airway management and ventilation

INTRODUCTION

While all EMT-I skills are important to master and maintain, none aremore important than those associated with airway management and ven-tilation. Airway and breathing are the first and most critical steps in theinitial assessment of every patient you care for. No matter what else youdo, what other procedures you perform, what medications you give, with-out adequate airway maintenance and ventilation, the patient will sufferbrain injury or even death within as little as 6 to 10 minutes. This chapterwill provide the information and skills you need to manage even the mostdifficult airway.

OBJECTIVES

1. Review the anatomy and physiology of the respiratory system, specif-ically the upper and lower airways. (see Chapter 2, pp. 200–213)

2. Define the terms hypoxia (p. 354), hypoxemia (p. 352), pulsus para-doxus (p. 355), gag reflex (p. 370), and gastric distention (p. 367).

3. Explain the primary objective of airway maintenance. (p. 350)4. Identify commonly neglected prehospital skills related to airway.

(pp. 358–360)5. List factors that decrease oxygen concentrations in the blood and

increase or decrease carbon dioxide production in the body. (p. 352)6. Describe how to measure oxygen and carbon dioxide in the blood.

(pp. 357–360)7. List causes of upper airway obstruction and respiratory disease, and

describe the modified forms of respiration. (pp. 350–352, 354)8. Identify types of oxygen cylinders and pressure regulators (including

a high-pressure regulator and a therapy regulator), and explainsafety considerations of oxygen storage and delivery. (p. 360)

9. Describe supplemental oxygen delivery devices, including their indi-cations, contraindications, advantages, disadvantages, complications,liter flow range, and concentrations of delivered oxygen. (pp. 360–361)

10. Describe the use, advantages, and disadvantages of an oxygenhumidifier. (p. 361)

11. Explain the risk of infection to EMS providers associated withventilation. (pp. 366–368, 379, 396)

12. Describe the indications, contraindications, advantages, disadvantages,complications, and techniques for ventilating a patient: mouth-to-mouth; mouth-to-nose; mouth-to-mask; one, two, and three personbag-valve mask; flow-restricted, oxygen-powered ventilation device;and automatic transport ventilator (ATV). (pp. 361–365)

CHAPTER 5 Airway Management and Vent i lat ion 187

CHAPTER 5

Airway Management and Ventilation

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ADDITIONAL RESOURCES

Instructional Methods inEmergency Services, 2nd ed.,Brady.

BTLS: Basic Trauma Life Supportfor Paramedics and OtherAdvanced Providers, 5th ed.,Brady.

Bledsoe/EMT-I_IRMch05 10/27/03 1:39 PM 87

13. Compare the ventilation techniques used for an adult patient tothose used for pediatric patients. (pp. 363–364)

14. Define, identify, and describe a tracheostomy, a laryngectomy, astoma, a tracheostomy tube, and how to ventilate and manage theairway of a patient with a stoma. (pp. 397–398)

15. Describe a complete airway obstruction and related maneuvers. (pp. 350–352)

16. Define and explain the implications of partial airway obstructionwith good and poor air exchange. (pp. 350–351)

17. Describe laryngoscopy for the removal of a foreign body airwayobstruction. (p. 386)

18. Identify the different types of suction equipment, including catheters.(pp. 365–366)

19. Explain the purpose, indications, techniques, and special considera-tions for suctioning the upper airway. (pp. 365–367)

20. Describe the technique of tracheobronchial suctioning in the intu-bated patient. (pp. 366–367)

21. Describe the indications, contraindications, advantages, disadvan-tages, complications, equipment, and technique for inserting a naso-gastric tube and an orogastric tube. (p. 367)

22. Describe manual airway maneuvers. (pp. 368–370)23. Describe the indications, contraindications, advantages, disadvan-

tages, complications, and technique for inserting the oropharyngealand nasopharyngeal airways. (pp. 370–374)

24. Describe Sellick’s maneuver and the use of cricoid pressure duringintubation. (pp. 369–370)

25. Differentiate endotracheal intubation from other methods ofadvanced airway management. (p. 374)

26. Describe the indications, contraindications, advantages, disadvan-tages, and complications of endotracheal intubation. (pp. 379–382)

27. Describe the visual landmarks for direct laryngoscopy. (pp. 382–385)28. Describe the methods of assessing, confirming, and securing correct

placement of an endotracheal tube. (pp. 385–386)29. Describe the indications, contraindications, advantages, disadvan-

tages, complications, equipment, and technique for extubation. (pp. 390–391)

30. Describe methods of endotracheal intubation in the pediatric patient.(pp. 386–390)

31. Describe the indications, contraindications, advantages, disadvan-tages, complications, equipment, and techniques for using a duallumen airway. (pp. 391–395)

32. Describe the special considerations in airway management and venti-lation for patients with facial injuries, (pp. 386–387)

FRAMING THE LESSON

Begin class by reviewing the important points from Chapter 4, “VenousAccess and Medication Administration.” Discuss any aspects of the chap-ter not fully understood by students. Then start Chapter 5 material.

Ask students to recall from their CPR training the length of time aperson may be in cardiac and/or respiratory arrest with no ventilation oroxygen flow to the brain before brain cells begin to die. Review the infor-mation that the brain is the most sensitive organ in the body to any reduc-tion in oxygen delivery. Brain cells begin to die within 4 to 6 minutes if thebrain is not perfused.

