BASIC AIRWAY MANAGEMENT

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BASIC AIRWAY MANAGEMENT
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Basic Airway Objectives

• Upon completion the student will be able to
• Describe the anatomy of the airway and the
  physiology of respiration.
• Explain the primary objective of airway
  maintenance
• Identify commonly neglected prehospital skills
  related to the airway
• Describe assessment of the airway and the
  respiratory system
• Describe the modified forms of respiration and
  list the factors that affect respiratory rate and
  depth
• Discuss the methods for measuring oxygen and
  carbon dioxide in the blood and their prehospital
  use.

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Basic AirwayObjectives

• Define and explain the implications of partial
  airway obstruction with good and poor air
  exchange and complete airway obstruction
• Describe the common causes of upper airway
  obstruction, including
• The tongue
• Foreign body aspiration
• Laryngeal spasm
• Laryngeal edema
• Trauma

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Basic AirwayObjectives

• Describe complete airway obstruction maneuvers,
  including
• Heimlich maneuver
• Removal with magill forceps
• Describe causes of respiratory distress,
  including
• Upper and lower airway obstruction
• Inadequate ventilation
• Impairment of respiratory muscles
• Explain the risk of infection to EMS providers
  associated with airway management and ventilation

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Basic AirwayObjectives

• Describe manual airway maneuvers including
• Head0tilt/chin-lift maneuver
• Jaw-thrust maneuver
• Modified jay-thrust maneuver
• Discuss the indications, contraindications,
  advantages, disadvantages, complications, special
  considerations, equipment, and techniques of the
  following
• Upper airway and tracheobronchial suctioning
• Nasogastric and orogastric tube insertion

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Basic AirwayObjectives

• Oropharyngeal and nasopharyngeal airway
• Ventilating a patient by mouth-to-mouth,
  mouth-to-nose, mouth-to-mask, one/two/three
  person bag-valve mask, flow-restricted
  oxygen-powered ventilation device, automatic
  transport ventilator
• Compare the ventilation techniques used for an
  adult patient to those used for pediatric
  patients, and describe special considerations in
  airway management and ventilation for the
  pediatric patient

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Basic AirwayObjectives

• Identify types of oxygen cylinders and pressure
  regulators, and explain safety considerations of
  oxygen storage and delivery, including steps for
  delivering oxygen, from a cylinder and regulator
• Describe the indications, contraindications,
  advantages, disadvantages, complication, liter
  flow range, and concentration of delivered oxygen
  for the following supplemental oxygen delivery
  devices
• Nasal cannula
• Simple face mask

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Basic AirwayObjectives

• Partial rebreather mask
• Nonrebreather mask
• Venturi mask
• Describe the use, advantages, and disadvantages
  of an oxygen humidifier

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ADMINISTRATION

• Oxygen is the most important drug that we
• can give a patient. Without it, the bodys cells
  
• die and thus the patient dies also.
• Room air contains approximately 30 oxygen

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ADMINISTRATION

• Usually stored in seamless, steel cylinders -
  color GREEN
• Sizes and Capacity
• D 350 L
• E 600 L
• M 3,000 L
• Pressure 2,000-2,200 psi

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ADMINISTRATION

• Pin Index Safety System (PISS)
• Prevents interchanging different gases and
  regulators
• Delivery
• 1. Demand Valve
• Activated manually or by negative
• pressure

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ADMINISTRATION

• 2. Flow Meter (Two Types)
• Pressure Compensated
• Small ball in a calibrated tube affected
• by gravity, measures actual delivered
• flow found in Units mounted on wall.
• Bourdon Gauge
• Not affected by gravity records a higher
• reading when an obstruction blocks
• tubing used on portable O2 tanks

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ADMINISTRATION

• Nasal Cannula 2-6 lpm 25-50
• Basic Mask 6-10 lpm 35-60
• Partial Rebreather 10 higher lpm 60
• Non Rebreather 10 higher lpm 60-95
• Demand Valve 100 lpm 100
• BVM 0 lpm 21
• 15 w/o reservoir 50
• 15 w/reservoir up to 95

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MANUAL TECHNIQUES

• Head Tilt/Chin Lift
• Opens most common cause of obstruction, the
• tongue

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MANUAL TECHNIQUES

• Modify for suspected spinal injury
• 1. Tongue/jaw lift
• 2. Modified jaw thrust

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BODY POSITION

• Left or right lateral positioning of a patient
  aids airway maintenance by allowing
  fluids/vomitus to drain out
• Only to be used when spinal injury is NOT
  suspected
• If spinal injury is suspected, the patient must
  be secured solidly to a rigid board so that the
  body can be turned to the side as a total unit.

