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Airway Management

Level 1

Airway EMT Refresher Course EMSNeeds.com Continuing Education (CE)

Overview | Assessment | Treatment | Roles

Objectives

Airway Refresher Course

In this Airway Basics course you will earn 3 CE hours. This course is accredited for all levels since all EMS personnel are technically First Responders.

At the end of this course you will be able to:

  • List the signs of inadequate breathing.
  • Describe the steps in the head-tilt chin-lift.
  • Describe the techniques of suctioning.
  • Describe how to ventilate a patient with a resuscitation mask or barrier device.
  • Describe how to measure and insert a nasopharyngeal (nasal) airway.
  • Describe how to clear a foreign body airway obstruction in a responsive adult.
  • Describe how to clear a foreign body airway obstruction in an unresponsive adult.
  • Place the interests of the patient with airway problems as the foremost consideration when making any and all patient care decisions.

References for content used by permission are on the left side under "EMS Resources." A technical :word: when clicked instantly accesses the EMS glossary online.

There are four sections: Overview, Assessment, Treatment, and Roles. Take the section tests in order by clicking the Take Test button. Your results are saved if you are interrupted. Then do the next section—no lost time or effort with mini-test sections!


EMS Course Levels

Overview

The respiratory system functions to deliver oxygen to the body and remove carbon dioxide from the body. Components or the anatomy of the airway include the nose and mouth, pharynx (oropharynx and nasopharynx), epiglottis, windpipe (trachea), voice box (larynx), lungs, and diaphragm.

Physiology

As the diaphragm moves down, the chest moves out, drawing air into the lungs (inhalation). This exchanges oxygen and carbon dioxide in the lungs, and the diaphragm moves up causing air to exit the lung (exhalation).

In infant and children, all structures are smaller and more easily obstructed than in adults. Infant and children's tongues take up proportionally more space in the mouth than adults. The trachea is more flexible in infants and children also. The primary cause of cardiac arrest in infants and children is an uncorrected respiratory problem.

 

Definitions

  • BSI - Body Substance Isolation
  • Cyanosis - bluish skin color due to lack of oxygen; deoxygenated hemoglobin of >5g/dL
  • FBAO - Foreign Body Airway Obstruction
  • Oropharyngeal
  • Universal Distress Signal - clutching the neck with thumb and fingers
  • Tracheostomy - an artificial permanent opening in the trachea
Emergency Stop
Assessment

One of the most important actions that the first responder can perform is opening the airway of an unresponsive patient. An unresponsive patient loses muscle tone, and the soft tissue and base of the tongue may occlude the airway. The tongue is the most common cause of airway obstruction in an unresponsive patient. Since the tongue is attached to the lower jaw, forward displacement of the jaw will lift the tongue away from the back of the throat.

Inadequate Breathing Signs and Symptoms

  1. Rate
    • Less than 8 in adults
    • Less than 10 in children
    • Less than 20 in infants
  2. Inadequate chest wall motion
  3. Cyanosis
  4. Mental status changes
  5. Increased effort
  6. Gasping
  7. Grunting
  8. Slow heart rate associated with slow respirations

 

Determining the Presence of Breathing

A. Immediately after opening the airway, check for breathing.

B. As you determine the presence of breathing, look at the effort or work of breathing.

    1. Breathing should be effortless.
    2. Observe the chest for adequate rise and fall.
    3. Look for accessory muscle use.

    • Techniques
      • Responsive patients - Ask: "Can you speak?" or "Are you choking?" The ability to talk or make vocal sounds indicates that air is moving past the vocal cords.
      • Unresponsive patients - Maintain an open airway while you place your ear close to the patient’s mouth and nose. Assess for three to five seconds:

        1. Look for the rise and fall of the chest.
        2. Listen for air escaping during exhalation.
        3. Feel for air coming from the mouth and nose.The first responder may observe the rise and fall of the chest even if an airway obstruction is present, but will not hear or feel air movement. Some reflex gasping (agonal respirations) may be present just after cardiac arrest. This should not be confused with breathing.