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Next, have students do two exercises. First, have them hold theirbreath as long as they can. Ask how they feel once they resume breathing.Then distribute a plastic coffee stirring stick to each student. Have themplace the sticks in their mouths and breathe in and out only through theirmouths. This will graphically depict how people in respiratory distress,such as asthma attacks, feel when they breathe. Stress that no matter whatadvanced skill or procedure is done for a patient, the patient will not sur-vive if he does not have an adequate airway and ventilation.

TEACHING STRATEGIES

People learn in a variety of ways. Some do better with the spoken word,while others prefer the written. Some prefer to work alone, while othersprofit from working in groups. Recognizing these different ways of acquir-ing knowledge, the authors of this Instructor’s Resource Manual have pro-vided a variety of teaching strategies for the different types of learners.These strategies are intended to foster higher-level cognitive skills andencourage creative learning and problem solving.

For greatest effectiveness, incorporate these strategies into your classlecture. Symbols in the Lecture Outline indicate the spots at which variousexercises might be most appropriate. Other strategies can be used to pre-view the lesson or to sum it up.

The strategies below are keyed to specific sections of the lesson.

1. Airway Familiarization. Ask your local butcher for a pig pluck,which is the trachea, esophagus, lungs, and heart of a pig. These can

be kept without smelling for up to a week in the refrigerator. Let studentsintubate the trachea and ventilate the lungs. You will marvel at the wonder-ful demonstration of the alveoli, lung parenchyma, and even atelectasis.Since this specimen is fresh, it is even better than a human cadaver, whichwill lack the elasticity of the pig pluck. This activity is fun for your visual andkinesthetic learners but can be messy. Have students take BSI precautions,plus have lots of plastic bags, premoistened towelettes, and gloves on hand.

2. Pulse Oximeter Familiarization. Use the pulse oximeter onevery student in class. Students love to learn what their own readings

are, and you can even have contests for the lowest and highest pulse oxreading. This will be a great lead into a conversation about what condi-tions affect pulse oximeter readings. If your program does not have a pulseox, arrange for an ambulance or rescue unit to stop by for an hour or so.Borrow the equipment without taking the vehicle out of service.Alternatively, borrow one from a hospital emergency department.

3. Developing Suctioning Skills. Have a variety of actual sub-stances for students to suction during this lab session. Practice with

such materials can go a long way toward preparing them for managing adifficult airway with massive quantities of liquid or food. Pudding simu-lates mucus; apple juice simulates bile; tomato juice simulates blood; andsoup looks like vomit. This activity helps add realism to your classroomlab activities.

You might then test students’ suctioning skills in a contest. Have avariety of suctioning devices available. Divide the class into groups. Assignstudents in the first group one of the suctioning devices. Then bring outbowls of cold oatmeal. Challenge students to see who can do the most effi-cient job of suctioning. Time their efforts. Repeat with other groups untilall students have had a chance. Have a runoff among the group winners.You might use pea soup or a chunky barley soup, instead.

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4. Intubating the Class. Pass out six or seven endotracheal tubesto several students (or the whole class). Instruct them to breathe

through the tubes for the duration of the class. The difficulties they willexperience when breathing through a small-diameter tube should give stu-dents a new perspective and a greater empathy for what it is like to be anintubated patient.

5.Ventilation Drills. Test students’ grasp of some airway basics atthis point. Have them practice ventilation drills using a recording

Resusci-Annie. Ask for several students who think they “know how tobag.” Do not use the intubation heads. These heads can be ventilated inalmost any position. After five minutes, start recording the effectiveness ofventilations. This experiment can be very enlightening. Add to learning byshowing how even one finger break in the seal can markedly decrease theventilations’ effectiveness.

Also consider having a contest between teams. One team uses a bag-valve mask while the other uses a pocket mask. Again, let ventilations con-tinue for five minutes before you start to record. The results often tell a greatdeal about the effectiveness of the bag-valve mask over the pocket mask.

The strategy below can be used at various points throughout the les-son or to help summarize and demonstrate what the students have learned.

Airway Cam. The new “airway camera” technology provides amazingvideo of actual human airways during intubation. If this technology is notavailable to you for use by your students, purchase or borrow a video fromone of the manufacturing companies or a university with a medical school.While the technology is expensive, it is also relatively common.Demonstrations of “airway cam” have even been offered at EMS confer-ences around the country.

TEACHING OUTLINE

Distribute Handout 5-1 so that students can familiarize themselves withthe learning goals for this chapter. If students have any questions about theobjectives, answer them at this time. Then present the chapter. One possi-ble lecture outline is given below. In the outline, the parenthetical refer-ences in regular type are references to text pages; those in dark, heavy typeare to figures or tables.

I. Introduction: Airway management and ventilation skills are the firstand most critical steps in the initial assessment of every patient EMT-Iswill encounter. This chapter will provide the information and skillsneeded to manage even the most difficult airway. (p. 350)

II. Respiratory problems: EMT-Is must calmly and quickly assess theseverity of a patient’s illness or injury while considering the potentialcauses of and treatment for his respiratory distress. (pp. 350–352)

A. Airway obstruction (pp. 350–352)1. Tongue (Fig. 5-1, p. 351)2. Foreign bodies3. Trauma4. Laryngeal spasm and edema5. Aspiration

B. Inadequate ventilation (p. 352)


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HANDOUT 5-1Chapter 5 Objectives Checklist

POWERPOINT SLIDES

Brady’s PowerPoint Slides on CD-ROM offer a wealth of imagesthat can be tailored to yourcourse needs. See specific slidereferences throughout.

