2. Chapter 9 Airway Management and Ventilation

3. Objectives (1 of 27)
Describe the anatomy of the following: upper airway, tongue, hypopharynx, nasopharynx, oropharynx, larynx, vocal cords.
Describe the function of the vocal cords.
Describe the flow of air from outside the body into the trachea.

4. Objectives (2 of 27)
Describe the reasons for and mechanisms of humidification and warming of the air as it passes through the naso- and oral pharynx.
Describe the pathological conditions that can occur in the nose, pharynx, and larynx to obstruct or retard air flow and identify the complications of laryngeal fracture.
Describe the methods of airway management.

5. Objectives (3 of 27)
Describe the methods and management of an obstructed airway.
Describe the mechanical methods of airway management including the benefits and limitations. Oral, nasal and EOA.
Describe how the cervical spine is protected throughout these maneuvers.

6. Objectives (4 of 27) 1.6.20 Describe the anatomy of the following:
Lungs
Trachea
Alveolus
Diaphragm
Thoracic wall
Pleural space
Describe how pulmonary ventilation (inhalation and exhalation) is accomplished.

7. Objectives (5 of 27)
Describe the gaseous exchange across the alveoli-capillary membrane (O2 and CO2.).
Describe the pulmonary problems that can complicate exhalation and inhalation, the mechanisms by which they reduce ventilation and management of each problem, including:
Open pneumothorax
Diaphragmatic injury
Closed pneumothorax (simple and tension)
Flail chest.

8. Objectives (6 of 27) 1.6.24 Describe the problems of ventilation.
Define mouth-to-mask ventilation, its benefits and limitations.
Discuss the bag-valve-mask (BVM), its benefits and limitations.
Discuss the techniques for evaluating the effectiveness of ventilation.
Discuss ventilation with an EOA.

9. Objectives (7 of 27)
* Discuss ventilation with an endotracheal tube.
* Describe the equipment and method of suctioning the airway, pharynx, and endotracheal tube.
S Demonstrate effective mouth-to-mask ventilation.
S Demonstrate effective bag-valve:
Mask
EOA
*ET
*Indicates optional.
“S” indicates a skill objective.

10. Objectives (8 of 27)
S Demonstrate the manual methods of airway management.
S Demonstrate the methods of management of an obstructed airway.
S Demonstrate the mechanical methods of airway management:
Nasal
Oral
EOA
*ET
“S” indicates a skill objective.

11. Objectives (9 of 27)
S Demonstrate the use of various types of portable and fixed suction devices.
1.7.1 Describe the anatomy of the following: upper airway, tongue, hypopharynx, nasopharynx, oropharynx, larynx, and vocal cords.
“S” indicates a skill objective.

12. Objectives (10 of 27) 1.7.2 Describe the relationship between:
Cords and larynx
Esophagus and larynx
Epiglottis and larynx
Tongue and larynx
True cords and false cords
Pharynx and larynx
1.7.3        Given a list of arterial oxygen concentrations, the student should be able to select the normal PO2, for a young adult breathing air.

13. Objectives (11 of 27)
1.7.4        Given a list of arterial carbon dioxide concentrations, the student should be able to select the normal PCO2.
1.7.5        Given an increase in arterial PCO2, the student should be able to name this condition and describe its effect on respiratory activity and on blood pH in the normal individual.

14. Objectives (12 of 27)
1.7.6        Given a decrease in arterial PO2, the student should be able to name this condition and describe its effect on respiratory activity in the normal individual.
1.7.7        Given an increase in CO2 production, the student should be able to list at least two ways in which this increase may occur.
1.7.8        Given an increase in CO2 elimination, the student should be able to describe how this elimination can occur.

15. Objectives (13 of 27)
1.7.9        Given a list of statements, the student should be able to identify the statement that best describes the purpose of suctioning a patient.
1.7.10        Given a diagram of a piston-powered suction unit, the student should be able to label and describe the operation and cleaning of each component and attached part.

16. Objectives (14 of 27)
Given that there are various types of suction units, the student should be able to list at least four different types of units determined by the method in which the suction effect is obtained.
Given that there are various types of suction catheters, the student should be able to list at least three different types, determined by difference in use and material composition.

