week 2 Flashcards
Patient Airway
Establishing, maintaining, and ensuring effective oxygenation and ventilation are vital aspects of effective prehospital patient care
No airway, no patient
Function of respiratory system
The function is quite simple: bring oxygen (O2) into the body and eliminate carbon dioxide (co2), the primary byproduct of aerobic metabolism
Anatomy of the Upper Airway
All anatomical airway structuresabove the level of the vocal cords
Major function
Warm, filter, and humidify air
Pharynx
Throat
Muscular tube that extends from the nose and mouth to the level of the esophagus and trachea
Made up of the nasopharynx, oropharynx, and laryngopharynx (hypopharynx)
Nasopharynx
Formed by the union of the facial bones
During Inhalation Air enters the body through the nose, the nares and passes through into the nasopharnyx
Nasal turbinates
Turbinates
Three bony shelves- superior, middle and inferior turbinates
Protrude from the lateral walls of the nasal cavity and extend into the nasal passageway
Increase the surface area of the nasal mucosa which Improves the processes of warming, filtering, and humidification of inhaled air
Nasal cavity
Nasal septum
Divides the nasopharynx into two passages
One passage is larger than the other.
Rigid partition composed of bone and cartilage
Normally in the midline of the nose
sinuses
Sinuses
Cavities formed by the cranial bones
Fractures of these bones may cause cerebrospinal fluid to leak from the nose or the ears.
Significant bleeding may arise from sinus fractures
Oropharynx
Forms the posterior portion of the oral cavity
Bordered superiorly by the hard and soft palates, laterally by the cheeks, and inferiorly by the tongue
32 adult teeth- Usually requires Significant force to dislodge teeth. If dislodged they may create an airway obstruction or be aspirated into lungs
Oropharynx hyoid bone
Hyoid bone
Lies Beneath the mandible- horseshoe shaped
Only human bone that does not articulate with any other bone
Anchors tongue muscles to jaw to suspend airway
Anchors to the thyroid cartilage by the thyroid membrane
oropahrynx tongue
May fall back against posterior pharyngeal wall when the mandible relaxes creating an anatomical a/w obstruction
It is the most common cause of anatomical a/w obstruction in patients with a decreased loc
Oropharynx palate
Comprised of hard and soft palate
Forms the roof of the mouth
Creates a separation between the oropharynx and nasopharynx
Oropharynx uvula
Soft-tissue structure
Located in the posterior aspect of the oral cavity, at the base of the tongue
Oropharynx epiglopttis
Epiglottis
Located on the Superior border of the glottic opening
Leaf-shaped cartilaginous flap
Prevents food and liquid from entering the larynx during swallowing
Bacterial infection can cause swelling, creating an airway obstruction.
Oropharynx vallecula
Anatomical space or “pocket” Located between the base of the tongue and the epiglottis
Important landmark for endotracheal intubation
Larynx
Complex structure
Formed by many independentcartilaginous structures
Marks where the upperairway ends and the lowerairway begins
Thyroid cartilage LARYNX
Thyroid cartilage
Shield-shaped structure
Formed by two plates that join in a V shape anteriorly
Form the laryngeal prominence known as the Adam’s apple
Suspended in place by the thyroid ligament
Directly anterior to the glottic opening
Cricoid cartilage LARYNX
Cricoid cartilage
Lies inferiorly to the thyroid cartilage
Forms the lowest portion of the larynx and the First ring of the trachea
Only upper airway structure that forms a complete ring
Cricothyroid membrane LARYNX
Situated Between the thyroid and cricoid cartilages
Site for emergency surgical and nonsurgical access to the airway
Bordered laterally and inferiorly by the highly vascular thyroid gland
You must locate the anatomical landmarks carefully when accessing the airway via this site.
Glottis (glottic opening)
larynx
Space in betweenthe vocal cordsand the narrowestportion of theadult’s airway
Vocal cords make up the lateral
Borders of opening
Arytenoid cartilage
larynx
Pyramid-like cartilaginous structures
Form the posterior attachment of the vocal cords
Valuable guides for endotracheal intubation
As they pivot, the vocal cords open and close, regulating the passage of air through the larynx and controlling the production of sound.
Pyriform fossae
Two pockets of tissue on the lateral borders of the larynx
Airway devices are occasionally inadvertently inserted into these pockets.
Tenting of the skin under the jaw
Laryngospasm
Spasmodic closure of the vocal cords, which causes a partial or complete airway obstruction
Typically A defensive reflex that normally lasts a few seconds when stimulated during aspiration of foreign material or submersion
If persistent it threatens the airway by preventing ventilation.
