Chapter 15 AIRWAY MANAGEMENT

1. Review the anatomy of the respiratory system, including the major structures of the upper and lower airway. (pp 776-778)

-Brings in oxygen -Eliminates carbon dioxide -Vital organs will not function properly if process is interrupted UPPER AIRWAY -anything above the vocal cords -tounge -pharynx ( extends from nose and mouth to esophagus and trachea .) nasopharynx, orophatynx , larygopharnx Lower airway larynx marks where the upper airway ends and the lower airway begins -thyroid cartilage is a shield shaped structure palpable on the anterior neck -the cricoid cartilage lies inferior to the thyroid cartilage ; it forms the lowest portion of the larynx . -cricoid ring is more prominent in women then males -the cricothyroid membrane is located between the thyroid and cricoid cartilages -the glottis is the narrowest portion of the adult airway -epiglottis closes over the trachea during swallowing

23. Describe the importance of giving supplemental oxygen to patients who are hypoxic. (p 806)

Administer to any patient that oxygen saturation is less then 94 percent with distress

11. Explain how to assess a patient's breath sounds. (pp 785-787)

Auscultate breath sounds with stethoscope Should be equal and clear Normal breath sounds Tracheal : inspiratory and expiratory sounds are both loud Bronchial: inspiratory sounds are shorter then expiratory sounds Brochovesicular: inspiratory and expiratory sounds are about the same and if medium intensity Vesicular : inspiratory sounds last longer then expiratory sounds , and both are faint Duration : length of time for inspiratory and expiratory phases -normal I/E ratio is 1:2 - expiration is prolonged with lower airway obstruction - expiration is short with tachypneic patients Pitch: higher or lower than normal (stridor or wheezing ) -intensity of sounds depends on: airflow rate, constancy of flow through out inspiration, patient position , site selected for auscultation Abnormal breath sounds Wheezing Rhonchi Crackles Stridor Pleural friction rub

26. Describe the indications for using a nasal cannula rather than a nonrebreathing mask. (p 809)

Best for patients who need long- term therapy

9. List the signs of inadequate breathing. (pp 783-785)

Breathing rate of less then 12 breaths/min or more then 20/min -cyanosis :: indicator of low blood oxygen -preferential positioning -upright sniffing (tripod) position - semi- Fowler position Potential causes : Severe infection Trauma Brainstem insult Poison Oxygen poor environment Renal failure Note the following Position Orthopena Chest rise/fall Skin Flared nostril Pursed lips Retractions Use of accessory muscles Quick breaths, long exhalation Labored breathing Asymmetric chest wall movement Signs Fewer then 12 or more then 20 breaths Irregular Rythms Diminished , absent or noisy sounds Abdominal breathing Reduced flow Unequal chest expansion Increases effort Shallow breathing Pale , clammy skin Retractions Staccato speech Feel for air movement Observe chest for symmetry Note any paradoxical movement Asses for pulsus paradoxus ( systolic blood pressure drops more then 10 mm Hg during inhalation )

6. Discuss acid/base imbalance, specifically respiratory acidosis and respiratory alkalosis. (pp 781-782)

Can be distributed by Hypoventilation Hyperventilation Hypoxia May rapidly lead to deterioration and death Respiratory and renal systems help maintain homeostasis -tendency toward stability in the body - requires balance between acids and bases -Acid in the body can be expelled as CO2 from the lungs -Acidosis can develop if respiratory function is inhibited -Alkalosis can develop if the respiratory rate is to high -respiratory acidosis / alkalosis -metabolic acidosis / alkalosis

21. Describe the causes of foreign body airway obstruction. (pp 802-803)

Causes of airway obstruction Foreign body Tongue Laryngeal edema /spasm Trauma Aspiration Infection or severe allergic reaction

