Chapter 10: Airway Part 2

pressure regulator: after the pressure is reduced to a workable level, the final attachment for delivering the gas to the patient is usually?

- a quick connect female fitting that will accept a quick connect male plug from a pressure hose or ventilator/resuscitator -a flowmeter that will permit regulated release of gas measured in liters per minute

basic airway adjuncts: when to not use an airway?

- conscious patients -any patient that is conscious or unconscious who has an intact gag reflex

basic airway adjuncts: when to use a nasal airway?

- semiconscious or unconscious patients with an intact gag reflex -patients who otherwise will not tolerate an oropharyngeal airway

basic airway adjuncts: indications of when to use an oral airway are?

- unresponsive patients with no gag reflex (breathing or apneic) -any apneic patient being ventilated with a BVM

inadequate signs of breathing in an adult patient

-RR rate of fewer than 12 breaths/min or more than 20 breaths/min in the presence of shortness of breath (dyspnea) -irregular rhythm such as a patient taking a series of deep breaths followed by periods of apnea -diminished, absent or noisy auscultated breath sounds -reduced flow of expired air at the nose and mouth -unequal or inadequate chest expansion , resulting in reduced tidal volume increased effort of breathing (use of accessory muscles) -shallow depth (reduced tidal volume) -skin that is pale, cyanotic (blue), cool, or moist (clammy)

opening of the airway: what are some other ways to keep the airway patent?

-airway adjunct(such as oral or nasal) -suction

emergency medical care with patients with inadequate breathing include?

-airway management -supplemental oxygen -ventilatory support

assessment of respiration: what is ambient air ?

-ambient air is the atmospheric air in its own natural state -it is what we breathe when the atmosphere is not contaminated with airborne pollutants -ambient air is vital to the survival of humans and animals -the composition of ambient air varies depending on the elevation above sea level as well as human factors such as the level of pollution -ambient air is affected by the activities of people

assessment of respiration: if poor perfusion or oxygenation is not corrected, what can happen?

-anaerobic metabolism will take place -can cause the skin to become marked with blotches of different colors, commonly referred to as mottling

assessment of respiration: how do you measure pulse oximetry?

-clean patients finger, remove nail polish as needed, -place the index or middle finger into the pulse oximeter probe -turn on the pulse oximeter and note the leed reading of the Sp02 (oxygen concentration) -palpate the radial pulse to ensure that it correlates with the LED display on the pulse meter

opening of the airway: what are some other stuff that can create an airway obstruction?

-dentures -blood -vomitus -mucus -food -other foreign objects

Assessment of respiration: cyanosis becomes noticeable first where?

-fingertips -mucous membrane -around the lips

assessment of respiration: An inaccurate reading of a pulse oximetry reading may be caused by?

-hypovolemia -severe peripheral vasoconstriction (chronic hypoxia, smoking, or hypothermia) -time delay in detecting respiratory insufficiency -dark or metallic nail polish -dirty fingers -carbon monoxide poisoning

a pressure compensated flowmeter

-incorporates a float ball within the tapered calibrated tube -the flow of gas is controlled by a needle valve located downstream from the float ball -this type of flow meter is affected by gravity and must always be maintained upright position for an accurate flow reading

the bourdon-gauge flowmeter

-is not affected by gravity and can be used in any position -it is a pressure gauge that is calibrated to record flow rate -it is now considered out dated

oxygen cylinders: safety considerations on handling a gas cylinder

-make sure that the correct pressure regulator is firmly attached before you transport the cylinder. -a puncture or hole in the tank can cause the cylinder to become a deadly missle -do not handle a cylinder by the neck assembly alone -secure cylinders with mounting brackets when they are stored on the ambulance

basic airway adjuncts: when to not use a nasal airway?

-severe head injury with blood draining from the nose -history of fractured nasal bone

