Airway and Ventilation Michael Clanton, M.Ed, ATC, CSCS, EMT-I Director of Athletic Training Brenau University UGA ATEC Course May 17th - 19th.
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Airway and Ventilation Michael Clanton, M.Ed, ATC, CSCS, EMT-I Director of Athletic Training Brenau University UGA ATEC Course May 17th - 19th Need to Breathe UGA ATEC Course 2 Need to Breathe UGA ATEC Course Respiration Respiration is defined as the sum of the physical and chemical processes in an organism by which oxygen is conveyed to the tissues and cells and the oxidation products , carbon dioxide and water are given off … Four Stages 1)Air into Body 2) Oxygen onto RBCs 3)RBCs to cells 4)Transfer o2/Co2 at cellular level Reverse Procedure UGA ATEC Course Airway Control Ensuring airway is the first priority in trauma management and resuscitation Remember to consider cervical spine injuries in securing the airway UGA ATEC Course Opening the Airway Techniques Head-tilt/Chin-lift Jaw Thrust Suctioning Nasopharyngeal airway Oropharyngeal airway UGA ATEC Course 6 Clearing the Airway The first step in airway management is a quick visual inspection Foreign material (blood, teeth, food) needs to either be swept away with your finger or use suction (vomitus) UGA ATEC Course Manuel Maneuvers In unresponsive patients the tongue becomes flaccid, falling back and blocking the hypopharnyx. The tongue is the most common cause of airway obstruction Any maneuver that moves the mandible forward will pull the tongue out the hypopharnyx UGA ATEC Course Manuel Maneuvers Trauma Jaw Thrust Trauma Chin Lift UGA ATEC Course Trauma Jaw Thrust This is for patients with suspected cervical spine injuries It allows the cervical spine to stay in the neutral position The mandible is thrust forward by placing the thumbs on each zygoma (cheekbone), placing the index and long fingers on the mandible and at the same angle pushing the mandible forward UGA ATEC Course Jaw Thrust Used when spinal injury suspected Temporary procedure Must be replaced with airway adjunct unless patient begins adequate spontaneous ventilation 11 Trauma Jaw Thrust UGA ATEC Course Modified jaw-thrust in trauma 13 UGA ATEC Course Jaw Thrust Technique Place one hand on either side of patient’s head, resting elbows on surface on which victim is lying Grasp angles of patient’s lower jaw, lift with both hands If patient’s lips close, retract lower lips with thumbs 14 Jaw-thrust maneuver 15 UGA ATEC Course Jaw Thrust Patients needing jaw thrust Unresponsive trauma patient Unresponsive patient with undetermined mechanism of injury 16 Trauma Chin Lift The chin and lower incisors are grasped and then lifted to pull the mandible forward. UGA ATEC Course Trauma Chin lift UGA ATEC Course Head-Tilt/Chin-Lift Used when no neck injury is suspected Temporary procedure Must be replaced with an airway adjunct unless patient begins adequate spontaneous ventilation 19 Head-tilt/chin-lift 20 UGA ATEC Course Head-Tilt/Chin-Lift Technique Place one hand on patient’s forehead Apply firm, backward pressure with palm causing head to tilt backward Place fingers of other hand under bony part of patient’s lower jaw near chin Lift jaw upward to bring chin forward 21 Head Tilt Chin Lift UGA ATEC Course Head-Tilt/Chin-Lift Patients needing head-tilt/chin-lift Unresponsive patient without history of trauma Cardiac arrest patients without signs of trauma Apneic patients without signs of trauma 23 Suctioning Purpose Remove blood, vomit, other liquids, food particles from airway May not be adequate for removing large, solid objects (teeth, foreign bodies, food) Should be performed immediately when gurgling is heard with spontaneous or artificial ventilation 24 Suctioning Suction devices Mounted in ambulance Portable Electrical Hand operated Should generate 300mm Hg vacuum Ensure batteries in units remain properly charged 25 Suctioning V-VAC Hand powered Disposable Ease of use Always suction on the way out UGA ATEC Course UGA ATEC Course SUCTION CATHETERS Hard/Rigid Use with unresponsive athlete Soft (French) Use to suction nasopharynx Suctioning Rigid Suction Catheter Used to suction mouth, oropharynx of unresponsive patient