fingers is best. 2 — Distance from hyoid bone to thyroid notch of 2 fingers wide is best. © Jones & Bartlett Learning. © Jones & Bartlett Learning. © Jones & Bartlett Learning.

LEMON:

LEMON Mallampati Note oropharyngeal structures visible in an upright, seated patient. © Jones & Bartlett Learning.

LEMON:

LEMON Courtesy of Steve Rahm. Courtesy of Steve Rahm. Courtesy of Steve Rahm. Courtesy of Steve Rahm.

LEMON:

LEMON Obstruction Note anything that might interfere with visualization or ET tube placement. Foreign body Obesity Hematoma Masses

LEMON:

LEMON Neck mobility Sniffing position is ideal. Neck mobility problems most common with: Trauma patients Elderly patients

Endotracheal Intubation:

Endotracheal Intubation ET tube passes through glottic opening and is sealed with a cuff inflated against the tracheal wall. Orotracheal intubation: Through the mouth Nasotracheal intubation: Through the nose

Endotracheal Intubation:

Endotracheal Intubation Advantages Secure airway Protection against aspiration Alternative to IV or IO route Disadvantages Special equipment Physiologic functions bypassed

Endotracheal Intubation:

Endotracheal Intubation Complications Bleeding Hypoxia Laryngeal swelling Laryngospasm Vocal cord damage Mucosal necrosis Barotrauma

Endotracheal Tubes:

Endotracheal Tubes Basic structure includes: Proximal end Tube Cuff and pilot balloon Distal tip © Jones & Bartlett Learning.

Endotracheal Tubes:

Endotracheal Tubes Sizes range 2.5 to 9.0 mm in inside diameter 12 to 32 cm in length © American Academy of Orthopaedic Surgeons.

Laryngoscopes and Blades:

Laryngoscopes and Blades Stylet: Semirigid wire inserted into ET tube Molds and maintains shape of tube Should be lubricated for removal End should be bent to form a gentle curve. End should rest at least 1/2 ″ from end of ET tube.

Endotracheal Tubes:

Endotracheal Tubes Pediatric patients 2.5 to 4.5 mm tubes used. Funnel-shaped cricoid ring forms an anatomic seal with ET tube. No need for distal cuff in most cases.

Endotracheal Tubes:

Endotracheal Tubes Anatomic clues can determine tube size. Internal diameter of the nostril approximates diameter of glottic opening. Diameter of the little finger or size of thumbnail approximates airway size. Always have three sizes ready!

Laryngoscopes and Blades:

Laryngoscopes and Blades A laryngoscope is required to perform orotracheal intubation by direct laryngoscopy. Consists of a handle and interchangeable blades © Jones & Bartlett Learning. © Jones & Bartlett Learning.

Laryngoscopes and Blades:

Laryngoscopes and Blades Straight (Miller and Wisconsin) blades Tip extends beneath epiglottis and lifts it up. Useful with infants and small children More likely to damage teeth in adults © Jones & Bartlett Learning.

Laryngoscopes and Blades:

Laryngoscopes and Blades Curved (Macintosh) blades Curve conforms to tongue and pharynx. Tip is placed in the vallecula. Indirectly lifts epiglottis to expose vocal cords © Jones & Bartlett Learning.

Laryngoscopes and Blades:

Laryngoscopes and Blades Blade sizes range from 0 to 4. 0, 1, and 2: Appropriate for infants and children 3 and 4: Considered adult sizes Pediatric patients: Based on age or height Adults: Based on experience, size of patient

Laryngoscopes and Blades:

Laryngoscopes and Blades Magill forceps Remove airway obstructions under direct visualization Guide tip of ET tube through glottic opening if the proper angle cannot be achieved by manipulating the tube

Orotracheal Intubation by Direct Laryngoscopy:

Orotracheal Intubation by Direct Laryngoscopy ET tube inserted through mouth and into trachea while visualizing the glottic opening with a laryngoscope

Orotracheal Intubation by Direct Laryngoscopy:

Orotracheal Intubation by Direct Laryngoscopy Indications Airway control needed due to coma, respiratory or cardiac arrest Ventilatory support before impending respiratory failure Prolonged ventilatory support Absence of gag reflex Traumatic brain injury Unresponsiveness Impending airway compromise Medication administration

Orotracheal Intubation by Direct Laryngoscopy:

Orotracheal Intubation by Direct Laryngoscopy Contraindications Intact gag reflex Inability to open mouth because of trauma, dislocation of the jaw, or a pathologic condition Inability to see the glottic opening Copious secretions, vomitus, or blood in airway

Standard Precautions:

Standard Precautions Intubation can expose you to bodily fluids. Take proper precautions. Gloves Mask that covers your entire face

Preoxygenation:

Preoxygenation Critical before intubating 2 – 3 minutes for apneic or hypoventilating patient Prevents hypoxia from occurring Monitor Sp o 2 and achieve as close to 100% saturation as possible.

