1、Airway Management Part 1,EMS Professions Temple College,Topics for Discussion,Airway Maintenance Objectives Airway Anatomy & Physiology Review Causes of Respiratory Difficulty & Distress Assessing Respiratory Function Methods of Airway Management Methods of Ventilatory Management Common Out-of-Hospi
2、tal Equipment Utilized Advanced Methods of Airway Management and Ventilation Risks to the Paramedic,Objectives of Airway Management & Ventilation,Primary Objective: Ensure optimal ventilation Deliver oxygen to blood Eliminate carbon dioxide (C02) from body Definitions What is airway management? How
3、does it differ from spontaneous, manual or assisted ventilations?,Objectives of Airway Management & Ventilation,Why is this so important? Brain death occurs rapidly; other tissue follows EMS providers can reduce additional injury/disease by good airway, ventilation techniques EMS providers often neg
4、lect BLS airway, ventilation skills,Airway Anatomy Review,Upper Airway Anatomy Lower Airway Anatomy Lung Capacities/Volumes Pediatric Airway Differences,Anatomy of the Upper Airway,Upper Airway Anatomy,Functions: warm, filter, humidify air Nasal cavity and nasopharynx Formed by union of facial bones
5、 Nasal floor towards ear not eye Lined with mucous membranes, cilia Tissues are delicate, vascular Adenoids Lymph tissue - filters bacteria Commonly infected,Upper Airway Anatomy,Oral cavity and oropharynx Teeth Tongue Attached at mandible, hyoid bone Most common airway obstruction cause Palate Roof
6、 of mouth Separates oropharynx and nasopharynx Anterior= hard palate; Posterior= soft palate,Upper Airway Anatomy,Oral cavity and oropharynx Tonsils Lymph tissue - filters bacteria Commonly infected Epiglottis Leaf-like structure Closes during swallowing Prevents aspiration Vallecula “Pocket” formed
7、 by base of tongue, epiglottis,Upper Airway Anatomy,Upper Airway Anatomy,Sinuses cavities formed by cranial bones act as tributaries for fluid to, from eustachian tubes, tear ducts trap bacteria, commonly infected,Upper Airway Anatomy,Larynx Attached to hyoid bone Horseshoe shaped bone Supports trac
8、hea Thyroid cartilage Largest laryngeal cartilage Shield-shaped Cartilage anteriorly, smooth muscle posteriorly “Adams Apple” Glottic opening directly behind,Upper Airway Anatomy,Larynx Glottic opening Adult airways narrowest point Dependent on muscle tone Contains vocal bands Arytenoid cartilage Po
9、sterior attachment of vocal bands,Upper Airway Anatomy,Larynx Cricoid ring First tracheal ring Completely cartilaginous Compression (Sellick maneuver) occludes esophagus Cricothyroid membrane Membrane between cricoid, thyroid cartilages Site for surgical, needle airway placement,Upper Airway Anatomy
10、,Larynx and Trachea Associated Structures Thyroid gland below cricoid cartilage lies across trachea, up both sides Carotid arteries branch across, lie closely alongside trachea Jugular veins branch across and lie close to trachea,Upper Airway Anatomy,Upper Airway Anatomy,Pediatric vs Adult Upper Air
11、way Larger tongue in comparison to size of mouth Floppy epiglottis Delicate teeth, gums More superior larynx Funnel shaped larynx due to undeveloped cricoid cartilage Narrowest point at cricoid ring before 8 years old,Upper Airway Anatomy,From: CPEM, TRIPP, 1998,Upper Airway Anatomy,Glottic Opening,
12、Lower Airway Anatomy,Function Exchange O2 , CO2 with blood Location From glottic opening to alveolar-capillary membrane,Lower Airway Anatomy,Trachea Bifurcates (divides) at carina Right, left mainstem bronchi Right mainstem bronchus shorter, straighter Lined with mucous cells, beta-2 receptors,Lower