Inserted only as far as you can see Take caution not to touch back of airway, particularly in infants and children (can cause heart rate to drop) 29 Suctioning Soft Suction Catheter Useful for suctioning nasopharynx or tracheostomy tubes Should be inserted only as far as base of tongue or end of tracheostomy UGA ATEC Course tube 30 SUCTION TECNIQUES Insert catheter without suction Insert only to tougue base Apply suction 15 seconds max. SPECIAL SUCTION SITUATIONS 1. If suction does not work quickly & easily - Log roll and clear oropharynx 2. Frothy secretions form as rapidly as suction can remove, suction 15 seconds - Ventilate 2 minutes\Repeat Suctioning Videos http://www.youtube.com/watch?v=7 LSRIOtmX_c&feature=related http://www.youtube.com/watch?v=T wNSNodYfEw&feature=related 33 Airway before applying Sellick’s 34 UGA ATEC Course Sellick’s maneuver (cricoid pressure) 35 UGA ATEC Course Oropharyngeal Airway UGA ATEC Course Oropharyngeal Airway The most frequently used airway Inserted either direct or inverted Indications Patient who is unable to maintain airway To prevent intubated patient from biting ET tube UGA ATEC Course Oral Airways Used on unresponsive patients without gag reflex Helps hold tongue away from back of throat UGA ATEC Course 38 Oral Airways Patients needing oral airway Unresponsive, apneic patients with or without trauma Any apneic patient being ventilated with a BVM 39 Types of Oral Airways – Berman (hollow edges) & Geudal (hollow middle) UGA ATEC Course 40 Oropharyngeal Airway Contraindications Patient who is conscious or semiconscious Complications Because it stimulates the gag reflex, the use of OPA may lead to gagging , vomiting, and laryngospasms in patients who are conscious UGA ATEC Course Oropharyngeal Airway Sizing UGA ATEC Course UGA ATEC Course Oropharyngeal Airway Insertion There are 2 ways Insert and rotate 180 degrees Use a tongue depressor to hold push the tongue back and insert( for children and infants) UGA ATEC Course Rotate airway 180º into position. 45 UGA ATEC Course Improper placement of oropharyngeal airway Tongue 46 UGA ATEC Course UGA ATEC Course May 17th - 19th Oropharyngeal Airway UGA ATEC Course Oropharyngeal Airway UGA ATEC Course Oropharyngeal Airway UGA ATEC Course Oropharyngeal Airway UGA ATEC Course Oral Airway videos http://www.bing.com/videos/watch/vi deo/oropharyngeal-airway-insertionanimationsample/4c75a32d7ab31818e53a4c75 a32d7ab31818e53a932854628358?q=video%2bof%2bna sal%2bairway%2binsertion&FROM=L KVR5>1=LKVR5&FORM=LKVR&adlt =strict http://www.youtube.com/watch?v=s VlRylzLor0&feature=related 52 Nasopharyngeal airway, inserted 53 UGA ATEC Course Nasopharyngeal Airway The NPA is a soft, rubberlike device that is inserted through one of the nares and then along the curvature of the posterior wall of the nasopharynx and oropharynx UGA ATEC Course Nasopharyngeal Airway Indications Patient who is unable to maintain their airway Contraindications Avoid with patients who have a suspected Fx to base of the skull or mid face Fx Complications Bleeding caused by insertion UGA ATEC Course Nasal Airways Used on responsive patients who need help keeping tongue out of airway Insertion is uncomfortable for responsive patients Not to be used in patients with suspected skull fractures, oral maxilfacial trauma UGA ATEC Course 56 Nasal Airways Patients needing nasal airway Unresponsive patients who are snoring Unresponsive patients with gag reflex UGA ATEC Course 57 Nasal Airways Technique Measure from tip of nose to earlobe Ensure airway will fit through nostril Lubricate with water-soluble lubricant Insert with bevel toward base of nostril or septum If resistance is met, try other nostril Do not use in patients with mid-face trauma or possible basilar skull fractures 58 Nasopharyngeal Airway Insertion Lubricate the nasal airway Use the right nares first Beveled side in Stop if you hit an obstruction and go to the other nares UGA ATEC Course Nasopharyngeal Airway UGA ATEC Course Nasal Airway Videos http://www.youtube.com/watch?v=h qwS6e8aLJs&feature=related http://www.youtube.com/watch?v=9r wXFIJPfEs&feature=related 61 Airway Limitations Nasal/oral airways are not definitive devices