Airway Management Flashcards
1
Q
Overview
A
-applies knowledge of general anatomy and physiology to patient assessment and management in order to assure a patent airway, adequate mechanical ventilation, and respiration for patients of all ages
2
Q
respiratory system function
A
- oxygen delivery to tissue, carbon dioxide removal from tissue
- any interruption in this process impairs organ function
- brain tissue begins to die within 4 to 6 minutes
- important to detect airway problems quickly and intervene properly and rapidly
- requires constant reassessment
- must be able to locate parts of the respiratory system and understand how the system works
3
Q
two primary functions of respiratory system anatomy
A
- two primary functions:
- ventilation- moving air in and out of lungs
- respiration- gas exchange
- > upper airway- structures above vocal cords (nose, mouth, jaw, oral cavity, and pharynx)
- > lower airway- trachea to alveoli
4
Q
upper airway anatomy
A
- main functions:
- warm
- moisten
- filter air
- nasal cavity:
- conchae and meatuses increase turbulence
5
Q
the pharynx
A
- three regions:
- nasopharynx- air passage with pharyngeal tonsil
- oropharynx- common rout for food and air
- laryngopharynx - extends to the larynx
- differing types of epithelial tissue here
6
Q
anatomy of the upper airway: nasopharynx
A
- formed by the union of facial bones
- warms and humidifies air as it enters the body
7
Q
the larynx
A
- keeps food and drink out of airway
- marks where the upper airway ends and the lower airway begins
- extrinsic muscles connect larynx and elevate it during swallowing
- intrinsic muscles control vocal cords
- epiglottis
- cartilage
- hypoid bone
- ligaments
8
Q
lower airway anatomy
A
- function- conduct air to gas exchange surfaces
- trachea, bronchi, and lungs
- trachea and bronchi supported by cartilage
- smooth muscle is walls of bronchial tree allow for dilation and constriction
- smallest bronchioles connect to alveoli
- oxygen transported back to heart, distributed to rest of body
9
Q
musculoskeletal system support of respiration
A
- main muscle of ventilation: diaphragm
- innervation- phrenic nerve (C3, C4, C5)
- changes in size/volume of thoracic cavity drive inspiration (active) and expiration (passive)
- accessory muscles: intercostals, abdominals, and pectorals
- if patient is using accessory muscle to breathe, list “respiratory compromise” or “impending respiratory failure” in DD
10
Q
ventilation
A
- regulation of ventilation is primarily by the pH of the cerebrospinal fluid
- directly related to the amount of carbon dioxide in the plasma
- failure to meet the bodys need for oxygen may result in hypoxia
- patients with COPD have difficulty eliminating carbon dioxide through exhalation
11
Q
respiratory system physiology
A
- blood flows back to the heart (right side) -> lungs -> heart (left side) -> entire body
- main function of respiratory system: exchange gases at alveocapillary membrane
- regulated by nerves, sensors, and hormones
- CO2 level in body is the prime modulator of respiration
12
Q
respiration: chemical control
A
- chemical control of breathing:
- respiratory center in brainstem has sensors for CO2 levels in blood and CSF
- when CO2 levels increase, pH decrease -> medulla signals phrenic nerve to move diaphragm
- chemoreceptors monitor blood/body fluid for change in H+, CO2 and O2
13
Q
eventually all cells will die if deprived of oxygen
A
- time is critical
- 0-1 min -> cardiac irritability
- 0-4 min -> brain damage not likely
- 4-6 min -> brain damage possible
- 6-10 min -> brain damage very likely
- more than 10 minutes -> irreversible brain damage
14
Q
patient assessment
A
- recognizing abnormal breathing
- unequal or inadequate chest expansion
- increased effort of breathing
- shallow depth
- skin that is pale, cyanotic, cool or moist
- skin pulling in around ribs or above clavicles during inspiration
- 12-20 respiration rate?
