Lower Airway <ul><li>Trachea </li></ul><ul><li>Cricothyroid </li></ul><ul><li>Bronchi </li></ul><ul><li>Bronchioles </li></ul><ul><li>Alveoli </li></ul><ul><ul><li>One cell thick, functional units of the lungs, for gas exchange </li></ul></ul>
Oxygenation <ul><li>The term “Oxygenation” describes: </li></ul><ul><li>Movement of oxygen into the blood stream </li></ul><ul><li>Provision of oxygen to the cells </li></ul>
Ventilation <ul><li>The term “Ventilation” describes: </li></ul><ul><li>Movement of air in and out of the lungs </li></ul><ul><li>Removal of carbon dioxide, CO2 </li></ul>
Oxygenation and Ventilation A decrease in ventilation = a decrease in oxygenation...usually . For example, the lungs require ventilation to move the CO2 out of the body, but a hypoventilating patient with a NRB on will have increased carbon dioxide AND increased oxygen. Not ideal.
Oxygen and Carbon Dioxide <ul><li>The body needs optimal amounts of oxygen and carbon dioxide to function properly. </li></ul><ul><li>Oxygen is affected by: hypoventilation and the oxygen carrying ability of the blood </li></ul><ul><li>CO2 is affected by: hypo- or hyperventilation, and the acidity of the body (sepsis, rhabdomyolysis, etc) </li></ul><ul><li>More on ETCO2 later... </li></ul>Oxygen: SPO2 ≥95% or >90% in COPD pts Carbon dioxide: End tidal CO2 35-45 mmHg
Clinical Assessment Oxygenation Pink skin, mucous membranes and nail beds Mental status Pulse oximetry Ventilation Depth of respiration Respiratory rate Mental status Capnography General Positioning (Tripod); Ability to speak
Tripod position Respiratory retractions Perioral cyanosis
Auscultation The lungs are divided into lobes. The right lung has three lobes while the left lung only has an upper and a lower lobe. The upper lobes of the lungs are more anteriorly placed while the lowers are placed more posteriorly.
Auscultation A minimum auscultation includes bilateral checks of both upper and lower lobes, a four point listen. Listen to the uppers at just below the clavicles bilaterally. The lowers are best heard from the back, however patient's cannot always sit forward for you. If so, then listen to the lowers @ midaxillary, just below the armpits, bilaterally. If you are able to listen through the back, auscultate at points around the scapula. LS: CTA x4
Auscultation Crackles or rales - A fine, bubbling sound heard on inspiration and associated with fluid in the smaller bronchioles. Secondary to CHF/ pulmonary edema, drowning, or an acute cardiac event. Wheezes – A musical squeaking or whistling sound heard more on expiration, but can also be heard on inspiration. Secondary to bronchospasm associated with asthma, COPD, pneumonia, or allergic reaction. Types of lung sounds:
Auscultation Rhonchi - A coarse bubbling or plopping sound heard on inspiration or expiration. Can be emphasized by having the patient exhale forcefully. Secondary to pneumonia. Stridor – A high-pitched noise heard while inhaling during a partial airway obstruction. Secondary to FBAO, or laryngospasm.
Respiratory Distress – having difficulty getting oxygen into lungs and into blood Respiratory Failure – unable to take in enough oxygen to meet body's needs Respiratory Arrest – no longer breathing
Do I need to intervene? Is the patient adequately oxygenated? Is the patient adequately ventilated?
