3. Patient Airway
Establishing, maintaining, and ensuring effective
oxygenation are vital aspects of effective patient
care.
Open
No airway, no patient
4. Anatomy of the Upper Airway
All anatomic airway structures
above the level of the vocal cords
– Major function
Warm, filter, and humidify air
5. Pharynx
Throat
– Muscular tube that extends from the nose and mouth
to the level of the esophagus and trachea
– Composed of the nasopharynx, oropharynx, and
laryngopharynx
6. Nasopharynx (1 of 5)
Inhalation
– Air enters the body through the nose.
– Passes into the nasopharynx
– Formed by the union of the facial bones
7. Nasopharynx (2 of 5)
Nasal cavity
– Lined with ciliated mucous membrane
– Mucous membrane
Trauma to the nasal cavity
– Bleeding cannot be controlled by direct pressure.
– Concern for deeper skull and cranial injury
8. Nasopharynx (3 of 5)
Turbinates
– Three bony shelves
– Protrude from the lateral walls of the nasal cavity
and extend into the nasal passageway
– Increase the surface area of the nasal mucosa
– Improve the processes of warming, filtering, and
humidification of inhaled air
9. Nasopharynx (4 of 5)
Nasal septum
– Divides the nasopharynx into two passages
– One passage is larger than the other.
– Rigid partition composed of bone and cartilage
– Normally in the midline of the nose
10. Nasopharynx (5 of 5)
Sinuses
– Cavities formed by the cranial bones
– Fractures of these bones may cause cerebrospinal
fluid to leak from the nose or the ears.
– Significant bleeding from sinus fractures
– Prevent contaminants from entering the respiratory
tract
11. Oropharynx (1 of 7)
Forms the posterior portion of the oral cavity
– Bordered superiorly by the hard and soft palates,
laterally by the cheeks, and inferiorly by the tongue
– 32 adult teeth
– Significant force to dislodge teeth
Easily create an airway obstruction
12. Oropharynx (2 of 7)
Hyoid bone
– Beneath the mandible
– Only human bone that does not articulate with any
other bone
– Anchors tongue muscles to jaw to suspend airway
– Anchors to the thyroid cartilage by the thyroid
membrane
13. Oropharynx (3 of 7)
Palate
– Forms the roof of the mouth
– Separates the oropharynx and nasopharynx
– Hard palate
– Soft palate
14. Oropharynx (4 of 7)
Adenoids and tonsils
– Located on the posterior nasopharyngeal wall
– Lymphatic tissues that filter bacteria
– Adenoids and tonsils often become swollen and
infected
– Severe swelling of the tonsils can cause obstruction
of the upper airway.
15. Oropharynx (5 of 7)
Uvula
– Soft-tissue structure
– Resembles a punching bag
– Located in the posterior aspect of the oral cavity,
at the base of the tongue
16. Oropharynx (6 of 7)
Epiglottis
– Superior border of the glottic opening
– Leaf-shaped cartilaginous flap
– Prevents food and liquid from entering the larynx
during swallowing
– Bacterial infection can cause swelling, creating
an airway obstruction.
17. Oropharynx (7 of 7)
Vallecula
– Anatomic space or “pocket”
– Located between the base of the tongue
and the epiglottis
– Important landmark for endotracheal intubation
18. Larynx (1 of 8)
Complex structure
– Formed by many independent
cartilaginous structures
– Marks where the upper
airway ends and the lower
airway begins
19. Larynx (2 of 8)
Thyroid cartilage
– Shield-shaped structure
– Formed by two plates that join in a “V” shape
anteriorly
– Form the laryngeal prominence known as the Adam’s
apple
– Suspended in place by the thyroid ligament
– Directly anterior to the glottic opening
20. Larynx (3 of 8)
Cricoid cartilage
– Lies inferiorly to the thyroid cartilage
– Forms the lowest portion of the larynx
– First ring of the trachea
– Only upper airway structure that forms a complete
ring
21. Larynx (4 of 8)
Cricothyroid membrane
– Between the thyroid and cricoid cartilages
– Site for emergency surgical and nonsurgical access to
the airway
– Bordered laterally and inferiorly by the highly vascular
thyroid gland
– EMS personnel must locate the anatomical landmarks
carefully when accessing the airway via this site.
22. Larynx (5 of 8)
Glottis
– Space in between
the vocal cords
and the narrowest
portion of the
adult’s airway
– Airway patency is
heavily dependent
on adequate
muscle tone.
23. Larynx (6 of 8)
Arytenoid cartilage
– Pyramid-like cartilaginous structures
– Form the posterior attachment of the vocal cords
– Valuable guides for endotracheal intubation
– As they pivot, the vocal cords open and close,
regulating the passage of air through the larynx
and controlling the production of sound.
24. Larynx (7 of 8)
Pyriform fossae
– Two pockets of tissue on the lateral borders
of the larynx
– Airway devices are occasionally inadvertently
inserted into these pockets.
– Tenting of the skin under the jaw
25. Larynx (8 of 8)
Laryngospasm
– Spasmodic closure of the vocal cords, which seals
off the airway
– Reflex normally lasts a few seconds
– If persistent it threatens the airway by preventing
ventilation.
26. Anatomy of the Lower Airway (1 of 7)
Function
– Exchange oxygen and carbon dioxide
Location
– Externally, it extends from the fourth cervical vertebra
to the xiphoid process.
– Internally, it spans the glottis to the pulmonary
capillary membrane.
28. Anatomy of the Lower Airway (3 of 7)
Trachea
– Conduit for air entry into the lungs
– Tubular structure
– Approximately 10 to 12 cm in length and consists
of a series of C-shaped cartilaginous rings
– Begins immediately below the cricoid cartilage
– Descends anteriorly down the midline of the neck and
chest to the level of the fifth or sixth thoracic vertebra
– Divides into the right and left mainstem bronchi at the
level of the carina
29. Anatomy of the Lower Airway (4 of 7)
Hilum
– All of the blood vessels and the bronchi enter each
lung at this spot.
– Lungs consist of the entire mass of tissue that
includes the smaller bronchi, bronchioles, and alveoli.
30. Anatomy of the Lower Airway (5 of 7)
Lungs
– Right lung has three lobes.
– Left lung has two lobes.
– Visceral pleura
– Parietal pleura
– Small amount of fluid is found between the pleurae.
31. Anatomy of the Lower Airway (6 of 7)
Bronchus
– Divides into increasingly smaller bronchi
– Bronchioles
– Smaller bronchioles branch into alveolar ducts that
end at the alveolar sacs.
32. Anatomy of the Lower Airway (7 of 7)
Alveoli
– Balloon-like clusters of single-layer air sacs
– Functional site for the exchange of oxygen
and carbon dioxide
– Surfactant
– Atelectasis
33. Total Lung Capacity
Average adult male
– 6 L
– Only a fraction of this capacity is used during normal
breathing.
– Most of the gas exchange occurs in the alveoli.
34. Tidal Volume (VT)
Measure of the depth of breathing
– Volume of air that is inhaled or exhaled during
a single respiratory cycle
– Inspiratory reserve volume
– Dead space
Anatomic dead space
Physiologic dead space
35. Alveolar Volume
Remaining volume of inhaled air
Reaches the alveoli and participates in gas exchange
Equal to tidal volume minus dead space volume
36. Minute Volume (1 of 2)
Amount of air that moves into and out of the
respiratory tract per minute
– Multiply the tidal volume (minus dead space volume)
by the respiratory rate
– Will increase if either the tidal volume or the
respiratory rate increases
– Will decrease if either the tidal volume or the
respiratory rate decreases
38. Functional Reserve Capacity
Amount of air that can be forced from the lungs
in a single exhalation
– Expiratory reserve volume
– Residual volume
39. Fraction of Inspired Oxygen (FIO2)
Percentage of oxygen in inhaled air
– Increases when supplemental oxygen is given
to a patient
– Commonly documented as a decimal point
40. Ventilation (1 of 2)
Process of moving air into and out of the lungs
– Two phases
Inspiration: process of moving air into the lungs
Expiration: process of moving air out of the lungs
41. Ventilation (2 of 2)
Cycle
– One inspiration and one expiration
Inspiration: one third of the ventilation cycle
Expiration: two thirds of the ventilation cycle
42. Regulation of Ventilation (1 of 4)
Body’’s need for oxygen
– Dynamic
– Constantly changing
– Respiratory system must be able to accommodate
those changes by altering the rate and depth
of ventilation.
