Management of Airway and
Breathing
Emergency Medical Technician Basic
Temple College EMS Program
1
Airway Functions
• Passage that allows air to move from
atmosphere to alveoli
• Must remain patent (open) at all times
• Anything that blocks airway will cause
decrease in oxygen available to body
• Size of obstruction affects available air
exchange
Temple College EMS Program
2
Opening the Airway
• Techniques
–
–
–
–
–
Head-tilt/Chin-lift
Jaw Thrust
Suctioning
Nasopharyngeal airway
Oropharyngeal airway
Temple College EMS Program
3
Head-Tilt/Chin-Lift
• Used when no neck injury is suspected
• Temporary procedure
• Must be replaced with an airway adjunct
unless patient begins adequate spontaneous
ventilation
Temple College EMS Program
4
Head-Tilt/Chin-Lift
• Technique
– Place one hand on patient’s forehead
– Apply firm, backward pressure with palm
causing head to tilt backward
– Place fingers of other hand under bony part of
patient’s lower jaw near chin
– Lift jaw upward to bring chin forward
Temple College EMS Program
5
Head-Tilt/Chin-Lift
• Patients needing head-tilt/chin-lift
– Unresponsive patient without history of trauma
– Cardiac arrest patients without signs of trauma
– Apneic patients without signs of trauma
Temple College EMS Program
6
Jaw Thrust
• Used when spinal injury suspected
• Temporary procedure
• Must be replaced with airway adjunct
unless patient begins adequate spontaneous
ventilation
Temple College EMS Program
7
Jaw Thrust
• Technique
– Place one hand on either side of patient’s head,
resting elbows on surface on which victim is
lying
– Grasp angles of patient’s lower jaw, lift with
both hands
– If patient’s lips close, retract lower lips with
thumbs
Temple College EMS Program
8
Jaw Thrust
• Patients needing jaw thrust
– Unresponsive trauma patient
– Unresponsive patient with undetermined
mechanism of injury
Temple College EMS Program
9
Suctioning
• Purpose
– Remove blood, vomit, other liquids, food
particles from airway
– May not be adequate for removing large, solid
objects (teeth, foreign bodies, food)
– Should be performed immediately when
gurgling is heard with spontaneous or artificial
ventilation
Temple College EMS Program
10
Suctioning
• Suction devices
– Mounted in ambulance
– Portable
• Electrical
• Hand operated
– Should generate 300mm Hg vacuum
– Ensure batteries in units remain properly
charged
Temple College EMS Program
11
Suctioning
• Rigid Suction Catheter
– Used to suction mouth, oropharynx of
unresponsive patient
– Inserted only as far as you can see
– Take caution not to touch back of airway,
particularly in infants and children (can cause
heart rate to drop)
Temple College EMS Program
12
Suctioning
• Soft Suction Catheter
– Useful for suctioning nasopharynx or
tracheostomy tubes
– Should be inserted only as far as base of tongue
or end of tracheostomy tube
Temple College EMS Program
13
Suctioning
• Techniques
–
–
–
–
–
–
Turn on unit
Attach catheter
Insert catheter into oral cavity without suction
Insert only to base of tongue
Apply suction, move catheter from side to side
Suction no longer than 15 seconds in adults, 10 seconds
in children, 5 seconds in infants
– Rinse catheter with saline or water to prevent
obstruction
Temple College EMS Program
14
Nasal Airways
• Used on responsive patients who need help
keeping tongue out of airway
• Insertion is uncomfortable for responsive
patients
Temple College EMS Program
15
Nasal Airways
• Technique
–
–
–
–
–
–
Measure from tip of nose to earlobe
Ensure airway will fit through nostril
Lubricate with water-soluble lubricant
Insert with bevel toward base of nostril or septum
If resistance is met, try other nostril
Do not use in patients with mid-face trauma or possible
basilar skull fractures
Temple College EMS Program
16
Nasal Airways
• Patients needing nasal airway
– Unresponsive patients who are snoring
– Unresponsive patients with gag reflex
Temple College EMS Program
17
Oral Airways
• Used on unresponsive patients without gag
reflex
• Helps hold tongue away from back of throat
Temple College EMS Program
18
Oral Airways
• Technique
– Measure from corner of mouth to earlobe or angle of
jaw
– Open patient’s mouth
– In adults insert with tip facing roof of patient’s mouth,
advance until resistance encountered, turn 180o until
flange comes to rest on patient’s teeth
– In infants and children use tongue depressor to lift
tongue, insert oral airway right side up
Temple College EMS Program
19
Oral Airways
• Patients needing oral airway
– Unresponsive, apneic patients with or without
trauma
– Any apneic patient being ventilated with a
BVM
Temple College EMS Program
20
Airway Limitations
• Nasal/oral airways are not definitive devices
• Manual maneuvers must be used with nasal/oral
airways to ensure airway stays open
• Patients may require frequent suctioning to
remove blood, vomit, other secretions from airway