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OROPHARYNGEAL AIRWAY (OP AIRWAY)

• Semicircular, disposable and made of hard
  plastic. Guedel and Berman are the frequent
  types.
• Guedel is tubular and has a hollow center.
• Berman is solid and has channeled sides.
• Displaces the tongue away from the posterior
  pharyngeal wall.

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OP AIRWAY

• Even when in place, it is necessary to
• maintain manual positioning of the airway by
• a head-tilt, chin-lift or jaw-thrust maneuver.
• INDICATIONS
• Adjunct for airway control, determines presence
  of gag reflex.
• Unconscious/unresponsive

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OP AIRWAY

• INDICATIONS
• Remove the airway if patient regains a gag reflex
• May be inserted as a bite block after successful
  intubation

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OP AIRWAY

• SIZING
• Hold the airway next to the side of the patient's
  face and measuring the length of the airway from
  the corner of the mouth to the tip of the
  earlobe,
• Center of the mouth to the angle of the mandible.

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INSERTION

• Choose the appropriate size
• Open the airway
• Insert the airway
• 1. Using a tongue blade. Preferred method in
• children.
• 2. Insert upside down and rotate into place.
• Not to be used in children.

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COMPLICATIONS

• With intact gag reflex could cause vomiting.
• Laryngospasm
• Inappropriate size
• 1. To Long may push the epiglottis closed
• over the glottic opening, causing complete
• airway obstruction
• 2. To Short May be easily displaced, distal
  opening may become obstructed by tongue

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COMPLICATIONS

• May occur from insertion. Improperly placed may
  push the tongue back into the pharynx and cause
  obstruction.
• Aggressive insertion may cause trauma to the
  upper airway and bleeding.
• The lumen of the tube is not large enough to
  allow for suctioning. Suctioning must be
  performed around the tube.

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NASOPHARYNGEAL AIRWAYNP AIRWAY

• A curved hollow tube constructed of soft
• plastic or rubber with a bevel at the distal end
• and a flange or flare at the proximal end.
• This airway is less likely to stimulate gagging
• and vomiting because the the pliable tube
• moves and flexes as the patient swallows.

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NP AIRWAY

• It may be used in a patient who is breathing
• but needs assistance in maintaining a patent
• airway.
• 15cm in length.
• The distal tip sits at the posterior pharynx
• while the proximal flare is seated on the
• external nare.

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NP AIRWAY

• Still requires manual airway maneuvers be
  maintained during its use.

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NP AIRWAY

• Indications
• 1. When OP is not able to be inserted
• 2. Airway of choice in spontaneously breathing,
  but less responsive patient needing airway
  control.
• Sizing
• 1. Proximal end of the tube at the tip of the
  nose and the distal end at the earlobe

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NP AIRWAY

• Technique of Insertion
• Needs to be lubricated.
• Proper size
• Advance with bevel toward the septum
• If patient is breathing you should feel
• airflow when placed properly.
• If you meet resistance, remove and use
• other nare.

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NP AIRWAY

• Complications
• Improper size and too long could end up
• in the esophagus
• Too short could be occluded by the
• tongue
• Laryngospasm
• Trauma

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ESOPHAGEAL OBTURATOR AIRWAY (EOA)

• Was widely used, but due to complications and ET
  training its use has dropped.
• Recommended in situations when airway control was
  necessary and not able to intubate.
• Comprised of a mask and a cuffed esophageal tube
  with a sealed distal end.
• 16 air holes allow for ventilation.

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EOA

• Inflation port to inflate the cuff with a syringe
  and a pilot balloon to indicate the cuff volume.
• Placed in the esophagus, to seal and not allow
  air entry into the esophagus
• During ventilation, the air is forced through the
  mask and out of the openings in the proximal end.
  Air is facilitated in to the glottic opening and
  hence the trachea.

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EOA/COMPLICATIONS

• Esophageal rupture
• Laryngospasm
• Stimulation of vomiting
• Aspiration of gastric contents during insertion
• Soft tissue damage from cuff pressure

• Inadequate mask seal
• Unrecognized tracheal intubation
• Do not leave in place for longer than 2 hours
• Have suction available when removing
• Remove when patient resumes breathing

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EOA/CONTRAINDICATIONS

• Patient is alert, responsive, or has gag reflex
• Less than 16 years of age
• Ingested caustic substance

• Less than 5 feet tall, greater than 7 feet tall
• Significant airway bleed

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EOA/ADVANTAGES

• Insertion does not require visualization and no
  equipment is necessary
• Prevents air from entering the stomach
• Prevents vomitus from traveling up the esophagus

• ET may still be inserted with EOA in place
• Head and neck of a C-Spine Injury may be
  maintained in a neutral in-line position during
  its insertion

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EOA/DISADVANTAGES

• Tight mask seal must still be maintained
• May cause trauma to the esophagus or airway
• Can be easily misplaced in the trachea

• Cannot be left in place for prolonged periods of
  time
• Does not isolate the trachea and prevent
  aspiration of contents from the upper airway
• Tracheobronchial suctioning cannot be performed.

