1. Temple College EMS Program1 Management of Airway and Breathing Emergency Medical Technician - Basic

2. Temple College EMS Program2 Airway Functions Passage that allows air to move from atmosphere to alveoli Must remain patent (open) at all times Anything that blocks airway will cause decrease in oxygen available to body Size of obstruction affects available air exchange

3. Temple College EMS Program3 Opening the Airway Techniques –Head-tilt/Chin-lift –Jaw Thrust –Suctioning –Nasopharyngeal airway –Oropharyngeal airway

4. Temple College EMS Program4 Head-Tilt/Chin-Lift Used when no neck injury is suspected Temporary procedure Must be replaced with an airway adjunct unless patient begins adequate spontaneous ventilation

5. Temple College EMS Program5 Head-Tilt/Chin-Lift Technique –Place one hand on patient’s forehead –Apply firm, backward pressure with palm causing head to tilt backward – Place fingers of other hand under bony part of patient’s lower jaw near chin –Lift jaw upward to bring chin forward

6. Temple College EMS Program6 Head-Tilt/Chin-Lift Patients needing head-tilt/chin-lift –Unresponsive patient without history of trauma –Cardiac arrest patients without signs of trauma –Apneic patients without signs of trauma

7. Temple College EMS Program7 Jaw Thrust Used when spinal injury suspected Temporary procedure Must be replaced with airway adjunct unless patient begins adequate spontaneous ventilation

8. Temple College EMS Program8 Jaw Thrust Technique –Place one hand on either side of patient’s head, resting elbows on surface on which victim is lying –Grasp angles of patient’s lower jaw, lift with both hands –If patient’s lips close, retract lower lips with thumbs

9. Temple College EMS Program9 Jaw Thrust Patients needing jaw thrust –Unresponsive trauma patient –Unresponsive patient with undetermined mechanism of injury

10. Temple College EMS Program10 Suctioning Purpose –Remove blood, vomit, other liquids, food particles from airway –May not be adequate for removing large, solid objects (teeth, foreign bodies, food) –Should be performed immediately when gurgling is heard with spontaneous or artificial ventilation

11. Temple College EMS Program11 Suctioning Suction devices –Mounted in ambulance –Portable Electrical Hand operated –Should generate 300mm Hg vacuum –Ensure batteries in units remain properly charged

12. Temple College EMS Program12 Suctioning Rigid Suction Catheter –Used to suction mouth, oropharynx of unresponsive patient –Inserted only as far as you can see –Take caution not to touch back of airway, particularly in infants and children (can cause heart rate to drop)

13. Temple College EMS Program13 Suctioning Soft Suction Catheter –Useful for suctioning nasopharynx or tracheostomy tubes –Should be inserted only as far as base of tongue or end of tracheostomy tube

14. Temple College EMS Program14 Suctioning Techniques –Turn on unit –Attach catheter –Insert catheter into oral cavity without suction –Insert only to base of tongue –Apply suction, move catheter from side to side –Suction no longer than 15 seconds in adults, 10 seconds in children, 5 seconds in infants –Rinse catheter with saline or water to prevent obstruction

15. Temple College EMS Program15 Nasal Airways Used on responsive patients who need help keeping tongue out of airway Insertion is uncomfortable for responsive patients

16. Temple College EMS Program16 Nasal Airways Technique –Measure from tip of nose to earlobe –Ensure airway will fit through nostril –Lubricate with water-soluble lubricant –Insert with bevel toward base of nostril or septum –If resistance is met, try other nostril –Do not use in patients with mid-face trauma or possible basilar skull fractures

17. Temple College EMS Program17 Nasal Airways Patients needing nasal airway –Unresponsive patients who are snoring –Unresponsive patients with gag reflex

18. Temple College EMS Program18 Oral Airways Used on unresponsive patients without gag reflex Helps hold tongue away from back of throat

19. Temple College EMS Program19 Oral Airways Technique –Measure from corner of mouth to earlobe or angle of jaw –Open patient’s mouth –In adults insert with tip facing roof of patient’s mouth, advance until resistance encountered, turn 180 o until flange comes to rest on patient’s teeth –In infants and children use tongue depressor to lift tongue, insert oral airway right side up

20. Temple College EMS Program20 Oral Airways Patients needing oral airway –Unresponsive, apneic patients with or without trauma –Any apneic patient being ventilated with a BVM