Positioning the Patient:

Positioning the Patient Airway has three axes: Mouth, pharynx, and larynx At acute angles in neutral position Place patient in sniffing position to facilitate visualization of the airway. © Jones & Bartlett Learning.

Positioning the Patient:

Positioning the Patient Sniffing position 20º extension of the atlanto-occipital joint 30º flexion at C6 and C7 with short neck and/or no chin Elevate head and/or neck until ear is at the level of the sternum © Jones & Bartlett Learning.

Laryngoscope Blade Insertion:

Laryngoscope Blade Insertion Position yourself at the patient ’ s head. Grasp laryngoscope. If mouth is not open: Place thumb below bottom lip and push open. “Scissor” thumb and index finger between molars Open with tongue-jaw lift © Jones & Bartlett Learning.

Blade Insertion:

Blade Insertion Insert blade into right side of mouth. Sweep tongue to the left while moving blade into midline. Slowly advance the blade. © Jones & Bartlett Learning. Courtesy of MIEMSS. Specimens provided by the Maryland State Anatomy Board, Department of Health and Mental Hygiene at the Anatomical Services Division, University of Maryland School of Medicine.

Blade Insertion:

Blade Insertion Exert gentle traction at a 45º angle as you lift the patient ’ s jaw. Keep your back and arm straight as you pull upward. © Jones & Bartlett Learning. © Jones & Bartlett Learning.

Visualization of the Glottic Opening:

Visualization of the Glottic Opening Place tip of curved blade in vallecular space. Position straight blade directly under epiglottis. Gently lift until glottic opening is in full view. © CNRI/Science Source .

Visualization of the Glottic Opening:

Visualization of the Glottic Opening Gum elastic bougie Flexible device Approximately 5 mm in diameter, 70 cm long Used in epiglottis-only views to facilitate intubation © Jones & Bartlett Learning.

Visualization of the Glottic Opening:

Visualization of the Glottic Opening Gum elastic bougie (cont ’ d) Insert through the glottic opening under direct laryngoscopy. Once placed, it becomes a guide for the ET tube. © Jones & Bartlett Learning.

ET Tube Insertion:

ET Tube Insertion Pick up ET tube. Hold it near connector as you would a pencil. Insert tube from the right corner of mouth through the vocal cords. Continue until the proximal end of the cuff is 1 to 2 cm past the vocal cords. If you cannot see the vocal cords, do not insert the tube.

ET Tube Insertion:

ET Tube Insertion Do not pass the tube down the barrel of the laryngoscope blade. Will obscure your view of the glottic opening © Jones & Bartlett Learning.

Ventilation:

Ventilation After you have seen the ET tube cuff pass roughly 1 to 2 cm beyond the vocal cords: Gently remove the blade . Secure tube with right hand. Remove stylet from tube.

Ventilation:

Ventilation Inflate the distal cuff with 5 to 10 mL of air, then detach the syringe from the inflation port. Have your assistant attach the bag-mask device to the ET tube; continue ventilation. Ensure that the patient ’ s chest rises with each ventilation.

Ventilation:

Ventilation Listen to both lungs and to the stomach. You should hear equal breath sounds and a quiet epigastrium. Ventilation should be dictated by age. Adult with a pulse: 10 to 12 breaths/min Infant/child with a pulse: 12 to 20 breaths/min Patient in cardiac arrest: 8 to 10 breaths/min

Confirmation of Tube Placement:

Confirmation of Tube Placement Visualize ET tube passing between the vocal cords. Auscultate. Unequal or absent breath sounds suggest: Esophageal placement Right mainstem bronchus placement Pneumothorax Bronchial obstruction

Confirmation of Tube Placement:

Confirmation of Tube Placement Auscultate (cont ’ d ) Bilaterally absent breath sounds or gurgling over the epigastrium: Esophagus was intubated Immediately remove ET tube. Be prepared to suction the airway.

Confirmation of Tube Placement:

Confirmation of Tube Placement Auscultate (cont ’ d ) Breath sounds only on right means tube has been advanced too far. Reposition the tube.

Confirmation of Tube Placement:

Confirmation of Tube Placement With proper tube position: Bag-mask device should be easy to compress. You should see corresponding chest expansion. Increased resistance may indicate: Gastric distention Esophageal intubation Tension pneumothorax

Confirmation of Tube Placement:

Confirmation of Tube Placement Continuous waveform capnography plus clinical assessment Most reliable method of confirming placement Attach capnography T-piece when bag-mask device is attached to the ET tube.

Confirmation of Tube Placement:

Confirmation of Tube Placement Esophageal detector device Syringe model: Plunger is withdrawn. Tube in the trachea: Plunger does not move. Tube in the esophagus: Plunger moves back. Courtesy of Marianne Gausche -Hill, MD, FACEP, FAAP .

Confirmation of Tube Placement:

Confirmation of Tube Placement Esophageal detector device (cont ’ d) Bulb model: Bulb is squeezed. Tube in the esophagus: Bulb remains collapsed. Tube in the trachea: Bulb briskly expands. Courtesy of Marianne Gausche -Hill, MD, FACEP, FAAP.

