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Emergency Care

CHAPTER

Copyright © 2016, 2012, 2009 by Pearson Education, Inc.All Rights Reserved

Emergency Care, 13eDaniel Limmer | Michael F. O'Keefe

THIRTEENTH EDITION

Airway Management

9



Multimedia Directory

Slide 22 Responding to an Adult with an Obstructed Airway Video

Slide 73 Suctioning—Oral Pharyngeal Video



Topics

• Airway Physiology

• Airway Pathophysiology

• Opening the Airway

• Airway Adjuncts

• Suctioning

• Keeping an Airway Open: Definitive Care

• Special Considerations



Airway Physiology



Airway Physiology

• Upper airway

Begins at mouth and nose

• Air is warmed and humidified in nasal turbinates.

Pharynx

• Oropharynx, nasopharynx, and laryngopharynx

Ends at glottic opening



Airway Physiology

The upper airway.



Airway Physiology

• Lower airway

Begins below the larynx

Composed of:

• Trachea

• Bronchial passages

• Alveoli



Airway Physiology

The lower airway. (A) The bronchial tree.



Airway Physiology

• Alveoli

Tiny sacs in grapelike bunches at the end of the airway

Surrounded by pulmonary capillaries

Oxygen and carbon dioxide diffuse through pulmonary capillary membranes.



Airway Physiology

The lower airway. (B) The alveolar sacs (clusters of individual alveoli).



Airway Pathophysiology




• Variety of obstructions interfere with air flow

Foreign bodies

• Food, small toys

Liquids

• Blood, vomit

• Obstruction may also result from poor muscle tone caused by altered mental status.

continued on next slide




• Obstructions can be acute or chronic.

• Providers must initially evaluate airway and monitor patency over time.





• Airway obstructions

Acute

• Foreign bodies

• Vomit

• Blood

Occurring over time

• Edema from burns, trauma, or infection

• Decreasing mental status





• Airway obstructions

Bronchoconstriction

• Disorder of lower airway

• Smooth muscle constricts internal diameter of airway.



Patient Assessment

• Addressed in primary assessment

• Two questions must be answered.

Is airway open?

Will airway stay open?



Is the Airway Open?

• In most patients, can be determined by simply saying hello

• "Sniffing position" seen when swelling obstructs airflow through upper airway




Is the Airway Open?

• Findings indicating breathing problems

Inability to speak

Unusual raspy quality to voice

Stridor

Snoring

Gurgling



Will the Airway Stay Open?

• Airway assessment is not just a moment in time.

• Must give constant consideration



Signs of an Inadequate Airway

• No signs of breathing or air movement

• Evidence of foreign bodies in airway

• No air felt or heard

• Inability or difficulty speaking

• Unusual hoarse or raspy voice

• Absent, minimal, or uneven chest movement




Signs of an Inadequate Airway

• Abdominal breathing

• Diminished or absent breath sounds

• Abnormal noises such as wheezing, crowing, stridor, snoring, gurgling, or gasping during breathing

• In children and infants, nasal flaring

• In children, retractions above the clavicles



Responding to an Adult with an Obstructed Airway Video

Click on the screenshot to view a video on the subject of obstructed airway in an adult.

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Opening the Airway



Patient Care

• The airway

When primary assessment indicates inadequate airway, a life-threatening condition exists.

Take prompt action to open and the maintain airway



Opening the Airway

• If airway is not open, use position to open it.

• Indications of head, neck, spinal injury

Mechanism of injury known to cause such injuries

Any injury at or above the level of the shoulders

Family or bystanders give information leading you to suspect it.




Opening the Airway

• Head-tilt, chin-lift maneuver and jaw-thrust maneuver move airway structures into position allowing air movement.



Head-Tilt, Chin-Lift Maneuver

Head-tilt, chin-lift maneuver, side view. Right image shows EMT’s fingertips under the bony area at the center of the patient’s lower jaw.



