Chapter 11: Airway Management

Question 1

Describe the major structures of the respiratory
system. (pp 418–423)

Answer 1

The Upper airway:
- Nasopharynx
- Nasal Air passage
- Pharynx
- Oropharynx
- Mouth
- Epiglottis
- Larynx

The lower airway:
- trachea
- bronchioles
- main broncus

Question 2

Discuss the physiology of breathing.
(pp 423–428)

Answer 2

Air enters the body via the nose because the diaphragm contracts and creates negative pressure. The air passes through the nasopharynx where it is warmed and moistened, passes the epiglotus into the trachea and travels down the bronchi until it reaches the alveoli where oxygen is diffused into hemoglobin via the capillaries and then transported to the heart via the pulmonary veins. At the same time, carbon dioxide diffuses from the blood stream into the alveoli to be expelled as waste when the diaphragm relaxes

Question 3

Give the signs of adequate breathing. (p 432)

Answer 3

• A normal rate (between 12 - 20 breaths/min)
• A Regular pattern of inhalation and exhalation
• Clear and equal lung sounds on both sides of the chest (bilateral)
• Regular and equal chest rise and fall (chest expansion)
• Adequate depth (tidal volume)

Question 4

Give the signs of inadequate breathing.
(pp 432–434)

Answer 4

• Respiratory rate of fewer than 12 breaths/min or more than 20/breaths/min in the presence of shortness of breath (dyspnea)
• Irregular rhythm, a series of deep breathe followed by periods of apnea
• diminished, absent, or noisy auscultated breath sounds
• Use of tripod position
• Reduced flow of expired air at the nose and mouth
• Unequal or inadequate chest expansion, resulting in reduced tidal volume
• Increased effort of breathing (accesory muscles)
• Shallow depth (reduced tidal volume)
• Skin that is pale, cyanotic (blue), cool, or moist (clammy)
• Skin pullin in around the ribs of above the clavicles during inspiration

Question 5

Describe the assessment and care of a patient
with apnea. (p 434)

Answer 5

• Count the breaths/min
• Check for irregular rhythm
• Auscultate for diminished, absent or noisy breath sounds

Question 6

Explain how to assess for adequate and
inadequate respiration, including the use of
pulse oximetry. (pp 434–439)

Answer 6

• Assess environmental factors such as altitude or the possibility of gas exposure or infectious disease exposure such as pneumonia in the community
• Patients level of consciousness and skin color as indicators of respiration. Altered mentals may indicate a lack of oxygen to the brain or previous condition
• Poor skin color can indicate poor perfusion or shock
• measure pulse oximetry for SpO2 levels; the percentage of hemoglobin molevules that are bound in arterial blood; use this as a continuing monitor of the effect of your interventions

Question 7

Explain how to assess for a patent airway.
(pp 439–440)

Answer 7

• first check for a pulse and breathing
• the patient should be in the supine position but you must immediately assess the airway if the patient is not in a position to move
• look in the mouth for obstructions such as vomitus, dentures, broken teeth, etc. Be prepared to give suction to clear and obstruction

Question 8

Describe how to perform the head tilt–chin lift
maneuver. (pp 440–441)

Answer 8

• Position yourself at the patients head
• push down on the patients forehead while pulling up on their chin

Question 9

Describe how to perform the jaw-thrust
maneuver. (pp 441–442)

Answer 9

The Jaw thrust maneuver is a technique to open the airway by placing the fingers behind the angle of the jaw and lifting the jaw upward. Specifically useful if you suspect cervical spinal injuries

• kneel above a patients head. PLace your fungers behind the angles of the lower jaw and move the jaw upward. Use your thumbs to help position the lower jaw to allow breathing through the mouth and nose.
• the completed maneuver should open the airway with the mouth slightly open and the jaw jutting forward.

Question 10

Explain the importance of and techniques for
suctioning. (pp 442–446)

Answer 10

You must keep the airway clear so that you can properly ventilate the patient. If the airway is not clear you will force fluids and secretions into the lungs resulting in aspiration.

1. Turn on the suction unit and test that you are getting 300 mm Hg when the hose is clamped
2. Measure the catheter to the correct depth
3. Turn the patients head (unless you expect c spine injury), and open their mouth with the cross-finger technique. Insert the catheter to the measured length while OFF.
4. Insert the catheter to the premeasured depth and suction in a circular motion as you withdraw the catheter

Question 11

Explain how to measure and insert an
oropharyngeal (oral) airway. (pp 446–448)

Answer 11

Measure the OPA from the corner of the mouth to the earlobe
insert the airway with the tip towards the roof of the mouth
position the opa flange so it rest at the lips or teeth
turn it into position making sure not to push the tongue deeper

Question 12

Describe how to measure and insert a
nasopharyngeal (nasal) airway. (p 449)

Answer 12

measure from the nostril to the tip of the NPA
lubricate the NPA
Insert with the bevel facing the septum until the flange touches the nostril

Question 13

Explain the use of the recovery position to
maintain a clear airway. (pp 449–451)

Answer 13

It prevents the aspiration of vomitus but only for uninjured patients

Question 14

Describe the importance of giving supplemental
oxygen to patients who are hypoxic. (p 451)

Answer 14

The tissues and cells of the patient are not being supplied enough oxygen and some like the heart and brain require a constant supply of oxygen to function.

