Airway Management Part 1

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Airway ManagementPart 1

• EMS Professions
• Temple College

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Topics for Discussion

• Airway Maintenance Objectives
• Airway Anatomy Physiology Review
• Causes of Respiratory Difficulty Distress
• Assessing Respiratory Function
• Methods of Airway Management
• Methods of Ventilatory Management
• Common Out-of-Hospital Equipment Utilized
• Advanced Methods of Airway Management and
  Ventilation
• Risks to the Paramedic

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Objectives of Airway Management Ventilation

• Primary Objective
• Ensure optimal ventilation
• Deliver oxygen to blood
• Eliminate carbon dioxide (C02) from body
• Definitions
• What is airway management?
• How does it differ from spontaneous, manual or
  assisted ventilations?

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Objectives of Airway Management Ventilation

• Why is this so important?
• Brain death occurs rapidly other tissue follows
• EMS providers can reduce additional
  injury/disease by good airway, ventilation
  techniques
• EMS providers often neglect BLS airway,
  ventilation skills

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Airway Anatomy Review

• Upper Airway Anatomy
• Lower Airway Anatomy
• Lung Capacities/Volumes
• Pediatric Airway Differences

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Anatomy of the Upper Airway
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Upper Airway Anatomy

• Functions warm, filter, humidify air
• Nasal cavity and nasopharynx
• Formed by union of facial bones
• Nasal floor towards ear not eye
• Lined with mucous membranes, cilia
• Tissues are delicate, vascular
• Adenoids
• Lymph tissue - filters bacteria
• Commonly infected

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Upper Airway Anatomy

• Oral cavity and oropharynx
• Teeth
• Tongue
• Attached at mandible, hyoid bone
• Most common airway obstruction cause
• Palate
• Roof of mouth
• Separates oropharynx and nasopharynx
• Anterior hard palate Posterior soft palate

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Upper Airway Anatomy

• Oral cavity and oropharynx
• Tonsils
• Lymph tissue - filters bacteria
• Commonly infected
• Epiglottis
• Leaf-like structure
• Closes during swallowing
• Prevents aspiration
• Vallecula
• Pocket formed by base of tongue, epiglottis

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Upper Airway Anatomy
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Upper Airway Anatomy

• Sinuses
• cavities formed by cranial bones
• act as tributaries for fluid to, from eustachian
  tubes, tear ducts
• trap bacteria, commonly infected

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Upper Airway Anatomy

• Larynx
• Attached to hyoid bone
• Horseshoe shaped bone
• Supports trachea
• Thyroid cartilage
• Largest laryngeal cartilage
• Shield-shaped
• Cartilage anteriorly, smooth muscle posteriorly
• Adams Apple
• Glottic opening directly behind

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Upper Airway Anatomy

• Larynx
• Glottic opening
• Adult airways narrowest point
• Dependent on muscle tone
• Contains vocal bands
• Arytenoid cartilage
• Posterior attachment of vocal bands

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Upper Airway Anatomy

• Larynx
• Cricoid ring
• First tracheal ring
• Completely cartilaginous
• Compression (Sellick maneuver) occludes esophagus
• Cricothyroid membrane
• Membrane between cricoid, thyroid cartilages
• Site for surgical, needle airway placement

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Upper Airway Anatomy

• Larynx and Trachea
• Associated Structures
• Thyroid gland
• below cricoid cartilage
• lies across trachea, up both sides
• Carotid arteries
• branch across, lie closely alongside trachea
• Jugular veins
• branch across and lie close to trachea

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Upper Airway Anatomy
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Upper Airway Anatomy

• Pediatric vs Adult Upper Airway
• Larger tongue in comparison to size of mouth
• Floppy epiglottis
• Delicate teeth, gums
• More superior larynx
• Funnel shaped larynx due to undeveloped cricoid
  cartilage
• Narrowest point at cricoid ring before 8 years
  old

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Upper Airway Anatomy
From CPEM, TRIPP, 1998
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Upper Airway Anatomy
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Glottic Opening
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Lower Airway Anatomy

• Function
• Exchange O2 , CO2 with blood
• Location
• From glottic opening to alveolar-capillary
  membrane

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Lower Airway Anatomy

• Trachea
• Bifurcates (divides) at carina
• Right, left mainstem bronchi
• Right mainstem bronchus shorter, straighter
• Lined with mucous cells, beta-2 receptors