17. Objectives (15 of 27)
1.7.13    Given a list of situations describing patients who require suctioning, the student should indicate which type of catheter should be used.
1.7.14    Given a list of statements, the student should be able to identify the statement that best describes the purpose of using the esophageal obturator airway.

18. Objectives (16 of 27)
1.7.15    Given a list of situations describing patients with airway maintenance problems or potential airway maintenance problems, the student should be able to identify situations in which the use of the esophageal obturator airway is indicated and contraindicated.
1.7.16    Given a list of situations, the student should be able to identify those situations in which the esophageal airway may be removed.

19. Objectives (17 of 27)
1.7.17    Given a list of advantages, the student should be able to identify the advantages of using the esophageal obturator airway over other methods of airway control.
Given a list of airway adjuncts, advantages, and disadvantages, the student should be able to match the airway adjuncts with the advantages and disadvantages.

20. Objectives (18 of 27)
S Given an adult manikin, oropharyngeal and nasopharyngeal airways, pocket mask, oxygen cylinder, and bag-valve-mask, the student should be able to demonstrate the procedure for administering intermittent positive pressure ventilation using:
Pocket mask
Bag-valve-mask and oropharyngeal airway
Bag-valve-mask with oxygen
Nasopharyngeal airway with bag-valve-mask
“S” indicates a skill objective.

21. Objectives (19 of 27)
S Given a bag-valve-mask, the student should be able to demonstrate the assembly, disassembly, and cleaning of the bag-valve-mask unit.
S Given an adult manikin, an oropharyngeal airway, and a demand-valve unit, the student should be able to demonstrate the procedure for performing intermittent positive pressure ventilation.
“S” indicates a skill objective.

22. Objectives (20 of 27)
S Given a demand-valve unit, the student should be able to demonstrate the assembly, disassembly, and cleaning of the unit.
1.7.23    Given a list of disadvantages, the student should be able to identify the disadvantages of using the esophageal obturator airway over other methods of airway control.
“S” indicates a skill objective.

23. Objectives (21 of 27)
1.7.24    Given a diagram of the esophageal obturator airway, the student should be able to label and describe the function of all component parts.
1.7.25    Given a list of equipment and materials, the student should be able to identify those items that must be available before esophageal obturation is begun.

24. Objectives (22 of 27)
1.7.26    Given that a patient requires an esophageal obturator airway, the student should be able to list the procedures for insertion of the esophageal airway, including all steps in the proper sequence.
1.7.27    Given a list of errors, the student should be able to identify common errors involved in the use of the esophageal obturator airway.
* Describe laryngoscope, suction, endotracheal tube, and bag-valve-mask.
*Indicates optional.

25. Objectives (23 of 27)
* Discuss indications and contraindications of endotracheal intubation.
* Discuss alternatives to endotracheal intubation.
* Discuss skill deterioration and methods of prevention.
* Discuss need for rapid placement of the ET tube.
* Discuss methods of assuring and maintaining correct placement of the ET tube.
*Indicates optional.

26. Objectives (24 of 27)
* Given that a patient needs suctioning and already has an endotracheal tube in place, the student should be able to describe the difference between endotracheal suctioning and oropharyngeal suctioning, including:
Dangers
Precautions
*Indicates optional.

27. Objectives (25 of 27)
*S Given an adult intubation manikin, an esophageal obturator airway, 30cc syringe, and a bag-valve unit, the student should be able to demonstrate the technique for the insertion of an esophageal airway. He should further be able to demonstrate endotracheal intubation with the esophageal obturator in place and subsequent correct removal of the obturator.
*S Demonstrate placement of an ET within 45 seconds.
*Indicates optional.
“S” indicates a skill objective.

28. Objectives (26 of 27)
*S Demonstrate ventilation with a bag-valve and endotracheal tube.
*S Demonstrate method by assuring and maintaining correct placement of ET tube.
*S Demonstrate reventilation for missed intubation.
*S Demonstrate skills described above both on manikin and a live patient.
Define acid-base balance.
*Indicates optional.
“S” indicates a skill objective.