Head-Tilt, Chin-Lift Maneuver

1. Place one hand on patient's forehead and fingertips of other hand at the center of patient's lower jaw.

2. Tilt head.

3. Lift chin.

4. Do not allow mouth to close.



Jaw-Thrust Maneuver

Jaw-thrust maneuver, side view. Inset shows EMT’s finger position at angle of the jaw just below the ears.



Jaw-Thrust Maneuver

1. Keep patient's head, neck, and spine aligned, moving patient as a unit into the supine position.

2. Kneel at the top of patient's head.

3. Place one hand on each side of patient's lower jaw, at angles of jaw below ears.

4. Stabilize patient's head with your forearms.




Performing Jaw-Thrust Maneuver

5. Using index fingers, push angles of patient's lower jaw forward.

6. You may need to retract patient's lower lip with your thumb to keep the mouth open.

7. Do not tilt or rotate patient's head.



Airway Management

• After airway has been opened, position must be maintained to keep airway open.

• Airway must be cleared of secretions and other obstructions.



Airway Adjuncts



Airway Adjuncts

• Airway position and maneuvers are short-term solutions.

• Airway adjunct provides longer term air channel.

• Two most common airway adjuncts

Oropharyngeal airway (OPA)

Nasopharyngeal airway (NPA)



Rules for Using Airway Adjuncts

• Use OPA only on patients not exhibiting gag reflex.

• Open patient's airway manually before using adjunct device.

• When inserting airway, take care not to push patient's tongue into pharynx.





• Have suction ready prior to inserting any airway.

• Do not continue inserting airway if patient gags.

• Maintain head position after adjunct insertion and monitor airway.





• Continue to be ready to provide suction if fluid or blood obstructs the airway.

• If patient regains consciousness or develops a gag reflect, remove the airway immediately.

• Use infection control practices while maintaining airway.



Oropharyngeal Airway

• Device used to move tongue forward as it curves back to pharynx

• Sizes

Infant to large adult




Oropharyngeal airways.



Sizing Oropharyngeal Airways

Ensure the oropharyngeal airway is the correct size by checking to make sure it either extends from the center of the mouth to the angle of the jaw or…



Sizing Oropharyngeal Airways

Measure from the corner of the patient's mouth to the tip of the earlobe.




• Inserting OPA

1. Place patient on his back, and use appropriate method to open the airway

2. Open mouth with crossed-finger technique

3. Position airway with tip pointing toward roof of mouth



Inserting OPA

Use the crossed-fingers technique to open the patient's mouth.




• Inserting OPA

4. Insert device along roof of mouth

5. Gently rotate airway 180 degrees so tip is pointing down into patient's pharynx

6. Position patient

7. Check that flange of airway is against patient's lips

8. Monitor patient closely




Inserting OPA

Insert the airway with the tip pointing to the roof of the patient's mouth.




• Inserting OPA

Use tongue depressor or rigid suction tip and insert OPA directly



Nasopharyngeal Airway

• Soft, flexible tube inserted through nostril and into hypopharynx

• Moves tongue and soft tissue forward to provide a channel for air





• Can be used in patients with intact gag reflex or clenched jaw

• Contraindicated if clear (cerebrospinal) fluid coming from nose or ears





• Come in various sizes

• Must be measured

• Typical adult sizes

34, 32, 30, and 28 French



Inserting NPA

• Inserting NPA

1. Measure for correct size

2. Lubricate outside of tube with water-based lubricant before insertion



Inserting NPA

Measure the nasopharyngeal airway from the patient's nostril to the tip of the earlobe or to the angle of the jaw.



Inserting NPA

Apply a water-based lubricant before insertion.



Inserting NPA

• Inserting NPA

3. Push tip of nose upward; keep head in neutral position

4. Insert into nostril; advance until flange rests firmly against nostril



Inserting NPA

Gently push the tip of the nose upward, and insert the airway with the beveled side toward the base of the nostril or toward the septum (wall that separates the nostrils).

Insert the airway, advancing it until the flange rests against the nostril.



Suctioning



Suctioning

• Obvious liquids (blood, secretions, vomitus) must be removed from airway to prevent aspiration into lungs.