31. Describe the signs associated with adequate and inadequate artificial ventilation. (p 816)

Chest rise and fall

10. Describe the five abnormal breathing patterns to recognize when assessing a patient's breathing. (p 785)

Cheyenne-stokes respiration's : -Gradually increasing rate and depth of respiration's followed by a gradual decrease of respiration's with intermittent periods of apnea; associated with brainstem insult (TRAUMATIC BRAIN INJURY ) Kussmaul respiration's : -Deep, rapid respiration's; seen in patients with diabetic ketoacidsis( ASPRIN OVERDOSE) Biot(ataxic) respiration's: -Irregular pattern , rate, and depth of breathing with intermittent periods of apnea ; results from increased ICP( Apneustic respiration's -Prolonged , gasping inhalation followed by extremely short , in effective exhalation ; associated with brainstem insult Agonal gasps -Slow , shallow , irregular or occasional gasping breaths ; results from cerebral anoxia . Agonal gasps may be seen when the heart has stopped but the brain continues to send signals to the muscles of respiration

13. Discuss the methods for end-tidal carbon dioxide assessment, including its importance. (pp 790-794)

Detects carbon dioxide in exhaled air -adjunct for determining ventilation adequacy -confirms advanced airway placement -Types of ETCO2 (Colorimetric , digital , and digital wave form) Waveform capnography -provides real-time CO2 information - displays a graphic waveform Quanative waveform capnography - shows ongoing placement of advanced airways - Abnormal capnographic waveforms -HYPOVENTILATION *tall waveforms and high ETCO2 value -HYPERVENTILATION *small wave forms and low ETCO2 value -USES OF WAVEFORM CAPNOGRAPHY IN NONITUBATED PATIENT * asses pathological process that causes pulmonary air trapping Abnormal capnographic waveforms -inadvertent extubation -

3. Describe factors related to the pathophysiology of respiration, including ventilation-perfusion ratio mismatch, hypoventilation, hyperventilation, and circulatory compromise. (pp 778-782)

Disruption of pulmonary ventilation , oxygenation and respiration causes immediate effects. -must recognize and correct immediately Every cell needs constant supply of oxygen to survive — perfusion : circulation of blood in adequate Amounts to meet cells needs Hypoxia Tissues and cells do not recieve enough oxygen -varying signs and symptoms - early signs: restlessness, irritability , tachycardia and anxiety -late signs : cyanosis , Ams, weak pulse (thready) Hypoventilation Slow and shallow breathing Carbon dioxide production exceeds elimination Hyperventilation Rapid and deep breathing Carbon dioxide elimination exceeds production Factors in ambient air -high altitudes: partial pressure decreases -closed environments: oxygen decreases Toxic gases displace oxygen in the environment

27. Describe the indications for using a humidifier during supplemental oxygen therapy. (pp 810-811)

For long term care Not dry nose out

22. Describe the management of mild and severe foreign body airway obstruction in an adult, a child, and an infant. (pp 804-806)

Foreign body -typical victim : middle-aged or older, dentures , alcohol Signs may include Choking Gagging Stridor Dyspena Aphonia or dysphonia

43. Describe how to secure an ET tube. (pp 840-841)

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44. Discuss the indications, contraindications, advantages, disadvantages, and complications of nasotracheal intubation. (p 847)

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45. Discuss the indications, advantages, disadvantages, and contraindications, of digital intubation. (pp 849, 851)

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46. Discuss the indications, contraindicationa , advantages , disadvanatges and conplications of digital intubation (pp 849 , 851)

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47. Discuss the indications, contraindications, disadvantages, and complications advantages, of retrograde intubation. (p 853)

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48. Explain what to do when intubation fails. (p 858)

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49. Explain how to perform tracheobronchial suctioning. (pp 858-860)

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5.)Explain positive pressure ventilation versus negative pressure ventilation, (p 781)

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50. Discuss considerations related to field extubation. (pp 859, 861)

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51. List possible pharmacologic adjuncts to ainway management and ventilation, including both sedatives and neuromuscular blocking agents used for emergency intubation. (pp 861-864)

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52. Discuss the procedure for performing rapid sequence intubation. (pp 864-866)

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53. Discuss King LT airway devices, including how they work, the indications, contraindications,and complications, and the procedure for inserting them. (pp 866-869)

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54. Discuss the laryngeal mask airway, including how it works, its indications, contraindications, and complications, and the procedure for inserting it (pp 868-872)

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55. Discuss the i-gel supraglottic airway device, including how it works, and the procedure for inserting it. (pp 871-874)