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EOA/INSERTION

• Head neutral or flexed forward.
• Insert the tube (with mask attached) blindly into
  the mouth and throat
• Pass the tube gently until the mask seats on the
  patients face

• Cuff Inflation
• Do not inflate the cuff until proper
  placements is confirmed
• Auscultate 4 lung fields and the epigastric
  region

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EOA/INSERTION

• Cuff Inflation
• If accidentally placed in the trachea and the
  cuff is inflated before checking for proper
  placement, serious damage to the trachea can
  result (30-35 ccs of air)

• REMOVAL
• Patient regains gag reflex, position patient
  on side
• Stand by with crash suction
• Remove the mask
• Deflate the cuff

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EOA/REMOVAL

• Remove the tube at peak inhalation
• Get ready to SUCTION

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ESOPHAGEAL GASTRIC TUBE AIRWAY (EGTA)

• More recent design of the older version of the
  EOA.
• Allows for the placement of a nasogastric tube
  through the lumen of the obturator for
  decompression of the stomach
• Ventilation occurs directly into the oropharynx,
  rather than through the holes of the obturator

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EGTA/ESSENTIALS

• It is used only in patients who are unresponsive
  and without protective reflexes
• It should NOT be used in patients with upper
  airway or facial trauma where bleeding into the
  oropharynx is a problem
• It must NOT be used in any patient with injury to
  the esophagus, or in children who are below the
  age of 16

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EGTA/ESSENTIALS

• Adequate mask seal must be ensured
• Great attention must be paid to proper placement.
• One of the great disadvantages of this airway is
  the fact that correct placement can be determined
  only by auscultation and observation of chest
  movement, both may be quite unreliable in the
  field setting
• Insertion must be gentle and without force

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EGTA/INSERTION

• Ventilate and suctioning performed prior to
  insertion of the airway
• After lubrication, the airway, with mask
  attached, is slid into the oropharynx while the
  tongue and jaw are pulled forward
• The airway is advanced along the tongue and into
  the esophagus

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EGTA/INSERTION

• Following gentle insertion so that the mask now
  rests easily on the face, the mask is sealed
  firmly on the face as the jaw is pulled forward
  to ensure an airway
• Prior to inflating the cuff, ventilation is
  attempted as well as auscultation
• If there is any doubt about placement of the
  airway remove it and reinsert

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PHARYNGOTRACHEAL LUMEN AIRWAY (PTL)

• PTL consists of a smaller-diameter long tube
  inside of a short large-diameter tube.
• The tube goes either into the trachea or the
  esophagus, while the shorter tube opens into the
  lower pharynx
• Each tube has a cuff, the longer tube seals the
  esophagus or trachea, the shorter tube seals the
  oropharynx so that there is no air leak when
  ventilating

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PTL

• Insertion is blind, you must determine placement.
• If longer tube is in trachea you ventilate
  through it
• If longer tube is in the esophagus you ventilate
  through the shorter tube

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PTL/ESSENTIALS

• Use only in patients who are unresponsive and
  without gag reflexes
• Do NOT use in patient with injury to the
  esophagus or in children under the age of 15
• Pay careful attention to placement
• Insertion must be gentle and without force
• In the patient regains consciousness, you must
  remove the PTL (vomiting)

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PTL/INSERTION

• Ventilate and suction before insertion
• Prepare the airway
• Lubricate, and slide the airway into the
  oropharynx
• Immediately inflate both cuffs
• Determine placement
• Secure

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ESOPHAGEAL TRACHEAL COMBITUBE

• Similar to the PTL in that it has a double lumen.
• The two lumens are separated by a partition
  rather than one being inside of the other.
• One tube is sealed at the distal end, and there
  are perforations in the area of the tube that
  would be in the pharynx.

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COMBITUBE

• When the long tube is in the esophagus, the
  patient is ventilated through this short tube
• The long tube is open at the distal end, and it
  has a cuff that is blown up to seal the esophagus
  or the trachea
• If the long tube goes into the esophagus, the
  cuff is inflated and the patient is ventilated
  through the short tube.

