Airway and Ventilation Greg Smith, B.S., EMT-P

Objectives Discuss patient assessment Demonstrate assessment tools Discuss oxygenation devices Discuss airway research Demonstrate airway & ventilation devices

Assessment Recognize Failure vs. Distress Sounds Appearance Position Speech Failure: Load & Go, tell everyone

Assessment Rate, <10 or > 30 Pattern, regular Volume: shallow vs. deep Lung sounds on every patient Deep breathes, in & out thru mouth Present, diminished Crackles Wheezing

Pulse Oximeter Measures O2 saturation & pulse rate Factors affecting reliability: Poor perfusion: hypotension, cool extremities, hypothermia Excessive sensor movement High ambient light, wash out effect Measures hemoglobin bound with O2 or CO, it can’t tell the difference

Nonin 8500, yellow case Sp02 & pulse Perfusion light On, off Green = good Yellow = marginal Red = unreliable On, off 6 AA batteries, replace when display flashes

Nonin 9843, orange case Includes CO2 detection, NOT capnography Perfusion light Battery light CO2 display Bottom bar = Ok 3rd & 6th bar = problem Store with airway adapter connected and cable not plugged in

Pulse Oximeter Procedure Attach, verify perfusion and signal strength, NO SpO2 yet, no snapshot reading Compare radial vs. pulse ox HR No radial = unreliable reading, try ear lobe Consistent green light, radial & HR within 10 bpm, now determine SpO2 Ear sensor, rub ear 5 seconds, cover lobe, limit stray light in

Treatment Oxygenation: Aerosol treatments Ventilation N/C, NRB, CPAP Mouthpiece, mask, BVM, CPAP Ventilation BVM, Transport Ventilator BVM 2 Rescuer most effective in unprotected airway

CPAP- Continuous Positive Airway Pressure Indications CHF/Pulmonary Edema Work of breathing, Failure GCS 10 or > Asthma or COPD, if not responding to other treatments Contraindications Agonal, apenic BP < 90 systolic, persistent vomiting pneumothorax

CPAP- Load & Go O2 on, turn counterclockwise & ensure at 0 Coach patient, in thru nose & out thru mouth Clockwise to 5 cm on Inspiration, up to 10 cm Advise receiving hospital of CPAP Many hospitals use Bi-Pap No improvement, check equipment, consider switching to BVM

Airway Management Head tilt, chin lift Jaw thrust Oral- center of mouth to angle of jaw or corner of mouth to ear lobe Nasal- nose to ear lobe Suction Devices

Suction Devices Suction-Easy Portable Suction- take to every unresponsive patient On-board suction Troubleshooting: Lid, caps, tubing, catheter

Suctioning Technique Oral- Tonsil tip- Hi-D Tip Portable- regulator in- 525 mm Hg On-board- clockwise to increase Tracheal- whistle tip- 6-14 Fr Portable- regulator out- 125 mm Hg On-board- counterclockwise to decrease Measure catheter depth, limit to 15 seconds, watch pulse ox & HR

Portable Suction S-SCORT VX2 Weekly check Confirm power light on, remove from charger Regulator in, turn on, occlude tubing, lid & motor change, release vacuum Run 15 minutes only, no more, full power, no vacuum, if it stops, slows, or battery lights on, lead acid battery needs replacement If Ok, reinsert into charger, verify charging lights on

Research on Intubation Arrived in ED with improperly placed or dislodged tubes Univ. of Pittsburgh School of Medicine, 22.7% of almost 2000 patients Patients need an airway to survive, NOT always an airway DEVICE

Brian Bledsoe , D.O. FACEP “Endotracheal intubation is problematic and the procedure should probably be stopped.” “Everybody better get used to … rescue airways because routine prehospital ETI is probably a thing of the past.” JEMS, August 2007

Intubation for I & P Study of 1,941 intubations, # of attempts 1st: 69.9% 2nd: 84.9% 3rd: 89.9% successful Get everything ready Partner holds the ET Tube Go Slow to insert blade, if you see pink mushy, withdraw and Go Slow You perform thyroid pressure to view glottic opening, then partner assumes Partner hands you ET Tube, don’t look away Insert ET Tube, verify and secure

ETT Confirmation Direct visualization Tube depth: Male: 23-21 cm, Female: 22-20 cm Epigastric sounds, lack of Breath sounds, mid-axillary, evaluate before & after Chest expansion Bag Compliance EID End tidal CO2 Problems: obesity, thoracic trauma, pregnancy, ambient noise, lung disease Don’t let one parameter sway you if others say no

King Airway Procedure Indications- primary or secondary device for adult AND Peds airway Apenic- I & P Pulseless & Apenic- B, I, & P Contraindications- gag reflex, esophageal disease, caustic substance

King Airway (Supraglottic) > 6’ tall: #5, purple, cuff 80 ml 5-6’: #4, red, cuff 70 ml 4-5’: #3, yellow, cuff 50 ml 41-51” or 25-35 kg: #2.5, orange, cuff 40 ml 35-45” or 12-25 kg: #2, green, cuff 35ml

King Airway Procedure Lift jaw, insert corner of mouth Advance behind base of tongue, rotate back to mid-line, blue line faces chin Advance until connector base aligned with teeth/gums Inflate cuff While ventilating, withdraw tube until ventilation is easy with minimal pressure, can add air to cuff to ensure seal Assess lung sounds, CO2 detection

Transport Ventilator Paramedic only No breaths on their own Attach to regulator & ventilation circuit Set tidal volume and BPM Listen for gas flow Check high pressure alarm Attach CO2 Detection Monitor and reassess patient

Controlled Airway Problems ET Tube, Trach, King Airway Think DOPE to troubleshoot Displaced- reinsert Obstruction- suction Pneumothorax- no field tx Equipment- trace back to source

Colorimetric CO2 detection Intact package, purple paper, check expiration date Attach to ETT or King, min. of 6 ventilations before assessing color change Change to gray, tan, yellow based on perfusion

Other tools Thomas ET holder Cervical Collar Backboard, CID, and tape

Review Recognize Failure = Load & Go Every patient needs an Airway, but not a device Lung Sounds on every patient Treatment & short on scene times can reduce untimely death Questions?