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

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

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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

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

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

15. 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

16. 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

17. 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

18. 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

19. ETT Confirmation Direct visualization
Tube depth: Male: cm, Female: 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

20. 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

21. 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 kg: #2.5, orange, cuff 40 ml
35-45” or kg: #2, green, cuff 35ml

22. 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

23. 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

24. 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

25. 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

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

27. 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?