Airway Management

1. April 2012 Airway Management

2. Topics covered in this module: • Airway Foreign Body Removal • Airway Maneuvers • Oropharyngeal Airways and Nasopharyngeal Airways • Oxygen Administration • Oxygen Masks and Bag Valve Masks • Suctioning

3. Airway Foreign Body Removal

4. Learning Objectives Identify the indications for AFB removal Describe the methods of relieving airway obstructions Describe the differences in technique required for AFB removal in various age groups Perform AFB removal under a variety of presentations Adjust to changes in patient presentation Identify potential complications of AFB removal

5. What causes an airway foreign body (AFB) obstruction? tongue food teeth/dentures toys vomit liquid

6. What are signs and symptoms of a partial AFB obstruction? Fig. 1 Bergeron, J. David, Murray, Robert H. Jr., & Grant, Harvey forceful coughing clutching neck unusual breathing sounds (wheezing, gurgling, snoring) patient appears anxious Note: your patient may present with one or all of the signs and symptoms of a partial AFB obstruction

7. What are signs and symptoms of a complete AFB obstruction? Fig. 2 Bergeron, J. David, Murray, Robert H. Jr., & Grant, Harvey unable to speak unable to breathe clutching neck skin discoloration Note: your patient may present with one or all of the signs and symptoms of a complete AFB obstruction

8. What are some methods for clearing an airway obstruction? chest compressions suctioning finger sweep back blows abdominal thrusts (Heimlich maneuver) artificial respiration forceful coughing

9. How can we help choking patients? Conscious adults/children with a partial airway obstruction: encourage coughing Conscious adults/children with a complete airway obstruction: 5 Back blows follow by 5 abdominal thrusts. Keep doing this until airway is clear or until they go unconscious Unconscious adults/children: chest compressions/breaths (30/2) Conscious or unconscious infants with a partial or complete airway obstruction: back blows and chest compressions

10. How do we clear the airway for different age groups?

11. What are some complications of airway foreign body removal? Fig. 2 Mistovich, Hafen & Karren Unable to open patient’s mouth Facial/neck trauma Suspected spinal injury Pregnancy Obesity Swollen tongue/mouth Equipment malfunction

12. Airway Maneuvers

13. Learning Objectives Use manual maneuvers and positioning to maintain airway patency Define methods of relieving the symptoms of airway obstruction Describe the types of airway opening maneuvers for various patients Describe the indications, contraindications and precautions of performing airway maneuvers Apply problem solving techniques required with various types of patients

14. Learning Objectives Demonstrate maneuvers for head, neck and jaw positioning which improve airway patency Demonstrate manual airway maneuvers under a variety of patient and environmental presentations Adjust to changes in patient’s airway patency Demonstrate management of potential complications of airway maneuvers

15. How do we open a mouth? 1. Tongue-jaw lift 2. Crossed-finger technique Fig. 1 Grant, Murry Jr. & Bergeron Fig. 2Grant, Murry Jr. & Bergeron

16. How do we clear an airway obstruction? Open mouth using tongue-jaw lift or crossed-finger technique. Provide artificial respiration for unconscious, non-breathing patients. Remove foreign object using suctioning, finger sweep, chest compressions, back blows or abdominal thrusts (according to guidelines and age group).

17. What are different airway maneuvers? • Modified jaw thrust • use this technique when you suspect spinal injury • this method can be used on all age groups Fig. 3Henry & Stapleton

18. What are different airway maneuvers? 2. Head tilt-chin lift • use this technique when you do not suspect spinal injury • this method can be used on all age groups Fig. 4Henry & Stapleton

19. How can we help choking patients? Conscious adults/children with a partial airway obstruction: encourage coughing Conscious adults/children with a complete airway obstruction: 5 Back blows follow by 5 abdominal thrusts. Keep doing this until airway is clear or until they go unconscious Unconscious adults/children: chest compressions/breaths (30/2) Conscious or unconscious infants with a partial or complete airway obstruction: back blows and chest compressions

20. Some things to consider before clearing an airway Abdominal thrusts should not be performed on pregnant women in their third trimester Finger sweeps should not be performed on children and infants Back blows should performed – Adults, Children and Infants Abdominal thrusts (Heimlich maneuver) should only be performed on conscious adults with a complete airway obstruction Artificial respiration must only be performed on unconscious, unresponsive patients

21. What difficulties can we encounter when clearing an airway? Unable to open patient’s mouth Facial/neck trauma Suspected spinal injury Pregnancy Obesity Swollen tongue/mouth Equipment malfunction

22. Oropharyngeal and Nasopharyngeal Airways

23. Learning Objectives Identify the purpose and indications for inserting an oropharyngeal airway Discuss oropharyngeal airway types and sizes Perform oropharyngeal airway sizing procedures Perform insertion of an oropharyngeal airway Adjust to changes in patient presentation

24. Learning Objectives Identify the purpose and indications for inserting an nasopharyngeal airway Discuss nasopharyngeal airway types and sizes Perform nasopharyngeal airway sizing procedures Perform insertion of an nasopharyngeal airway Adjust to changes in patient presentation

25. What is an oropharyngeal airway (OPA)? Fig. 2 Mistovich, Hafen & Karren An oral airway device that holds the tongue away from the back of the throat An OPA also allows for suctioning secretions An OPA is only used in unresponsive patients An OPA cannot be used on patients with a gag reflex

26. What are different types and sizes of OPAs? Fig. 2 Canadian Red Cross Fig. 3 Mistovich, Hafen & Karren There are two different types of OPAs: one is tubular (Fig. 2) and the other is channeled (Fig. 3). Both are disposable. All OPAs are available in adult, child, infant and newborn sizes.

