Management of Airway and Breathing

1. Management of Airway and Breathing Emergency Medical Technician - Basic Temple College EMS Program

2. Airway Functions • Passage that allows air to move from atmosphere to alveoli • Must remain patent (open) at all times • Anything that blocks airway will cause decrease in oxygen available to body • Size of obstruction affects available air exchange Temple College EMS Program

3. Opening the Airway • Techniques • Head-tilt/Chin-lift • Jaw Thrust • Suctioning • Nasopharyngeal airway • Oropharyngeal airway Temple College EMS Program

4. Head-Tilt/Chin-Lift • Used when no neck injury is suspected • Temporary procedure • Must be replaced with an airway adjunct unless patient begins adequate spontaneous ventilation Temple College EMS Program

5. Head-Tilt/Chin-Lift • Technique • Place one hand on patient’s forehead • Apply firm, backward pressure with palm causing head to tilt backward • Place fingers of other hand under bony part of patient’s lower jaw near chin • Lift jaw upward to bring chin forward Temple College EMS Program

6. Head-Tilt/Chin-Lift • Patients needing head-tilt/chin-lift • Unresponsive patient without history of trauma • Cardiac arrest patients without signs of trauma • Apneic patients without signs of trauma Temple College EMS Program

7. Jaw Thrust • Used when spinal injury suspected • Temporary procedure • Must be replaced with airway adjunct unless patient begins adequate spontaneous ventilation Temple College EMS Program

8. Jaw Thrust • Technique • Place one hand on either side of patient’s head, resting elbows on surface on which victim is lying • Grasp angles of patient’s lower jaw, lift with both hands • If patient’s lips close, retract lower lips with thumbs Temple College EMS Program

9. Jaw Thrust • Patients needing jaw thrust • Unresponsive trauma patient • Unresponsive patient with undetermined mechanism of injury Temple College EMS Program

10. Suctioning • Purpose • Remove blood, vomit, other liquids, food particles from airway • May not be adequate for removing large, solid objects (teeth, foreign bodies, food) • Should be performed immediately when gurgling is heard with spontaneous or artificial ventilation Temple College EMS Program

11. Suctioning • Suction devices • Mounted in ambulance • Portable • Electrical • Hand operated • Should generate 300mm Hg vacuum • Ensure batteries in units remain properly charged Temple College EMS Program

12. Suctioning • Rigid Suction Catheter • Used to suction mouth, oropharynx of unresponsive patient • Inserted only as far as you can see • Take caution not to touch back of airway, particularly in infants and children (can cause heart rate to drop) Temple College EMS Program

13. Suctioning • Soft Suction Catheter • Useful for suctioning nasopharynx or tracheostomy tubes • Should be inserted only as far as base of tongue or end of tracheostomy tube Temple College EMS Program

14. Suctioning • Techniques • Turn on unit • Attach catheter • Insert catheter into oral cavity without suction • Insert only to base of tongue • Apply suction, move catheter from side to side • Suction no longer than 15 seconds in adults, 10 seconds in children, 5 seconds in infants • Rinse catheter with saline or water to prevent obstruction Temple College EMS Program

15. Nasal Airways • Used on responsive patients who need help keeping tongue out of airway • Insertion is uncomfortable for responsive patients Temple College EMS Program

16. Nasal Airways • Technique • Measure from tip of nose to earlobe • Ensure airway will fit through nostril • Lubricate with water-soluble lubricant • Insert with bevel toward base of nostril or septum • If resistance is met, try other nostril • Do not use in patients with mid-face trauma or possible basilar skull fractures Temple College EMS Program

17. Nasal Airways • Patients needing nasal airway • Unresponsive patients who are snoring • Unresponsive patients with gag reflex Temple College EMS Program

18. Oral Airways • Used on unresponsive patients without gag reflex • Helps hold tongue away from back of throat Temple College EMS Program

19. Oral Airways • Technique • Measure from corner of mouth to earlobe or angle of jaw • Open patient’s mouth • In adults insert with tip facing roof of patient’s mouth, advance until resistance encountered, turn 180o until flange comes to rest on patient’s teeth • In infants and children use tongue depressor to lift tongue, insert oral airway right side up Temple College EMS Program

20. Oral Airways • Patients needing oral airway • Unresponsive, apneic patients with or without trauma • Any apneic patient being ventilated with a BVM Temple College EMS Program

