CHAPTER 5

Airway Management and Ventilation

INTRODUCTION
While all EMT-I skills are important to master and maintain, none are more important than those associated with airway management and ventilation. Airway and breathing are the first and most critical steps in the initial assessment of every patient you care for. No matter what else you do, what other procedures you perform, what medications you give, without adequate airway maintenance and ventilation, the patient will suffer brain injury or even death within as little as 6 to 10 minutes. This chapter will provide the information and skills you need to manage even the most difficult airway.
ADDITIONAL RESOURCES
Instructional Methods in Emergency Services, 2nd ed., Brady. BTLS: Basic Trauma Life Support for Paramedics and Other Advanced Providers, 5th ed., Brady.

OBJECTIVES
1. Review the anatomy and physiology of the respiratory system, specifically the upper and lower airways. (see Chapter 2, pp. 200213) 2. Define the terms hypoxia (p. 354), hypoxemia (p. 352), pulsus paradoxus (p. 355), gag reflex (p. 370), and gastric distention (p. 367). 3. Explain the primary objective of airway maintenance. (p. 350) 4. Identify commonly neglected prehospital skills related to airway. (pp. 358360) 5. List factors that decrease oxygen concentrations in the blood and increase or decrease carbon dioxide production in the body. (p. 352) 6. Describe how to measure oxygen and carbon dioxide in the blood. (pp. 357360) 7. List causes of upper airway obstruction and respiratory disease, and describe the modified forms of respiration. (pp. 350352, 354) 8. Identify types of oxygen cylinders and pressure regulators (including a high-pressure regulator and a therapy regulator), and explain safety considerations of oxygen storage and delivery. (p. 360) 9. Describe supplemental oxygen delivery devices, including their indications, contraindications, advantages, disadvantages, complications, liter flow range, and concentrations of delivered oxygen. (pp. 360361) 10. Describe the use, advantages, and disadvantages of an oxygen humidifier. (p. 361) 11. Explain the risk of infection to EMS providers associated with ventilation. (pp. 366368, 379, 396) 12. Describe the indications, contraindications, advantages, disadvantages, complications, and techniques for ventilating a patient: mouth-tomouth; mouth-to-nose; mouth-to-mask; one, two, and three person bag-valve mask; flow-restricted, oxygen-powered ventilation device; and automatic transport ventilator (ATV). (pp. 361365)

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13. Compare the ventilation techniques used for an adult patient to those used for pediatric patients. (pp. 363364) 14. Define, identify, and describe a tracheostomy, a laryngectomy, a stoma, a tracheostomy tube, and how to ventilate and manage the airway of a patient with a stoma. (pp. 397398) 15. Describe a complete airway obstruction and related maneuvers. (pp. 350352) 16. Define and explain the implications of partial airway obstruction with good and poor air exchange. (pp. 350351) 17. Describe laryngoscopy for the removal of a foreign body airway obstruction. (p. 386) 18. Identify the different types of suction equipment, including catheters. (pp. 365366) 19. Explain the purpose, indications, techniques, and special considerations for suctioning the upper airway. (pp. 365367) 20. Describe the technique of tracheobronchial suctioning in the intubated patient. (pp. 366367) 21. Describe the indications, contraindications, advantages, disadvantages, complications, equipment, and technique for inserting a nasogastric tube and an orogastric tube. (p. 367) 22. Describe manual airway maneuvers. (pp. 368370) 23. Describe the indications, contraindications, advantages, disadvantages, complications, and technique for inserting the oropharyngeal and nasopharyngeal airways. (pp. 370374) 24. Describe Sellicks maneuver and the use of cricoid pressure during intubation. (pp. 369370) 25. Differentiate endotracheal intubation from other methods of advanced airway management. (p. 374) 26. Describe the indications, contraindications, advantages, disadvantages, and complications of endotracheal intubation. (pp. 379382) 27. Describe the visual landmarks for direct laryngoscopy. (pp. 382385) 28. Describe the methods of assessing, confirming, and securing correct placement of an endotracheal tube. (pp. 385386) 29. Describe the indications, contraindications, advantages, disadvantages, complications, equipment, and technique for extubation. (pp. 390391) 30. Describe methods of endotracheal intubation in the pediatric patient. (pp. 386390) 31. Describe the indications, contraindications, advantages, disadvantages, complications, equipment, and techniques for using a dual lumen airway. (pp. 391395) 32. Describe the special considerations in airway management and ventilation for patients with facial injuries, (pp. 386387)

Begin class by reviewing the important points from Chapter 4, Venous Access and Medication Administration. Discuss any aspects of the chapter not fully understood by students. Then start Chapter 5 material. Ask students to recall from their CPR training the length of time a person may be in cardiac and/or respiratory arrest with no ventilation or oxygen flow to the brain before brain cells begin to die. Review the information that the brain is the most sensitive organ in the body to any reduction in oxygen delivery. Brain cells begin to die within 4 to 6 minutes if the brain is not perfused.

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FRAMING THE LESSON

Next, have students do two exercises. First, have them hold their breath as long as they can. Ask how they feel once they resume breathing. Then distribute a plastic coffee stirring stick to each student. Have them place the sticks in their mouths and breathe in and out only through their mouths. This will graphically depict how people in respiratory distress, such as asthma attacks, feel when they breathe. Stress that no matter what advanced skill or procedure is done for a patient, the patient will not survive if he does not have an adequate airway and ventilation.

