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Volume 1, Chapter 1 Airway Management and VentilationPart 1 Respiratory Anatomy, Physiology and AssessmentAirway management and ventilation are the ____________________________________ and most critical steps in the initial assessment of every patient you will encounter.Anatomy of the Respiratory SystemOverview of the Respiratory SystemThe respiratory system provides passage for ____________________________________

and carbon dioxideRespiration: gas exchange2 divisions are the upper and lower airwaysUpper Airway AnatomyThe upper airway extends from ____________________________________ and nose to

larynxConsists of the nasal cavity, oral cavity, and pharynxThe ____________________________________ joins upper and lower airwaysFigure 15-2 The Larynx (Page 518)Glottis (Glottic Opening)The LarynxCricoid ____________________________________: inhibits vomiting and aspiration during

airway management and allows better visualization of vocal cords____________________________________ membrane connects the inferior border of the

thyroid cartilage with the superior aspect of the cricoid cartilage– Site for surgical airway techniques

Cricothyroid MembraneFigure 15-1 Anatomy of the Upper Airway (Page 516)Lower Airway Anatomy Lower airway are the structures below larynx that extend to

____________________________________Where respiratory ____________________________________ of oxygen and carbon

dioxide occursFigure 15-3 Anatomy of the Lower Airway (Page 519)The LungsEach lung has lobes: Right lung has ___________ lobes Left lung has ___________ lobesThe Pleura____________________________________ are membranous connective tissue that covers

lungsConsist of 2 layers:

– ____________________________________ pleura: envelops the lungs– ____________________________________ pleura: Lines the thoracic cavity

Pleural space: space between the visceral and parietal pleura that normally contains a small amount of fluid to prevent friction

The Pediatric AirwayFundamentally the same as an adult’s airway but is smaller in all aspects; softer and more

____________________________________Epiglottis is floppier and rounderCricoid cartilage is the ____________________________________ part of the airwayRibs and cartilage of pediatric thoracic cage softer and more pliablePhysiology of the Respiratory SystemThe Respiratory Cycle (1 of 2)

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Pulmonary ventilation: depends on changes in ____________________________________ within thoracic cavity

Respiratory cycle: coordinated interaction among respiratory system, central nervous system, and the musculoskeletal system

The Respiratory Cycle (2 of 2) Inspiration is an ____________________________________ process, using energy

– Intercostal muscles and diaphragm contracts making the lungs expand– Through the change in pressure, air enters the lungs

Normal expiration is a ____________________________________ process– Intercostal muscles and diaphragm relaxes

Pulmonary CirculationRespiration requires intact circulatory system providing adequate blood flowHeart pumps as much blood to ____________________________________ as it pumps to

peripheral tissuesPulmonary ____________________________________ carries unoxygenated blood to the

lungsPulmonary veins carry oxygenated blood from the lungs to the heartFigure 15-7 Pulmonary Circulation (Page 522)Measuring Oxygen and Carbon Dioxide Levels (1 of 3)Partial Pressure: • Pressure exerted by each component of gas ____________________________________• The partial pressure of a gas is its ____________________________________ of the

mixture’s total pressure• Measured in torr (same as mmHg)• The partial pressure of oxygen at normal atmospheric pressure is 21%Measuring Oxygen and Carbon Dioxide Levels (2 of 3)Partial Pressure (cont’d): • Earth’s atmosphere consists of 4 major respiratory gases:

– ____________________________________ (N2)– Oxygen (O2)– Carbon Dioxide (CO2)– ____________________________________ (H2O)

Measuring Oxygen and Carbon Dioxide Levels (3 of 3)Alveolar and arterial pressures are usually the sameNormal Partial Pressures:• Oxygen (PaO2): ___________ to ___________ torr

–Referred to PO2• Carbon dioxide (PaCO2): __________ to ___________ torr

–Referred to a PCO2Diffusion____________________________________: movement of gas from area of higher

concentration to area of lower concentrationTransfers gases between lungs and blood and between the

____________________________________ and peripheral tissuesOxygen that diffuses into blood plasma combines with hemoglobin (SaO2)Figure 15-6 Diffusion of Gases Across an Alveolar Membrane (Page 521)Oxygen Concentration in the Blood (1 of 2)Remaining oxygen dissolved in blood (PaO2)____________________________________ carries vast majority of oxygen in bloodDecreased hemoglobin concentration can be due to:

– ____________________________________ and/or hemorrhage– Inadequate alveolar ventilation

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– Decreased diffusion– Ventilatory/perfusion mismatch

Oxygen Concentration in the Blood (2 of 2)Correct oxygen derangements by increasing ventilation; administering supplemental

oxygen; using intermittent positive-pressure ventilation (IPPV); and/or ____________________________________

FiO2: the ____________________________________ concentration of oxygenCarbon Dioxide in the Blood (1 of 2)Blood transports carbon dioxide in form of ____________________________________ ionHyperventilation ____________________________________ CO2 levelsCauses of increased CO2 production include:

–____________________________________–Muscle exertion–Shivering–Metabolic processes forming acids

Carbon Dioxide in the Blood (2 of 2)Decreased CO2 elimination results from ____________________________________ that

can be caused by:–Respiratory depression by drugs–Airway obstruction–Impairment of respiratory muscles–Obstructive diseases

____________________________________: increased CO2 levelsRemember, the normal stimulus to breathe is the level of CO2 in the blood (Respiratory Drive)

Respiratory ProblemsAirway ObstructionThe ____________________________________is the most common cause of airway

obstruction.Other Causes:Foreign bodies____________________________________ Laryngeal spasm and edemaAspirationThe Tongue as an Airway ObstructionInadequate Ventilation Insufficient minute volume can compromise adequate oxygen intake and carbon dioxide

____________________________________A reduction of either the rate or ____________________________________of inhalation

leads to reduction in minute volumeCan be caused by numerous medical and/or traumatic conditions, exposure, high altitudes,

oxygen deficient atmospheres or any other condition affecting the process or the environment

Respiratory System AssessmentPrimary Assessment Is the airway ____________________________________? Is breathing ____________________________________? Look, listen, and feel. If patient is not breathing, open the airway and assist ventilations as necessary.Secondary Assessment (1 of 8) Inquire about recent history leading to onset of symptoms and identify possible

____________________________________

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Past medical history (____________________________________)Physical examination techniques of inspection, auscultation, palpation to evaluate injury or

illness– CHECK LUNG SOUNDS!