Primarily regulated by the pH of the CSF
43. Regulation of Ventilation (2 of 4)
Neural control of ventilation
– Involuntary control of breathing originates
in the brain stem.
– Impulses descend through the spinal cord
and can be overridden by voluntary control.
– Phrenic nerve
– Intercostal nerve
– Respiratory rhythmicity center
– Hering-Breur reflex
– Apneustic center
– Pneumotaxic center
44. Regulation of Ventilation (3 of 4)
Chemical control of ventilation
– Chemoreceptors
– Carbon dioxide content monitors
– Central chemoreceptors
– Increase in acidity of the CSF causes increased rate
and depth of breathing.
– Primary respiratory drive
– Hypoxic drive
45. Regulation of Ventilation (4 of 4)
Control of ventilation by other factors
– Body temperature
– Medications
– Hypoxia
– Acidosis
– Metabolic rate
46. The Mechanics of Ventilation (1 of 2)
Accomplished
– Pressure changes brought about by contraction and
relaxation of the intercostal muscles and diaphragm
Inhalation
– Active process
Initiated by contraction of the respiratory muscles
Net effect is to increase the volume of the chest.
Lungs undergo a comparable increase in volume.
Negative-pressure ventilation
47. The Mechanics of Ventilation (2 of 2)
Exhalation
– Passive process
At the end of inhalation, the respiratory muscles
relax.
Natural elasticity of the lungs passively exhales
the air.
48. Respiration (1 of 2)
Mechanism to ensure a constant oxygen supply
and the removal of excess carbon dioxide
– External respiration (pulmonary respiration)
– Internal respiration (cellular respiration)
49. Respiration (2 of 2)
Diffusion
– Gas exchange in the body
– Process in which a gas moves from an area of higher
concentration to an area of lower concentration
– Dissolved oxygen crosses the pulmonary capillary
membrane and binds to the hemoglobin molecule
of the red blood cell.
– Approximately 97% of the body’s total oxygen is
bound to hemoglobin.
– Pulse oximetry measures the percentage of
hemoglobin that is saturated with oxygen.
50. Decreased Oxygen Concentrations (1 of 4)
Numerous conditions
– Lower partial pressure of atmospheric oxygen
– Severe bleeding
– Anemia: deficiency in red blood cells
– Carbon monoxide poisoning
51. Decreased Oxygen Concentrations (2 of 4)
Conditions that reduce the surface air for gas
exchange
– Flail chest
– Diaphragmatic injury
– Simple or tension pneumothorax
– Open pneumothorax
– Hemothorax
– Hemopneumothorax
52. Decreased Oxygen Concentrations (3 of 4)
Decreased mechanical effort
– Severe chest pain secondary to trauma or a medical
condition
– Traumatic asphyxia
– Hypoventilation
53. Decreased Oxygen Concentrations (4 of 4)
Medical conditions
– Pneumonia, pulmonary edema, and chronic
obstructive pulmonary disease
– Nonfunctional alveoli
– Intrapulmonary shunting
– Diminished lung capacity due to disease or injury
54. Abnormal Carbon Dioxide
Concentrations (1 of 3)
Balance
– Amount of CO2 produced remains relatively constant.
– As metabolic rate goes up more carbon dioxide is
produced.
– Type of metabolism affects the levels as well.
55. Abnormal Carbon Dioxide
Concentrations (2 of 3)
Hypoventilation
– Carbon dioxide production exceeds the body’s ability
to eliminate it by ventilation.
Hyperventilation
– Occurs when carbon dioxide elimination exceeds
production
56. Abnormal Carbon Dioxide
Concentrations (3 of 3)
Minute volume
– Decrease in minute volume causes a decrease
in carbon dioxide elimination.
– Hypercarbia
– Hypocarbia
57. Measurement of Gases
Dalton’’s law of partial pressure
– Total pressure of a gas is the sum of the partial
pressure of the components of that gas, or the
pressure exerted by a specific atmospheric gas.
58. You are dispatched to a private home for an unconscious
patient.
When you arrive on scene you find the fire department
performing CPR.
You note the patient’s abdomen to be grossly distended.
59. Airway Evaluation (1 of 2)
If you can see or hear a patient breathing
– Usually a problem
– Breathing at rest should appear effortless.
– Respiratory rate between 12 and 20 breaths/min
60. Airway Evaluation (2 of 2)
Patients will try to compensate.
– Preferential positioning
– Upright tripod position (elbows out)
– Semi-Fowler’s (semi-sitting) position
– Avoid a supine position.
61. Recognition of Airway Problems (1 of 4)
Conscious, alert, and able to speak
– No immediate airway or breathing problems
– You must still closely monitor a patient’s airway
and breathing status and be prepared to intervene.
Adult patient with abnormal respiratory rate
– Evaluate for other signs of inadequate ventilation.
62. Recognition of Airway Problems (2 of 4)
Causes of inadequate ventilation
– Severe infection
– Trauma
– Brain stem insult
– Noxious or oxygen-poor atmosphere
– Renal failure
Causes of respiratory distress
– Upper and/or lower airway obstructions
– Impairment of the respiratory muscles
– Impairment of the nervous system
63. Recognition of Airway Problems (3 of 4)
Dyspnea
– Any difficulty in respiratory rate, regularity, or effort
– Hypoxemia
– Hypoxia
– Anoxia
64. Recognition of Airway Problems (4 of 4)
Nonpatent airway or absent/inadequate breathing
– Proper airway management involves
Opening the airway
Clearing the airway
Assessing, intervening, and reassessing breathing
65. Evaluation of the Airway (1 of 4)
Visual techniques
– How is the patient positioned?
– Is rise and fall of the chest adequate?
– Is the patient gasping for air?
– What is the skin color?
– Is there flaring of the nostrils?
66. Evaluation of the Airway (2 of 4)
Visual techniques (continued)
– Is the patient breathing through pursed lips?
– Do you note any retractions?
– Is the patient using accessory muscles to breathe?
– Is the patient’s chest wall moving symmetrically?
67. Evaluation of the Airway (3 of 4)
Listen
– Air movement at the patient’s nose and mouth
– Auscultate breath sounds with a stethoscope.
68. Evaluation of the Airway (4 of 4)
Feel
– Note any resistance or change in ventilatory
compliance
Increased compliance
Decreased compliance
– Pulsus paradoxus
– Change in pulse quality, or even the disappearance
of a pulse during inhalation may also be detected.
69. History of the Patient’’s
Present Illness (1 of 2)
Was the onset of the problem sudden or gradual
over time?
Is there any known cause or ““trigger”” of the event?
What is the duration?
Does anything alleviate or exacerbate the problem?
Are there any other associated symptoms, such as a
productive cough, chest pain or pressure, or fever?
70. History of the Patient’’s
Present Illness (2 of 2)
Were any interventions attempted prior to EMS
arrival?
Has the patient been evaluated by a physician
or admitted to the hospital for this condition
in the past?
Is the patient currently taking any medications?
Does the patient have any risk factors that could
cause or exacerbate his or her condition, such as
alcohol or illicit drug use, cigarette smoking, or a
poor diet?