TEACHING STRATEGIES
People learn in a variety of ways. Some do better with the spoken word, while others prefer the written. Some prefer to work alone, while others profit from working in groups. Recognizing these different ways of acquiring knowledge, the authors of this Instructors Resource Manual have provided a variety of teaching strategies for the different types of learners. These strategies are intended to foster higher-level cognitive skills and encourage creative learning and problem solving. For greatest effectiveness, incorporate these strategies into your class lecture. Symbols in the Lecture Outline indicate the spots at which various exercises might be most appropriate. Other strategies can be used to preview the lesson or to sum it up. The strategies below are keyed to specific sections of the lesson.

1. Airway Familiarization. Ask your local butcher for a pig pluck,

which is the trachea, esophagus, lungs, and heart of a pig. These can be kept without smelling for up to a week in the refrigerator. Let students intubate the trachea and ventilate the lungs. You will marvel at the wonderful demonstration of the alveoli, lung parenchyma, and even atelectasis. Since this specimen is fresh, it is even better than a human cadaver, which will lack the elasticity of the pig pluck. This activity is fun for your visual and kinesthetic learners but can be messy. Have students take BSI precautions, plus have lots of plastic bags, premoistened towelettes, and gloves on hand.

2. Pulse Oximeter Familiarization. Use the pulse oximeter on

every student in class. Students love to learn what their own readings are, and you can even have contests for the lowest and highest pulse ox reading. This will be a great lead into a conversation about what conditions affect pulse oximeter readings. If your program does not have a pulse ox, arrange for an ambulance or rescue unit to stop by for an hour or so. Borrow the equipment without taking the vehicle out of service. Alternatively, borrow one from a hospital emergency department.

3. Developing Suctioning Skills. Have a variety of actual sub2004 Pearson Education, Inc. Intermediate Emergency Care: Principles & Practice

stances for students to suction during this lab session. Practice with such materials can go a long way toward preparing them for managing a difficult airway with massive quantities of liquid or food. Pudding simulates mucus; apple juice simulates bile; tomato juice simulates blood; and soup looks like vomit. This activity helps add realism to your classroom lab activities. You might then test students suctioning skills in a contest. Have a variety of suctioning devices available. Divide the class into groups. Assign students in the first group one of the suctioning devices. Then bring out bowls of cold oatmeal. Challenge students to see who can do the most efficient job of suctioning. Time their efforts. Repeat with other groups until all students have had a chance. Have a runoff among the group winners. You might use pea soup or a chunky barley soup, instead.

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4. Intubating the Class. Pass out six or seven endotracheal tubes

to several students (or the whole class). Instruct them to breathe through the tubes for the duration of the class. The difficulties they will experience when breathing through a small-diameter tube should give students a new perspective and a greater empathy for what it is like to be an intubated patient.

5.Ventilation Drills. Test students grasp of some airway basics at

this point. Have them practice ventilation drills using a recording Resusci-Annie. Ask for several students who think they know how to bag. Do not use the intubation heads. These heads can be ventilated in almost any position. After five minutes, start recording the effectiveness of ventilations. This experiment can be very enlightening. Add to learning by showing how even one finger break in the seal can markedly decrease the ventilations effectiveness. Also consider having a contest between teams. One team uses a bagvalve mask while the other uses a pocket mask. Again, let ventilations continue for five minutes before you start to record. The results often tell a great deal about the effectiveness of the bag-valve mask over the pocket mask. The strategy below can be used at various points throughout the lesson or to help summarize and demonstrate what the students have learned.

Airway Cam. The new airway camera technology provides amazing video of actual human airways during intubation. If this technology is not available to you for use by your students, purchase or borrow a video from one of the manufacturing companies or a university with a medical school. While the technology is expensive, it is also relatively common. Demonstrations of airway cam have even been offered at EMS conferences around the country.
HANDOUT 5-1
Chapter 5 Objectives Checklist

TEACHING OUTLINE
Distribute Handout 5-1 so that students can familiarize themselves with the learning goals for this chapter. If students have any questions about the objectives, answer them at this time. Then present the chapter. One possible lecture outline is given below. In the outline, the parenthetical references in regular type are references to text pages; those in dark, heavy type are to figures or tables. I. Introduction: Airway management and ventilation skills are the first and most critical steps in the initial assessment of every patient EMT-Is will encounter. This chapter will provide the information and skills needed to manage even the most difficult airway. (p. 350) II. Respiratory problems: EMT-Is must calmly and quickly assess the severity of a patients illness or injury while considering the potential causes of and treatment for his respiratory distress. (pp. 350352) A. Airway obstruction (pp. 350352) 1. Tongue (Fig. 5-1, p. 351) 2. Foreign bodies 3. Trauma 4. Laryngeal spasm and edema 5. Aspiration B. Inadequate ventilation (p. 352)
2004 Pearson Education, Inc. Intermediate Emergency Care: Principles & Practice

POWERPOINT SLIDES
Bradys PowerPoint Slides on CD-ROM offer a wealth of images that can be tailored to your course needs. See specific slide references throughout.

POWERPOINT SLIDES
Slide 1

POWERPOINT SLIDES
Slides 48

TEACHING STRATEGY 1
Airway Familiarization

POINT

TO

EMPHASIZE

Your deliberate and precise use of simple, basic airway skills is the key to successful airway management and good patient outcome.