- patients with inadequate breathing need to be treated immediately
15
Q
intercostal retractions
A
- ribs come out under the soft tissue
- become viable while breathing
16
Q
sternum retractions
A
-sternum becomes visible while breathing moving up and down
17
Q
know lung sounds and where
A
- wheezing (bronchoconstriction)
- rails (crackles) - pneumonia -> fluid
- ronchi
18
Q
stridor
A
-lung sound in upper airway
19
Q
oxygen saturation
A
- lower than 90 respiratory failure
- 90-94 respiratory distress
20
Q
COPD
A
-chronic obstructive pulmonary disease
-emphysema and chronic bronchitis
-trouble releasing CO2
-
21
Q
tidal volume
A
- amount inhaled or exhaled in one breath under resting conditions
- giving someone too much tidal volume on a ventilator can cause pneumothorax
- 500ml is average
- 5-6cc per kilo = tidal volume
22
Q
agonal respirations*
A
a patient may appear to be breathing after the heart has stopped
23
Q
cheyne stokes respirations*
A
- cheyne-stokes respirations are often seen in stroke and head injury patients
- breathing normal for a minute (ex. 20/mins) then breathing drops (ex. 6/mins)
24
Q
ataxic/biots respirations
A
- irregular or unidentifiable pattern
- may follow serious head injuries
25
Q
Kussmals respirations
A
- deep and fast gasping respirations
- lacking any apneic periods
- associated with metabolic/toxic disorders (diabetes mellitus)
26
Q
assessment of respiration
A
- skin color and level of consciousness are excellent indicators of respiration
- also consider oxygenation
- pulse oximetry is the initial method to assess oxygenation status
27
Q
health tilt-chin lift maneuver
A
- maneuver will open the airway in most patients
- for patients who have not sustained or are not suspected of having sustained trauma (you can cause major damage if they do)
- with patient supine, position yourself beside patients head
- place heel of one hand on forehead, apply firm backward pressure with palm
- place fingertips of other hand under lower jaw
- lift chin upward, with entire lower jaw
28
Q
jaw-thrust maneuver
A
- use if you suspect a cervical spine injury
- kneel above the patients head
- place your fingers behind the angles of the lower jaw
- move the jaw upward
- use your thumb to help position the jaw
29
Q
initial observations
A
- awake and alert -> may be respiratory distress -> can go into respiratory failure
- respiratory distress vs respiratory failure
- distress- patient will improve with simple resuscitation methods (positioning, oxygen administration by simple face masks)
- if not or if pt has signs of fatigue or altered mental status, respiratory failure is imminent
- if color is changing -> may be respiratory failure
- look at eyes, cap refill -> failure
30
Q
signs of respiratory failure
A
impending respiratory failure
- respiratory rate greater than 30 or greater less then 6 breaths/min
- oxygen saturation less then 90%
- use of multiple accessory muscle groups
- inability to lie supine
- tachycardia with a rate greater than 140 beats/min (heart is beating faster to compensate for low oxygen)
- mental status change
- inability to clear oral secretion/mucous
- cyanosis of nail beds or lips
31
Q
first thing to do if someone is having trouble breathing
A
-sit them up!
32
Q
things to look for
A
- circulation/perfusion:
- skin color is fastest way to get initial impression of patients circulation
- generalized cyanosis: oxygen desaturation
- pallor- shock
- assess mucous membranes for more subtle info (inside mouth, under eyelids), color moisture
- skin assessment not as valuable in older patient
33
Q
first impression: initial presentation
A
- asses for LOC and work of breathing and do aquick check of perfusion status
- look for clues in field assessment and confirm by thorough assessment
- have you been intubated before? (tube down trachea)
- tripod positioning?
- pursed lip breathing?
34
Q
key findings in patients with dyspnea
A
- duration:
- chronic- usually related to cardiac disease, asthma, COPD, or neuromuscular disease
- acute- asthma exacerbation, infection, pulmonary embolus, acute cardiac dysfunction, inhalation toxic substance, allergen, foreign body
- onset:
- sudden- pulmonary embolism, spontaneous, pneumothorax
- slow- pneumonia, CHF, malignancy
35
Q
detailed assessment
A
- vital signs- baseline vital signs: temp, pulse, respiration, BP, O2 saturation, end-tidal CO2
- repeat periodically depending on condition
- monitor how respiration and perfusion are affecting pts mental status
- primary survey determined vital functions and life threats
- now determine respiratory rate
- Pt breathing without difficulty, but at a high rate (tachypnea): shock: metabolic acidosis triggers increase in RR. Bradypnea with no accessory muscle use: may be CNS problem or drug use.