Securing the Tube:

Securing the Tube Never take your hand off the ET tube before securing with an appropriate device. Support the tube manually while you ventilate to avoid a sudden jolt from the bag-mask device.

Securing the Tube:

Securing the Tube Steps Note the centimeter marking on the ET tube. Remove the bag-mask device. Position the tube in the center of the mouth. Place the securing device over the tube. Reattach the bag-mask device, auscultate, and note the capnography reading and waveform.

Securing the Tube:

Securing the Tube Many devices feature a built-in bite block. Alternative: Secure tube with tape and insert a bite block or oral airway. Minimize head movement in patient.

Orotracheal Intubation by Video Laryngoscopy:

Orotracheal Intubation by Video Laryngoscopy F acilitates visualization of the glottic opening and vocal cords Allows placement of ET tube with use of a video monitor However, requires better hand-to-eye coordination than does direct laryngoscopy

Orotracheal Intubation by Video Laryngoscopy:

Orotracheal Intubation by Video Laryngoscopy Types of video laryngoscopes: With a laryngoscope and separate video monitor With a video monitor attached to the laryngoscope itself Feature single-use blades of various sizes Some require displacement of the tongue. Some are inserted midline.

Orotracheal Intubation by Video Laryngoscopy:

Orotracheal Intubation by Video Laryngoscopy Courtesy of Verathon ® . © 2017 Medtronic. All rights reserved. Used with the permission of Medtronic. © Ambu . © Photo Courtesy of KARL SOTRZ Endoscopy-America, Inc.

Nasotracheal Intubation:

Nasotracheal Intubation Insertion of tube into trachea through nose Indicated: Breathing spontaneously but requires definitive airway management Contraindicated: Apnea Head trauma and midface fractures Anatomic abnormalities; frequent cocaine use

Nasotracheal Intubation:

Nasotracheal Intubation Advantages Can be performed on responsive patients No need for laryngoscope Mouth does not need to be opened Does not require sniffing position Patient cannot bite the tube. Can be secured more easily

Nasotracheal Intubation:

Nasotracheal Intubation Disadvantage Blind technique Confirming proper tube position requires diligence Complications Bleeding

Nasotracheal Intubation Equipment:

Nasotracheal Intubation Equipment Same as for orotracheal intubation Minus laryngoscope and stylet Some tubes are designed for blind method. Some devices allow confirmation of intubation without placing face next to tube.

Technique for Nasotracheal Intubation:

Technique for Nasotracheal Intubation Patient ’ s spontaneous respirations guide the tube and confirm proper placement. Tube is advanced as patient inhales. © Jones & Bartlett Learning. Courtesy of MIEMSS.

Technique for Nasotracheal Intubation:

Technique for Nasotracheal Intubation Insert tube into nostril, bevel facing toward the nasal septum. Aim tip straight back toward ear. Position just above the glottic opening. © Jones & Bartlett Learning. Courtesy of MIEMSS.

Technique for Nasotracheal Intubation:

Technique for Nasotracheal Intubation Manipulate head to control tube tip position and to maximize air movement. Instruct patient to take a deep breath, and gently advance tube. Placement will be evidenced by an increase in air movement through the tube.

Technique for Nasotracheal Intubation:

Technique for Nasotracheal Intubation Soft-tissue bulge on either side of the airway Tube is probably in the piriform fossa Hold head still, slightly withdraw the tube. Once maximum airflow is detected, advance tube. No soft-tissue bulge Tube has entered the esophagus. Withdraw until you detect airflow; extend head.

Technique for Nasotracheal Intubation:

Technique for Nasotracheal Intubation Once tube is in place, inflate the distal cuff. Attach bag-mask device and ventilate. Clean up any secretions or excess lubricant. Secure the tube with tape. Document depth of insertion at the nostril.

Digital Intubation:

Digital Intubation Directly palpate the glottic structures and elevate the epiglottis with your finger while guiding the ET tube into the trachea. Option in extreme circumstances

Digital Intubation:

Digital Intubation A dvantageous in case of equipment failure Primary disadvantage: Requires placing fingers in patient’s mouth

Digital Intubation:

Digital Intubation Absolutely contraindicated if patient is: Breathing Not deeply unresponsive Has intact gag reflex Major complication is misplacement of the ET tube.

Technique for Digital Intubation:

Technique for Digital Intubation Prepare equipment as assistant ventilates. Select tube: One-half to a full size smaller than with direct laryngoscopy Tip of the tube is guided into the trachea.

Technique for Digital Intubation:

Technique for Digital Intubation Two configurations are recommended. “Open J” configuration “U-handle” configuration © Jones & Bartlett Learning. Courtesy of MIEMSS © Jones & Bartlett Learning.