21. Airway Limitations • Nasal/oral airways are not definitive devices • Manual maneuvers must be used with nasal/oral airways to ensure airway stays open • Patients may require frequent suctioning to remove blood, vomit, other secretions from airway • Definitive devices such as endotracheal tubes are required to completely protect the airway Temple College EMS Program

22. Adequate Breathing • Normal Rate • Adult: 12 to 20/minute • Child: 15 to 30/minute • Infant: 25 to 50/minute • Regular Rhythm • Adequate Quality • Movement of air at mouth, nose • Chest expansion adequate, symmetrical (equal) • Breath sounds present, equal • Minimum effort of breathing • Adequate tidal volume (depth) Temple College EMS Program

23. Inadequate Breathing • Abnormal Rate • Adult: <12 to >20/minute • Child: <15 to >30/minute • Infant: <25 to >50/minute • Irregular Rhythm • Inadequate Quality • Absent or reduced at mouth, nose • Chest expansion inadequate or asymmetrical (unequal) • Breath sounds diminished, unequal, noisy, absent • Increased effort of breathing, use of accessory muscles • Indequate (shallow) tidal volume Temple College EMS Program

24. Inadequate Breathing • Skin changes • Pale, cool, clammy: Early sign • Cyanosis: Late, unreliable sign • Retractions of soft tissues above clavicles, between ribs, below rib cage • Flaring of nostrils • “Seesaw” breathing in infants Temple College EMS Program

25. Ventilation Techniques(In order of preference) • Mouth-to-mask with supplemental oxygen • Two-person bag-valve mask with oxygen reservoir and supplemental oxygen • Flow restricted, oxygen-powered ventilation device (manually-triggered ventilator) • One-person bag-valve mask with oxygen reservoir and supplemental oxygen Temple College EMS Program

26. Ventilation Techniques • Mouth-to-Mouth • Open airway • Pinch nose closed or seal nose with cheek • Take deep breath • Seal lips around patient’s mouth to create airtight seal • Blow into patient’s mouth slowly over 2 seconds until patient’s chest rises Temple College EMS Program

27. Ventilation Techniques • Mouth-to-Mask • Connect mask to oxygen at 15 liters per minute • Kneel directly above patient’s head • Apply mask to patient’s face • Place thumbs along sides of mask, index fingers of both hands under patient’s mandible • Lift jaw into mask, tilt head if neck injury not suspected • Blow into one-way valve slowly over 2 seconds until patient’s chest rises Temple College EMS Program

28. Ventilation Techniques • Bag-valve mask • Self-inflating bag • One-way valve • Face mask • Oxygen reservoir Must be connected to oxygen to perform most effectively Temple College EMS Program

29. Ventilation Techniques • BVM Issues • Provides less volume than mouth-to-mask • Single rescuer may have difficulty maintaining air-tight seal • Two rescuers using device are more effective • Position yourself at top of patient’s head for best performance • Oral or nasal airway should be inserted Temple College EMS Program

30. Ventilation Techniques • BVM Technique (Two Rescuer) • Open airway, insert oral or nasal airway • Position thumbs over top half of mask, index and middle fingers over bottom half • Place apex of mask over bridge of nose, lower mask over mouth/upper chin • Use ring and little fingers to bring jaw up to mask • Have assistant squeeze bag with two hands until chest rises • Ventilate every 5 seconds for adults, every 3 seconds for infants and children Temple College EMS Program

31. Ventilation Techniques • BVM Technique (One Rescuer) • Open airway, insert oral or nasal airway • Form a “C” around ventilation port with thumb, index finger • Use middle, ring, little fingers under jaw to maintain chin lift, complete seal • Squeeze bag with other hand until chest rises • Ventilate every 5 seconds for adults, every 3 seconds for infants and children Temple College EMS Program

32. Ventilation Techniques • BVM Technique (Suspected Trauma) • Open airway, insert oral or nasal airway • Have assistant hold patient’s head or use your knees to prevent movement • Position thumbs over top half of mask, index and middle fingers over bottom half • Place apex of mask over bridge of nose, lower mask over mouth/upper chin • Use ring and little fingers to bring jaw up to mask without tilting head or neck • Have assistant squeeze bag with two hands until chest rises • Ventilate every 5 seconds for adults, every 3 seconds for infants and children continue to hold jaw up without moving head or neck Temple College EMS Program