13、 Airway Anatomy,Bronchi Branch into secondary, tertiary bronchi that branch into bronchioles Bronchioles No cartilage in walls Small smooth muscle tubes Branch into alveolar ducts that end at alveolar sacs,Lower Airway Anatomy,Alveoli “Balloon-like” clusters Site of gas exchange Lined with surfactan
14、t Decreases surface tension eases expansion surfactant atelectasis (focal collapse of alveoli0,Lower Airway Anatomy,Lungs Right lung = 3 lobes; Left lung = 2 lobes Parenchymal tissue Pleura Visceral Parietal Pleural space,Lower Airway Anatomy,Lower Airway Anatomy,Occlusion of bronchioles Smooth musc
15、le contraction (bronchospasm Mucus plugs Inflammatory edema Foreign bodies,Lung Volumes/Capacities,Typical adult male total lung capacity = 6 liters Tidal Volume (VT) Gas volume inhaled or exhaled during single ventilatory cycle Usually 5-7 cc/kg (typically 500 cc),Lung Volumes/Capacities,Dead Space
16、 Air (VD) Air unavailable for gas exchange,Lung Volumes/Capacities,Dead Space Air (VD) Anatomic dead space (150cc) Trachea Bronchi Physiologic dead space Shunting Pathological dead space Formed by factors like disease or obstruction Examples: COPD,Lung Volumes/Capacities,Alveolar Air (alveolar volum
17、e) VA Air reaching alveoli for gas exchange Usually 350 cc,Lung Volumes/Capacities,Minute Volume Vmin(minute ventilation) Amount of gas moved in, out of respiratory tract per minute Tidal volume X RR Alveolar Minute Volume Amount of gas moved in, out of alveoli per minute (tidal volume - dead space
18、volume) X RR,Lung Volumes/Capacities,Functional Reserve Capacity (FRC) After optimal inspiration, amount of air that can be forced from lungs in single exhalation,Lung Volumes/Capacities,Inspiratory Reserve Volume (IRV) Amount of gas that can be inspired in addition to tidal volume Expiratory Reserv
19、e Volume (ERV) Amount of gas that can be expired after passive (relaxed) expiration,Lung Volumes/Capacities,Ventilation,Movement of air in, out of lungs Control via: Respiratory center in medulla Apneustic, pneumotaxic centers in pons,Ventilation,Inspiration Stimulus from respiratory center of brain
20、 (medulla) Transmitted via phrenic nerve to diaphragm, spinal cord/intercostal nerves to intercostal muscles Diaphragm contracts, flattens Intercostal muscles contract; ribs move up and out Air spaces in lungs stretch, increase in size intrapulmonic pressure (pressure gradient) Air flows into airway
21、s, alveoli inflate until pressure equalizes,Ventilation,Expiration Stretch receptors in lungs signal respiratory center via vagus nerve to inhibit inspiration (Hering-Breuer reflex) Natural elasticity of lungs pulls diaphragm, chest wall to resting position Pulmonary air spaces decrease in size Intr
22、apulmonary pressure rises Air flows out until pressure equalizes,Ventilation,Ventilation,Ventilation,Respiratory Drive Chemoreceptors in medulla Stimulated PaCO2 or pH PaCO2 is normal neuroregulatory control of ventilations Hypoxic Drive Chemoreceptors in aortic arch, carotid bodies Stimulated by Pa
23、O2 Back-up regulatory control,Ventilation,Other stimulants or depressants Body temp: fever; hypothermia Drugs/meds: increase or decrease Pain: increases, but occasionally decreases Emotion: increases Acidosis: increases Sleep: decreases,Gas Measurements,Total Pressure Combined pressure of all atmosp
24、heric gases 760 mm Hg (torr) at sea level Partial Pressure Pressure exerted by each gas in a mixture,Gas Measurements,Partial Pressures Atmospheric Nitrogen 597.0 torr (78.62%); Oxygen 159.0 torr (20.84%); Carbon Dioxide 0.3 torr (0.04%); Water 3.7 torr (0.5%) Alveolar Nitrogen 569.0 torr (74.9%); O
25、xygen 104.0 torr (13.7%); CO2 40.0 torr (5.2%); Water 47.0 torr (6.2%),Respiration,Ventilation vs. Respiration Exchange of gases between living organism, environment External Respiration Exchange between lungs, blood cells Internal Respiration Exchange between blood cells, tissues,Respiration,How ar