Five reasons to intervene <ul><li>Non-patent airway </li></ul><ul><li>Massive facial trauma </li></ul><ul><li>Copious amount of </li></ul><ul><li>foreign material </li></ul><ul><li>Extreme exacerbation of </li></ul><ul><li>disease to the airway </li></ul><ul><li>(epiglottitis, etc) </li></ul>
Five reasons to intervene <ul><li>Inability to maintain a patent airway </li></ul><ul><li>Blood and Vomit </li></ul><ul><li>Facial Trauma </li></ul><ul><li>Depressed mental </li></ul><ul><li>status </li></ul>
Five reasons to intervene <ul><li>Failure to oxygenate </li></ul><ul><li>Severe difficulty breathing </li></ul><ul><li>(dyspnea) </li></ul><ul><li>Impairment of oxygen </li></ul><ul><li>diffusion (pneumonia, </li></ul><ul><li>pulmonary edema, </li></ul><ul><li>pulmonary contusion, etc) </li></ul>
Five reasons to intervene <ul><li>Failure to ventilate </li></ul><ul><li>Difficult to maintain an adequate mask seal </li></ul><ul><li>Foreign material in the airway </li></ul><ul><li>Chest trauma that causes a pneumothorax or rib </li></ul><ul><li>fractures (hypoventilation due to severe pain) </li></ul><ul><li>Upper airway trauma </li></ul>
Five reasons to intervene <ul><li>Anticipated deterioration in the </li></ul><ul><li>patient or airway patency </li></ul><ul><li>Inhalation burns that cause airway edema. Airway </li></ul><ul><li>edema can occur rapidly, close off the airway, and </li></ul><ul><li>may not allow placement of an advanced airway. </li></ul><ul><li>Overdose </li></ul><ul><li>Facial trauma </li></ul><ul><li>Intoxicants </li></ul><ul><li>Brain injury </li></ul>
Oxygenation Interventions Acute mask: Flow rate @ 4-8 lpm Non-rebreather: Tighten the seal around the nose and with the elastic band, otherwise it only provides maybe 60% O2. 10-15 lpm, enough to allow the reservoir bag to reinflate between respirations. Bag Valve Mask (BVM): With a tight face seal. BVM is a 2-3 person job optimally. 10-15 lpm.
Ventilation Interventions Positioning : Sniffing postion is a position where there is slight flexion of the neck and extension of the head. This position is sometimes helped by placing a folded sheet or towel underneath the patient's occiput. For children, the occiput is much larger than an adult's and will cause enough flexion in the neck to crimp off the softer airway of the child. Place a folded sheet or towel under the child's shoulders to raise them up. Jaw thrust is the position for trauma patients.
Ventilation Interventions Airway Adjuncts : Always use! If the patient can tolerate an oral airway, use it. If the patient cannot tolerate the oral airway, place a nasal airway. It is A-OK to place TWO nasal airways and an oral airway in a difficult to ventilate patient in order to maximize the airway.
Ventilation Interventions BVM Ventilations: Use the C-E position with the hands. BVM is a two person job, use two people if there is enough manpower.
In order to do it properly, one-person BVM ventilation requires a substantial amount of Practice and Experience
Ventilation Rates: Adults 10-12 breaths/minute or a vent q 5-6 seconds Pediatrics 12-20 bpm or a vent q 3-5 seconds Adv airway rate 8-10 bpm
Ventilation Interventions <ul><li>Assisting Ventilations: If the patient is breathing on their own, but inadequately, assist their ventilations with a BVM. </li></ul><ul><li>Time the squeeze to their breaths. If they are breathing too fast then assist them with every other breath. If they are breathing too slow then sneak in an extra breath in between theirs. This takes a lot of concentration, so this person should not be the team leader. </li></ul><ul><li>Sometimes you can feel the patient relax into your assistance. </li></ul>
Ventilation Interventions <ul><li>Dentures: In general, tight fitting dentures can provide facial support and help you with the seal. Loose fitting dentures can obstruct the airway and should be removed. (Don't lose them!) </li></ul>Ventilation Volume: Ventilate just enough to get chest rise, preventing barotrauma to the lungs from too much pressure.
Sellick's Maneuver (Cricoid pressure) <ul><li>Pressure from anterior to posterior on the cricoid ring of the larynx (Adam's apple). </li></ul><ul><li>Moves trachea posterior and compresses esophagus to prevent aspiration and gastric inflation. </li></ul>
Suctioning <ul><li>Suctioning removes foreign material from the airway </li></ul><ul><li>Suctioning also removes oxygen from the patient </li></ul>
Suctioning <ul><li>BSI precautions – Where are your safety goggles!?! </li></ul><ul><li>Gurgling is the most frequent sign of liquid in the airway. </li></ul><ul><li>Suction for 5-10 seconds. No more. </li></ul><ul><li>Suction only on the way out. </li></ul>
A Word on Aspiration Aspiration is the active inhalation of stuff into the airway (stuff = vomitus, saliva, blood, etc) Pulmonary aspiration secondary to vomitus can be disastrous. The acidity of the gastric acid can destroy lung surfactant and cause alveolar collapse. It can fill up the alveoli and bronchi with fluid, causing pulmonary edema, hypoventilation and hypoxemia. These patients have prolonged recovery times and much higher mortality rates.