71. Evaluate for Modified Forms
of Respiration (1 of 3)
Protective reflexes of the airway
– Coughing
– Sneezing
– Gagging
– Gag reflex
– Aspiration
72. Evaluate for Modified Forms
of Respiration (2 of 3)
Protective reflexes (continued)
– Eyelash reflex
– Sighing
– Hiccupping
74. Diagnostic Testing (1 of 3)
Pulse oximeter
– Measures the percentage of hemoglobin
in the arterial blood that is saturated
– Designed to assess pulsating blood vessels
– Normally oxygenated should be between 95%
and 99%
– Monitor the oxygenation of a patient during an
intubation attempt or during suctioning.
78. Peak Expiratory Flow
Peak rate of a forceful exhalation
– Increasing suggests that the patient is responding
to treatment.
– Decreasing is an early indication that the patient’s
condition is deteriorating.
80. Airway Management (1 of 2)
Positioning the patient
– Supine position
In a perfect world all patients would present
in this position.
Quickly open the airway, assess breathing,
and intervene without moving them.
Log roll the individual as a unit
81. Airway Management (2 of 2)
– Recovery position
Left lateral recumbent position
Should be used in all nontrauma patients with
a decreased LOC who are able to maintain their
own airway spontaneously and are breathing
adequately
82. Manual Airway Maneuvers
Most common cause of airway obstruction
– Tongue
– Manually maneuver the
patient’s head to propel
the tongue forward.
83. Head Tilt–Chin Lift Maneuver
Tilting the patient’’s head back and lifting the chin
– Preferred technique for opening the airway of a
patient who has not sustained trauma
– Indications
– Contraindications
– Advantages
– Disadvantages
85. Jaw-Thrust Maneuver
If you suspect a cervical spine injury
– Open the airway by placing your fingers behind
the angle of the jaw and lifting the jaw forward.
– Indications
– Contraindications
– Advantages
– Disadvantages
89. Tongue-Jaw Lift Maneuver
Used more commonly to open a patient’’s airway
for the purpose of suctioning or inserting an
oropharyngeal airway
Cannot be used to ventilate a patient
91. Causes of Airway Obstruction (1 of 5)
Secondary to an infectious process or a severe
allergic reaction
Tongue
– Snoring respirations in partial obstruction
– Complete obstruction, no respiration
– Simple to correct
92. Causes of Airway Obstruction (2 of 5)
Foreign body
– Typical victim is middle-aged or older and wears
dentures.
– Patients with conditions that decrease their airway
reflexes are at an increased risk.
– Mild or severe airway obstruction
93. Causes of Airway Obstruction (3 of 5)
Laryngeal spasm and edema
– Results in spasmodic closure of the vocal cords
– Often caused by trauma during an overly aggressive
intubation attempt or immediately upon extubation
94. Causes of Airway Obstruction (4 of 5)
Fractured larynx
– Patency depends on good muscle tone to keep the
trachea open
– Increases airway resistance by decreasing airway
size secondary to decreased muscle tone, laryngeal
edema, and ventilatory effort
– Advanced airway may be required.
95. Causes of Airway Obstruction (5 of 5)
Aspiration
– Blood or other fluid significantly increases mortality.
– Destroys delicate bronchiolar tissue, introduces
pathogens into the lungs, and decreases the patient’s
ability to ventilate
– Suction should be readily available.
96. Recognition of an Airway
Obstruction (1 of 3)
Foreign body lodged in the upper airway
– Can cause a mild or severe airway obstruction
– Rapid but careful assessment
97. Recognition of an Airway
Obstruction (2 of 3)
Mild airway obstruction
– Conscious and able to exchange air
– May show varying degrees of respiratory distress
– Usually have noisy respirations and may be coughing
– Should be left alone; a forceful cough is the most
effective means of dislodging the obstruction.
98. Recognition of an Airway
Obstruction (3 of 3)
Severe airway obstruction
– Typically experiences a sudden inability to breathe,
talk, or cough
– Grasps at his
or her throat
– Weak, ineffective,
or absent cough
Photographed by Kimberly Potvin.
99. Care for Foreign Body
Airway Obstruction (1 of 4)
Patient with a suspected airway obstruction
– If conscious, ask “Are you choking?” If the patient
nods “yes,” begin treatment.
– If the obstruction is not promptly cleared the amount
of oxygen in the blood will decrease dramatically.
100. Care for Foreign Body
Airway Obstruction (2 of 4)
Unresponsive patient
– Manage as if he or she has a compromised airway.
– Open and maintain the airway with the appropriate
manual maneuver.
– Assess for breathing.
– Provide artificial ventilation if necessary.
101. Care for Foreign Body
Airway Obstruction (3 of 4)
After opening the airway
– If you are unable to ventilate or if you feel resistance
when ventilating, reopen the airway and again attempt
to ventilate the patient.
– Lung compliance
102. Care for Foreign Body
Airway Obstruction (4 of 4)
Large pieces of vomitus, mucus, loose dentures,
or blood clots
– If found in the airway, sweep them forward and out
of the mouth with your gloved index finger.
– Blind finger sweeps of the mouth
– Take care not to force the foreign body deeper into
the airway.
– Do not blindly insert any object into the patient’s
mouth.
– Suction to clear the airway of secretions.
107. Heimlich Maneuver
Abdominal thrusts
– Most effective method of dislodging and forcing an
object out of the airway
– Aims to create an artificial cough by forcing residual
air out of the victim’s lungs
– If the patient is in the advanced stages of pregnancy
or is morbidly obese, perform chest thrusts instead.
108. Direct Laryngoscopy (1 of 2)
Visualization of the airway with a laryngoscope for
the removal of the foreign body in unresponsive
patients
– If you are unable to relieve a severe airway
obstruction in an unconscious patient
– Insert the blade into the patient’s mouth.
109. Direct Laryngoscopy (2 of 2)
– If you see the foreign body, carefully remove it from
the upper airway.
– Magill forceps
110. Skill Drill 11-11:
Removal of an Upper Airway
Obstruction With Magill Forceps
Step 1
Step 2
Step 3
Step 4
111. Suctioning
Patient’’s mouth filled
– Vomitus, blood, or secretions
– Suction apparatus enables you to remove the liquid
quickly and efficiently.
– Ventilating a patient with secretions in his or her
mouth will force material into the lungs, resulting
in an upper airway obstruction or aspiration.
– If you hear gurgling, the patient needs suctioning!
112. Suctioning Equipment (1 of 7)
Ambulances should carry:
– Fixed suction unit
– Portable suction unit
– Regardless of location
Hand-operated suctioning units
– Disposable containers
– Reliable, effective, and relatively inexpensive
113. Suctioning Equipment (2 of 7)
Mechanical or vacuum-powered suction units
– Should be capable of generating a vacuum of
300 mm Hg within 4 seconds of clamping off the
tubing
– Amount of suction should be adjustable for use in
children and intubated patients.
– Check the vacuum at the beginning of every shift.
116. Suctioning Equipment (5 of 7)
Other supplies
– Wide-bore, thick-walled, nonkinking tubing
– Soft and rigid suction catheters
– A nonbreakable, disposable collection bottle
– A supply of water for rinsing the catheters
117. Suctioning Equipment (6 of 7)
Suction catheter
– Hollow, cylindrical device
– Used to remove fluids and secretions from the
patient’s airway
– Yankauer catheter
(tonsil-tip catheter)
Rigid catheter
119. Suctioning Techniques (1 of 3)
Mortality increases significantly if a patient
aspirates.
– Suctioning the upper airway is critical to avoid
this fatal event.
– Removes not only liquids from the airway,
but also oxygen
– Any patient who is to be suctioned should be
adequately preoxygenated first.
120. Suctioning Techniques (2 of 3)
Using soft-tip catheters
– Must be lubricated when suctioning the nasopharynx
– Used through an ET tube
– Catheter is inserted and suction is applied during
extraction of the catheter to clear the airway.
