Airway and CPAP

1. Airway and CPAP

2. Topics to be Discussed • Anatomy and Physiology Review • Opening the Airway • Techniques of Suctioning • Airway Adjuncts • Advanced Airway Adjuncts • Assessment of Breathing • Artificial Ventilation • Supplemental Oxygen • Special Considerations • CPAP

3. Anatomy and Physiology of the Respiratory System

4. Anatomy of the Respiratory System Nasopharynx Pharynx Oropharynx Epiglottis Thyroid cartilage Larynx Cricoid cartilage Trachea Bronchiole Left main bronchus Right main bronchus Bronchiole Diaphragm Lungs Alveolus This is what we are trying to fix with CPAP Alveolar sac

5. Physiology of Respiration • Inhalation • Regular inhalation is an active process. • External Intercostals • Diaphragm • Inhalation draws the ribs up and out and increases the size of the rib cage.

6. Physiology of Respiration • Exhalation • Regular exhalation is a passive process. • Muscles used in Inhalation simply relax. • Forceful exhalation is active and decreases the size of the rib cage. • Abdominal Muscles • Internal Intercostals

7. . O O CO 2 2 2 Respiratory Physiology CO 2 Blood from right side of heart Aveolus (low in O2, O high in CO2) O 2 2 Blood to left CO CO 2 2 side of heart Reoxygenated blood (high in O2, low in CO2 ) Capillary Red blood cells

8. Infant/Child Anatomy Considerations Mouth & Nose Pharynx Trachea Cricoid Cartilage Diaphragm

9. Opening the Airway

10. The best way to maintain the airway is the have the patient do it themselves. • When this fails, we must do it ourselves. • Two Basic Techniques for Manual airway control. • Head-Tilt Chin-Lift Method • Jaw Thrust Method Opening the Airway

11. Head-Tilt Chin-Lift (No neck injury suspected)

12. (Suspected Spinal Injury)—AHA Guidelines state if not successful on the first attempt, use head tilt-chin lift Jaw Thrust

13. Techniques of Suctioning

14. Don’t forget your Body Substance Isolation Equipment

15. Suctioning • The purpose of suctioning is to remove blood, vomitus, other liquids, and food particles from the airway • A patient needs to be suctioned immediately when a gurgling sound is heard or a substance is found upon opening the airway!

16. Types of Suction Units Portable Portable Wall Mounted Oxygen Powered

17. Yankauer aka “tonsil sucker” aka “tonsil tip” Hard or Rigid Suction Catheter

18. Soft Tip Suction Catheter You measure it the same as an Oral-pharyngeal Airway

19. Suction units should be inspected on a daily basis!!!

20. Position yourself at patient’s head Attach a catheter Turn on suction unit – just to make sure it works Insert catheter into the oral or nasal cavity without suction Insert only to the base of the tongue Techniques of Suctioning More 

21. Apply suction, moving catheter from side to side Suction for no more than 15 seconds at a time in adults and no more than 5 seconds in infants and children. Techniques of Suctioning More 

22. If the patient produces frothy secretions as rapidly as suctioning can remove, suction for 15 seconds, then artificially ventilate for two minutes, then suction for 15 seconds. Repeat this process until the airway is clear. Techniques of Suctioning More 

23. Techniques of Suctioning • Heavy vomitus may require that the patient is log-rolled onto his side and the oral cavity cleared by a finger sweep.

24. Be aware of hypoxia during suctioning. • Increase in heart rate in adults • Decrease in heart rate in infants and children • Heart rate decrease may be due to stimulation of posterior pharynx and/or epiglottis Techniques of Suctioning

25. Airway Adjuncts

26. Airway adjuncts are used in conjunction with manual airway maneuvers to establish and maintain the airway. Airway Adjuncts

27. Oropharyngeal airways may be used to assist in maintaining an open airway on unresponsive patients without a gag reflex. Oropharyngeal Airways

28. A range of sizes should be available on the emergency vehicle. Measure for Correct Size

29. Other Methods: • Insert right side up, and use a tongue depressor • Insert at corner of mouth sideways and rotate 90 degrees while advancing. Insert gently until resistance, rotate 180 degrees

30. Nasopharyngeal airways are less likely to stimulate the gag reflex and may be used on patients who are not fully responsive but need assistance maintaining an open airway. Nasopharyngeal Airways

31. Measure from tip of the nose to the tip of the patient’s ear lobe The diameter of the airway must fit in the nostril Select the Proper Size

32. Lubricate the airway with a water soluble lubricant Nasopharyngeal Airways

33. Insert posteriorily with the bevel toward the base of the nostril toward the septum Nasopharyngeal Airways

34. Nasopharyngeal Airways YOU MAY USE MORE THAN ONE!!!!

35. Assessment of Breathing

36. Assessment of Breathing is essential for the assurance that an airway is patent or easily maintainable. • Assessment is a factor of four areas • Rate • Quality • Rhythm • Depth Assessment of Breathing

37. Adequate Breathing • Normal Rates • Adult - 12-20/minute • Child - 15-30/minute • Infant - 25-50/minute • Rhythm • Regular • Irregular

38. Quality • Breath sounds - present and equal • Chest expansion - adequate and equal • Effort of breathing - use of accessory muscles - predominantly in infants and children • Depth • Tidal volume - Adequate Adequate Breathing

39. Rate • Outside normal Ranges • Too Fast • Too Slow Inadequate Breathing

40. Rhythm • Irregular • Unusual Patterns • Kussmal • Cheyne Stokes • Hyperventilation • Agonal • Slow and Irregular Inadequate Breathing

41. Inadequate Breathing • Quality • Breath sounds - diminished or absent • Chest expansion - unequal or inadequate • Increased effort of breathing - use of accessory muscles - predominantly in infants and children More 

42. Inadequate Breathing • Quality cont. • There may be retractions above the clavicles, between the ribs and below the rib cage, especially in children. • Nasal flaring may be present, especially in children • In infants, there may be "see-saw" breathing where the abdomen and chest move in opposite directions.

43. Quality cont. • Agonal breathing (occasional gasping breaths) may be seen just before death. • The skin may be pale or cyanotic (blue) and cool and clammy. • Depth • Tidal Volume - inadequate/shallow Inadequate Breathing

44. Inadequate Breathing • Irregular rhythm • Fast or slow respiratory rate • Unequal/ inadequate chest • expansion • Increased effort • Retractions above, between or below ribs • Inadequate volume • Cyanosis • Cool, clammy skin • Nasal flaring • Occasional gasping breaths may be seen just before • death • Use of accessory • ` muscles

45. Techniques of Artificial Ventilation

46. Mouth-to-Mask • More volume than BVM • 2-Person Bag-Valve-Mask • Tight seal • Fully compressed bag • Flow-Restricted Oxygen-Powered Ventilation Device • Difficult to regulate • Mask seal issues • 1-Person Bag-Valve-Mask • Questionable Seal • Variable bag compression Artificial Ventilation In order of preference

47. Adequate Artificial Ventilation • Chest Rises and Falls • Sufficient Rate • 12 / minute for Adults • 20 / minute for Children/Infants • Heart Rate Returns to Normal

48. Inadequate Artificial Ventilation • Chest Does Not Rise and Fall • Rate Too Fast or Too Slow • Heart Rate Does Not Return to Normal

49. Body Substance Isolation

50. Connect mask to high-flow oxygen 15 liters/ minute if able Mouth-to- Mask Ventilation