airway management part 1

1. Airway ManagementPart 1 EMS Professions Temple College

3. 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?

4. 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

5. Airway Anatomy Review Upper Airway Anatomy Lower Airway Anatomy Lung Capacities/Volumes Pediatric Airway Differences

6. Anatomy of the Upper Airway

7. 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

8. 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

9. 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

10. Upper Airway Anatomy

11. Upper Airway Anatomy Sinuses cavities formed by cranial bones act as tributaries for fluid to, from eustachian tubes, tear ducts trap bacteria, commonly infected

12. 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 �Adam�s Apple� Glottic opening directly behind

13. Upper Airway Anatomy Larynx Glottic opening Adult airway�s narrowest point Dependent on muscle tone Contains vocal bands Arytenoid cartilage Posterior attachment of vocal bands

14. 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

15. 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

16. Upper Airway Anatomy

17. 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

18. Upper Airway Anatomy

19. Upper Airway Anatomy

20. Glottic Opening

21. Lower Airway Anatomy Function Exchange O2 , CO2 with blood Location From glottic opening to alveolar-capillary membrane

22. Lower Airway Anatomy Trachea Bifurcates (divides) at carina Right, left mainstem bronchi Right mainstem bronchus shorter, straighter Lined with mucous cells, beta-2 receptors

23. 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

24. 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

25. Lower Airway Anatomy Lungs Right lung = 3 lobes; Left lung = 2 lobes Parenchymal tissue Pleura Visceral Parietal Pleural space

26. Lower Airway Anatomy

27. Lower Airway Anatomy Occlusion of bronchioles Smooth muscle contraction (bronchospasm Mucus plugs Inflammatory edema Foreign bodies

28. 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)

29. Lung Volumes/Capacities Dead Space Air (VD) Air unavailable for gas exchange

30. 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

31. Lung Volumes/Capacities Alveolar Air (alveolar volume) [VA] Air reaching alveoli for gas exchange Usually 350 cc

32. 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

33. Lung Volumes/Capacities Functional Reserve Capacity (FRC) After optimal inspiration, amount of air that can be forced from lungs in single exhalation

34. 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

35. Lung Volumes/Capacities

36. Ventilation Movement of air in, out of lungs Control via: Respiratory center in medulla Apneustic, pneumotaxic centers in pons

37. 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

38. 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

39. Ventilation

40. Ventilation

41. 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

42. 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

43. 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

44. 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%)

45. 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

46. 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

47. 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 >96% of total) O2 content divided by O2 carrying capacity

48. 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

49. 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

50. Respiration

51. Inspired Air: PO2 160 & PCO2 0.3

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

53. 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

54. Causes of Airway/Ventilatory Compromise Airway Obstruction Tongue Foreign body obstruction Anaphylaxis/angioedema Upper airway burn Maxillofacial/laryngeal/trachebronchial trauma Epiglottitis Croup

55. Obstruction Tongue Most common cause Snoring respirations Corrected by positioning

56. Foreign Body Partial or Full Symptoms include Choking Gagging Stridor Dyspnea Aphonia Dysphonia

57. Laryngeal Spasm Spasmatic closure of vocal cords Frequently caused by Overly aggressive technique during intubation Immediately upon extubation

58. Laryngeal Edema Causes Angioedema Anaphylaxis Upper airway burns Epiglottitis Croup Trauma

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

60. Obstructive Airway Disease Obstructive airway disease Asthma Emphysema Chronic Bronchitis

61. Gas Exchange Surface Pulmonary edema Left-sided heart failure Toxic inhalation Near drowning Pneumonia Pulmonary embolism Blood clots Amniotic fluid Fat embolism

62. Causes of Airway/Ventilatory Compromise Thoracic Bellows Chest trauma Fib fractures Flail chest Pneumothorax Hemothorax Sucking chest wound Diaphragmatic hernia