Begin physical assessment by inspecting patientSecondary Assessment (2 of 8)Check for any modified forms of respirations:____________________________________: forced exhalation of a large volume of air

from the lungs____________________________________: sudden, forceful exhalation from the noseHiccoughing (hiccups): sudden inspiration caused by spasmodic contraction of the

diaphragm with spastic closure of the glottis– May be associated with an MI

Secondary Assessment (3 of 8)Modified forms of respirations (cont’d):____________________________________: slow, deep, involuntary inspiration followed

by a prolonged expiration____________________________________: a forceful expiration that occurs against a

partially closed epiglottis– Indicates respiratory distress

Secondary Assessment (4 of 8)Observe for abnormal breathing patterns:____________________________________respirations: deep, slow or rapid, gasping

breathing– Commonly found in DKA

____________________________________ respirations: progressively deeper, faster breathing alternating gradually with slow, shallow breathing– Indicates a brainstem injury

Secondary Assessment (5 of 8)Observe for abnormal breathing patterns (cont’d):____________________________________ Respirations: irregular pattern of rate and

depth with sudden periodic episodes of apnea– Indicates increased ICP

____________________________________Neurogenic Hyperventilation: deep, rapid respirations– Indicates increased ICP

Secondary Assessment (6 of 8)Observe for abnormal breathing patterns (cont’d):____________________________________respirations: shallow, slow or infrequent

breathing. May be gasping– Indicates brain anoxia

Secondary Assessment (7 of 8)Listen to chest with stethoscope (auscultate). Note any:____________________________________: obstruction by tongueGurgling: fluid, blood, or vomitus in the upper airways____________________________________: harsh, high-pitched sound on inhalationWheezing: musical, squeaking, or whistling soundSecondary Assessment (8 of 8)Note any (cont’d):Quiet: diminished or absent sounds____________________________________(rales): fine, bubbling sound on inspiration____________________________________: coarse rattling noise on inspiration associated

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with inflammation, mucus, or fluidPosition for auscultating breath sounds (Page 531)Non-Invasive Respiratory MonitoringPulse Oximetry (1 of 4)Referred to as the "fifth vital sign" Measures ____________________________________oxygen saturation in peripheral

tissuesNoninvasive, easy to operateDisplay SpO2 (oxygen saturation level) and pulse rate as detected by sensorsPulse rate must match ____________________________________to assure accuracyPulse Oximetry (2 of 4)Should be used on ___________________________________patientsNormal is generally between ____________ and 99%Readings between 91 and 95% indicate

____________________________________hypoxiaReadings between 86 and 90% indicate

____________________________________hypoxiaReadings of 85% and lower indicate severe hypoxia Pulse Oximetry (3 of 4)Administration of ____________________________________is not without riskExcess oxygen can cause the body to manufacture toxic chemicals called free radicals____________________________________: excessive oxygen levelsOxygen should be administered with any signs of respiratory distress or signs of shockPulse Oximetry (4 of 4)General rule is if no S/S of respiratory distress or shock give oxygen if:

– If SpO2 < 94% for medical patientsDo not allow ____________%

– If SpO2 < 95% for ____________________________________patientsGive all patients oxygen if:

– Toxic exposure or SCUBA emergencies– Distressed ____________________________________– S/S of shock or respiratory distress

CapnographyAt the cellular level Oxygen and glucose combine to produce energy for cells. Carbon

Dioxide is created as a waste product and is diffused into the blood and is carried back to the lungs.

This is known as the ____________________________________CycleCapnographyMeasures the carbon dioxide levels in ____________________________________air: End

Tidal CO2 (ETCO2)Types

– ____________________________________waveform– Colormetric devices– Electronic sensing devices

May not be very ____________________________________after prolonged cardiac arrest; especially the colormetrics

Now part of the primary confirmation process of advanced airwaysCapnographyEnd-Tidal Carbon Dioxide Monitoring in a Non-Intubated and Intubated PatientColormetric CapnographyChanges from purple to ____________________________________in the presence of CO2Numbers correspond with CO2 levels

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Not very accurate long termOnce color changes, it will ____________________________________change back Waveform CapnographyHighly ____________________________________by the AHA through their ACLS and

PALS programsUse is rapidly growing in EMS and emergency medicineFurther uses are expected with more ____________________________________Can be a valuable tool if used correctlyWaveform CapnographyWaveform Capnography has two components:1. A ____________________________________Value: Gives a numerical value of the peak

ETCO22. ____________________________________: Shows a visual graph of the patient’s

respiration Both components are important, and can aid in treating patients.

– Think of it as the end tidal number as your heart rate and the waveform as the ECG.Phases of Waveform CapnographyPhase I (AB)Respiratory ____________________________________Represents post ____________________________________and dead air exhalation (air

that has not reached the alveoli). No CO2 is presentPhase II (BC)Respiratory ____________________________________ (exhalation upstroke)• Air is being exhaled that is ____________________________________in CO2Phase III (CD)Respiratory ____________________________________ (exhalation plateau)The end of phase III is the ____________________________________ETCO2 and is

where we get our numerical valuePhase IV (DE)• ____________________________________Phase (inhalation downstroke)• Represents ____________________________________Normal WaveformVertical measures CO2 levelsHorizontal measures ____________________________________Normal ETCO2 values

– Between ___________-____________mmHg– Normal respiratory rate is 12-20

Benefits of Waveform CapnographyProvides a “real time” look at respirationsAllows for confirmation of an ____________________________________airwayAids in determination of the effectiveness of chest compressionsHelps to monitor for ____________________________________ (Return of Spontaneous

Circulation) and loss of spontaneous circulationHelps us to recognize loss of paralysis/sedation of RSI (PAI) patientsWaveform Capnography and the Patient’s Respirations (1 of 2)It is a real time look at the pt’s respiratory ____________________________________:Waveform capnography shows us a real time waveform of each breath. If a patient were to suddenly become ____________________________________, it could

be several minutes before you see any changes in the pt’s O2 sats. With waveform you be able to see it instantly.

Waveform Capnography and the Patient’s Respirations (2 of 2)

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It can help us determine how ____________________________________and the cause of the patient’s respiratory distress

It can also help us determine how effective our ____________________________________is for the respiratory distress.

Waveform Capnography as a Confirmation Device for ETT (1 of 2)One of the easiest and most accurate ways to verify proper ET tube placement.ETCO2 is considered the ____________________________________for confirming ETT

placement. It provides documented ____________________________________that the ET Tube is in

the trachea.Waveform Capnography as a Confirmation Device for ETT (2 of 2) It cannot determine if the tube is in the right main stem

____________________________________. Lung sounds still need to be auscultated. It is more ____________________________________than color metric devices.

– Able to constantly monitor the waveform.Goal is to maintain ETCO2 readings between 30 and 34mmHg for perfusing patientsWhich Tracing Confirms Proper ETT Placement?Waveform Capnography and Chest Compressions (1 of 2)It can help show effectiveness of chest compressions:____________________________________is needed for the gas exchange in the lungs.Without a pulse, the patient’s ETCO2 are going to

____________________________________.During CPR try to keep your ETCO2 levels as high as possible by “Pushing hard and pushing

fast” on chest.Waveform Capnography and Chest Compressions (2 of 2)ETCO2 readings of less than ____________ mmHg has been shown to have NO chance of

ROSCETCO2 readings should be maintained at or above _____________mmHg at all times

during CPRAdjustments of rate, hand position, or depth can be made to assure proper ETCO2Waveform Capnography and Spontaneous Circulation It can help determine ROSC:

– During CPR if you see a sudden ____________________________________in your ETCO2 it is a good indication that the pt has ROSC.

It can help determine the loss of spontaneous circulation.– A sudden ____________________________________in the pt’s ETCO2 can be an

indication that the pt has lost pulses.Waveform Capnography and RSI (PAI) (1 of 2)Waveform capnography can help detect when a patient is coming out of paralysis or

____________________________________By looking at waveform we can see when a pt is starting to wake up from PAI and needs to

be sedated.Waveform Capnography and RSI (PAI) (2 of 2)Will see signs of a pt waking up in the waveform long before other traditional signs such

as:– Increase pulse rate– ____________________________________– “____________________________________” the tube– Purposeful movement

Sign of Loss of Paralysis/SedationNotice the ____________________________________at the end of the waveform.

– Sign that the pt is starting to ____________________________________on their own.

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If you notice the notch, this indicates need for additional sedatives/analgesics to maintain sedation.