Technique for Digital Intubation:

Technique for Digital Intubation Sniffing position is not required. Insert bite block between molars. Insert index and middle fingers into right side of the mouth. Press against tongue. Pull epiglottis forward. © American Academy of Orthopaedic Surgeons.

Technique for Digital Intubation:

Technique for Digital Intubation Hold ET tube in right hand; insert it into the left side of the mouth. Advance tube toward the glottis. Once you feel the cuff pass 2 inches beyond your fingertip, stabilize the tube and withdraw fingers. Remove the stylet and inflate the cuff.

Technique for Digital Intubation:

Technique for Digital Intubation Attach bag-mask device and ventilate. Confirm placement. Auscultate lungs and epigastrium. Monitor etco 2 . Properly secure the tube in place.

Transillumination Techniques for Intubation:

Transillumination Techniques for Intubation Bright light source placed inside the trachea emits a bright, well-circumscribed light. © Jones & Bartlett Learning. Courtesy of MIEMSS.

Transillumination Techniques for Intubation:

Transillumination Techniques for Intubation Indicated when other techniques have failed Contraindicated Intact gag reflex Airway obstruction May be difficult in obese or short neck patients Pediatric patients: Stylet must fit inside tube.

Transillumination Techniques for Intubation:

Transillumination Techniques for Intubation Advantages No laryngoscope Visual parameter Does not require visualization of the glottic opening Safe with possible spinal injuries Disadvantages Special equipment Proficiency with equipment Can be difficult in brightly lit areas Complications Misplacement

Transillumination Equipment:

Transillumination Equipment Device with a rigid stylet and a bright light source at the end Light should shine laterally and forward. Stylet must be long enough to accommodate a standard-length ET tube. Stylet must be secured within the tube.

Technique for Transillumination-Guided Intubation:

Technique for Transillumination-Guided Intubation Preoxygenate for at least 2 to 3 minutes. Choose ET tube and check the cuff. Lubricate and insert the lighted stylet. Ensure it is firmly seated into the tube.

Technique for Transillumination-Guided Intubation:

Technique for Transillumination-Guided Intubation Bend tube into the proper shape. Head in neutral or slightly extended position While holding the stylet, displace the jaw forwardly. Turn on the lighted stylet, and insert it in the midline of the mouth.

Technique for Transillumination-Guided Intubation:

Technique for Transillumination-Guided Intubation Continue insertion; draw wrist toward you . Tightly circumscribed light slightly below the thyroid cartilage: Tube has entered trachea Faintly glowing light and bulging of the soft tissue: Tube is in the vallecular space. Dim, diffuse light at the anterior part of the neck: Esophageal placement

Technique for Transillumination-Guided Intubation:

Technique for Transillumination-Guided Intubation Once light is visible at the midline, hold the stylet in place and advance the tube. When the tube is in the trachea, stabilize it and withdraw the stylet. Inflate the distal cuff, detach the syringe, and attach the bag-mask device.

Technique for Transillumination-Guided Intubation:

Technique for Transillumination-Guided Intubation Ventilate the patient while auscultating both lungs and the epigastrium. Secure the tube and continue ventilations.

Retrograde Intubation:

Retrograde Intubation Needle is placed percutaneously within the trachea via the cricothyroid membrane. Wire is placed through the needle, through the trachea, into the mouth. Wire is visualized, secured. ET tube is placed over wire and guided into trachea.

Retrograde Intubation:

Retrograde Intubation Indications Copious secretions in the airway Failure to intubate by less invasive methods Contraindications Lack of familiarity with the procedure Laryngeal trauma Unrecognizable or distorted landmarks Coagulopathy Severe hypoxia

Retrograde Intubation:

Retrograde Intubation Complications Hypoxia Cardiac dysrhythmia Mechanical trauma Infection Increased intracranial pressure (ICP)

Face-to-Face Intubation:

Face-to-Face Intubation Paramedic ’ s face is at same level as patient ’ s. Head is stabilized, not in sniffing position. Laryngoscope is held in right hand; ET tube in left hand. Once blade is placed, head may be adjusted by pulling mandible forward while pressing down. © Jones & Bartlett Learning.

Failed Intubation:

Failed Intubation Definition: Failure to maintain oxygen saturation during or after one or more failed intubation attempts Total of three failed intubation attempts

Tracheobronchial Suctioning:

Tracheobronchial Suctioning Involves passing a suction catheter into the ET tube to remove pulmonary secretions Do not do it if you do not have to! If it must be performed: Use sterile technique. Monitor cardiac rhythm and oxygen saturation.

Tracheobronchial Suctioning:

Tracheobronchial Suctioning Preoxygenate for at least 2 to 3 minutes. Insert suction catheter until resisted. Apply suction as the catheter is extracted. Reattach bag-mask device, continue ventilations, and reassess.

Field Extubation:

Field Extubation Extubation: Process of removing tube from an intubated patient Before performing, contact medical control or follow local protocols.

Field Extubation:

Field Extubation Risks Over-estimating patient ’ s ability to protect airway Laryngospasm Upper airway swelling Do not remove tube unless you can reintubate!

