7: Airway
Cognitive Objectives
(1 of 5)
2-1.1 Name and label the major structures of the
respiratory system on a diagram.
2-1.2 List signs of adequate breathing.
2-1.3 List signs of inadequate breathing.
2-1.4 Describe the steps in performing the head tilt-chin
lift maneuver.
2-1.5 Relate mechanism of injury to opening the airway.
2-1.6 Describe the steps in performing the jaw-thrust
maneuver.
2
Cognitive Objectives
(2 of 5)
2-1.7 State the importance of having suction ready for
immediate use when providing emergency care.
2-1.8 Describe the techniques of suctioning.
2-1.9 Describe how to artificially ventilate a patient with
a pocket mask.
2-1.10 Describe the steps in performing the skill of
artificially ventilating a patient with a bag-valvemask device while using the jaw-thrust maneuver.
3
Cognitive Objectives
(3 of 5)
2-1.11 List the parts of the bag-valve-mask system.
2-1.12 Describe the steps in performing the skill of
artificially ventilating a patient with a bag-valvemask device for one and two rescuers.
2-1.13 Describe the signs of adequate artificial
ventilation using the bag-valve-mask device.
2-1.14 Describe the signs of inadequate artificial
ventilation using the bag-valve-mask device.
2-1.15 Describe the steps in ventilating a patient with a
flow-restricted oxygen-powered ventilation
device.
4
Cognitive Objectives
(4 of 5)
2-1.16 List the steps in performing the actions taken
when providing mouth-to-mouth and mouth-tostoma ventilation.
2-1.17 Describe how to measure and insert
oropharyngeal (oral) airway.
2-1.18 Describe how to measure and insert a
nasopharyngeal (nasal) airway.
2-1.19 Define the components of an oxygen delivery
system.
2-1.20 Identify a nonrebreathing face mask and state the
oxygen flow requirements needed for its use.
5
Cognitive Objectives (5 of 5)
2-1.21 Describe the indications for using a nasal cannula
versus a nonrebreathing face mask.
2-1.22 Identify a nasal cannula and state the flow
requirements needed for its use.
6
Affective Objectives
2-1.23 Explain the rationale for basic life support,
artificial ventilation, and airway protective skills
taking priority over most other basic life support
skills.
2-1.24 Explain the rationale for providing adequate
oxygenation through high inspired oxygen
concentrations to patients who, in the past, may
have received low concentrations.
7
Psychomotor Objectives (1 of 4)
2-1.25 Demonstrate the steps in performing the head tiltchin lift maneuver.
2-1.26 Demonstrate the steps in performing the jawthrust maneuver.
2-1.27 Demonstrate the techniques of suctioning.
2-1.28 Demonstrate the steps in providing mouth-tomouth artificial ventilation with body substance
isolation (barrier shields).
2-1.29 Demonstrate how to use a pocket mask to
artificially ventilate a patient.
8
Psychomotor Objectives (2 of 4)
2-1.30 Demonstrate the assembly of a bag-valve-mask
unit.
2-1.31 Demonstrate the steps in performing the skill of
artificially ventilating a patient with a bag-valvemask device for one and two rescuers.
2-1.32 Demonstrate the steps in performing the skill of
artificially ventilating a patient with a bag-valvemask device while using the jaw-thrust maneuver.
2-1.33 Demonstrate artificial ventilation of a patient with
a flow-restricted, oxygen-powered ventilation
device.
9
Psychomotor Objectives (3 of 4)
2-1.34 Demonstrate how to artificially ventilate a patient
with a stoma.
2-1.35 Demonstrate how to insert an oropharyngeal
(oral) airway.
2-1.36 Demonstrate how to insert a nasopharyngeal
(nasal) airway.
2-1.37 Demonstrate the correct operation of oxygen
tanks and regulators.
2-1.38 Demonstrate the use of a nonrebreathing face
mask and state the oxygen flow requirements
needed for its use.
10
Psychomotor Objectives (4 of 4)
2-1.39 Demonstrate the use of a nasal cannula and state
the flow requirements needed for its use.