Waveform and HyperventilationWith ____________________________________, patient is blowing off more CO2. ETCO2 values are going to be ____________________________________. Note that the

waves start to get smaller and more frequentWaveform and HypoventilationWith hypoventilation, the respirations are ____________________________________and

the pt is retaining CO2. ETCO2 readings are ____________________________________. Note that the waves are

less frequent and starting to get taller Waveform and ApneaWith apnea, the patient is no longer exhaling CO2 Waveform with go ____________________________________and you will not get a

numerical reading.Waveform and Bronchocontriction (Shark Fin)During bronchoconstrictions (asthma/COPD) it takes longer for the air to be exhaled and

uneven alveolar emptying. This cause phase II and III to slur giving a shark ____________________________________appearance.– The more pronounced the shark fin the more

____________________________________the bronchoconstriction. Waveform and BronchodilatorsThe waveform can also determine how

____________________________________bronchodilators are working.– During and after a breathing treatment, if you notice the waveform start to

____________________________________out and the ETCO2 go back to a normal range it is a sign that patient’s condition is improving

Capnography of Asthma PatientChanging ETCO2 values in Asthma (1 of 2)____________________________________Asthma:A pt with a mild asthma attack the ETCO2 will begin to drop (<35) due to the pt

hyperventilating to compensate for the respiratory distress.____________________________________Asthma:As the respiratory distress starts to get worse the pt’s ETCO2 will begin to rise to a normal

level.Changing ETCO2 values in Asthma (2 of 2)Severe Asthma:As the respiratory distress becomes severe pt’s ETCO2 will rise to a high number due to

____________________________________, air trapping, and moving little air.ETCO2 may ____________________________________to dangerous levels (> 60)Capnography – PitfallsMay provide false ____________________________________on colormetrics or increased

CO2 levels on Waveform– Antacid use– Carbonated beverages

Continues to drop CO2 levels in ____________________________________arrestPart 2 Basic Airway and VentilationProper Positioning (1 of 2)____________________________________patients: many confined to supine position due

to spinal immobilizationConscious patients: maintained in position of comfort if not in cervical immobilizationUnconscious patients: who do not require other interventions should be placed on their side

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with head ____________________________________Proper Positioning (2 of 2)Unconscious patients: who do require airway and ventilation interventions maintained in

ear-to-sternal-notch position____________________________________position: non-obese patients____________________________________position: obese patientsFigure 15-38 The "Sniffing Position" Provides Adequate Ear-To-Sternal Notch Alignment in Non Obese Adults (Page 541)Figure 15-39a In the Supine Obese Patient, the Line from Ear to Sternal Notch Is Not Horizontal (Page 542)Figure 15-39b The “Ramped Position” with the Upper Body Raised Achieves Horizontal Ear-To-Sternal Notch Alignment in Obese Patients (Page 542)Oxygenation (1 of 3)Oxygen important drug; understand its indications and precautions.Never withhold oxygen from any patient for whom it is indicated.Caution advised in patients with ____________________________________

– Goal is generally to maintain SPO2 readings between ____________-____________%High oxygen levels (hyperoxia) may be as dangerous as low levels (hypoxia).Oxygenation (2 of 3)Goal is to keep oxygen saturation in normal range, using

____________________________________necessary oxygen flowOxygen is no longer given indiscriminately due to the potential of oxygen toxicity

(hyperoxia)Generally, medical patients should receive oxygen if oxygen saturation is below

___________% and trauma patient should receive oxygen if oxygen saturation level is below ____________%

Oxygenation (3 of 3)All patients with the following should receive oxygen REGARDLESS of pulse ox reading:S/S of respiratory distressS/S of ____________________________________ Inhalation of toxic vapors or fumes____________________________________patients in any type of distressAny ____________________________________diving victimAll cardiac or respiratory arrest patientsPart 3 Advanced Airway ManagementExtraglottic Airway Devices____________________________________airway devices are inserted blindly into airway

to facilitate oxygenation and ventilation via self-inflating bag or transport ventilator, but do not enter glottis

Retroglottic airways sit ____________________________________vocal cordsSupraglottic airways sit above vocal cordsDual Lumen Airway Devices• Dual-lumen devices are inserted ____________________________________into esophagus

and may be used in event of accidental tracheal placement.• Has ____________ ventilation lumens Esophageal Tracheal Combitube (ETC™):

Combitube™; may enter trachea or esophagus.Advantages of Combitube (1 of 2)Provides ____________________________________airway control when conventional

intubation techniques are unsuccessful or unavailable Insertion is rapid and easy and does not require

____________________________________of the larynx or special equipmentPharyngeal balloon anchors the airway behind the hard palate

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Patient may be ventilated regardless of tube placement (trachea or esophagus)Advantages of Combitube (2 of 2)Significantly diminishes gastric ____________________________________and

regurgitationCan be used on trauma patients, since the neck can remain in

____________________________________position during insertion and use If tube is placed in esophagus, gastric contents can be suctioned for decompression

through the distal portDisadvantages of Combitube (1 of 2)____________________________________tracheal secretions is impossible when the

airway is in the esophagusCannot be used in conscious patients or in those with a gag reflexCuffs can cause esophageal, tracheal, and hypopharyngeal ischemiaPt must be at least ___________’ tallCan traumatize the esophagusDisadvantages of Combitube (2 of 2)Does not ____________________________________and completely protect the tracheaCannot be used in patients with esophageal disease or caustic ingestionsCannot be used with ____________________________________patientsPlacement of CombiTube is not foolproof—errors can be made if assessment skills are

inadequateETC Placement (1 of 4)Perform optimal BVM ventilation with high-concentration oxygen: PREOXYGENATE (not

hyperventilate)Place patient ____________________________________in neutral positionPrepare and check equipment

– Inflate and check cuffsStabilize cervical spine if cervical injury possiblePerform ____________________________________Maneuver to pre-shape ETCFigure 15-51a Lipp Maneuver. The Lipp Maneuver Will Aid in E T C Placement and Will Help to Minimize Associated Trauma to the Airway (Page 552)ETC Placement (2 of 4)____________________________________as needed

– Water soluble lubricant Insert gently in midline and advance past hypopharynx to depth indicated by

____________________________________on tube– Until teeth are between 2 black lines

Inflate pharyngeal and distal cuffs– Amount is marked on cuffs and package– 100mL for pharyngeal and 15mL for distal

ETC Placement (3 of 4)Ventilate through longer, blue, ____________________________________, proximal port Immediately assess lung sounds:

– If lung sounds are present, tube is in the esophagus. Continue to ventilate If lung sounds are absent and you hear gastric sounds over epigastrium change ports

– Tube is in the ____________________________________Use multiple confirmation techniques

– Lung sounds, chest rise, capnographyETC Placement (4 of 4)Secure tube while continuing to ventilate with 100 percent oxygen

– Use ____________________________________or commercial securing device such as a “tube tamer”

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____________________________________airway and adequacy of ventilationFigure 15-49 The Esophageal Tracheal Combitube (ETC) (Page 551)The Esophageal Tracheal Combitube (ETC) is a dual- lumen airway with a ventilation port for each lumen. The longer, blue port (#1) is the proximal port; the shorter, clear port (#2) is the distal port, which opens at the distal end of the tube. The E T C has two inflatable cuffs—a 100-mL cuff just proximal to the distal port and a 15-mL cuff just distal to the proximal port. First, ventilate through the longer, blue port (#1). Ventilation will be successful if the tube has been placed (as is most common) in the esophagus.Key Points on ETCNasogastric tube may be placed through port #2 if in

____________________________________Drugs can be given down tube if in the trachea (Port #2)You ____________________________________know where the tube is placed!