26、e O2, CO2 transported? Diffusion Movement of gases along a concentration gradient Gases dissolve in water, pass through alveolar membrane from areas of higher concentration to areas of lower concentration FiO2 % oxygen in inspired air expressed as a decimal FiO2 of room air = 0.21,Respiration,Blood
27、Oxygen Content dissolved O2 crosses capillary membrane, binds to Hgb of RBC Transport = O2 bound to hemoglobin (97%) or dissolved in plasma O2 Saturation % of hemoglobin saturated with oxygen (usually carries 96% of total) O2 content divided by O2 carrying capacity,Respiration,Oxygen saturation affe
28、cted by: Low Hgb (anemia, hemorrhage) Inadequate oxygen availability at alveoli Poor diffusion across pulmonary membrane (pneumonia, pulmonary edema, COPD) Ventilation/Perfusion (V/Q) mismatch Blood moves past collapsed alveoli (shunting) Alveoli intact but blood flow impaired,Respiration,Blood Carb
29、on Dioxide Content Byproduct of work (cellular respiration) Transported as bicarbonate (HCO3- ion) 20-30% bound to hemoglobin Pressure gradient causes CO2 diffusion into alveoli from blood Increased level = hypercarbia,Respiration,Alveoli PO2 100 & PCO2 40,PO2 40 & PCO2 46 - Pulmonary circulation -
30、PO2 100 & PCO2 40,Heart,PO2 40 & PCO2 46 - Systemic circulation - PO2 100 & PCO2 40,Tissue cell PO2 46,Inspired Air: PO2 160 & PCO2 0.3,Oxygenated,Deoxygenated,Diagnostic Testing,Pulse Oximetry Peak Expiratory Flow Testing Pulmonary Function Testing End-Tidal CO2 Monitoring Laboratory Testing of Blo
31、od Arterial Venous,Causes of Hypoxemia,Lower partial pressure of atmospheric O2 Inadequate hemoglobin level in blood Hemoglobin bound by other gas (CO) pulmonary alveolar membrane distance Reduced surface area for gas exchange Decreased mechanical effort,Causes of Airway/Ventilatory Compromise,Airwa
32、y Obstruction Tongue Foreign body obstruction Anaphylaxis/angioedema Upper airway burn Maxillofacial/laryngeal/trachebronchial trauma Epiglottitis Croup,Obstruction,Tongue Most common cause Snoring respirations Corrected by positioning,Foreign Body,Partial or Full Symptoms include Choking Gagging St
33、ridor Dyspnea Aphonia Dysphonia,Laryngeal Spasm,Spasmatic closure of vocal cords Frequently caused by Overly aggressive technique during intubation Immediately upon extubation,Laryngeal Edema,Causes Angioedema Anaphylaxis Upper airway burns Epiglottitis Croup Trauma,Aspiration,Significantly increase
34、s mortality Obstructs Airway Destroys bronchial tissue Introduces pathogens Decreases ability to ventilate Frequently occult,Obstructive Airway Disease,Obstructive airway disease Asthma Emphysema Chronic Bronchitis,Gas Exchange Surface,Pulmonary edema Left-sided heart failure Toxic inhalation Near d
35、rowning Pneumonia Pulmonary embolism Blood clots Amniotic fluid Fat embolism,Causes of Airway/Ventilatory Compromise,Thoracic Bellows Chest trauma Fib fractures Flail chest Pneumothorax Hemothorax Sucking chest wound Diaphragmatic hernia,Causes of Airway/Ventilatory Compromise,Thoracic Bellows Pleur
36、al effusion Spinal cord trauma Morbid obesity (Pickwickian Syndrome) Neurological/neuromuscular disease Poliomyelitis Myasthenia gravis Muscular dystrophy Gullian-Barre syndrome,Causes of Airway/Ventilatory Compromise,Control System Head trauma Cerebrovascular accident Depressant drug toxicity Narco
37、tics Sedative-Hypnotics Ethanol,Assessment of Airway/Ventilatory Compromise,Respiratory Distress/Dyspnea = Possible Life Threat Assess/Manage Simultaneously Priorities Airway Breathing Circulation Disability,Assessment of Airway/Ventilatory Compromise,Airway Listen to patient talk/breathe Noisy brea