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Lower Airway Anatomy

• Bronchi
• Branch into secondary, tertiary bronchi that
  branch into bronchioles
• Bronchioles
• No cartilage in walls
• Small smooth muscle tubes
• Branch into alveolar ducts that end at alveolar
  sacs

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Lower Airway Anatomy

• Alveoli
• Balloon-like clusters
• Site of gas exchange
• Lined with surfactant
• Decreases surface tension ? eases expansion
• ? surfactant ? atelectasis (focal collapse of
  alveoli0

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Lower Airway Anatomy

• Lungs
• Right lung 3 lobes Left lung 2 lobes
• Parenchymal tissue
• Pleura
• Visceral
• Parietal
• Pleural space

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Lower Airway Anatomy
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Lower Airway Anatomy

• Occlusion of bronchioles
• Smooth muscle contraction (bronchospasm
• Mucus plugs
• Inflammatory edema
• Foreign bodies

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Lung Volumes/Capacities

• Typical adult male total lung capacity 6 liters
• Tidal Volume (VT)
• Gas volume inhaled or exhaled during single
  ventilatory cycle
• Usually 5-7 cc/kg (typically 500 cc)

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Lung Volumes/Capacities

• Dead Space Air (VD)
• Air unavailable for gas exchange

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Lung Volumes/Capacities

• Dead Space Air (VD)
• Anatomic dead space (150cc)
• Trachea
• Bronchi
• Physiologic dead space
• Shunting
• Pathological dead space
• Formed by factors like disease or obstruction
• Examples COPD

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Lung Volumes/Capacities

• Alveolar Air (alveolar volume) VA
• Air reaching alveoli for gas exchange
• Usually 350 cc

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Lung Volumes/Capacities

• Minute Volume Vmin(minute ventilation)
• Amount of gas moved in, out of respiratory tract
  per minute
• Tidal volume X RR
• Alveolar Minute Volume
• Amount of gas moved in, out of alveoli per minute
• (tidal volume - dead space volume) X RR

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Lung Volumes/Capacities

• Functional Reserve Capacity (FRC)
• After optimal inspiration, amount of air that can
  be forced from lungs in single exhalation

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Lung Volumes/Capacities

• Inspiratory Reserve Volume (IRV)
• Amount of gas that can be inspired in addition to
  tidal volume
• Expiratory Reserve Volume (ERV)
• Amount of gas that can be expired after passive
  (relaxed) expiration

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Lung Volumes/Capacities
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Ventilation

• Movement of air in, out of lungs
• Control via
• Respiratory center in medulla
• Apneustic, pneumotaxic centers in pons

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Ventilation

• Inspiration
• Stimulus from respiratory center of brain
  (medulla)
• Transmitted via phrenic nerve to diaphragm,
  spinal cord/intercostal nerves to intercostal
  muscles
• Diaphragm contracts, flattens
• Intercostal muscles contract ribs move up and
  out
• Air spaces in lungs stretch, increase in size
• ? intrapulmonic pressure (pressure gradient)
• Air flows into airways, alveoli inflate until
  pressure equalizes

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Ventilation

• Expiration
• Stretch receptors in lungs signal respiratory
  center via vagus nerve to inhibit inspiration
  (Hering-Breuer reflex)
• Natural elasticity of lungs pulls diaphragm,
  chest wall to resting position
• Pulmonary air spaces decrease in size
• Intrapulmonary pressure rises
• Air flows out until pressure equalizes

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Ventilation
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Ventilation
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Ventilation

• Respiratory Drive
• Chemoreceptors in medulla
• Stimulated ? PaCO2 or ? pH
• PaCO2 is normal neuroregulatory control of
  ventilations
• Hypoxic Drive
• Chemoreceptors in aortic arch, carotid bodies
• Stimulated by ? PaO2
• Back-up regulatory control

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Ventilation

• Other stimulants or depressants
• Body temp fever? hypothermia?
• Drugs/meds increase or decrease
• Pain increases, but occasionally decreases
• Emotion increases
• Acidosis increases
• Sleep decreases

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Gas Measurements

• Total Pressure
• Combined pressure of all atmospheric gases
• 760 mm Hg (torr) at sea level
• Partial Pressure
• Pressure exerted by each gas in a mixture