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56. Discuss the Cobra perilaryngeal airway, including how it works, its indications, contraindications ad complications, and the procedure for inserting it. (pp 872-875)

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57. Discuss the esophageal tracheal Combitube, including how it works, its indications, contraindications, and complications, and the procedure for inserting it. (pp 875-877)

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58. Discuss the indications, contraindications, advantages, disadvantages, and complications of performing open cricothyrotomy. (pp 878-879)|

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59. Discuss the indications, contraindications, advantages, disadvantages, and complications of performing needle cricothyrotomy. (pp 882-8831

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7. Explain how to assess for a patent airway. (pp 782-783)

If the patient is talking or crying shows a parent airway

16. Describe how to perform the jaw-thrust maneuver. (pp 795-796)

Indications Suspected spinal injury Unresponsive patient Unable to protect airway Contraindications Resistance to opening the mouth Advantages Use with spinal injury Disadvantages Difficult to maintain for an extended time Difficult to use BVM

15. Describe how to perform the head tilt-chin lift maneuver. (pp 795-796)

Indications Unresponsive No spinal injury Unable to protect airway Contraindications Responsive Possible spinal injury Advantages No equipment Noninvasive Disadvantages Hazardous to spinal injury No protection from aspiration

Explain the considerations surrounding gastric distention, including how to perform nasogastric and orogastric decompression. (pp 820-823)

Inflation of the stomach with air -likely to occur when excessive pressure is used to inflate the lungs , ventilations are performed too fast or too forcefully , airway is partially obstructed during ventilation attempts Harmful for at least two reasons Promotes regurgitation, can lead to aspiration Pushes diaphram up , limits lung expansion Signs include: increased diameter , distended abdomen , increases resistance to BVM If signs are noted Reasses and re position head and airway Invasive gastric decompression Involves inserting a gastric tube into the stomach and suctioning contents Should be considered : for any patient who will need positive pressure ventilation for an extended period , when gastric distinction interferes with ventilations NG Tube Instert through nose Contraindicated with sever facial injuries

4. Describe factors related to ventilation, including partial pressure and volumes. (pp 779-780)

Intrinsic factors : infection , allergic reactions , unresponsiveness -the tounge is the most common obstruction in a unresponsive patient -factors may not be directly from respiratory system Extrinsic factors : trauma and foreign body airway obstruction -trauma requires immediate intervention - blunt / penetrating trauma and burns can disrupt airflow to the lungs - trauma to the chest wall can lead to inadequate pulmonary ventilation Conditions that reduce surface area for gas exchange also decrease oxygen supply -nonfunctional alveoli inhibit diffusion. -fluid in the alveoli inhibits gas exchange : submersion victims , patients with pulmonary edema , exposure to environmental conditions or occupational hazards Hypoglycemia Infection Hormonal imbalances Circulatory compromise Inadequate perfusion Oxygen demands will not be met: obstruction of blood flow is usually from trauma Heart conditions reduce blood flow to tissues Blood loss and anemia reduce the bloods oxygen carrying ability Shock : oxygen is not delivered to body Acid

14. Explain the use of the recovery position to maintain a clear airway. (p 795)

Involves placing the patient in a left lateral recumbent position , is indicated if the patient has a decreased LOC, is not able to maintain his or her own airway spontaneously and is breathing adequately

33. Describe the indications, contraindications, and complications of using continuous positive airway pressure (CPAP). (pp 817-820)

Noninvasive means of providing ventilatory support for patients with respiratory distress -increases pressure in the lungs -opens collapsed alveoli -pushes oxygen across alveoli membrane Typically delivered through a face mask secured with a strapping system Guidelines Patient is alert and able to follow commands Obvious sighs of moderate to severe distress Pulse ox below 90 percent Contraindications Unable to follow verbal commands Respiratory arrest Unable to speak Hypotensive Hypoventilation Pneumothorax Closed head injury Facial trauma Cardio genie shock Tracheostomy GI bleed , nausea or vomiting Unable to sit up Cannot tolerate mask

8. List the signs of adequate breathing. (p 783)

Normal breather rate 12-20 Adequate depth Regular pattern Clear equal breath sounds