– Many physicians and ER personnel are NOT familiar with the CombiTubePharyngea-Tracheal Airway PtLTM (1 of 3)The PtL airway is a two-tube systemAdvantages and disadvantages are the same as the ETCInsertion: Prepare and ____________________________________equipment

– Inflate and test cuffsPatient the patient, ____________________________________neck if no spine injury

suspected Lubricate and insert to proper depthFigure 15-52 Pharyngo-Tracheal Lumen (PtL) Airway (Page 553)Pharyngea-Tracheal Airway PtLTM (2 of 3) Inflate ____________________________________cuffs on both PtL tubes simultaneously.Deliver breath into green oropharyngeal tube

– If chest rises properly and lung sounds are present, the tube is in the esophagus– If chest does not rise and no lung sounds, the tube is in the

____________________________________, remove stylet from clear tube and ventilate through the clear tube

Pharyngea-Tracheal Airway PtLTM (3 of 3)Continue ventilatory support with 100 percent ____________________________________.Multiple placement confirmation techniques essential

– ____________________________________, continual monitoring, absent sounds over epigastrium, etc.

King Airway Device (1 of 11)Single lumen ____________________________________deviceRequires no visualizationGreat ____________________________________device for AEMTs and Paramedics; if

unable to intubateComes in multiple sizes ranging from infants to adultsKing Airway Device (2 of 11)King Airway Device (3 of 11)Two Types:King ____________________________________: has no port for gastric tubeKing ____________________________________: has port for gastric tubeIndicated for patients with no gag reflex when there is a need for advanced airway and other devices have failedContraindicated for patient s with ingestion of caustic substances or known esophageal diseasesKing Airway Device (4 of 11)

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Insertion:Select appropriate size based on patient’s ____________________________________Test ____________________________________ (remove air)Apply water-based lubricantPre-oxygenatePosition patient in “sniffing” or neutral positionKing Airway Device (5 of 11)Holding the King at the connector with ____________________________________hand,

hold the patient’s mouth open and apply chin lift unless contraindicated due to trauma and/or Spinal immobilization

King Airway Device (6 of 11)With the King rotated ____________________________________45-90 degrees, such that

the blue orientation line is touching the corner of the mouth, introduce tip into the mouth and advance behind the base of the tongue, Never force the tube into position

King Airway Device (7 of 11)As the tip passes under tongue rotate tube back to

____________________________________ (blue orientation line faces chin). Without exerting excessive force, advance the King until base of connector aligns with

____________________________________or gums. King Airway Device (8 of 11)____________________________________the cuffs based on the listed volumes for the

tube size used– Found on package instructions AND on tube

King Airway Device (9 of 11)Attach BVM and verify placement by all of the following criteria:

– Rise and fall of the chest– Bilateral ____________________________________sounds– Absent ____________________________________breath sounds– Capnography/Capnometry

King Airway Device (10 of 11) If ventilation is ____________________________________, pull out very slightly until

ventilation is performed easilyRe-verify placement

– Lung sounds, absent epigastric sounds, etc.____________________________________TubeKing Airway Device (11 of 11)Key Points on King Airway:Must guess the patient’s height____________________________________At ALS level, introduction may be aided with laryngoscopeLaryngeal Airways (1 of 2) Laryngeal airways are supraglottic airways Laryngeal mask airway (LMA™) was the first laryngeal airwayThe ____________________________________ airway is a variation of the LMA with no

inflation ports; but uses a gel formed distal endLMA and I-GelI-Gel Comes in Multiple SizesLaryngeal Mask Airway (LMA) (Page 555)Laryngeal Airways (2 of 2)Comes in various sizes based on ____________________________________body weight Insertion is similar to King but the tube is inserted in-line

____________________________________rotation

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Inflation of LMA is required, but no inflation for ____________________________________

Confirmation is the sameEndotracheal IntubationEndotracheal Intubation OverviewEndotracheal intubation is the process of inserting an endotracheal tube into

____________________________________, – Usually with direct visualization of vocal cords using a laryngoscope

Provides optimal aspiration protection and ventilationSkill and ____________________________________is required as intubation may result in

prolonged scene times, potential airway trauma, potential hypoxemia and aspirationEndotracheal IntubationEndotracheal intubation is the ____________________________________airway that totally isolates the airway and is clearly the preferred method of advanced airway management in prehospital emergency careIntubationVariations of Intubation Procedures:Oral: through the mouthNasal: through the noseDigital: use of ____________________________________to perform____________________________________assisted intubation (RSI)Cricothyrotomy: through the neck

– Needle or surgicalIndications for IntubationRespiratory or cardiac arrestUnconsciousness without ____________________________________reflexRisk of ____________________________________Obstruction due to foreign bodies, trauma, burns, or anaphylaxisRespiratory insufficiency due to ____________________________________Pneumothorax, hemothorax, hemopneumothorax with respiratory difficultyAdvantages of Endotracheal Intubation____________________________________the trachea and provides total control of the

airway Impedes gastric distentionEliminates need for mask sealOffers a route for direct ____________________________________of tracheaOffers a route for certain drugs

– NAVEL: Naloxone, ____________________________________, Vasopressin, ____________________________________, and Lidocaine

Disadvantages of Endotracheal IntubationRequires significant ____________________________________and experienceRequires specialized equipmentRequires direct ____________________________________of the vocal cordsBypasses upper airway’s function of warming, filtering, and humidifying inhaled airTime consumingRisk of aspiration, airway trauma, and ____________________________________Has not been shown to improve survivalTips for SuccessSelect patients carefully:

– Is there a true ____________________________________?– Can you intubate?

Perform procedure correctly

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Practice regularly to maintain proficiencyMove early to ____________________________________plan in event of difficultyWhen to IntubateConsider intubation on all patients where a gag reflex is absent Intubation should be performed for all patients in

____________________________________arrestDon’t ____________________________________transport for trauma patients unless

there is a significant need to do soEquipment Needed____________________________________(with blades)Endotracheal Tube (ETT)10cc syringe or manometer type syringe____________________________________BVMSuction DeviceBite BlockMagill ____________________________________Tape or commercial securing deviceEngaging Laryngoscope Blade and Handle (Page 557)Activating Laryngoscope Light Source (Page 558)Laryngoscope Blades (1 of 2)Two Basic Types:____________________________________Blades: Curved Blades____________________________________Blades: Straight BladesSizes from 0 to 4Laryngoscope Blades (2 of 2)Some are disposable and some are reusableHave a ____________________________________source to provide illuminationSome are lit by fiber optics while some or lit by

____________________________________King Vision allows for a screen to be usedOther Variations of BladesKing Vision SystemMacintosh (Curved) BladesDesigned to fit into the valleculaWhen lifted anteriorly, blade elevates the ____________________________________, and

indirectly the epiglottis, allowing you to see the glottic opening (vocal cords)Permits more room for ____________________________________ Less trauma to epiglottisPlacement of Macintosh blade into ValleculaMiller (Straight) BladesDesigned to fit under the ____________________________________ Lifts the epiglottis directlyPreferred in ____________________________________Preferred in adults with large tonguesPlacement of Miller Blade Under EpiglottisEndotracheal Tubes (1 of 2) Lengths range from 12 cm to 32 cmBVM or other ventilation devises connects to proximal endMost have ____________________________________to seal the tracheaTube Diameters range from ___________mm to _____________mm

– 2.5mm to 4.5mm are may be cuffed or uncuffed

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– Tubes from 5.0 and larger are cuffedEndotracheal Tubes (2 of 2)Pilot balloon indicates whether the distal cuff is inflatedPilot balloon is normally inflated at _____________-_____________cmH2O (5 to 7cc) of air

from a syringe– Hydrometer syringe is preferred

Normal Adult Sizes– Females: _____________ to 8.0mm– Males: _____________ to 8.5mm