Field Extubation:

Field Extubation Contraindicated with any risk of recurrent respiratory failure or uncertainty about a patient ’ s ability to maintain airway If indicated, ensure adequate oxygenation.

Field Extubation:

Field Extubation Explain procedure to patient. Have patient sit up or lean slightly forward. Assemble equipment to suction, ventilate, and reintubate.

Field Extubation:

Field Extubation Confirm patient can protect airway. Suction oropharynx. Deflate distal cuff as patient exhales. On next exhalation, remove tube.

Pharmacologic Adjuncts to Airway Management and Ventilation:

Pharmacologic Adjuncts to Airway Management and Ventilation Decrease the discomfort of intubation Decrease the incidence of complications Make aggressive airway management possible for patients who are unable to cooperate

Sedation in Emergency Intubation:

Sedation in Emergency Intubation Reduces anxiety, induces amnesia, decreases gag reflex Undersedation: Inadequate cooperation Complications of gagging Incomplete amnesia

Sedation in Emergency Intubation:

Sedation in Emergency Intubation Oversedation: Uncontrolled general anesthesia Loss of protective airway reflexes Respiratory depression Complete airway collapse Hypotension

Sedation in Emergency Intubation:

Sedation in Emergency Intubation Desired level of sedation dictates dose. Two major classes: Analgesics: Decrease perception of pain Sedative-hypnotics: Induce sleep, decrease anxiety

Benzodiazepines:

Benzodiazepines Sedative-hypnotic drugs Diazepam and midazolam Provide muscle relaxation, mild sedation Used as anxiolytic and antiseizure medications Provide anterograde amnesia

Benzodiazepines:

Benzodiazepines Neuromuscular blockers preferred for muscle relaxation. Potential side effects: Respiratory depression Slight hypotension Flumazenil: Benzodiazepine antagonist

Dissociative Anesthetics:

Dissociative Anesthetics Produce anesthesia by: D istorting perception of sight and sound I nducing a feeling of detachment (dissociation) from environment and self Ketamine Rapid acting, short duration Used as analgesic or to facilitate intubations

Opioids/Narcotics:

Opioids/Narcotics Potent analgesics with sedative properties Two most common: Fentanyl, alfentanil Can cause respiratory and central nervous system depression Naloxone: Narcotic antagonist

Nonnarcotic/Nonbarbituate:

Nonnarcotic/Nonbarbituate Etomidate (Amidate) Hypnotic-sedative drug Often used in induction of general anesthesia Fast-acting, short duration Little effect on pulse rate, blood pressure, ICP

Nonnarcotic/Nonbarbituate:

Nonnarcotic/Nonbarbituate Etomidate (cont ’ d) No histamine release and bronchoconstriction High incidence of myoclonic muscle movement Useful induction agent in patients with: Coronary artery disease Increased ICP Borderline hypotension/hypovolemia

Neuromuscular Blockade in Emergency Intubation:

Neuromuscular Blockade in Emergency Intubation Cerebral hypoxia can make patients combative and uncooperative. Requires aggressive oxygenation, ventilation Neuromuscular blocking agents are safer.

Neuromuscular Blocking Agents:

Neuromuscular Blocking Agents Affect every skeletal muscle Within about 1 minute, patient is paralyzed. Must be able to secure the airway No effect on LOC

Pharmacology of Neuromuscular Blocking Agents:

Pharmacology of Neuromuscular Blocking Agents Skeletal muscles are voluntary. Impulse to contract reaches a motor nerve. Acetylcholine (Ach) is released. Diffuses, occupies receptor sites Triggers changes in electrical properties of the muscle fiber (depolarization)

Pharmacology of Neuromuscular Blocking Agents:

Pharmacology of Neuromuscular Blocking Agents Paralytic medications Relax the muscle by impeding the action of Ach Two categories: Depolarizing and nondepolarizing

Depolarizing Neuromuscular Blocking Agent:

Depolarizing Neuromuscular Blocking Agent Competitively binds with ACh receptor sites Not affected as quickly by acetylcholinesterase Succinylcholine chloride is the only agent. Fasciculations can be observed during its administration.

Depolarizing Neuromuscular Blocking Agent:

Depolarizing Neuromuscular Blocking Agent Very rapid onset of total paralysis Short duration of action Use with caution in patients with burns, crush injuries, and blunt trauma. Can cause bradycardia

Nondepolarizing Neuromuscular Blocking Agents:

Nondepolarizing Neuromuscular Blocking Agents Bind to ACh receptor sites but do not cause depolarization of the muscle fiber Prevent fasciculations before a depolarizing paralytic

Nondepolarizing Neuromuscular Blocking Agents:

Nondepolarizing Neuromuscular Blocking Agents Most commonly used: Vecuronium bromide (Norcuron) Pancuronium bromide (Pavulon) Rocuronium bromide (Zemuron) Do not give before the airway is secured.