Ventilation

  1. Slow heart rate may be associated with slow respirations.
  2. Once the airway has been assured and breathing is assessed, breathing for the patient may be necessary.
  3. If the patient is not breathing, they only have the oxygen in their lungs and their bloodstream remaining.
  4. In order to prevent death, the First Responder must ventilate the patient.
  5. There are many techniques for ventilation such as mouth-to-mask, two-person bag-valve-mask, flow restricted, oxygen-powered ventilation device, and the one-person bag-valve-mask using the fist and thigh squeeze (FATS) method.

Foreign Body Airway Obstructions (FBAO) in the adult can be the cause of cardiac arrest:

  • Choking/food
  • Bleeding into the airway
  • Vomit
  • Dentures
  • Trauma
  • Tongue

Types of airway obstructions

  • Partial: There may be good air exchange and the patient remains responsive. They may be able to speak and can cough forcefully, but there may be wheezing between coughs. If there is poor air exchange, the cough is weak and ineffective. Listen for high-pitched noise on inhalation with increased respiratory difficulty with possible cyanotic symptoms.

  • Complete: No air can be exchanged, and the patient will be unable to speak, breathe, or cough. The patient may clutch the neck with thumb and fingers, which is the universal distress signal. Death will follow rapidly if prompt action is not taken.

Listen to the differences in breathing (MP3 audio):

Refer to current American Heart Association Guidelines for the Management of Foreign Body Airway Obstruction - SEE APPENDICES B and C

Foreign Body Airway Obstructions in Infants and Children

More than 90% of childhood deaths from FBAO are in children below the age of five and 65% of the patients are infants. FBAO in children is caused by toys, balloons, small objects, food (hot dogs, round candies, nuts, and grapes). These should be suspected in infants and children who demonstrate a sudden onset of respiratory distress associated with coughing, gagging, stridor, or wheezing.

Airway obstructions also may be caused by infection. The First Responder should only attempt to clear a complete or partial airway obstruction with poor air exchange. Blind finger sweeps are not done in infants or children. For more details on management of foreign body airway obstructions in infants and children, refer to current American Heart Association Guidelines for Foreign Body Airway Obstruction.

Airway Lungs

 

 

 

 

 

Nail in throat

 

Treatment

Airway Adjuncts

Oropharyngeal (oral) airways

  1. Oropharyngeal (OP) airways may be used to assist in maintaining an open airway in an unresponsive patient without a gag reflex.
  2. Patients with a gag reflex may vomit when this airway is placed.

Technique

    • Select the proper size: Measure from the corner of the patient's lips to the tip of the earlobe or angle of jaw.
    • Open the patient's mouth.
    • Insert the airway upside down, with the tip facing toward the roof of the patient's mouth.
    • Advance the airway gently until resistance is encountered.
    • Turn the airway 180 degrees so that it comes to rest with the flange on the patient's teeth
  1. Alternate technique - For use with infants and children
    • Select the proper size: Measure from the corner of the patient's lips to the bottom of the earlobe or angle of jaw.
    • Open the patient's mouth.
    • Use a tongue blade to press tongue down and away.
    • Insert airway in upright (anatomic) position

Nasopharyngeal (nasal) airways

  1. Nasopharyngeal (NP) airways are less likely to stimulate vomiting.
  2. May be used on patients who are responsive but need assistance keeping the tongue from obstructing the airway.
  3. Even though the tube is lubricated, this is a painful stimulus.

Technique

    • Select the proper size: Measure from the tip of the nose to the tip of the patient's ear.
    • Also consider diameter of airway in the nostril. NP airways should not be so large that it causes blanching of the nostril.
    • Lubricate the airway with a water soluble lubricant.
    • Insert it posteriorly. Bevel should be toward the base of the nostril or toward the septum.
    • If the airway cannot be inserted into one nostril, try the other nostril.
    • Do not force this airway

Clearing the Compromised Airway and Maintaining the Open Airway

  1. There are three ways that First Responders can clear or maintain an airway.
  2. These techniques are not sequential; the situation will dictate which technique is most appropriate.
  3. There are three methods of clearing the airway:

    • The Recovery Position is the first step in maintaining an open airway. This method is used in unresponsive, uninjured patient, breathing adequately by using gravity to keep the airway clear. The airway is likely to remain open in this position. Unrecognized airway obstructions are less likely to occur. All along, monitor the patient until additional EMS resources arrive and assume care. Allows fluids to drain from the mouth and not into the airway.

