Airway

1. Airway Management
and Ventilation

2. Airway management
and ventilation are the first
and most critical steps in the
initial assessment of every
patient you will encounter.

3. Topics
Anatomy of the Respiratory System
Physiology of the Respiratory
System
Respiratory Problems
Respiratory System Assessment
Airway Management

4. Anatomy of the
Respiratory System

5. The respiratory system
provides a passage for
oxygen to enter the body
and for carbon dioxide to exit
the body.

6. Anatomy of the Upper Airway

7. Upper Airway
 Nasal cavity
 Oral cavity
 Pharynx

8. Oral Cavity
 Cheeks
 Hard palate
 Soft palate
 Tongue
 Gums
 Teeth

9. Nasal Cavity
 Maxillary bone
 Frontal bone
 Nasal bone
 Ethmoid bone
 Sphenoid bone
 Septum
 SinusesSinuses
 Eustachian tubesEustachian tubes
 Nasolacrimal ductsNasolacrimal ducts
 NaresNares
 Mucous membranesMucous membranes

10.  Nasopharynx
 Oropharynx
 Laryngopharynx
Pharynx

11. Larynx
 Thyroid cartilage
 Cricoid cartilage
 Glottic opening
 Vocal cords
 Arytenoid cartilage
 Pyriform fossae
 Cricothyroid cartilage

12. Internal Anatomy of the
Upper Airway

13. Lower Airway Anatomy
 Trachea
 Bronchi
 Alveoli
 Lung parenchyma
 Pleura

14. Anatomy of the Lower Airway

15. Anatomy of the Alveoli

16. Anatomy of the Pediatric Airway

17. Smaller and more flexible than an
adult.
Tongue proportionately larger.
Epiglottis floppy and round.
Glottic opening higher and more
anterior.
Vocal cords slant upward, and are
closer to the base of the tongue.
Narrowest part is the cricoid cartilage.
The Pediatric Airway

18. Physiology of the
Respiratory System

19.  Maximum lung capacity
 Average adult male TLC—6 liters
Total Lung Capacity (TLC)

20. Average volume of gas inhaled
or exhaled in one respiratory cycle.
Average adult male:
Tidal Volume (V
T
)
V
T
= 500 ml (5-7 cc/kg)

21. Amount of gases in tidal volume
that remains in the airway.
Approximately 150 ml in adult male.
Dead Space Volume (V
D
)

22. Alveolar Volume (V
A
)
Amount of gas that reaches the
alveoli for gas exchange
V
A
= (V
T
- V
P
)

23. Minute Volume (V
min
)
Amount of gas moved in and out of
the respiratory tract in one minute.
V
min
= V
T
x respiratory rate

24. Residual Volume
(RV)
The amount of air remaining in
the lungs at the end of maximal
expiration.

25. Inspiratory Reserve Volume
(IRV)
The amount of air that can be
maximally inhaled after normal
inspiration.

26. Expiratory Reserve Volume
(ERV)
The amount of air that can be
maximally exhaled after a normal
expiration.

27. Functional Residual
Capacity (FRC)
The volume of gas that remains in
the lungs at the end of normal
expiration.
FRC = ERV + RV

28. Forced Expiratory Volume
(FEV)
The amount of air that can be
maximally expired after maximum
inspiration.

29.  Respiration is the exchange of
gases between a living organism
and its environment.
 Ventilation is the mechanical
process that moves air into and
out of the lungs.
Introduction

30. The Respiratory Cycle
Pulmonary ventilation depends upon
pressure changes within the
thoracic cavity.

31. Pulmonary Circulation

32. Diffusion of
Gases Across
an Alveolar
Membrane

33. Measuring Oxygen and
Carbon Dioxide Levels
 Partial pressure is the pressure
exerted by each component of a
gas mixture.
Partial pressure of a gas is its
percentage of the mixture’s total
pressure.

35. Oxygen (PaO
2
) =
100 torr (average = 80 –100).
Carbon dioxide (PaCOCarbon dioxide (PaCO
22) =) =
40 torr (average = 35 – 45).40 torr (average = 35 – 45).
Normal Arterial Partial
Pressures

36. Movement of a gas from an area
of higher concentration to an area
of lower concentration.
Diffusion transfers gases
between the lungs and the blood
and between the blood and
peripheral tissues.
Diffusion

37. Oxygen saturation =

O
2
content/ O
2
capacity x 100%
Oxygen Concentration
in the Blood

38. Factors Affecting Oxygen
Concentration in the Blood
 Decreased hemoglobin concentration.
 Inadequate alveolar ventilation.
 Decreased diffusion across the
pulmonary membrane when diffusion
distance increases or the pulmonary
membrane changes.
 Ventilation/perfusion mismatch occurs
when a portion of the alveoli collapses.

