Chapter 10: Airway management

Venturi masks

1. A number of attachments can vary the percentage of oxygen while a constant flow is maintained from the regulator. a. The Venturi principle causes air to be drawn into the flow of oxygen as it passes a hole in the line. 2. The Venturi mask is a medium-flow device that delivers 24% to 40% oxygen, depending on the manufacturer. 3. Useful in long-term management of physiologically stable patients

Ventilation/perfusion ratio and mismatch

1. Air and blood flow must be directed to the same place at the same time. a. Ventilation and perfusion must be matched. 2. A failure to match ventilation and perfusion is the cause of most abnormalities of oxygen and carbon dioxide exchange. 3. When ventilation is compromised but perfusion continues, blood passes over some alveolar membranes without gas exchange taking place. a. Results in a lack of oxygen diffusing across the membrane and into blood circulation b. Carbon dioxide is not able to diffuse across the membrane into the lungs and instead is recirculated within the bloodstream, which can lead to severe hypoxemia. 4. Similar problems can occur when perfusion across the alveolar membrane is disrupted.

Facial Bleeding

1. Airway problems can be particularly challenging in patients with serious facial injuries. 2. The blood supply to the face is very rich, so injuries can result in severe tissue swelling and bleeding into the airway. 3. Control bleeding with direct pressure and suction as necessary.

Recognizing adequate breathing

1. An awake, alert adult who is talking to you usually has no immediate airway or breathing problems. 2. Always have supplemental oxygen and a bag-valve mask (BVM) or pocket mask close at hand to assist with breathing if this becomes necessary. 3. Signs of abnormal breathing: a. Fewer than 12 breaths/min b. More than 20 breaths/min in the presence of shortness of breath (dyspnea) c. Irregular rhythm d. Diminished, absent, or noisy auscultated breath sounds e. Reduced flow of expired air at nose and mouth f. Unequal or inadequate chest expansion, resulting in reduced tidal volume g. Increased effort of breathing—use of accessory muscles h. Shallow depth (reduced tidal volume) i. Skin that is pale, cyanotic (blue), cool, or moist (clammy) j. Skin pulling in around ribs or above clavicles during inspiration (retractions) 4. A patient may appear to be breathing after the heart has stopped. a. These occasional, gasping breaths are called agonal gasps. 5. Cheyne-Stokes respirations are often seen in patients with stroke or head injury. a. Breathing with increasing rate and depth of respirations followed by apnea (or lack of spontaneous breathing) 6. Ataxic respirations have an irregular or unidentifiable pattern and may follow serious head injuries. 7. Patients experiencing a metabolic or toxic disorder may display other abnormal respiratory patterns such as Kussmaul respirations. a. Kussmaul respirations: deep, rapid respirations commonly seen in patients with metabolic acidosis 8. Patients with inadequate breathing need to be treated immediately. 9. Emergency medical care: a. Airway management b. Supplemental oxygen c. Ventilatory support

Supplemental Oxygen equipment

1. Become familiar with how oxygen is stored and the various hazards associated with its use. 2. Oxygen cylinders a. The oxygen that you will give to patients is usually supplied as a compressed gas in green, seamless, steel or aluminum cylinders. b. Some cylinders may be silver or chrome with a green area around the valve stem on top. c. Newer cylinders are often made of aluminum or spun steel; older cylinders are much heavier. d. Check that the cylinder is labeled for medical oxygen. Look for letters and numbers stamped into the metal on the collar of the cylinder. i. Check the month and year stamps indicating when the cylinder was last tested. ii. Aluminum cylinders are tested every 5 years. iii. Composite cylinders are tested every 3 years. e. Most often the D (or jumbo D) and M cylinder sizes will be used. i. Can be carried from the unit to the patient f. The M tank remains on board the unit as a main supply tank. g. Other sizes: A, E, G, H, and K h. In an alternative naming system for identifying the size of the oxygen cylinder, cylinders are labeled with M (for medical), followed by a number. i. The length of time you can use an oxygen cylinder depends on the pressure in the cylinder and the flow rate. 3. Liquid oxygen a. A more commonly used alternative to compressed gas oxygen b. Liquid oxygen containers: i. Tend to be more expensive than compressed oxygen tanks ii. Hold a larger volume and therefore do not need to be filled as often iii. Weigh less than aluminum or steel tanks iv. Need to be kept upright v. Have special requirements for filling, large-volume storage, and cylinder transfer c. People who receive long-term oxygen therapy use liquid oxygen units. 4. Safety considerations a. Handle gas cylinders carefully because their contents are under pressure. b. Make sure the correct pressure regulator is firmly attached before transporting cylinders. c. A puncture or hole in a tank can turn it into a deadly missile. d. Secure cylinders with mounting brackets when they are stored on the ambulance. e. Oxygen cylinders that are in use during transport should be positioned correctly and secured. 5. Pin-indexing system a. Prevents such mistakes as an oxygen regulator being accidently connected to a carbon dioxide cylinder b. When preparing to administer oxygen, check that the pinholes on the cylinder exactly match the corresponding pins on the regulator. c. Each cylinder of a specific gas type has a given pattern and a given number of pins, following accepted national standards. d. For large cylinders, the safety system is the American Standard Safety System. i. Oxygen cylinders are equipped with threaded gas outlet valves. ii. Inside and outside thread sizes vary depending on the gas in the cylinder. iii. Like the pin-indexing system, this prevents accidental attachment of a regulator to a wrong cylinder. 6. Pressure regulators a. Pressure regulators reduce the cylinder's pressure to a useful therapeutic range for the patient—usually 40 to 70 psi. b. After the pressure is reduced to a workable level, the final attachment for delivering the gas is one of the following: i. A quick-connect female fitting that will accept a quick-connect male plug from a pressure hose or ventilator/resuscitator ii. A flowmeter that will permit the regulated release of gas measured in liters per minute 7. Flowmeters a. Usually permanently attached to pressure regulators on emergency medical equipment b. A pressure-compensated flowmeter incorporates a float ball within a tapered calibrated tube. i. Is affected by gravity and must always be upright c. The Bourdon-gauge flowmeter is a gauge calibrated to record flow rate. i. Can be used in any position ii. Generally considered outdated

Mechanism of CPAP

1. CPAP increases pressure in the lungs, opens collapsed alveoli, pushes more oxygen across the alveolar membrane, and forces interstitial fluid back into the pulmonary circulation. 2. The therapy is typically delivered through a face mask held to the head with a strapping system. a. A good seal with minimal leakage between the face and mask is essential. 3. Many CPAP systems use oxygen as the driving force to deliver the positive ventilatory pressure to the patient. 4. Use caution with patients with potentially low blood pressure, because CPAP causes a drop in cardiac output.

Factors in the NS affecting respiration

1. Chemoreceptors monitor levels of oxygen, carbon dioxide, hydrogen ions, and the pH of cerebrospinal fluid and provide feedback to the respiratory centers.