Rapid-Sequence Intubation (RSI):

Rapid-Sequence Intubation (RSI) Safe, smooth, rapid sedation and paralysis followed immediately by intubation Generally used for patients who are unable to cooperate

Preparation of the Patient and Equipment:

Preparation of the Patient and Equipment Explain procedure and reassure patient. Apply a cardiac monitor and pulse oximeter. Check, prepare, and assemble equipment. Have suction available.

Preoxygenation:

Preoxygenation Adequately preoxygenate all patients. If the patient is breathing spontaneously and has adequate tidal volume: Apply high-flow oxygen via nonrebreathing mask. If patient is hypoventilating: Assist ventilations with a bag-mask device and high-flow oxygen.

Premedication:

Premedication If your initial paralytic is succinylcholine, administer nondepolarizing paralytic. Atropine sulfate should be administered to decrease potential for bradycardia.

Sedation and Paralysis:

Sedation and Paralysis As soon as patient is sedated, administer paralytic agent. Onset should be complete within 2 minutes. Signs of adequate paralysis include: Apnea Laxity of the mandible Loss of the eyelash reflex

Intubation:

Intubation RSI procedure is no different than other situations. If you cannot intubate quickly, ventilate with 100% oxygen. Reattempt once oxygen saturation is acceptable. If ventilating with a bag-mask device, do so slowly.

Intubation:

Intubation Once tube is in the trachea: Inflate cuff. Remove stylet. Verify position of the ET tube. Secure the tube. Continue ventilations.

Maintenance of Paralysis and Sedation:

Maintenance of Paralysis and Sedation Additional paralytic administration may be necessary after intubation. If you administered succinylcholine, administer a nondepolarizing agent to maintain paralysis. If you administered a long-acting paralytic, additional dosing is usually not necessary.

Maintenance of Paralysis and Sedation:

Maintenance of Paralysis and Sedation Modification for unstable patients If oxygen saturation drops, ventilate slowly. If patient is hemodynamically unstable, judge whether sedation is appropriate.

King LT Airway:

King LT Airway Latex-free, single-use, single-lumen Positive pressure ventilation for apneic patients Maintains airway in spontaneously breathing patients who need advanced management Courtesy of King Systems.

King LT Airway:

King LT Airway Curved tube with ventilation ports between two inflatable cuffs Can be inserted more easily than the Combitube © Jones & Bartlett Learning.

King LT Airway :

King LT Airway Two types: King LT-D: Used for adults and children King LTS-D: Used for adults Five sizes of each type Courtesy of Candice M. Thompson, NREMT-P.

King LT Airway :

King LT Airway King LT-D and LTS-D share many features: Proximal pharyngeal cuff, distal cuff, ventilation outlets ET tube introducer (gum elastic bougie) can be inserted through the tube. Distal end: Closed in LT-D; open in LTS-D

King LT Airway :

King LT Airway Indications Alternative to bag-mask ventilation when a rescue airway device is required Same considerations as Combitube Contraindications Patients with an intact gag reflex Patients with known esophageal disease Patients who have ingested a caustic substance

Complications of the King LT Airway:

Complications of the King LT Airway Laryngospasm, vomiting, hypoventilation Trauma from improper insertion technique Pharyngeal balloon may push the epiglottis over the glottic opening. May make ventilation difficult

Insertion Technique:

Insertion Technique Patient ’ s height and weight determine size you should use.

Laryngeal Mask Airway (LMA):

Laryngeal Mask Airway (LMA) Option for patients who: Require more support than bag-mask Do not require ET intubation Conduit from glottic opening to ventilation device © Jones & Bartlett Learning.

Laryngeal Mask Airway (LMA):

Laryngeal Mask Airway (LMA) Surrounds larynx opening with an inflatable cuff Cuff conforms to airway contours, forms airtight seal © Jones & Bartlett Learning.

Laryngeal Mask Airway (LMA):

Laryngeal Mask Airway (LMA) Indications and contraindications Alternative to bag-mask ventilation Less effective in obese patients Pregnant patients and patients with a hiatal hernia are at risk for regurgitation. Ineffective with patients requiring high pulmonary pressures

Laryngeal Mask Airway (LMA):

Laryngeal Mask Airway (LMA) Advantages Better ventilation No continual maintenance of a mask seal No laryngoscopy Less risk of trauma Protection from secretions Disadvantages No protection against aspiration Air may be insufflated into the stomach Not a primary airway in emergency situations

Complications of Using LMA :

Complications of Using LMA Involve regurgitation and aspiration Weigh against risk of hypoventilation. Hypoventilation of patients who require high ventilatory pressures can occur. Upper airway swelling has been reported.

Equipment for LMA:

Equipment for LMA Several sizes based on the patient weight Consists of tube and inflatable mask cuff Two bars at opening prevent occlusion. Proximal end is fitted with standard adapter.

Equipment for LMA:

Equipment for LMA Cuff has a one-way valve assembly. 6.0-mm ET tube can be passed through size 3 or 4 LMA. Fasttrach LMA guides ET tube into trachea. © Jones & Bartlett Learning.

