Airway Management
Oxygenation and Ventilation
Jeffrey A. Orphal NREMT-P
Flight Paramedic
St. Vincent Mercy Medical Center
UTMC
St. Rita’s Medical Center
Life Flight/Mobile Life
Continuing Education #2092
Do we have an Airway????
Introduction:
The body’s need for oxygen
• Primary objective of emergency care
– Ensure optimal ventilation
• Delivery of oxygen
• Elimination of CO2
• Brain death occurs within 6 to 10
minutes
Major prehospital causes of
preventable death
• Early detection
• Early intervention
• Lay-person BLS education
Most often neglected of
prehospital skills
• Basics taken for granted
• Poor techniques
– BVM seal
– Improper positioning
– Failure to reassess
Airway Anatomy Review
• Divisions of the airway
– Upper airway
– Lower airway
Upper Airway Anatomy
• Pharynx
– Nasopharynx
– Oropharynx
– Laryngopharynx
• Upper Airway Function
– Warm
– Filter
– Humidify
Glottic Opening
• Glottis
– True vocal cords and the
space between them
• Glottic opening
directly behind
thyroid cartilage
– Narrowest part of adult
larynx
Cricoid Cartilage
• Most inferior of the
laryngeal cartilages
• First tracheal ring
• Only completely
cartilaginous ring in
the larynx
• Cricoid pressure =
Sellick maneuver
Epiglottis
• Small, leaf-shaped
cartilage
• Prevents food from
entering trachea
during swallowing
• Important landmark
for intubation
Lower Airway Anatomy
• Trachea
• Bronchi and bronchioles
• Alveoli
• Lungs
* Function of the lower airway
– Exchange of O2 and CO2
Trachea
• Rigid tube, 4 to 5 inches
long
• Carina
• Supported by C-shaped
cartilaginous rings
• Obstruction results in death
in minutes
Bronchi/Alveoli
• Primary (mainstem) bronchi
branch into secondary and
tertiary bronchi
• Bronchioles composed of
smooth muscle
• Right mainstem bronchus
shorter, wider, straighter
than the left
• Alveoli
Lung Volumes
• Tidal
volume
• Minute
volume
Lung/ respiratory volumes
• Total lung volume
– Adult male, 6 liters
– Not all inspired air enters alveoli
– Minor diffusion of O2 takes place in alveolar
ducts and terminal bronchioles
• Tidal volume
– Volume of gas inhaled or exhaled during a
single respiratory cycle
– 5-7cc/ kg (500 cc normally)
Dead space air
• Air remaining in air passageways, unavailable
for gas exchange (approximately 150cc)
• Anatomic dead space
– Trachea
– Bronchi
• Physiologic dead space
– Dead space formed by factors like disease or
obstruction
• COPD
Minute volume
• Amount of gas moved in and out of the
respiratory tract per minute
• Determined by:
– (Tidal volume - dead space volume) times
respiratory rate
Ventilation
• Definition - movement of air into and out
of the lungs
SO……. We ventilate patients, We bag
groceries
Inspiration
– Stimulus to breathe from respiratory center
– Impulse transmitted to diaphragm
– Diaphragm - "muscle of respiration"
– Separates thoracic from abdominal cavity
– Diaphragm contracts - "flattens"
– Causes intrapulmonic pressure to fall slightly
below atmospheric pressure
Inspiration cont.