Hazards of Supplemental Oxygen

1. Combustion a. Oxygen does not burn or explode. b. Oxygen speeds up the combustion process. i. A small spark, such as a glowing cigarette, can become a flame. c. Keep any possible source of fire away from the area while oxygen is in use. d. Make sure the area is adequately ventilated, especially in industrial settings. e. Sparks during vehicle extraction are a possible source of ignition. f. Never leave an oxygen cylinder standing unattended. i. It can be knocked over, injuring a patient or damaging equipment. 2. Oxygen toxicity a. The administration of oxygen to patients is a common practice. b. While many patients in the prehospital environment require high concentrations of oxygen, not all patients do. c. Excessive supplemental oxygen can have a detrimental effect on patients with certain illnesses (i.e., COPD, bronchopulmonary dysplasia). d. Oxygen toxicity refers to damage to cellular tissue due to excessive oxygen levels in the blood. e. Increased cellular oxygen levels contribute to the production of oxygen free radicals, which can lead to tissue damage and cellular death in some patients. f. The International Liaison Committee on Resuscitation guidelines published by the American Heart Association recognize there may be negative effects of oxygen toxicity and recommend that oxygen be administered to patients experiencing signs of a myocardial infarction when they have signs of heart failure, are short of breath, or have a room air oxygen saturation less than 94%. i. Patients experiencing signs of shock should be placed on oxygen. ii. Hypoxemia is much worse than oxygen toxicity; when in doubt, or if unable to measure oxygen saturation reliably, supplemental oxygen should be administered. g. When pulse oximetry is available, tailor oxygen therapy to the patient's needs and administer the minimum amount of oxygen necessary to maintain oxygen saturation at or above 94%. i. Exceptions to these minimums include patients who have been exposed to carbon monoxide.

Application of CPAP

1. Components of a CPAP unit: a. Generator b. Mask c. Circuit containing corrugated tubing d. Bacteria filter e. One-way valve 2. The CPAP generator creates resistance throughout the respiratory cycle. a. This resistance creates a back pressure into the airways that pushes open the smaller airway structures, such as bronchioles and alveoli, as the patient exhales. b. The amount of pressure can be determined by adjusting a valve within the CPAP system or with a separate valve that can be attached. c. A pressure of 7.0 to 10.0 cm H2O is generally an acceptable therapeutic range. 3. Most CPAP units are powered by oxygen, so it is important to have a full cylinder of oxygen when using CPAP. 4. Disposable CPAP devices are lightweight and relatively easy to operate. 5. To use CPAP, see Skill Drill 10-10.

Nasal Cannulas

1. Deliver oxygen through two small, tubelike prongs that fit into the patient's nostrils 2. Can provide 24% to 44% inspired oxygen when the flowmeter is set at 1-6 L/min a. For patient comfort, flow rates above 6 L/min are not recommended. 3. When you anticipate a long transport time, consider using humidification. a. Over a prolonged period, a nasal cannula can dry or irritate the mucous membrane lining of the nose. 4. In the prehospital setting, a nasal cannula has limited use. a. A patient who breathes through the mouth, or has a nasal obstruction, will get little or no benefit. b. Always try to give high-flow oxygen through a nonrebreathing mask.

Structures that help us breath

1. Diaphragm 2. Chest wall muscles 3. Accessory muscles of breathing 4. Nerves from the brain and spinal cord to those muscles

Recognition of FBAO

1. Early recognition of airway obstruction is crucial. 2. Mild airway obstruction a. Patients can still exchange air, but will have varying degrees of respiratory distress. b. Great care must be taken to prevent a mild airway obstruction from becoming a severe airway obstruction. c. The patient may have noisy breathing and may be coughing. d. With good air exchange, the patient can cough forcefully, although you may hear wheezing between coughs (the production of whistling sounds during respiration). i. Wheezing usually indicates a mild lower airway obstruction. ii. As long as the patient can breathe, cough forcefully, or talk, you should not interfere with the patient's efforts to expel the foreign object on his or her own. iii. Continually reassess the patient's condition. e. With poor air exchange, the patient has a weak, ineffective (not forceful) cough and may have increased difficulty breathing, stridor (high-pitched noise heard mainly on inspiration), and cyanosis. i. Stridor indicates mild upper airway obstruction. ii. Treat immediately as if there is a severe airway obstruction. 3. Severe airway obstruction a. Patients cannot breathe, talk, or cough. b. The patient may clutch or grasp the throat (the universal distress signal), begin to turn cyanotic, and have extreme difficulty breathing. c. There is little or no air movement. d. Ask the conscious patient, "Are you choking?" i. If the patient nods "yes," provide immediate treatment. e. If the obstruction is not cleared quickly, the amount of oxygen in the patient's blood will decrease dramatically. f. If not treated, the patient will become unconscious and die. g. Some patients will be unconscious as you form your general impression. i. You may not know that an airway obstruction is the cause. h. Other causes of unconsciousness and respiratory failure: i. Stroke ii. Heart attack iii. Trauma iv. Seizures v. Drug overdoses i. If the patient is found unresponsive, does not appear to be breathing, and does not have a pulse, begin CPR with high-quality chest compressions. i. When you open the airway and attempt two ventilations following chest compressions, it will be obvious if the airway is blocked. ii. If there is no chest rise and fall after several attempts to ventilate, or if you feel resistance while ventilating, consider the possibility of an airway obstruction. iii. Resistance to ventilation can also be due to poor lung compliance.

If an obstruction completely blocks the airway

1. It will result in death if not treated immediately. 2. In an adult, sudden foreign body airway obstruction usually occurs during a meal. 3. In a child, it can occur while eating, playing with small toys, or crawling around the house. 4. By far, the most common airway obstruction in an unconscious patient is the tongue, which relaxes and falls back into the throat. 5. Causes of airway obstruction that do not involve foreign bodies: a. Swelling, from infection or acute allergic reaction i. Repeated attempts to clear the airway could be dangerous. ii. These patients require specific emergency medical care. iii. Rapid transport to the hospital is critical. b. Trauma (tissue damage from injury)

assessment of respiration

1. Even though the patient may be ventilating appropriately, the actual exchange of oxygen and carbon dioxide at the tissue level may still be compromised by several factors: a. High altitudes b. Poisonous gases, including carbon monoxide i. Some EMS services carry hand-held carbon monoxide detectors. c. Enclosed spaces 2. A patient's level of consciousness and skin color are excellent indicators of respiration. 3. When assessing patients, consider proper oxygenation, which can be assessed by pulse oximetry. 4. Oxygen saturation (Spo2) is a measure of the percentage of hemoglobin molecules that are bound in arterial blood. a. A pulse oximeter measures the percentage of hemoglobin saturation. i. Spo2 should be 98% to 100% while breathing room air. ii. Although no definitive threshold for normal values exists, an Spo2 of less than 96% in a nonsmoker can indicate hypoxemia. iii. An Spo2 of 90% or lower generally requires treatment unless the patient has a chronic condition causing perpetually low oxygen saturations. iv. Pulse oximeters can take as long as 60 seconds to reflect changes in a patient's oxygenation status. v. The time delay is important because a patient can develop respiratory insufficiency well before the pulse oximetry values begin to decline. vi. It is critical to monitor the patient and supplement the assessment with information from the pulse oximeter. vii. Pulse oximetry is considered a routine vital sign and can be used as part of any patient assessment (see Skill Drill 10-1). b. Factors that may cause inaccurate pulse oximetry readings: i. Hypovolemia ii. Severe peripheral vasoconstriction (chronic hypoxia, smoking, or hypothermia) iii. Time delay in detecting respiratory insufficiency iv. Dark or metallic nail polish v. Dirty fingers vi. Carbon monoxide poisoning c. Pulse oximeters do not replace a complete assessment. d. Pulse oximetry cannot measure the effectiveness of ventilation or provide information about cellular metabolism. e. To assess ventilation, you will need to measure end-tidal CO2. f. End-tidal CO2 is measured by capnometry and capnography devices.