procedures of operating and administering oxygen

1- inspect the cylinder and its markings. If the cylinder was commercially filled, it will have a plastic seal around the valve stem covering the opening in the stem. remove the seal and inspect the opening to make sure it is free of dirt and debris in the valve stem should not be sealed or covered with adhesive tape or any petroleum-based substances. these contaminate the oxygen and can contribute to combustion when mixed with pressurized oxygen. crack the cylinder by slowly opening and then reclosing the valve to help make sure that dirt or other particles and other possible contaminants do not enter the oxygen flow. never face the tank towards yourself or other while cracking the cylinder. open the tank by attaching a key (wrench) to the valve and rotating the valve counterclockwise. you should be able to hear clearly the rush of oxygen coming from the tank. close the tank by rotting the valve clockwise. 2- attach the regulator/flowmeter to the valve stem after clearing the opening. on one side of the valve stem, you will find three holes. the larger one on top, is a true opening through which the oxygen flows. the two smaller holes below it do not extend to the inside of the tank. they provide stability to the regulator. following the design of the pin-indexing system, these two holes are very precisely located in positions that are unique to the oxygen cylinders. 3-place the regulator collar over the cylinder valve, with the oxygen port and pin-indexing pins on the side of the valve stem that has the three holes. open the screw bolt just enough to allow the collar to fit freely over the valve stem. move the regulator so that the oxygen port and the pins fit into the correct holes on the valve stem. the screw bolt on the opposite side should be aligned with the dimple depression. as you hold the regulator securely against the valve stem, hand tighten the screw bolt until the regulator is firmly attached to the cylinder. at this point, you should not see any open spaces between the sides of the valve stem and the interior walls of the collar. 4- with the regulator firmly attached, open the cylinder completely check for air leaking from the regulator-oxygen cylinder connection, and read the pressure level on the regulator gauge. Most portable cylinders have a maximum pressure of approx. 2000 psi. most ems systems consider a cylinder with less than 500 to 1000 psi to be too low to keep in service. learn you departments policies in this regard and follow them. the flowmeter will have a second gauge or a selector dial that indicates the oxygen flow rate. several popular types of devices are widely used. attache the selected oxygen device to the flowmeter by connecting the universal oxygen connecting tubing to the christmas tree nipple on the flowmeter

basic airway adjuncts: steps to put patient in recovery position

1- roll the patient onto either side so that the head shoulders and torso move at the same time without twisting 2- extend the patients lower arm and place the upper hand under his or her cheek.

basic airway adjuncts: how to properly insert a oropharyngeal airway?

1- to select the proper size measure from the patients earlobe or angle of the jaw to corner of the mouth 2-open the patients mouth with the cross finger technique . hold the airway upside down with your other hand. Insert the airway with the tip facing the roof of the mouth. 3- rotate the airway 180 degrees. When inserted properly, the airway will rest in the mouth with the curvature of the airway following the contour of the anatomy. the flange should rest agains the lips or teeth with the other end opening into the pharynx.

oxygen cylinders: what are the two sizes of oxygen tanks we will typically use?

D (jumbo D) and M cylinders

basic airway adjuncts: inserting the airway at a 90 degree angle

1- use a tongue depressor or bite stick to depress the tongue, ensuring the tongue remains forward. 2- insert the oral airway sideways from the corner of the mouth, until the flange reaches the teeth. 3- rotate the oral airway to a 90 degrees, removing the depressor or bite stick as you exert gentle backward pressure on the oral airway until it rests securely in place against the lips and teeth.

an oropharyngeal airways has two purposes, what are they?

1-keep tongue from blocking the upper airway 2-to make it easier to suction the oropharynx if necessary.

basic airway adjuncts: the oropharyngeal airway has two principal purposes. What are they?

1. to keep the tongue from blocking the upper airway 2. to make it easier to suction the oropharynx if necessary.

techniques of suctioning: how do you properly suction a patient?

1. turn on the assembled suction unit. to test the suction, clamp the tubing, and make sure that the unit generates a vacuum of more than 300 mm Hg. 2. measure the catheter to the correct depth by measuring the catheter from the corner of the patients mouth to the edge of the earlobe or angle of the jaw. 3. before applying suction turn the patients head to the side (unless you suspect cervical spine injury). open the patients mouth using the cross-finger technique or tongue jaw lift and insert the tip of the catheter to the depth measured. DO NOT SUCTION WHILE INSERTING THE CATHETER 4. insert the catheter into the pre-measured depth and apply suction in circular motion as you withdraw the catheter. do not suction an adult for more than 15 seconds

Normal respiratory rate for adults

12 to 20 breathers per minute

normal respiratory rate for children

15 to 30 breaths per minute

pressure regulators: what is the pressure of the gas in a full oxygen cylinder?

2,000 psi (which is far too much pressure to be safe or useful for your purposes)

Normal respiratory rate for infants

25 to 50 breaths per minute

assessment of respiration: how much oxygen does the hemoglobin deliver to the body's tissue?

97% and oxygen dissolved in plasma delivers the other 3%

assessment if respiration: the oxygen saturation (Spo2) percentage under normal conditions should be ?

98-100% while breathing room air

assessment of respiration: Would a patient with an oxygen saturation (Spo2 ) of 90% or lower require treatment?