• Definitive devices such as endotracheal tubes are
required to completely protect the airway
Temple College EMS Program
21
Adequate Breathing
• Normal Rate
– Adult: 12 to 20/minute
– Child: 15 to 30/minute
– Infant: 25 to 50/minute
• Regular Rhythm
• Adequate Quality
–
–
–
–
–
Movement of air at mouth, nose
Chest expansion adequate, symmetrical (equal)
Breath sounds present, equal
Minimum effort of breathing
Adequate tidal volume (depth)
Temple College EMS Program
22
Inadequate Breathing
• Abnormal Rate
– Adult: <12 to >20/minute
– Child: <15 to >30/minute
– Infant: <25 to >50/minute
• Irregular Rhythm
• Inadequate Quality
–
–
–
–
–
Absent or reduced at mouth, nose
Chest expansion inadequate or asymmetrical (unequal)
Breath sounds diminished, unequal, noisy, absent
Increased effort of breathing, use of accessory muscles
Indequate (shallow) tidal volume
Temple College EMS Program
23
Inadequate Breathing
• Skin changes
– Pale, cool, clammy: Early sign
– Cyanosis: Late, unreliable sign
• Retractions of soft tissues above clavicles,
between ribs, below rib cage
• Flaring of nostrils
• “Seesaw” breathing in infants
Temple College EMS Program
24
Ventilation Techniques
(In order of preference)
1. Mouth-to-mask with supplemental oxygen
2. Two-person bag-valve mask with oxygen
reservoir and supplemental oxygen
3. Flow restricted, oxygen-powered
ventilation device (manually-triggered
ventilator)
4. One-person bag-valve mask with oxygen
reservoir and supplemental oxygen
Temple College EMS Program
25
Ventilation Techniques
• Mouth-to-Mouth
–
–
–
–
Open airway
Pinch nose closed or seal nose with cheek
Take deep breath
Seal lips around patient’s mouth to create
airtight seal
– Blow into patient’s mouth slowly over 2
seconds until patient’s chest rises
Temple College EMS Program
26
Ventilation Techniques
• Mouth-to-Mask
–
–
–
–
Connect mask to oxygen at 15 liters per minute
Kneel directly above patient’s head
Apply mask to patient’s face
Place thumbs along sides of mask, index fingers of both
hands under patient’s mandible
– Lift jaw into mask, tilt head if neck injury not suspected
– Blow into one-way valve slowly over 2 seconds until
patient’s chest rises
Temple College EMS Program
27
Ventilation Techniques
• Bag-valve mask
–
–
–
–
Self-inflating bag
One-way valve
Face mask
Oxygen reservoir
Must be connected to oxygen to perform
most effectively
Temple College EMS Program
28
Ventilation Techniques
• BVM Issues
– Provides less volume than mouth-to-mask
– Single rescuer may have difficulty maintaining
air-tight seal
– Two rescuers using device are more effective
– Position yourself at top of patient’s head for
best performance
– Oral or nasal airway should be inserted
Temple College EMS Program
29
Ventilation Techniques
• BVM Technique (Two Rescuer)
– Open airway, insert oral or nasal airway
– Position thumbs over top half of mask, index and
middle fingers over bottom half
– Place apex of mask over bridge of nose, lower mask
over mouth/upper chin
– Use ring and little fingers to bring jaw up to mask
– Have assistant squeeze bag with two hands until chest
rises
– Ventilate every 5 seconds for adults, every 3 seconds
for infants and children
Temple College EMS Program
30
Ventilation Techniques
• BVM Technique (One Rescuer)
– Open airway, insert oral or nasal airway
– Form a “C” around ventilation port with thumb,
index finger
– Use middle, ring, little fingers under jaw to
maintain chin lift, complete seal
– Squeeze bag with other hand until chest rises
– Ventilate every 5 seconds for adults, every 3
seconds for infants and children
Temple College EMS Program
31
Ventilation Techniques
• BVM Technique (Suspected Trauma)
– Open airway, insert oral or nasal airway
– Have assistant hold patient’s head or use your knees to prevent
movement
– Position thumbs over top half of mask, index and middle fingers
over bottom half
– Place apex of mask over bridge of nose, lower mask over
mouth/upper chin
– Use ring and little fingers to bring jaw up to mask without tilting
head or neck
– Have assistant squeeze bag with two hands until chest rises
– Ventilate every 5 seconds for adults, every 3 seconds for infants
and children continue to hold jaw up without moving head or neck
Temple College EMS Program
32
Ventilation Techniques
• If chest does not rise, reevaluate
– If abdomen rises, reposition head or jaw
– If air escapes under mask, reposition fingers
and mask
– Check for obstruction
– If chest still does not rise and fall use another
method of ventilation
Temple College EMS Program
33
Ventilation Techniques
• Flow Restricted, Oxygen-Powered Ventilation Devices
(Manually-Triggered Ventilator)
–
–
–
–
Peak flow of 100% oxygen at maximum of 40 lpm
Pressure relief valve that opens at 60 cm H2O
Audible alarm that sounds when relief valve pressure is exceeded
Trigger so both hands remain on mask to maintain seal
Do NOT use on children or infants!!!