21. Temple College EMS Program21 Airway Limitations Nasal/oral airways are not definitive devices Manual maneuvers must be used with nasal/oral airways to ensure airway stays open Patients may require frequent suctioning to remove blood, vomit, other secretions from airway Definitive devices such as endotracheal tubes are required to completely protect the airway

22. Temple College EMS Program22 Adequate Breathing Normal Rate –Adult: 12 to 20/minute –Child: 15 to 30/minute –Infant: 25 to 50/minute Regular Rhythm Adequate Quality –Movement of air at mouth, nose –Chest expansion adequate, symmetrical (equal) –Breath sounds present, equal –Minimum effort of breathing –Adequate tidal volume (depth)

23. Temple College EMS Program23 Inadequate Breathing Abnormal Rate –Adult: 20/minute –Child: 30/minute –Infant: 50/minute Irregular Rhythm Inadequate Quality –Absent or reduced at mouth, nose –Chest expansion inadequate or asymmetrical (unequal) –Breath sounds diminished, unequal, noisy, absent –Increased effort of breathing, use of accessory muscles –Indequate (shallow) tidal volume

24. Temple College EMS Program24 Inadequate Breathing Skin changes –Pale, cool, clammy: Early sign –Cyanosis: Late, unreliable sign Retractions of soft tissues above clavicles, between ribs, below rib cage Flaring of nostrils “Seesaw” breathing in infants

25. Temple College EMS Program25 Ventilation Techniques (In order of preference) 1.Mouth-to-mask with supplemental oxygen 2.Two-person bag-valve mask with oxygen reservoir and supplemental oxygen 3.Flow restricted, oxygen-powered ventilation device (manually-triggered ventilator) 4.One-person bag-valve mask with oxygen reservoir and supplemental oxygen

26. Temple College EMS Program26 Ventilation Techniques Mouth-to-Mouth –Open airway –Pinch nose closed or seal nose with cheek –Take deep breath –Seal lips around patient’s mouth to create airtight seal –Blow into patient’s mouth slowly over 2 seconds until patient’s chest rises

27. Temple College EMS Program27 Ventilation Techniques Mouth-to-Mask –Connect mask to oxygen at 15 liters per minute –Kneel directly above patient’s head –Apply mask to patient’s face –Place thumbs along sides of mask, index fingers of both hands under patient’s mandible –Lift jaw into mask, tilt head if neck injury not suspected –Blow into one-way valve slowly over 2 seconds until patient’s chest rises

28. Temple College EMS Program28 Ventilation Techniques Bag-valve mask –Self-inflating bag –One-way valve –Face mask –Oxygen reservoir Must be connected to oxygen to perform most effectively

29. Temple College EMS Program29 Ventilation Techniques BVM Issues –Provides less volume than mouth-to-mask –Single rescuer may have difficulty maintaining air-tight seal –Two rescuers using device are more effective –Position yourself at top of patient’s head for best performance –Oral or nasal airway should be inserted

30. Temple College EMS Program30 Ventilation Techniques BVM Technique (Two Rescuer) –Open airway, insert oral or nasal airway –Position thumbs over top half of mask, index and middle fingers over bottom half –Place apex of mask over bridge of nose, lower mask over mouth/upper chin –Use ring and little fingers to bring jaw up to mask –Have assistant squeeze bag with two hands until chest rises –Ventilate every 5 seconds for adults, every 3 seconds for infants and children

31. Temple College EMS Program31 Ventilation Techniques BVM Technique (One Rescuer) –Open airway, insert oral or nasal airway –Form a “C” around ventilation port with thumb, index finger –Use middle, ring, little fingers under jaw to maintain chin lift, complete seal –Squeeze bag with other hand until chest rises –Ventilate every 5 seconds for adults, every 3 seconds for infants and children

32. Temple College EMS Program32 Ventilation Techniques BVM Technique (Suspected Trauma) –Open airway, insert oral or nasal airway –Have assistant hold patient’s head or use your knees to prevent movement –Position thumbs over top half of mask, index and middle fingers over bottom half –Place apex of mask over bridge of nose, lower mask over mouth/upper chin –Use ring and little fingers to bring jaw up to mask without tilting head or neck –Have assistant squeeze bag with two hands until chest rises –Ventilate every 5 seconds for adults, every 3 seconds for infants and children continue to hold jaw up without moving head or neck

33. Temple College EMS Program33 Ventilation Techniques If chest does not rise, reevaluate –If abdomen rises, reposition head or jaw –If air escapes under mask, reposition fingers and mask –Check for obstruction –If chest still does not rise and fall use another method of ventilation

34. Temple College EMS Program34 Ventilation Techniques Flow Restricted, Oxygen-Powered Ventilation Devices (Manually-Triggered Ventilator) –Peak flow of 100% oxygen at maximum of 40 lpm –Pressure relief valve that opens at 60 cm H 2 O –Audible alarm that sounds when relief valve pressure is exceeded –Trigger so both hands remain on mask to maintain seal Do NOT use on children or infants!!!