Components of an ET Tube (Page 559)A Standard Endotracheal Tube (Page 559)Syringe That Shows Reading in cmH20Other Equipment (1 of 2)____________________________________: malleable plastic covered wire used to direct

the ETT by bending the distal end10mL syringe: used to inflate cuffTube-Holding Devices: used to secure tube Magill Forceps: scissor-style clamps used to remove

____________________________________bodies or direct ETTOther Equipment (2 of 2) Lubricant: Water soluble solution (KY)____________________________________ detector

– Colormetric or waveformBite Block (oral airway or commercial device)____________________________________unitProper BSI equipmentETT, Stylet, and Syringe: UnassembledETT, Stylet, and Syringe: Assembled (Page 560)Magill Forceps (Page 561)Commercial ETT Securing DevicesEndotracheal Tube IntroducerEndotracheal tube ____________________________________ (gum-elastic bougie): 60-

or 70-cm straight, semi-rigid, stylet-like device with distal bent tip covered with protective resin

Complications of Endotracheal iIntubation (1 of 3)Equipment malfunction

– Batteries, lights, etc.____________________________________breakage and soft tissue lacerations

– Due to improper technique____________________________________

– Due to stimulation or return of gag reflexElevated ICP

– Due to vagal stimulationComplications of Endotracheal Intubation (2 of 3)____________________________________delays:

– Can take significant time to set up and performHypoxemia

– Due to delays or inappropriate pre-oxygenation____________________________________intubation

– Tube in esophagusComplications of Endotracheal Intubation (3 of 3)____________________________________intubation:

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– Tube into a mainstem bronchus– Characterized by lung sounds only on ____________________________________side

(right side most common)– If present, gently pull back on the tube until lung sounds are bilateral

Tension pneumothorax– From excessive pressures from BVM

Orotracheal Intubation Procedure (1 of 5)Position patient supinePre-oxygenate with 100% oxygenPrepare Equipment

– Check handle and ____________________________________on blade, close handle– Inflate cuff and check for leaks– Insert ____________________________________and bend as needed (do not allow

stylet to be exposed on distal end of ETT)– Lubricate as needed

Prepare suction equipmentOrotracheal Intubation Procedure (2 of 5)Remove ____________________________________if presentPlace in “sniffing position”. Flex neck forward and head backwardHold laryngoscope in ____________________________________handHave partner apply Sellick’s maneuver (cricoid pressure) Insert blade into ____________________________________side of mouth and sweep

tongueOrotracheal Intubation Procedure (3 of 5)Move blade to midline

– Advance Macintosh blade until distal end is at base of the tongue in ____________________________________

– Advance Miller blade until the distal end is under the epiglottis Lift the handle slightly upward and toward the feet at ___________° Angle

– Do not ____________________________________on teeth– Observe for vomitus, fluids, or foreign bodies– Suction as needed

Orotracheal Intubation Procedure (4 of 5)Adjust blade until ____________________________________are visibleHold ETT in right hand and advance through right corner of mouthVisualize tube passing through the vocal ____________________________________with

cuff advancing 1-2cm past cordsHold tube in place and remove bladeUse BVM to ventilate in tube Inflate cuff with 20-30cmH2O (5 to 7cc) of air from a syringeOrotracheal Intubation Procedure (5 of 5)____________________________________check for proper tube placement

– Auscultate Both ____________________________________– Auscultate Over ____________________________________

Attach ETCO2 MonitorVentilate the patientSecure tubeDocument tube depthContinually verify tube placement15-1A Ventilate the Patient15-1B Prepare the Equipment15-1C Apply the Cricoid Pressure and Insert Laryngoscope

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15-1D Visualize the Larynx and Insert the ETTLaryngoscope View of the Glottis15-1E Inflate the Cuff, Ventilate, and Auscultate15-1F Confirm Placement with an ETCO2 Detector15-1G Secure the Tube15-1H Reconfirm ETT PlacementVerification of Proper Tube Placement (1 of 2) It is imperative that endotracheal placement of tube confirmed immediately after placement

and ____________________________________throughout careDo not become overly reliant on ____________________________________Patient's clinical condition deciding factor in patient management decisions

– Color, ____________________________________, pulse ox, capnography, etc.Verification of Proper Tube Placement (2 of 2)The most reliable confirmation of tube placement is

____________________________________of tube passing through cordsPresence of bilateral lung soundsAbsence of breath sounds over epigastrium____________________________________end-tidal CO2Presence of ____________________________________in tubeAbsence of vomitus in tubeAbsence of vocal soundsKey Points on Intubation (1 of 3) Limit attempts to 20-30 seconds or less. If unable to intubate,

____________________________________ before reattemptingAdvance distal cuff no more than 1-2cm past vocal cords to avoid endobronchial intubationCheck lung sounds in ____________________________________lungs AND epigastric

soundsHave suction ready before attemptingKey Points in Intubations (2 of 3) If unsuccessful after 2nd attempt, consider alternative airway device (king airway or combi-

tube) or let ____________________________________else attemptSecure the tube immediately Intubation may ____________________________________be a priority. If the airway can

be controlled with other maneuvers, consider the true benefit of intubation– Consider ____________________________________, timeframe, AND patient need

Key Points in Intubations (3 of 3)However, remember that ETT is the ONLY means to totally isolate the airwayDo NOT ____________________________________

– THINK and ____________________________________down!Retrograde IntubationNeedle inserted into airway through cricoid membrane from the outside____________________________________passed through needle; retrieved in oral cavity;

withdrawn through mouthEndotracheal tube passed over ____________________________________into airwaySeldom used in EMSOptical and Video LaryngoscopesOptical Laryngoscopes:____________________________________: fiber-optic technology; disposable; transmits

view from end of device to small attached screen via prism mechanism.____________________________________Vision is widely used in this areaVideo Laryngoscopy:

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Camera on distal end of device; transmits high-quality magnified image to video screenFigure 15-80 McGrath® Video LaryngoscopeKing VisionImproving Intubation SuccessGood initial ____________________________________Ongoing practiceUsing endotracheal tube ____________________________________Managing ____________________________________pressureOptimal positioningVideo laryngoscopy; other technologyRapid sequence intubationBlind Nasotracheal IntubationNasotracheal Intubation Insertion of an ETT through a ____________________________________and into the

tracheaNot commonly used in EMSRequires cooperative or unresponsive spontaneously

____________________________________patientDoes not require direct visualizationDoes not produce as much of a gag reflex as does an orotracheal tubeNasotracheal Intubation may be Useful in Some Situations:Possible spinal injuryClenched ____________________________________Fractured jaw, oral injuries, or recent oral surgeryFacial or airway swelling____________________________________Arthritis preventing sniffing positionContraindications for Nasotracheal Intubation (1 of 2)Relative Contraindications:Possible ____________________________________fracturesSuspected basilar skull fractureSuspected elevation of ____________________________________Combative/uncooperative patientPatient on anticoagulants____________________________________septum or nasal destructionHypoxemia Contraindications for Nasotracheal Intubation (2 of 2)Absolute Contraindication:Cardiac or respiratory ____________________________________

– Patient ____________________________________be breathingAdvantages of Nasotracheal IntubationThe head and neck can remain in neutral position It does not produce as much ____________________________________response and is

better tolerated by the awake patient It can be ____________________________________more easily than an orotracheal tubeThe patient cannot ____________________________________the ETTDisadvantages of Nasotracheal IntubationMore difficult and time consumingSignificant risk of trauma and ____________________________________Smaller diameter tube must be used