• Use vacuum device to remove liquids from airway.



Suction Devices

• Mounted suction systems

Installed near head of stretcher

Furnish air intake of at least 30 liters per minute

Generate vacuum of no less than 300 mmHg when collecting tube clamped




Suction Devices

• Portable suction units

Same requirements as mounted

Oxygen- or air-powered or powered by batteries/electricity

Manual




Suction Devices

• Tubing, tips, and catheters

Tubing

Suction tips

Suction catheters

Collection container

Container of clean or sterile water



Suction Systems

A mounted suction unit installed in the ambulance’s patient compartment.



Suction Devices


Rigid pharyngeal suction tip

• Also called Yankauer tip

• Larger bore than flexible catheters



Rigid Pharyngeal Tip

Place the convex side of the rigid tip against the roof of the mouth. Insert just to the base of the tongue.



Suction Devices


Rigid pharyngeal suction tip

• Suction only as far as you can see.

• Do not lose sight of distal end.

• Careful insertion helps prevent gag reflex or vagal stimulation.




Suction Devices


Flexible suction catheters

• Designed to be used when a rigid tip cannot be used

• Can be passed through a tube such as the nasopharyngeal or endotracheal tube

• Can be used for suctioning the nasopharynx




Suction Devices



• Come in various sizes identified by a number "French"

• Larger the number, larger the catheter




Suction Devices



• Not typically large enough to suction vomitus or thick secretions

• May kink

• In event of copious, thick secretions consider removing tip or catheter and using large bore, rigid suction tubing.




Suction Devices



• Measured in similar way as OPA

• Length of catheter that should be inserted into patient's mouth equals distance between corner of patient's mouth and earlobe.



Measuring Flexible Suction Catheter

If you are using a flexible catheter, measure it from the patient's earlobe to the corner of the mouth or from the center of the mouth to the angle of the jaw.



Techniques of Suctioning

• Use appropriate infection control practices while suctioning

Includes protective eyewear, mask, disposable gloves



Suctioning Techniques

Position yourself at the patient's head and turn the patient's head or entire body to the side.




• Suction no longer than ten seconds at a time.

Prolonged suctioning can cause hypoxia and bradycardia.

If patient vomits for longer than ten seconds, continue suction.





• Place tip or catheter where you want to begin suctioning and suction on the way out.



Suctioning—Oral Pharyngeal Video

Click on the screenshot to view a video on the subject of suctioning.

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Keeping an Airway Open: Definitive Care




• Keeping the airway open may exceed capabilities of a basic EMT.

• Medications and/or surgical procedures may be necessary to resolve airway obstruction.





• Rapidly evaluate and treat airway problems.

• Quickly recognize when more definitive care is necessary.

May be Advanced Life Support intercept

May be closest hospital



Think About It

• If you were not able to manage an airway at the basic level, what advanced resources might be available to you?



Special Considerations




• Facial injuries

Frequently result in severe swelling or bleeding that may block or partially block airway

Bleeding may require frequent suctioning or more definitive airway.





• Obstructions

Many suction units are not adequate for removing solid objects.

Objects may have to be removed with manual techniques

• Abdominal thrusts

• Chest thrusts

• Finger sweeps





• Dental appliances

Leave in place during airway procedures when possible.

Partial dentures may become dislodged during an emergency.

Be prepared to remove if airway endangered.



Pediatric Note

• Variety of anatomical differences to consider when managing the airway

• Anatomic considerations

Smaller mouth and nose

Larger tongue

Narrow, flexible trachea



Pediatric Anatomical Considerations

Comparison of child and adult respiratory passages.



Pediatric Note

• Management considerations

Open airway gently

Do not hyperextend neck

Consider adjuncts when other measures fail

Use rigid tip with adjunct, but do not touch back of airway



Chapter Review



Chapter Review

• The airway is the passageway by which air enters the body during respiration, or breathing.

• A patient cannot survive without an open airway.