Opening the Mouth

1. Even though you may have opened the airway with a head tilt-chin lift or jaw-thrust maneuver, the patient's mouth may be closed. a. To open the mouth, place the tips of your index finger and thumb on the patient's teeth. b. Open the mouth by pushing your thumb on the lower teeth and index finger on the upper teeth. c. The pushing motion will cause the index finger and the thumb to cross over each other, which is why this is called the cross-finger technique.

Factors affecting respiration

1. External factors, such as atmospheric pressure and the partial pressure of oxygen in the ambient environment 2. Internal factors, such as conditions that reduce the surface area for gas exchange and consequently decrease the body's oxygen supply, leading to inadequate tissue perfusion (eg, pneumonia, pulmonary edema, and COPD/emphysema)

Jaw-thrust maneuver

1. If you suspect a cervical spine injury, use the jaw-thrust maneuver. 2. Follow these steps: a. Kneel above the patient's head. b. Place your fingers behind the angles of the lower jaw. c. Move the jaw upward. d. Use your thumbs to help position the lower jaw. 3. Once the airway has been opened, assess whether breathing has returned by quickly looking at the chest and observing for obvious movement. 4. With complete airway obstruction, there will be no movement of air. a. The chest and abdomen may rise and fall with the patient's frantic attempts to breathe. b. Chest wall movement alone does not indicate that breathing is adequate.

Nasopharyngeal Airways

1. Indications: a. Patient who is unresponsive or has an altered level of consciousness b. Patient who has an intact gag reflex c. Patient who is unable to maintain his or her own airway spontaneously 2. Patients with an altered mental status or who have just had a seizure may benefit from this type of airway. 3. Consult medical control before inserting a nasopharyngeal airway in a patient who has sustained severe trauma to the head or face. a. It may penetrate into the brain. 4. A nasopharyngeal airway is usually better tolerated by patients who have an intact gag reflex. a. Less likely to cause vomiting compared to the oropharyngeal airway 5. Indications: a. Semiconscious or unconscious patients with an intact gag reflex b. Patients who otherwise will not tolerate an oropharyngeal airway 6. Contraindications: a. Severe head injury with blood draining from the nose b. History of fractured nasal bone 7. To insert the airway correctly, see Skill Drill 10-6.

Techniques of Suctioning

1. Inspect your suctioning equipment regularly to ensure it is in proper working condition. 2. Steps to operate the suction unit: a. Check the unit for proper assembly of all its parts. b. Turn on the suctioning unit and test it to ensure a vacuum pressure of more than 300 mm Hg. c. Select and attach the appropriate suction catheter to the tubing. 3. Never suction the mouth or nose for more than 15 seconds at one time for adult patients, 10 seconds for children, and 5 seconds for infants. a. Suctioning can result in hypoxia. b. Rinse the catheter and tubing with water to prevent clogging. c. Repeat suctioning only after the patient has been adequately ventilated and reoxygenated. 4. To properly suction a patient, see Skill Drill 10-3. 5. Sometimes a patient may have secretions or vomitus that cannot be suctioned quickly and easily, and some units cannot remove objects such as teeth, foreign bodies, and food. In these cases: a. Remove the catheter from the patient's mouth. b. Log roll the patient to the side. c. Clear the mouth carefully with a gloved finger. 6. If a patient who requires assisted ventilations produces frothy secretions as quickly as you can suction them: a. Suction the airway for 15 seconds (less in infants and children). b. Ventilate for 2 minutes. c. Continue this alternating pattern of suctioning and ventilating until all secretions have been cleared from the airway. d. Continuous ventilation is not appropriate if vomitus or other particles are present in the airway. 7. Clean and decontaminate your suctioning equipment after each use.

Assisting ventilation in respiratory distress/failure

1. Intervene quickly to prevent further deterioration. 2. Two treatment options: assisted ventilation and continuous positive airway pressure (CPAP) a. The purpose of assisted ventilations is to improve the overall oxygenation and ventilatory status of the patient. 3. Signs and symptoms of inadequate ventilation: a. Altered mental status b. Inadequate minute volume c. Excessive accessory muscle use and fatigue 4. To assist a patient with ventilations using a BVM: a. Explain the procedure to the patient. b. Place the mask over the patient's nose and mouth. c. Squeeze the bag each time the patient breathes, maintaining the same rate as the patient. d. After the initial 5 to 10 breaths, slowly adjust the rate and deliver an appropriate tidal volume. e. Adjust the rate and tidal volume to maintain an adequate minute volume.

Oropharyngeal airways

1. Keep the tongue from blocking the upper airway 2. Make it easier to suction the oropharynx if necessary a. Suctioning is possible through an opening down the center or along either side of the oropharyngeal airway. 3. Indications: a. Unresponsive patients without a gag reflex (breathing or apneic) b. Apneic patients being ventilated with a BVM 4. Contraindications: a. Conscious patients b. Any patient (conscious or unconscious) who has an intact gag reflex 5. The gag reflex is a protective reflex mechanism that keeps food from entering the airway. a. Attempting to insert an oral airway in a patient with an intact gag reflex may result in vomiting or spasm of the vocal cords. 6. An oral airway is a good way to help maintain the airway of a spinal injury patient. 7. An oral airway may make the head tilt-chin lift and jaw-thrust maneuvers easier to perform. 8. An oral airway that is too large could push the tongue back into the pharynx, blocking the airway. 9. An oral airway that is too small could block the airway directly, like any foreign body obstruction. 10. To insert the airway properly, see Skill Drill 10-4. 11. If you encounter difficulty inserting the oral airway, an alternative method may be used: inserting with a 90° rotation (see Skill Drill 10-5).

Factors affecting pulmonary ventilation

1. Maintaining a patent airway is critical. 2. Intrinsic factors that can cause airway obstruction: a. Infections b. Allergic reactions c. Unresponsiveness (eg, tongue obstruction) 3. Extrinsic factors that can cause airway obstruction: a. Trauma b. Foreign body airway obstruction

Dental Appliances

1. Many dental appliances can cause an airway obstruction. a. Examples: a crown, a bridge, dentures, or a piece of braces 2. Manually remove the dental appliance before providing ventilations. 3. Simple manual removal may relieve the obstruction and allow the patient to breathe on his or her own. 4. Leaving well-fitting dentures in place usually makes BVM or mouth-to-mask ventilation much easier. a. Provides more "structure" to the face b. Helps you provide a good face-to-mask seal 5. Loose dentures interfere with the process and should be removed. 6. Appliances may loosen while you are providing care. a. Periodically reassess the patient's mouth to make sure they are firmly in place. 7. If possible, place dislodged dentures in a container and transport them with the patient.