39. Inadequate minute volume
respirations can compromise
adequate oxygen intake and
carbon dioxide removal.

40. Factors Affecting Carbon
Dioxide Concentrations in
the Blood (1 of 2)
Hyperventilation lowers CO
2
levels
due to increased respiratory rates
or deeper respiration.
Causes of increased CO
2

production include:
Fever, muscle exertion, shivering,
metabolic processes resulting in
the formation of metabolic acids.

41. Factors Affecting Carbon
Dioxide Concentrations in
the Blood (2 of 2)
Decreased CO
2
elimination results
from decreased alveolar
ventilation.
Respiratory depression, airway
obstruction, respiratory muscle
impairment, obstructive diseases.

42. Regulation of
Respiration

43. Involuntary; however, can be
voluntarily controlled.
Chemical and physical mechanisms
provide involuntary impulses to
correct any breathing irregularities.
Respiratory Rate

44. Normal Respiratory Rates
Age
Adult
Children
Infants
12-20
18-24
40-60
Rate Per Rate Per
MinuteMinute

45. Respiratory Factors
Factor EffectEffect
Stimulants
Fever
Emotion
Pain
Hypoxia
Acidosis
Depressants
Sleep
Increases
Decrease
Decreases
Increases
Increases
Increases
Increases
Increase

46. Nervous Impulses from the
Respiratory Center
 Main respiratory center is the medulla.
 Neurons within medulla initiate impulses
that produce respiration.
 Apneustic center assumes respiratory
control if the medulla fails to
initiate impulses.
 Pneumotaxic center controls respiration.

47. Stretch Receptors
The Hering-Breuer reflex
prevents over-expansion
of the lungs.

48. Located in carotid bodies, arch of
the aorta, and medulla.
Stimulated by decreased PaO
2
,
increased PaCO
2
, and decreased
pH.
Cerebrospinal fluid (CSF) pH is
primary control of respiratory
center.
Chemoreceptors

49. Hypoxemia is a profound stimulus
of respiration in a normal
individual.
Hypoxic drive increases respiratory
stimulation in people with chronic
respiratory disease.
Hypoxic Drive

50. Respiratory Problems

51. Airway Obstruction
The tongue is the most common
cause of airway obstruction.

52. The Tongue as an Airway Obstruction

53. Other Causes of Airway
Obstruction
 Foreign bodies
 Trauma
 Laryngeal spasm and edema
 Aspiration

54. Respiratory System
Assessment

55. Is the airway patent?
Is breathing adequate?
Look, listen, and feel.
If patient is not breathing, open
the airway and assist ventilations
as necessary.
Initial Assessment

56. Look.

57.  Skin color
 Patient’s position
 Dyspnea
 Modified forms of respiration
 Rate
 Pattern
 Mentation
Inspection

58. Abnormal Respiratory
Patterns (1 of 3)
Kussmaul’s respirations
Deep, slow or rapid, gasping; common
in diabetic ketoacidosis.
Cheyne-Stokes respirations
Progressively deeper, faster breathing
alternating gradually with shallow,
slower breathing, indication brain
stem injury.

59. Biot’s respirations:
Irregular pattern of rate and depth withIrregular pattern of rate and depth with
sudden, periodic episodes of apnea, sudden, periodic episodes of apnea,
indicating increased intracranial indicating increased intracranial
pressure. pressure.
Central neurogenic Central neurogenic
hyperventilationhyperventilation::
Deep, rapid respirations, indicatingDeep, rapid respirations, indicating
increased intracranial pressure. increased intracranial pressure.
Abnormal Respiratory
Patterns (2 of 3)

60. Abnormal Respiratory
Patterns (3 of 3)
Agonal respirations:Agonal respirations:
Shallow, slow, or infrequent breathing,Shallow, slow, or infrequent breathing,
indicating brain anoxia.indicating brain anoxia.