2-1.40 Demonstrate how to artificially ventilate the infant
and child patient.
2-1.41 Demonstrate oxygen administration for the infant
and child patient.
11
Additional Objectives*
1. Describe how to perform the Sellick maneuver
(cricoid pressure).
2. Explain the rationale for applying cricoid pressure.
3. Demonstrate how to perform the Sellick maneuver
(cricoid pressure).
•
These are noncurriculum objectives.
12
Anatomy Review
13
Breathing Process: Inhalation
• Active part of breathing
• Diaphragm and intercostal
muscles contract, allowing
the lungs to expand.
• The decrease in pressure
allows lungs to fill with air.
• Air travels to the alveoli
where exchange of gases
occurs.
14
Breathing Process: Exhalation
• Does not normally require
muscular effort
• Diaphragm and intercostal
muscles relax.
• The thorax decreases in size, and
ribs and muscles assume their
normal positions.
• The increase in pressure forces air
out.
15
The Body’s Need for Oxygen
16
Gas Exchange
• Inhalation delivers oxygenrich air to alveoli.
• Oxygen diffuses into the
blood.
• Breathing is primarily
adjusted by the level of
carbon dioxide in the blood.
17
Hypoxia
• Not enough oxygen for metabolic needs
• Develops when patient is:
– Breathing inadequately
– Not breathing
18
Signs of Hypoxia
• Nervousness, irritability, and fear
• Tachycardia
• Mental status changes
• Use of accessory muscles for breathing
• Difficulty breathing, possible chest pain
19
Conditions Resulting in Hypoxia
• Myocardial infarction
• Chest injury
• Pulmonary edema
• Shock
• Acute narcotic overdose
• Lung disease
• Smoke inhalation
• Asthma
• Stroke
• Premature birth
20
Recognizing Adequate Breathing
• Normal rate and depth
• Regular pattern
• Regular and equal chest rise and fall
• Adequate depth
21
Normal Respiration Rates
• Adults
12 to 20 breaths/min
• Children
15 to 30 breaths/min
• Infants
25 to 50 breaths/min
22
Recognizing Inadequate Breathing
• Fast or slow rate
• Irregular rhythm
• Abnormal lung sounds
• Reduced tidal volumes
• Use of accessory muscles
• Cool, damp, pale or cyanotic
skin
23
Head Tilt–Chin Lift
• Kneel beside patient’s
head.
• Place one hand on
forehead.
• Apply backward pressure.
• Place tips of finger under
lower jaw.
• Lift chin.
24
Jaw-Thrust Maneuver
• Kneel above patient’s head.
• Place fingers behind angle of lower jaw.
• Use thumbs to position the lower jaw.
25
Assessment of the Airway (1of 2)
26
Assessment of the Airway (2 of 2)
• Assess whether breathing has returned using look,
listen, and feel technique.
– Listen by placing your ear about 10 inches above
patient’s nose and mouth.
– Feel and listen for movement of air.
– Watch the patient’s chest and abdomen.
– Place a hand on patient’s chest to feel for
movement.
27
Severe Airway Obstruction
•
•
•
•
There will be no movement of air.
Chest and abdomen may rise and fall with
patient’s attempts to breathe.
Chest wall movement alone does not
indicate breathing.
Always use three-part approach: look, listen, and feel
for movement of air.
28
Basic Airway Adjuncts (1 of 6)
• Oropharyngeal airways
– Keep the tongue from
blocking the upper airway
– Allow for easier suctioning
of the airway
– Used in conjunction with
BVM device
– Used on unconscious
patients without a gag
reflex
29
Basic Airway Adjuncts (2 of 6)
Inserting an oropharyngeal airway
1. Select the proper size airway.
2. Open the patient’s mouth.
3. Hold the airway upside down and insert it in
the patient’s mouth.
4. Rotate the airway 180° until the flange rests
on the patient’s lips.