The lower airway
function : exchange oxygen and carbon dioxide
location: externally extends from the 4th clavical vertebrae to xiphoid process.
internally is spans the glottis to the pulmonary capillary membrane
Trachea
anatomy of the airway
Serves as a conduit for air entry into the lungs
Tubular structure, approximately 10 to 12 cm in length and consists of a series of C-shaped cartilaginous rings
Begins immediately below the cricoid cartilage
Descends anteriorly down the midline of the neck and chest to the level of the fifth or sixth thoracic vertebra
Divides into the right and left main stem bronchi at the level of the carina
Hilum
anatmoy of lower airway
Point of entry for blood vessels and the bronchi on each lung
Lungs consist of the entire mass of tissue that includes the smaller bronchi, bronchioles, and alveoli.
LUNGS Anatomy of the Lower Airway
Right lung has three lobes.
Left lung has two lobes.
Bronchus
Divides into increasingly smaller bronchi once it enters the lungs
Further divide into smaller bronchioles
Smaller bronchioles branch into alveolar ducts that end at the alveolar sacs.
Alveoli
Balloon-like clusters of single-layer air sacs
Functional site for the exchange of oxygen and carbon dioxide with the pulmonary capillaries
Surfactant is present on the alveoli to decrease surface tension to keep alveoli open
Atelectasis-when alveoli collapse
Airway Evaluation
Thorough assessment and appropriate management are of utmost importance in the prehospital setting
Can “see” or hear a patient breathing
Usually indicative of a problem. breathing at rest should appear effortless not labored.
Normal adult respiratory rate between 12 and 20 breaths/min
POSITIONING of patient with compromised airway
Patients experiencing compromise to their a/w status will try to compensate with preferential positioning
Upright tripod position (elbows out)
Semi-Fowler (semi-sitting) position
Avoid a supine position.
Airway Status
Is the airway open and patent?
Is it likely to remain so?
Sonorous sounds
Gurgling or bubbling sounds
order of problem to solve
Simple to complex
Easiest problem to solve is position.
Possibility of spine injury drives the decision of which technique to use to open the airway.
Obstruction requires BLS procedures to clear the obstruction.
Recognition of Airway Problems
Is the pt Conscious, alert, and able to speak without difficulty?
Most likely indicates no immediate airway or breathing problems
However, You must still closely monitor a patient’s airway and breathing status and be prepared to intervene.
airway problems Dyspnea hypoxemia hypoxia anoxia
dyspnea
Any difficulty in respiratory rate, regularity, or effort
Hypoxemia- a decrease in arterial O2 levels, left untreated may lead to…..
Hypoxia- a lack of O2 to the body’s cells and tissues, left untreated may lead to…..
Anoxia- an absence of O2, results in cellular and tissue death
non-patent airway or absent/inadequate breathing
Proper airway management involves
Opening the airway
Clearing the airway
Sequence of treatment should follow these steps
1. Assessing
2. intervening
3. reassess breathing
4. And repeat 1-3
airway evaluation visual techniques
How is the patient positioned?
Is rise and fall of the chest adequate?
Is the patient gasping for air?
What is the skin colour?
Is there flaring of the nostrils?
Are they drooling?
Can you visualize blood, vomit or other foreign bodies?
Is the patient breathing through pursed lips?
Do you note any retractions?
Is the patient using accessory muscles to breathe?
Is the patient’s chest wall moving symmetrically?
Evaluation of the airway sounds
Air movement at the patient’s nose and mouth
Auscultate breath sounds with a stethoscope.
to Open And Clear The Airway
Chin lift and/or modified jaw thrust maneuver.
Visualize the oro-pharynx
Suction and/or remove foreign bodies.
Insert an oral airway if the patient has a decreased LOC and NO gag reflex.
Insert a nasal airway if the patient has a decreased LOC and a gag reflex.
airway eval Feel
Note any resistance or change in ventilatory compliance
Increased compliance or decreased compliance
For any changes in tidal volume (amount of air going in and out)
Change in pulse quality, or even the disappearance of a pulse during inhalation may also be detected.
Positioning the patient
Supine position or semi-fowlers position
In a perfect world, all patients would present in this position for ease of evaluation. If patient found prone, log roll the patient as a unit
Quickly open the airway, assess breathing, and intervene as needed
In nontraumatic patient with decreased LOC the recovery position may be utilized
Recovery position
Left lateral recumbent position
Should be used in all nontrauma patients with a decreased LOC who are able to maintain their own airway spontaneously and are breathing adequately
Manual Airway Maneuvers
Most common cause of airway obstruction In the pt with a decreased LOC is the Tongue
Manually maneuver thepatient’s head to lift the tongue forward.