Circulatory compromise

1. Obstruction of blood flow to individual cells and tissue is typically related to trauma emergencies: a. Pulmonary embolism b. Simple or tension pneumothorax c. Open pneumothorax (sucking chest wound) d. Hemothorax e. Hemopneumothorax 2. Other causes of circulatory compromise: a. Blood loss b. Anemia c. Hypovolemic shock: abnormal decrease in blood volume d. Vasodilatory shock: abnormal increase in blood vessel diameter, decreasing blood pressure 3. Any patient suspected of being in shock should be treated aggressively to prevent further interruptions to tissue perfusion.

Contraindication of needing CPAP

1. Patient in respiratory arrest 2. Signs and symptoms of pneumothorax or chest trauma 3. Patient who has a tracheostomy 4. Active gastrointestinal bleeding or vomiting 5. Patient who is unable to follow verbal commands 6. Always reassess the patient for signs of deterioration and/or respiratory failure.

Artificial Ventilation

1. Patients in respiratory arrest need immediate treatment to live. 2. Once you determine that a patient is not breathing, begin artificial ventilation immediately. 3. Available methods: a. Mouth-to-mask technique b. One- or two-person BVM c. Manually triggered ventilation device 4. Normal ventilation versus positive-pressure ventilation a. Artificial ventilations are necessary to sustain life, but are not the same as normal breathing. i. In normal breathing, the diaphragm contracts and negative pressure is generated in the chest cavity, which sucks air into the chest. ii. Positive-pressure ventilation generated by a device forces air into the chest cavity. b. With positive-pressure ventilation: i. Increased intrathoracic pressure causes compression of the vena cava and reduces blood return to the heart, which reduces the amount of blood pumped by the heart. ii. More volume is required to have the same effects as normal breathing, which pushes the airway walls out of their normal anatomic shape. iii. Air is forced into the stomach, causing gastric distention that could result in vomiting and aspiration. c. The EMT must regulate the rate and volume of artificial ventilations to help prevent the drop in cardiac output. i. Cardiac output = stroke volume × heart rate d. Ventilation rates (for apneic patients with a pulse) i. Adult: 1 breath per 5-6 seconds ii. Child: 1 breath per 3-5 seconds iii. Infant: 1 breath per 3-5 seconds 5. Mouth-to-mouth and mouth-to-mask ventilation a. A barrier device is routinely used in mouth-to-mouth ventilations. i. A plastic barrier is placed on the patient's face that includes a one-way valve to prevent the backflow of secretions, vomitus, and gases. ii. Mouth-to-mouth ventilations without a barrier device should be provided only in extreme situations. b. A mask with an oxygen inlet provides oxygen during mouth-to-mask ventilation. i. Supplements the air supplied by your lungs ii. The gas you exhale contains 16% oxygen. iii. With the mouth-to-mask system, patients get the benefit of significant oxygen enrichment. iv. This system frees both of the EMT's hands to help keep the airway open and provide a better seal between the mask and face. c. To provide mouth-to-mask ventilation, see Skill Drill 10-8. d. Signs of adequate ventilations: i. Patient's color improves ii. Chest rises adequately iii. No resistance when ventilating iv. You hear and feel air escape as the patient exhales. e. To increase the oxygen concentration, administer high-flow oxygen at 15 L/min through the oxygen inlet valve of the mask. i. Combined with your exhaled breath, this will deliver about 55% oxygen. 6. Bag-valve mask a. The most common method used to ventilate patients in the field b. With an oxygen flow rate of 15 L/min, a BVM can deliver nearly 100% oxygen. i. It can deliver only as much volume as you can squeeze by hand. c. The BVM provides less tidal volume than mouth-to-mask ventilation but delivers a much higher concentration of oxygen. i. An experienced EMT can provide adequate tidal volume. ii. As a new EMT, develop proficiency by ventilating airway-training manikins before using a BVM on a patient. d. If you have difficulty adequately ventilating a patient with a BVM, switch immediately to another method, such as the mouth-to-mask technique. e. BVM components: i. Disposable self-refilling bag ii. No pop-off valve, or a disabled pop-off valve iii. Nonrebreathing outlet valve iv. Oxygen reservoir that allows for delivery of high-concentration oxygen v. One-way, no-jam inlet valve with a flow of up to 15 L/min vi. Transparent face mask f. Offers the capability of performing under extreme heat or cold g. Total volume i. Adult: 1,200-1,600 mL ii. Pediatric: 500-700 mL iii. Infant: 150-240 mL h. The volume of oxygen delivered is based on observing chest rise and fall. i. Only means of assessing tidal volume in the field i. When using a BVM with high-flow oxygen on an adult patient, squeeze the bag just enough to cause a noticeable rise of the patient's chest—about 600 mL/s. j. By delivering just enough tidal volume to see the chest rise, the risk of gastric distention and associated complications is reduced. k. It is impractical for EMTs to accurately measure tidal volume in millimeters per kilogram in the field. The key is to watch for good chest rise and fall—let this determine the appropriate amount of volume to deliver. 7. BVM technique a. Whenever possible, work together with your partner to provide BVM ventilation. i. One EMT maintains a good mask seal by securing the mask to the patient's face with two hands. ii. The other EMT squeezes the bag. b. To use the one-person BVM technique, follow these steps: Select the proper size of mask and assemble your equipment. Kneel above the patient's head. iii. Maintain the patient's neck in an extended position unless you suspect a cervical spine injury. For a cervical spine injury, stabilize the patient's head and neck and use the jaw-thrust maneuver. You can use your knees to stabilize the head. iv. Open the patient's mouth. v. Suction as needed. vi. Insert an oral or nasal airway to maintain airway patency. vii. Place the mask on the patient's face. Make sure the top is over the bridge of the nose and the bottom is in the groove between the lower lip and the chin. viii. If the mask has a large, round cuff around the ventilation port, center the port over the patient's mouth. Inflate the collar for a better fit and seal to the face if necessary. ix. Create a seal by holding your index finger over the lower part of the mask and your thumb over the upper part of the mask. Use your remaining fingers to pull the lower jaw into the mask (EC-clamp method). x. Bring the lower jaw up to the mask with the last three fingers of your hand. This helps maintain an open airway. xi. Squeeze the bag with your other hand until you see adequate chest rise. xii. Perform this in a rhythmic manner once every 5 seconds for an adult and once every 3 seconds for infants and children. xiii. In patients with ongoing CPR and an advanced airway in place, such as an endotracheal tube, a laryngeal mask airway, or a King airway, use a simplified ventilation rate of 1 breath every 6 seconds, without pausing chest compressions. c. If two EMTs are available, follow these steps: i. One EMT holds the mask in position by placing the thumbs over the top part of the mask and the index fingers over the bottom half. ii. The first EMT uses the last three fingers of the hands to bring the lower jaw up to the mask. This helps to seal the mask to the face and maintain an open airway. iii. The second EMT squeezes the bag with two hands until the chest rises adequately in the same manner as the one-rescuer technique. d. For a patient who is breathing too slowly (hypoventilation) with reduced tidal volume: i. Squeeze the bag as the patient tries to breathe in. ii. For the next 5 to 10 breaths, slowly adjust the rate and delivered tidal volume until adequate minute volume is achieved. e. For a patient who is breathing too fast (hyperventilation) with reduced tidal volume: i. Explain the procedure to the patient if the patient is coherent. ii. Initially assist respirations at the rate the patient has been breathing, squeezing the bag each time the patient inhales. iii. For the next 5 to 10 breaths, slowly adjust the rate and the delivered tidal volume until an adequate minute volume is achieved. f. If the patient's chest does not rise and fall, you may need to reposition the head or use an airway adjunct. g. If the patient's chest still does not rise and fall after you have made these corrections, check for an airway obstruction. h. If an obstruction is not present, attempt ventilations using an alternative method, such as the mouth-to-mask technique. i. The BVM may be used in conjunction with an endotracheal tube or with other advanced airway techniques. 8. Gastric distention a. When using a BVM or any other ventilation device, be alert for gastric distention (ie, inflation of the stomach with air). b. Most commonly affects children, but can affect adults c. Most likely to occur when you ventilate the patient too forcefully or too rapidly with a BVM or pocket mask d. May occur when the airway is obstructed as a result of a foreign body or improper head position e. For this reason, give slow, gentle breaths during artificial ventilation over 1 second. f. As compliance decreases, you will notice it becoming increasingly difficult to squeeze the BVM to get air into the lungs. g. Slight gastric distention is not of concern. h. Severe inflation of the stomach is dangerous. i. May cause vomiting and increase aspiration risk during CPR ii. Can significantly reduce lung volume by elevating the diaphragm, especially in infants and children i. Gastric distention is a common complication with manually triggered ventilation devices—a key reason these devices are not highly recommended. j. To prevent or alleviate distention: i. Ensure that the patient's airway is appropriately positioned. ii. Ventilate the patient at the appropriate rate. iii. Ventilate the patient with the appropriate volume. k. If the patient's stomach appears to be distending, recheck and reposition the head, and watch for rise and fall of the chest wall as you perform rescue breathing. l. Continue slow rescue breathing without attempting to expel the stomach contents. m. If gastric distention makes it impossible to ventilate the patient and an ALS provider is not available to perform decompression, consider applying pressure over the upper abdomen (last resort). i. If vomiting occurs as a result, turn the patient's entire body to the side, suction and/or wipe out the mouth with your gloved hand, return the patient to a supine position, and continue rescue breathing. 9. Passive ventilation a. The process of expansion and contraction of the chest creates a "pump" for air movement in and out of the chest. b. During cardiac arrest, you are responsible for providing chest compressions to circulate blood and artificial ventilations to oxygenate the hemoglobin. c. Since chest wall movement assists in the ventilation process, patients receiving high-quality chest compressions benefit from passive ventilation. d. In passive ventilation, air movement in and out of the chest cavity occurs passively as a result of compressing the chest. i. When the chest is compressed, air is forced out of the thorax. ii. As the chest recoils following compression, a negative pressure is created within the chest, which results in a vacuum. iii. Air is sucked into the chest cavity, similar to what occurs with muscle contraction during active inhalation. e. Passive ventilation can be enhanced by inserting an oropharyngeal airway and providing supplemental oxygen to the patient. f. You can also improve oxygenation by applying supplemental oxygen with a nasal cannula or a nonrebreathing mask. 10. Manually triggered ventilation devices a. Also known as flow-restricted, oxygen-powered ventilation devices b. Allow a single rescuer to use both hands to maintain a mask-to-face seal while providing positive-pressure ventilation i. This reduces rescuer fatigue associated with using a BVM on extended transports. c. Disadvantages: i. May be difficult to maintain adequate ventilation without assistance ii. Should not be used routinely because of high incidence of gastric distention and possible damage to structures within the chest cavity iii. Special unit and additional training are required for infants and children. iv. Should not be used with COPD or suspected cervical spine or chest injuries d. Manually triggered ventilation device components: i. Peak flow rate of 100% oxygen at up to 40 L/min ii. Inspiratory pressure safety release valve iii. Audible alarm that sounds when you exceed the relief valve pressure iv. Ability to function satisfactorily under normal and varying environmental conditions v. Trigger or lever positioned so that both your hands can remain on the mask to provide an airtight seal while supporting and tilting the patient's head and keeping the jaw elevated e. Proper training and considerable practice are required. f. As with BVMs, you must make sure there is an effective seal between the patient's face and mask. g. The amount of pressure required varies according to patient size, lung volume, and lung condition. i. A COPD patient will need greater pressure. ii. Pressures that are too great can cause a pneumothorax. 11. Automatic transport ventilator (ATV)/resuscitator a. The ATV is a manually triggered ventilation device attached to a control box that allows the variables of ventilation to be set. i. Lacks the sophisticated control of a hospital ventilator ii. Frees the EMT to perform tasks such as maintaining the mask seal or ensuring continued airway patency b. A BVM and mask should always be prepared and ready for use should an ATV malfunction. c. Most models have adjustments for respiratory rate and tidal volume. i. Estimate tidal volume at 6 to 7 mL/kg. d. The pressure relief valve may lead to hypoventilation in patients with: i. Poor lung compliance (ability of alveoli to expand when air is drawn in during inhalation) ii. Increased airway resistance iii. Airway obstruction e. Constant reassessment of the patient is necessary. i. Assess for full chest recoil.