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III. Respiratory system assessment: Assessment of the respiratory system begins with the initial assessment and should continue through the focused history and physical exam and the ongoing assessment. (pp. 352360) A. Initial assessment (pp. 352353) (Fig. 5-2, p. 353) B. Focused history and physical examination (pp. 353360) 1. Focused history 2. Physical exam a. Inspection b. Auscultation (Fig. 5-3, p. 355) c. Palpation 3. Noninvasive respiratory monitoring a. Pulse oximetry (Fig. 5-4, p. 357) b. Capnography (Figs. 5-5 and 5-6, p. 358; Fig. 5-7, p. 359) c. Esophageal detector device (Fig. 5-8, p. 359) d. Peak expiratory flow testing IV. Oxygenation: Oxygen is an important drug, and its indications and precautions must be thoroughly understood. (pp. 360361) A. Oxygen supply and regulators (p. 360) B. Oxygen delivery devices (pp. 360361) 1. Nasal cannula 2. Venturi mask 3. Simple face mask 4. Partial rebreather mask 5. Nonrebreather mask 6. Small-volume nebulizer 7. Oxygen humidifier V. Ventilation: Effective artificial ventilation requires a patent airway, an effective seal between the mask and the patients face, and delivery of adequate ventilatory volumes. (pp. 361365) A. B. C. D. Mouth-to-mouth/mouth-to-nose ventilation (p. 362) Mouth-to-mask ventilation (p. 362) Bag-valve devices (pp. 362364) (Fig. 5-9, p. 363) Flow-restricted, oxygen-powered ventilation devices (demand valves) (pp. 364365) (Fig. 5-10, p. 364) E. Automatic transport ventilator (p. 365) (Fig. 5-11, p. 365)

POWERPOINT SLIDES
Slides 929

TEACHING STRATEGY 2
Pulse Oximeter Familiarization

TEACHING TIP
Bring into class models of pulse oximeters and end-tidal carbon dioxide detectors in use in your area. Demonstrate the operation of these devices. Let students take turns obtaining pulse oximetry readings on each other.

POWERPOINT SLIDES
Slides 3033

POINT

TO

EMPHASIZE

Never withhold oxygen from any patient for whom it is indicated.

READING/REFERENCE
Brocato, B. Breathing Room: Tips for the Assessment and Management of Respiratory Emergencies, JEMS, Feb. 2001.

POWERPOINT SLIDES
Slides 3436

ON

THE

NET

For effective BVM skills and techniques, go to: www.enw.org/MaskVentilation. htm

VI. Suctioning: EMT-Is must be prepared to suction all airways in order to remove blood or other secretions and patient vomitus. (pp. 365367) (Table 5-1, p. 366)
2004 Pearson Education, Inc. Intermediate Emergency Care: Principles & Practice

POWERPOINT SLIDES
Slides 3739

A. Suctioning equipment (pp. 365366) B. Suctioning techniques (p. 366) C. Tracheobronchial suctioning (pp. 366367) VII. Gastric decompression: A common problem with ventilating a nonintubated patient is gastric distention, which occurs when the procedures high pressures trap air in the stomach. (p. 367) A. Routes of decompression (p. 367) 1. Nasogastric 2. Orogastric B. Tube placement technique (p. 367)

TEACHING STRATEGY 3
Developing Suctioning Skills

POWERPOINT SLIDES
Slides 4042

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POWERPOINT SLIDES
Slides 4357

TEACHING TIP
Have students practice manual airway maneuvers on each other. Mannequin practice is good, but nothing beats the feel of opening a human airway. Have students practice stabilizing the head and neck and using the jaw-thrust to simultaneously open the airway.

VIII. Basic airway management: Once it is determined that intervention is needed, simple manual airway maneuvers and equipment should be used before proceeding with more advanced techniques. (pp. 368374) A. Manual airway maneuvers (pp. 368370) 1. Head-tilt/chin-lift 2. Jaw-thrust maneuver 3. Sellicks maneuver (Fig. 5-12, p. 369; Fig. 5-13, p. 369) B. Basic mechanical airways (pp. 370374) 1. Nasopharyngeal airway (Figs. 5-14 and 5-15, p. 371) 2. Oropharyngeal airway (Fig. 5-16, p. 373; Fig. 5-17, p. 374) IX. Advanced airway management: Inserting advanced mechanical airways requires special training; the preferred method of airway management is endotracheal intubation. (pp. 374396) A. Endotracheal intubation (pp. 374390) (Proc 5-1, p. 383) 1. Equipment a. Laryngoscope (Figs. 5-18, 5-19, and 5-20, p. 375; Figs. 5-21 and 5-22, p. 376) b. Endotracheal tubes (Figs. 5-23 and 5-24, p. 377) c. Stylet (Figs. 5-25 and 5-26, p. 378) d. 10 mL syringe e. Tube-holding devices f. Magill forceps (Fig. 5-27, p. 378) g. Lubricant h. Suction unit i. Capnometer or other confirmation device j. Additional airways k. Protective equipment 2. Endotracheal intubation indications a. Respiratory or cardiac arrest b. Unconsciousness or obtusion with no gag reflex c. Risk of aspiration d. Obstruction e. Respiratory extremis due to disease f. Pneumothorax, hemothorax, or hemopneumothorax with breathing difficulty 3. Advantages of endotracheal intubation a. Isolates trachea; permits complete control of airway b. Impedes gastric distention c. Eliminates need for mask seal d. Offers direct route for suctioning e. Permits administration of some medications 4. Disadvantages of endotracheal intubation a. Requires considerable training and expertise b. Requires specialized equipment c. Requires direct visualization of vocal cords d. Bypasses upper airway warming, filtering, humidifying of air 5. Complications of endotracheal intubation a. Equipment malfunction b. Teeth breakage and soft tissue lacerations c. Hypoxia d. Esophageal intubation e. Endobronchial intubation f. Tension pneumothorax

POWERPOINT SLIDES
Slides 58123

TEACHING STRATEGY 4
Intubating the Class

POINT

TO

EMPHASIZE

Esophageal intubation is lethal if you do not recognize it immediately.

TEACHING STRATEGY 5
Ventilation Drills

POINT

TO

EMPHASIZE

If you do not correct any significant decrease in the patients rate or depth of breathing, respiratory or cardiac arrest may occur.