Manual maneuvers must be used with nasal/oral airways to ensure airway stays open Patients may require frequent suctioning to remove blood, vomit, other secretions from airway Definitive devices such as endotracheal tubes are required to completely protect the airway 62 Special Considerations in Airway Management Anaphlaxis-Angioedema causing engorgement of tissue occluding ariway Laryngeal Fractice-Trauma resulting in bleeding or structural changes to entrance to lower airway 2008 Finnish study found sports to be the cause in 39% of all cases in the study. UGA ATEC Course Laryngeal Fractures UGA ATEC Course Needle Cricothyroidectomy UGA ATEC Course Athletes with Laryngeal Fractures Steve Yeager-LAD C Stefon Johnson-USC RB UGA ATEC Course Needle Cricothyroidectomy UGA ATEC Course Oxygen Delivery “When in doubt err on benefiting the patient and deliver oxygen.” UGA ATEC Course BLS Airway/Ventilation Methods Supplemental Oxygen Increased FiO2 increases available oxygen Objective = Maximize hemoglobin saturation UGA ATEC Course 69 Oxygen Concerns about giving too much oxygen to patients with COPD, infants, and children are NOT valid during short-term emergency administration Patients with COPD, infants, and children who require oxygen should be given high concentration oxygen. 34 Oxygen Delivery UGA ATEC Course Oxygen Delivery Oxygen is an odorless, colorless gas normally present in the atmosphere at 21% Oxygen cylinders vary in size from D – 350 liters to H – 6900 liters. The are colored green or have a green top half. Even though the volume may vary the pressure is the same when the cylinders are full at 2,000 psi UGA ATEC Course Oxygen Delivery UGA ATEC Course Oxygen Delivery Indications for O2 Use Any patient with an altered mental status or who is unresponsive Injuries to any body cavity or central nervous system component Multiple Fxs and multiple soft tissue injuries Severe bleeding Any evidence of shock UGA ATEC Course Oxygen Delivery Indications for O2 Use Any patient in cardiac arrest or respiratory arrest Any signs of hypoxia in a patient with an adequate respiratory rate and adequate tidal volume Medical conditions that may cause hypoxia to cells or organ, such as stroke, heart attack, drug overdose, asthma attack, allergic reaction, seizures, airway obstruction and environmental emergencies UGA ATEC Course Oxygen Delivery Safety Precautions Never allow combustible materials such as oil or grease to touch the cylinder, regulator or fittings. Never smoke or allow someone to smoke in the area where they are in are located or in use. Store them below 125 degrees Fahrenheit Never use without a safe, properly fitting regulator Keep all valves closed Store them laying down or secured strapped standing up. They are under pressure and could be punctured and move like an missile UGA ATEC Course Pressure Regulators Gas flow from the O2 cylinder is controlled by a regulator that reduces the high pressure to a safe range of 30 to 70 PSI and controls the flow of O2 from 1 to 15 lpm These regulators connect to the cylinder at the yoke The regulator generally has 2 gauges or a gauge and a dial The gauge indicates the pressure in the tank and the dial selects the flow of O2 UGA ATEC Course Oxygen Delivery UGA ATEC Course Oxygen Delivery UGA ATEC Course Oxygen Delivery UGA ATEC Course Oxygen Delivery UGA ATEC Course Oxygen Delivery UGA ATEC Course Oxygen Delivery UGA ATEC Course Oxygen Delivery UGA ATEC Course Oxygen Delivery UGA ATEC Course Oxygen Administration Videos http://www.youtube.com/watch?v=fy g5FnGk0zA&feature=related http://www.youtube.com/watch?v=2 KaP18PjUmU&feature=related http://www.youtube.com/watch?v=z dIXQVVuLs4&feature=related 86 BLS Airway/Ventilation Methods Mouth to Mouth Mouth to Nose Mouth to Mask UGA ATEC Course 87 Delivery Devices Nasal cannula Simple face mask Partial rebreather mask Non-rebreather mask Venturi mask Small volume nebulizer UGA ATEC Course 88 Oxygen Delivery Devices Device Oxygen Percentage Nasal cannula 24% - 44% Venturi mask 24, 28, 35, or 40% Simple face mask 40 – 60% Nonrebreather mask 80 – 95% 89 Oxygen Administration Oxygen Delivery Systems Device Function Common Flow Rate Oxygen