Temple College EMS Program
34
Ventilation Techniques
• Manually-Triggered Ventilator
– Open airway, insert oral or nasal airway
– Position thumbs over top half of mask, index/middle
fingers over bottom half
– Place apex of mask over bridge of nose, lower mask
over mouth and chin
– Use ring/little fingers to bring jaw up to mask
– Trigger device until chest rises
– Repeat every 5 seconds
Temple College EMS Program
35
Ventilation Techniques
• Manually-Triggered Ventilator (Suspected Trauma)
– Open airway, insert oral or nasal airway
– Have assistant hold head manually or use knees to prevent
movement
– Position thumbs over top half of mask, index/middle fingers over
bottom half
– Place apex of mask over bridge of nose, lower mask over mouth
and chin
– Use ring/little fingers to bring jaw up to mask without tilting head
and neck
– Trigger device until chest rises
– Repeat every 5 seconds
Temple College EMS Program
36
Assisting Patients Who Are Breathing
• Who needs assistance?
– A patient who is not breathing
– A patient who has reduced respiratory rate and
tidal volume
– A patient whose breathing rate is increased, but
whose tidal volume is inadequate
Temple College EMS Program
37
Assisting Patients Who Are Breathing
• Patients with rapid, shallow breathing
– Explain procedure to patient
– Place mask over patient’s mouth and nose
– Initially assist ventilations at rate at which
patient is breathing. Squeeze bag as patient
inhales
– Slowly adjust rate and tidal volume until
adequate ventilations are achieved
Temple College EMS Program
38
Assisting Patients Who Are Breathing
• Patients with slow, shallow breathing
– Place bag over patient’s mouth and nose
– Squeeze bag each time patient inhales
– Adjust rate and tidal volume until adequate
ventilations are achieved
Temple College EMS Program
39
Special Considerations
• Stoma or tracheostomy tube
– Attach BVM to tube, or use infant/child mask
to make seal over stoma
– Seal mouth/nose if air is escaping when
ventilating at stoma
– If unable to ventilate
• Suction stoma or tracheostomy tube
• Seal stoma, attempt to ventilate through mouth/nose
Temple College EMS Program
40
Special Considerations
• Infants and children
–
–
–
–
Place infant’s head in neutral position
Extend child’s head slightly past neutral
Avoid excessive hyperextension
Avoid excessive ventilation, just make chest
rise
– Gastric distension is more common in children
– Do not use BVMs with pop-off valves
Temple College EMS Program
41
Special Considerations
• Dentures
– Leave in place unless obviously loose
– Remove if loose
– Be prepared to remove if displacement occurs
Temple College EMS Program
42
Oxygen
• Oxygen cylinder sizes
–
–
–
–
–
D cylinder 350 liters
E cylinder 625 liters
M cylinder 3,000 liters
G cylinder 5,300 liters
H cylinder 6,900 liters
• Contents under pressure
• Should be positioned to prevent falling, blows to
valve-gauge assembly
Temple College EMS Program
43
Oxygen
• Operating procedures
–
–
–
–
–
–
–
–
Remove protective seal
Quickly open, then shut valve
Attach regulator-flow meter to tank
Select proper size of oxygen mask for patient
Attach oxygen mask to flowmeter
Open flow meter to desired setting
Apply device to patient
When complete, remove device from patient, turn off
device, remove all pressure from regulator
Temple College EMS Program
44
Oxygen
• Non-rebreather mask
– Preferred method of giving oxygen to
prehospital patients
– Up to 90% oxygen can be delivered
– Non-rebreather bag must be full before mask is
placed on patient
– Flow rate should be adjused so when patient
inhales, bag does not collapse (~15 lpm)
Temple College EMS Program
45
Oxygen
• Nasal cannula
– Rarely best method for giving adequate oxygen
in emergency care settings
– Should be used only if patient will not tolerate
non-rebreather mask in spite of coaching
Temple College EMS Program
46
Oxygen
• Concerns about giving too much oxygen to
patients with COPD, infants, and children
are NOT valid during short-term emergency
administration
• Patients with COPD, infants, and children
who require oxygen should be given high
concentration oxygen.
Temple College EMS Program
47