• Airway adjuncts—the oropharyngeal and nasopharyngeal airways—can help keep the airway open.




Chapter Review

• It may be necessary to suction the airway or to use manual techniques to remove fluids and solids from the airway before, during, or after artificial ventilation.



Remember

• Always use proper personal protective equipment when managing an airway.

• Airway assessment must be an ongoing process. Airway status can change over time.

• Airway management should start simply and become more complicated only if necessary.



Questions to Consider

• Name the main structures of the airway.

• Explain why care for the airway is the first priority of emergency care.

• Describe the signs of an inadequate airway.





• Explain when the head-tilt, chin-lift maneuver should be used and when the jaw-thrust maneuver should be used to open the airway—and why.

• Explain how airway adjuncts and suctioning help in airway management.



Critical Thinking

• On arrival at the emergency scene, you find an adult female patient with gurgling sounds in the throat and inadequate breathing slowing to almost nothing. How do you proceed to protect the airway?




Critical Thinking

• When evaluating a small child you hear stridor. What does this sound tell you? What are your immediate concerns regarding this sound?




Critical Thinking

• When assessing an unconscious patient, you note snoring respirations. Should you be concerned with this and if so, what steps can you take to correct this situation?

Emergency Care

CHAPTER



THIRTEENTH EDITION

Respiration and Artificial Ventilation

10



Multimedia Directory

Slide 93 Oxygen Administration via a Non-Rebreather Mask Video

Slide 107 In-Hospital Endotracheal Intubation Video



Topics

• Physiology and Pathophysiology

• Respiration

• Positive Pressure Ventilation

• Oxygen Therapy

• Special Considerations

• Assisting with Advanced Airway Devices



Physiology and Pathophysiology



Mechanics of Breathing

• Ventilation

Process of moving air into and out of chest





• Inhalation

Active process

Muscles expand; size of chest increases

Negative pressure pulls air into lungs





• Exhalation

Passive process

Muscles relax; size of chest decreases

Positive pressure created; air pushed out



Respiration Terminology

• Tidal volume

Amount of air moved in one breath

• Minute volume

Amount of air moved into and out of lungs per minute



Physiology of Respiration

• Dead space air

Air moved in ventilation not reaching alveoli

• Alveolar ventilation

Air actually reaching alveoli

• Diffusion

Movement of gases from high concentration to low concentration





• External respiration

Diffusion of oxygen and carbon dioxide (exchange of gases) between alveoli and circulating blood

• Internal respiration

Exchange of gases between blood and cells





• Cellular respiration

Oxygen from blood diffused into cell

Carbon dioxide diffused from cell into blood



Pathophysiology of the Cardiopulmonary System

• Mechanics of breathing disrupted

• Gas exchange interrupted

• Circulation issues



Respiration



Adequate and Inadequate Breathing

• Brain and body cells need a steady supply of oxygen.

Hypoxia

• Low oxygen level in cells

• Carbon dioxide must be continuously removed.

Hypercapnea

• High carbon dioxide level





• Assesses how well cardiopulmonary system is accomplishing oxygenation and carbon dioxide removal





• Compensation for hypoxia or hypercapnea is predictable.

• Signs

Shortness of breath (symptom)

Increased respiratory rate and depth

Increased heart rate





• Early on, steps of adjustment can meet the needs of the body despite respiratory challenge.

• Respiratory distress

Body compensating for a respiratory challenge and meeting metabolic needs



Inadequate Breathing

• Occurs when challenge are too great for body's compensation mechanisms

• Also known as respiratory failure

• Exceptionally important to recognize; often a precursor to respiratory arrest



Respiratory Distress

Respiratory distress usually involves accessory muscle use and increased work of breathing. Severe or prolonged respiratory distress can proceed to respiratory failure and inadequate ventilation when the body can no longer work so hard to breathe. In this case you will see a reduced level of

responsiveness or an appearance of tiring, shallow ventilations, and other signs of