30
Basic Airway Adjuncts (3 of 6)
1
2
3
31
Basic Airway Adjuncts (4 of 6)
• Nasopharyngeal airways
– Conscious patients who cannot maintain
airway
– Can be used with intact gag reflex
– Should not be used with head injuries or
nosebleeds
32
Basic Airway Adjuncts (5 of 6)
Inserting a nasopharyngeal airway
1. Select the proper size airway.
2. Lubricate the airway.
3. Gently push the nostril open.
4. With the bevel turned toward the
septum, insert the airway.
33
Basic Airway Adjuncts (6 of 6)
1
2
3
4
34
Suctioning Equipment (1 of 2)
35
Suction Equipment (2 of 2)
French, or whistle-tip, catheter
36
Suctioning Technique (1 of 2)
• Check the unit and turn it on.
• Select and measure proper
catheter to be used.
• Open the patient’s mouth
and insert tip.
• Suction as you withdraw the
catheter.
• Never suction adults for
more than 15 seconds.
37
Suctioning Technique (2 of 2)
1
2
3
4
38
Recovery Position
39
Supplemental Oxygen
• All patients in cardiac arrest should get oxygen.
• Any patient with a respiratory or cardiac emergency
needs oxygen.
• Never withhold oxygen from anyone who may
benefit from it.
40
Supplemental Oxygen Equipment
• Oxygen cylinders
– Available as a compressed
combustible gas
– Available in several sizes
– Pin-indexing safety system
– Oxygen regulators
– Humidified oxygen
41
Oxygen Flowmeters
• Pressure-compensated flowmeter
– Affected by gravity; must be kept
upright
• Bourdon-gauge flowmeter
– Not affected by gravity; can be
used in any position
42
Using Supplemental Oxygen (1 of 2)
• Inspect cylinder and markings.
• “Crack” the cylinder.
• Attach the regulator/flowmeter.
• Open the cylinder.
• Attach proper delivery device to flowmeter.
43
Using Supplemental Oxygen (2 of 2)
• Adjust flowmeter to desired flow rate.
• Apply the oxygen device to the patient.
• When done, discard the delivery device.
• Turn off the flowmeter.
44
Hazards of Oxygen
• Oxygen supports combustion.
• Keep possible ignition sources away from the
area.
• Oxygen tanks are under high pressure.
45
Oxygen Delivery Equipment
• Nonrebreathing mask
– Provides up to 90%
oxygen
– Used at 10 to 15 L/min
• Nasal cannula
– Provides 24% to 44%
oxygen
– Used at 1 to 6 L/min
46
Methods of Ventilation
• Mouth to mask
• Two-person BVM device
• Flow-restricted,
oxygen-powered device
• One-person BVM device
Bag-valve-mask
47
Rate of Artificial Ventilations
Adult — 1 breath every 5-6 seconds
Children — 1 breath every 3-5 seconds
Infants — 1 breath every 3-5 seconds
Bag-valve-mask
48
Mouth-to-Mask Technique (1 of 2)
• Kneel at patient’s head and open airway.
• Place the mask on the patient’s face.
• Take a deep breath and breathe into the patient for 1
second.
• Remove your mouth and watch for patient’s chest to
fall.
49
Mouth-to-Mask Technique (2 of 2)
50
Bag-Valve-Mask Device
• Can deliver more than 90% oxygen
• Delivers less tidal volume than mouth-to-mask
• Requires practice to be proficient
• May be used with advanced airways
51
Bag-Valve-Mask Components
52
Two-Person BVM Technique (1 of 2)
• Insert an oral airway.
• One caregiver maintains seal while the other
delivers ventilations.
• Place mask on patient’s face.
• Squeeze bag to deliver ventilations.
53
Two-Person BVM Technique (2 of 2)
54
One-Person BVM Technique
55
Flow-Restricted, Oxygen-Powered
Devices
56
Ongoing Assessment of Ventilation
• Adequate Ventilation
– Equal chest rise and fall
– Ventilating at appropriate rate
– Heart rate returns to normal
• Inadequate Ventilation
– Minimal or no chest rise and fall
– Ventilations too fast or slow
– Heart rate does not return to normal
57
Sellick Maneuver
• Also referred to as cricoid pressure.