33. Ventilation Techniques • If chest does not rise, reevaluate • If abdomen rises, reposition head or jaw • If air escapes under mask, reposition fingers and mask • Check for obstruction • If chest still does not rise and fall use another method of ventilation Temple College EMS Program

34. Ventilation Techniques • Flow Restricted, Oxygen-Powered Ventilation Devices (Manually-Triggered Ventilator) • Peak flow of 100% oxygen at maximum of 40 lpm • Pressure relief valve that opens at 60 cm H2O • Audible alarm that sounds when relief valve pressure is exceeded • Trigger so both hands remain on mask to maintain seal Do NOT use on children or infants!!! Temple College EMS Program

35. Ventilation Techniques • Manually-Triggered Ventilator • Open airway, insert oral or nasal airway • Position thumbs over top half of mask, index/middle fingers over bottom half • Place apex of mask over bridge of nose, lower mask over mouth and chin • Use ring/little fingers to bring jaw up to mask • Trigger device until chest rises • Repeat every 5 seconds Temple College EMS Program

36. Ventilation Techniques • Manually-Triggered Ventilator (Suspected Trauma) • Open airway, insert oral or nasal airway • Have assistant hold head manually or use knees to prevent movement • Position thumbs over top half of mask, index/middle fingers over bottom half • Place apex of mask over bridge of nose, lower mask over mouth and chin • Use ring/little fingers to bring jaw up to mask without tilting head and neck • Trigger device until chest rises • Repeat every 5 seconds Temple College EMS Program

37. Assisting Patients Who Are Breathing • Who needs assistance? • A patient who is not breathing • A patient who has reduced respiratory rate and tidal volume • A patient whose breathing rate is increased, but whose tidal volume is inadequate Temple College EMS Program

38. Assisting Patients Who Are Breathing • Patients with rapid, shallow breathing • Explain procedure to patient • Place mask over patient’s mouth and nose • Initially assist ventilations at rate at which patient is breathing. Squeeze bag as patient inhales • Slowly adjust rate and tidal volume until adequate ventilations are achieved Temple College EMS Program

39. Assisting Patients Who Are Breathing • Patients with slow, shallow breathing • Place bag over patient’s mouth and nose • Squeeze bag each time patient inhales • Adjust rate and tidal volume until adequate ventilations are achieved Temple College EMS Program

40. Special Considerations • Stoma or tracheostomy tube • Attach BVM to tube, or use infant/child mask to make seal over stoma • Seal mouth/nose if air is escaping when ventilating at stoma • If unable to ventilate • Suction stoma or tracheostomy tube • Seal stoma, attempt to ventilate through mouth/nose Temple College EMS Program

41. Special Considerations • Infants and children • Place infant’s head in neutral position • Extend child’s head slightly past neutral • Avoid excessive hyperextension • Avoid excessive ventilation, just make chest rise • Gastric distension is more common in children • Do not use BVMs with pop-off valves Temple College EMS Program

42. Special Considerations • Dentures • Leave in place unless obviously loose • Remove if loose • Be prepared to remove if displacement occurs Temple College EMS Program

43. Oxygen • Oxygen cylinder sizes • D cylinder 350 liters • E cylinder 625 liters • M cylinder 3,000 liters • G cylinder 5,300 liters • H cylinder 6,900 liters • Contents under pressure • Should be positioned to prevent falling, blows to valve-gauge assembly Temple College EMS Program

44. Oxygen • Operating procedures • Remove protective seal • Quickly open, then shut valve • Attach regulator-flow meter to tank • Select proper size of oxygen mask for patient • Attach oxygen mask to flowmeter • Open flow meter to desired setting • Apply device to patient • When complete, remove device from patient, turn off device, remove all pressure from regulator Temple College EMS Program

45. Oxygen • Non-rebreather mask • Preferred method of giving oxygen to prehospital patients • Up to 90% oxygen can be delivered • Non-rebreather bag must be full before mask is placed on patient • Flow rate should be adjused so when patient inhales, bag does not collapse (~15 lpm) Temple College EMS Program

46. Oxygen • Nasal cannula • Rarely best method for giving adequate oxygen in emergency care settings • Should be used only if patient will not tolerate non-rebreather mask in spite of coaching Temple College EMS Program

47. Oxygen • Concerns about giving too much oxygen to patients with COPD, infants, and children are NOT valid during short-term emergency administration • Patients with COPD, infants, and children who require oxygen should be given high concentration oxygen. Temple College EMS Program