inadequate breathing.© Dan Limmer



Patient Assessment

• Signs of adequate breathing

Relatively normal mental status

Relatively normal pulse oximetry reading

Relatively normal skin color




Patient Assessment

• Signs of inadequate breathing

Chest movements are absent, minimal, or uneven

Abdominal breathing

No air can be felt or heard at the nose or mouth

Breath sounds are diminished or absent

Wheezing, crowing, stridor, gurgling, or gasping during breathing




Patient Assessment

• Signs of inadequate breathing

Rate of breathing is too rapid or too slow

Breathing is very shallow, very deep, or appears labored

Cyanosis

Inspirations or expirations are prolonged

Retractions and nasal flaring in children

Low oxygen saturation reading (<95%)




Patient Assessment

• Hypoxia

Major causes

• A patient is trapped in a fire.

• A patient has emphysema.

• A patient overdoses on a drug that has a depressing effect on the respiratory system.

• A patient has a heart attack.



Patient Care

• Inadequate breathing

Provide artificial ventilation to the nonbreathing patient and the patient with inadequate breathing.

Provide supplemental oxygen to the breathing patient.




Patient Care

• When Do I Intervene?

Often respiratory failure patients will be breathing and conscious.

Identify adequacy of breathing.

• If breathing is inadequate, immediate intervention is necessary.



Think About It

• What signs might identify the need to intervene in a breathing patient?



Positive Pressure Ventilation




• Forcing air or oxygen into lungs when a patient has stopped breathing or has inadequate breathing

• Uses force exactly opposite of how the body normally draws air into the lungs





• Negative side effects of positive pressure ventilation

Decreasing cardiac output/dropping blood pressure

Gastric distention

Hyperventilation



Techniques of Artificial Ventilation

• Do not ventilate patient who is vomiting or has vomitus in airway

PPV will force vomitus into patient's lungs

• Watch chest rise and fall with each ventilation

• Ensure rate of ventilation is sufficient




Techniques of Artificial Ventilation

• Carefully assess the adequacy of respiration

• Explain procedure to patient

• Place the mask over the patient's mouth and nose

• After sealing mask on patient's face, squeeze bag with patient's inhalation



CPAP/BiPAP

• Form of noninvasive positive pressure ventilation (NPPV)

• CPAP

Continuous positive airway pressure

• BiPAP

Biphasic positive airway pressure



Mouth-to-Mask Ventilation

• Performed using a pocket face mask





Pocket face mask.© Laerdal Corporation




• Patient without suspected spine injury

EMT at top of patient's head

1. Position yourself directly above the patient's head.

2. Apply the mask to the patient.

3. Place your thumbs over the top of the mask, your index fingers over the bottom of the mask, and the rest of your fingers under the patient's jaw.




Performing Mouth-to-Mask Ventilation

• Patient without suspected spine injury

EMT at top of patient's head

4. Lift jaw to the mask as you tilt patient's head backward and place remaining fingers under the angle of the jaw.

5. While lifting the jaw, squeeze the mask with your thumbs to achieve a seal between the mask and patient's face.

6. Give breaths into one-way valve of the mask. Watch for the chest to rise.



Performing Mouth-to-Mask Ventilation

Use only a pocket mask with a one-way valve.



Bag-Valve Mask

• Handheld ventilation device

• Used to ventilate nonbreathing patient and/or patient in respiratory failure



Bag-Valve Mask

Adult, child, and infant bag-valve-mask units.



Bag-Valve Mask

• Standard features

Self-refilling shell that is easily cleaned and sterilized

Non-jam valve that allows an oxygen inlet flow of 15 liters per minute

Nonrebreathing valve




Bag-Valve Mask

• Mechanics of BVM

Supply of 15 liters per minute of oxygen attached and enters reservoir

When squeezed, air inlet closed and oxygen delivered to patient

When released, passive expiration by patient occurs




Bag-Valve Mask

• Two-rescuer BVM ventilation—no trauma suspected

Strongly recommended by AHA

Most difficult part of BVM ventilation is obtaining adequate mask seal

Hard to maintain seal while squeezing bag

One rescuer squeezes bag; other rescuer maintains seal.