• Use on unconscious patients to prevent
gastric distention.
• Place pressure on cricoid with thumb and
index finger.
58
Gastric Distention
• Artificial ventilation fills stomach with air.
• Occurs if ventilations are too forceful or too
frequent or when airway is blocked
• May cause patient to vomit and increase risk
of aspiration
59
Stomas and Tracheostomy Tubes
• Ventilations are delivered
through the stoma.
• Attach BVM device to tube or
use infant mask.
• Stoma may need to be
suctioned.
60
Causes of Foreign Body Obstruction
• Relaxation of the tongue
• Vomited stomach contents
• Blood clots, bone
fragments, damaged
tissue
• Swelling caused by allergic
reactions
• Foreign objects
61
Recognizing an Obstruction (1 of 2)
• Obstruction may be mild or severe.
• Is patient able to speak or cough?
• If patient is unconscious, attempt
to deliver artificial ventilation.
62
Removing an Obstruction (2 of 2)
• Perform Heimlich maneuver.
• Use suction if needed.
• If attempts to clear the airway are
unsuccessful, transport rapidly.
63
Review
1. Breathing is controlled by an area in the:
A. lungs.
B. brain stem.
C. spinal cord.
D. diaphragm.
64
Review
Answer: B
Rationale: The pons and the medulla are the respiratory
centers in the brain stem that control breathing.
65
Review
1. Breathing is controlled by an area in the:
A. lungs.
Rationale: The lungs contain small pockets called alveoli where the
exchange of oxygen and carbon dioxide takes place.
B. brain stem.
Rationale: Correct answer
C. spinal cord.
Rationale: Impulses are sent down the spinal cord from the brain
stem.
D. diaphragm.
Rationale: The diaphragm receives the impulses which cause it to
contract and bring air in.
66
Review
2. The EMT-B should assess a patient’s tidal volume by:
A. observing for adequate chest rise.
B. assessing the facial area for cyanosis.
C. counting the patient’s respiratory rate.
D. measuring the patient’s oxygen saturation.
67
Review
Answer: A
Rationale: Tidal volume—the volume of air that is moved
into or out of the lungs in a single breath—is assessed
by observing for adequate chest rise. If shallow chest
rise is noted, the patient’s tidal volume is likely
reduced.
68
Review
2. The EMT-B should assess a patient’s tidal volume by:
A. observing for adequate chest rise.
Rationale: Correct answer
B. assessing the facial area for cyanosis.
Rationale: Cyanosis is an indication of hypoxia and not tidal volume.
C. counting the patient’s respiratory rate.
Rationale: Counting the respiratory rate gives you minute volume:
the number of times a patient breaths in one (1) minute. The
normal respiratory rate is 12 – 20 breaths/min for an adult.
D. measuring the patient’s oxygen saturation.
Rationale: Oxygen saturation is an indication of tissue perfusion,
which is the amount of oxygen attached to the hemoglobin. 69
Review
3. In an otherwise healthy individual, the primary stimulus
to breathe is a/an:
A. increased level of oxygen in the blood.
B. decreased level of oxygen in the blood.
C. increased level of carbon dioxide in the blood.
D. decreased level of carbon dioxide in the blood.
70
Review
Answer: C
Rationale: Under control of the brain stem, rising levels
of carbon dioxide in arterial blood normally stimulate
breathing in an otherwise healthy patient. In some
patients with chronic lung disease, low levels of
oxygen in the blood stimulate breathing; this is called
the hypoxic drive.
71
Review
3. In an otherwise healthy individual, the primary stimulus to breathe
is a/an:
A. increased level of oxygen in the blood.
Rationale: Increased levels of oxygen can be a result of
Hyperventilation Syndrome.
B. decreased level of oxygen in the blood.
Rationale: This is typically not normal in healthy individuals. It can
be a sign of inadequate breathing and results in hypoxia.