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Gas Measurements

• Partial Pressures
• Atmospheric
• Nitrogen 597.0 torr (78.62) Oxygen 159.0 torr
  (20.84) Carbon Dioxide 0.3 torr (0.04) Water
  3.7 torr (0.5)
• Alveolar
• Nitrogen 569.0 torr (74.9) Oxygen 104.0 torr
  (13.7) CO2 40.0 torr (5.2) Water 47.0 torr
  (6.2)

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Respiration

• Ventilation vs. Respiration
• Exchange of gases between living organism,
  environment
• External Respiration
• Exchange between lungs, blood cells
• Internal Respiration
• Exchange between blood cells, tissues

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Respiration

• How are O2, CO2 transported?
• Diffusion
• Movement of gases along a concentration gradient
• Gases dissolve in water, pass through alveolar
  membrane from areas of higher concentration to
  areas of lower concentration
• FiO2
• oxygen in inspired air expressed as a decimal
• FiO2 of room air 0.21

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Respiration

• Blood Oxygen Content
• dissolved O2 crosses capillary membrane, binds
  to Hgb of RBC
• Transport O2 bound to hemoglobin (?97) or
  dissolved in plasma
• O2 Saturation
• of hemoglobin saturated with oxygen (usually
  carries gt96 of total)
• O2 content divided by O2 carrying capacity

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Respiration

• Oxygen saturation affected by
• Low Hgb (anemia, hemorrhage)
• Inadequate oxygen availability at alveoli
• Poor diffusion across pulmonary membrane
  (pneumonia, pulmonary edema, COPD)
• Ventilation/Perfusion (V/Q) mismatch
• Blood moves past collapsed alveoli (shunting)
• Alveoli intact but blood flow impaired

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Respiration

• Blood Carbon Dioxide Content
• Byproduct of work (cellular respiration)
• Transported as bicarbonate (HCO3- ion)
• ? 20-30 bound to hemoglobin
• Pressure gradient causes CO2 diffusion into
  alveoli from blood
• Increased level hypercarbia

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Respiration
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Inspired Air PO2 160 PCO2 0.3
Alveoli PO2 100 PCO2 40
PO2 40 PCO2 46 - Pulmonary circulation - PO2
100 PCO2 40
Heart
Oxygenated
Deoxygenated
PO2 40 PCO2 46 - Systemic circulation - PO2
100 PCO2 40
Tissue cell PO2 lt40 PCO2 gt46
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Diagnostic Testing

• Pulse Oximetry
• Peak Expiratory Flow Testing
• Pulmonary Function Testing
• End-Tidal CO2 Monitoring
• Laboratory Testing of Blood
• Arterial
• Venous

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Causes of Hypoxemia

• Lower partial pressure of atmospheric O2
• Inadequate hemoglobin level in blood
• Hemoglobin bound by other gas (CO)
• ? pulmonary alveolar membrane distance
• Reduced surface area for gas exchange
• Decreased mechanical effort

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Causes of Airway/Ventilatory Compromise

• Airway Obstruction
• Tongue
• Foreign body obstruction
• Anaphylaxis/angioedema
• Upper airway burn
• Maxillofacial/laryngeal/trachebronchial trauma
• Epiglottitis
• Croup

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Obstruction

• Tongue
• Most common cause
• Snoring respirations
• Corrected by positioning

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Foreign Body

• Partial or Full
• Symptoms include
• Choking
• Gagging
• Stridor
• Dyspnea
• Aphonia
• Dysphonia

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Laryngeal Spasm

• Spasmatic closure of vocal cords
• Frequently caused by
• Overly aggressive technique during intubation
• Immediately upon extubation

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Laryngeal Edema

• Causes
• Angioedema
• Anaphylaxis
• Upper airway burns
• Epiglottitis
• Croup
• Trauma

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Aspiration

• Significantly increases mortality
• Obstructs Airway
• Destroys bronchial tissue
• Introduces pathogens
• Decreases ability to ventilate
• Frequently occult

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Obstructive Airway Disease

• Obstructive airway disease
• Asthma
• Emphysema
• Chronic Bronchitis

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Gas Exchange Surface

• Pulmonary edema
• Left-sided heart failure
• Toxic inhalation
• Near drowning
• Pneumonia
• Pulmonary embolism
• Blood clots
• Amniotic fluid
• Fat embolism

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Causes of Airway/Ventilatory Compromise