POWERPOINT SLIDES

Slide 1

POWERPOINT SLIDES

Slides 4–8

TEACHING STRATEGY 1Airway Familiarization

POINT TO EMPHASIZE

Your deliberate and precise use ofsimple, basic airway skills is thekey to successful airway manage-ment and good patient outcome.


III. Respiratory system assessment: Assessment of the respiratorysystem begins with the initial assessment and should continue throughthe focused history and physical exam and the ongoing assessment. (pp. 352–360)

A. Initial assessment (pp. 352–353) (Fig. 5-2, p. 353)B. Focused history and physical examination (pp. 353–360)

1. Focused history2. Physical exam

a. Inspectionb. Auscultation (Fig. 5-3, p. 355)c. Palpation

3. Noninvasive respiratory monitoringa. Pulse oximetry (Fig. 5-4, p. 357)b. Capnography (Figs. 5-5 and 5-6, p. 358; Fig. 5-7, p. 359)c. Esophageal detector device (Fig. 5-8, p. 359)d. Peak expiratory flow testing

IV. Oxygenation: Oxygen is an important drug, and its indications andprecautions must be thoroughly understood. (pp. 360–361)

A. Oxygen supply and regulators (p. 360)B. Oxygen delivery devices (pp. 360–361)

1. Nasal cannula2. Venturi mask3. Simple face mask4. Partial rebreather mask5. Nonrebreather mask6. Small-volume nebulizer7. Oxygen humidifier

V. Ventilation: Effective artificial ventilation requires a patent airway,an effective seal between the mask and the patient’s face, and deliveryof adequate ventilatory volumes. (pp. 361–365)

A. Mouth-to-mouth/mouth-to-nose ventilation (p. 362)B. Mouth-to-mask ventilation (p. 362)C. Bag-valve devices (pp. 362–364) (Fig. 5-9, p. 363)D. Flow-restricted, oxygen-powered ventilation devices (demand valves)

(pp. 364–365) (Fig. 5-10, p. 364)E. Automatic transport ventilator (p. 365) (Fig. 5-11, p. 365)

VI. Suctioning: EMT-Is must be prepared to suction all airways in orderto remove blood or other secretions and patient vomitus. (pp. 365–367)(Table 5-1, p. 366)

A. Suctioning equipment (pp. 365–366)B. Suctioning techniques (p. 366)C. Tracheobronchial suctioning (pp. 366–367)

VII. Gastric decompression: A common problem with ventilating anonintubated patient is gastric distention, which occurs when theprocedure’s high pressures trap air in the stomach. (p. 367)

A. Routes of decompression (p. 367)1. Nasogastric2. Orogastric

B. Tube placement technique (p. 367)


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POWERPOINT SLIDES

Slides 9–29

TEACHING STRATEGY 2Pulse Oximeter Familiarization

TEACHING TIP

Bring into class models of pulseoximeters and end-tidal carbondioxide detectors in use in yourarea. Demonstrate the operationof these devices. Let studentstake turns obtaining pulse oxime-try readings on each other.

POWERPOINT SLIDES

Slides 30–33

POINT TO EMPHASIZE

Never withhold oxygen from anypatient for whom it is indicated.

READING/REFERENCE

Brocato, B. “Breathing Room: Tips for the Assessment andManagement of RespiratoryEmergencies,” JEMS, Feb. 2001.

POWERPOINT SLIDES

Slides 34–36

ON THE NET

For effective BVM skills andtechniques, go to:www.enw.org/MaskVentilation.htm

POWERPOINT SLIDES

Slides 37–39

TEACHING STRATEGY 3Developing Suctioning Skills

POWERPOINT SLIDES

Slides 40–42


VIII. Basic airway management: Once it is determined thatintervention is needed, simple manual airway maneuvers and equipmentshould be used before proceeding with more advanced techniques. (pp. 368–374)

A. Manual airway maneuvers (pp. 368–370)1. Head-tilt/chin-lift2. Jaw-thrust maneuver3. Sellick’s maneuver (Fig. 5-12, p. 369; Fig. 5-13, p. 369)

B. Basic mechanical airways (pp. 370–374)1. Nasopharyngeal airway (Figs. 5-14 and 5-15, p. 371)2. Oropharyngeal airway (Fig. 5-16, p. 373; Fig. 5-17, p. 374)

IX. Advanced airway management: Inserting advanced mechanicalairways requires special training; the preferred method of airwaymanagement is endotracheal intubation. (pp. 374–396)

A. Endotracheal intubation (pp. 374–390) (Proc 5-1, p. 383)1. Equipment

a. Laryngoscope (Figs. 5-18, 5-19, and 5-20, p. 375; Figs. 5-21and 5-22, p. 376)

b. Endotracheal tubes (Figs. 5-23 and 5-24, p. 377) c. Stylet (Figs. 5-25 and 5-26, p. 378)d. 10 mL syringee. Tube-holding devicesf. Magill forceps (Fig. 5-27, p. 378)g. Lubricanth. Suction uniti. Capnometer or other confirmation devicej. Additional airwaysk. Protective equipment

2. Endotracheal intubation indicationsa. Respiratory or cardiac arrestb. Unconsciousness or obtusion with no gag reflexc. Risk of aspirationd. Obstructione. Respiratory extremis due to diseasef. Pneumothorax, hemothorax, or hemopneumothorax with

breathing difficulty3. Advantages of endotracheal intubation

a. Isolates trachea; permits complete control of airwayb. Impedes gastric distentionc. Eliminates need for mask seald. Offers direct route for suctioninge. Permits administration of some medications

4. Disadvantages of endotracheal intubationa. Requires considerable training and expertiseb. Requires specialized equipmentc. Requires direct visualization of vocal cordsd. Bypasses upper airway warming, filtering, humidifying of air

5. Complications of endotracheal intubationa. Equipment malfunctionb. Teeth breakage and soft tissue lacerationsc. Hypoxiad. Esophageal intubatione. Endobronchial intubationf. Tension pneumothorax


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POWERPOINT SLIDES

Slides 43–57

TEACHING TIP

Have students practice manualairway maneuvers on each other.Mannequin practice is good, butnothing beats the feel of openinga human airway. Have studentspractice stabilizing the head andneck and using the jaw-thrust tosimultaneously open the airway.