– Intercostal muscles contract
– Ribs elevate and expand
– Air is drawn into lungs like a vacuum
– Alveoli Inflate
– O2/ CO2 are able to diffuse across membrane
Expiration
• Stretch receptors in lungs signal
respiratory center via vagus nerve to
inhibit inspiration (Hering-Breuer Reflex)
• Natural elasticity (recoil) of the lungs
passively expires air
Respiration:
• Definition
– Exchange of gases between a living
organism and its environment
– The major gases of respiration are oxygen
and carbon dioxide
• Types
– External respiration - exchange of gasses
between the lungs and the blood cells
– Internal respiration - exchange of gases
between the blood cells and tissues
Oxygen in the blood
• Approximately 97% of total O2 is bound to
hemoglobin
• O2 saturation
– % of hemoglobin saturated
– Normally greater than 98%
Carbon dioxide
• CO2 is a byproduct of cellular work
(cellular respiration)
• CO2 is transported in blood as
bicarbonate ion
• About 33% is bound to hemoglobin
• As O2 crosses into blood, CO2 diffuses
into alveoli
• Carbon dioxide in the blood: PaCO2
Diagnostic testing
• Pulse oximetry
• End-tidal CO2 monitoring
• Other equipment
Manual Airway Maneuvers
Airway Obstruction
• Tongue
– Common cause of partial airway obstruction in unresponsive patient
– Snoring respirations characteristic sign
• Reposition head and jaw
Manual Airway Maneuvers
Head Tilt Chin Lift
Modified Jaw-Thrust
Suctioning
• Purpose
– Remove vomitus, saliva, blood, and other material from the
patient’s airway
– Improve gas exchange
– Obtain secretions for diagnosis
Suctioning
• Insert suction catheter WITHOUT applying suction
• Apply intermittent suction while withdrawing the
catheter
• Suction should not be applied for more than 10 to
15 seconds
• Before repeating the procedure, ventilate with
100% oxygen for about 30 seconds
Complications of Suctioning
• Hypoxia
• Dysrhythmias
• Increased intracranial pressure
• Local edema
• Hemorrhage
• Tracheal ulceration
• Tracheal infection
• Bronchospasm
• Bradycardia and hypotension due to vagal stimulation
Airway Adjuncts
• Oral Airways
• Nasal Airway
Bag-Valve-Mask (BVM)
Ventilation
• Oxygen delivery
Bag-Valve-Mask (BVM)
Ventilation
• Tidal volumes and inspiratory times
(adult patient)
– Oxygen available
• Lower tidal volumes recommended
– 6 to 7 mL/kg (400 to 600 mL) given over 1 to 2 seconds
until chest rises
– No oxygen available
• 10 mL/kg (700 to 1000 mL) delivered over 2 seconds
sufficient to make chest rise
Bag Value Mask
• Advantages
– Provides a means for delivery
of an oxygen enriched mixture
to the patient
– Conveys a sense of
compliance of patient’s lungs
to the
BVM operator
– Provides a means for
immediate ventilatory support
– Can be used with
spontaneously breathing
patient as well as apneic
patient
Bag Value Mask
• Disadvantages
– Inability to provide adequate
ventilatory volumes
– Should only be used by
trained operators
– Difficult to use by
inexperienced operators
– Gastric distention
Endotracheal Intubation
ET Equipment
• Laryngoscope
• Blades
– Straights
– Curves
•
•
•
•
•
•
•
10 cc syringe
Lubricant
Stylet
Securing device
Comfirmation Device
Suction
BSI Precaution
Straight Blade
• Miller Blade
• Straight blade
positioned under
epiglottis
• Directly lifts
epiglottis to expose
glottic opening
Curve Blade
• Macintosh blade
• Curved blade is inserted
into the vallecula
– Space or “pocket” between
base of tongue and epiglottis
– Blade elevates tongue and
indirectly lifts epiglottis,
allowing visualization of glottic
opening
Curve Blade Technique
Endotracheal Tube (ETT)
• Curved tube open at both ends
• Standard 15-mm connector at proximal end
• Some ETT have an inflatable balloon cuff at
distal tip of tube
Stylet
• Flexible plasticcoated wire
• Used to mold and
maintain shape of
ETT
• When used, tip of
stylet must be
recessed ½ inch
from end of
ET tube
ET Intubation - Indications
• Inability of the patient to