28. Explain how to perform mouth-to-mask ventilation. (pp 813-814)

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12. Explain how to assess for adequate and inadequate respiration, including the use of pulse oximetry. (pp 787-794)

Pulse oximeter: Measures oxygen saturation of hemoglobin( normal SP02 of greater then 95 percent) Used for : -monitoring oxygenation status during intubation attempt or suctioning -identifying high-risk patients -assessing vascular status in orthopedic trauma -identifying deterioration in a patient with trauma or cardiac disease Erroneous reading may result from -bright light -poor perfusion -venous pulsation -patient motion -nail polish -abnormal hemoglobin Types of hemoglobin -oxyhemoglobin -reduced hemoglobin CO-oximeter Determines HbO2 saturation (percentage of oxygenated Hb compared with total hemoglobin)

2. Discuss the physiology of breathing, including ventilation, oxygenation, and respiration. (pp 777-778)

Respiratory and cardiovascular systems work together -bring Oxygen and nutrients to cells -removes waste and Ventilation -physical act of moving air into and out of lungs -inhalation / exhalation You must ensure adequate ventilation Oxygenation -process of loading oxygen molecules onto hemoglobin molecules in the blood stream -requires adequate fraction of inspired oxygen ( FIO2) Respiration -respiration : process of exchanging O2 and CO2 -external : exchange of O2 and CO2 between alveoli and blood in pulmonary capillaries -internal: exchange of O2 and CO2 between the systemic circulation and the cells

40. List factors to consider when determining correct laryngoscope blade size. (p 833)

See before

30. Describe the use of a one- and two-person bag-mask device. (pp 815-816)

See book you should know this

20. Explain how to measure and insert a nasopharyngeal (nasal) airway. (pp 801-802)

See photo

36. List the advanced airway devices and techniques available to you as a paramedic. (p 829)

See photo

37. Discuss methods used to predict the difficult airway. (pp 829-831)

See photo

38. Describe the advantages, disadvantages, and equipment used when performing endotracheal (ET) intubation. (pp 831-833)

See photo

41. Discuss the indications and contraindications of orotracheal intubation. (p 833)

See photo

Normal ventilation versus positive pressure ventilation

See photo

19. Explain how to measure and insert an oropharyngeal (oral) airway. (pp 800-801)

See picture

39. Explain how to determine correct ET tube size. (p 832)

Sizes range from 2.5-9 and 12-32 cm in length Pediatrics 2.5 -4.5mm tubes used no need for distal cuff in most cases . Funnel shaped cricoid ring forms an anatomic seal with ET tube Anatomic clues can determine tube size Internal diameter of the nostril approximates diameter of glottic opening , always have the size up and size down

32. Discuss automatic transport ventilators and how to use them. (pp 816-817)

Steps for using: -attach to wall mounted oxygen source -Set total volume and ventilatory rate -Connect to fitting on Et tube or airway device -Auscultate breath sounds and observe chest rise Have BVM in case vent fails

24. Describe the basics of how oxygen is stored and the various hazards associated with its use. (pp 806-807)

Store oxygen cylinders in a cool, well-ventilated area. Do not subject the cylinders to temperatures above 125F -keep combustible materials away -no smoking -store in a cool, ventilated areas -use only with a properly fitting regulator valve -close all valves when not in use -secure cylinders -have cylinders tested every 10 years -

18. Describe the importance and techniques of suctioning. (pp 797-799)

Suction on the way out now 15 seconds adult 10 for children Clears the airway of debris and liquid Suction -300 adult 150 kids

25. Explain how to use a nonrebreathing mask, including the oxygen flow requirements for its use. (pp 808-809)

Used at 12/15 LPM so bag doesn't collapse Indications : spontaneously breathing patients Fill bag before you put on patient

17. Describe how to perform the tongue-jaw lift maneuver. (p 796)

You know how

35. Discuss airway management considerations for patients with a laryngectomy, tracheostomy, or stoma. (pp 823-828)

cannot ventilate through the mouth May become occluded with mucous plugs Suction with extreme care Limit suction to 10 seconds

42. List the methods available for confirming correct ET tube placement and the advantages and disadvantages of each method. (pp 839-840)

enco2 Capnogroohy And lung sounds