Concentration Nasal cannulla 1-4 lpm 24-36 Mask 6+ lpm 35-55 Breathing and non breathing BVM 10+ lpm 90+ % nonbreathing Breathing victims only Breathing and Pocket Masks The ideal mask has the following characteristics Is a good fit Is equipped with a one way valve Is made of a transparent material Has a supplemental oxygen port Is available in adult, pediatric and infant sizes UGA ATEC Course Oxygen Administration Selecting a Resuscitation Mask Be transparent and made out of a pliable material Have a one-way valve Have a standard coupling assembly Have an inlet for supplemental oxygen Work well in all environmental conditions Be easy to assemble and use Pocket Masks UGA ATEC Course Nasal Cannula Delivery 1-6 LPM 24 to 44% Indication Low FiO2 Long term therapy Contraindications Apnea Mouth breathing Need for High UGA ATEC Course FiO2 94 Oxygen Delivery Nasal Cannula Rarely the best method Thus, DO NOT USE WITH ATHLETES Venturi Mask Specific O2 Concentrations 24% 28% 35% 40% Not a good choice in Athletic situations UGA ATEC Course 96 Oxygen Delivery Equipment Non rebreather mask UGA ATEC Course Indications for Nonrebreather Cyanotic (blue) Cool Clammy Short of Breath Oxygen Delivery Nonrebreather Mask Preferred method of delivery Up to 90% oxygen can be delivered Technique- reservior bag fill before placement 15 LPM Flow rate Non-Rebreather The preferred method in the pre-hospital setting This device has an O2 reservoir bag attached to a mask with a one way valve With use of an nonrebreather mask the patient is delivered 90%- 100% O2 The flow rate for a nonrebreather is 15 lpm Inflate the reservoir bag completely before applying it to the patient UGA ATEC Course Bag-Valve -Mask UGA ATEC Course Bag Valve Mask Device Bag Valve device Hand powered Room air 21% Oxygen @ 15 LPM = 60% Oxygen @ 15 LPM with reservoir = 95% UGA ATEC Course 102 Oxygen Administration Concentration of Oxygen Delivered Rescue breathing - 16% Resuscitation mask - 16% w/ O2 it goes up to 50 % BVM - 21% and w/ O2 it goes up to 100% Oxygen Administration Advantages of BVM Higher concentration of oxygen than mask alone Limits potential for disease transmission It is very effective when used by two rescuers Disadvantages It is a tough skill for 1 rescuer to master Without practice you cannot stay proficient It takes longer to assemble It is not readily available to you BLS Airway/Ventilation Methods One-Person BVM Difficult to master Mask seal often inadequate May result in inadequate tidal volume Gastric distention risk Ventilate only until see chest rise UGA ATEC Course 105 BLS Airway/Ventilation Methods Two-person BVM Most efficient method Useful in C-spine injury improved mask seal, tidal volume Three-person BVM Less utilized Used when difficulty with mask seal Crowded UGA ATEC Course 106 Bag-Valve -Mask The BVM consists of a self inflating bag and a nonrebreathing device It can be used with basic or advance airways Most on the market today have a volume of 1600 ml and can deliver O2 concentration of 90% to 100% Children under 8 and infants use a BVM of 450 to 500 ml Some models have a built in CO2 detector UGA ATEC Course Bag-Valve -Mask A BVM should have the following features A self refilling bag A non jamming valve system that lets in 30 lpm Standard fittings to fit a variety of adjuncts An O2 inlet and reservoir that can be connected to an O2 source A true nonrebreather valve Adaptability to all environmental conditions A variety of mask sizes Transparent mask UGA ATEC Course BVM Techniques UGA ATEC Course May 17th - 19th Oxygen Administration To maintain a tight seal and an open airway follow these three steps Tilt the persons head back Lift the jaw upward Keep the mouth open If you suspect a head or neck injury use the jaw thrust technique BVM Techniques Single Person Technique Straddle the head Thumb over the bridge of the nose Index finger over the cleft above the chin Seal the mask with your thumb and index finger while pulling up on the mandible with your other fingers The “E-C” technique will be performed with one hand Squeeze the bag with the other hand The bag may be compressed against your body if you have small hands UGA ATEC Course BVM Techniques