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Airway Management Part 1

Airway Management Part 1. Prof. M.H. MUMTAZ. Topics for Discussion. Airway Maintenance Objectives Airway Anatomy & Physiology Review Causes of Respiratory Difficulty & Distress Assessing Respiratory Function Methods of Airway Management Methods of Ventilatory Management

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Airway Management Part 1

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  1. Airway ManagementPart 1 Prof. M.H. MUMTAZ

  2. Topics for Discussion Airway Maintenance Objectives Airway Anatomy & Physiology Review Causes of Respiratory Difficulty & Distress Assessing Respiratory Function Methods of Airway Management Methods of Ventilatory Management Common Out-of-Hospital Equipment Utilized Advanced Methods of Airway Management and Ventilation Risks to the Paramedic

  3. Objectives of Airway Management & Ventilation Primary Objective: Ensure optimal ventilation Deliver oxygen to blood Eliminate carbon dioxide (C02) from body Definitions What is airway management? How does it differ from spontaneous, manual or assisted ventilations?

  4. Objectives of Airway Management & Ventilation Why is this so important? Brain death occurs rapidly; other tissue follows EMS providers can reduce additional injury/disease by good airway, ventilation techniques EMS providers often neglect BLS airway, ventilation skills

  5. Airway Anatomy Review Upper Airway Anatomy Lower Airway Anatomy Lung Capacities/Volumes Pediatric Airway Differences

  6. Anatomy of the Upper Airway

  7. Upper Airway Anatomy Functions: warm, filter, humidify air Nasal cavity and nasopharynx Formed by union of facial bones Nasal floor towards ear not eye Lined with mucous membranes, cilia Tissues are delicate, vascular Adenoids Lymph tissue - filters bacteria Commonly infected

  8. Upper Airway Anatomy Oral cavity and oropharynx Teeth Tongue Attached at mandible, hyoid bone Most common airway obstruction cause Palate Roof of mouth Separates oropharynx and nasopharynx Anterior= hard palate; Posterior= soft palate

  9. Upper Airway Anatomy Oral cavity and oropharynx Tonsils Lymph tissue - filters bacteria Commonly infected Epiglottis Leaf-like structure Closes during swallowing Prevents aspiration Vallecula “Pocket” formed by base of tongue, epiglottis

  10. Upper Airway Anatomy

  11. Upper Airway Anatomy Sinuses cavities formed by cranial bones act as tributaries for fluid to, from eustachian tubes, tear ducts trap bacteria, commonly infected

  12. Upper Airway Anatomy Larynx Attached to hyoid bone Horseshoe shaped bone Supports trachea Thyroid cartilage Largest laryngeal cartilage Shield-shaped Cartilage anteriorly, smooth muscle posteriorly “Adam’s Apple” Glottic opening directly behind

  13. Upper Airway Anatomy Larynx Glottic opening Adult airway’s narrowest point Dependent on muscle tone Contains vocal bands Arytenoid cartilage Posterior attachment of vocal bands

  14. Upper Airway Anatomy Larynx Cricoid ring First tracheal ring Completely cartilaginous Compression (Sellick maneuver) occludes esophagus Cricothyroid membrane Membrane between cricoid, thyroid cartilages Site for surgical, needle airway placement

  15. Upper Airway Anatomy Larynx and Trachea Associated Structures Thyroid gland below cricoid cartilage lies across trachea, up both sides Carotid arteries branch across, lie closely alongside trachea Jugular veins branch across and lie close to trachea

  16. Upper Airway Anatomy

  17. Upper Airway Anatomy Pediatric vs Adult Upper Airway Larger tongue in comparison to size of mouth Floppy epiglottis Delicate teeth, gums More superior larynx Funnel shaped larynx due to undeveloped cricoid cartilage Narrowest point at cricoid ring before ~8 years old

  18. Upper Airway Anatomy From: CPEM, TRIPP, 1998

  19. Upper Airway Anatomy

  20. Glottic Opening

  21. Lower Airway Anatomy Function Exchange O2 , CO2 with blood Location From glottic opening to alveolar-capillary membrane

  22. Lower Airway Anatomy Trachea Bifurcates (divides) at carina Right, left mainstem bronchi Right mainstem bronchus shorter, straighter Lined with mucous cells, beta-2 receptors

  23. Lower Airway Anatomy Bronchi Branch into secondary, tertiary bronchi that branch into bronchioles Bronchioles No cartilage in walls Small smooth muscle tubes Branch into alveolar ducts that end at alveolar sacs

  24. Lower Airway Anatomy Alveoli “Balloon-like” clusters Site of gas exchange Lined with surfactant Decreases surface tension  eases expansion  surfactant  atelectasis (focal collapse of alveoli0

  25. Lower Airway Anatomy Lungs Right lung = 3 lobes; Left lung = 2 lobes Parenchymal tissue Pleura Visceral Parietal Pleural space