POWERPOINT SLIDES

Slides 58–123

TEACHING STRATEGY 4Intubating the Class

POINT TO EMPHASIZE

Esophageal intubation is lethal if you do not recognize itimmediately.

TEACHING STRATEGY 5Ventilation Drills

POINT TO EMPHASIZE

If you do not correct any signifi-cant decrease in the patient’s rateor depth of breathing, respiratoryor cardiac arrest may occur.


6. Orotracheal intubationa. Procedure (Proc. 5-1, p. 383)b. Verification of proper endotracheal tube placement

(Fig. 5-28, p. 384)c. Trauma patient intubation (Proc. 5-2, p. 387)

7. Pediatric intubation (Table 5-2, p. 388; Proc. 5-3, p. 389)B. Field extubation (pp. 390–391)C. Esophageal Tracheal CombiTube (pp. 391–393)

1. Advantages2. Disadvantages3. Insertion (Fig. 5-29, p. 391; Fig. 5-30, p. 392)

D. Pharyngo-tracheal lumen airway (pp. 393–395) (Fig. 5-31, p. 394)1. Advantages2. Disadvantages3. Insertion

E. Laryngeal mask airway (LMA) (pp. 395–396) (Fig. 5-32, p. 395)1. Advantages2. Disadvantages3. Insertion

X. Managing patients with stoma sites: A stoma is an opening in theanterior neck that connects the trachea with the ambient air; patients withstomas often have problems with excessive secretions. (pp. 397–398)(Fig. 5-33, p. 397)

SKILLS LAB

Divide the class into as many groups as appropriate. Have the groups cir-culate through the stations. Monitor the groups to be sure all groups havea chance to practice each of the skills. You may wish to have other instruc-tors or qualified EMT-Is assist students in these activities.


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Equipment and Station Personnel Needed Activities

Adult Basic Airway Maneuvers

Adult ET headAdult CPR mannequinAirway management kit1 instructor

Have students practice the following skills:manual airway maneuvers; insertion of oraland nasal airways; oropharyngealsuctioning.

Pediatric BasicAirway Maneuvers

Child/infant CPR mannequinsInfant ET headAirway management kit1 instructor

Have students practice the following skills:manual maneuvers; insertion of oral andnasal airways; suctioning.

Ventilation and Oxygenation Techniques

Adult/infant ET headsAdult/child/infant CPR mannequinsAirway management kit1 instructor

Have students practice the following skills:ventilation using pocket mask, BVM,demand valve; oxygen administration viamasks and cannulae.

Adult Endotracheal Intubation

Adult ET headAirway management kit1 instructor

Have students practice on adultmannequins.

Pediatric Intubation

Infant ET headAirway management kit1 instructor

Have students practice on infantmannequins.

POWERPOINT SLIDES

Slides 124–125

HANDOUTS 5-2 TO 5-9Chapter 5 Skills Sheets


ASSIGNMENTS

Assign students to complete workbook Chapter 5, “Airway Managementand Ventilation.” Also assign them to read textbook Chapter 6, “HistoryTaking.”

EVALUATION

You can use the quiz provided in Handout 5-10 and/or the case study pro-vided in Handout 5-11 to help you evaluate student understanding of thischapter. If you wish, you can also create custom-tailored tests using thePrentice Hall TestGen (combined package) that accompanies IntermediateEmergency Care: Principles & Practice.

REINFORCEMENT

If classroom discussion or student performance in evaluation activitiesindicates that students have not fully mastered the chapter content, youmay wish to assign some or all of the Reinforcement Handouts for thischapter.


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WORKBOOK

Chapter 5 Activities

TEXTBOOK

Chapter 6, pp. 399–417

HANDOUT 5-10Chapter 5 Quiz

HANDOUT 5-11Chapter 5 Scenario

TESTGEN

Chapter 5 Test

HANDOUTS 5-12 TO 5-14Reinforcement Activities

COMPANION WEBSITE

Encourage students to visit Brady’sEMT-I Website athttp://www.prenhall.com/bledsoe


CHAPTER 5 OBJECTIVES CHECKLIST

Knowledge Objectives Date Mastered

1. Review the anatomy and physiology of the respiratory system, specificallythe upper and lower airways.

2. Define the terms hypoxia, hypoxemia, pulsus paradoxus, gag reflex, andgastric distention.

3. Explain the primary objective of airway maintenance.

4. Identify commonly neglected prehospital skills related to airway.

5. List factors that decrease oxygen concentrations in the blood and increaseor decrease carbon dioxide production in the body.

6. Describe how to measure oxygen and carbon dioxide in the blood.

7. List causes of upper airway obstruction and respiratory disease, anddescribe the modified forms of respiration.

8. Identify types of oxygen cylinders and pressure regulators (including ahigh-pressure regulator and a therapy regulator), and explain safetyconsiderations of oxygen storage and delivery.