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B. C.

D.

E.

6. Orotracheal intubation a. Procedure (Proc. 5-1, p. 383) b. Verification of proper endotracheal tube placement (Fig. 5-28, p. 384) c. Trauma patient intubation (Proc. 5-2, p. 387) 7. Pediatric intubation (Table 5-2, p. 388; Proc. 5-3, p. 389) Field extubation (pp. 390391) Esophageal Tracheal CombiTube (pp. 391393) 1. Advantages 2. Disadvantages 3. Insertion (Fig. 5-29, p. 391; Fig. 5-30, p. 392) Pharyngo-tracheal lumen airway (pp. 393395) (Fig. 5-31, p. 394) 1. Advantages 2. Disadvantages 3. Insertion Laryngeal mask airway (LMA) (pp. 395396) (Fig. 5-32, p. 395) 1. Advantages 2. Disadvantages 3. Insertion
POWERPOINT SLIDES
Slides 124125

X. Managing patients with stoma sites: A stoma is an opening in the anterior neck that connects the trachea with the ambient air; patients with stomas often have problems with excessive secretions. (pp. 397398) (Fig. 5-33, p. 397)

SKILLS LAB
Divide the class into as many groups as appropriate. Have the groups circulate through the stations. Monitor the groups to be sure all groups have a chance to practice each of the skills. You may wish to have other instructors or qualified EMT-Is assist students in these activities. Equipment and Personnel Needed Adult ET head Adult CPR mannequin Airway management kit 1 instructor Child/infant CPR mannequins Infant ET head Airway management kit 1 instructor Adult/infant ET heads Adult/child/infant CPR mannequins Airway management kit 1 instructor Adult ET head Airway management kit 1 instructor Infant ET head Airway management kit 1 instructor
HANDOUTS 5-2
Chapter 5 Skills Sheets
TO

5-9

Station Adult Basic Airway Maneuvers Pediatric Basic Airway Maneuvers Ventilation and Oxygenation Techniques Adult Endotracheal Intubation Pediatric Intubation

Activities Have students practice the following skills: manual airway maneuvers; insertion of oral and nasal airways; oropharyngeal suctioning. Have students practice the following skills: manual maneuvers; insertion of oral and nasal airways; suctioning. Have students practice the following skills: ventilation using pocket mask, BVM, demand valve; oxygen administration via masks and cannulae. Have students practice on adult mannequins. Have students practice on infant mannequins.

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WORKBOOK
Chapter 5 Activities

ASSIGNMENTS
Assign students to complete workbook Chapter 5, Airway Management and Ventilation. Also assign them to read textbook Chapter 6, History Taking.

TEXTBOOK
Chapter 6, pp. 399417

HANDOUT 5-10
Chapter 5 Quiz

EVALUATION
You can use the quiz provided in Handout 5-10 and/or the case study provided in Handout 5-11 to help you evaluate student understanding of this chapter. If you wish, you can also create custom-tailored tests using the Prentice Hall TestGen (combined package) that accompanies Intermediate Emergency Care: Principles & Practice.

HANDOUT 5-11
Chapter 5 Scenario

TESTGEN
Chapter 5 Test

REINFORCEMENT
TO

HANDOUTS 5-12 5-14 COMPANION WEBSITE

Reinforcement Activities

If classroom discussion or student performance in evaluation activities indicates that students have not fully mastered the chapter content, you may wish to assign some or all of the Reinforcement Handouts for this chapter.

Encourage students to visit Bradys EMT-I Website at http://www.prenhall.com/bledsoe

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ANDOUT 5-1

Students Name _________________________________

OBJECTIVES

CHAPTER 5 OBJECTIVES CHECKLIST

Knowledge Objectives 1. Review the anatomy and physiology of the respiratory system, specifically the upper and lower airways. 2. Define the terms hypoxia, hypoxemia, pulsus paradoxus, gag reflex, and gastric distention. 3. Explain the primary objective of airway maintenance. 4. Identify commonly neglected prehospital skills related to airway. 5. List factors that decrease oxygen concentrations in the blood and increase or decrease carbon dioxide production in the body. 6. Describe how to measure oxygen and carbon dioxide in the blood. 7. List causes of upper airway obstruction and respiratory disease, and describe the modified forms of respiration. 8. Identify types of oxygen cylinders and pressure regulators (including a high-pressure regulator and a therapy regulator), and explain safety considerations of oxygen storage and delivery. 9. Describe supplemental oxygen delivery devices, including their indications, contraindications, advantages, disadvantages, complications, liter flow range, and concentrations of delivered oxygen. 10. Describe the use, advantages, and disadvantages of an oxygen humidifier. 11. Explain the risk of infection to EMS providers associated with ventilation. 12. Describe the indications, contraindications, advantages, disadvantages, complications, and techniques for ventilating a patient: mouth-to-mouth; mouth-to-nose; mouth-to-mask; one, two, and three person bag-valve mask; flow-restricted, oxygen-powered ventilation device; and automatic transport ventilator (ATV). 13. Compare the ventilation techniques used for an adult patient to those used for pediatric patients. 14. Define, identify, and describe a tracheostomy, a laryngectomy, a stoma, a tracheostomy tube, and how to ventilate and manage the airway of a patient with a stoma.
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Date Mastered

15. Describe a complete airway obstruction and related maneuvers. 16. Define and explain the implications of partial airway obstruction with good and poor air exchange. 17. Describe laryngoscopy for the removal of a foreign body airway obstruction. 18. Identify the different types of suction equipment, including catheters. 19. Explain the purpose, indications, techniques, and special considerations for suctioning the upper airway.