27. How do we know what size OPA to use? Fig. 4 Canadian Red Cross Measure from the corner of the mouth to the tip of the earlobe or edge of the jaw.

28. How do we properly insert an OPA in an adult? Fig. 5 Mistovich, Hafen & Karren Select the proper size airway. Open the patient’s mouth. Insert the airway with the tip pointing to the roof of the mouth.

29. How do we properly insert an OPA in an adult? Fig. 6 Mistovich, Hafen & Karren 4. When the airway touches the roof of the mouth, turn the airway 180° until the airway follows the natural curve of the tongue.

30. How do we properly insert an OPA in an adult? Fig. 7 Mistovich, Hafen & Karren 5. Once the OPA is properly in place, make sure the patient is not gagging. If so, remove the OPA immediately.

31. How do we properly insert an OPA in a child? Select the proper size airway. Open the patient’s mouth. Insert the airway with the tip pointing to the tongue and gently advance until the airway is in place. Do not rotate the OPA. The roof of a child’s mouth is very soft and can be damaged easily.

32. What is an nasopharyngeal airway (NPA)? Nasopharyngeal airways (NPAs) provide an alternate method for ventilating patients when OPAs cannot be used. NPAs should be used when: • the patient’s teeth are clenched • the patient has a gag reflex MFRs should consider using NPAs because: • they are less likely to cause vomiting • they can be used on semi-conscious patients

33. Things to consider when using an NPA Choosing an NPA that is too long may cause gastric distention (air in the stomach) Inserting an NPA requires lubrication Inserting an NPA is painful, even with lubrication They do not protect the airway Insertion may cause a nosebleed, which may lead to aspiration or airway obstruction NPAs should not be used with head injured patients

34. What are different sizes and types of NPAs? An NPA is a curved, hollow tube made of soft plastic or rubber The NPA may vary in size and diameter, depending on the manufacturer NPAs are available in a variety of adult, child, infant and newborn sizes

35. How do we know what size NPA to use? Fig. 8 Grant, Murray Jr., & Bergeron Length: measure from the nose to the tip of the earlobe Diameter: make sure it can easily fit inside the patient’s nostril

36. How do we properly insert an NPA? Fig. 9 Grant, Murray Jr., & Bergeron Lubricate the NPA with a sterile, water-based lubricant.

37. How do we properly insert an NPA? Fig. 10 Grant, Murray Jr., & Bergeron Select a nostril that does not have any obstruction (the right nostril is preferred- WHY????) Insert the NPA with the bevel toward the septum (the wall between the nostrils).

38. How do we properly insert an NPA? Fig. 11 Grant, Murray Jr., & Bergeron 4. Insert the NPA carefully. If you meet resistance, gently rotate the NPA side-to-side while advancing. If this does not work, remove the NPA and try the other nostril.

39. Oxygen Administration

40. Learning Objectives Identify indications for oxygen administration Identify the purpose of oxygen administration Identify oxygen administration complications Describe the safe handling of oxygen delivery systems Identify oxygen administration precautions Identify various types of oxygen delivery systems

41. Learning Objectives Explain the difference between portable and fixed delivery systems Describe the sequential steps for setting up oxygen delivery systems Operate oxygen delivery systems Ensure adequacy of oxygen supply Demonstrate cleaning and disinfectant

42. Why do we give oxygen to patients? Fig. 1 Henry & Stapleton To replenish oxygen-deprived cells in our organs caused by disease or trauma.

43. When do we give oxygen to patients? We give oxygen to patients suffering from: Shock Trauma Chest pain Cardiac arrest Shortness of breath Confused/decreased level of consciousness Seizures General malaise (aka “sick person complaint”)

44. Things to consider for oxygen administration COPD (chronic lung disease) patients may have side effects from long term use of high concentrations of oxygen. This should not be a concern for short term care from medical first responders. Remember, monitor the patient’s level of consciousness and breathing. Do not use oxygen around highly flammable substances, fire or bystanders who are smoking. Oxygen cylinders are under pressure; excessive impact may cause an explosion.

45. How do we safely transport oxygen? The “D” cylinder in your “A” kit should always be secured with the straps provided. An oxygen cylinder inside your rescue vehicle should be secured to the wall or floor.

46. Things to consider for oxygen delivery systems Oxygen cylinders are steel or aluminum “D” size oxygen cylinders have a safety pin index system to make sure the correct regulators are used Oxygen cylinders vary in size, ranging from small to large. In Nova Scotia, we use “D” cylinders and “M” cylinders. “D” cylinders are stored in our “A” kits.

47. What is the difference between portable and fixed delivery systems?

48. How do we properly set up a “D” cylinder? Fig. 2 Henry & Stapleton Check cylinder tag. Remove protective cover from safety pin index system. Make sure there is a single washer on the regulator or on the cylinder. Before attaching the regulator, use a wrench to slowly open the cylinder’s main valve to clear the dust from the opening. Close the valve once oxygen is released.

49. How do we properly set up a “D” cylinder? Fig. 3 Mistovich, Hafen & Karren Make sure the regular pins are lined up with the cylinder holes as you attach the regulator. Hand tighten the regulator clamp. Turn on the cylinder’s main valve. Listen for leaking around the seal (hand tighten the regulator clamp until the leaking stops).

50. How do we properly set up a “D” cylinder? Fig. 4 Mistovich, Hafen & Karren Check the pressure gauge and make sure there is approximately 2000 lb of pressure in the tank. When you are putting the tank back into your “A” kit, make sure the main valve is turned off. Turn on the flow meter to drain the pressure from the regulator.