121. Suctioning Techniques (3 of 3)
Before inserting any suction catheter
– Make sure you measure for the proper size.
– Never insert a catheter past the base of the tongue.
123. Your partner takes over the airway from the fire
department.
You immediately apply the ECG monitor and see the
patient is in asystole.
You partner is asking for a suction unit to remove
vomitus from the airway.
– What is your next immediate treatment?
(continued)
124. Airway Adjuncts
First step
– Open the airway, initially by manual methods.
If the patient has an altered LOC, an artificial
airway may then be needed to help maintain an
open air passage.
An artificial airway is not a substitute for proper
head positioning.
125. Oropharyngeal Airway (1 of 3)
Oral
– Curved, hard plastic device
– Fits over the back of the tongue
– Designed to hold the tongue away from the posterior
pharyngeal wall
127. Oropharyngeal Airway (3 of 3)
Improperly sized or inserted incorrectly
– Could actually push the tongue back into the pharynx,
creating an airway obstruction
– Rough insertion can injure the hard palate, resulting in
oral bleeding and creating a risk of vomiting or
aspiration.
– Prior to inserting, suction the oropharynx as needed
to ensure that the mouth is clear of blood or other
fluids.
130. Nasopharyngeal Airway (1 of 2)
Nasal
–
– Inserted through the nose into the posterior pharynx
behind the tongue
– Allows passage of air from the nose to the lower
airway
– Much better tolerated than an oral airway in patients
who have an intact gag reflex yet an altered LOC
133. Measuring the Nasal Airway
Tip of the nostril to the angle of the jaw rather than
the earlobe
– If it is too long it may obstruct the patient’s airway.
– If the patient becomes intolerant of the nasal airway,
gently remove it from the nasal passage.
134. Supplemental Oxygen Therapy
Should be administered to any patient with potential
hypoxia, regardless of his or her clinical appearance
– In some conditions, a part of the patient’s body does
not receive enough oxygen, even though the oxygen
supply to the body as a whole is entirely adequate.
– Increasing the available oxygen supply also enhances
the body’s compensatory mechanisms during shock
and other distressed states.
135. Oxygen Sources (1 of 2)
Pure (100%) oxygen
– Stored in seamless steel or aluminum cylinders
– Labeled “medical oxygen”
– Month and year stamps
136. Oxygen Sources (2 of 2)
Delivery
– Measured in terms of
liters per minute (L/min)
– Replace an oxygen
cylinder with a full one
when the pressure falls
to 200 psi or below.
137. Liquid Oxygen
Cooled to an aqueous state
– Converts to a gaseous state when
warmed
– Special requirements for large
volume storage and cylinder transfer
HELiOS® Marathon™ portable oxygen unit. Courtesy of Nellcor Puritan Bennett in affiliation with Tyco Healtcare.
138. Oxygen Regulators and Flowmeters (1 of 5)
High-pressure regulators
– Attached to the cylinder stem
– Used to transfer cylinder gas from tank to tank
– Pressure of gas in a full oxygen cylinder is
approximately 2,000 psi.
– Too much pressure to deliver directly into a patient’s
airway
139. Oxygen Regulators and Flowmeters (2 of 5)
Therapy regulator
– Controls gas flow from an oxygen cylinder to the
patient
– Attaches to the stem of the oxygen cylinder and
reduces the high pressure of gas to a safe range
140. Oxygen Regulators and Flowmeters (3 of 5)
Flowmeters
– Usually permanently attached to the therapy regulator
– Allow the oxygen delivered to the patient to be
adjusted within a range of 1 to 25 L/min
141. Oxygen Regulators and Flowmeters (4 of 5)
Pressure-compensated flowmeter
– Incorporates a float ball within a
tapered calibrated tube
– Gas flow is controlled by a needle
valve located downstream from
the float ball.
142. Oxygen Regulators and Flowmeters (5 of 5)
Bourdon-gauge flowmeter
– Not affected by gravity
and can be placed
in any position
– Calibrated to record
the flow rate
– Major disadvantage
is that it does not
compensate for
backpressure.
144. Safety Considerations (1 of 3)
Cylinder containing compressed gas under high
pressure
– Under the right conditions, it has the potential
to become a rocket.
– Oxygen presents the additional hazard of fire.
145. Safety Considerations (2 of 3)
Handling oxygen cylinders
– Keep combustible materials, such as oil or grease, away
from contact with the cylinder itself, the regulators,
fittings, valves, or tubing.
– Do not permit smoking in any area where oxygen
cylinders are in use or on standby.
– Store oxygen cylinders in a cool, well-ventilated area.
– Use an oxygen cylinder only with a safe, properly fitting
regulator valve.
– Close all valves when the cylinder is not in use, even if
the tank is empty.
146. Safety Considerations (3 of 3)
Handling oxygen cylinders (continued)
– Secure cylinders so that they will not topple over. In
transit, keep them in a proper carrier or rack, or strap
them onto the stretcher with the patient.
– When working with an oxygen cylinder, always
position yourself to its side. Never place any part
of your body over the cylinder valve.
– Have the cylinder hydrostat tested every 10 years,
to make sure it can still sustain the high pressures
required. The original test date is stamped onto the
cylinder together with its serial number.
147. Supplemental Oxygen-Delivery
Devices (1 of 11)
Nonrebreathing mask
– Preferred device
Good mask-to-face seal
Flow rate of 15 L/min
Capable of delivering
between 90% and
100% inspired oxygen
148. Supplemental Oxygen-Delivery
Devices (2 of 11)
– Combination mask and reservoir bag system
Oxygen fills a reservoir bag that is attached to the
mask by a one-way valve.
Permits the patient to inhale from the reservoir bag
but not to exhale back into it
Exhaled gas escapes through one-way flapper
valves located on the side of the mask.
149. Supplemental Oxygen-Delivery
Devices (3 of 11)
– Prior to administering oxygen
Ensure that the reservoir bag is completely filled.
Oxygen flow rate is adjusted from 12 to 15 L/min
to prevent collapse of the bag during inhalation.
Use a pediatric nonrebreathing mask for infants
and small children.
150. Supplemental Oxygen-Delivery
Devices (4 of 11)
– Considerations
Indications
Contraindications
Patient’s respirations must be of adequate depth
to open the one-way valve and draw air from the
reservoir bag into the lungs.
Patient with reduced tidal volume will benefit very
little.
151. Supplemental Oxygen-Delivery
Devices (5 of 11)
Nasal cannula
– Delivers oxygen via two small prongs that fit into the
patient’s nostrils
Oxygen flow rate
of 1 to 6 L/min
Oxygen
concentration
of 24% to 44%
Higher flow rates
irritate the nasal
mucosa.
152. Supplemental Oxygen-Delivery
Devices (6 of 11)
Nasal cannula (continued)
– Oxygen humidifier should be used when delivering
oxygen via nasal cannula for a prolonged period
of time.
– Low to moderate oxygen enrichment
– Generally well tolerated, especially in patients who
are claustrophobic and intolerant of an oxygen mask
over their face
153. Supplemental Oxygen-Delivery
Devices (7 of 11)
Simple face mask
– Full mask enclosure with open side ports
Room air is drawn
through the ports.
Exhaled air is vented
through holes.
Delivers between
40% and 60%
oxygen at 10 L/min
Rarely used
in the field
154. Supplemental Oxygen-Delivery
Devices (8 of 11)
Partial rebreathing mask
– Similar to nonrebreathing mask
Room air is not drawn in with inspiration.
Residual expired air is
mixed and rebreathed.
Higher concentrations
are attainable at flow
rates of 6 to 10 L/min
(35% to 60%).