    Technique

    1. Raise the patient's left arm above his/her head and cross the patient's right leg over the left.
    2. Support the face and grasp the patient's right shoulder.
    3. Roll the patient toward you onto his or her left side.
    4. Place the patient's right hand under the side of his/her face.
    5. The patient's head, torso, and shoulders should move simultaneously without twisting.
    6. The head should be in as close to a midline position as possible.
    • Finger sweeps (Blind finger sweeps should not be performed in infants or children.)
    1. Uses your fingers to remove solid objects from the airway.
    2. Use body substance isolation.
    3. Remove any visible foreign material or vomit.
    4. Do this quickly.

    Technique

    1. If uninjured, roll patients to their side.
    2. Wipe out liquids or semi-liquids with the index and middle fingers covered with a cloth.
    3. Remove solid objects with a hooked index finger.
    • Suctioning uses negative pressure to keep the airway clear. A patient needs to be suctioned immediately when a gurgling sound is heard during breathing or ventilation. Suction is only indicated if the recovery position and finger sweeps are ineffective in draining the airway or trauma is suspected and the patient cannot be placed in the recovery position. The purpose is to remove blood, other liquids, and food particles from the airway. Most suction units are inadequate for removing solid objects like teeth, foreign bodies, and food. Portable suction equipment is available and may be manually or electrically operated.

    Technique

    1. Observe body substance isolation.
    2. A hard or rigid "tonsil sucker" or "tonsil tip" is preferred to suction the mouth of an unresponsive patient.
    3. The tip of the suction catheter should not be inserted deeper than the base of the tongue.
    4. Because air and oxygen are removed during suction, it is recommended that you suction for no more than 15 seconds.
    5. Decrease the time in infants and children (infants 5 seconds; children 10 seconds).
    6. Watch for decreased heart rate in infants.
    7. If a decrease in heart rate is noted, stop suctioning and provide ventilation.

Head-Tilt Chin-Lift

The head-tilt chin-lift is the method of choice for opening the airway in uninjured patients. Research has indicated that the head-tilt chin-lift consistently provides the optimal airway. it is also used for uninjured, unresponsive patients. Watch the video.

Technique

  1. Place your hand that is closer to the patient's head on his/her forehead, apply firm backward pressure to tilt the head back.
  2. Place the fingers of your hand that is closer to the patient's feet on the bony part of his/her chin.
  3. Lift the chin forward and support the jaw, helping to tilt the head back.

Precautions

  1. Finger must not press deeply into the soft tissues of the chin as this may lead to airway obstruction.
  2. The thumb should not be used for lifting the chin.
  3. The mouth must not be closed.

Jaw Thrust Without Head Tilt

This technique is an alternative method of opening the airway. It is effective but fatiguing and technically difficult. This is the safest approach to opening the airway in the patient with a suspected spinal injury. Use it for trauma patients and unresponsive patients.

Technique

  1. Grasp the angles of the patient's lower jaw.
  2. Lift with both hands displacing the mandible forward.
  3. Open the lower lip with your gloved thumb if the lips close.

Inspect the Airway

  1. An unresponsive patient may have fluid or solids in the airway that may compromise the airway.
  2. Responsive patients who cannot protect their airway should also have their airways inspected.

Technique

  1. Open the patient's mouth with a gloved hand.
  2. Look inside the airway. Is it clear or blocked? If it is blocked, is ther fluid or solids (teeth, including dentures)?