Yes , unless the patient has a chronic condition causing perpetually low oxygen saturations (Sp02)

Basic airway adjuncts: if you encounter difficulty while inserting the airway, insert the airway at a what degree angle?

a 90 degree angle.

basic airway adjuncts: what is a better choice of airway for a patient for have an intact gag reflex?

a nasal airway

basic airway adjuncts: nasopharyngeal airway

a nasopharyngeal airway is often used on an unconscious patient or a patient with an altered level on consciousness who has an intact gag reflex and is not able to maintain his or her airway spontaneously.

kussmaul respiration

a respiration characterized as deep, rapid respirations commonly seen on patient with metabolic acidosis

flowmeter:

a valve that indicates the flow of oxygen in liters per minute

when a persons heart stops you may hear occasional, gasping breaths called?

agonal gasps

What is hypoglycemia?

Low blood glucose

opening the airway: does adequate breathing aways equate to adequate airway?

No

Conditions that reduce the surface area for gas exchange also decrease the body's?

Oxygen

oxygen cylinders: D cylinders volume, liters are?

Size D Volume, Liter is 350

oxygen cylinders: M cylinders volume anf liters are?

Size M volume, liter is 3,000

drowning patients or patients with pulmonary edema have fluids in the what?

alveoli

cheyne-stokes respiration

an irregular respiratory pattern in which the patient breathes with an increasing rate and depth of respirations. -Cheyne-stroke is often seen in patients with stroke or patients with serious head injury -cheyne-stroke is may include apnea or lack of spontaneous breathing

patients with agonal gasps need to be provided with what?

artificial ventilations and more than likely chest compressions.

drowning patients or patients with pulmonary edema have fluids in the alveoli, this accumulation of fluid inhibits adequate gas exchange at the alveolar membrane and results in decreased what?

decreased oxygen and respiration

what does dyspnea mean?

difficult or labored breathing

flowmeters

flowmeters are usually permanently attached to pressure regulators on emergency medical equipment. the two types of flowmeters that are commonly used are pressure compensated flow meters and bourdon-gauge flowmeters

Supplemental oxygen

in addition to knowing when and how to give supplemental oxygen, you must understand how oxygen is stored and the various hazards associated with its use

assessment of respiration: what does it indicate when the c02 is low or absent?

it indicates a decreased level of co2 in the lungs , this maybe be caused by absent or decreased ventilation, cardiac arrest, ineffective cpr, hypothermia, or shock.

opening the airway: jaw-thrust maneuver

its a technique o open the airway by placing the fingers behind the angle of the jaw upward.

opening the airway: if you suspect a cervical spine injury, what will you do? head-tilt-chin lift or jaw-thrust maneuver?

jaw-thrust maneuver

assessment of respiration: what is a pulse oximeter

measure the percentage of the hemoglobin saturation.

assessment of respiration:a patient with an altered level of consciousness may not have adequate oxygen levels reaching to the brain. this lack of oxygen can cause rapid changes in the patients what?

mental status

techniques of suctioning: how long do you suction the nose or mouth on a child?

no more than 10 seconds on children

techniques of suctioning: how long do you suction the mouth or nose for an adult patient?

no more than 15 seconds on an adult

techniques of suctioning: how long do you suction the nose or mouth on an infant?

no more than 5 seconds

basic airway adjuncts: an oral airway on conscious or unconscious patients?

on unconscious patients who have no gag reflex. It keeps the tongue from blocking the airway and makes suctioning easier.

assessment of respiration: when the Sp02 drops below 94% what is applied?

oxygen

assessment of respiration: what is (Sp02)

oxygen saturation

assessment of respiration: describe Pallor

pale skin and mucous membrane , typically associated with poor perfusion caused by illness or shock.

assessment of respiration: skin color indicates what in inadequate respiration?

poor skin color indicates inadequate ventilation, just as an altered LOC does. As oxygen fails to reach the skin tissue of the body, either from lack of perfusion or poor oxygenation the color of the skin changes to reflect the low level of oxygenation.

assessment of respiration: if you approach a space and suspect ambient air what do you do?

remove yourself if possible asap from the scene and contact the appropriate resources

assessment of respiration: what does ROSC stand for?

return of spontaneous circulation

opening the airway: what is the cross finger technique?

sometimes the mouth does not open hen you do the head tilt chin lift or jaw thrust maneuver so you have to use your fingers to open the mouth.