Rarely used
in the field
155. Supplemental Oxygen-Delivery
Devices (9 of 11)
Venturi mask
– Draws room air along with oxygen flow
Allows for the administration
of highly specific
oxygen concentrations
Delivers 24%, 28%,
35%, or 40% oxygen
Long-range transport
of patients
156. Supplemental Oxygen-Delivery
Devices (10 of 11)
Small-volume nebulizer
– Nebulizer
Used primarily to deliver aerosolized medications
Oxygen enters an aerosol chamber that contains
3 to 5 mL of fluid.
157. Supplemental Oxygen-Delivery
Devices (11 of 11)
Oxygen humidifier
– Oxygen stored in cylinders
Zero humidity
Rapidly dries the patient’s
mucous membranes
Small bottle of water
moisturizes oxygen before it
reaches the patient.
Practical only for the fixed
oxygen unit
158. Assisted and Artificial Ventilation
Patient who is not breathing
– Needs artificial ventilation with 100% oxygen
– Same is true of patients who are breathing inadequately
– Inadequate negative-pressure ventilation is treated with
some form of positive-pressure ventilation.
159. Mouth-to-Mouth
and Mouth-to-Nose Ventilation (1 of 3)
Mouth-to-mouth
– Most basic form of ventilation
Mouth-to-nose
– Simply involves ventilating through the nose.
– Apnea and when other ventilation devices
are not available
160. Mouth-to-Mouth
and Mouth-to-Nose Ventilation (2 of 3)
Disadvantages
– Psychological barriers secondary to sanitary and
communicable disease issues
– Potential for exposure to blood and other body fluids
through direct contact
– Other methods are safer for the rescuer.
161. Mouth-to-Mouth
and Mouth-to-Nose Ventilation (3 of 3)
Potential complications
– Hyperventilation of the patient’s lungs
– Hyperventilation of the rescuer
– Gastric distention, increasing the risk of vomiting
and aspiration
– Always carry a pocket mask or face shield.
162. Mouth-to-Mask Ventilation (1 of 2)
Eliminates direct contact
– Use of a one-way valve over the mask’s mouthpiece
virtually eliminates any possibility of contact with the
patient’s secretions and diverts the patient’s exhaled
air away from the rescuer’s mouth.
– Easier to maintain an effective seal and deliver
excellent tidal volume
163. Mouth-to-Mask Ventilation (2 of 2)
Complications
– Hyperinflation of the patient’s lungs
– Hyperventilation of the rescuer
– Gastric distention
165. One-Person Bag-Mask Ventilation (1 of 2)
Bag-mask device
– Most common device used to ventilate patients
in the field
– Oxygen flow rate of 15 L/min and a reservoir attached
– Indicated for apneic patients and for patients who are
breathing inadequately
– Allows the rescuer to ventilate the patient for
extended periods of time without fatigue
166. One-Person Bag-Mask Ventilation (2 of 2)
Major challenge
– Maintaining an
effective
mask-to-face seal
– Single person must
keep the airway
properly positioned,
maintain a mask seal,
and squeeze the bag.
– Complications
168. Two-Person Bag-Mask Ventilation (1 of 2)
Much more efficient
– One can maintain an adequate mask-to-face seal,
while the other squeezes the bag.
– Facilitates the delivery of excellent tidal volume
and high oxygen concentrations
– Indications
– Contraindications
169. Two-Person Bag-Mask Ventilation (2 of 2)
Disadvantage
– Requires additional personnel
– Complications include hyperinflation of the patient’s
lungs and gastric distention.
171. Three-Person Bag-Mask Ventilation (1 of 2)
Indications
– Apneic patients
– Patients who are breathing inadequately
– Patients who cannot be ventilated by one
or two rescuers
– Patients with a possible spinal injury
– Contraindicated in patients who are intolerant
of the device.
172. Three-Person Bag-Mask Ventilation (2 of 2)
Disadvantages
– Technique requires additional personnel.
– Area around the patient’s head can become very
crowded.
Complications
– Hyperinflation of the patient’s lungs
– Gastric distention
174. Flow-Restricted, Oxygen-Powered
Ventilation Device (1 of 4)
Third potential source for artificial ventilation
– Manually triggered ventilator or demand valve
– Used to ventilate apneic patients or to administer
supplemental oxygen to spontaneously breathing
patients
175. Flow-Restricted, Oxygen-Powered
Ventilation Device (2 of 4)
– Demand valve triggered by the negative pressure
generated during inhalation
– Valve automatically delivers
100% oxygen and stops
the flow of gas at the
end of inhalation.
– Patients find it most
comfortable if they hold
the mask to their face
themselves.
176. Flow-Restricted, Oxygen-Powered
Ventilation Device (3 of 4)
Apneic patients
– Pushbutton on top of the FROPVD can control
the flow of oxygen.
– When depressed, 100% oxygen flows at a rate
of 40 L/min.
Requires an oxygen source
– Operator cannot feel whether the patient is being
adequately ventilated with this device.
177. Flow-Restricted, Oxygen-Powered
Ventilation Device (4 of 4)
Use
– Has been used for several years
– Recent findings suggest that it should not be used
routinely because of the high incidence of gastric
distention and damage to intrathoracic structures
caused by barotraumas.
– Should not be used when ventilating infants or children
or for patients with possible cervical spine or chest
injury
– Cricoid pressure must be maintained to ventilate
nonintubated patients.
181. Automatic Transport Ventilators (1 of 5)
Solves the problems of other ventilators
– Maintaining a mask seal
– Variations in the rate and duration of ventilation
Courtesy of Impact Instrumentation, Inc.
182. Automatic Transport Ventilators (2 of 5)
Control box
– Allows the variables of ventilation (tidal volume and
respiratory rate) to be set
– Minute volume controlled with considerable accuracy
– Indicated when patients need extended periods
of ventilation
183. Automatic Transport Ventilators (3 of 5)
Small and compact
– Some no larger than portable tape players
– Mechanical simplicity, durability, and portability
– Frees up your hands to tend to other tasks
184. Automatic Transport Ventilators (4 of 5)
Settings
– Respiratory rate is set at the midpoint for the patient’s
age.
– Tidal volume is usually set in a range of 6 to 7 mL/kg.
– Deliver a preset volume at a preset ventilatory rate
186. Cricoid Pressure (1 of 4)
Sellick maneuver
Gastric distention
– Can be partially
prevented or alleviated
– Can also help prevent
passive regurgitation
with aspiration
187. Cricoid Pressure (2 of 4)
Posterior pressure to the cricoid cartilage
– Esophagus is partially occluded.
– Provides more air delivery into the lungs and less air
delivery into the stomach
– Indicated only in unconscious patients who cannot
protect their own airway and are at imminent risk
for vomiting
188. Cricoid Pressure (3 of 4)
Disadvantages
– Extreme or a large quantity of emesis if pressure
is removed
– Should be maintained until the patient is intubated
– Requires two providers
– If a cervical spine injury is present, may cause further
injury.
189. Cricoid Pressure (4 of 4)
Potential complications
– Trauma to the larynx if excessive force is used
– Esophageal rupture from unrelieved high gastric
pressures
– Obstruction of the trachea when used in small
children
191. Your partner finishes suctioning, ventilates the patient,
and attempts intubation.
You partner verbalizes that he is unable to “see
anything.”
– What do you want to consider next?
(continued)
192. Gastric Distention (1 of 2)
Inflation of the stomach with air
– Any form of artificial ventilation that blows air into the
patient’s mouth
– Likely to occur when
Excessive pressure is used to inflate the lungs
Ventilations are performed too fast
Airway is partially obstructed during ventilation
attempts
193. Gastric Distention (2 of 2)
Signs
– Increase in the diameter of the stomach
– Increasingly distended abdomen
– Increased resistance to bag-mask ventilations
194. Invasive Gastric Decompression
Gastric tube
– Inserted into the stomach; removes the contents
with suction
Decreases the pressure on the diaphragm
Virtually eliminates the risk of regurgitation
and aspiration
Orogastric tube or nasogastric tube
Should be considered for any patient who will need
positive-pressure ventilation for an extended
period of time
195. Nasogastric Tube
Inserted through the nose
– Also used to perform gastric lavage
– Relatively well tolerated
– Most patients who are awake
will gag and may vomit.