– May kink or clog more easilySignificant risk of ____________________________________

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Greater incidence of improper placementNasotracheal Intubation Procedure (1 of 3)Use Standard PrecautionsUsing ____________________________________manual and adjunctive maneuvers, open

airway and ventilate patient with 100 percent oxygenPrepare equipment: tube, syringe, etc. Place patient in position of ____________________________________ Inspect nose; select ____________________________________nostrilNasotracheal Intubation Procedure (2 of 3)Select correct size endotracheal tubeNormally ½ to one full size ____________________________________than for oral____________________________________tube generously Insert ETT into nostril with ____________________________________facing septum Listen closely at proximal end for patient's respiratory sounds Nasotracheal Intubation Procedure (3 of 3)Advance quickly but gently with next inhaled breathNormal depth is ____________cm for adult females and ___________cm for adult males Inflate cuff, ventilate with BVM and oxygen and monitor for exhaled CO2 ____________________________________tube, reconfirm and continuously monitorFigure 15-87 Blind Nasotracheal Intubation (Page 572)Digital IntubationDigital Intubation Overview Oral insertion of an ETT without a laryngoscope;

____________________________________are used insteadOlder technique and has generally been replaced by newer extraglottic airways and devicesDo not use with any patient who may have intact gag reflexDanger of patient ____________________________________fingersDigital Intubation Procedure (1 of 3) BSIContinue oxygenation with bag-valve mask and high-concentration oxygenPrepare and check equipment Remove front of collar (if present) and ____________________________________stabilize

neck.Place ____________________________________block device between patient's molars.Digital Intubation Procedure (2 of 3) Insert your left middle and index fingers into patient's mouth and

“____________________________________” hand down midline to palpate the epiglottisPress ____________________________________forward; insert endotracheal tube into

mouthAdvance tube with right handDigital Intubation Procedure (3 of 3) Advance ETT through cords while simultaneously maneuvering it

____________________________________with your left index and middle fingersHold tube in place with your hand, remove stylet, and inflate cuff____________________________________placement with multiple techniquesVentilate patient with 100 percent oxygenInsert Middle and Index Finger Into Patient’s Mouth“Walk” Fingers Down to Palpate the Epiglottis and Push it ForwardGuide Tube Into PlaceSpecial Intubation ConsiderationsTrauma Patient ObstaclesDifficult ____________________________________

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Need for extrication____________________________________in oropharynxDistorted ____________________________________due to injuryNeed to protect cervical spineGetting adequate seal on maskEndotracheal Intubation with In-Line Stabilization15-2A Ventilate the Patient and Apply Manual C-Spine Stabilization15-2B Apply Cricoid Pressure and Intubate15-2C Ventilate the Patient and Confirm Placement15-2D Secure the ETT and Place a Cervical Collar15-2E Reconfirm PlacementForeign Body Removal with LaryngoscopeUse of ____________________________________to visualize airwayUse Magill forceps or ____________________________________deviceProcedure for visualizing airway identical to orotracheal intubationFigure 15-94 Foreign Body Removal with Direct Visualization and Magill ForcepsPediatric Intubation (1 of 4)Anatomy and physiology differences:Structures ____________________________________Nasal openings small and adenoids largeNasal airway diameters inadequateCricoid ____________________________________can worsen situationTube sizing is criticalPediatric Intubation Tube SizingSizing Selection Options:ChartsPediatric tapes (____________________________________Tape)Formula: (Age in Years + 16)/4ETT size of the child’s ____________________________________fingerTable 15-7 Approximate Size of ETT for Pediatrics (Page 578)Pediatric Intubation (2 of 4)Anatomy and physiology differences (cont’d):Surgical airways unavailable

– ____________________________________cricothyrotomy is an optionDepth of ETT insertion differentOcciput relatively largeEpiglottis ____________________________________and round ("omega" shaped)Tongue larger in relation to oropharynxPediatric Intubation (3 of 4)Anatomy and physiology differences (cont’d):Glottic opening higher and more ____________________________________in neckNarrowest part of airway is cricoid cartilage, not glottic opening as in adultsGreater ____________________________________tone (can create bradycardia)Higher basal metabolism combined with less functional residual capacityPediatric Intubation (4 of 4)The intubation procedure is the same as for an adult but the anatomical differences makes

pediatrics much more ____________________________________Many studies have shown that pediatrics respond better to

____________________________________airway management than advanced proceduresConsider if there is a true need for intubationProcedure 15-3 Endotracheal Intubation in the Child15-3A Ventilate the Child

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15-3B Prepare the Equipment15-3C Insert the Laryngoscope15-3D Visualize the Child’s Larynx and Insert the E T T15-3E Ventilate, Inflate the E T T Cuff (If It Is a Cuffed Tube), and Auscultate15-3F Confirm Placement with an E T C O2 Detector or Waveform Capnography15-3G Secure the Tube15-3H Reconfirm Proper ETT PlacementMonitoring Cuff Pressure (1 of 2)Use extreme caution as over pressurization can cause trauma to the tracheaHistorically, 10cc of air has been inserted into ETT

– This is too much pressure in most cases___________-___________mL of air is sufficient in most casesMost proficient means is to use a cuff ____________________________________Monitoring Cuff Pressure (2 of 2)Place only enough air into cuff to eliminate ____________________________________leak

– As little as ___________-___________cc of air will suffice on some adultsAn option is to inflate with 10cc of air and leave syringe attached for 10 to 20 seconds to

allow back-pressure to releasePost-Intubation Agitation and Field ExtubationOccasionally, intubated patient will ____________________________________ and be

intolerant of ETT– Options are sedation, extubation, or restraint

Rarely extubation considered in fieldUse Standard Precautions Ensure adequate ____________________________________Prepare intubation equipment and suctionExtubation Procedure (1 of 2)Use Standard Precautions Ensure adequate oxygenationPrepare intubation equipment and suctionConfirm patient responsivenessPosition patient on his ____________________________________if possible____________________________________patient's oropharynxExtubation Procedure (2 of 2)Deflate ETT cuff; remove ETT upon ____________________________________or

expirationProvide supplemental oxygen____________________________________adequacy of ventilation and oxygenationCricothyrotomyCricothyrotomy Types (1 of 2)Needle cricothyrotomy:AKA: transtracheal jet ventilation or transtracheal jet insufflationUses a IV ____________________________________inserted into the trachea____________________________________procedure; makes providing adequate

ventilation more difficultCricothyrotomy Types (2 of 2)Open (surgical) cricothyrotomy:Opening is ____________________________________made into the tracheaMore difficult procedure, but allows for more effective oxygenation and

____________________________________Indications and Contraindications for CricothyrotomyOnly indication for surgical airway is ____________________________________to

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establish airway by any other method– Edema, swelling, trauma, etc.