Bag-Valve Mask


1. Open airway with head-tilt, chin-lift maneuver.

2. Select correct bag-valve mask size.

3. Kneel at patient's head; position thumbs over top half of mask, index fingers over bottom half.




Bag-Valve Mask


4. Place apex of triangular mask over bridge of nose; lower mask over mouth and upper chin.

5. Use middle, ring, and little fingers to bring patient's jaw up to mask.

• Maintain head-tilt, chin-lift maneuver.




Bag-Valve Mask


6. Second rescuer connects and squeezes bag.

7. Second rescuer releases bag; patient exhales passively.




Bag-Valve Mask

• Two-rescuer BVM ventilation—trauma suspected

1. Open airway using jaw-thrust maneuver.

2. Select correct bag-valve mask size.

3. Kneel at patient's head; place thumb sides of your hands along mask to hold it firmly on patient's face.




Bag-Valve Mask

• Two-rescuer BVM ventilation—trauma suspected

4. Use remaining fingers to bring jaw upward toward mask, without tilting head or neck.

5. Second rescuer releases bag; patient exhales passively.



Two-Rescuer BVM Ventilation: Trauma Suspected

Delivering two-rescuer BVM ventilation while providing manual stabilization of the head and neck when trauma is suspected in the patient.



Bag-Valve Mask

• One-rescuer BVM ventilation

1. Open airway.

2. Select correct size mask.

3. Form a "C" around the ventilation port with thumb and index finger; use middle and little fingers to hold the jaw to mask.




Bag-Valve Mask

• One-rescuer BVM ventilation

4. Squeeze bag.

5. Release pressure on bag and let patient exhale passively.




Bag-Valve Mask

• If the chest does not rise and fall during BVM ventilation, you should:

1. Reposition head

2. Check for escape of air around mask; reposition fingers and mask

3. Check for airway obstruction or obstruction in BVM system

4. Use alternative method




Bag-Valve Mask

• Artificial ventilation of a stoma breather

1. Clear mucus plugs or secretions from stoma

2. Leave head and neck in neutral position

3. Use pediatric-sized mask to establish seal around stoma




Bag-Valve Mask

• Artificial ventilation of a stoma breather

4. Ventilate at appropriate rate for patient's age.

5. If unable to artificially ventilate through stoma, seal stoma and attempt artificial ventilation through mouth and nose.



Flow-Restricted, Oxygen-Powered Ventilation Device

• Also called manually triggered ventilation device

• Uses oxygen under pressure to deliver artificial ventilations through a mask placed over the patient's face

,




Flow-Restricted, Oxygen-Powered Ventilation Device

• Use on adults only.

• Follow same procedures for mask seal as for BVM.

• Trigger device until chest rises.



Using Flow-Restricted, Oxygen-Powered Ventilation Device

Providing ventilations with a flow-restricted, oxygen-powered ventilation device (FROPVD).



Automatic Transport Ventilator

• Provides positive pressure ventilations

• Can adjust ventilation rate and volume

• Provider must assure appropriate respiratory rate and volume for patient's size and condition.



Think About It

• How would you decide which positive pressure delivery method to use for your patient?



Oxygen Therapy



Importance of Supplemental Oxygen

• Issues to consider when making decisions about oxygen administration

Oxygen is a drug.

Oxygen can cause harm.

Oxygen should be administered based on your overall evaluation of the patient's presentation and possible underlying conditions.



Oxygen Therapy Equipment

• Portable

In the field

Lightweight, safe, dependable

• Installed

Inside the ambulance



Oxygen Systems

For safety, to prevent them from tipping over, oxygen cylinders must be placed in a horizontal position or, if upright, must be securely supported.



Oxygen Systems

Larger cylinders are used for fixed systems on ambulances.



Oxygen Cylinders


D cylinder

• About 350 liters of oxygen

E cylinder

• About 625 liters of oxygen

M cylinder

• About 3,000 liters of oxygen




Oxygen Cylinders


G cylinder


H cylinder





Oxygen Cylinders

• Use pressure gauges, regulators, and tubing intended for use with oxygen.