  26. Lower Airway Anatomy

  27. Lower Airway Anatomy Occlusion of bronchioles Smooth muscle contraction (bronchospasm Mucus plugs Inflammatory edema Foreign bodies

  28. Lung Volumes/Capacities Typical adult male total lung capacity = 6 liters Tidal Volume (VT) Gas volume inhaled or exhaled during single ventilatory cycle Usually 5-7 cc/kg (typically 500 cc)

  29. Lung Volumes/Capacities Dead Space Air (VD) Air unavailable for gas exchange

  30. Lung Volumes/Capacities Dead Space Air (VD) Anatomic dead space (~150cc) Trachea Bronchi Physiologic dead space Shunting Pathological dead space Formed by factors like disease or obstruction Examples: COPD

  31. Lung Volumes/Capacities Alveolar Air (alveolar volume) [VA] Air reaching alveoli for gas exchange Usually 350 cc

  32. Lung Volumes/Capacities Minute Volume [Vmin](minute ventilation) Amount of gas moved in, out of respiratory tract per minute Tidal volume X RR Alveolar Minute Volume Amount of gas moved in, out of alveoli per minute (tidal volume - dead space volume) X RR

  33. Lung Volumes/Capacities Functional Reserve Capacity (FRC) After optimal inspiration, amount of air that can be forced from lungs in single exhalation

  34. Lung Volumes/Capacities Inspiratory Reserve Volume (IRV) Amount of gas that can be inspired in addition to tidal volume Expiratory Reserve Volume (ERV) Amount of gas that can be expired after passive (relaxed) expiration

  35. Lung Volumes/Capacities

  36. Ventilation Movement of air in, out of lungs Control via: Respiratory center in medulla Apneustic, pneumotaxic centers in pons

  37. Ventilation Inspiration Stimulus from respiratory center of brain (medulla) Transmitted via phrenic nerve to diaphragm, spinal cord/intercostal nerves to intercostal muscles Diaphragm contracts, flattens Intercostal muscles contract; ribs move up and out Air spaces in lungs stretch, increase in size  intrapulmonic pressure (pressure gradient) Air flows into airways, alveoli inflate until pressure equalizes

  38. Ventilation Expiration Stretch receptors in lungs signal respiratory center via vagus nerve to inhibit inspiration (Hering-Breuer reflex) Natural elasticity of lungs pulls diaphragm, chest wall to resting position Pulmonary air spaces decrease in size Intrapulmonary pressure rises Air flows out until pressure equalizes

  39. Ventilation

  40. Ventilation

  41. Ventilation Respiratory Drive Chemoreceptors in medulla Stimulated  PaCO2 or  pH PaCO2 is normal neuroregulatory control of ventilations Hypoxic Drive Chemoreceptors in aortic arch, carotid bodies Stimulated by  PaO2 Back-up regulatory control

  42. Ventilation Other stimulants or depressants Body temp: fever; hypothermia Drugs/meds: increase or decrease Pain: increases, but occasionally decreases Emotion: increases Acidosis: increases Sleep: decreases

  43. Gas Measurements Total Pressure Combined pressure of all atmospheric gases 760 mm Hg (torr) at sea level Partial Pressure Pressure exerted by each gas in a mixture

  44. Gas Measurements Partial Pressures Atmospheric Nitrogen 597.0 torr (78.62%); Oxygen 159.0 torr (20.84%); Carbon Dioxide 0.3 torr (0.04%); Water 3.7 torr (0.5%) Alveolar Nitrogen 569.0 torr (74.9%); Oxygen 104.0 torr (13.7%); CO2 40.0 torr (5.2%); Water 47.0 torr (6.2%)

  45. Respiration Ventilation vs. Respiration Exchange of gases between living organism, environment External Respiration Exchange between lungs, blood cells Internal Respiration Exchange between blood cells, tissues

  46. Respiration How are O2, CO2 transported? Diffusion Movement of gases along a concentration gradient Gases dissolve in water, pass through alveolar membrane from areas of higher concentration to areas of lower concentration FiO2 % oxygen in inspired air expressed as a decimal FiO2 of room air = 0.21

  47. Respiration Blood Oxygen Content dissolved O2 crosses capillary membrane, binds to Hgb of RBC Transport = O2 bound to hemoglobin (97%) or dissolved in plasma O2 Saturation % of hemoglobin saturated with oxygen (usually carries >96% of total) O2 content divided by O2 carrying capacity

  48. Respiration Oxygen saturation affected by: Low Hgb (anemia, hemorrhage) Inadequate oxygen availability at alveoli Poor diffusion across pulmonary membrane (pneumonia, pulmonary edema, COPD) Ventilation/Perfusion (V/Q) mismatch Blood moves past collapsed alveoli (shunting) Alveoli intact but blood flow impaired

  49. Respiration Blood Carbon Dioxide Content Byproduct of work (cellular respiration) Transported as bicarbonate (HCO3- ion)  20-30% bound to hemoglobin Pressure gradient causes CO2 diffusion into alveoli from blood Increased level = hypercarbia

  50. Respiration

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