Highly ____________________________________and is prone to long-term complications.No absolute contraindications in emergency situationsNeedle CricothyrotomyPlacing large-bore needle with plastic cannula through cricothyroid membrane into tracheaDue to the high pressures, ____________________________________, including

pneumothorax, is a potential complicationUsed for ____________minutes or less and restricted to pediatric patients in which a

surgical procedure is contraindicated In emergent situations, a BVM may temporarily work with an

____________________________________adapter from a small ETT Figure 15-95 Anatomic Landmarks for Cricothyrotomy (Page 582)Needle Cricothyrotomy with Jet Ventilation Procedure (1 of 6)Use Standard Precautions.Manage airway with ____________________________________maneuvers and

supplemental oxygen.Prepare equipment

– IV catheter, disinfectant, syringe, ventilator, etc.Patient supine: ____________________________________head and neckNeedle Cricothyrotomy with Jet Ventilation Procedure (2 of 6)Palpate inferior portion of thyroid cartilage and cricoid cartilage. The

____________________________________between the two is the cricothyroid membraneNeedle Cricothyrotomy with Jet Ventilation Procedure (3 of 6)Prepare neck with ____________________________________solutionAttach a large bore IV needle to a 10 or 20mL syringe

– Adults: ____________ or _____________ gauge– Pediatrics: 18 or 20 gauge

Firmly grasp laryngeal cartilages; reconfirm site of cricothyroid membraneCarefully insert needle at a _____________ degree angle into cricothyroid membrane at

midlineNeedle Cricothyrotomy with Jet Ventilation Procedure (4 of 6)Advance needle while aspirating with syringe

– Syringe should easily aspirate once in tracheaHold needle steady; advance ____________________________________Then withdraw ____________________________________Reconfirm placementSecure catheter in placeNeedle Cricothyrotomy with Jet Ventilation Procedure (5 of 6)Attach ____________________________________-ventilation device to catheter and 50psi

oxygen supplyOpen release valve to introduce oxygen jet into tracheaWatch ____________________________________carefully, turning off release valve as

soon as chest risesNeedle Cricothyrotomy with Jet Ventilation Procedure (6 of 6)Continue ventilatory supportAnticipate need for ____________________________________means of oxygenation and

ventilation within ___________ minutesFigure 15-96 Locate/Palpate the Cricothyroid MembraneFigure 15-97 Proper Positioning for Cricothyroid PunctureFigure 15-98 Advance the Catheter with the Needle. Then Withdraw NeedleFigure 15-99 Cannula Properly Placed in the Trachea

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Figure 15-100 Jet Ventilation with Needle CricothyrotomyOpen (Surgical) CricothyrotomyPlacing endotracheal or tracheostomy tube directly into trachea through surgical

____________________________________at cricothyroid membranePreferred in older pediatric patients and

____________________________________patients Indications same as for needle cricothyrotomyProcedure 15-4 Open (Surgical) Cricothyrotomy15-4A Locate the Cricothyroid Membrane15-4B Stabilize the Larynx and Make a __________to ___________cm Vertical Skin Incision over the Cricothyroid Membrane15-4C Using Fingers to Open Incision and Find the Cricothyroid Membrane. Make a 1-cm ____________________________________Incision Through the Cricothyroid Membrane15-4D Using a Curved ____________________________________, Spread the Membrane Incision Open15-4E Insert an ETT (6.0 or 7.0) or ____________________________________ (6.0 or 8.0)15-4F ____________________________________the Cuff15-4G Confirm Placement15-4H Ventilate15-4I Secure the Tube, Reconfirm Placement, and Evaluate the PatientVariations of Open CricothyrotomyRapid Four-Step: utilizes only a ____________________________________incision

through the cricothyroid membraneBougie-aided: ETT introducer is inserted into the incision and the tube is placed over the

introducer into the tracheaMedication-Assisted IntubationOverview (1 of 2)Also known as Rapid ____________________________________Intubation (RSI) or

Pharmacologically Assisted Intubation (PAI)Giving medications to sedate and temporarily ____________________________________a

patient to facilitate intubationA patient who needs intubation may be awake. RSI paralyzes the patient to facilitate

endotracheal intubation.Overview (2 of 2)Rapid sequence intubation (RSI): series of steps that includes administration of

neuromuscular ____________________________________drug (paralytics) to critically ill or injured patient to facilitate oral intubation without aspiration or other complications.

Indications for RSI Impending or actual respiratory ____________________________________from any

cause– Severe asthma, COPD, etc.

Impending or actual inability to protect the airway from any cause– Burns, ____________________________________, edema

Combativeness secondary to ____________________________________traumaHypoxemia despite maximal therapyRelative Contraindications for RSIPredicted difficult airwayShort ETA to hospitalOnly ____________________________________Paramedic on sceneAbility to manage airway by other ____________________________________risky means

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When the only reason is airway protection Absolute Contraindications for RSIRespiratory and/or ____________________________________arrestNo gag ____________________________________

– If there is no gag reflex, intubate without the assistance of drugs!General Procedure for RSI (1 of 3)PreoxygenatePrepare all drugsAdminister an ____________________________________agent (Benzodiazepine or other

sedative)– Etomidate, Midazolam, Ketamine, Propofol

Check to see if gag reflex is suppressed– If so, ____________________________________. Do not give paralytic

General Procedure for RSI (2 of 3)Administer Paralytic (neuromuscular blocker)

– ____________________________________, Rocuronium, Vecuronium IntubateUse sedatives or ____________________________________to maintain sedation

– Narcotics, benzodiazepines, Propofol, KetamineGeneral Procedure for RSI (3 of 3)Other possible drugs:Atropine: to prevent bradycardias in younger ____________________________________ Lidocaine: for patients with head injury with ____________________________________Pain medications:

– Morphine, Fentanyl, etc.The Difficult AirwayTable 15-12 Predictors of Difficult Airway and Ventilation (Page 593)Mallampati Classification System (1 of 2)Based on assessment of the tonsillar pillars and the

____________________________________The more ____________________________________the tonsillar pillars and the uvula, the

more difficult the airwayMallampati Classification System (2 of 2)Class I: Entire tonsil clearly visible

– ____________________________________intubationClass II: Upper half of tonsil fossa visible

– Mildly difficultClass III: Soft and hard palate clearly visible

– ____________________________________difficultClass IV: Only hard palate visible

– Difficult Cormack and LeHane Classification System Grade 1: Entire glottic opening and vocal cords may be seenGrade 2: Epiglottis and posterior portion of glottic opening may be seen with a partial view

of vocal cordsGrade 3: Only epiglottis and (sometimes) posterior cartilages seen.Grade 4: Neither epiglottis nor glottis seen.Figure 15-101 Airway Scoring Systems. Mallampati Classification System (Top); Cormack and Lehane Classification System (Bottom) (Page 594)LEMONS "LEMONS": acronym to remember assessments and findings with difficult airway.____________________________________externally

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Evaluate 3-3-2 ruleMallampati score________________________________________________________________________mobilitySaturationsThe 3-3-2 Rule (Page 595)Effects of ObesityProper positioning: ____________________________________position Limits effects of preoxygenationBVM ventilation more difficultExtraglottic rescue devices may not generate enough airway

____________________________________to lift very heavy chest Identification of landmarks difficultPredicting DifficultyAn Imperfect Science Look for ____________________________________warning signs of difficult intubation or

BVM ventilationPrepare accordinglyAny patient, no matter how favorable airway appears, may prove

____________________________________or impossible to intubatePart 4 Additional Airway and Ventilation IssuesStomas (1 of 2)Stoma: opening in anterior neck that connects trachea with ambient airTracheostomy tubes: inner and outer ____________________________________; keep

soft-tissue stoma openTube ____________________________________common problem If tube becomes dislodged, replace as soon as possibleStomas (2 of 2) If airway is not otherwise manageable, an ____________________________________may

be used temporarily– Remove cannula and insert ETT just until ____________________________________is

fully in trachea– Inflate an ventilate

Need for ____________________________________is a common occurrenceSuctioningTurning patient or just his head to side is ____________________________________and

more effective than any suction deviceSuctioning devices: handheld, oxygen-powered,