Head Tilt–Chin Lift Maneuver
Tilting the patient’s head back and lifting the chin
technique used for opening the airway of a patient who has not sustained trauma
Indications- unresponsive pt with no C-spine injury, or pt is unable to protect own A/W
Contraindications- possible C-spine injury
Advantages- no equip, simple, safe, noninvasive
Disadvantages- does not protect from aspiration
Jaw-Thrust Maneuver
If you suspect a cervical spine injury
Open the airway by placing your fingers behind the angle of the jaw and lifting the jaw forward.
Indications- pt unable to protect own A/W, ?? C-spine injury
Contraindications- not tolerated
Advantages- can be used with C-collar, no equip required
Disadvantages- does not protect against aspiration, fatigue, require 2 medics for BVM
Jaw-Thrust Maneuver With Head Tilt
Similar to the head tilt–chin lift maneuver
Employ both maneuvers simultaneously
Causes of Airway Obstruction
Tongue- most common cause of obstruction in an unconscious pt or one with a decreased LOC.
- the jaw relaxes, and the tongue falls back on the posterior pharyngeal wall
You will note Snoring respirations in partial obstruction, Complete obstruction- no respirations (apnea)
Simple to correct with manual maneuvers
Causes of Airway Obstruction 2
Foreign body
Typical victim is middle-aged or older and wears dentures.
Patients with conditions that decrease their airway reflexes are at an increased risk, ie. CVA, ETOH (alcohol)use
Mild or severe airway obstruction depending on size and location
S&S-
Choking, gagging, stridor, dyspnea, aphonia, dysphonia,
Laryngeal spasm (laryngospasm) and edema
airway obstruction
Results in spasmodic closure of the vocal cords, completely occluding the A/W
Many different causes- examples…..asthma, anaphylaxis, epiglottitis, stress, inhalation injury, GERD
May be caused by trauma during an overly aggressive intubation attempt or immediately upon extubation
May be relieved by PPV
Fractured larynx
airway obstruction
Patency depends on good muscle tone to keep the trachea open
Increases airway resistance by decreasing airway size secondary to decreased muscle tone, laryngeal edema, and ventilatory effort
Aspiration
airway obstruction
Blood or other fluid significantly increases mortality.
In addition being a foreign body in the A/W, aspirated substances can destroy delicate bronchiolar and lung tissue as well as introduces pathogens into the lungs, and decreases the patient’s ability to ventilate
Suction should be readily available for any patient with an unprotected A/W
Recognition of an Airway
airway obstruction
Can cause a partial to completely obstructed A/W
Important- Rapid but careful assessment is required to determine the severity of the obstruction as treatment differs
Common causes airway obstruction
Relaxation of tongue in unresponsive pt
Foreign body- food, dentures, small toys
Blood clots, broken teeth or other damaged tissue following trauma
Airway tissue swelling- infection, allergic reaction
Aspirated vomit
Severe/complete airway obstruction
Typically experiences a sudden inability to breathe, talk, or cough
Pt typically grasps at his or her throat,
Will turn cyanotic and make attempts to move air; they will appear frantic and in a state of panic
May exhibit a Weak, ineffective,or absent cough.
Care for Foreign BodyAirway Obstruction
Unresponsive patient
Manage as if he or she has a compromised airway.
Open and maintain the airway with the appropriate manual maneuver.
Assess for breathing.
Provide artificial ventilation if necessary.
Care for Foreign BodyAirway Obstruction After opening the airway
If you are unable to ventilate or if you feel resistance when ventilating, reopen the airway and again attempt to ventilate the patient.
Lung compliance is the ability of the alveoli to expand during ventilation. Poor lung compliance is characterized by increased resistance during ventilation
Care for Foreign BodyAirway Obstruction 2
If Large pieces of vomitus, mucus, loose dentures, or blood clots are found in the airway, sweep them forward and out of the mouth with your gloved index finger.
Blind finger sweeps of the mouth are not recommended
Take care not to force the foreign body deeper into the airway.
Do not blindly insert any object into the patient’s mouth.
Suction to clear the airway of secretions.
Heimlich Maneuver
Abdominal thrusts
Most effective method of dislodging and forcing an object out of the airway
Aims to create an artificial cough by forcing residual air out of the victim’s lungs
If the patient is in the advanced stages of pregnancy or is morbidly obese, perform chest thrusts instead.
Suctioning
Patient’s mouth filled Vomitus, blood, or secretions?
Suction apparatus enables you to remove the liquid quickly and efficiently.
Ventilating a patient with secretions in his or her mouth will force material into the lungs, resulting in an upper airway obstruction or aspiration.
If you hear gurgling, the patient needs suctioning!
Suctioning Equipment
Ambulances should carry:
Fixed suction unit
Portable suction unit
Regardless of your location, must have quick access to suction unit
Suctioning Equipment 2
Mechanical or vacuum-powered suction units
Should be capable of generating sufficient vacuum
Amount of suction should be adjustable for use in children and intubated patients.