UGA ATEC Course Oxygen Administration Using the BVM Resuscitator It is best that a BVM be used by two rescuers One rescuer positions the mask and opens the airway The first rescuer maintains a tight seal while the second provides ventilation's by squeezing the bag The two person technique is preferred because of the tight seal. BVM Techniques 2 Person technique Position yourself at the top of the patients head Open the airway using proper technique Select the correct size mask and insert an airway if needed Place the upper narrow part of the mask over the bridge of the nose and lower it over the mouth and chin Place your thumbs on the top half and your index fingers over the bottom The other person should squeeze the bag with 2 hands UGA ATEC Course BVM Techniques With O2 connected the flow rate is 15 lpm Deliver steadily over 1 second until chest rise If no O2 you should ventilate over 1 to 2 second period until the chest obviously rises Children should be 1 to 1.5 seconds Connect O2 as soon as possible Your patient may be awake and conscious when you use a BVM. Check their O2 saturation. The BVM may be used to increase respiration rate UGA ATEC Course Bag Valve Mask Videos http://www.youtube.com/watch?v=J Wm4FG6k3TY&feature=related http://www.youtube.com/watch?v=fh MeMXXpZAc&feature=related 116 Thank You! UGA ATEC Flail Chest UGA ATEC Course Flail Chest UGA ATEC Course Pneumothorax UGA ATEC Course Pneumothorax UGA ATEC Course Tension Pneumothorax UGA ATEC Course Treatment for Tension Pneumothorax UGA ATEC Course UGA ATEC Course Advanced Airway Adjuncts UGA ATEC Course Combi-Tube Combi-Tube •Under medical direction only •Two types available, depending on size of the athlete •Need to lubricate with KY jelly before use. •Inflate balloons before insertion to make sure they are functioning properly •Always inflate blue then white -the same with deflation. UGA ATEC Course Combi-Tube Insert with a thumb grasping tongue and forefinger the jaw – insert until black line are at the teeth UGA ATEC Course Combi-Tube Combi-Tube Installed UGA ATEC Course King LTD Airway UGA ATEC Course King LTD Airway UGA ATEC Course King LTD Airway Test cuff and inflation system for leaks by injecting the maximum recommended volume of air into the cuffs (size 4 80 ml; size 5 - 90 ml). Remove all air from both cuffs prior to insertion. The inflation volume is printed on the tube. UGA ATEC Course King LTD Airway Apply lubricant to the beveled distal tip and posterior aspect of the tube, be careful that you don’t get lubricant into the ventilation openings. UGA ATEC Course King LTD Airway The ideal head position for insertion of the KING LT-D is the “sniffing position”. However, the angle and shortness of the tube also allows it to be inserted with the head in a neutral position. Hold the KING LT-D at the connector with your dominant hand. hold mouth open and apply chin lift with your other hand. UGA ATEC Course King LTD Airway UGA ATEC Course King LTD Airway Rotate the King Airway laterally 4590 degrees so that the blue orientation line is touching the corner of the mouth. Introduce the tip into mouth and advance the airway behind the base of the tongue. UGA ATEC Course King LTD Airway As tube tip passes under the tongue, rotate the tube back to midline (blue orientation line facing chin). UGA ATEC Course King LTD Airway Without exerting excessive force, advance tube until base of connector is aligned with teeth or gums. UGA ATEC Course King LTD Airway Using the syringe provided, inflate the cuffs of the KING LT-D with the appropriate volume: Size 4 70 ml Size 5 80 ml Inflation volume is printed on the tube. UGA ATEC Course King LTD Airway Attach BVM to the KING LT-D. While gently bagging the patient to assess ventilation, simultaneously withdraw the KING LTD until ventilation is easy and free flowing (large tidal volume with minimal airway pressure). UGA ATEC King LTD Airway Secure KING LT-D to patient using tape or other accepted means. A bite block can also be used, if desired. The KING LT-D is not an ET tube and can’t be used as a med route. The end of the KING airway should be in the esophagus, not the trachea; UGA ATEC Course Thank You! UGA ATEC