Equipment for LMA:

Equipment for LMA Property of Teleflex Incorporated. Copyright © 2017 Teleflex Incorporated. All rights reserved. Property of Teleflex Incorporated. Copyright © 2017 Teleflex Incorporated. All rights reserved. Property of Teleflex Incorporated. Copyright © 2017 Teleflex Incorporated. All rights reserved.

i-gel:

i-gel Inserted in a manner similar to the LMA Seals pharyngeal, laryngeal, and perilaryngeal structures W hile avoiding compression trauma © Photo Researchers, Inc./Science Source.

i-gel:

i-gel Alternative when intubation is unsuccessful F eatures: Integral bite block Gastric access channel for passing a 12-Fr gastric tube Supplemental oxygen inlet port for passive oxygenation Support strap to secure i-gel in position

i-gel:

i-gel © Jones & Bartlett Learning.

Cobra Perilaryngeal Airway (CobraPLA):

Cobra Perilaryngeal Airway (CobraPLA) Shape lets device: Slide easily along the hard palate Hold airway ’ s soft tissue away from the laryngeal inlet Available in eight sizes Courtesy of Pulmodyne , Inc.

Cobra Perilaryngeal Airway (CobraPLA):

Cobra Perilaryngeal Airway (CobraPLA) Indications Usage similar to other supraglottic airway devices Can be used in pediatric patients Does not protect against aspiration Contraindications Risk for aspiration Risk for massive trauma to oral cavity

Cobra Perilaryngeal Airway (CobraPLA):

Cobra Perilaryngeal Airway (CobraPLA) Complications Laryngospasm may occur with intact gag reflex. Cuff inflation may cause tongue to disrupt seal. Patient cannot be ventilated if device is too small.

Cobra Perilaryngeal Airway (CobraPLA):

Cobra Perilaryngeal Airway (CobraPLA) Insertion technique Deflate the cuff and apply a water-soluble gel. Open airway and insert distal end. Advance until modest resistance. Inflate cuff, but do not overinflate. Ventilate patient. Use waveform capnography.

Cobra Perilaryngeal Airway (CobraPLA):

Cobra Perilaryngeal Airway (CobraPLA) © Jones & Bartlett Learning. © Jones & Bartlett Learning.

Multilumen Airways:

Multilumen Airways Combitube Inserted blindly Proven to secure airway and allow for better ventilation Contain two lumens Contain an oropharyngeal balloon, which eliminates the need for a mask seal

Multilumen Airways:

Multilumen Airways © Jones & Bartlett Learning. © Jones & Bartlett Learning. © Jones & Bartlett Learning.

Multilumen Airways:

Multilumen Airways Indications Unresponsive, apneic patients with no gag reflex in whom intubation is not possible Older than 16 years Patients between 5 and 7 feet tall

Multilumen Airways:

Multilumen Airways Contraindications Esophageal trauma Known pathologic condition of the esophagus Ingestion of a caustic substance History of alcoholism

Multilumen Airways:

Multilumen Airways Advantages Ventilation in esophagus or trachea Insertion is easier than ET intubation. Minimal cervical spine movement No mask seal Airway patency Disadvantages Wrong port results in no pulmonary ventilation. Temporary Risk of aspiration Intubating the trachea via direct laryngoscopy is challenging .

Complications of Multilumen Airways :

Complications of Multilumen Airways Unrecognized displacement into esophagus Laryngospasm, vomiting, hypoventilation Pharyngeal or esophageal trauma Ventilation may be difficult if the pharyngeal balloon pushes the epiglottis over the glottic opening.

Insertion Techniques :

Insertion Techniques Combitube consists of: Single tube with two lumens Two balloons Two ventilation attachments Before insertion, prepare equipment.

Insertion Techniques :

Insertion Techniques Head should be in a neutral position. Insert thumb into the mouth and lift the jaw. Insert device until incisors are between the two black lines. Two valves must be inflated sequentially.

Insertion Techniques:

Insertion Techniques After inflation of balloons, begin to ventilate. Through the longer (blue) tube first Observe for chest rise and auscultate. If there are no breath sounds, switch to the shorter (clear) tube. Continuously monitor ventilation.

Surgical and Nonsurgical Cricothyrotomy :

Surgical and Nonsurgical Cricothyrotomy Used when conventional techniques fail Be familiar with: Anatomy of the anterior aspect of the neck Important blood vessels in area © Jones & Bartlett Learning.

Open Cricothyrotomy :

Open Cricothyrotomy Involves: Incising the cricothyroid membrane Inserting an ET or tracheostomy tube directly into the subglottic area of the trachea Cricothyroid membrane is ideal for surgical opening into the trachea.

Open Cricothyrotomy :

Open Cricothyrotomy Several types: Open (surgical) cricothyrotomy Modified cricothyrotomy (Seldinger technique) Device that functions as an introducer and an airway © VBM Medizintechnik GmbH.