61. Listen.

62. Listen at the mouth and nose
for adequate air movement.
Listen with a stethoscope for
normal or abnormal air movement.
Ausculation

63. Position for auscultating
breath sounds.

64. Airway Sounds
Airflow
Compromise
Gas Exchange
Compromise
Snoring
Stridor
Wheezing
Quiet
Gurgling
Crackles
Rhonchi

65. Feel.

66. Palpate chest wall for tenderness,
symmetry, abnormal motion,
crepitus, and subcutaneous
emphysema.
Assess compliance of lungs.
Palpation

67. Onset
Symptom development
Associated symptoms
Past medical history
Recent history
Does anything make symptoms
better or worse?
Focused History

68. Non-Invasive
Respiratory Monitoring

69. Pulse Oximeter

70. Combined devices check pulse
oximetry, ETCO
2
blood pressure,
pulse, respiratory rate, and
temperature.

71. Oxygenation

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

73. To calculate how long an oxygen tank
will last:
Oxygen Supply and
Regulators
tank life in minutes =tank life in minutes =
(tank pressure in psi x .28)(tank pressure in psi x .28)
liters per minuteliters per minute

74. Oxygen Delivery Devices
Device Oxygen
percentage
Nasal cannula
Simple face mask
Nonrebreather mask
Venturi mask
40%
24, 28, 35, or 40%
40 – 60%
80 – 95%

75. Manual Airway
Maneuvers

76. Personal Protective
Equipment

77. Head Tilt/Chin Lift

78. Modified Jaw Thrust
in Trauma

79. Jaw-Thrust Maneuver

80. Jaw-Lift Maneuver

81. Basic Mechanical
Airways

82. Insert oropharyngeal airway
with tip facing palate.

83. Rotate airway 180º into position.

84. Improper placement of
oropharyngeal airway

85. Nasopharyngeal Airway

86. Nasopharyngeal airway,
inserted

87. Ventilation Methods
 Mouth-to-mouth
 Mouth-to-nose
 Bag-valve device
 Demand valve device
 Automatic transport ventilator

88. Bag-valve-mask ventilation

89. Bag-valve-mask with
built-in colorimetric
ETCO
2
detector

90. Demand Valve and Mask

91. Portable Mechanical
Ventilator

92. Ventilation of
Pediatric Patients
Mask seal can be more difficult.
Bag size depends on age of child.
Ventilate according to current
standards.
Obtain chest rise and fall with
each breath.
Assess adequacy of ventilations by
observing chest rise, listening to lung
sounds, and assessing clinical
improvement.

93. Direct visualization of the
larynx with a laryngoscope
may enable the removal of an
obstructing foreign body.

94. Magill Forceps

95. Foreign body removal with direct
visualization and Magill forceps

96. Suctioning
Anticipating complications
when managing an airway is
the key for successful
outcomes.
Be prepared to suction
all airways to remove blood
or other secretions and for
the patient to vomit.

99. Suctioning Techniques
Wear protective eyewear, gloves,
and face mask.
Preoxygenate the patient.
Determine depth of catheter insertion.
With suction off, insert catheter.
Turn on suction and suction while
removing catheter (no more than
10 seconds).
Hyperventilate the patient.

100. Advanced Airway
Management

101. Endotracheal intubation
is clearly the preferred method
of advanced airway management in
prehospital emergency care.

102. Laryngoscope Blades

103. Engaging laryngoscope
blade and handle

104. Activating laryngoscope light source

105. Placement of Macintosh blade
into vallecula

106. Placement of Miller blade Placement of Miller blade
under epiglottisunder epiglottis

107. Endotrol ETT

108. ETT, Stylet, and Syringe,
unassembled

109. ETT and Syringe

110. ETT, Stylet, and Syringe,
assembled for intubation

111. Disadvantages of
Endotracheal Intubation
Requires considerable training and
experience.
Requires specialized equipment.
Requires direct visualization of vocal
cords.
Bypasses upper airway’s functions
of warming, filtering, and humidifying
the inhaled air.

112. Endotracheal Intubation
Indicators
Respiratory or cardiac arrest.
Unconsciousness.
Risk of aspiration.
Obstruction due to foreign bodies, trauma,
burns, or anaphylaxis.
Respiratory extremis due to disease.
Pneumothorax, hemothorax,
hemopneumothorax with respiratory
difficulty.

113. Complications of
Endotracheal Intubation
Equipment malfunction
Teeth breakage and soft tissue
lacerations
Hypoxia
Esophageal intubation
Endobronchial intubation
Tension pneumothorax

114. Advantages of Endotracheal
Intubation
Isolates trachea and permits
complete control of airway.
Impedes gastric distention.
Eliminates need to maintain a mask
seal.
Offers direct route for suctioning.
Permits administration of some
medications.