• Thoracic Bellows
• Chest trauma
• Fib fractures
• Flail chest
• Pneumothorax
• Hemothorax
• Sucking chest wound
• Diaphragmatic hernia

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Causes of Airway/Ventilatory Compromise

• Thoracic Bellows
• Pleural effusion
• Spinal cord trauma
• Morbid obesity (Pickwickian Syndrome)
• Neurological/neuromuscular disease
• Poliomyelitis
• Myasthenia gravis
• Muscular dystrophy
• Gullian-Barre syndrome

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Causes of Airway/Ventilatory Compromise

• Control System
• Head trauma
• Cerebrovascular accident
• Depressant drug toxicity
• Narcotics
• Sedative-Hypnotics
• Ethanol

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Assessment of Airway/Ventilatory Compromise

• Respiratory Distress/Dyspnea Possible Life
  Threat
• Assess/Manage Simultaneously
• Priorities
• Airway
• Breathing
• Circulation
• Disability

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Assessment of Airway/Ventilatory Compromise

• Airway
• Listen to patient talk/breathe
• Noisy breathing Obstructed breathing
• But, all obstructed breathing is not noisy
• Adventitious sounds
• Snoring Tongue
• Stridor Tight Upper Airway

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Assessment of Airway/Ventilatory Compromise

• Breathing
• Look
• Symmetry of Chest Expansion
• Signs of Increased Effort
• Skin Color
• Listen
• Mouth and Nose
• Lung Fields
• Feel
• Mouth and Nose
• Symmetry of Expansion

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Assessment of Airway/Ventilatory Compromise

• Breathing
• Tachypnea
• Bradypnea
• Signs of distress
• Nasal flaring
• Tracheal tugging
• Retractions
• Accessory muscle use
• Tripod positioning
• Cyanosis

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Assessment of Airway/Ventilatory Compromise

• Circulation
• Dont let respiratory failure distract you!!!
• Tachycardia Early hypoxia in adults
• Bradycardia Early hypoxia in infants, children
  Late hypoxia in adults

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Assessment of Airway/Ventilatory Compromise

• Disability
• Restlessness, anxiety, combativeness hypoxia
  until proven otherwise
• Drowsiness, lethargy hypercarbia until proven
  otherwise
• When the fighting stops, a patient isnt always
  getting better

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Assessment of Airway/Ventilatory Compromise

• Focused Exam
• Respiratory Patterns
• Cheyne-Stokes diffuse cerebral cortex injury
• Kussmaul acidosis
• Biots (cluster) increased ICP pons, upper
  medulla injury
• Central Neurogenic Hyperventilation increased
  ICP mid-brain injury
• Agonal brain anoxia

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Assessment of Airway/Ventilatory Compromise

• Focused Exam
• Neck
• Trachea mid-line?
• Jugular vein distension?
• Subcutaneous emphysema?
• Accessory muscle use?/hypertrophy?

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Assessment of Airway/Ventilatory Compromise

• Focused Exam
• Chest
• Barrel chest?
• Deformity, discoloration, asymmetry?
• Flail segment, paradoxical movement?
• Adventitious breath sounds?
• Third heart sound?
• Subcutaneous emphysema?
• Fremitus?
• Dullness, hyperresonance to percussion?

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Assessment of Airway/Ventilatory Compromise

• Focused Exam
• Extremities
• Edema?
• Nail bed color?
• Clubbing?

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Assessment of Airway/Ventilatory Compromise

• Mechanical Ventilation
• Increased resistance
• Changing compliance

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Assessment of Airway/Ventilatory Compromise

• Pulsus Paradoxus
• Systolic BP drops gt 10 mm Hg w/inspiration
• May detect change in pulse quality
• COPD, asthma, pericardial tamponade

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Assessment of Airway/Ventilatory Compromise

• History
• Onset gradual or sudden?
• What makes it worse, better?
• How long?
• Cough? Productive? Of what?
• Pain? What kind?
• Fever?

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Assessment of Airway/Ventilatory Compromise

• Past History
• Hypertension, AMI, diabetes
• Chronic cough, smoking, recurrent colds
• Allergies, acute/seasonal SOB
• Lower extremity trauma, recent surgery,
  immobilization
• Interventions
• Past admission? Ever admitted to ICU?
• Medications? Frequency of prn medication use?
• Ever intubated before?