protect his or her own
airway due to the
absence of protective
reflexes
– Coma, respiratory and/or cardiac
arrest
• Inability of the rescuer to
ventilate the
unresponsive patient with
less invasive methods
• When prolonged
ventilatory support is
required
• Present or impending
airway obstruction /
respiratory failure
– Inhalation injury
– Severe asthma
– Exacerbation of COPD
– Severe pulmonary edema
– Severe flail chest or
pulmonary contusion
ET Intubation - Advantages
• Isolates the airway
• Keeps the airway patent
• Reduces the risk of aspiration
• Ensures delivery of a high concentration of oxygen
• Permits suctioning of the trachea
• Provides a route for administration of some medications
–
“ALONE” – atropine, lidocaine, oxygen, naloxone (Narcan), epinephrine
• Ensures delivery of a selected tidal volume to maintain
lung inflation
ET Intubation – Disadvantages
• Considerable training and experience required
• Special equipment needed
• Bypasses physiologic function of upper airway
– (e.g., warming, filtering, humidifying of inhaled air)
• Requires direct visualization of vocal cords
ET Intubation – Technique
• Personal protective equipment
• Open airway
• Auscultate lung sounds to establish baseline
• Assemble and prepare equipment
• Select blade of proper size
• Attach blade to handle
• Check blade for “white, bright, light”
ET Intubation – Technique
• Select proper size ET tube
• Test for leaks
• Insert stylet
– Ensure tip is recessed ½ inch from distal tip of ET tube
• Lubricate end of tube with water-soluble
lubricant
ET Intubation – Technique
• If trauma is not
suspected, place
patient’s head in
“sniffing” position
– Aligns axes of mouth, pharynx, and
trachea
ET Intubation – Technique
• Stop ventilations
• Remove ventilation mask and
OPA (if present)
• Direct assistant to apply cricoid
pressure
• Hold laryngoscope in left hand
• Insert blade into right side of
patient’s mouth, sweeping
tongue to the left
ET Intubation – Technique
• Advance the laryngoscope blade
until the distal end reaches the base
of the tongue
ET Intubation – Technique
• Lift the laryngoscope to
elevate the mandible
without putting
pressure on the front
teeth
• Visualize the epiglottis
– Suction the laryngopharynx as
necessary
• Identify the vocal cords
• Place the blade in
proper position
ET Intubation – Technique
• View of the epiglottis and vocal cords
ET Intubation – Technique
• If using a curved blade, advance the tip of the
blade into the vallecula.
• Tip of curved blade inserted in vallecula.
• Curved blade is lifted anteriorly to expose the
vocal cords.
ET Intubation – Technique
• The straight blade is advanced under the epiglottis.
• The blade is then lifted anteriorly, directly exposing the
vocal cords.
ET Intubation – Technique
• Advance the ET tube until the proximal
end of the cuff lies 1/2 to 1 inch beyond
the cords.
ET Intubation – Technique
• Ventilate the patient
• Auscultate
– Epigastrium first
– Midaxillary and anterior chest line on
right and left sides
– Observe chest rise and fall
• Verify placement by at
least one additional
method
– ETCO2
– Esophageal detector
– Chest x-ray
• Note cm marking of tube
at teeth
ET Intubation - Technique
• Secure ET tube with
commercial tube-holder
(preferred) or tape
• Provide ventilatory
support with
supplemental oxygen
• After securing the tube,
observe and record tube
depth at the patient’s
teeth
Confirming ET Tube Placement
• Primary methods
– Visualizing passage of ET tube between the vocal cords
– Auscultating presence of bilateral breath sounds
– Confirming absence of sounds over epigastrium during ventilation
– Adequate chest rise with each ventilation
– Absence of vocal sounds after placement of ET tube
• Secondary methods
– Monitoring for changes in the color (colorimetric device) or number
(digital device) on an end-tidal CO2 detector
– Verification by an esophageal detector device
– Chest x-ray