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COMBITUBE

• If the long tube goes into the trachea, the cuff
  is inflated and the patient is ventilated through
  the long tube.
• The Combitube is somewhat quicker and easier to
  insert than the PTL

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COMBITUBE/ESSENTIALS

• Use only in patients who are unresponsive and
  without protective gag reflex
• Do not use in any patient with injury to the
  esophagus and children below 15
• Pay attention to placement
• Insert gently and without force
• Remove once patient regains consciousness

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COMBITUBE/TECHNIQUE

• Insert the tube blindly, watching for the two
  black rings on the tube for measuring the depth
  of insertion. These rings should be positioned
  between the teeth and the lips
• Use the large syringe to inflate the pharyngeal
  cuff with 100 cc of air
• Use the small syringe to fill the distal cuff
  with 10-15 cc of air

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COMBITUBE/INSERTION

• The long tube will usually go into the esophagus.
  Ventilate through the esophageal connector.
  Longer of the tubes and marked 1.
• Check placement, if not placed properly
• Ventilate through the shorter tracheal connector
  which is marked 2

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LARYNGEAL MASK AIRWAY (LMA)

• Developed as an alternative to the face mask for
  achieving and maintaining control of the airway
  during routine anesthetic procedures in the
  operating room.
• Found to be useful in the emergency situation
  when intubation is not possible and you cant
  ventilate with a BVM
• May prevent doing a surgical procedure to open
  the airway

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LMA

• Not designed to seal the esophagus and was not
  originally meant for emergency use.
• It is not equal to the ET and should only be used
  when efforts to intubate the trachea have been
  unsuccessful and ventilation is compromised.

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LMA/WARNINGS

• Use only in patients who are unresponsive and
  without protective reflexes.
• Do not use in any patient with injury to the
  esophagus
• Lubricate only the posterior surface of the LMA
  to avoid blockage of the aperture or aspiration
  of the lubricant
• Patients should be adequately monitored

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LMA/WARNINGS

• Never force the device to avoid trauma to the
  airway
• Never overinflate the cuff. May cause
  malposition, loss of seal, or trauma.
• If airway problems persist, it should be removed
  and reinserted.
• Does not prevent aspiration if the patient vomits

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LMA/WARNINGS

• If the patient regains consciousness, you must
  remove it.

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LMA/INSERTION

• Ventilate with mouth-to-mask or BVM, and suction
• Remove the valve tab and check the integrity of
  the LMA cuff by inflating with maximum volume
• Cuff should be tightly deflated using the
  enclosed syringe so that it forms a flat oval
  disk with the rim facing away from the aperture.

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LMA/INSERTION

• Lubricate the posterior surface
• Preoxygenate the patient
• If no danger of spinal injury, position the
  patient with the neck flexed and the head
  extended, otherwise neutral position.
• Hold the LMA like a pen and insert.
• Use the index finger to guide the LMA, pressing
  upwards and backwards toward the ears

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LMA/INSERTION

• Without holdings the tube, inflate the cuff with
  just enough air to obtain a seal. The tube will
  bob when properly placed.
• Connect the LMA to the BVM and check position.

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SUCTIONING

• Often a neglected skill.
• Very important skill that must accompany airway
  maintenance
• Can be used to open an airway or to maintain an
  airway
• All suctioning should be considered sterile

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SUCTIONINGGENERAL RULES

• Hyperventilate the patient, or apply oxygen in a
  high-concentration to those who are spontaneously
  breathing and monitor ECG
• Use only sterile devices

• Be gentle
• Lubricate all suction catheters and tips
• Maximum of 10 seconds of suction time
• Suction on withdrawal of catheter, rotating
  slowly (ET)

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SUCTIONING

• NASO, OROPHARYNX
• Use either the soft, flexible catheter or the
  tonsil tip catheter
• The tonsil tip is preferred for oropharyngeal
  suctioning
• Another consideration is the V-Vac Suction Device
• Flexible catheter preferred for naso

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SUCTIONING

• ET TUBE
• Sterility is especially important since you
  have by-passed the bodys natural protective
  elements
• Use only soft flexible catheters
• Be GENTLE
• Observe the monitor for arrhythmias

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SUCTIONING

• CRASH SUCTIONING
• For those times when the patient suddenly vomits,
  it can be very catastrophic for the patient
• Involves increasing the bore of the suction
  device
• Remember Since CRASH suctioning removes large
  amounts of fluids, it also removes large amount
  of air