____________________________________-operated, mounted (non-portable)Suction catheters: hard/rigid catheters ("Yankauer" or "tonsil tip"); soft catheters ("whistle

tip")Suctioning interrupts oxygen therapyTracheobronchial Suctioning (1 of 2)Occasionally need to suction through endotracheal or tracheostomy tube to remove

secretions or ____________________________________plugs from tracheobronchialairway

Ensure adequate oxygenation before and after procedureUse only ____________________________________tip cathetersTracheobronchial Suctioning (2 of 2) Insert until you meet slight resistance (at ____________________________________)Suction as you twist and ____________________________________the catheter for no

more than 10 seconds

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You may need to inject 3-5mL of sterile water or saline down the ETT before suctioning to loosen thick secretions

Figure 15-107 Tracheostomy Suction Technique (Page 600)Gastric Distention and Decompression (1 of 2)Gastric ____________________________________is a common problem during BVM

ventilation– Air enters stomach (gastric insufflation) and increases risk of vomiting and regurgitation

Gastric decompression: insertion of a gastric tube into ____________________________________via mouth (orogastric) or nose (nasogastric) or through extraglottic airway (EGA)

Gastric Distention and Decompression (2 of 2)Nasogastric tube placement are used for

____________________________________patientsOrogastric tube placement are used on ____________________________________patientsAll three routes—nasogastric, orogastric, and EGA carry risk of misplacement into lungsOrogastric Tube Insertion (1 of 3)Take Standard PrecautionsPlace patient's head in ____________________________________position while

ventilating via endotracheal tube or EGASelect correct size gastric tube

– Most adults take a ____________Fr when placed orallyDetermine approximate length of tube insertion by measuring from the epigastrium to the

angle of the jaw, then to the mouth opening or to the proximal end of the EGAOrogastric Tube Insertion (2 of 3) Lubricate tip of gastric tube; gently insert it into oral cavity at

____________________________________Advance tube gently to predetermined lengthCheck tube has not ____________________________________in mouthConfirm placement by injecting 30 to 50 mL of air while listening to epigastric region for air

entry into stomachOrogastric Tube Insertion (3 of 3)Apply gentle ____________________________________to tube to evacuate gastric fluids

and gas____________________________________tube in placeDocument indication for gastric decompression and procedures doneTransport Ventilators (1 of 2)Transport ventilators apply mechanical ventilation to assist or replace patient's own

breathingSuperior to manual ventilation except in ____________________________________patientFrees up provider ____________________________________ Less likely to cause hemodynamic impairment or CO2 fluctuationsTransport Ventilators (2 of 2)Most have inspired oxygen concentration fixed at 100 percent, but may be adjustableMost do not provide ____________________________________Most have settings for rate, volume, and ____________________________________Know any ventilator that you may useAirway Management Documentation (1 of 2)Airway management, especially intubation, is one of the most common reasons EMS

personnel get ____________________________________Most is due to improper or incomplete ____________________________________ If it wasn’t written down, it didn’t happen!Document not only what was done but thought process of why it was done

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Airway Management Documentation (2 of 2)Document any complications that occurredProper ETT placement should be not only be verified but

____________________________________by at least 3 confirmation methods– If more confirmation techniques used, ____________________________________them

all!Good practice is to have receiving physician ____________________________________a

form stating tube is in proper positionDocumentation Example 1 “Patient was intubated with a 4.0 ET tube on first attempt. Good lung sounds noted

bilaterally. Tube secured with 14cm line at the teeth. Patient then ventilated at a rate of 18 breaths per minute with a BVM and supplemental oxygen at 10lpm”

Documentation Example 2“Patient was intubated with a 4.0 ET tube on first attempt by Paramedic Jones. Tube was visualized passing through the vocal cords. Cuff inflated with 4cc of air. Good lung sounds noted bilaterally with no sounds over epigastrium. Tube secured with tube tamer with 14cm line at the teeth. Waveform capnography showed a good pattern with ETCO2 reading of 31mmHg. Patient continually ventilated at a rate of 18 breaths per minute with a BVM and supplemental oxygen at 10lpm. Waveform capnography continually monitored throughout. Dr. Smith verified proper tube placement at the receiving ER and signed acknowledgment”CPAP and BiPAPCPAP and BiPAPCPAP = ____________________________________ Positive Airway PressureBiPAP = ____________________________________ Positive Airway PressureBoth utilizes machines or devices that produce pressure to maintain PEEP and keep the

alveoli open Can eliminate the need to ____________________________________certain patients by

decreasing the work of breathingBoth were developed for sleep apneaCPAPBiPAPDifferences (1 of 3)CPAP delivers a predetermined level of ____________________________________pressureOne level and delivers a constant flowNormally 6-30cm H2OPatient must overcome the constant pressure to

____________________________________Differences (2 of 3)BiPAP delivers ___________ levels of pressure Inspiratory and ExpiratoryNormally 20-30cmH2O for inspiratory and less for expiratory____________________________________pressures to overcome during exhalationDifferences (3 of 3)CPAP is best utilized by EMS for reduction of pulmonary

____________________________________– Presence of rales or crackles

BiPAP is best utilized by EMS for ____________________________________patients AND for the reduction of pulmonary edema– Emphysema, Bronchitis, Pneumonia, CHF

CommonalitiesDecreases ____________________________________Decreases need for intubation

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Decreases left ventricular ____________________________________and afterload in patients with pulmonary edema– (pushes fluids from alveoli)

General Indications for CPAPPatients must be over ___________ years of agePulmonary edema____________________________________: rate > 25, pulse ox < 92, use of accessory

musclesPatient must be alert and able to follow commandsGeneral Indications for BiPAPPatients must be over 12 years of ageCHF ____________________________________rales/cracklesCOPDPneumoniaPatient must be ____________________________________and able to follow commandsUnstable: rate > 25, pulse ox < 92, use of accessory musclesContraindications for CPAP and BiPAPRespiratory/cardiac arrest____________________________________or chest traumaTracheostomyNausea, vomiting, or GI bleedingFull ____________________________________where mask will not sealGeneral Procedure for CPAPPlace patient on pulse ox and end tidal CO2 to monitor O2/CO2 exchangeMonitor EKG (as Paramedic)Place mask on face, check for ____________________________________Use ___________-_____________cm H20 of PEEP or as indicated by ProtocolsMonitor VSAdminister ____________________________________as neededGeneral Procedure for BiPAPSame as for CPAP except, you must set 2 settingsSet Inspiratory and Expiratory settings for BiPAP

– Inspiratory ___________-_____________cm H20 (Normally)– Expiratory ___________-_____________cm H2O (Normally)– Settings are more patient dependentRefer to protocols

Special Notes on CPAP and BiPAPMust make an airtight sealCPAP therapy should be ____________________________________Notify ED of CPAP useWatch for gastric ____________________________________May be used on patients with DNRsKey Points on CPAP and BiPAPAs this is an invasive procedure, you must have medical directionSince there are numerous devices and machines, you must be familiar with what your

service usesCPAP and BiPAP will NOT ____________________________________your patient. Don’t

waste time using when the patient needs assisted ventilationsBoth require high flow ____________________________________, watch you oxygen

bottle levelConclusionAirway management is of highest importance

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Intubation is a significant skill and should be used wisely It is your responsibility to maintain proficiency in all airway management skills that you are

allowed to perform

Phases of Waveform Capnographyp g p y

IIIIIICCCC DDDD

IIII IVIV

IIIIAAAA BBBB EEEE

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