63. 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

64. Causes of Airway/Ventilatory Compromise Control System Head trauma Cerebrovascular accident Depressant drug toxicity Narcotics Sedative-Hypnotics Ethanol

65. Assessment of Airway/Ventilatory Compromise Respiratory Distress/Dyspnea = Possible Life Threat Assess/Manage Simultaneously Priorities Airway Breathing Circulation Disability

66. 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

67. 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

68. Assessment of Airway/Ventilatory Compromise Breathing Tachypnea Bradypnea Signs of distress Nasal flaring Tracheal tugging Retractions Accessory muscle use Tripod positioning Cyanosis

69. Assessment of Airway/Ventilatory Compromise Circulation Don�t let respiratory failure distract you!!! Tachycardia = Early hypoxia in adults Bradycardia = Early hypoxia in infants, children; Late hypoxia in adults

70. 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 isn�t always getting better

71. Assessment of Airway/Ventilatory Compromise Focused Exam Respiratory Patterns Cheyne-Stokes = diffuse cerebral cortex injury Kussmaul = acidosis Biot�s (cluster) = increased ICP; pons, upper medulla injury Central Neurogenic Hyperventilation = increased ICP; mid-brain injury Agonal = brain anoxia

72. Assessment of Airway/Ventilatory Compromise Focused Exam Neck Trachea mid-line? Jugular vein distension? Subcutaneous emphysema? Accessory muscle use?/hypertrophy?

73. 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?

74. Assessment of Airway/Ventilatory Compromise Focused Exam Extremities Edema? Nail bed color? Clubbing?

75. Assessment of Airway/Ventilatory Compromise Mechanical Ventilation Increased resistance Changing compliance

76. Assessment of Airway/Ventilatory Compromise Pulsus Paradoxus Systolic BP drops > 10 mm Hg w/inspiration May detect change in pulse quality COPD, asthma, pericardial tamponade

77. 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?

78. 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?

79. BLS Airway/Ventilation Methods Supplemental Oxygen Increased FiO2 increases available oxygen Objective = Maximize hemoglobin saturation

80. Oxygen Equipment Oxygen source Compressed gas Tank size D 400L E 660L M 3450 L Liquid oxygen

81. Oxygen Equipment Regulators High Pressure Cylinder to cylinder Low Pressure Cylinder to patient Humidifier

82. Delivery Devices Nasal cannula Simple face mask Partial rebreather mask Non-rebreather mask Venturi mask Small volume nebulizer

83. Nasal Cannula Optimal delivery 40% at 6 LPM Indication Low FiO2 Long term therapy Contraindications Apnea Mouth breathing Need for High FiO2

84. Venturi Mask Specific O2 Concentrations 24% 28% 35% 40%

85. 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

86. Non-Rebreather Mask Range 80-95% at 15 LPM Indications Delivery of high FiO2 Contraindications Apnea Poor respiratory effort

87. Partial Rebreather Range 40 � 60% Indications Moderate FiO2 Contraindications Apnea Need for High FiO2

88. BLS Airway/Ventilation Methods Airway Maneuvers Head-tilt/Chin-lift Jaw thrust Sellick�s maneuver Other Types Tracheostomy with tube Tracheostomy with stoma Airway Devices Oropharyngeal airway Nasopharyngeal airway

89. 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

90. BLS Airway/Ventilation Methods Mouth to Mouth Mouth to Nose Mouth to Mask

91. 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

92. 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

93. 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

94. 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

95. BLS Airway/Ventilation Methods Pediatric considerations Mask seal force may obstruct airway Best if used with jaw thrust BVM sizes: neonate, infant=450 ml + Children > 8 y.o. require adult BVM Just enough volume to see chest rise Squeeze - Release - Release

96. BLS Airway/Ventilation Methods Stoma patients Expose stoma Pocket mask BVM Seal around stoma site Seal mouth, nose if air leak is evident

97. 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

98. BLS Airway/Ventilation Methods Suctioning Manual or powered devices Suction catheters Rigid Soft

99. 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