29. Objectives (27 of 27)
Discuss acid-base balance based on hydrogen concentration, pH, and buffer systems.
Define and discuss the following:
Respiratory acidosis
Respiratory alkalosis
Metabolic acidosis
Metabolic alkalosis.

30. Airway
The most important steps in patient care are obtaining and maintaining a patent airway.
Oxygenation of the body’s tissues occurs through the processes of breathing and circulation.
The primary objective of emergency care is to ensure optimal ventilation.
Airway maneuvers are often neglected skills.

31. Anatomy of the Upper Airway (1 of 2)
Divided into upper and lower airways
Major functions of the upper airway
Warm, filter, and humidify air brought into the body
Pharynx
First portion of the upper airway
Composed of the nasopharynx and oropharynx

32. Anatomy of the Upper Airway (2 of 2)
Nasopharynx
Union of facial bones
Divided by septum
Contains the cilia and the turbinates
Oropharnyx
Oral cavity; begins with the mouth and teeth
Tongue, palate, epiglottis, and vallecula
Larynx
Complex structure
Glottic opening is the narrowest portion of the trachea

33. Anatomy of the Lower Airway
The function of the lower airway is to exchange oxygen and carbon dioxide.
Extends from C4 to the xiphoid process (externally); glottic opening to pulmonary capillary membrane (internally).
Inhalation
Surfactant
Atelectasis

34. Lung and Respiratory Volumes
Average adult male total lung capacity is 6 L
Tidal volume (average 5-7 mL/kg)
Dead space
Alveolar air
Minute volume
Functional reserve capacity
Residual volume
Inspiratory/expiratory reserve volumes

35. Ventilation (1 of 2) Movement of air into and out of the lungs
Two phases of ventilation:
Inspiration
Stimulus to breathe comes from the respiratory center located in the medulla
Expiration
Stretch receptors in the chest wall and bronchioles send a signal to the apneustic center to inhibit the inspiratory center
Hering-Breuer reflex

36. Ventilation (2 of 2)
Respiration is the exchange of gases between a living organism and its environment.
Two types of respiration:
External – exchange of gases between the lungs and the blood cells
Internal – exchange of gases between the blood cells and tissues

37. Causes of Decreased Oxygen Concentration in the Blood
Any condition that reduces the surface area for gas exchange also decreases the oxygen supply
Pneumothorax
Decreased mechanical effort
Medical conditions
Pulmonary edema

38. Carbon Dioxide in the Blood
Fluctuates in relation to changes in breathing.
Hyperventilation rids the body of excessive amounts of carbon dioxide.

39. The Measurement of Gases
Dalton’s law of partial pressure
Total pressure of air (sea level) 760 torr
Major components
Nitrogen
Oxygen
Carbon dioxide
Water vapor

40. Respiratory Rate (1 of 2) Neural control Comes from medulla and pons
Apneustic center
Chemical stimuli
Chemoreceptors monitor the chemical composition of body fluids
Hypoxic drive is a “backup system”

41. Respiratory Rate (2 of 2) Control of respiration by other factors
Increase or decrease respirations according to need.
Certain medications cause the respiratory rate to increase or decrease.
Respirations decrease as metabolism slows.

42. Airway Evaluation Essential parameters Bellows system
Normal rate: breaths/min
Recognition of airway problems
Respiratory rate, regularity, or effort
Look, listen, and feel technique
History of present illness
Respiratory pattern changes

43. Acid-Base Balance (1 of 2)
Defining the acidity of a solution
Amount of free hydrogen ion
Ion shifts
Acid-base balance on both sides of the cell
Buffers
Imagined as a bucket
Circulating bicarbonate buffer
Holds and neutralizes excess acid

44. Acid-Base Balance (2 of 2)
Respiratory component
Fastest way to rid the body of excess hydrogen ions
Maintaining circulating levels of carbon dioxide in the blood
Renal component
Kidneys respond but take hours to days to restore pH
Excreting the acid

45. Compensatory Mechanisms
Acid-base disorders not immediately correctable by the body’s buffering systems initiate compensatory mechanisms to help return levels to normal.