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H A N D O U T 5 - 1 Continued

Knowledge Objectives 20. Describe the technique of tracheobronchial suctioning in the intubated patient. 21. Describe the indications, contraindications, advantages, disadvantages, complications, equipment, and technique for inserting a nasogastric tube and an orogastric tube. 22. Describe manual airway maneuvers. 23. Describe the indications, contraindications, advantages, disadvantages, complications, and technique for inserting the oropharyngeal and nasopharyngeal airways. 24. Describe Sellicks maneuver and the use of cricoid pressure during intubation. 25. Differentiate endotracheal intubation from other methods of advanced airway management. 26. Describe the indications, contraindications, advantages, disadvantages, and complications of endotracheal intubation. 27. Describe the visual landmarks for direct laryngoscopy. 28. Describe the methods of assessing, confirming, and securing correct placement of an endotracheal tube. 29. Describe the indications, contraindications, advantages, disadvantages, complications, equipment, and technique for extubation. 30. Describe methods of endotracheal intubation in the pediatric patient. 31. Describe the indications, contraindications, advantages, disadvantages, complications, equipment, and techniques for using a dual lumen airway. 32. Describe the special considerations in airway management and ventilation for patients with facial injuries.

Date Mastered

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ANDOUT 5-2

Students Name _________________________________

SKILLS

MANUAL AIRWAY MANEUVERS

Key to Charting Student Progress: 1. Learning skill 2. Performs skill with direction 3. Performs skill independently

HEAD-TILT/CHIN-LIFT
Procedure 1. Takes BSI precautions 2. Places patient supine and positions self at the side of the patients head 3. Places one hand on the patients forehead and, using firm downward pressure with the palm, tilts the head back 4. Puts two fingers of the other hand under the bony part of the chin and lifts the jaw anteriorly to open the airway Comments: 1 2 3

JAW-THRUST
Procedure 1. Takes BSI precautions 2. Places the patient supine and kneels at the top of his head 3. Applies fingers to each side of the jaw at the mandibular angles 4. Lifts the jaw forward (anteriorly) with a gentle tilting of the patients head to open the airway Comments: 1 2 3

MODIFIED JAW-THRUST
Procedure
2004 Pearson Education, Inc. Intermediate Emergency Care: Principles & Practice

1. Takes BSI precautions 2. Places the patient supine and kneels at the top of his head 3. Applies fingers to each side of the jaw at the mandibular angles 4. Lifts the jaw using fingers behind the mandibular angles, without tilting the head 5. Jaw-thrust without head-tilt: lifts the jaw by grasping under the chin and behind the teeth, without tilting the head Comments:

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H
SKILLS

ANDOUT 5-3

Students Name _________________________________

NASOPHARYNGEAL/OROPHARYNGEAL AIRWAYS
Key to Charting Student Progress: 1. Learning skill 2. Performs skill with direction 3. Performs skill independently

NASOPHARYNGEAL AIRWAY
Procedure 1. Takes BSI precautions 2. Hyperextends patients head and neck if no history of trauma 3. Hyperventilates with 100% oxygen 4. Measures tube from tip of nose to angle of jaw and the diameter of nostril 5. Lubricates exterior of the tube with water-soluble gel or lidocaine gel 6. Pushes gently up on tip of nose and passes tube into the right nostril, bevel toward septum 7. Verifies appropriate position of airway: clear breath sounds, chest rise, airflow at proximal end on expiration 8. Hyperventilates patient with 100% oxygen Comments: 1 2 3

OROPHARYNGEAL AIRWAY
Procedure 1. Takes BSI precautions 2. Hyperextends patients head and neck if no history of trauma; opens mouth and removes visible obstructions 3. Hyperventilates patient with 100% oxygen, if indicated 4. Measures airway from corner of mouth to earlobe 5. Grasps patients jaw and lifts anteriorly
2004 Pearson Education, Inc. Intermediate Emergency Care: Principles & Practice

6. With other hand, holds airway at proximal end and inserts into patients mouth, with curve reversed and tip pointing toward roof of mouth 7. As tip reaches level of soft palate, gently rotates airway 180 until it comes to rest over the tongue 8. Verifies appropriate position of airway: clear breath sounds, and chest rise 9. Hyperventilates patient with 100% oxygen Comments:

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Students Name _________________________________

SKILLS

OROTRACHEAL INTUBATION
Key to Charting Student Progress: 1. Learning skill 2. Performs skill with direction 3. Performs skill independently Procedure 1. Takes BSI precautions 2. Places patient supine 3. Uses appropriate basic manual and adjunct airway maneuvers; hyperventilates with 100% oxygen 4. Assembles and checks equipment 5. Places head in sniffing position 6. Has partner apply Sellicks maneuver 7. Holds laryngoscope in the left hand; inserts it into the right side of mouth 8. Displaces tongue to the left and brings laryngoscope midline 9. Lifts laryngoscope forward to displace jaw without putting pressure on teeth 10. Suctions the hypopharynx as necessary 11. Places blade in proper position, visualizing tip of epiglottis 12. Lifts jaw at 45 angle to the ground, exposing glottis 13. Holds ETT in right hand and advances tube through right corner of patients mouth 14. Directly visualizes vocal cords, passes ETT through the glottic opening until distal cuff disappears beyond vocal cords 15. Removes stylet, inflates distal cuff with 510 mL of air, attaches BVM with ETCO2 detector to connector on ETT 16. Checks for proper tube placement; equal bilateral breath sounds, symmetrical rise and fall of chest 17. Hyperventilates patient with 100% oxygen
2004 Pearson Education, Inc. Intermediate Emergency Care: Principles & Practice