Ventilation Techniques

Mouth-to Mask

  1. Review techniques learned in BLS course.
  2. Connect the mask to high flow oxygen = 15 liters per minute.

Two-Person Bag-Valve-Mask

  1. Connect it to oxygen to perform most effectively. It consists of a self-inflating bag, one-way valve, face mask, and oxygen reservoir with a volume of approximately 1,600 milliliters, less than mouth-to-mask.
  2. Maintain an airtight seal. Two FIrst Responders are more effective than one.
  3. Position yourself at the top of the patient's head for optimal performance.
  4. Determine if adjunctive airways (oral or nasal) may be necessary in conjunction with bag-valve-mask.
  5. Check if it has a self-refilling bag that is easily cleaned and sterilized with a non-jam valve that allows a maximum oxgen inlet flow of 15/lpm with no pop-off valve, or the pop-off valve must be disabled. Failure to do so may result in inadequate artificial ventilations.
  6. Use standardized 15/22 mm fittings.
  7. Use a true valve for non-rebreather and an oxygen inlet and reservoir to allow for high concentration of oxygen.
  8. Check if it performs in all environmental conditions including temperature extemes.
  9. Keep infant, child, and adult sizes.

Uses When No Trauma Is Suspected

  1. Select the correct mask size after opening the airway.
  2. Position thumbs over top half of mask, index, and middle fingers over the bottom half.
  3. Place the apex of the mask over the bridge of the nose, and then lower the mask over the mouth and upper chin. If the mask has large round cuff surrounding the ventilation port, center the port over the mouth.
  4. Use the ring and little fingers to bring the jaw up to the mask.
  5. Connect the bag to mask if not already done.
  6. Have assistant squeeze the bag with two hands until the chest rises.
  7. Repeat a minimum of ervery 5 seconds for adults and every 3 seconds for children and infants.
  8. If the chest does not rise and fall, re-evaluate:
    • Reposition the head.
    • Reposition fingers and mask if air is escaping from under the mask.
    • Check for obstruction.
    • Use an alternative methof of artificial ventilation, e.g., pocket mask, manually triggered device, etc.
  9. Consider use of adjuncts: oral and nasal airway.

Use with Suspected Trauma

  1. After opening airway, select correct mask size (adult, infant or child).
  • Immobilize head and neck, e.g., have an assistant hold head manually or use your knees to prevent movement.
  • Position thumbs over top half of mask, index and middle fingers over bottom half.
  • Place apex of mask over bridge of nose, then lower mask over mouth and upper chin. If mask has large round cuff surrounding a ventilation port, center port over mouth.
  • Use ring and little fingers to bring jaw up to mask without tilting head or neck.
  • Connect bag to mask if not already done.
  • Have assistant squeeze bag with two hands until chest rises.
  • Repeat every 5 seconds for adults and every 3 seconds for children and infants, continuing to hold jaw up without moving head or neck.
  • If chest does not rise, re-evaluate.
    • If abdomen rises, reposition jaw.
    • If air is escaping from under the mask, reposition fingers and mask.
    • Check for obstruction.
    • (If chest still does not rise, use alternative method of artificial ventilation, e.g., pocket mask.
  • If necessary, consider use of adjuncts.
    • Oral airway
    • Nasal airway

Flow-restricted, oxygen-powered ventilation devices

Flow-restricted, oxygen-powered ventilation devices (for use in adults only) should provide these:

  • A peak flow rate of 100% oxygen at up to 40 lpm. An inspiratory pressure relief valve that opens at approximately 60 centimeters water and vents any remaining volume to the atmosphere or ceases gas flow.
  • An audible alarm that sounds whenever the relief valve pressure is exceeded.
  • Satisfactory operation under ordinary environmental conditions and extremes of temperature.
  • A trigger positioned so that both hands of the First Responder can remain on the mask to hold it in position.