- history taking- ask patient to relate current symptoms to those of previous episodes
36
Q
tension pneumothorax
A
-air hunger r-respiratory distress -pressure increases -hypotensive- putting pressure on something that normally doesnt -tachycardia -respiratory distress -tracheal deviation- (opposite side of injury) -unilateral absence of breath sounds -jugular vein distention (JVD) -cyanosis (late) -treatment: -needle decompression to relive pressure -incision to decrease pressure -thoracotomy is the treatment* -chest x-ray is the diagnostic tool* -
37
Q
physical exam
A
- by now LOC and degree of stress should be known
- proceed with focused PE noting relevance to dyspnea
- neurologic exam- brain is intolerant to long periods without blood, O2 and glucose
- keep re-evaluating mental status in pts with dyspnea (person, place, time, verbal coherence, response time
- neck exam- look for JVD when pt is sitting upright (common with COPD, asthma, cardiac failure, cardiac tamponade, pneumothorax)
- JVD in otherwise healthy, young person lying flat (but not while sitting) would be normal
38
Q
tracheal deviation
A
-late sign of tension pneumothorax
39
Q
thoracotomy
A
-incision and insertion of tube to relive pressure and inflate lung
40
Q
basic airway adjuncts
A
- prevents obstruction by the tongue and allows for passage of air and O2 to the lungs
- stick it into the mouth and have it sit at the teeth
- prevents closing of mouth so you can ventilate the patient
- if they are awake and/or have a gag reflex -> dont use this (they can vomit/aspirate)
- use on unconscious patients without gag reflex
41
Q
basic airway adjuncts: oropharyngeal airways
A
- OPA
- keep tongue from blocking upper airway
- easier to suction oropharynx if necessary
- indications:
- unresponsive patients without a gag reflex
- apneic patients being ventilated with a bag mask device
- contraindications includes:
- conscious patients
- any patient who has an intact gag reflex
42
Q
basic airway adjuncts: nasopharyngeal airways
A
- NPA*
- used with a patient who:
- is unresponsive or has an altered LOC
- has intact gag reflex
- is unable to maintain his or her own airway spontaneously
- indications:
- semiconscious or unconscious patients with an intact gag reflex
- patients who will not tolerate an oropharyngeal airway
- contraindications:
- suspected head injury of any kind
- history of fractured nasal bone
- dont use on people with head trauma
43
Q
suctioning
A
- you must keep the airway clear to ventilate properly
- portable, hand operated and fixed equipment is essential for resuscitation
- any patient having difficulty breathing can use this
- stick a rigid tube in the mouth and suction out any blood, vomit, secretions that may be in the mouth
- decreases risk of aspiration pneumonia
44
Q
supplemental oxygen
A
- always give to patients who are hypoxic
- some tissues and organs need constant supply of O2
- never withhold oxygen from any patient who might benefit from it
- supplemental oxygen equipment
- become familiar with how oxygen is stored
- oxygen cylinders contain compressed gas
- liquid oxygen is becoming a more commonly used alternative
45
Q
oxygen delivery equipment
A
- nonbreathing masks
- bag mask devices- BVM
- nasal cannulas- goes into nose
- use a nasal cannulas for minor distress
- use a BVM for manual ventilations (pt cant do it themselves) -> going through failure phase
- nonbreathing masks for moderate respiratory distress
46
Q
nonrebreathing masks
A
- preferred way to give oxygen in the prehospital setting
- to patients who are breathing adequately but are suspected of having hypoxia
- combination mask and reservoir bag system
- use for moderate respiratory distress patients
- Make sure the reservoir bag is full before placing the mask on the patient
- Adjust the flow rate so the bag does not collapse when the patient inhales
- Usually 10 to 15 L/min*******
- Moderate respiratory distress
- When oxygen therapy is discontinued, remove the mask
- Delivers oxygenation at 60-95%
47
Q
nasal cannulas
A
- delivers oxygen through two small, tube-like prongs that fit into the nostrils
- can provide 24% to 44% inspired oxygen when the flowmeter is set a 1 to 6 L/min*******
- when you anticipate sustained long term therapy, consider using humidification as you can have a burning sensation to the nares
- humidification helps to keep tissues moistened
- when is it appropriate for use?