• Use nonferrous wrenches.

• Ensure valve seat inserts and gaskets are in good condition.

• Use medical-grade oxygen.




Oxygen Cylinders

• Open the valve of an oxygen cylinder fully then close it half a turn to prevent someone else from thinking the valve is closed and trying to force it open.

• Store reserve oxygen cylinders in cool, ventilated room, properly secured in place.

• Have oxygen cylinders hydrostatically tested every five years.




Oxygen Cylinders

• Never drop a cylinder or let it fall against any object.

• Never leave an oxygen cylinder standing in an upright position without being secured.

• Never allow smoking around oxygen equipment in use.




Oxygen Cylinders

• Never use oxygen equipment around open flame.

• Never use grease, oil, or fat-based soaps on devices that will be attached to an oxygen supply cylinder.

• Never use adhesive tape on a cylinder.

• Never try to move an oxygen cylinder by dragging it or rolling it on its side or bottom.



Pressure Regulators

• Connected to the oxygen cylinder to provide a safe working pressure of 30 to 70 psi.



Flowmeters

• Allow control of the flow of oxygen in liters per minute

• Low-pressure flowmeters

Pressure-compensated flowmeter

Constant flow selector valve

• High-pressure flowmeters

Thumper™ CPR device

Respirators and ventilators such as CPAP and BiPAP devices



Flowmeters

Low-pressure flowmeters: (Left) A pressure-compensated flowmeter; (Right) a constant flow selector valve.



Flowmeters

High-pressure flowmeter. High-pressure oxygen is delivered through hoses attached to a threaded connector.



Humidifiers

• Connected to flowmeter

• Provide moisture to dry oxygen from supply cylinder



Humidifier

Humidifier in use on board an ambulance.



Hazards of Oxygen Therapy

• Common hazards of oxygen and oxygen equipment

If the tank is punctured or a valve breaks off, the supply tank can become a missile.

Oxygen supports combustion.

• Can saturate towels, sheets, clothing

Oxygen and oil do not mix under pressure.




Hazards of Oxygen Therapy

• Rare medical situations

Oxygen toxicity or air sac collapse

Infant eye damage

Respiratory depression or respiratory arrest



Administering Oxygen

• Work with your instructor or follow your instructor's directions to understand how to use specific equipment.

• Various devices available



Nonrebreather Mask

• Best way to deliver high concentrations of oxygen to a breathing patient



Delivery Devices:Nonrebreather Mask

Nonrebreather mask. Note the round disks—flutter valves that allow air exhaled by the patient to escape so it is not rebreathed.



Nonrebreather Mask

• Provides oxygen concentrations of 80 to 100 percent

• Optimum flow rate is 12 to 15 liters per minute.

• A new design feature allows for one emergency port in the mask to the patient can still receive atmospheric air should the oxygen supply fail.



Nasal Cannula

• Best choice for a patient who refuses to wear an oxygen face mask



Delivery Devices: Nasal Cannula

Nasal cannula.



Nasal Cannula

• Provides oxygen concentrations between 24 and 44 percent

• Oxygen is delivered to patient by two prongs that rest in patient's nostrils.

Should deliver no more than 4 to 6 liters per minute



Partial Rebreather Mask

• Very similar to nonrebreather mask

• No one-way valve in opening to reservoir bag

• Delivers 40 to 60 percent oxygen at 9–10 liters per minute



Venturi Mask

• Delivers specific concentrations of oxygen by mixing oxygen with inhaled air

• Some have set percentage and flow rate; others have adjustable Venturi port.



Delivery Devices: Venturi Mask

Venturi mask.



Tracheostomy Mask

• Placed over stoma or tracheostomy tube to provide supplemental oxygen

• Connected to 8 to 10 liters per minute of oxygen via supply tubing



Delivery Devices: Tracheostomy Mask

Tracheostomy mask.