Question 15

Discuss the basics of how oxygen is stored
and the various hazards associated with its
use. (pp 451–457)

Answer 15

In aluminum or steel tubes most commonly that must be treated carefully because they are under pressure. Never store tanks where they might fall or be dislodged in an accident, they might become missile

Question 16

Explain the use of a nonrebreathing mask and the
oxygen flow requirements for its use. (p 458)

Answer 16

Used to administer high concentrations of oxygen to significantly hypoxemic patients who are otherwise breathing adequately. With a flow of 15 L/min the mask is capable of providing up to 90% inspired oxygen.

You must make sure the bag stays inflated as they breathe, if it collapses up the volume of oxygen. Don’t leave a mask on when not administering air, the patient will rebreathe carbon dioxide if you do.

Question 17

Describe the indications for using a nasal
cannula rather than a nonrebreathing face
mask. (p 458)

Answer 17

For patients with mild hypoxemia or when the patient won’t tolerate a rebreathing mask

Question 18

Describe the indications for using a humidifier
during supplemental oxygen therapy. (p 460)

Answer 18

When using a nasal cannula it delivers dry oxygen that can cause dryness or irritation. Humidifying can make it more comfortable for long rides but also increases the risk of aeresolizing droplets and spreading disease in the small cabin.

Typically only indicated for long term oxygen therapy

Question 19

Describe how to perform mouth-to-mouth or
mouth-to-mask ventilation. (pp 462–463)

Answer 19

Mouth-to-mouth or mouth-to-mask is only done outside of work when a bag -mask device isn’t available. IT should always be performed with a shield or mask but even those devices won’t protect from TB or Covid.

Question 20

Describe the use of a one- or two-person
bag-mask device. (pp 463–467)

Answer 20

Ideally with two people one operates the mask and the other creates and maintains the positive seal to the face. When working solo you maintain the seal with the EC Clamp grip.

1. open the airway using the tilt-chin lift or jaw thrust
2. open the patients mouth and suction as necessary, insert oral or nasal airway
3. Select the appropriate maske and position it over the patients face creating and maintaining a proper seal
4. Squeeze the bag until you see adequate chest rise. For adults, once every 6 seconds, for children once every 2 to 3 seconds.

Question 21

Describe the signs associated with adequate
and inadequate artificial ventilation. (p 468)

Answer 21

adequate:
- Visible and equal chest rise and fall with ventilation
- ventilations delivered at appropriate rate
- heart rate returns to normal range
- patients color improves
-oxygen sat increases

inadequate:
- minimal or no chest rise and fall
- ventilations are delivered to fast/slow for patients age
- heart rate does not return to normal
- patients color remains cyanotic, mottled, or deteriorates
- oxxygen saturation does not increase or decreases

Question 22

Describe the use of continuous positive airway
pressure (CPAP). (pp 469–474)

Answer 22

A CPAP can be very helpful to patients who are conscious, speaking and able to maintain their own airway. It creates positive pressure in the chest, expanding the smaller structures of respiration when the patient is exhaling, delivering relief for conditions like COPD but NOT curing the pathology.

Question 23

Explain how to recognize and care for a foreign
body airway obstruction. (pp 474–477)

Answer 23

• look for difficulty exchanging air, or respiratory distress when breathing
• If they can cough or forcefully wheeze they should be allowed to try and expell the foreign body on their own.
• If there is strider, or the patient cannot speak or cyanosis is present provide immediate treatment

Question 24

Describe the four-step process of assisting
with advanced life support (ALS) skills.
(pp 477–482)

Answer 24

• Patient prep - getting the patient oxygenated and ready for the forced apnea of the attempt usually with a bag mask and nasal or oral airway
• Equipment set-up - PPE, Suction, lubricant etc.
• Performing the procedure - BEMAGIC
• Continuing care - you must continue to monitor a patients readings, as well as monitor for signs of potential complications.

Question 25

Discuss the importance of preoxygenation
when performing endotracheal (ET) intubation.
(p 477)

Answer 25

Preoxygenation helps the alveoli maintain adequate oxygen exchange during the process.

Question 26

Describe the six steps of the BE MAGIC
intubation procedure. (pp 478–481)

Answer 26

B Perform bag-mask preoxygenation
E Evaluate for airway difficulties
M Manipulate the patient
A A attempt first-pass intubation
GI Use a supraglottic airway if unable to intubate
C Confirm successful intubation/correct any issues

Question 27

Describe the signs that indicate a complication
with an intubated patient. (pp 481–482)

Answer 27

Absence of an end-tidal C02 level - CO2 waveform disappears, the T tube may have shifted out of the proper position

Decreasing Spo2 level - if it drops below 94% the ET tube may have shifted out of position

Increasing resistance when ventilating - this may indicate incorrect placement into the esophagus

Other signs of poor ventilation or perfusion - pale skin, cyanosis etc.

Improper position or dislodgement of the ET Tube - everytime the patient moves reassess the position of the ET Ttube.

Question 28

What is an agonal gasp?

Answer 28

Abnormal breathing pattern characterized by slow gasping breaths, sometimes seen in patients in cardiac arrest.

Question 29

What are the indications that an OPA is appropriate?

Answer 29

• Unconscious patients
• who require BVM ventilation
• without a gag reflex

Question 30

Who gets oxygen?

Answer 30

Respiratory distress
- Shortness of breath
- Restless
- Normal Mental Status
- Increased pulse rate and breathing rate
- upright and/or tripod position
- Noisy breathing
- 2-3 word dyspnea
- retractions

Question 31

Which patients get a BVM?

Answer 31

Respiratory failure
- unconscious due to respirator cause
- cyanotic
- breathing less than 10 or greater than 30 per minute
- cardiac arrest
- shallow rapid breathing
- altered mental status
- confused lethargic unconscious