Stomas and Tracheostomy tubes

1. Patients who have had a laryngectomy (surgical removal of the larynx) have a permanent tracheal stoma, which is an opening in the neck that connects the trachea directly to the skin. a. Known as a tracheostomy 2. Patients may have other openings in the neck, depending on the type of operation performed. a. Ignore any opening other than the midline tracheal stoma. b. It is the only one that can be used to put air into the patient's lungs. 3. Neither the head tilt-chin lift maneuver nor the jaw-thrust maneuver is required to ventilate a patient with a stoma. 4. If the patient has a tracheostomy tube, ventilate through the tube with a BVM. a. A standard 15/22-mm adapter on the BVM will fit onto the tube in the tracheal stoma. b. Use 100% oxygen attached directly to the BVM. 5. If the patient has a stoma but no tube is in place: a. Use an infant or child mask with your BVM to make a seal over the stoma. 6. Seal the patient's mouth and nose with one hand to prevent a leak of air through the upper airway when you ventilate through a stoma. a. Release the seal of the patient's mouth and nose for exhalation. b. This allows the air to exhale through the upper airway. 7. If you cannot ventilate a patient with a stoma: a. Try suctioning the stoma and the mouth with a French or soft-tip catheter. b. Seal the stoma while giving mouth-to-mouth ventilation.

Tracheostomy masks

1. Patients with tracheostomies do not breathe through their mouth and nose. 2. Tracheostomy masks cover the tracheostomy hole and have a strap that goes around the neck. a. These may not be available in an emergency setting, in which case you should improvise by placing a face mask over the stoma. i. Although the mask is shaped to fit the face, you can usually get an adequate fit over the patient's neck by adjusting the strap.

Complications of CPAP

1. Some patients may find CPAP claustrophobic and resist application of the mask. a. Coach patients through the process rather than forcing the mask on them. 2. Due to the high volume of pressure generated by CPAP, pneumothorax is a risk. 3. High pressure in the chest can lower the patient's blood pressure. 4. If the patient shows signs of deterioration, remove CPAP and begin positive-pressure ventilation using a BVM attached to high-flow oxygen.