Oxygen Administration via aNon-Rebreather Mask Video

Click on the screenshot to view a video on the topic of oxygen delivery using a simple mask.

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• Facial injuries

Bleeding and swelling can disrupt movement of air.

Aggressive suction and advanced airway maneuvers may be necessary.





• Obstructions

Foreign bodies can impede ventilation of patients.

If unable to ventilate, always consider the possibility of obstruction.





• Dental appliances

Dentures should ordinarily be left in place during airway procedures.

Partial dentures may become dislodged during an emergency.

Leave a partial denture in place if possible, but be prepared to remove it if it endangers the airway.



Pediatric Note

• Hypoxia often occurs rapidly.

Children burn oxygen at twice the rate of adults

Accounted for by the many anatomical differences associated with airway




Pediatric Note

• Ventilating pediatric patients

Avoid excessive pressure and volume.

Use properly sized face masks.

Flow-restricted, oxygen-powered ventilation devices contraindicated

Use pediatric-sized nonrebreather masks and nasal cannulas.

Gastric distention may impair adequate ventilations.



Assisting with Advanced Airway Devices



Assisting with Advanced Airway Devices

• Devices requiring direct visualization of the glottic opening (endotracheal intubation)

• Devices inserted "blindly," meaning without having to look into the airway to insert the device.



Types of Advanced Airway Devices

In the BURP maneuver, press your thumb and index finger on either side of the throat over the cricoid cartilage and gently direct the throat upward and toward the

patient’s right. © Edward T. Dickinson, MD



Preparing the Patient for Intubation

• Maximize oxygenation prior to procedure.

• Position patient in sniffing position.

• Cricoid pressure

• Confirmation

• Securing tube in place



Ventilating the Intubated Patient

• Very little movement can displace an endotracheal tube.

• Pay attention to resistance to ventilations; report changes.

• If patient is defibrillated, carefully remove bag from tube.

• Watch for any change in patient's mental status.



Assisting with a Trauma Intubation

• Provide manual in-line stabilization throughout procedure.

• Position hands to hold stabilization, but allow for movement of jaw.



Blind-Insertion Airway Devices

• Examples

King LT™ airway

Laryngeal mask airway (LMA™)

• Usually do not require head to be placed in sniffing position



In-Hospital Endotracheal Intubation Video

Click on the screenshot to view a video on the subject of in-hospital endotracheal intubation.

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Chapter Review



Chapter Review

• Respiratory failure is the result of inadequate breathing, breathing that is insufficient to support life.

• A patient in respiratory failure or respiratory arrest must receive artificial ventilations.

• Oxygen can be delivered to the nonbreathing patient as a supplement to artificial ventilation.




Chapter Review

• Oxygen can also be administered as therapy to the breathing patient whose breathing is inadequate or who is cyanotic, cool and clammy, short of breath, suffering chest pain, suffering severe injuries, or displaying an altered mental status.



Remember

• Always use proper personal protective equipment when managing an airway.

• Assessment of breathing must be an ongoing process. Respiratory status can change over time.

• Inadequate breathing requires immediate action.




Remember

• Positive pressure ventilations are very different than normal breathing and can have negative side effects.

• Select the most appropriate method of positive pressure ventilations based upon the needs of the individual.




Remember

• Always use appropriate safety measures when handling oxygen.

• Select the appropriate delivery device to provide supplemental oxygen.




• What are the signs of respiratory distress?

• What are the signs of respiratory failure?

• For BVM ventilation, what are recommended variations in technique for one or two rescuers?





• How does the way positive pressure ventilation moves air differ from how the body normally moves air?

• Describe a patient problem that would benefit from administration of oxygen and explain how to decide what oxygen delivery device should be used.



Critical Thinking

• On arrival at the emergency scene, you find an adult female patient who is semiconscious. Her respiratory rate is 7 per minute. She appears pale and slightly blue around her lips




Critical Thinking

• Is this patient in respiratory failure, and if so what signs and symptoms indicate this? Does this patient require artificial ventilations?

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