38、thing = Obstructed breathing But, all obstructed breathing is not noisy Adventitious sounds Snoring = Tongue Stridor = “Tight” Upper Airway,Assessment of Airway/Ventilatory Compromise,Breathing Look Symmetry of Chest Expansion Signs of Increased Effort Skin Color Listen Mouth and Nose Lung Fields Fe
39、el Mouth and Nose Symmetry of Expansion,Assessment of Airway/Ventilatory Compromise,Breathing Tachypnea Bradypnea Signs of distress Nasal flaring Tracheal tugging Retractions Accessory muscle use Tripod positioning Cyanosis,Assessment of Airway/Ventilatory Compromise,Circulation Dont let respiratory
40、 failure distract you! Tachycardia = Early hypoxia in adults Bradycardia = Early hypoxia in infants, children; Late hypoxia in adults,Assessment of Airway/Ventilatory Compromise,Disability Restlessness, anxiety, combativeness = hypoxia until proven otherwise Drowsiness, lethargy = hypercarbia until
41、proven otherwise When the fighting stops, a patient isnt always getting better,Assessment of Airway/Ventilatory Compromise,Focused Exam Respiratory Patterns Cheyne-Stokes = diffuse cerebral cortex injury Kussmaul = acidosis Biots (cluster) = increased ICP; pons, upper medulla injury Central Neurogen
42、ic Hyperventilation = increased ICP; mid-brain injury Agonal = brain anoxia,Assessment of Airway/Ventilatory Compromise,Focused Exam Neck Trachea mid-line? Jugular vein distension? Subcutaneous emphysema? Accessory muscle use?/hypertrophy?,Assessment of Airway/Ventilatory Compromise,Focused Exam Che
43、st Barrel chest? Deformity, discoloration, asymmetry? Flail segment, paradoxical movement? Adventitious breath sounds? Third heart sound? Subcutaneous emphysema? Fremitus? Dullness, hyperresonance to percussion?,Assessment of Airway/Ventilatory Compromise,Focused Exam Extremities Edema? Nail bed col
44、or? Clubbing?,Assessment of Airway/Ventilatory Compromise,Mechanical Ventilation Increased resistance Changing compliance,Assessment of Airway/Ventilatory Compromise,Pulsus Paradoxus Systolic BP drops 10 mm Hg w/inspiration May detect change in pulse quality COPD, asthma, pericardial tamponade,Asses
45、sment of Airway/Ventilatory Compromise,History Onset gradual or sudden? What makes it worse, better? How long? Cough? Productive? Of what? Pain? What kind? Fever?,Assessment of Airway/Ventilatory Compromise,Past History Hypertension, AMI, diabetes Chronic cough, smoking, recurrent “colds” Allergies,
46、 acute/seasonal SOB Lower extremity trauma, recent surgery, immobilization Interventions Past admission? Ever admitted to ICU? Medications? Frequency of prn medication use? Ever intubated before?,BLS Airway/Ventilation Methods,Supplemental Oxygen Increased FiO2 increases available oxygen Objective =
47、 Maximize hemoglobin saturation,Oxygen Equipment,Oxygen source Compressed gas Tank size D 400L E 660L M 3450 L Liquid oxygen,Oxygen Equipment,Regulators High Pressure Cylinder to cylinder Low Pressure Cylinder to patientHumidifier,Delivery Devices,Nasal cannula Simple face mask Partial rebreather ma
48、sk Non-rebreather mask Venturi mask Small volume nebulizer,Nasal Cannula,Optimal delivery 40% at 6 LPM Indication Low FiO2 Long term therapy Contraindications Apnea Mouth breathing Need for High FiO2,Venturi Mask,Specific O2 Concentrations 24% 28% 35% 40%,Simple Face Mask,Range 40-60% at 10 LPM Volu
49、mes greater that 10 LPM does not increase O2 delivery Indications Moderate FiO2 Contraindications Apnea Need for High FiO2,Non-Rebreather Mask,Range 80-95% at 15 LPM Indications Delivery of high FiO2 Contraindications Apnea Poor respiratory effort,Partial Rebreather,Range 40 60% Indications Moderate FiO2 Contraindications Apnea Need for High FiO2,BLS Airway/Ventilation Methods,Airway Maneuvers Head-tilt/Chin-lift Jaw thrust Sellicks maneuver Other Types Tracheostomy with tube Tracheostomy with stoma Airway Devices Oropharyngeal airway Nasopharyngeal airway,