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BLS Airway/Ventilation Methods

• Supplemental Oxygen
• Increased FiO2 increases available oxygen
• Objective Maximize hemoglobin saturation

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Oxygen Equipment

• Oxygen source
• Compressed gas
• Tank size
• D 400L
• E 660L
• M 3450 L
• Liquid oxygen

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Oxygen Equipment

• Regulators
• High Pressure
• Cylinder to cylinder
• Low Pressure
• Cylinder to patient
• Humidifier

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Delivery Devices

• Nasal cannula
• Simple face mask
• Partial rebreather mask
• Non-rebreather mask
• Venturi mask
• Small volume nebulizer

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Nasal Cannula

• Optimal delivery 40 at 6 LPM
• Indication
• Low FiO2
• Long term therapy
• Contraindications
• Apnea
• Mouth breathing
• Need for High FiO2

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Venturi Mask

• Specific O2 Concentrations
• 24
• 28
• 35
• 40

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Simple Face Mask

• Range 40-60 at 10 LPM
• Volumes greater that 10 LPM does not increase O2
  delivery
• Indications
• Moderate FiO2
• Contraindications
• Apnea
• Need for High FiO2

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Non-Rebreather Mask

• Range 80-95 at 15 LPM
• Indications
• Delivery of high FiO2
• Contraindications
• Apnea
• Poor respiratory effort

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Partial Rebreather

• Range 40 60
• Indications
• Moderate FiO2
• Contraindications
• Apnea
• Need for High FiO2

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BLS Airway/Ventilation Methods

• Airway Maneuvers
• Head-tilt/Chin-lift
• Jaw thrust
• Sellicks maneuver
• Other Types
• Tracheostomy with tube
• Tracheostomy with stoma
• Airway Devices
• Oropharyngeal airway
• Nasopharyngeal airway

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BLS Airway/Ventilation Methods

• Mouth-to-Mouth
• Mouth-to-Nose
• Mouth-to-Mask
• One-person BVM
• Two-person BVM
• Three-person BVM
• Flow-restricted, gas powered ventilator
• Transport ventilator

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BLS Airway/Ventilation Methods

• Mouth to Mouth
• Mouth to Nose
• Mouth to Mask

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BLS Airway/Ventilation Methods

• One-Person BVM
• Difficult to master
• Mask seal often inadequate
• May result in inadequate tidal volume
• Gastric distention risk
• Ventilate only until see chest rise

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BLS Airway/Ventilation Methods

• Two-person BVM
• Most efficient method
• Useful in C-spine injury
• improved mask seal, tidal volume
• Three-person BVM
• Less utilized
• Used when difficulty with mask seal
• Crowded

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BLS Airway/Ventilation Methods

• Flow-restricted, gas-powered ventilator
• Cardiac sphincter opens at 30 cm H2O
• High volume/high concentration
• Not recommended for children, poor pulmonary
  compliance, or poor tidal volume
• Oxygen delivered on inspiratory effort
• May cause barotrauma

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BLS Airway/Ventilation Methods

• Automatic transport ventilators
• Not like real ventilator
• Usually only controls volume, rate
• Useful during prolonged ventilation times
• Not useful in obstructed airway, increased airway
  resistance
• Frees personnel
• Cannot respond to changes in airway resistance,
  lung compliance

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BLS Airway/Ventilation Methods

• Pediatric considerations
• Mask seal force may obstruct airway
• Best if used with jaw thrust
• BVM sizes neonate, infant450 ml
• Children gt 8 y.o. require adult BVM
• Just enough volume to see chest rise
• Squeeze - Release - Release

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BLS Airway/Ventilation Methods

• Stoma patients
• Expose stoma
• Pocket mask
• BVM
• Seal around stoma site
• Seal mouth, nose if air leak is evident

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BLS Airway/Ventilation Methods

• Airway obstruction techniques
• Positioning
• Finger sweep with caution
• Suctioning
• Oral airway/nasal airway (tongue)
• Heimlich maneuver
• Chest thrusts
• Chest thrust/back blows for infants
• Direct laryngoscopy

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BLS Airway/Ventilation Methods

• Suctioning
• Manual or powered devices
• Suction catheters
• Rigid
• Soft

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BLS Airway/Ventilation Methods

• Gastric Distention
• Common when ventilating without intubation
• Complications
• Pressure on diaphragm
• Resistance to BVM ventilation
• Vomiting, aspiration
• Increase BVM ventilation time