Open Cricothyrotomy :

Open Cricothyrotomy Indications Patent airway cannot be secured with conventional means. Severe foreign body obstructions Swelling of airway Maxillofacial trauma Inability to open mouth

Open Cricothyrotomy :

Open Cricothyrotomy Contraindications Ability to secure a patent airway Inability to identify anatomic landmarks Crushing injuries to the larynx and tracheal transection Underlying anatomic abnormalities Age younger than 8 years

Open Cricothyrotomy:

Open Cricothyrotomy Advantages Can be performed quickly Do not need to manipulate cervical spine Disadvantages Difficult to perform in children and patients with short, muscular, or fat necks More difficult than needle cricothyrotomy

Open Cricothyrotomy:

Open Cricothyrotomy Complications Severe bleeding from laceration of the external jugular vein Risk of perforating the esophagus and damaging the laryngeal nerves Taking too long will result in hypoxia. Subcutaneous emphysema from tube misplacement

Open Cricothyrotomy Equipment :

Open Cricothyrotomy Equipment If a commercial kit is not available, prepare: Scalpel ET or tracheostomy tube Commercial device (or tape) to secure tube Curved hemostats Suction apparatus Sterile gauze pads Bag-mask device attached to 100% oxygen

Technique for Performing Open Cricothyrotomy:

Technique for Performing Open Cricothyrotomy Proceed rapidly yet cautiously. Palpate for V notch of thyroid cartilage. Slide index finger into depression between thyroid and cricoid cartilage. Cricothyroid membrane Males have more prominent thyroid notch and thyroid prominence. F emales have more prominent cricoid ring.

Technique for Performing Open Cricothyrotomy:

Technique for Performing Open Cricothyrotomy Partner prepares equipment. Maintain aseptic technique. Stabilize larynx; make a 1- to 2-cm vertical incision over the cricothyroid membrane. © Medline Industries, Inc.

Technique for Performing Open Cricothyrotomy:

Technique for Performing Open Cricothyrotomy Insert a 6.0-mm cuffed ET tube or a 6.0 tracheostomy tube into trachea. Inflate the distal cuff. © Jones & Bartlett Learning.

Technique for Performing Open Cricothyrotomy:

Technique for Performing Open Cricothyrotomy Attach the bag-mask device, and ventilate while your partner auscultates. Confirm proper tube placement. Ensure bleeding has been controlled. Secure tube and continue to ventilate.

Needle Cricothyrotomy :

Needle Cricothyrotomy 14- to 16-gauge over-the-needle IV catheter is inserted into the trachea. High-pressure jet ventilator is attached to catheter hub. Translaryngeal catheter ventilation © Jones & Bartlett Learning.

Needle Cricothyrotomy :

Needle Cricothyrotomy Indications Inability to ventilate by less invasive means Maxillofacial trauma Inability to open mouth Uncontrolled oropharyngeal bleeding Contraindications Severe airway obstruction above catheter insertion High-pressure ventilator leads to barotrauma and pneumothorax If equipment is not immediately available

Needle Cricothyrotomy :

Needle Cricothyrotomy Advantages Easier than open cricothyrotomy Lower risk of damaging structures Allows for intubation No manipulation of cervical spine Disadvantages Does not provide protection from aspiration Technique requires a specialized, high-pressure jet ventilator

Needle Cricothyrotomy :

Needle Cricothyrotomy Complications Improper placement can cause severe bleeding. Excessive air leakage can cause subcutaneous emphysema and compression of the trachea. Overinflation of lungs: Barotrauma Underinflation of lungs: Hypoventilation

Needle Cricothyrotomy Equipment :

Needle Cricothyrotomy Equipment Large-bore IV catheter (14 – 16 gauge) 10-mL syringe 3 mL of sterile water or saline Oxygen source (50 psi) High-pressure jet ventilator device and oxygen tubing

Technique for Performing Needle Cricothyrotomy :

Technique for Performing Needle Cricothyrotomy Draw up approximately 3 mL of sterile water or saline into a 10-mL syringe. Attach to IV catheter. Place head in neutral position. Locate the cricothyroid membrane. Cleanse area if time permits.

Technique for Performing Needle Cricothyrotomy :

Technique for Performing Needle Cricothyrotomy Stabilize the larynx; insert the needle at a 45° angle toward the feet. You should feel a pop as the needle penetrates the membrane. After a pop is felt, insert needle 1 cm farther; aspirate with the syringe.

Technique for Performing Needle Cricothyrotomy :

Technique for Performing Needle Cricothyrotomy Advance catheter over needle until catheter hub is flush with skin. Withdraw the needle; dispose of properly. Attach one end of the oxygen tubing to the catheter and other end to the jet ventilator.

Technique for Performing Needle Cricothyrotomy :

Technique for Performing Needle Cricothyrotomy Begin ventilations by opening the release valve on the jet ventilator. Turn release valve off with chest rise. Secure catheter and continue ventilations.

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