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NREMT Airway Management and Ventilation

Airway management and ventilation are…
FIRST and MOST critical steps in assessment of every patient you encounter.
Lower airway anatomy
trachea (C-shaped rings)
bronchi (main stems)
bronchioles (bronchiole rings)-have unique property: stimulated by drugs
alveoli (perfusion takes place)-surfactant keeps them open
lung parenchyma
pleura (parietal and visceral)
Upper airway anatomy
nose
nasal cavity
para-nasal sinus
nasopharynx
oropharynx
laryngopharynx
larynx
Pediatric airway is different because…
smaller jaw
larger tongue
cricoid cartilage is narrowest part of airway
epiglottis is rounder and floppier
respiration is…
the exchange of gases between organisms and it’s environment
ventilation is….
the mechanical process of moving air IN and OUT of the lungs
Pulmonary Circulation is…
the perfusion of O2 and CO2
Diffusion…
movement of gas from an area of HIGHER CONCENTRATION to area of lower concentration
Diffusion transfers gases between???
LUNGS and BLOOD
and
BLOOD and PERIPHERAL TISSUES
Normal arterial pressures
oxygen(PaO2)=100 torr
Carbon dioxide(PaCO2)=35-45 avg.=40
SPO2 and ETCO2
SPO2=94-100
ETCO2=40
Factors affecting O2 concentration in Blood…
decreased hemoglobin concentration
inadequate alveolar ventilation
decreased diffusion across pulmonary membrane, when diffusion distance increases, or pulmonary membrane changes
Ventilation/perfusion mismatch occurs when portion of alveoli collapses
Factors affecting CO2 concentrations in Blood…
Lowers CO2 levels are due to increased respiratory rates or deeper respiration or hyperventilation
and
Higher CO2 levels are caused by: fever, muscle exertion, shivering, or metabolic processes resulting in the formation of metabolic acids
So, a pt. w/ a PaCO2 of 30 will be…
ALKALOTIC thus decreasing respiratory rate…
Respiratory Rate
is INVOLUNTARY however can be VOLUNTARILY controlled.
chemical and physical mechanisms provide involuntary impulses to correct breathing irregularities
chemoreceptors are located in…
carotid bodies
arch of the aorta
and medulla
baroreceptors in carotid artery
regulate BP
stimulated by decreased PaCO2, increased PaCO2, and decreased PH
Cerebrospinal fluid (CSF)pH
primary control of respiratory center
main respiratory center
medulla
(neurons in medulla initiate impulses that produce respiration)
apneustic center
assumes respiratory control if the medulla fails to initiate impluse
pneumotaxic center
controls respiration
Stretch receptors (HERING BREUER REFLEX)
prevents over expansion of the lungs
Normal respiratory rates:
adults: 12-20
pedi: 18-24
infant: 40-60
airway obstruction caused by:
foreign bodies
trauma
laryngeal spasm
edema
aspiration
MOST COMMON OBSTRUCTION: YOUR TONGUE…
Respiratory system assessment:
is airway patent?
is breathing adequate?
look, listen, feel
respiratory physical exam:
inspection (mouth, nose)
skin color (flush, pale, blue)
pt. position
dyspnea
modified form of respiration
rate, pattern, mentation, auscultation
listen at mouth and nose for adequate air movement
stethoscope for normal or abnormal air movement
auscultation anterior and posterior
kussmaul’s respirations
deep slow
or
rapid gasping

(common in DKA)

cheyne-stokes respirations
progressively deeper, faster, breathing
and
alternating gradually with shallow, slower, breathing

(indication of brain stem injury)

agonal respirations
shallow
slow
or
infrequent

(indicating brain anoxia)