Emergency medical care for foreign body airway obstruction

1. Perform a head tilt-chin lift maneuver to clear a tongue obstruction. a. If spinal trauma is suspected, open the airway with a jaw-thrust maneuver. 2. Large pieces of vomited food, mucus, loose dentures, or blood clots in the mouth should be swept forward and out of the mouth with your gloved index finger. 3. When available, perform suctioning to maintain a clear airway. 4. Abdominal thrusts are the most effective method of dislodging and forcing an object out of the airway of a conscious patient. a. Residual air, always present in the lungs, is compressed upward and used to expel the object. b. Use the abdominal thrusts until the object dislodges or the patient becomes unconscious. 5. For the unresponsive patient with a severe foreign body airway obstruction, reassess to confirm apnea and inability to ventilate. 6. Begin chest compression just as you would for CPR, following the 30 compressions to 2 breaths ratio. 7. At the completion of the 30 compressions, perform a tongue-jaw lift by grasping the jaw with your thumb and index finger. a. Place your thumb onto the tip of the patient's lower teeth and tongue while placing your index finger under the bony portion of the chin. b. Be careful not to compress the soft tissues under the chin. c. Pull the jaw/mouth open and look at the back of the oropharynx for any foreign objects. d. If you see an object, remove it with a gloved index finger or suction. e. Never perform a blind sweep of the back of the oropharynx, which may push an object farther down in the airway, making the obstruction worse. f. Once the object is removed, or if no object was seen, attempt to ventilate. g. If you are still unable to ventilate, repeat the process. 8. If you are unsuccessful, begin rapid transport and continue abdominal thrusts on the way to the hospital. 9. Treat patients with a mild airway obstruction and poor air exchange as if they have a severe airway obstruction. 10. Patients with a mild airway obstruction and good air exchange should be monitored closely for deterioration of their condition. a. If the patient is unable to clear the obstruction and remains conscious, support (or let the patient control) the airway position that is most efficient and comfortable. b. Provide supplemental oxygen and transport.

Suctioning Equipment

1. Portable, hand-operated, and fixed (mounted) equipment is essential for resuscitation. a. A portable suctioning unit must provide enough vacuum pressure and flow to allow you to suction the mouth and nose effectively. b. Hand-operated suctioning units with disposable chambers are reliable, effective, and relatively inexpensive. c. A fixed suctioning unit should generate airflow of more than 40 L/min and a vacuum of more than 300 mm Hg when the tubing is clamped. 2. A portable or fixed unit should be fitted with the following: a. Wide-bore, thick-walled, nonkinking tubing b. Plastic, rigid pharyngeal suction tips, called tonsil tips or Yankauer tips c. Nonrigid plastic catheters, called French or whistle-tip catheters d. A nonbreakable, disposable collection bottle e. Water supply for rinsing the tips 3. A suction catheter is a hollow, cylindrical device used to remove fluids from the airway. 4. A tonsil-tip catheter is the best kind of catheter for infants and children. a. The large-diameter plastic tips are rigid and do not collapse. 5. Tips with a curved contour allow for easy, rapid placement in the oropharynx. 6. French or whistle-tip catheters are soft plastic, nonrigid catheters. a. They are used to suction the nose and liquid secretions in the back of the mouth and in situations when you cannot use a rigid catheter: i. A patient who has a stoma ii. A patient with clenched teeth iii. If suctioning the nose is necessary 7. Before inserting any catheter, measure for the proper size. a. Use the same technique as measuring for an oropharyngeal airway. b. Do not touch the back of the airway with a suction catheter—this can activate the gag reflex, causing vomiting, and increase the possibility of aspiration.

Emergency medical care begins with ensuring an open airway.

1. Rapidly assess whether an unconscious patient has a patent airway and pulse, and is breathing adequately. 2. Airway and breathing are two closely related, but separate, components. Adequate breathing does not always equal an adequate airway. 3. Position the patient correctly. a. The supine position is most effective. b. Sometimes the airway must be opened and assessed in the position in which you find the patient, as in a vehicle entrapment. c. A patient found in the prone position (lying face down) must be repositioned. i. Log roll the patient as a unit so the head, neck, and spine all move together without twisting. ii. While care should be taken to avoid injury, remember that airway management almost always takes priority and should not be delayed when caring for patients with life-threatening conditions. d. Unconscious patients should be moved as a unit because of the potential for spinal injury (see Skill Drill 10-2). e. In an unconscious patient, the most common airway obstruction is the patient's tongue, which falls back into the throat when the muscles of the throat and tongue relax. f. Other causes of airway obstruction: i. Dentures (false teeth) ii. Blood iii. Vomitus iv. Mucus v. Food vi. Other foreign objects

Partial rebreathing masks

1. Similar to nonrebreathing masks, except there is no one-way valve between the mask and the reservoir 2. Patients rebreathe a small amount of their exhaled air. a. This is advantageous if the patient is hyperventilating. 3. The oxygen enriches the air mixture so that patients receive 80% to 90% oxygen. 4. To convert a nonrebreathing mask to a partial rebreathing mask, remove the one-way valve between the mask and the reservoir bag.

Humidification

1. Some EMS systems provide humidified oxygen. a. During extended transport b. For certain conditions such as croup 2. Dry oxygen is not considered harmful for short-term use. a. Many EMS systems do not use humidified oxygen in the prehospital setting. 3. Always refer to medical control or local protocols for guidance involving patient treatment issues.

Respiration

1. The actual exchange of oxygen and carbon dioxide in the alveoli and in tissues of the body 2. Cells take energy from nutrients through a series of chemical processes known as metabolism (cellular respiration). a. Each cell combines nutrients and oxygen, producing energy and waste products (mainly water and carbon dioxide). 3. External respiration (pulmonary respiration) a. Brings fresh air into the respiratory system b. Exchanges oxygen and carbon dioxide between the alveoli and blood in the pulmonary capillaries i. Surfactant keeps alveoli expanded, making it easier for gas exchange. 4. Internal respiration a. Exchange of oxygen and carbon dioxide between the systemic circulatory system and the cells of the body b. Oxygen passes from blood in capillaries to tissue cells. c. Carbon dioxide and cell wastes pass from the cells into the capillaries, where they are then transported in the venous system back to the lungs. d. All cells need a constant supply of oxygen to survive. e. Time is critical! Without oxygen: i. 0-1 minute: Cardiac irritability occurs. ii. 0-4 minutes: Brain damage is not likely. iii. 4-6 minutes: Brain damage is possible. iv. 6-10 minutes: Brain damage is very likely. v. More than 10 minutes: Irreversible brain damage occurs. f. When there is enough oxygen, cells convert glucose into energy through aerobic metabolism. g. Without adequate oxygen, anaerobic metabolism takes place, which cannot meet the metabolic demands of the cell. h. If this process is not corrected, the cells will eventually die.