C. increased level of carbon dioxide in the blood.
Rationale: Correct answer
D. decreased level of carbon dioxide in the blood.
Rationale: This is usually not seen in healthy adults. It is typically 72a
result of Hyperventilation Syndrome.
Review
4. Signs of adequate breathing in the adult include all of
the following, EXCEPT:
A. pink, warm, dry skin.
B. shallow chest rise.
C. symmetrical chest movement.
D. a respiratory rate of 16 breaths/min.
73
Review
Answer: B
Rationale: Signs of inadequate breathing in the adult
include a respiratory rate less than 12 breaths/min or
greater than 20 breaths/min, shallow chest rise
(reduced tidal volume), cyanosis, and asymmetrical
chest movement (both sides of the chest do not move
equally).
74
Review
4. Signs of adequate breathing in the adult include all of the
following, EXCEPT:
A. pink, warm, dry skin.
Rationale: This shows that breathing and perfusion are adequate.
B. shallow chest rise.
Rationale: Correct answer
C. symmetrical chest movement.
Rationale: This shows that the mechanical process of breathing is
adequate, equal, and symmetrical bilaterally.
D. a respiratory rate of 16 breaths/min.
Rationale: This is a normal respiratory rate for an adult.
75
Review
5. A patient is found unconscious after falling from a third
floor window. His respirations are slow and irregular.
You should:
A. place him in the recovery position.
B. apply oxygen via nonrebreathing mask.
C. suction his airway for up to 15 seconds.
D. assist his breathing with a bag-mask device.
76
Review
Answer: D
Rationale: The patient is not breathing adequately. Slow,
irregular respirations will not result in adequate
oxygenation. You should assist the patient’s breathing
with a bag-mask device attached to 100% oxygen.
Suctioning is indicated if the patient has blood or other
liquids in the airway; there is no evidence of this in the
scenario.
77
Review
5. A patient is found unconscious after falling from a third floor
window. His respirations are slow and irregular. You should:
A. place him in the recovery position.
Rationale: Due to a significant MOI, the patient will be placed supine
on a long backboard with the head immobilized.
B. apply oxygen via nonrebreathing mask.
Rationale: A BVM device is indicated if the patient’s respirations are
less than 12 breaths/min.
C. suction his airway for up to 15 seconds.
Rationale: Suction is indicated if a patient has blood or other
secretions in the airway.
D. assist his breathing with a bag-mask device.
Rationale: Correct answer
78
Review
6. When ventilating an apneic adult with a bag-mask
device, you should squeeze the bag:
A. until it is empty.
B. over a period of 2 seconds.
C. at a rate of 20 breaths/min.
D. until visible chest rise is noted.
79
Review
Answer: D
Rationale: When ventilating any apneic patient with a
bag-mask device, you should squeeze the bag over a
period of 1 second and observe for visible chest rise.
Ventilate the apneic adult at a rate of 10 to 12
breaths/min (one breath every 5 to 6 seconds).
Ventilate infants and children at a rate of 12 to 20
breaths/min (one breath every 3 to 5 seconds).
80
Review
6. When ventilating an apneic adult with a bag-mask device, you
should squeeze the bag:
A. until it is empty.
Rationale: An appropriately sized bag for an adult will not totally
empty.
B. over a period of 2 seconds.
Rationale: You should squeeze the bag over a period of 1 second.
C. at a rate of 20 breaths/min.
Rationale: Ventilate the apneic adult at a rate of 10 to 12
breaths/min (or one breath every 5 to 6 seconds).
D. until visible chest rise is noted.
Rationale: Correct answer
81
Review
7. During insertion of an oropharyngeal airway into an
unconscious patient, she begins to vomit. Immediately
the first thing you should do is:
A. turn the patient on her side.
B. remove the airway at once.
C. suction the patient's mouth.
D. use a smaller sized oral airway.
82
Review
Answer: A
Rationale: Any time an unconscious patient begins to
vomit—whether you are inserting an oropharyngeal
airway or not—you should immediately turn the patient
onto his or her side; this will allow drainage of vomit
from the mouth and prevent aspiration. After the
patient is on his or her side, remove the oral airway
and suction the mouth.