disruption in ventilation caused by
nervous system
trauma
poison
over dose
disease
airway sounds:
stridor
wheezing
rales
rhonchi
snoring
crackles
palpate chest wall for:
tenderness
symmetry
abnormal motion
crepitus
subcutaneous emphysema
monitoring devices for airway
ETCO2 electronic and colormetric
SPO2
esophageal detector device EDD (bulb refills easily upon release indicates correct placement of ET tube)
manual airway maneuvers
head tilt/chin lift
modified jaw thrust (used in trauma b/c C-collar)
jaw-thrust maneuver
sellick’s maneuver (cricoid pressure)
jaw lift maneuver
basic mechanical airways
nasopharyngeal airway (NPA)
or
oropharyngeal airway (OPA)-tip facing palate & rotate 180 degrees into position
advanced airway management
Endotracheal intubation is performed if basic airway management is NOT effective
Laryngoscope blades:
Macintosh blade (vallecula)
or
Miller blade (lifts up the epiglottis)
ET intubation indicators:
cardiac arrest, respiratory arrest, unconsciousness
risk aspiration or obstruction from foreign bodies
trauma, burns, anaphylaxis,
respiratory extremis due to disease
pneumothorax, hemo-thorax, hemo-pneumothorax w/ respiratory difficulty
complications ET intubation:
equipment malfunction
teeth breakage or soft tissue lacerations
hypoxia-esophageal intubation, endo-bronchial intubation, or due to TIME
tension pneumothorax
advantages of ET intubation:
isolates trachea and permits complete control of airway
impedes gastric distention
eliminates need to maintain mask seal
offers direct route suctioning
administration of medications
disadvantages of ET intubation:
considerable training and experience
requires special equipment
requires direct visual of vocal cords
bypasses upper airway functions of warming, filtering and humidifying the air
after ETT intubation:
Check, Check, Check and check again…
don’t be a D.O.P.E.
DISLODGE
Obstruction
Pneumo
Equipment
Foreign body removal with direct visualization…
Magill forceps
Nasotracheal intubation useful when?
possible spinal injury
clenched teeth
fractured jaw
oral injuries or recent oral surgery
facial or airway swelling
obesity
arthritis
other advanced airways:
esophageal CombiTube
laryngeal mask airway
pharyngo-tracheal lumen airway
exophageal gastric tube
esophageal obturator airway (EOA)
surgical airway when:
inability to establish airway any other way…
Jet ventilation w/ cricothrotomy-14G w/ positive pressure air delivery
anatomical landmarks for cricothrotomy: between cricoid cartilage and thyroid cartilage
make a 1cm horizontal incision through the cricothyroid membrane
O2 delivery devices % O2 delivery:
N/C- 40%
simple face mask- 40%-60%
NRB-80%-95%
BVM w/ reservoir- 100%
BVM w/o reservoir- 21%
ventilation methods:
mouth to mouth
mouth to nose
bag valve devise
demand valve devise
automatic transport ventilator
Ventilating a patient proper tidal volume
5-10 cc/kg
adult respiratory distress syndrome is what type of lung injury…
CHRONIC. CHRONIC. CHRONIC… a lung injury
ARDS causes:
sepsis, aspiration, pneumonia, pulmonary injury, burns/inhalation injury, drugs, high altitude, hypothermia…
pathophysiology of ARDS:
affects interstitial fluid, causes INCREASE of fluid in interstitial space, and disrupts diffusion and perfusion..
(high mortality, by multiple organ failure)
ARDS assessment:
abnormal breath sounds & CRACKLES and RALES
Management of ARDS:
manage underlying condition, provide O2, support respiratory effort, provide PPV if respiratory failure is imminent.
monitor cardiac rhythm, V/S
MEDS: corticosteroids
Obstructive Lung Disease:
emphysema
chronic bronchitis
asthma

(causes: genetic disposition, smoking, allergies, and other risk factors)