– Poor technique can cause
trauma.
199. Orogastric Tube
Inserted through the mouth instead of the nose
– No risk of nasal bleeding
– Safer in patients
with severe facial
trauma
– Less comfortable
for conscious patients
202. Endotracheal Intubation (1 of 6)
Defined
– Passing an endotracheal (ET) tube through the glottic
opening and sealing the tube with a cuff inflated
against the endotracheal wall
– Orotracheal
– Nasotracheal
– Most definitive means of achieving complete control
of the airway
204. Endotracheal Intubation (3 of 6)
Structure
– Proximal end, the tube, the cuff and pilot balloon,
and the distal tip
– Inflation port
with a pilot balloon
– Distal cuff
– Pilot balloon
205. Endotracheal Intubation (4 of 6)
Structure (continued)
– Centimeter markings provide a measurement
of its depth.
– Murphy’s eye
– Range in size from
2.5 to 9.0 mm inside
diameter, and length
from 12 to 32 cm
206. Endotracheal Intubation (5 of 6)
Laryngoscope
– Required to perform orotracheal intubation
by direct laryngoscopy
– Laryngoscope
– Handle contains
the power source
207. Endotracheal Intubation (6 of 6)
Laryngoscope (continued)
– Straight (Miller) blade
– Curved blade
– Blade sizes range
from 0 to 4.
– Stylet
– Magill forceps
208. Orotracheal Intubation
by Direct Laryngoscopy (1 of 16)
Considerations
– Indications
– Contraindications
– Advantages
– Disadvantages
– Complications
210. Orotracheal Intubation
by Direct Laryngoscopy (3 of 16)
Body substance isolation
– Intubation may expose you to blood or other fluids.
– Mask that covers your entire face
Preoxygenation
– Critical step prior to intubation
– Monitor the patient’s saturated oxygen levels.
211. Orotracheal Intubation
by Direct Laryngoscopy (4 of 16)
Positioning the patient
– Three axes: mouth, pharynx, and larynx
– “Sniffing” position
213. Orotracheal Intubation
by Direct Laryngoscopy (6 of 16)
Blade insertion
– Position yourself at the top of the patient’s head.
– Hold the laryngoscope as low down on the handle
as possible.
– Insert the blade into
the right side of the
patient’s mouth.
214. Orotracheal Intubation
by Direct Laryngoscopy (7 of 16)
Blade insertion (continued)
– Use the flange of the blade to sweep the tongue
gently to the left side of the mouth while moving the
blade into the midline.
– Slowly advance the
blade.
– Exert gentle traction
at a 45° angle to the
floor as you lift the
patient’s jaw.
216. Orotracheal Intubation
by Direct Laryngoscopy (9 of 16)
Visualization of the glottic opening
– Continue lifting the laryngoscope as you look down
the blade.
– With the curved blade, walk the
blade down the tongue.
– With the straight blade, insert
the blade straight back until
the tip touches the posterior
pharyngeal wall.
217. Orotracheal Intubation
by Direct Laryngoscopy (10 of 16)
Visualization (continued)
– Vocal cords are white
fibrous bands that lie
vertically within the glottic
opening.
– If you are having difficulty
seeing the opening, take
your right hand and locate
the lower third of the thyroid
cartilage.
– Gum bougie
218. Orotracheal Intubation
by Direct Laryngoscopy (11 of 16)
Tube insertion
– Insert the tube from the right corner of the patient’s
mouth through the vocal cords.
– Continue to insert the
tube until the proximal
end of the cuff is
1 to 2 cm past the
vocal cords.
– Blade is not a guide
for the tube.
219. Orotracheal Intubation
by Direct Laryngoscopy (12 of 16)
Ventilation
– Remove the blade, hold the tube securely, and
remove the stylet from the tube.
– Inflate the distal cuff with 5 to 10 mL of air and
then detach the syringe from the inflation port.
– Have your assistant attach the bag-mask device
to the ET tube and continue ventilation.
– Monitor the patient’s chest to ensure that it rises
with each ventilation.
220. Orotracheal Intubation
by Direct Laryngoscopy (13 of 16)
Confirmation of tube placement
– Misplaced tube that goes undetected is a fatal error.
– Auscultation
– Bilaterally absent breath sounds or gurgling over
the epigastrium indicate you have intubated the
esophagus.
221. Orotracheal Intubation
by Direct Laryngoscopy (14 of 16)
Repositioning the tube
– Loosen or remove the tube-securing device.
– Deflate the distal cuff.
– Place your stethoscope over the left side of the chest.
– While ventilation continues, slowly retract the tube
while simultaneously listening for breath sounds over
the left side of the chest.
222. Orotracheal Intubation
by Direct Laryngoscopy (15 of 16)
Repositioning the tube (continued)
– Stop as soon as bilaterally equal breath sounds
are heard.
– Note the depth of the tube at the patient’s teeth.
– Reinflate the distal cuff.
– Secure the tube.
– Resume ventilations.
223. Orotracheal Intubation
by Direct Laryngoscopy (16 of 16)
End-tidal carbon dioxide detectors
– Detect the presence of carbon dioxide in exhaled air
– Reliable method for confirming proper tube placement
– Capnographer
– Capnometer
Courtesy of Marianne Gausche-Hill, MD, FACEP, FAAP
224. Skill Drill 11-26:
Using Colorimetric Capnography
for Carbon Dioxide Detection
Step 1 Step 2
Step 3 Step 4
225. Esophageal Detector Device (EDD)
Bulb or syringe with a 15/22-mm adapter
– Syringe model
– Bulb model
Courtesy of Marianne Gausche-Hill, MD, FACEP, FAAP
226. Securing the Tube
Last step
– Inadvertent extubation caused by the patient
or someone else is relatively common.
– Reintubaton will almost certainly be more difficult.
– Never take your hand off the ET tube before it has
been secured with tape or a commercial device.
231. Bite Block
If the patient bites the tube or experiences a seizure,
the ET tube may become occluded.
– Insert a bite block or oral airway in between the
patient’s molars.
– Minimize head movement in the intubated patient.
236. Nasotracheal Intubation (1 of 6)
““Blind””
– Performed without direct visualization of the vocal
cords
– Excellent technique for establishing control over
the airway in situations where it is either difficult
or hazardous to perform laryngoscopy
– Must be performed on patients with spontaneous
breathing
237. Nasotracheal Intubation (2 of 6)
Considerations
– Indications and contraindications
– Advantages and disadvantages
– Complications
238. Nasotracheal Intubation (3 of 6)
Equipment
– Same equipment for orotracheal intubation—
minus the laryngoscope and stylet
– Standard ET tubes
– Endotrol tube
240. Nasotracheal Intubation (5 of 6)
Techniques for nasotracheal intubation
– Use the patient’s spontaneous respirations
to guide the ET tube.
– Tube is advanced as
the patient inhales.
– Angle of insertion is
critical; aim the tip of
the tube straight back
toward the ear.
241. Nasotracheal Intubation (6 of 6)
Techniques for nasotracheal intubation (continued)
– Position the tube just above the glottic opening.
– Patient will draw the tube into the trachea when he
or she inhales deeply.
– Placement of the tube in the trachea will be evidenced
by an increase in air movement through the tube.
245. Digital Intubation (1 of 4)
Intubation without a laryngoscope
– Blind or tactile intubation
– Involves directly palpating the glottic structures
and elevating the epiglottis with your middle finger
– Option in extreme circumstances
246. Digital Intubation (2 of 4)
Considerations
– Indications and contraindications
– Advantages and disadvantages
– Complications
Equipment
– Less equipment is needed.