Use when no neck injury is suspected

  1. After opening airway, insert correct size oral or nasal airway and attach adult mask.
  2. Position thumbs over top half of mask, index and middle fingers over bottom half.
  3. Place apex of mask over bridge of nose, then lower mask over mouth and upper chin.
  4. Use ring and little fingers to bring jaw up to mask.
  5. Connect flow-restricted, oxygen-powered ventilation device to mask if not already done.
  6. Trigger the flow-restricted, oxygen-powered ventilation device until chest rises.
  7. Repeat every five seconds.
  8. If necessary, consider use of adjuncts.
  9. If chest does not rise, re-evaluate.
    • If abdomen rises, reposition head.
    • If air is escaping from under the mask, reposition fingers and mask.
    • If chest still does not rise, use alternative method of artificial ventilation, e.g., pocket mask.
    • Check for obstruction.

Use when there is suspected neck injury

  1. After opening airway, attach adult mask.
  2. Immobilize head and neck, e.g., have an assistant hold head manually or use your knees to prevent movement.
  3. Position thumbs over top half of mask; index and middle fingers over bottom half.
  4. Place apex of mask over bridge of nose, then lower mask over mouth and upper chin.
  5. Use ring and little fingers to bring jaw up to mask without tilting head or neck.
  6. Connect flow-restricted, oxygen-powered ventilation device to mask, if not already done.
  7. Trigger the flow-restricted, oxygen-powered ventilation device until chest rises.
  8. Repeat every five seconds.
  9. If necessary, consider use of adjuncts.
  10. If chest does not rise and fall, re-evaluate.
    • Reposition jaw.
    • If air is escaping from under the mask, reposition fingers and mask.
    • If chest still does not rise, use alternative method of artificial ventilation, e.g., pocket mask.
    • Check for obstruction.

One person Bag-Valve-Mask using the FATS technique (fist and thighs).

  1. Insert oropharyngeal airway.
  2. Select correct mask size.
  3. Apply mask.
  4. Hold mask:
    • Place heel of hand on top of mask or valve.
    • Extend fingers and thumb straight forward.
    • Drop fingers and grasp jaw with middle fingers.
  1. Use head-tilt/chin-lift to open airway.
  2. Squeeze knees together to keep head hyperextended.
  3. Squeeze bag against your thigh with your other hand.
  4. Elaboration:
    • Correct mask size is determined by patient features. Apply the apex of the mask over the bridge of the nose and its base between the lower lip and chin.
    • Thighs help to stabilize neck and take pressure off of the hand holding the mask so the seal can be effectively held.
    • To maximize oxygen concentration, use an oxygen reservoir bag connected to Oxygen. It is strongly recommended that the reservoir bag be connected to the BVM unit at all times.
  5. Ventilating Pediatric Patients
    • To open the airway in an infant, place the infant in a supine position and put a rolled towel under the shoulders. The large cranium causes flexion of the neck, thus creating a potential anatomical obstruction of the airway.
    • Jaw thrust - displace mandible anteriorly by placing fingers behind the angle of the jaw on both sides and gently lifting.
    • Head-tilt/chin-lift - place one hand on the forehead, one lifting the chin by placing the fingers on the mandible. Avoid putting any pressure on the soft tissues under chin or hyperextending neck, because both can cause airway compromise.
    • To open the airway in a child, place the child in a supine position with a slight extension of the neck (not hyperextended). Perform the jaw thrust and head-tilt/chin-lift same as you would for an infant.
    • Indications for Use of BVM:
      1. respiratory arrest
      2. inadequate respiratory effort
      3. inadequate respiratory rate (for age of child)
      4. bradycardia
      5. central cyanosis
  • Select a mask that covers the mouth and nose but does not put any pressure on the eyes or throat.
  • Support the chin with your ring finger; Be careful not to put any pressure on the soft tissue under the chin - airway compromise can result. Grasp the mask with the third finger and thumb and apply enough pressure to form a seal.
  • Watch for chest movement and use this to gauge tidal volume. Remember that tidal volume in an infant or child is very small, only 10 cc/kg; Infant weight is 3 kg and tidal volume is 30 cc. 1 teaspoon = approx. 5 cc.

Bag to stoma or tracheostomy tube

A tracheostomy is an artificial permanent opening in the trachea. If you are unable to artificially ventilate, try suction, then artificial ventilation through mouth and nose; sealing stoma may improve ability to artificially ventilate from above or may clear obstruction. You need to seal the mouth and nose when air is escaping when artificially ventilating at the stoma.