End-Tidal Carbon Dioxide
(ETCO2) Detectors
• ETCO2 monitoring is used for:
– Assessment of conscious sedation safety
– Evaluation of mechanical ventilation
– Verification of ETT placement
ETCO2 Detectors
• ETCO2 device placed between ETT (or
Combitube, etc.) and ventilation device
• Presence of CO2 suggests tracheal placement
• Lack of CO2 suggests esophageal placement
• Inaccurate results may occur:
– Cardiopulmonary arrest
– Significant pulmonary embolus
– Ingestion of carbonated beverages before arrest
ETCO2 Detectors
Confirm placement with an ETCO2
detector
Esophageal Detector Devices
(EDD)
• Simple, inexpensive, easy to use
• Two types
– Syringe
– Bulb
• Principle
– Esophagus is a collapsible tube
– Trachea is a rigid tube
Esophageal Detector Device Syringe
• Connect the syringe to the ETT
with the plunger fully inserted into
the barrel of the syringe
• If the ETT is in the trachea, the
plunger can be easily withdrawn
from the syringe barrel
• If the ETT is in the esophagus, the
walls of the esophagus will collapse
when negative pressure is applied
to the syringe
– Prevents air from being drawn out of the
syringe
Esophageal Detector Device –
Bulb
• Compress the bulb before
connecting to the ETT
• A vacuum is created as
pressure on the bulb is
released
• If the ETT is in the trachea,
the bulb refills easily on
release of pressure
• If the ETT is in the esophagus,
the bulb remains collapsed
Esophageal Detector Device
• Results may be misleading in patients
with:
– Morbid obesity
– Late pregnancy
– Status asthmaticus
– Copious tracheal secretions
Securing the tube
• As critical as the intubation itself
• Multiple methods and products available
– Tape
– Tubing
– Commercial devices
• C-Collars
Tracheal Tube Holders:
Adult and Infant
ET Intubation Complications
• Bleeding
• Occlusion caused by patient
• Laryngospasm
• Laryngeal or tracheal edema
• Vocal cord damage
biting tube or secretions
• Tube occlusion
• Mucosal necrosis
• Inability to talk
• Barotrauma
• Hypoxia due to prolonged or
• Aspiration
• Cuff leak
• Esophageal intubation
• Right mainstem intubation
unsuccessful intubation
• Dysrhythmias
• Trauma to lips, teeth, tongue,
or soft tissues of oropharynx
• Increased intracranial pressure
Nasotracheal intubation
• Passage of ET tube through
nasopharynx into trachea
• Indications
– Breathing patients requiring intubation
• Contraindications
– Caution with facial trauma
– Caution with deviated septum
Nasotracheal intubation
• Advantages
– Does not require laryngoscope
– Does not require sniffing position
– More easily secured
– Patient cannot bite tube
• Disadvantages
– "Blind" technique
– Can only be performed on breathing
patients
Endotrol
BAAM
• Beck Airway Flow Monitor (BAAM)
is a disposable device that
magnifies the patients respirations
with a whistle sound. Simply
attach the BAAM to the end of an
ET tube to assist you with correct
tube placement, blind
nasotracheal intubation, and to
monitor the status of an airway. If
you hear a whistle sound you
know that there is air moving
through the device. If there is no
whistle sound it means the tube is
in the wrong place or the trachea
is obstructed. The BAAM can also
provide different whistle pitches
depending on how strong the
respiratory effort is.
Digital intubation
• Direct palpation of glottic structures to
intubate trachea
• Indications
– Apnea
– Confined space
– Inability to directly visualize
• Contraindications
– Breathing patient
– Present gag reflex
Digital intubation
• Advantages
– Does not require laryngoscope
– Does not require sniffing position
– May be passed through fluid obstructions
• Disadvantages
– Semi-blind technique
– May only be done on apneic patients
– Difficult with short fingers
Endotracheal Tube Introducer
• “BOUGIE” type Introducers will
assist in directional control of
the endotracheal tube,
especially when the laryngeal
opening is not fully visible.