83
Review
7. During insertion of an oropharyngeal airway into an unconscious
patient, she begins to vomit. Immediately the first thing you
should do is:
A. turn the patient on her side.
Rationale: Correct answer
B. remove the airway at once.
Rationale: Remove the airway after the patient has been rolled onto
his or her side.
C. suction the patient's mouth.
Rationale: This must be completed after the patient is positioned
and the airway is removed.
D. use a smaller sized oral airway.
Rationale: Oropharyngeal airways are contraindicated if the patient
has a gag reflex.
84
Review
8. You are delivering oxygen to a patient with a nasal
cannula at 4 L/min when he begins to complain of a
burning sensation in his nose. You should:
A. remove the nasal cannula.
B. apply a nonrebreathing mask.
C. attach an oxygen humidifier.
D. increase the flow rate to 6 L/min.
85
Review
Answer: C
Rationale: Administering “dry” oxygen through a nasal
cannula—especially over a prolonged period of time—
can result in drying of the nasal membranes, in which
the patient might complain of a burning sensation in
the nose. Humidified oxygen will serve to keep the
nasal membranes moist.
86
Review
8. You are delivering oxygen to a patient with a nasal cannula at 4
L/min when he begins to complain of a burning sensation in his
nose. You should:
A. remove the nasal cannula.
Rationale: The oxygen should be humidified.
B. apply a nonrebreathing mask.
Rationale: This can still cause an irritation due to providing “dry”
oxygen.
C. attach an oxygen humidifier.
Rationale: Correct answer
D. increase the flow rate to 6 L/min.
Rationale: The oxygen should be humidified.
87
Review
9. In which of the following patients would a
nasopharyngeal airway be contraindicated?
A. A semiconscious patient with a gag reflex
B. An unconscious patient with an intact gag reflex
C. A patient who fell 20' and landed on his or her head
D. An unconscious patient who gags when you insert an
oral airway
88
Review
Answer: C
Rationale: Nasopharyngeal (nasal) airways are
contraindicated in patients with severe head or facial
injuries and should be used with caution in patients
who have delicate nasal membranes or are prone to
nosebleeds. The nasal airway is better tolerated in
patients who are semiconscious and/or those with a
gag reflex.
89
Review
9. In which of the following patients would a nasopharyngeal airway
be contraindicated?
A. A semiconscious patient with a gag reflex
Rationale: This airway works best with an intact gag reflex.
B. An unconscious patient with an intact gag reflex
Rationale: This airway works best with an intact gag reflex.
C. A patient who fell 20' and landed on his or her head
Rationale: Correct answer
D. An unconscious patient who gags when you insert an oral airway
Rationale: This airway can be used when the patient gags with an
oral airway.
90
Review
10. You and your partner are ventilating an apneic adult
when you notice that his stomach is becoming
distended. You should:
A. suction his airway for up to 15 seconds.
B. reposition his head and use cricoid pressure.
C. increase the rate and volume of your ventilations.
D. decrease your ventilation rate but use more volume.
91
Review
Answer: B
Rationale: Gastric distension occurs when air enters the
stomach. Severe gastric distention can result in
vomiting and aspiration if not recognized and treated.
To minimize the amount of air that enters the stomach
during ventilations, you should reposition the patient’s
head and use cricoid pressure (Sellick maneuver).
92
Review
10. You and your partner are ventilating an apneic adult when you
notice that his stomach is becoming distended. You should:
A. suction his airway for up to 15 seconds.
Rationale: Suctioning is indicated when there is blood or secretions
in the airway.
B. reposition his head and use cricoid pressure.
Rationale: Correct answer
C. increase the rate and volume of your ventilations.
Rationale: This action may only result in more air going into the
stomach.
D. decrease your ventilation rate but use more volume.
Rationale: This action may only result in more air going into the
stomach.
93