46. Clinical Presentation (1 of 2)
Two types of acid-base disorders
Metabolic and respiratory
Respiratory acidosis
Always related to hypoventilation
COPD
Creates respiratory acidosis over time
Hypoxic drive stimulates breathing based on circulating oxygen levels in the bloodstream

47. Clinical Presentation (2 of 2)
Respiratory alkalosis
Always the result of hyperventilation
Metabolic acidosis
Any acidosis not related to the respiratory system
Metabolic alkalosis
Results from excessive loss of acid, either from urination or decreased acid levels in the stomach

48. Maintaining the Airway
Recovery position
Helps maintain a clear airway in a patient who has not had traumatic injuries and is breathing on their own with a normal rate and adequate tidal volume
Prevents aspiration of vomitus

49. Airway Management
Emergency medical care begins with ensuring a patient’s airway is open and breathing is adequate.
The most common cause of airway obstruction in an unresponsive patient is the tongue.

50. Manual Maneuvers Head tilt-chin lift maneuver Jaw-thrust maneuver
Jaw-thrust with head tilt
Tongue-jaw lift maneuver

51. Airway Obstructions (1 of 2)
Tongue
Falls back without muscle control, creating snoring respirations
Foreign body
Partial or full
Laryngeal spasm and edema
Aggressive intubation

52. Airway Obstructions (2 of 2)
Fractured larynx
Increases airway resistance
Aspiration
Destroys delicate bronchiolar tissue
Introduces pathogens into the lungs
Decreases ability to ventilate

53. Recognition Early recognition is crucial. Good air exchange
If they can cough forcefully, don’t interfere with their efforts to expel object on their own
Poor air exchange
Weak, ineffective cough
Treat immediately as if it were a severe air obstruction

54. Emergency Medical Care for FBAO
The Heimlich maneuver is the most effective method of dislodging an object from the airway.
Follow the Heimlich maneuver with finger sweeps.
Attempt to remove the object only if you are able to visualize and easily retrieve it.

55. Suctioning Suctioning equipment
Portable, hand-operated, oxygen-powered, battery-operated and fixed (mounted)
Techniques of suctioning
Turn on the unit.
Insert the catheter.
Open the patient’s mouth.
Apply suction.

56. Airway Adjuncts Oral airway Makes suctioning easier
Should be inserted promptly in unresponsive patients with no gag reflex
Nasal airway
Better tolerated by patients who have an intact gag reflex
Use with extreme caution in cases of trauma

57. Oral Airway and Nasal Airway

58. Supplemental Oxygen (1 of 2)
Oxygen sources
Supplied as compressed gas in cylinders
Delivery measured in LPM
Safety considerations
Contents under pressure
Can become a deadly missile
Liquid oxygen
Cooled to aqueous state

59. Supplemental Oxygen (2 of 2)
Pin-indexing system
Established by the gas industry
Series of pins on a yoke
Regulators
Attached to cylinder stem to deliver gas under high pressure
Flowmeters
Pressure-compensated and Bourdon-gauge

60. Operating Procedures Inspect the cylinder.
Attach the regulator/flowmeter.
Place the regulator collar.
Open the cylinder.
Open the flowmeter to desired rate.

61. Hazards of Oxygen-Delivery Devices
Oxygen supports combustion although it doesn’t burn or explode.
Be cautious in any enclosed environment because there is an increased chance of fire if a spark or flame is introduced.

62. Supplemental Oxygen-Delivery Devices
Non-rebreathing mask
Nasal cannula
Simple face mask
Partial rebreathing mask
Venturi mask
Small-volume nebulizer
Oxygen humidifiers

63. Assisted and Artificial Ventilation (1 of 2)
Mouth-to-mouth
Most basic form of ventilation
Requires no special equipment
Mouth-to-nose
Mouth-to-mask
Preferred technique over mouth-to-mouth or mouth-to-nose
Exhaled air contains roughly 16% oxygen

64. Assisted and Artificial Ventilation (2 of 2)
One-person BVM device
Can provide large volumes of inspired air
Can deliver nearly 100% oxygen
Two-person BVM method
Superior mask seal, tidal volume, and oxygen delivery
Three-person BVM method
Not always possible to perform

65. Two-Person and One-Person BVM Methods

66. Technique (1 of 2) Kneel above patient’s head.
Maintain neck in an extended position.
Open the mouth.
Select the mask size.
Place mask over face.
Bring lower jaw up to mask.
Hold mask in position.