35. Temple College EMS Program35 Ventilation Techniques Manually-Triggered Ventilator –Open airway, insert oral or nasal airway –Position thumbs over top half of mask, index/middle fingers over bottom half –Place apex of mask over bridge of nose, lower mask over mouth and chin –Use ring/little fingers to bring jaw up to mask –Trigger device until chest rises –Repeat every 5 seconds

36. Temple College EMS Program36 Ventilation Techniques Manually-Triggered Ventilator (Suspected Trauma) –Open airway, insert oral or nasal airway –Have assistant hold head manually or use knees to prevent movement –Position thumbs over top half of mask, index/middle fingers over bottom half –Place apex of mask over bridge of nose, lower mask over mouth and chin –Use ring/little fingers to bring jaw up to mask without tilting head and neck –Trigger device until chest rises –Repeat every 5 seconds

37. Temple College EMS Program37 Assisting Patients Who Are Breathing Who needs assistance? –A patient who is not breathing –A patient who has reduced respiratory rate and tidal volume –A patient whose breathing rate is increased, but whose tidal volume is inadequate

38. Temple College EMS Program38 Assisting Patients Who Are Breathing Patients with rapid, shallow breathing –Explain procedure to patient –Place mask over patient’s mouth and nose –Initially assist ventilations at rate at which patient is breathing. Squeeze bag as patient inhales –Slowly adjust rate and tidal volume until adequate ventilations are achieved

39. Temple College EMS Program39 Assisting Patients Who Are Breathing Patients with slow, shallow breathing –Place bag over patient’s mouth and nose –Squeeze bag each time patient inhales –Adjust rate and tidal volume until adequate ventilations are achieved

40. Temple College EMS Program40 Special Considerations Stoma or tracheostomy tube –Attach BVM to tube, or use infant/child mask to make seal over stoma –Seal mouth/nose if air is escaping when ventilating at stoma –If unable to ventilate Suction stoma or tracheostomy tube Seal stoma, attempt to ventilate through mouth/nose

41. Temple College EMS Program41 Special Considerations Infants and children –Place infant’s head in neutral position –Extend child’s head slightly past neutral –Avoid excessive hyperextension –Avoid excessive ventilation, just make chest rise –Gastric distension is more common in children –Do not use BVMs with pop-off valves

42. Temple College EMS Program42 Special Considerations Dentures –Leave in place unless obviously loose –Remove if loose –Be prepared to remove if displacement occurs

43. Temple College EMS Program43 Oxygen Oxygen cylinder sizes –D cylinder 350 liters –E cylinder 625 liters –M cylinder 3,000 liters –G cylinder 5,300 liters –H cylinder 6,900 liters Contents under pressure Should be positioned to prevent falling, blows to valve-gauge assembly

44. Temple College EMS Program44 Oxygen Operating procedures –Remove protective seal –Quickly open, then shut valve –Attach regulator-flow meter to tank –Select proper size of oxygen mask for patient –Attach oxygen mask to flowmeter –Open flow meter to desired setting –Apply device to patient –When complete, remove device from patient, turn off device, remove all pressure from regulator

45. Temple College EMS Program45 Oxygen Non-rebreather mask –Preferred method of giving oxygen to prehospital patients –Up to 90% oxygen can be delivered –Non-rebreather bag must be full before mask is placed on patient –Flow rate should be adjused so when patient inhales, bag does not collapse (~15 lpm)

46. Temple College EMS Program46 Oxygen Nasal cannula –Rarely best method for giving adequate oxygen in emergency care settings –Should be used only if patient will not tolerate non-rebreather mask in spite of coaching

47. Temple College EMS Program47 Oxygen Concerns about giving too much oxygen to patients with COPD, infants, and children are NOT valid during short-term emergency administration Patients with COPD, infants, and children who require oxygen should be given high concentration oxygen.