– Same equipment except the laryngoscope
247. Digital Intubation (3 of 4)
Techniques for digital
intubation
– Rarely performed
because of the variety
of alternative airway
devices available
– “Open J” configuration
– “U-handle”
configuration
248. Digital Intubation (4 of 4)
Techniques (continued)
– Positioned at the left side facing toward the head
– Insert a bite block.
249. Skill Drill 11-31: Digital Intubation (1 of 4)
Step 1 Step 2
Step 3 Step 4
250. Skill Drill 11-31: Digital Intubation (2 of 4)
Step 5 Step 6
Step 7 Step 8
253. Transillumination Techniques
for Intubation (1 of 4)
Rarely considered a first-line technique to
definitively secure the airway
– May prove valuable in some situations
– Number of devices can be used for this technique.
– “Lighted stylet”
254. Transillumination Techniques
for Intubation (2 of 4)
Considerations
– Indications and contraindications
– Advantages and disadvantages
– Complications
Equipment
– Device with a rigid stylet and a bright light source
at the end
– Must be long enough to accommodate a standard-
length ET tube
255. Transillumination Techniques
for Intubation (3 of 4)
Technique for transillumination-guided intubation
– Patient must be preoxygenated.
– Lubricate and insert the lighted stylet so that the light
is positioned immediately at the tip of the tube.
– Prepare the tube by bending it into the proper shape.
– Stylet will act as the pivot point when you direct it into
the trachea.
256. Transillumination Techniques
for Intubation (4 of 4)
Techniques (continued)
– Place the patient’s head in a neutral or slightly
extended position.
– Light should become visible at the midline of the neck.
– A tightly circumscribed light slightly below the thyroid
cartilage indicates that the tip of the tube has entered
the trachea.
261. Tracheobronchial Suctioning
Suction catheter into the ET tube
– Remove pulmonary secretions.
– First rule—Don’t do it if you don’t have to!
– Strict attention to sterile technique
– Can cause cardiac dysrhythmias
– Avoid unless secretions are so massive that they
interfere with ventilation.
– Preoxygenation is essential.
264. Field Extubation (1 of 3)
Process of removing the tube from an intubated
patient
– Rarely extubated in the prehospital setting
– Generally only if the patient is unreasonably intolerant
of the ET tube
– Better to sedate the patient than remove the ET tube.
265. Field Extubation (2 of 3)
Risk
– Overestimation of the patient’s ability to protect his
or her own airway
– High risk of laryngospasm when performed on
conscious patients
– Most patients experience some degree of upper
airway swelling because of the trauma of having the
tube in the trachea.
– If you are not absolutely sure that you can reintubate
the patient, do not remove the tube!
266. Field Extubation (3 of 3)
If indicated
– Hyperoxygenate the patient.
– Discuss the procedure with the patient.
– Have the patient sit up or lean slightly forward.
– Assemble and have available all equipment to
suction, ventilate, and reintubate, if necessary.
– Suction the oropharynx.
– Deflate the distal cuff.
– Remove the tube in one steady motion.
271. Pediatric Endotracheal Intubation (3 of 9)
Laryngoscope and blades
– Most paramedics prefer the thinner pediatric handles.
– Straight blades facilitate lifting of the floppy epiglottis.
– Blade should extend from the child’s mouth to the
tragus of the ear.
272. Pediatric Endotracheal Intubation (4 of 9)
Laryngoscope and blades (continued)
– Premature newborn: size 0 straight blade
– Full-term newborn to 1 year of age: size 1 straight
blade
– 2 years of age to adolescent: size 2 straight blade
– Adolescent or older: size 3 straight or curved blade
273. Pediatric Endotracheal Intubation (5 of 9)
Endotracheal tubes
– Selected by using a length-based resuscitation tape
measure
– For children older than 1 year of age: Age in years ÷ 4
+ 4 or Age in years + 16 ÷ 4
– Anatomic clues
Courtesy of Marianne Gausche-Hill, MD, FACEP, FAAP
275. Pediatric Endotracheal Intubation (7 of 9)
Pediatric stylet
– Matter of personal preference when intubating the
pediatric patient
– Bend the tube into a gentle upward curve.
Preoxygenation
– Adequate with a bag-mask device and 100% for
at least 30 seconds prior to attempting intubation
276. Pediatric Endotracheal Intubation (8 of 9)
Additional preparation
– Stimulation of the parasympathetic nervous system
can occur during intubation in children.
– Pulse oximeter should be used throughout the
intubation attempt.
– Suction should be readily available to clear oral
secretions.
– Atropine sulfate
277. Pediatric Endotracheal Intubation (9 of 9)
Intubation technique
– Place the child’s head in a sniffing position.
– Open his or her mouth by applying thumb pressure
on the chin.
– Record the depth of the tube as measured at the
right-side corner of the child’s mouth.
– Confirm proper ET tube placement.
– Breath sounds travel easily in a child.
281. If Condition Deteriorates (1 of 2)
Take immediate action to identify and correct the
underlying problem.
DOPE mnemonic
– Displacement
– Obstruction
– Pneumothorax
– Equipment failure
283. Complications of Endotracheal Intubation
Unrecognized esophageal intubation
Induction of emesis and possible aspiration
Hypoxia resulting from prolonged intubation
attempts
Damage to teeth, soft tissues, and intraoral
structures
284. Your partner asks you to “take a look.”
When you insert the blade, you agree with your partner
that you are unable to see anything.
You insert a secondary airway device and ventilate the
patient through it.
– What do you want to consider next?
(continued)
285. Multilumen Airways (1 of 7)
Combitube and pharyngeotracheal lumen
airway (PtL)
– Provide better airway management and ventilation
compared to esophageal airways
– Long tube blindly inserted into the airway
– Ventilation is possible regardless of whether the tube
is placed into the esophagus or the trachea.
289. Multilumen Airways (5 of 7)
Equipment (continued)
– Combitube
Single tube with two
lumens, two balloons,
and two ventilation
ports
290. Multilumen Airways (6 of 7)
Procedures before and during insertion
– Check and prepare all your equipment.
– Check both cuffs.
– Preoxygenate with 100% oxygen.
– Place head in a neutral position.
– Forwardly displace the jaw.
– Insert the device.
– Inflate the cuffs.
291. Multilumen Airways (7 of 7)
Procedures after insertion
– After you inflate the balloons, begin to ventilate
the patient.
– With the PtL, first ventilate the short tube.
– With the Combitube, ventilate through the longer tube.
– Confirm adequate chest rise and the presence
of breath sounds.
297. The Laryngeal Mask Airway (1 of 9)
Originally developed for use in the operating room
– Alternative to bag-mask ventilation
– Commonly used during short surgical procedures
– Not designed for emergency use
– Not a replacement for endotracheal intubation
298. The Laryngeal Mask Airway (2 of 9)
Designed
– Provides a conduit from the glottic opening to the
ventilation device
– Surrounds the opening of the larynx with an inflatable
silicone cuff
– Inflatable cuff conforms to the contours of the airway
and forms a relatively airtight seal.
299. The Laryngeal Mask Airway (3 of 9)
Considerations
– Indications and contraindications
– Advantages and disadvantages
– Complications
300. The Laryngeal Mask Airway (4 of 9)
Equipment
– 5 sizes
Selection of size based on patient’s weight
301. The Laryngeal Mask Airway (5 of 9)
Equipment (continued)
– Device
Consists of an inflatable cuff attached to an
obliquely cut tube
Two vertical bars at the opening of the tube
prevent occlusion.
Proximal end of the tube is fitted with a standard
15/22-mm adapter.
302. The Laryngeal Mask Airway (6 of 9)
Procedures before and during insertion
– Check and prepare all equipment.
– Preoxygenate the patient.