115. Endotracheal Intubation

116. Hyperventilate patient.

117. Prepare equipment.

118. Apply Sellick’s Maneuver
and insert laryngoscope.

119. Sellick’s Maneuver
(Cricoid Pressure)

120. Airway before
applying Sellick’s

121. Airway with Sellick’s applied (note
compression on the esophagus)

122. Visualize larynx and insert
the ETT.

123. Glottis visualized through
laryngoscopy

124. Inflate cuff, ventilate,
and auscultate.

125. Confirm placement with
an ETCO
2
detector.

126. Electronic End-Tidal
CO
2
Detector

127. Colorimetric End-Tidal
CO
2
Detector

128. Esophageal Detector Device

129. An esophageal intubation
detector-bulb style.
A.Attach device to
endotracheal tube
and squeeze
the detector.

130. If bulb refills easily upon release,
it indicates correct placement.

131. If the bulb does not refill, the
tube is improperly placed.

132. Secure tube.

133. Continuously recheck
and reconfirm the placement of
the endotracheal tube.

134. Reconfirm ETT placement.

135. Lighted Stylet for
Endotracheal Intubation

136. Insertion of lighted stylet/ETT

137. Lighted stylet/ETT in position

138. Transillumination of a lighted stylet

139. Digital Intubation
Insert your
middle
and index fingers
into patient’s
mouth

140. Digital Intubation
Walk your fingers
and palpate the
patient’s epiglottis.

141. Blind orotracheal intubation by
digital method

142. Digital Intubation—
insertion of the ETT

143. Endotracheal Intubation
with In-line Stabilization

144. Hyperventilate patient and
apply c-spine stabilization.

145. Apply Sellick’s Maneuver
and intubate.

146. Ventilate patient and
confirm placement.

147. Secure ETT and apply a
cervical collar.

148. Reconfirm placement.

149. Rapid Sequence Intubation
A patient who needs intubation
may be awake. RSI paralyzes
the patient to facilitate
endotracheal intubation.

152. Endotracheal Intubation
in a Child

154. ETT size (mm) =
(Age in years + 16)(Age in years + 16)
44

155. Hyperventilate the child.

156. Position the head.

157. Insert the laryngoscope.

158. Insert ETT and ventilate
the child.

159. Confirm placement and
secure ETT.

160. Nasotracheal intubation may
be useful in some situations:
 Possible spinal injury
 Clenched teeth
 Fractured jaw, oral injuries, or recent
oral surgery
 Facial or airway swelling
 Obesity
 Arthritis preventing sniffing position

161. Blind Nasotracheal Intubation

162. Other Intubation Devices
 Esophageal CombiTube (ECT)
 Laryngeal mask airway (LMA)
 Pharyngo-tracheal lumen airway (PtL)
 Esophageal gastric tube (EGTA)
 Esophageal obturator airway (EOA)

163. ECT Airway— ECT Airway—
tracheal placementtracheal placement

164. ECT Airway—
esophageal placement

165. Laryngeal Mask Airway

166. Pharyngo-Tracheal
lumen airway

167. The only indication
for a surgical airway is
the inability to establish an
airway by any other method.

168. Anatomical Landmarks
for Cricothyrotomy

169. Locate/palpate
cricothyroid membrane.

170. Proper positioning for
cricothyroid puncture

171. Advance the catheter
with the needle.

172. Jet ventilation with
needle cricothyrotomy

173. Open Cricothyrotomy

174. Cannula properly placed
in trachea

175. Locate cricothyroid membrane.

176. Stabilize larynx and make a 1–2 cm skin
incision over cricothyroid membrane.

177. Make a 1 cm horizontal incision
through the cricothyroid membrane.

178. Using a curved hemostat, spread
membrane incision open.

179. Insert an ETT (6.0)
or Shiley (6.0).

180. Inflate the cuff.

181. Confirm placement.

182. Ventilate.

183. Secure tube, reconfirm placement,
evaluate patient.

184. Tracheostomy Cannulae

185. Patients with Stoma Sites
Patients who have had a laryngectomy
or tracheostomy breathe through a
stoma.
There are often problems with excess
secretions, and a stoma may
become plugged.

186. Tracheostomy Suction Technique