Oropharyngeal Airway (OPA) <ul><li>Indications: Unresponsive patient with no gag reflex </li></ul><ul><li>Contraindications: Responsiveness or an intact gag reflex </li></ul>
OPAs <ul><li>Select the proper size. Measure from corner of pt's mouth to the bottom of ear. </li></ul><ul><li>Insert with tip aimed at roof of pt's mouth. Insert gently while rotating 180 °, resting the flange on the pt's teeth. </li></ul><ul><li>Use a tongue depressor in children, inserting with tip facing floor of pt's mouth. </li></ul>
Nasopharyngeal Airway (NPA) AKA Nose Trumpet <ul><li>Indications: Responsive or partially responsive patient, intact gag reflex </li></ul><ul><li>Contraindications: Facial trauma, head injury/skull fracture </li></ul><ul><li>NPAs are wonderful for prolonged seizure or overdose patients where their GCS is waxing and waning. </li></ul><ul><li>Chronically underused!! </li></ul>
NPAs <ul><li>Determine proper size. In general, women size 6, mid-sized people size 7, large man size 8. </li></ul><ul><li>Lube and insert with bevel towards septum. Insert with a gentle twisting back and forth motion. Advance until flange rests at the nostril. </li></ul>
Assisting an Advanced Provider <ul><li>Provide excellent oxygenation and ventilation </li></ul><ul><li>This buys time to prepare equipment and place an advanced airway </li></ul><ul><li>If the BLS airway is working great, then the ALS can de-prioritize the advanced airway and tend to other aspects of the call </li></ul>
LMA (Laryngeal Mask Airway) Advantages : BLS level advanced airway; minimal spinal movement is required for insertion Disadvantages : The patient must be unresponsive and have no gag reflex; not all pt's can be adequately ventilated with the LMA; the airway must be removed when the pt becomes responsive, agitated or vomits; the airway should be replaced with an ET tube as soon as possible Contraindications : Presence of a gag reflex; caustic ingestion; esophageal trauma or disease
LMA Placement <ul><li>Check the LMA to confirm working order </li></ul><ul><li>Gather all your supplies needed (steth, LMA, syringe, confirmation devices, suction, lube) </li></ul><ul><li>Insert the LMA thru the mouth into the pharynx, with the black line facing superior towards the nose. </li></ul><ul><li>Release the tube while inflating the LMA </li></ul><ul><li>Ventilate at 8-10 bpm, or a vent q 6-7 sec.s </li></ul>
Advanced Airway Confirmation Confirm placement with at least four measures, recorded on your PRF: Bilateral breath sounds and Absence of epigastric sounds (5 point check) ETCO2 SPO2 Equal chest rise and fall Condensation in the tube Direct visualization of placement (ET)
The LMA sits in the esophagus and closes it off, allowing ventilations through the larynx.
FBAO Foreign Body Airway Obstruction inevitably leads to cardiac arrest in all patients if not corrected within minutes. Incomplete obstruction : No heimlich, encourage pt to clear obstruction themselves Complete obstruction : Heimlich maneuver until person loses consciousness
FBAO Unconscious choking : Rescue breathing and CPR, checking for the foreign object each time you open the airway. No blind finger sweeps. Continue until advanced procedures become possible (magill forceps with laryngoscopy, or cricothyrotomy)
End Tidal CO2 End Tidal CO2 is an objective measurement of the quality of ventilation and perfusion. It records carbon dioxide both as a waveform and as a numerical value. Use of ETCO2 with advanced airways reduced Orlando, Florida's misplacement percentage from 25% to 0%!
End Tidal CO2 The orange bit of the ETCO2 line plugs into the top-left of the lifepak, above the SPO2 input.
End Tidal CO2 The nasal prong line measures CO2 through a flap that hangs over the mouth. It also can deliver oxygen to the patient. The advanced airway line connects to the top of the LMA or endotracheal tube. The line can become clogged and un-useable if the patient vomits.
ETCO2 The waveform does not automatically show up on the screen, you will need to spin the dial to highlight the bottom section, then switch the waveform to CO2. Have a play with the monitor next time you are on shift.