Anatomy of the Lower Airway

1. The function of the lower airway is to deliver oxygen to the alveoli. 2. Elements of the lower airway a. Trachea (windpipe) i. Conduit for air entry into the lungs ii. Begins directly below the cricoid cartilage iii. Descends anteriorly down the midline of the neck into the thoracic cavity b. In the thoracic cavity, the trachea divides at the carina into two main stem bronchi, right and left. i. The bronchi are supported by cartilage. ii. They distribute oxygen to the two lungs. (a) Lung tissue is covered with the visceral pleura, a slippery outer membrane. (b) The parietal pleura lines the inside of the thoracic cavity. iii. On entering the lungs, each bronchus divides into ever-smaller bronchi, which divide into bronchioles. iv. Bronchioles are made of smooth muscle; they dilate and constrict as oxygen passes through them. v. Smaller bronchioles connect to alveoli. (a) Oxygen and carbon dioxide are exchanged here. (b) Alveoli are millions of thin-walled, balloon-like sacs. (c) Alveoli are surrounded by blood vessels (pulmonary capillaries). (d) Oxygen diffuses across the alveolar membrane into the pulmonary capillaries. vi. Oxygen in pulmonary capillaries is transported back to the heart and distributed to the rest of the body. vii. Carbon dioxide (waste) diffuses from the pulmonary capillaries into the alveoli, where it is exhaled and removed from the body. 3. The heart and great vessels (the vena cava and aorta) are also present in the thoracic cavity and are important for respiration. a. The mediastinum is the area between the lungs, which contains: i. Heart ii. Great vessels iii. Esophagus iv. Trachea v. Major bronchi vi. Many nerves b. The phrenic nerve is also found in the thorax. i. Important structure of the nervous system ii. Allows the diaphragm to contract, which is necessary for breathing to occur

Indications of needing CPAP

1. The patient is alert and able to follow commands. 2. The patient displays obvious signs of moderate to severe respiratory distress from a condition such as pulmonary edema or obstructive pulmonary disease (ie, COPD). 3. The patient is breathing rapidly, such that it affects overall minute volume (greater than 26 breaths/min). 4. The pulse oximetry reading is less than 90%.

Ventilation

1. The physical act of moving air into and out of the lungs, which is necessary for oxygenation and respiration to occur 2. Inhalation a. The active, muscular part of breathing b. The diaphragm and intercostal muscles contract during inhalation, which allows air to enter the body and travel to the lungs. c. The lungs require the movement of the chest and supporting structures to expand and contract during inhalation and exhalation. d. Partial pressure: the amount of gas in the air or dissolved in fluid, such as blood i. Measured in millimeters of mercury (mm Hg) ii. The amount of gas in the oxygen (partial pressure) that resides in the alveoli is 104 mm Hg. iii. Carbon dioxide enters the alveoli from the blood and causes a carbon dioxide partial pressure of 40 mm Hg. iv. Oxygenated arterial blood from the heart has a partial pressure of oxygen that is lower than the partial pressure of carbon dioxide in the pulmonary capillaries. v. The body attempts to equalize the partial pressure, which results in oxygen diffusion across the membrane into the blood. vi. Oxygen and carbon dioxide both diffuse until the partial pressures in the air and the blood are equal. e. Inspiration is focused on delivering oxygen to the alveoli. i. Not all inspired air reaches the alveoli for gas exchange. f. Tidal volume: a measure of depth of breathing i. The amount of air in milliliters that is moved into or out of the lungs during a single breath ii. Tidal volume for an average adult is 500 mL. g. Dead space: the portion of inspired air that fails to reach the alveoli 3. Exhalation a. Unlike inhalation, exhalation does not normally require muscular effort; it is a passive process. b. The diaphragm and the intercostal muscles relax, which decreases the size of the thorax. c. The smaller thorax compresses air in the lungs into a smaller space. i. The air pressure in the thorax is then higher than the outside pressure. ii. Air is pushed out through the trachea. d. Air can enter and leave the lungs only if it travels through the trachea. i. This is why clearing and maintaining a patent airway is so important. 4. Regulation of ventilation involves a complex series of receptors and feedback loops that sense gas concentrations in the body fluids and send messages to the respiratory center in the brain to adjust the rate and depth of ventilation. a. The body's need for oxygen is constantly changing. b. Failure to meet this need may result in hypoxia, an extremely dangerous condition. i. The tissues and cells do not get enough oxygen. ii. If not corrected, patients may die quickly. c. For most people, the drive to breathe is based on pH changes in the blood and cerebrospinal fluid. i. Patients with chronic obstructive pulmonary disease (COPD) have difficulty eliminating carbon dioxide through exhalation. ii. Thus, they always have higher levels of carbon dioxide. iii. This condition potentially alters their drive for breathing. iv. Respiratory centers in the brain gradually adjust to accommodate high levels of carbon dioxide. v. In patients with COPD, the body uses a "backup system," known as the hypoxic drive, to control breathing. d. Use caution when administering high concentrations of oxygen to patients with obstructive pulmonary disease. i. High concentrations of oxygen should never be withheld from any patient who needs it. ii. Patients with severe respiratory and/or circulator compromise should receive high concentrations of oxygen regardless of their underlying medical conditions. e. Early signs of hypoxia: i. Restlessness ii. Irritability iii. Apprehension iv. Fast heart rate (tachycardia) v. Anxiety f. Late signs of hypoxia: i. Mental status changes ii. Weak (thready) pulse iii. Cyanosis iv. Conscious patients will complain of shortness of breath (dyspnea). g. The best time to give a patient oxygen is before signs and symptoms of hypoxia appear.

Nonrebreathing masks

1. The preferred way to give oxygen in prehospital setting to patients who are breathing adequately but are suspected of having or showing signs of hypoxia a. With a good mask-to-face seal, such a mask is capable of providing up to 90% inspired oxygen. 2. Combines a mask with a reservoir bag system a. Oxygen fills a reservoir bag attached to the mask by a one-way valve. b. Exhaled gas escapes through flapper valve ports at cheek areas of the mask. i. Prevent the patient from rebreathing exhaled gases 3. Make sure the reservoir bag is full before placing the mask on the patient. 4. Adjust the flow rate so the bag does not collapse when the patient inhales. a. Usually 10-15 L/min b. If the bag does collapse, increase the flow rate. 5. When oxygen therapy is discontinued, remove the mask from the patient's face. 6. Use a pediatric nonrebreathing mask for infants and children. a. Has a smaller reservoir bag

Oxygenation

1. The process of loading oxygen molecules onto hemoglobin molecules in the bloodstream 2. Required for internal respiration to take place a. Oxygenation does not guarantee that internal respiration is taking place. b. Ventilation without oxygenation can occur—for example, in places where oxygen levels in the breathing air have been depleted, such as in mines or confined spaces.