18. Secures ETT with tape or commercial device 19. Periodically rechecks tube placement Comments:

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H
SKILLS

ANDOUT 5-5

Students Name _________________________________

TRAUMA INTUBATION
Key to Charting Student Progress: 1. Learning skill 2. Performs skill with direction 3. Performs skill independently Procedure 1. Takes BSI precautions 2. One team member faces patient on one side, establishes cervical spine stabilization from the front 3. Intubating EMT-I sits behind patient on the ground with legs straddling patients shoulders, moves up until patients head is secured, applies firm pressure to ensure immobilization 4. Hyperventilates patient with 100% oxygen 5. Assembles and checks equipment 6. Holds laryngoscope in left hand and inserts it into right side of the mouth, displacing tongue to the left, and brings laryngoscope to midline 7. Advances blade until it reaches the base of the tongue 8. Lifts laryngoscope forward to displace the jaw without putting pressure on front teeth 9. Looks for tip of epiglottis and places blade into proper position 10. Lifts jaw at 45 angle to the ground until glottis is exposed 11. Grasps tube with the right hand and advances it through right corner of patients mouth 12. Advances the tube through the glottic opening until the distal cuff disappears past vocal cords 13. Removes stylet, inflates distal cuff with 510 mL of air, removes syringe 14. Verifies proper placement of tube: clear breath sounds, symmetrical chest rise 15. Hyperventilates patient with 100% oxygen 16. Periodically rechecks tube placement Comments:
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ANDOUT 5-6

Students Name _________________________________

SKILLS

PEDIATRIC INTUBATION
Key to Charting Student Progress: 1. Learning skill 2. Performs skill with direction 3. Performs skill independently Procedure 1. Takes BSI precautions 2. Hyperventilates patient with 100% oxygen 3. Assembles and checks equipment 4. Places patient head and neck in appropriate position 5. Has partner apply Sellicks maneuver 6. Holds laryngoscope in left hand and inserts into right side of mouth 7. Moves blade slightly toward midline, advancing it until the distal end reaches the base of the tongue 8. Looks for tip of epiglottis, and positions laryngoscope properly 9. Grasps ETT in right hand and, under direct visualization of the vocal cords, inserts it through the right corner of the patients mouth into the glottic opening until distal 10 mm or distal cuff disappears 23 cm beyond the vocal cords 10. Holds tube in place with left hand and attaches infant- or child-size BVM to the connector with CO2 detector 11. Delivers several breaths, checking for proper tube placement: symmetrical rise and fall of chest, equal bilateral breath sounds 12. Hyperventilates patient with 100% oxygen 13. Secures tube with tape or commercial device 14. Periodically rechecks tube placement Comments: 1 2 3

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SKILLS

ANDOUT 5-7

Students Name _________________________________

ESOPHAGEAL TRACHEAL COMBITUBE AIRWAY

Key to Charting Student Progress: 1. Learning skill 2. Performs skill with direction 3. Performs skill independently Procedure 1. Takes BSI precautions 2. Hyperventilates patient with 100% oxygen 3. Assembles and checks equipment 4. Places the patient supine and kneels at the top of his head 5. Places patients head in neutral position 6. Inserts ETC at midline through oropharynx, using a tongue-jaw-lift maneuver, advancing it past the hypopharynx to the depth indicated by the markings on the tube so that the black rings of the tube are between patients teeth 7. Inflates pharyngeal cuff with 100 mL of air and distal cuff with 1015 mL of air 8. Ventilates through the longer blue proximal port with BVM connected to 100% oxygen 9. Auscultates lungs and stomach 10. If gastric sounds are heard instead of breath sounds, changes ports and ventilates through the clear connector 11. Confirms bilateral lung sounds, visualizes chest rise, watches for color change in CO2 detector 12. Secures tube and continues ventilating with 100% oxygen 13. Frequently reassesses airway and adequacy of ventilation Comments: 1 2 3

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ANDOUT 5-8

Students Name _________________________________

SKILLS

PTL AIRWAY
Key to Charting Student Progress: 1. Learning skill 2. Performs skill with direction 3. Performs skill independently Procedure 1. Takes BSI precautions 2. Hyperventilates patient with 100% oxygen 3. Assembles and checks equipment 4. Places patients head in appropriate position 5. Inserts PtL gently, using the tongue-jaw-lift maneuver 6. Inflates distal cuffs of both PtL tubes simultaneously with sustained breath into inflation valve 7. Delivers breath into green tube and looks for chest rise 8. If chest rises, inflates pharyngeal balloon and continues ventilating through green tube, auscultating bilateral breath sounds 9. If chest does not rise and no breath sounds are audible with auscultation, removes stylet from clear tube and ventilates patient through that tube 10. Verifies proper placement by watching chest rise and auscultating lungs 11. Attaches BVM, secures tube, and hyperventilates patient with 100% oxygen 12. Frequently reassesses airway and adequacy of ventilation Comments: 1 2 3

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SKILLS

ANDOUT 5-9

Students Name _________________________________

SUCTIONING
Key to Charting Student Progress: 1. Learning skill 2. Performs skill with direction 3. Performs skill independently Procedure 1. Takes BSI precautions 2. Hyperventilates patient with 100% oxygen 3. Determines depth of catheter insertion by measuring from patients earlobe to lips 4. With suction turned off, inserts catheter into patients pharynx to the predetermined depth 5. Turns on suction unit and places thumb over suction control orifice 6. Suctions while withdrawing catheter, no more than 10 seconds 7. Hyperventilates patient with 100% oxygen Comments: 1 2 3