9. Describe supplemental oxygen delivery devices, including their indications,contraindications, advantages, disadvantages, complications, liter flowrange, and concentrations of delivered oxygen.

10. Describe the use, advantages, and disadvantages of an oxygen humidifier.

11. Explain the risk of infection to EMS providers associated with ventilation.

12. Describe the indications, contraindications, advantages, disadvantages,complications, and techniques for ventilating a patient: mouth-to-mouth;mouth-to-nose; mouth-to-mask; one, two, and three person bag-valvemask; flow-restricted, oxygen-powered ventilation device; and automatictransport ventilator (ATV).

13. Compare the ventilation techniques used for an adult patient to those usedfor pediatric patients.

14. Define, identify, and describe a tracheostomy, a laryngectomy, a stoma, atracheostomy tube, and how to ventilate and manage the airway of apatient with a stoma.

15. Describe a complete airway obstruction and related maneuvers.

16. Define and explain the implications of partial airway obstruction withgood and poor air exchange.

17. Describe laryngoscopy for the removal of a foreign body airwayobstruction.

18. Identify the different types of suction equipment, including catheters.

19. Explain the purpose, indications, techniques, and special considerationsfor suctioning the upper airway.


HA N D O U T 5 - 1 Student’s Name _________________________________©

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H A N D O U T 5 - 1 Continued

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Knowledge Objectives Date Mastered

20. Describe the technique of tracheobronchial suctioning in the intubatedpatient.

21. Describe the indications, contraindications, advantages, disadvantages,complications, equipment, and technique for inserting a nasogastric tubeand an orogastric tube.

22. Describe manual airway maneuvers.

23. Describe the indications, contraindications, advantages, disadvantages,complications, and technique for inserting the oropharyngeal andnasopharyngeal airways.

24. Describe Sellick’s maneuver and the use of cricoid pressure duringintubation.

25. Differentiate endotracheal intubation from other methods of advancedairway management.

26. Describe the indications, contraindications, advantages, disadvantages, andcomplications of endotracheal intubation.

27. Describe the visual landmarks for direct laryngoscopy.

28. Describe the methods of assessing, confirming, and securing correctplacement of an endotracheal tube.

29. Describe the indications, contraindications, advantages, disadvantages,complications, equipment, and technique for extubation.

30. Describe methods of endotracheal intubation in the pediatric patient.

31. Describe the indications, contraindications, advantages, disadvantages,complications, equipment, and techniques for using a dual lumen airway.

32. Describe the special considerations in airway management and ventilationfor patients with facial injuries.


MANUAL AIRWAY MANEUVERS

Key to Charting Student Progress:1. Learning skill2. Performs skill with direction3. Performs skill independently

HEAD-TILT/CHIN-LIFT

Procedure 1 2 3

1. Takes BSI precautions

2. Places patient supine and positions self at the side of the patient’s head

3. Places one hand on the patient’s forehead and, using firm downwardpressure with the palm, tilts the head back

4. Puts two fingers of the other hand under the bony part of the chin andlifts the jaw anteriorly to open the airway

Comments:

JAW-THRUST

Procedure 1 2 3


2. Places the patient supine and kneels at the top of his head

3. Applies fingers to each side of the jaw at the mandibular angles

4. Lifts the jaw forward (anteriorly) with a gentle tilting of the patient’s headto open the airway

Comments:

MODIFIED JAW-THRUST

Procedure 1 2 3



3. Applies fingers to each side of the jaw at the mandibular angles

4. Lifts the jaw using fingers behind the mandibular angles, without tiltingthe head

5. Jaw-thrust without head-tilt: lifts the jaw by grasping under the chin andbehind the teeth, without tilting the head

Comments:



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SKILLS


NASOPHARYNGEAL/OROPHARYNGEAL AIRWAYS


NASOPHARYNGEAL AIRWAY

Procedure 1 2 3


2. Hyperextends patient’s head and neck if no history of trauma

3. Hyperventilates with 100% oxygen

4. Measures tube from tip of nose to angle of jaw and the diameter of nostril

5. Lubricates exterior of the tube with water-soluble gel or lidocaine gel

6. Pushes gently up on tip of nose and passes tube into the right nostril, beveltoward septum

7. Verifies appropriate position of airway: clear breath sounds, chest rise,airflow at proximal end on expiration

8. Hyperventilates patient with 100% oxygen

Comments:

OROPHARYNGEAL AIRWAY

Procedure 1 2 3


2. Hyperextends patient’s head and neck if no history of trauma; opensmouth and removes visible obstructions

3. Hyperventilates patient with 100% oxygen, if indicated

4. Measures airway from corner of mouth to earlobe

5. Grasps patient’s jaw and lifts anteriorly

6. With other hand, holds airway at proximal end and inserts into patient’smouth, with curve reversed and tip pointing toward roof of mouth

7. As tip reaches level of soft palate, gently rotates airway 180° until it comesto rest over the tongue

8. Verifies appropriate position of airway: clear breath sounds, and chest rise


Comments:


HA N D O U T 5 - 3 Student’s Name _________________________________

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OROTRACHEAL INTUBATION


Procedure 1 2 3


2. Places patient supine

3. Uses appropriate basic manual and adjunct airway maneuvers;hyperventilates with 100% oxygen

4. Assembles and checks equipment

5. Places head in sniffing position

6. Has partner apply Sellick’s maneuver

7. Holds laryngoscope in the left hand; inserts it into the right side of mouth

8. Displaces tongue to the left and brings laryngoscope midline

9. Lifts laryngoscope forward to displace jaw without putting pressure onteeth

10. Suctions the hypopharynx as necessary

11. Places blade in proper position, visualizing tip of epiglottis

12. Lifts jaw at 45° angle to the ground, exposing glottis

13. Holds ETT in right hand and advances tube through right corner ofpatient’s mouth

14. Directly visualizes vocal cords, passes ETT through the glottic openinguntil distal cuff disappears beyond vocal cords

15. Removes stylet, inflates distal cuff with 5–10 mL of air, attaches BVMwith ETCO2 detector to connector on ETT

16. Checks for proper tube placement; equal bilateral breath sounds,symmetrical rise and fall of chest


18. Secures ETT with tape or commercial device

19. Periodically rechecks tube placement

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TRAUMA INTUBATION


Procedure 1 2 3


2. One team member faces patient on one side, establishes cervical spinestabilization from the front

3. Intubating EMT-I sits behind patient on the ground with legs straddlingpatient’s shoulders, moves up until patient’s head is secured, applies firmpressure to ensure immobilization



6. Holds laryngoscope in left hand and inserts it into right side of the mouth,displacing tongue to the left, and brings laryngoscope to midline

7. Advances blade until it reaches the base of the tongue

8. Lifts laryngoscope forward to displace the jaw without putting pressure onfront teeth

9. Looks for tip of epiglottis and places blade into proper position

10. Lifts jaw at 45° angle to the ground until glottis is exposed

11. Grasps tube with the right hand and advances it through right corner ofpatient’s mouth

12. Advances the tube through the glottic opening until the distal cuffdisappears past vocal cords

13. Removes stylet, inflates distal cuff with 5–10 mL of air, removes syringe

14. Verifies proper placement of tube: clear breath sounds, symmetrical chestrise



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PEDIATRIC INTUBATION


Procedure 1 2 3




4. Places patient head and neck in appropriate position

5. Has partner apply Sellick’s maneuver

6. Holds laryngoscope in left hand and inserts into right side of mouth

7. Moves blade slightly toward midline, advancing it until the distal endreaches the base of the tongue

8. Looks for tip of epiglottis, and positions laryngoscope properly

9. Grasps ETT in right hand and, under direct visualization of the vocalcords, inserts it through the right corner of the patient’s mouth into theglottic opening until distal 10 mm or distal cuff disappears 2–3 cm beyondthe vocal cords

10. Holds tube in place with left hand and attaches infant- or child-size BVMto the connector with CO2 detector

11. Delivers several breaths, checking for proper tube placement: symmetricalrise and fall of chest, equal bilateral breath sounds


13. Secures tube with tape or commercial device


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ESOPHAGEAL TRACHEAL COMBITUBE AIRWAY


Procedure 1 2 3





5. Places patient’s head in neutral position

6. Inserts ETC at midline through oropharynx, using a tongue-jaw-liftmaneuver, advancing it past the hypopharynx to the depth indicated by themarkings on the tube so that the black rings of the tube are betweenpatient’s teeth

7. Inflates pharyngeal cuff with 100 mL of air and distal cuff with 10–15 mLof air

8. Ventilates through the longer blue proximal port with BVM connected to100% oxygen

9. Auscultates lungs and stomach

10. If gastric sounds are heard instead of breath sounds, changes ports andventilates through the clear connector

11. Confirms bilateral lung sounds, visualizes chest rise, watches for colorchange in CO2 detector

12. Secures tube and continues ventilating with 100% oxygen

13. Frequently reassesses airway and adequacy of ventilation

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PTL AIRWAY


Procedure 1 2 3




4. Places patient’s head in appropriate position

5. Inserts PtL gently, using the tongue-jaw-lift maneuver

6. Inflates distal cuffs of both PtL tubes simultaneously with sustained breathinto inflation valve

7. Delivers breath into green tube and looks for chest rise

8. If chest rises, inflates pharyngeal balloon and continues ventilating throughgreen tube, auscultating bilateral breath sounds

9. If chest does not rise and no breath sounds are audible with auscultation,removes stylet from clear tube and ventilates patient through that tube

10. Verifies proper placement by watching chest rise and auscultating lungs

11. Attaches BVM, secures tube, and hyperventilates patient with 100%oxygen

12. Frequently reassesses airway and adequacy of ventilation

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SUCTIONING


Procedure 1 2 3



3. Determines depth of catheter insertion by measuring from patient’s earlobeto lips

4. With suction turned off, inserts catheter into patient’s pharynx to thepredetermined depth

5. Turns on suction unit and places thumb over suction control orifice

6. Suctions while withdrawing catheter, no more than 10 seconds


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CHAPTER 5 QUIZ

Write the letter of the best answer in the space provided.

______ 1. The potentially most ominous finding of auscultation is:A. snoring. C. wheezing.B. gurgling. D. quiet.

______ 2. You should use a ______ maneuver to open the airway of a patient with a suspected neckor head injury.A. Sellick’s C. modified jaw-thrustB. jaw-thrust D. head-tilt/chin-lift

______ 3. To prevent regurgitation during attempts at endotracheal intubation, use the ______maneuver.A. Sellick’s C. modified jaw-thrustB. jaw-thrust D. head-tilt/chin-lift

______ 4. One advantage of the nasopharyngeal airway over the oropharyngeal is that thenasopharyngeal airway:A. isolates the trachea.B. makes suctioning of the pharynx easier.C. may be used in the presence of a gag reflex.D. eliminates the possibility of pressure necrosis.