Techniques of suctioning

step 1: check the unit for proper assembly of all its parts step 2: turn on the suctioning unit and test it to ensure vacuum pressure of more than 300 mm Hg. step 3: select and attach the appropriate suction catheter to the tubing

techniques of suctioning: sometimes a patient may require assisted ventilation and produce frothy secretions as quickly as you can suction them from the airway. In this situation, what do you do?

suction the patient for 15 seconds (less time for children and infants) and then ventilate the patient for 2 minutes. continue the alternating pattern of suctioning and ventilating until all secretions have been cleared from the patients airway. continuous ventilation is not appropriate if vomitus or other particles are present in the airway

techniques of suctioning: what does suctioning remove?

suctioning removes oxygen from the airway along with the obstructive material.

opening the airway: what is the most effective position the patient may be in to open the airway?

supine position

What does apnea mean?

temporary cessation of breathing especially during sleep

assessment of respiration: do you treat the patients condition or environment if they have a cyanosis, or clammy, or pale skin or symptoms such as shortness of breath and normal sp02?

the condition

when assessing a patient with a potential airway compromise, pay attention to what?

the external environment. conditions such as poisonous gases like carbon monoxide or high altitudes, enclosed spaces alter the partial pressure of oxygen in the environment, making the process of oxygenation difficult. other conditions to pay attention for

assessment of respiration: oxygen saturation (Sp02) is?

the measure of the percentage of the hemoglobin molecules that are bound in arterial blood

assessment of respiration: what is end-tidal co2?

the partial pressure or maximal pressure of co2 at the end and of exhaled breath.

opening the airway: if your patient is found in the prone position laying face down, he or she must be repositioned to allow for assessment of airway and breathing and to begin CPR, should it become necessary. What is the most effective way to reposition your patient?

the patient should be log rolled as a unit so the head, neck and supine all move together as a unit

assessment of respiration: when treating patients with altered mental status, always consider?

the possibility that these patients may not be getting adequate oxygen level to their brain and you need to consider the possible underlying causes. -be sure to determine a baseline of the patients mental status -the mental baseline of a patient can sometimes be abnormal because of medical conditions -ask family members to describe the patients normal mental status

Basic airway adjuncts: what is the primary function of an airway adjunct?

the primary function of an airway adjunct is to prevent obstruction of the upper airway by the tongue, and allow the passage of air and oxygen to the lungs

basic airway adjuncts: Maintaining the airway, what is a good position to keep the airway maintained and clear for a patient who is not injured and breathing on his or her own with a normal respiratory rate and adequate tidal volume?

the recovery position

opening the airway: in an unconscious patient what is the patients most common airway obstruction?

the tongue

pressure regulators: pressure regulators reduce the pressure to a more useful range what is usually that range?

usually 40 to 70 psi

oxygen cylinders: how often are composite cylinders tested?

usually every 3 years

oxygen cylinders: how often are aluminum cylinders tested ?

usually every 5 years

What is intrapulmonary shunting

when blood enters the lung from the right side of the heart bypasses the alveoli and returns to the left side of the heart in an unoxygenated state

when does agonal gas occur?

when the respiratory center in the brain continues to send signals to the respiratory muscles.

techniques of suctioning: do you only attempt to remove an object if it is visible during examination of the open mouth? if yes, why?

yes, only attempt to remove a foreign object if it is visible. Blind finger sweeps of the back of the oropharynx may push an object farther down in the airway, making the obstruction worse.

opening the airway

you always have to ensure an open airway. if you cannot immediately open and maintain a patent airway, you cannot provide effective patient care. regardless of the patients condition the airway must remain patent at all times

techniques of suctioning: Sometimes a suctioning device cannot removed solid objects such as, teeth, foreign objects and food. What do you do?

you log roll the patient to the side, and then clear the mouth carefully with your gloved finger

assessment of respiration

you must assess adequate and inadequate signs of ventilation in all patients

opening the airway: if you have an unconscious patient positioned in a way you cannot assess the airway what do you do?

you still want to assess the patients airway, but if there were no witnesses around you do not know if the patient is suffering spinal injury. here is what you do to position the patient to open the airway: step 1: kneel beside the patient , make sure you kneel far enough away so that the patient, when rolled toward you, does not come to rest in your lap. place your hands behind the patients head and neck to provide inline stabilization of the cervical spine as your partner straightens the patients leg. step 2: have your partner place his or her hands on the patients far shoulder and hip. step 3: as you call the count to control movement, have your partner turn the patient towards you by pulling on the far shoulder and hip. control the head and neck so that they move as a unit with the rest of the torso. in this way, the head and neck stay the same vertical plane as the back. this single motion will minimize aggravation of any potential spine injury. at this point, apply a cervical collar. place the patients arm at his or her side. step 4: once the patient is positioned, maintain an open airway and check for breathing.