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EVALUATION

ANDOUT 5-10

Students Name _________________________________

CHAPTER 5 QUIZ
Write the letter of the best answer in the space provided. ______ 1. The potentially most ominous finding of auscultation is: A. snoring. C. wheezing. B. gurgling. D. quiet. 2. You should use a ______ maneuver to open the airway of a patient with a suspected neck or head injury. A. Sellicks C. modified jaw-thrust B. jaw-thrust D. head-tilt/chin-lift 3. To prevent regurgitation during attempts at endotracheal intubation, use the ______ maneuver. A. Sellicks C. modified jaw-thrust B. jaw-thrust D. head-tilt/chin-lift 4. One advantage of the nasopharyngeal airway over the oropharyngeal is that the nasopharyngeal airway: A. isolates the trachea. B. makes suctioning of the pharynx easier. C. may be used in the presence of a gag reflex. D. eliminates the possibility of pressure necrosis. 5. The single greatest danger of EOA insertion is: A. inadequate ventilation. C. tracheal intubation. B. esophageal intubation. D. poor mask seal. 6. The laryngoscope permits visualization of the vocal cords by lifting of the tongue and: A. soft palate. C. hyoid bone. B. epiglottis. D. none of the above 7. The curved blade made for the laryngoscope is the: A. Miller. C. Wisconsin. B. Flagg. D. Macintosh. 8. The curved laryngoscope blade is designed to fit into the: A. larynx. C. epiglottis. B. vallecula. D. pyriform fossa. 9. The greatest advantage of a straight blade is: A. greater displacement of the tongue. B. indirect elevation of the epiglottis. C. wider field of vision for intubation. D. lessened chance of stimulating the gag reflex.

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______ 10. Stylets are a valuable asset when intubating a patient with a: A. short, fat neck. C. posterior larynx. B. long, thin neck. D. none of the above ______ 11. The dangers of movement of an endotracheal tube once it is positioned include: A. elevation of intracranial pressure. C. cardiovascular depression. B. stimulation of the vallecula. D. all of the above

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H A N D O U T 5 - 1 0 Continued

______ 12. Potentially dangerous complications of improper endotracheal intubation include: A. esophageal intubation. C. right mainstem intubation. B. pyriform sinus intubation. D. all of the above ______ 13. Indications of proper endotracheal intubation include all of the following EXCEPT: A. presence of condensation in the tube. B. presence of bilateral breath sounds. C. absence of abdominal sounds. D. phonation. ______ 14. Which one of the following statements about the pediatric airway is NOT true? A. The tongue is larger in relation to the oropharynx than in adults. B. The glottic opening is lower and more posterior than in adults. C. The narrowest part is the cricoid cartilage. D. The vocal cords slant upward. ______ 15. Both the PtL and the ETC airways can be: A. inserted into either the esophagus or trachea. B. used in patients under 16 years of age. C. used in patients with a gag reflex. D. all of the above ______ 16. An absolute contraindication to oxygen administration in hypoxic patients is: A. a premature infant. C. COPD. B. hyperventilation. D. none of the above ______ 17. To ventilate the patient with a stoma, rescue personnel will generally use a(n): A. BVM device. C. mouth-to-stoma technique. B. demand valve device. D. automatic transport ventilator. ______ 18. The minimum acceptable vacuum level in suctioning units for the prehospital setting is ______ mmHg. A. 200 C. 500 B. 300 D. 750 ______ 19. Both standard routes of gastric decompression put the patient at risk for all of the following EXCEPT: A. vomiting. B. misplacement into the brain. C. misplacement into the trachea. D. trauma or bleeding from poor technique. ______ 20. The bag-valve device has an adjunct oxygen reservoir or corrugated tubing that can deliver ______ to ______ oxygen. A. 60%, 70% C. 80%, 90% B. 70%, 75% D. 90%, 95%
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EVALUATION

ANDOUT 5-11

Students Name _________________________________

CHAPTER 5 SCENARIO
Review the following real-life situation. Then answer the questions that follow. The call is for an unknown medical emergency, with a man down on the sidewalk in front of the county building. Unit 6 is literally around the corner from the call. The unit arrives to find a small crowd of people standing around the patient. The patient is well known to the crew as an alcoholic with a history of epileptic seizures. In this case, the patient apparently fell and struck his head, as blood is still oozing from a laceration to his forehead. A First Responder ensures stabilization of the head, while the EMT-I tries to arouse the patient. Witnesses say that the patient had a seizure that lasted for several minutes. No one reports that he turned cyanotic. After getting no response to his loud questions and commands, the EMT-I attempts a painful stimulation. This effort produces only a groan from the patient. The EMT-I attempts to insert an oral airway, but the patient gags and spits it out. The EMT-I then tries a nasopharyngeal airway. The patient tolerates this, so the crew supplies oxygen and prepares to package the patient for transport. When he is secured to the backboard, the patient suddenly seizes again. The crew rolls him onto his side while on the backboard, suctions his mouth, and reassesses his airway and breathing after he stops seizing. The seizure lasts less than one minute. 1. Why was the airway a concern in this patient?

2. What other causes of the seizure might be possible?

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3. Why would the EMT-I not immediately intubate this unconscious patient on scene?