- maintenance of O2 levels for chronic illnesses (COPD, emphysema, bronchitis)
- in mild respiratory distress and will help to calm patient with minimal oxygen levels
- used on people with minor distress (maybe chronic issues)
48
Q
assisted and artificial ventilation
A
- probably the most important skill in at any level
- basic airway and ventilation techniques are extremely effective
- assisting ventilation in respiratory distress/failure
- intervene quickly to prevent further deterioration
- 2 treatment options- assisted ventilation and CPAP
49
Q
artificial ventilation
A
- patients in respiratory arrest need immediate treatment to live
- forcing air through bag mask maybe
50
Q
signs and symptoms of inadequate ventilation
A
- altered mental status
- inadequate minute volume
- excessive accessory muscle use and fatigue
- head bobbing, sleepiness
51
Q
normal ventilation versus positive-pressure ventilation
A
- in normal breathing, the diaphragm contracts and negative pressure is generated in the chest cavity
- positive pressure ventilation generated by a device (such as bag mask device) forces air into the chest cavity
- with positive pressure ventilation- (forcing air into the chest)
52
Q
positive pressure ventilation
A
- forcing air into the chest
- must be careful about how much youre pumping (pneumothorax)
- increased intra thoracic pressure reduces the blood pumped by the heart
- more volume is required to have the same effects as normal breathing
- air is forced into the stomach, causing gastric distention
- You know that you are providing adequate ventilations if:
- Patient’s color improves
- Chest rises adequately
- You do not meet resistance when ventilating
- You hear and feel air escape as the patient exhales
53
Q
bag mask device
A
- Most common method used to ventilate patients in EMS and during initial respiratory failure in the ER
- Provides less tidal volume than mouth-to-mask ventilation
- If you have difficulty adequately ventilating a patient, switch to another method
- Volume of oxygen delivered is based on chest rise and fall
- Work together with your team to provide ventilation
- Oxygen administer at 10-15 L/min***
- Severe respiratory distress***
- 75-100%
54
Q
continuous positive airway pressure (CPAP)
A
- noninvasive ventilatory support for respiratory distress
- many people diagnosed with obstructive sleep apnea wear a CPAP unit at night
- forcing air into the lung cavity
- congestive heart failure, CHS, COPD
- becoming widely used at all levels of healthcare
- provides continuous positive airway pressure (same as BMV but it is automatic)
- allows for proper gas exchange
55
Q
CPAP mechanism
A
- Increases pressure in the lungs
- Opens collapsed alveoli
- Pushes more oxygen across the alveolar membrane
- Forces interstitial fluid back into the pulmonary circulation
- Therapy is delivered through a face mask held to the head with a strapping system
- Use caution with patients with potentially low BP
- increases intrathoracic pressure -> aspiration
56
Q
CPAP indications
A
- Patient is alert and able to follow commands.
- Patient displays obvious signs of moderate to severe respiratory distress.
- Patient is breathing rapidly.
- Pulse oximetry reading is less than 90%.
- patients needs to be breathing with the machine!
- alert, good mental status
57
Q
CPAP complications
A
- Some patients may find CPAP claustrophobic
- Possibility of causing a pneumothorax
- Can lower a patient’s blood pressure
- If the patient shows signs of deterioration, remove CPAP and begin positive-pressure ventilation using a bag-mask device
58
Q
CPAP contraindications
A
- Patient in respiratory arrest or unconscious
- Signs and symptoms of pneumothorax or chest trauma (if you add pressure on top of the already high pressure it can be bad!)
- Patient who has a tracheostomy
- Active gastrointestinal bleeding or vomiting
- Patient is unable to follow verbal commands
59
Q
gastric distention
A
- occurs when artificial ventilation fills the stomach with air
- most commonly affects children
- most likely to occur when you ventilate the patient too forcefully or too rapidly
- may also occur when the airway is obstructed
60
Q
foreign body airway obstruction
A
- If a foreign body completely blocks the airway, it is a true emergency.
- early recognition is crucial
- Will result in death if not treated immediately
- in an adult, it usually occurs during a meal
- In a child, it can occur while eating, playing with small toys, or crawling
- tongue is the most common airway obstruction
- causes of airway obstruction that do not involve foreign bodies include:
- swelling, from infection or acute allergic reaction
- trauma (tissue damage from injury)
61
Q
mild airway obstruction
A
- patients can still exchange air, but will have respiratory distress
- noisy breathing, wheezing, coughing
- with good air exchange, do not interfere with the patients efforts to expel the object on his or her own
- with poor air exchange, the patient may have increased difficulty breathing, stridor, and cyanosis
- treat immediately
62
Q
severe airway obstruction
A
- patients cannot breathe, talk, or cough
- patient may use the universal distress signal, begin to turn cyanotic, and have extreme difficulty breathing
- provide immediate treatment to the conscious patient
- if not treated, the patient will become unconscious and die
- any person found unconscious must be managed as if he or she has a compromised airway
63
Q
emergency medical care for foreign body airway obstruction
A
- perform a head tilt-chin lift maneuver to clear a tongue obstruction
- look for object
- abdominal thrusts are the most effective methods of dislodging and forcing out an object
- after you have tried everything (bag mask, nonbreathing, tube) -> if unable to open airway must consider needle/surgical cricothyrotomy at level of the cricothyroid membrane
64
Q
needle/surgical cricothyrotomy
A
- cricothyroid membrane incision to access the trachea
- insert a tube to provide positive pressure ventilation
- directly to the source
- bypasses
65
Q
summary
A
- What differentiates the upper airway from the lower airway?
- What is the function of the various structures located within each?
- What is the primary regulator of respiration?
- What does the process of gas exchange entail?
- What are the various respiratory patterns?
- What is the disease process that corresponds to each?
- What clinical findings allow you to differentiate the various respiratory patterns?
- Oxygen Administration Equipment:
- What are the various flow rates associated with the devices?
- Patient presentation will dictate what oxygen administration tool is most appropriate.
- CPAP:
- How is it effectively used?
- What are the various contraindications?