atelectasis
destruction of alveolar wall causing poor perfusion
emphysema pathophysiology:
exposure to noxious substances, exposure results in destruction of alveoli walls(atelectasis) causing poor perfusion
weakens walls of small bronchioles and results in INCREASE RESIDUAL VOLUME
loss of elasticity causes increased pressure
right sided heart failure RHF
failure-Cor Pulmonale
Polycythemia
Increased infection & Dysrhythmia
emphysema assessment:
Barrel chest
prolonged expiration and rapid rest phase
thin, pink, skin due to extra red cell production
hypertrophy of accessory muscles
EMPHYSEMA
PINK PUFFER PUFFER SMOKERS
PINK PUFFER PUFF PUFF PUFF
Chronic bronchitis pathophysiology
result from increase in mucus-secreting cells in respiratory tree
alveoli relatively unaffected
decreased alveolar ventilation
Chronic bronchitis history:
frequent infections
productive cough
smoker
HAS BEEN GOING ON FOR YEARS…
chronic bronchitis exam:
often overweight
rhonchi present on auscultation
JVD, JVD, JVD
ankle edema
hepatic congestion
“BLUE BLOATER”
Bronchitis & Emphysema management:
maintain airway, support breathing, monitor SpO2
position of comfort
be prepared to ventilate or intubate
monitor cardiac rhythm, IV access,
MEDS: bronchodilators & corticosteroids
asthma pathophysiology
chronic inflammatory disorder results in widespread but variable air flow obstruction.
airway becomes hyper responsive
induced by a trigger, varies by individual
trigger causes histamine release causing:
bronchoconstriction and bronchial edema
6-8 hours later immune system cells invade bronchial mucosa and cause additional edema…
asthma exam:
dyspnea
wheezing (in some NOT ALL)
cough
speech 1-2 consecutive words
hyperinflation of chest and accessory muscle use.
auscultate breath sounds and measure peak expiratory flow rate.
may stop breathing b/c decreased lung capacity
asthma management:
correct hypoxia, reverse bronchospasm, reduce inflammation
maintain airway, support breathing, high flow O2, assist ventilations, monitor cardiac rhythm, IV
MEDS: BETA-AGONISTS, IPRATROPIUM BROMIDE, CORTICOSTEROIDS
status asthmaticus
severe prolonged asthma attack that can NOT be broken by bronchodilators, greatly diminished breath sounds, RECOGNIZE IMMINENT RESPIRATORY ARREST.
AGGRESSIVELY MANAGE AIRWAY/BREATHING.
transport immediately
MEDS: need albuterol continuously
Upper respiratory infection
URI above the GLOTTIC OPENING
URI
frequent pt. complaint
common pediatric complaint
rarely life threatening
Worst URI
EPIGOLOTITIS
Pneumonia pathophysiology
infection in lungs, problem in immune suppressed pt.
bacterial and viral
hospital acquired vs. community acquired
infection spread throughout the lungs
alveoli may collapse resulting in ventilation disorder
pneumonia management
maintain airway, support breathing, high flow O2, assist ventilation, monitor V/S, IV access
MEDS: AVOID FLUID OVERLOAD, ANTIPYRETICS, BETA-AGONISTS
Toxic inhalation pathophysiology
heated air, chemical irritants, steam
airway obstruction due to edema and laryngospasm due to thermal and chemical burns
toxic inhalation assessment:
focused history and physical exam SAMPLE/OPQRST
determine nature of substance, length of exposure, and LOC
toxic inhalation management:
SCENE SAFE FIRST… SCENE SAFE… only enter with proper training and equipment. remove pt. from toxic environment. maintain airway, early aggressive management indicated, support breathing, IV access, TRANSPORT PROMPTLY.
Carbon Monoxide Inhalation
Carbon Monoxide is odorless, colorless gas, results from combustion of carbon-containing compounds.
Often builds up to dangerous level in confined spaces.
Carbon Monoxide Inhalation pathophysiology:
binds to Hemoglobin
200-300 times affinity of oxygen (way sticker)
prevents O2 from binding and creates hypoxia on cellular level.
Carbon Monoxide Inhalation assessment:
focused history and physical exam
SAMPLE/OPQRST, length of exposure
presence of headache, confusion, agitation, lack of coordination, loss of consciousness, and seizures
Carbon Monoxide Inhalation management:
SCENE SAFE…SCENE SAFE… only enter if properly trained and with proper equipment, remove pt. from toxic environment, maintain airway, support breathing, high flow O2, assist ventilation, IV access, transport.
(hyperbaric chamber)
Pulmonary Embolism
SpO2 in tank ETCO2 in tank
pulmonary Embolism pathophysiology:
obstruction pulmonary artery (typically occurs in Right Heart)
emboli may be air, thrombus, fat, amniotic, foreign bodies may cause an embolus
PE risk factors:
recent surgery, long-bone f(x), pregnancy (pregnant or postpartum), oral contraceptive use, tobacco use, IDDM, PE
PE assessment:
focused history and physical exam, SAMPLE/OPQRST presence of risk factors, unexplained tachycardia, sudden severe dyspnea & pain, pain w/ inhalation and exhalation, cough, cough is often blood tinged
PE exam:
anxiety
syncopy
diaphoretic
JVD
hypotension
warm swollen extremities
PE management:
maintain airway, support breathing, high flow O2, assist ventilations indicated, ETT intubation may be indicated, IV access, monitor V/S, transport to appropriate facility.
spontaneous pneumothorax:
occurs in the absence of blunt or penetrating trauma
spontaneous pneumothorax risk factors:
young, tall, skinny, lanky, males
spontaneous pneumothorax assessment:
focused history and physical exam, SAMPLE/OPQRST presence of risk factors, rapid onset of symptoms, sharp, pleuritic chest or shoulder pain.
OFTEN precipitated by COUGH or LIFTING.
spontaneous pneumothorax exam:
decreased or absent breath sounds on affected side, tachypnea, diaphoresis, and pallor
spontaneous pneumothorax management:
maintain airway, support breathing, monitor for tension pneumothorax, pleural decompression may be indicated if patient is cyanotic, hypoxic, and difficult to ventilate. JVD and tracheal deviation away from affected side.
hyperventilation syndrome assessment:
focused history and physical exam, SAMPLE/OPQRST fatigue, nervousness, dizziness, dyspnea, chest pain, numbness and tingling in hands, mouth, and feet. Presence of tachypnea and tachycardia. spasms of the fingers and feet. (you’ll see 100% SPO2 w/ Low ETCO2)
hyperventilation syndrome management:
maintain airway, support breathing, high flow O2, assist ventilations indicated. DO NOT ALLOW PATIENT TO REBREATHE EXHALED AIR. Reassure the patient………….
CNS dysfunction pathophysiology:
causes include traumatic/atraumatic brain injury, tumors, and drugs.
CNS assessment:
evaluate potentially treatable causes such as narcotic drug OverDose or CNS trauma. Evaluate breathing pattern.
CNS management:
general management principles, maintain airway, support breathing, use C-spine precautions if indicated.
Dysfunction Spinal cord, Nerves, or Respiratory muscles pathophysiology:
PNS problems affecting respiratory function may include trauma, polio, myasthenia gravis, viral infections, tumors
Dysfunction Spinal cord, Nerves, or Respiratory muscles assessment:
rule out traumatic injury, assess for numbness, pain, or signs PNS dysfunction
Dysfunction Spinal cord, Nerves, or Respiratory muscles management:
general management principles. maintain airway, support breathing. use C-spine precautions if indicated.

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