Anatomy of the Upper Airway

1. The upper airway consists of all anatomic airway structures above the vocal cords: a. Nose b. Mouth c. Jaw d. Oral cavity e. Pharynx f. Larynx 2. The main function of the upper airway is to warm, filter, and humidify air as it enters the body. 3. Pharynx a. Muscular tube extending from nose and mouth to the level of esophagus and trachea b. Composed, from top to bottom, of the nasopharynx, oropharynx, and laryngopharynx 4. Nasopharynx a. Lined with ciliated mucous membrane that filters out dust and small particles b. Warms and humidifies air as it enters the body 5. Oropharynx a. Posterior portion of the oral cavity b. The epiglottis is superior to the larynx. i. Helps prevent food and liquid from entering the larynx during swallowing 6. Larynx a. Complex structure formed by many independent cartilaginous structures b. Marks where the upper airway ends and the lower airway begins c. The thyroid cartilage forms a "V" shape anteriorly—the Adam's apple. d. The cricoid cartilage (cricoid ring) forms the lowest portion of the larynx. e. The cricothyroid membrane is the elastic tissue that connects the thyroid superiorly to the cricoid ring inferiorly. f. The glottis (glottis opening) is the area between the vocal cords. i. Narrowest part of an adult's airway g. Vocal cords are white bands of thin muscle tissue. i. Partially separated at rest ii. Produce speech iii. Protect the trachea from the entry of substances like water and vomitus

Procedures for administering Oxygen

1. To place an oxygen cylinder into service and administer medical oxygen to a patient, see Skill Drill 10-7.

Recognizing adequate breathing

1. Unless you are directly assessing a patient's airway, you should not be able to see or hear the patient breathe. 2. Signs of normal breathing for adults: a. 12-20 breaths/min b. Regular pattern of inhalation and exhalation c. Bilateral clear and equal lung sounds d. Regular, equal chest rise and fall e. Adequate depth (tidal volume)

Head tilt-chin lift maneuver

1. Will open the airway in most patients 2. For patients who have not sustained or are not suspected of having sustained spinal trauma, this simple maneuver is sometimes all that is needed for the patient to resume breathing. 3. Follow these steps: a. With the patient supine, position yourself beside the patient's head. b. Place the heel of one hand on the patient's forehead, and apply firm backward pressure with the palm. c. Place the fingertips of the other hand under the patient's lower jaw. d. Lift the chin upward, with the entire lower jaw, helping to tilt the head back.

Supplemental Oxygen

A. Always give supplemental oxygen to patients who are hypoxic, because not enough oxygen is being supplied to the tissues and cells of the body. 1. Some tissues and organs, such as the heart, central nervous system, lungs, kidneys, and liver, need a constant supply of oxygen to function normally. 2. Never withhold oxygen from any patient who might benefit from it, especially if you must assist ventilations. 3. When ventilating any patient in cardiac or respiratory arrest, use high-concentration supplemental oxygen. B. Supplemental oxygen equipment C. Procedures for operating and administering oxygen D. Hazards of supplemental oxygen

Basic Airway adjuncts

A. An airway adjunct prevents obstruction of the upper airway by the tongue and allows for passage of air and oxygen to the lungs. B. Oropharyngeal airways C. Nasopharyngeal airways

Assisted and Artificial Ventilation

A. Assisted and artificial ventilation techniques are probably the most important skills in EMS at any level. B. Basic airway and ventilation techniques are extremely effective when administered appropriately. 1. Mastery of these techniques at the EMT level is imperative. 2. Patients who are breathing inadequately (too fast or too slow, with reduced tidal volume) are usually unable to speak in complete sentences. a. Fast, shallow breathing can be just as dangerous as very slow breathing. 3. Follow standard precautions as needed when managing a patient's airway. C. Assisting ventilation in respiratory distress/failure D. Artificial ventilation

Continuous Positive Air Pressure

A. Continuous positive airway pressure (CPAP) is noninvasive ventilatory support for patients experiencing respiratory distress. 1. Many people diagnosed with obstructive sleep apnea wear a CPAP unit at night to maintain their airways while they sleep. 2. CPAP is becoming widely used at the EMT level. B. Mechanism C. Indications D. Contraindications E. Application F. Complications

Processes of Opening the Airway

A. Emergency medical care begins with ensuring an open airway. B. Head tilt-chin lift maneuver C. Jaw-thrust maneuver D. Opening the mouth

Aspects of Foreign body Airway Obstruction

A. If an obstruction completely blocks the airway, it is a true emergency. B. Recognition C. Emergency medical care for foreign body airway obstruction D. Dental appliances E. Facial bleeding

Oxygen-Delivery Equipment

A. In general, oxygen-delivery equipment used in the field should be limited to nonrebreathing masks, BVMs, and nasal cannulas. 1. You may encounter other devices during transports between medical facilities B. Nonrebreathing masks C. Nasal cannulas D. Partial rebreathing masks E. Venturi masks F. Tracheostomy masks G. Humidification

Aspects of Patient airway assessment

A. Recognizing adequate breathing B. Recognizing abnormal breathing C. Assessment of respiration

Maintaining the Airway

A. The recovery position is used to help maintain a clear airway in an unconscious patient who is not injured and is breathing on his or her own with a normal respiratory rate and adequate tidal volume (depth of breathing). 1. Steps to put the patient in the recovery position: a. Roll the patient onto either side so that the head, shoulders, and torso move at the same time without twisting. b. Extend the patient's lower arm and place the upper hand under his or her cheek. 2. For patients who have resumed spontaneous breathing after being resuscitated, the recovery position will prevent aspiration of vomitus. 3. The position is not appropriate for patients with suspected spinal, hip, or pelvic injuries who are unconscious and require ventilatory assistance. a. Reposition such patients to provide adequate airway access while maintaining appropriate spinal immobilization.

The Physiology of Breathing

A. The respiratory and cardiovascular systems work together. 1. Ensure that a constant supply of oxygen and nutrients is delivered to all of the cells of the body 2. Remove carbon dioxide and waste products from the cells B. The processes involved are ventilation, oxygenation, and respiration. C. Ventilation D. Oxygenation E. Respiration

Anatomy of the Respiratory system

A. The respiratory system consists of all the structures that make up the airway and help us breathe, or ventilate. B. The airway is divided into the upper and lower airways. C. Structures that help us breathe: D. Ventilation is the exchange of air between the lungs and the environment. E. The diaphragm and chest wall muscles are responsible for the regular rise and fall of the chest that accompany normal breathing. F.Anatomy of the upper airway G. Anatomy of the lower airway

Introduction

A. The single most important step in caring for patients is to address life threats, and a primary component of that step is to ensure that they can breathe adequately. B. When the ability to breathe is disrupted, oxygen delivery to tissues and cells is compromised. 1. Cells require a constant supply of oxygen to survive. 2. Within seconds of being deprived of oxygen, vital organs such as the heart and the brain may not function normally. a. Brain tissue will begin to die within 4 to 6 minutes without oxygen. C. Oxygen reaches body tissues and cells through two separate but related processes: breathing and circulation. During inhalation, oxygen moves from the atmosphere into the lungs. Oxygen then crosses the alveolar membrane and attaches to hemoglobin by a process called diffusion. Red blood cells carry the hemoglobin, and therefore oxygen, through the body, ultimately delivering it to the capillaries to oxygenate the body's cells. 4. At the same time, carbon dioxide, produced by the cells in the tissues of the body, moves from the blood into air sacs by diffusion. 5. Oxygen-enriched blood is pumped through the body by the heart. 6. Carbon dioxide leaves the body during exhalation. D. As an EMT, you must be able to locate the parts of the respiratory system, understand how the system works, and recognize which patients are breathing adequately and which are not.

Suctioning

A. You must keep the airway clear to ventilate the patient properly. 1. If the airway is not clear, you will force the fluids and secretions into the lungs and possibly cause a complete airway obstruction. 2. If you hear gurgling, the patient needs suctioning. B. Suctioning equipment C. Techniques of suctioning

Pathophysiology of Respiration

A.Factors in the nervous system B.Ventilation/perfusion ratio and mismatch C.Factors affecting pulmonary ventilation D.Factors affecting respiration E.Circulatory compromise