• Introduced in the early 1940s
it remains one of the best kept
secrets in airway management
• Tracheal clicking assist in
confirming that the bougie lies
in the trachea
Retrograde intubation
• A wire or epidural catheter is
passed through the
cricothyroid membrane in a
cephalad direction (towards
the head) until it comes out of
the nose or mouth. (In some
patients it is necessary to
grasp the catheter in the mouth
using a pair of Magills forceps).
At this point the patient has a
wire running from within the
trachea to the upper airway.
An endotracheal tube is then
inserted over this wire into the
trachea from either the nasal
or oral route. Ensure
oxygenation is maintained
throughout
Combitube
• Pharyngeal and endotracheal tube
molded into a single unit
• Indications
– Alternative airway control when
conventional intubation measures are
unsuccessful or unavailable
• Contraindications
– Children too small for the tube
– Esophageal trauma or disease
– Caustic ingestion
Combitube
• Advantages
– Rapid insertion
– No special equipment
– Does not require sniffing position
• Disadvantages
– Impossible to suction trachea when tube is in
esophagus
– Adults only
– Unconscious only
– Very difficult to intubate around
Combitube
Laryngeal Mask Airway (LMA)
The LMA is an adjunctive airway that consists of
a tube with a cuffed mask-like projection at
distal end
Laryngeal Mask Airway (LMA)
• Advantages
– Can be quickly inserted to provide ventilation when bagvalve-mask ventilation is not sufficient and endotracheal
intubation cannot be readily accomplished
– Less gastric insufflation than with bag-valve-mask
ventilation
– Easier to use, with only minimal training, when compared
to bag-valve-mask
– Provides equivalent ventilation to the tracheal tube
– Training simpler than with tracheal intubation
– Unaffected by anatomical factors (e.g., beard, absence of
teeth)
– No risk of esophageal or bronchial intubation
– When compared to tracheal intubation, less potential for
trauma from direct laryngoscopy and tracheal intubation
Laryngeal Mask Airway (LMA)
• Disadvantages
– Does not provide protection against aspiration
– Cannot be used if the mouth cannot be opened more than
0.6 in (1.5 cm)
– May not be effective when respiratory anatomy is
abnormal
– May be difficult to provide adequate ventilation if high
airway pressures are required
LMA
LMA
Insertion
Technique
Rapid sequence intubation
(RSI)
• Pre-medication to facilitate intubation on patient
potential and/or actual airway compromise.
• Sedation’s
– Etomidate
– Versed
– Fentanyl
• Paralytic’s
– Succinylcholine
– Norcuron
Special Consideration
• Pre-medication of Lidocaine (1.0-
1.5mg/kg IVP) in patients with suspected
head injuries
• Pre-medicate children less than 5 years of
age with Atropine (0.02 mg/kg IVP)
Cricothyrotomy
• Surgical access to the airway through the
cricothyroid membrane
• Indications
– Total upper airway obstruction (epiglotitis, acute
anaphylaxis, respiratory tract burns, etc.)
– Massive facial trauma
– Delayed or inability to intubate or ventilate the patient
by other means
– Contraindication to intubation
– Posterior laceration of the tongue
– Inability to open the mouth
Cricothyrotomy
• Contraindications
– Inability to identify anatomical landmarks
– Crush injury to the larynx
– Tracheal transection
– Underlying anatomical abnormality (trauma,
tumor, subglottic stenosis, etc.)
Cricothyrotomy
• Advantages
– Rapidly performed
– Much faster and technically easier than
tracheostomy
– Does not manipulate the cervical spine
• Disadvantages
– Difficult to perform in children
– Difficult to perform on patients with short,
muscular, or fat necks
Cricothyrotomy
• Equipment
– Endotracheal or tracheostomy tube
– Scalpel
– Curved hemostats
– Suction apparatus
Cricothyrotomy
• Method
• Complications
– Incorrect tube placement/ false passage
– Thyroid gland damage
– Severe bleeding
– Subcutaneous emphysema
– Laryngeal nerve damage