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REINFORCEMENT

ANDOUT 5-12

Students Name _________________________________

CHAPTER 5 REVIEW
Write the word or words that best complete the following sentences in the space(s) provided. 1. The most common cause of airway obstruction is the __________________ . 2. __________________ breathing is asymmetrical chest wall movement that lessens respiratory efficiency. 3. The measurement of exhaled carbon dioxide concentrations is called __________________ . 4. In the absence of cervical-spine trauma, the __________________ - __________________ / __________________ - __________________ maneuver is the best technique for opening the airway of an unresponsive patient. 5. The __________________ airway may be used for intubation in the presence of a gag reflex. 6. Once the tip of a(n) __________________ airway reaches the level of the soft palate, gently rotate it 180 degrees. 7. Miller, Wisconsin, and Flagg are types of __________________ laryngoscope blades. 8. Verification of proper endotracheal tube placement includes absence of __________________ __________________ over the epigastrium, the presence of __________________ breath sounds (lungs), and the presence of __________________ inside the tube. 9. Partial ingestion of caustic poisons is a contraindication to the use of the __________________ __________________ __________________ . 10. Often patients who have had a laryngectomy or tracheostomy breathe through a(n) __________________ , an opening in the anterior neck that connects the trachea with the ambient air. 11. Suctioning should be limited to __________________ seconds. 12. In an awake patient with gastric distention, the __________________ approach to decompression is generally preferred. 13. To calculate how many minutes the oxygen in a tank will last, multiply the psi in the tank by __________________ ; then divide by __________________ __________________ __________________ . 14. The difference between a partial rebreather mask and a nonrebreather mask is that the nonrebreather mask has a(n) __________________ __________________ __________________ attached. 15. The memory aid used to establish a rhythm for adequately ventilating a child is __________________ , __________________ , __________________ . 16. Most demand valve devices have a(n) __________________ __________________ __________________ that makes them useful in treating spontaneously breathing patients who need high oxygen concentrations.
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ANDOUT 5-13

Students Name _________________________________

ADVANCED AIRWAY MATCHING

Write the letter of the term in the space next to the appropriate description. A. B. C. D. E. F. G. H. I. J. K. L. ______ ______ ______ ______ ______ ______ ______ ______ ______ Demand valve Endotracheal tube ETC Macintosh Magill Nonrebreather Oropharyngeal airway PtL Stylet Venturi Wisconsin Yankauer

1. Type of scissors-style clamps with circle-shaped tips 2. Straight laryngoscope blade 3. Airway comprising a short, large-diameter, green tube and a longer, narrow-diameter clear tube 4. Manually triggered, oxygen-powered breathing device 5. Tonsil tip suction catheter 6. Semicircular plastic and rubber device that conforms to the palates curvature and lifts the base of the tongue 7. Metal wire covered with plastic 8. Two-tube airway in which tubes are combined with lumens separated by a partition 9. Oxygen administration device particularly useful with COPD patients

______ 10. Flexible, 3537 cm tube with adapter at one end and inflatable cuff at the other ______ 11. Device consisting of tubing, reservoir bag, and inlet/outlet ports covered by thin rubber flaps ______ 12. Curved laryngoscope blade

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REINFORCEMENT

ANDOUT 5-14

Students Name _________________________________

AIRWAY MANAGEMENT ADVANTAGES AND DISADVANTAGES

Complete the following lists. 1. What are three advantages of the nasopharyngeal airway?

2. What are three disadvantages of the oropharyngeal airway?

3. What are three disadvantages of endotracheal intubation?

4. What are three advantages of the PtL airway?

5. What are three advantages of the Esophageal Tracheal CombiTube?

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C H A PT E R 5 Answer Key
HANDOUT 5-10: Chapter 5 Quiz
1. 2. 3. 4. 5. D C A C C 6. 7. 8. 9. 10. B D B A A 11. 12. 13. 14. 15. A D D B A 16. 17. 18. 19. 20. D A B B D

HANDOUT 5-13: Advanced Airway Matching

1. 2. 3. 4. E K H A 5. 6. 7. 8. L G I C 9. 10. 11. 12. J B F D

HANDOUT 5-11: Chapter 5 Scenario

1. The unconscious patient has little, if any, control over the airway; therefore, aspiration becomes a very real threat. 2. Reasonably, the patient may have seized due to alcohol withdrawal, epilepsy, hypoglycemia, overdose of antifreeze or wood alcohol, closed head injuries such as a subdural hematoma, or from an infectious process. 3. The decision to intubate either the diabetic with hypoglycemia or the postictal epileptic patient must be made carefully. These patients often respond quickly to simple measures and without further complications that might result from the use of advanced airway control methods.

HANDOUT 5-14: Airway Management Advantages and Disadvantages

1. Rapid insertion, bypasses tongue, can be used with gag reflex, can be used in patients with oral cavity injury, can be used when teeth are clenched. 2. It does not isolate the trachea or prevent aspiration; it cannot be inserted when the teeth are clenched; it may obstruct the airway if not inserted properly; it is easily dislodged; return of the gag reflex may produce vomiting. 3. Requires considerable training and experience; requires specialized equipment; requires direct visualization of the vocal cords; bypasses the upper airways function of warming, filtering, and humidifying the inhaled air. 4. Functions in either trachea or esophagus, no face mask to seal, does not require visualization of the larynx, can be used with trauma patients, helps protect trachea from upper airway bleeding and secretions. 5. It provides alternate airway control when conventional intubation techniques are unsuccessful or unavailable; insertion is rapid and easy; insertion does not require visualization of the larynx or special equipment; pharyngeal balloon anchors the airway behind the hard palate; patient may be ventilated regardless of tube placement (esophageal or tracheal); significantly diminishes gastric distention and regurgitation.; can be used on trauma patients, since the neck can remain in neutral position during insertion and use; if the tube is placed in the esophagus, gastric contents can be suctioned for decompression through the distal port.

HANDOUT 5-12: Chapter 5 Review

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. tongue Paradoxical capnography head-tilt/chin-lift nasopharyngeal oropharyngeal straight gastric sounds, bilateral, condensation Esophageal Tracheal CombiTube stoma 10 nasogastric 0.28, liters per minute oxygen reservoir bag squeeze, release, release inspiratory release valve

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