67. Technique (2 of 2) Connect bag to mask.
Hold mask in place while partner squeezes bag.
If alone, hold index finger over the lower part of mask, and secure the upper part with thumb.
Observe for gastric distention.

68. Flow-Restricted Oxygen-Powered Ventilation Devices
FROPVD
Manually triggered devices
Components
Peak flow rate 100%
Safety release valves
Automatic transport ventilators
Same as above but attached to a control box
Adjustments for rate and volume

69. Gastric Distention Occurs when air becomes trapped in the stomach.
Most likely to occur when patient is ventilated too forcefully or too often or when the airway is obstructed.

70. Dental Appliances and Facial Bleeding
Appliances that become loose should be removed immediately before attempting ventilation.
Examples: crown, bridge, dentures
Facial bleeding
Injuries to the face can result in bleeding into the airway.
Suspect spinal injury.

71. Multilumen Airways (1 of 3)
Advantages and disadvantages
Easier insertion
Can be used only with deeply unresponsive patients
Indications
Deeply unresponsive, apneic patients
Contraindications
Pediatric patients
Known pathologic conditions/caustics

72. Multilumen Airways (2 of 2)
Complications
Vomiting, hypoventilation, and trauma
Equipment
Two tubes and two cuffs
Procedures before insertion
Forwardly displace the jaw.
Insert the device.
Inflate the cuffs.

73. Multilumen Airways (3 of 3)
Procedures after insertion
Begin to ventilate the patient.
With the PtL, ventilate the short tube.
With the Combitube, ventilate the long tube.
Confirm chest rise and breath sounds.
If none, change to the other inflation port

74. Combitube and PtL

75. Esophageal Obturator Airway (EOA) (1 of 3)
Advantages
Requires less technical skill
Disadvantages
Mask seal required to ventilate
Indications
Deeply unconscious patients
Contraindications
Not for use in patients younger than 16 years

76. Esophageal Obturator Airway (EOA) (2 of 3)
Complications
Hypoventilation, esophageal rupture.
Equipment
EOA no longer manufactured.
EGTA is a modification of the EOA.
Technique is intended to facilitate entry of the tube into the esophagus.

77. Esophageal Obturator Airway (EOA) (3 of 3)
Procedures before insertion
All equipment is checked.
Patient is preoxygenated and positioned.
Procedures after insertion
Following inflation of the balloon, obtain a mask seal.
Confirm presence of breath sounds.

78. Ventilation With an EGTA in Place

79. The Laryngeal Mask Airway (1 of 2)
Advantages
Insertion is easier and doesn’t require direct laryngoscopy
Disadvantages
Increased risk of aspiration and air may be insufflated into the stomach
Contraindications
Use only in “fasting” patients and is less effective in obese patients
Complications
Regurgitation and aspiration

80. The Laryngeal Mask Airway (2 of 2)
Technique for insertion
Prepare equipment
Inflate with 50% more air than is required
Deflate it and lubricate the base
Preoxygenate
Insert your finger between the cuff and tube
Insert the LMA and inflate the cuff
Procedures after insertion
Ventilate; confirm placement

81. The LMA Device

82. Tracheostomy, Stoma, and Tracheostomy Tubes
Tracheostomy – surgical opening into the trachea
Stoma – the resultant orifice connecting the trachea to the outside air
Neither the head tilt-chin lift nor the jaw-thrust maneuver is required for ventilating a patient with a stoma
If the patient has a tracheostomy tube, you should ventilate through the tube with a BVM device

83. Special Patient Considerations
Laryngectomy suctioning must be performed with extreme care.
The slightest irritation of the tracheal wall can result in a violent laryngospasm.
To further minimize the risk of complications, limit suctioning of the stoma to 10 seconds.