______ 5. The single greatest danger of EOA insertion is:A. inadequate ventilation. C. tracheal intubation.B. esophageal intubation. D. poor mask seal.

______ 6. The laryngoscope permits visualization of the vocal cords by lifting of the tongue and:A. soft palate. C. hyoid bone.B. epiglottis. D. none of the above

______ 7. The curved blade made for the laryngoscope is the:A. Miller. C. Wisconsin.B. Flagg. D. Macintosh.

______ 8. The curved laryngoscope blade is designed to fit into the:A. larynx. C. epiglottis.B. vallecula. D. pyriform fossa.

______ 9. The greatest advantage of a straight blade is:A. greater displacement of the tongue.B. indirect elevation of the epiglottis.C. wider field of vision for intubation.D. lessened chance of stimulating the gag reflex.

______ 10. Stylets are a valuable asset when intubating a patient with a:A. short, fat neck. C. posterior larynx.B. long, thin neck. D. none of the above

______ 11. The dangers of movement of an endotracheal tube once it is positioned include:A. elevation of intracranial pressure. C. cardiovascular depression.B. stimulation of the vallecula. D. all of the above


HA N D O U T 5 - 1 0 Student’s Name _________________________________©

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______ 12. Potentially dangerous complications of improper endotracheal intubation include:A. esophageal intubation. C. right mainstem intubation.B. pyriform sinus intubation. D. all of the above

______ 13. Indications of proper endotracheal intubation include all of the following EXCEPT:A. presence of condensation in the tube.B. presence of bilateral breath sounds.C. absence of abdominal sounds.D. phonation.

______ 14. Which one of the following statements about the pediatric airway is NOT true?A. The tongue is larger in relation to the oropharynx than in adults.B. The glottic opening is lower and more posterior than in adults.C. The narrowest part is the cricoid cartilage.D. The vocal cords slant upward.

______ 15. Both the PtL and the ETC airways can be:A. inserted into either the esophagus or trachea.B. used in patients under 16 years of age.C. used in patients with a gag reflex.D. all of the above

______ 16. An absolute contraindication to oxygen administration in hypoxic patients is:A. a premature infant. C. COPD.B. hyperventilation. D. none of the above

______ 17. To ventilate the patient with a stoma, rescue personnel will generally use a(n):A. BVM device. C. mouth-to-stoma technique.B. demand valve device. D. automatic transport ventilator.

______ 18. The minimum acceptable vacuum level in suctioning units for the prehospital setting is______ mmHg.A. 200 C. 500B. 300 D. 750

______ 19. Both standard routes of gastric decompression put the patient at risk for all of thefollowing EXCEPT:A. vomiting.B. misplacement into the brain.C. misplacement into the trachea.D. trauma or bleeding from poor technique.

______ 20. The bag-valve device has an adjunct oxygen reservoir or corrugated tubing that candeliver ______ to ______ oxygen.A. 60%, 70% C. 80%, 90%B. 70%, 75% D. 90%, 95%


H A N D O U T 5 - 1 0 Continued

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Bledsoe/EMT-I_IRMch05 10/27/03 1:39 PM 6

CHAPTER 5 SCENARIO

Review the following real-life situation. Then answer the questions that follow.

The call is for an unknown medical emergency, with a man down on the sidewalk in front of the countybuilding. Unit 6 is literally around the corner from the call. The unit arrives to find a small crowd ofpeople standing around the patient. The patient is well known to the crew as an alcoholic with a his-tory of epileptic seizures.

In this case, the patient apparently fell and struck his head, as blood is still oozing from a lacera-tion to his forehead. A First Responder ensures stabilization of the head, while the EMT-I tries to arousethe patient. Witnesses say that the patient had a seizure that lasted for “several minutes.” No one reportsthat he turned cyanotic. After getting no response to his loud questions and commands, the EMT-Iattempts a painful stimulation. This effort produces only a groan from the patient. The EMT-I attemptsto insert an oral airway, but the patient gags and spits it out. The EMT-I then tries a nasopharyngealairway. The patient tolerates this, so the crew supplies oxygen and prepares to package the patient fortransport.

When he is secured to the backboard, the patient suddenly seizes again. The crew rolls him ontohis side while on the backboard, suctions his mouth, and reassesses his airway and breathing after hestops seizing. The seizure lasts less than one minute.

1. Why was the airway a concern in this patient?

2. What other causes of the seizure might be possible?

3. Why would the EMT-I not immediately intubate this unconscious patient on scene?



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CHAPTER 5 REVIEW

Write the word or words that best complete the following sentences in the space(s) provided.

1. The most common cause of airway obstruction is the __________________ .

2. __________________ breathing is asymmetrical chest wall movement that lessens respiratory

efficiency.

3. The measurement of exhaled carbon dioxide concentrations is called __________________ .

4. In the absence of cervical-spine trauma, the __________________ - __________________ /

__________________ - __________________ maneuver is the best technique for opening the airway of

an unresponsive patient.

5. The __________________ airway may be used for intubation in the presence of a gag reflex.

6. Once the tip of a(n) __________________ airway reaches the level of the soft palate, gently rotate it

180 degrees.

7. Miller, Wisconsin, and Flagg are types of __________________ laryngoscope blades.

8. Verification of proper endotracheal tube placement includes absence of __________________

__________________ over the epigastrium, the presence of __________________ breath sounds (lungs),

and the presence of __________________ inside the tube.