For bag-valve-mask to stoma, use infant and child mask to make it seal. The technique otherwise is very similar to artificially ventilating through mouth. Head and neck do not need to be positioned.



Roles and Responsibilities

Place the interests of the patient with airway problems as the foremost consideration when making any and all patient care decisions.

Remember to apply BSI.

Review the Heimlich Maneuver.

NOTE: Children are notorious for putting objects in their mouths. Foreign body airway obstruction must always be considered when faced with a child in respiratory distress/arrest. Treat these cases per AHA guidelines.

Oxygen Cylinder Sizes

  • D cylinder has 350 liters
  • E cylinder has 625 liters
  • M cylinder has 3,000 liters
  • G cylinder has 5,300 liters
  • H cylinder has 6,900 liters

Handle these cylinders carefully since their contents are under pressure. Tanks should be positioned to prevent falling and blows to the valve-gauge assembly and secured during transport.

Pressure regulators show that a full tank is approximately 2000 psi. This varies with ambient temperature. Dry oxygen not harmful in short term; a humidifier is needed only for a patient on oxygen for a long time and is not generally needed for prehospital care.

Operating procedures

  1. Remove protective seal.
  2. Quickly open, then shut, the valve.
  3. Attach regulator-flow meter to tank.
  4. Attach oxygen device to flow meter.
  5. Open flow meter to desired setting.
  6. Apply oxygen device to patient.
  7. When complete, remove the device from patient, and then turn off valve and remove all pressure from the regulator.

Equipment for oxygen delivery

1. Non-rebreather

  • This is the preferred method of giving oxygen to prehospital patients.
  • Up to 90% oxygen can be delivered.
  • Non-rebreather bag must be full before mask is placed on patient.
  • Flow rate should be adjusted so that when patient inhales, bag does not collapse (15 lpm).
  • Patients who are cyanotic, cool, clammy or short of breath need oxygen. Concerns about the dangers of giving too much oxygen to patients with history of chronic obstructive pulmonary disease and infants and children have not been shown to be valid in the prehospital setting. Patients with chronic obstructive pulmonary disease and infants and children who require oxygen should receive high concentration oxygen.
  • Masks come in different sizes for adult, children and infants. Be sure to select the correct size mask.

2. Nasal cannula

  • This is rarely the best method of delivering adequate oxygen to the prehospital patient.
  • It should be used only when patients will not tolerate a non-rebreather mask, despite coaching from the First Responder.

Special Considerations

Patients with stomas

  • Persons who have undergone a laryngectomy (surgical removal of the voice box) have a permanent opening (stoma) that connects the trachea to the front of the neck
  • When such person requires rescue breathing, mouth-to-stoma ventilations are required

Technique

  1. Make an airtight seal around the stoma. Use a barrier device, if possible.
  2. Deliver a ventilation slowly, allowing the chest to rise.
  3. After delivering the ventilation, allow time for adequate exhalation.
  4. Some patients have partial laryngectomy. If, upon ventilating the stoma, air escapes from the mouth or nose, close the mouth and pinch the nostrils.

Infant and child patients

  • Place an infant's head in neutral position, but extend a little past neutral if the patient is a child.
  • Avoid excessive hyperextension of the head.
  • An oral airway may be considered when other procedures fail to provide a clear airway.
  • Gastric distension is more common in children.
  • Gastric distension may significantly impair ventilation attempts in children.

Facial injuries

  • Because the blood supply to the face is so rich, blunt injuries to the face frequently result in severe swelling
  • For the same reason, bleeding into the airway from facial injuries can be a challenge to manage

Dental appliances

  • Dentures should be left in place ordinarily.
  • Partial dentures (plates) may become dislodged during an emergency. Leave in place, but be prepared to remove it if it becomes dislodged.
REMEMBER: During practical skill practice, monitor performance and provide feedback for each other. Ventilations must be gentle and watch the patient’s abdomen. Mannequins often require more pressure to ventilate than a real patient.

Mask


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