Check the vacuum at the beginning of every shift.
Suctioning Equipment 3
Wide-bore, thick-walled, nonkinking tubing
Soft and rigid suction catheters
A nonbreakable, disposable collection bottle
A supply of water for rinsing the catheters
Suctioning Equipment 4
Suction catheter
Hollow, cylindrical device
Used to remove fluids and secretions from the patient’s airway
Yankauer catheter(tonsil-tip catheter)
Rigid catheter
Suctioning Equipment 5
Suction catheter (continued)
Whistle-tip catheters
Soft catheters
V-Vac
Suction only as far as you can see…
Measure from Middle of mouth to
tragus
Adult setting=380mmHg
No more than 10 sec intervals
Adequate oxygenation between intervals
Suctioning Techniques
Mortality increases significantly if a patient aspirates.
Suctioning the upper airway is critical to prevent aspiration.
Removes not only liquids from the airway, but also oxygen- limit suction intervals to 10 seconds
Any patient who is to be suctioned should be adequately preoxygenated first.
Suctioning Techniques soft tipped catheters
Using soft-tip catheters
Must be lubricated when suctioning the nasopharynx
Used through an ET tube
Catheter is inserted and suction is applied during extraction of the catheter to clear the airway
Suctioning Techniques catheter
Before inserting any suction catheter
Make sure you measure for the proper size.
Never insert a catheter past the base of the tongue.
Airway Adjuncts
First step
Open the airway, initially by manual methods, then cross finger/scissor to open mouth
If the patient has an altered LOC, an artificial airway may then be needed to help maintain an open air passage.
An artificial airway is not a substitute for proper head positioning.
Oropharyngeal Airway
Curved, hard plastic device
Fits over the back of the tongue
Designed to hold the tongue away from the posterior pharyngeal wall
Oropharyngeal Airway considerations
Considerations
Indications- unresponsive pt, absent gag reflex
Contraindications- conscious pt, intact gag reflex
Advantages- noninvasive, easily placed, prevents tongue from blocking the glottis
Disadvantages- does not prevent aspiration (not definitive A/W)
Complications- may induce gag and unexpected vomiting, soft tissue or dental trauma from poor technique
Oropharyngeal Airway risks
Improperly sized or inserted incorrectly- (measure from earlobe to corner of the mouth)
Could actually push the tongue back into the pharynx, creating an airway obstruction
Rough insertion can injure the hard palate, resulting in oral bleeding and creating a risk of vomiting or aspiration.
Prior to inserting, suction the oropharynx as needed to ensure that the mouth is clear of blood and fluids.
If the patient gags while being suctioned, consider using a nasopharyngeal airway instead
BASIC AIRWAY
Open And Clear The Airway:
An oropharyngeal airway holds back the tongue. Insert an oral airway if the patient has a decreased LOC and NO gag reflex.
Open the mouth and insert the airway inverted.
Rotate the airway 180◦ and slide down the curvature of the tongue.
Fully insert the airway so the flange rests on the teeth.
Nasopharyngeal Airway
Nasal
15-cm long, soft, rubber tube
Inserted through the nose into the posterior pharynx behind the tongue
Allows passage of air from the nose to the lower airway
Much better tolerated than an oral airway in patients who have an intact gag reflex yet an altered LOC
Nasopharyngeal Airway considerations
Indications- unresponsive patient or with Altered Mental Status(AMS), with intact gag reflex
Contraindications- intolerance, facial or skull Fx (basal)
Advantages- use as suction portal, tolerated by awake pts, used in pt with trismus
Disadvantages- severe bleeding from poor technique, does not protect from aspiration
Measuring the Nasal Airway
Tip of the nostril to the earlobe
If it is too long it may obstruct the patient’s airway.
If the patient becomes intolerant of the nasal airway, gently remove it from the nasal passage
I-Gel Adult Sizing
There are 3 adult sizes for the i-gel airway adjunct
Size 5 “Orange” Large adult 90 kg+
Size 4 “Green” Medium adult 50-90kg
Size 3 “Yellow” Small adult 30-60kg
Why use the I-gel over other airway adjuncts?
Ease and speed of insertion*Reduced trauma*Superior seal pressure*Gastricaccess*Integral bite block*Non-inflatable cuff
Nasal Cavity
Lined with ciliated mucous membrane which trap dust and small particles
Mucous membrane is delicate with a rich blood supply
Trauma to the posterior nasal cavity may result in Bleeding that cannot be controlled by direct pressure.
Concern for deeper skull and cranial injury (cribiform plate
Visceral pleura
lines the lungs
Parietal pleura
lines the thoracic cavity
Small amount of fluid is found between the pleurae