9. Partial ingestion of caustic poisons is a contraindication to the use of the __________________

__________________ __________________ .

10. Often patients who have had a laryngectomy or tracheostomy breathe through a(n)

__________________ , an opening in the anterior neck that connects the trachea with the ambient

air.

11. Suctioning should be limited to __________________ seconds.

12. In an awake patient with gastric distention, the __________________ approach to decompression is

generally preferred.

13. To calculate how many minutes the oxygen in a tank will last, multiply the psi in the tank by

__________________ ; then divide by __________________ __________________ __________________ .

14. The difference between a partial rebreather mask and a nonrebreather mask is that the

nonrebreather mask has a(n) __________________ __________________ __________________ attached.

15. The memory aid used to establish a rhythm for adequately ventilating a child is

__________________ , __________________ , __________________ .

16. Most demand valve devices have a(n) __________________ __________________ __________________

that makes them useful in treating spontaneously breathing patients who need high oxygen

concentrations.


HA N D O U T 5 - 1 2 Student’s Name _________________________________

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ADVANCED AIRWAY MATCHING

Write the letter of the term in the space next to the appropriate description.

A. Demand valveB. Endotracheal tubeC. ETCD. MacintoshE. MagillF. NonrebreatherG. Oropharyngeal airwayH. PtLI. StyletJ. VenturiK. WisconsinL. Yankauer

______ 1. Type of scissors-style clamps with circle-shaped tips

______ 2. Straight laryngoscope blade

______ 3. Airway comprising a short, large-diameter, green tube and a longer, narrow-diameterclear tube

______ 4. Manually triggered, oxygen-powered breathing device

______ 5. Tonsil tip suction catheter

______ 6. Semicircular plastic and rubber device that conforms to the palate’s curvature and lifts thebase of the tongue

______ 7. Metal wire covered with plastic

______ 8. Two-tube airway in which tubes are combined with lumens separated by a partition

______ 9. Oxygen administration device particularly useful with COPD patients

______ 10. Flexible, 35–37 cm tube with adapter at one end and inflatable cuff at the other

______ 11. Device consisting of tubing, reservoir bag, and inlet/outlet ports covered by thin rubberflaps

______ 12. Curved laryngoscope blade



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AIRWAY MANAGEMENT ADVANTAGES AND DISADVANTAGES

Complete the following lists.

1. What are three advantages of the nasopharyngeal airway?

2. What are three disadvantages of the oropharyngeal airway?

3. What are three disadvantages of endotracheal intubation?

4. What are three advantages of the PtL airway?

5. What are three advantages of the Esophageal Tracheal CombiTube?


HA N D O U T 5 - 1 4 Student’s Name _________________________________

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H A N D O U T 5 - 1 1 : Chapter 5 Scenario

1. The unconscious patient has little, if any, controlover the airway; therefore, aspiration becomes avery real threat.

2. Reasonably, the patient may have seized due toalcohol withdrawal, epilepsy, hypoglycemia, over-dose of antifreeze or wood alcohol, closed headinjuries such as a subdural hematoma, or from aninfectious process.

3. The decision to intubate either the diabetic withhypoglycemia or the postictal epileptic patientmust be made carefully. These patients oftenrespond quickly to simple measures and withoutfurther complications that might result from theuse of advanced airway control methods.

H A N D O U T 5 - 1 2 : Chapter 5 Review

1. tongue2. Paradoxical3. capnography4. head-tilt/chin-lift5. nasopharyngeal6. oropharyngeal7. straight8. gastric sounds, bilateral, condensation9. Esophageal Tracheal CombiTube

10. stoma11. 1012. nasogastric13. 0.28, liters per minute14. oxygen reservoir bag 15. squeeze, release, release16. inspiratory release valve

H A N D O U T 5 - 1 4 : Airway ManagementAdvantages and Disadvantages

1. Rapid insertion, bypasses tongue, can be used withgag reflex, can be used in patients with oral cavityinjury, can be used when teeth are clenched.

2. It does not isolate the trachea or prevent aspiration;it cannot be inserted when the teeth are clenched;it may obstruct the airway if not inserted properly;it is easily dislodged; return of the gag reflex mayproduce vomiting.

3. Requires considerable training and experience;requires specialized equipment; requires directvisualization of the vocal cords; bypasses the upperairway’s function of warming, filtering, andhumidifying the inhaled air.

4. Functions in either trachea or esophagus, no facemask to seal, does not require visualization of thelarynx, can be used with trauma patients, helpsprotect trachea from upper airway bleeding andsecretions.

5. It provides alternate airway control when conven-tional intubation techniques are unsuccessful orunavailable; insertion is rapid and easy; insertiondoes not require visualization of the larynx orspecial equipment; pharyngeal balloon anchors theairway behind the hard palate; patient may beventilated regardless of tube placement (esophagealor tracheal); significantly diminishes gastric disten-tion and regurgitation.; can be used on traumapatients, since the neck can remain in neutral posi-tion during insertion and use; if the tube is placedin the esophagus, gastric contents can be suctionedfor decompression through the distal port.


C H A P T E R 5 A n s w e r K e y©

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H A N D O U T 5 - 1 0 : Chapter 5 Quiz

1. D2. C3. A4. C5. C

6. B7. D8. B9. A

10. A

11. A12. D13. D14. B15. A

16. D17. A18. B19. B20. D

H A N D O U T 5 - 1 3 : Advanced Airway Matching

1. E2. K3. H4. A

5. L6. G7. I8. C

9. J10. B11. F12. D


airway management and ventilation

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