303. The Laryngeal Mask Airway (7 of 9)
Procedures before and during insertion (continued)
– Place the patient’s head in a sniffing position.
– Insert your finger between the cuff and the tube.
– Insert the LMA along the roof of the mouth.
– Inflate the cuff.
304. The Laryngeal Mask Airway (8 of 9)
Procedures after insertion
– Following inflation of the cuff, attach bag-valve device
and begin to ventilate the patient.
– Confirm chest rise and the presence of breath
sounds.
– Continuously and closely monitor for regurgitation
in the tube.
305. The Laryngeal Mask Airway (9 of 9)
Procedures after insertion (continued)
– Fast-trach LMA is designed to guide an ET tube
into the trachea and may prove a viable alternative
to direct laryngoscopy.
308. Pharmacologic Adjuncts (1 of 3)
Sedation in emergency intubation
– Used in airway management to reduce the patient’s
anxiety, induce amnesia, and decrease the gag reflex
– Useful for anxious, combative, or agitated patients
Complications
– Undersedation
– Oversedation
311. Neuromuscular Blockade
in Emergency Intubation (1 of 5)
Cerebral hypoxia
– Can make an ordinarily docile person combative,
aggressive, belligerent, and uncooperative
– Difficult and dangerous situation
312. Neuromuscular Blockade
in Emergency Intubation (2 of 5)
Cerebral hypoxia (continued)
– Common practice, in the past, to physically restrain
the patient to obtain a definitive airway
– Safer, more effective approach is to “chemically
paralyze” the patient with neuromuscular blocking
agents.
313. Neuromuscular Blockade
in Emergency Intubation (3 of 5)
Neuromuscular blocking agents
– Much more effective to administer a drug specifically
designed to induce paralysis
– Affect every skeletal muscle in the body
– Convert a breathing patient into an apneic patient
with no airway
– No effect on level of consciousness
314. Neuromuscular Blockade
in Emergency Intubation (4 of 5)
Pharmacology of neuromuscular blocking agents
– Acetylcholine
– Depolarizing
– Nondepolarizing
316. Rapid-Sequence Intubation (1 of 3)
Culmination and integration of all your skills
– Preparation of the patient and equipment
– Preoxygenation
– Premedication
– Sedation and paralysis
– Posterior cricoid pressure
– Intubation
– Maintenance of paralysis and sedation
319. Surgical and Nonsurgical Airways (1 of 2)
In most cases
– Paramedic is able to secure a patent airway with
relative ease using either basic or advanced methods.
– In some situations, the patient’s condition or other
factors preclude the use of conventional airway
techniques.
320. Surgical and Nonsurgical Airways (2 of 2)
– Two methods
Open cricothyrotomy
Translaryngeal catheter ventilation
– Blood vessels in this area
Superior cricothyroid vessels
External jugular vein
321. Open Cricothyrotomy (1 of 6)
Incising the cricothyroid membrane
– Scalpel
– Inserting an endotracheal or tracheostomy tube
directly into the subglottic area of the trachea
322. Open Cricothyrotomy (2 of 6)
Considerations
– Indications and contraindications
– Advantages and disadvantages
– Complications
324. Open Cricothyrotomy (4 of 6)
Equipment (continued)
– Scalpel
– ET tube or tracheostomy tube
– Commercial device (or tape) for securing the tube
– Curved hemostats
– Suction apparatus
– Sterile gauze pads for minor bleeding control
– Bag-mask device attached to 100% oxygen
325. Open Cricothyrotomy (5 of 6)
Technique for performing open cricothyrotomy
– Identify the cricothyroid membrane by palpating
for the V notch.
– Stabilize the larynx.
– Depression between the thyroid and cricoid cartilage
– Prepare equipment and ensure that the cardiac
monitor and pulse oximeter are attached to the
patient.
326. Open Cricothyrotomy (6 of 6)
Technique (continued)
– Maintain aseptic technique as you cleanse the area
with iodine.
– Make a 1- to 2-cm vertical incision over the
cricothyroid membrane.
– Insert the curved hemostats into the opening
and spread it apart.
– Gently insert the ET tube or tracheostomy tube.
– Confirm the correct tube placement.
330. Needle Cricothyrotomy (1 of 5)
14- to 16-gauge over-the-needle IV catheter
– Inserted through the cricothyroid membrane and into
the trachea
– Adequate oxygenation and ventilation are then
achieved by attaching a high-pressure jet ventilator
to the hub of the catheter.
– Temporary measure until a more definitive airway
can be obtained
331. Needle Cricothyrotomy (2 of 5)
Considerations
– Indications and contraindications
– Advantages and disadvantages
– Complications
332. Needle Cricothyrotomy (3 of 5)
Equipment
– Large-bore IV catheter (14 to 16 gauge)
– 10-mL syringe
– 3 mL of sterile water or saline
– Oxygen source (50 psi)
– High-pressure jet ventilator device and oxygen tubing
333. Needle Cricothyrotomy (4 of 5)
Technique for performing needle cricothyrotomy
– Place the patient’s head in a neutral position.
– Locate the cricothyroid membrane.
– Carefully insert the needle into the midline of the
cricothyroid membrane at a 45-degree angle toward
the feet.
334. Needle Cricothyrotomy (5 of 5)
Technique (continued)
– After the pop is felt, insert the needle approximately
1 cm farther and then aspirate the syringe.
– Secure the catheter.
– Continue ventilations.
338. Special Patient Considerations (1 of 3)
Laryngectomy, tracheostomy, stoma,
and tracheostomy tubes
– Laryngectomy
Surgical procedure in which the larynx is removed
Tracheostomy
Stoma
339. Special Patient Considerations (2 of 3)
– Laryngectomy (continued)
Total laryngectomy
“Neck breather”
Partial laryngectomy
“Partial neck breathers”
340. Special Patient Considerations (3 of 3)
Suctioning of a stoma
– Failure to recognize and identify these patients could
result in hypoxia.
– Common for a patient’s stoma to become occluded
with mucous plugs
– Less efficient cough
– Performed with extreme care
– Limit suctioning to 10 seconds.
343. Ventilation of Stoma Patients
Neither the head tilt–chin lift nor the jaw-thrust
maneuver is required for ventilating a patient with
a stoma.
Stoma and no tracheostomy tube, mouth-to-stoma
technique
Use an infant- or child-size mask to make an
adequate seal over the stoma.
Two rescuers needed
347. Tracheostomy Tubes
Plastic tube placed within the tracheostomy site
– Requires a 15/22-mm adapter to be compatible
with ventilatory devices
– Often have thick secretions in the tube
– Stenosis
350. Dental Appliances (1 of 2)
Many different forms
– Dentures (upper, lower, or both)
– Bridges
– Individual teeth
– Braces
– If the appliance fits well, leave it in place.
– If it is loose, it could easily become an airway
obstruction and should be removed.
351. Dental Appliances (2 of 2)
Airway obstruction caused by a dental appliance
– Perform the usual steps in clearing an obstruction.
– Bridge
352. Facial Trauma (1 of 2)
Especially challenging
– Face is highly vascular.
– Severe tissue swelling and bleeding into the airway
– Control bleeding with direct pressure and suction the
airway as needed.
– Suction the patient’s airway for 15 seconds and then
provide ventilation for 2 minutes.
353. Facial Trauma (2 of 2)
Increase your index of suspicion.
– Cervical spine injury
– Use the jaw-thrust maneuver and keep the patient’s
head in a neutral in-line position.
– Stay alert for changes in ventilation compliance
or sounds that may indicate laryngeal edema.
354. You believe that you have successfully inserted a
secondary airway device.
You also attempt to insert an NG tube to help relieve
some of the gastric distention caused by the inadequate
ventilations.
Summary
355. Summary
Anatomy of the airway
Ventilation and respiration
Airway management
Advanced airway management
Pharmacology
Surgical and nonsurgical airways
