This is the introduction to airway management for Advanced EMTs though some medics might find it useful too. Focuses mainly on supraglottic and periglottic airway devices as well as basic anatomy , physiology, etc. Talks about apniec defusion too.

1. 2 0 1 4 A E M T C O U R S E
P R E S E N T E D B Y :
R O B E R T S . C O L E
P A R A M E D I C , O C D
Airway Management

2. When ever I’m blue…..
I remember to breath again.
- Anonymous

3. Basic Concept:
 Air Goes in and Out
Blood Goes Round and Round
Any thing infringing on this is a
BAD THING!

4. Respiratory Anatomy

5. The Upper Airway
 1. Nose
 Warm and humidify air through
turbinates
 2. Mouth and oral cavity
 Advanced airway
 Entrance to the digestive system
 Also involved in the production of
speech
 Tongue
 3. Jaw
 Facial bones
 Maxilla
 mandible
 4. Pharynx
 Nasopharynx
 Oropharynx
 Hypopharynx
 Laryngopharyx
 5. Larynx
 Epiglottis – muscular structure
which protects the airway of
conscious patients during
swallowing
 Vocal cords – thin muscles which
are the center for speech and
protect the lower airways
 Thyroid cartilage
 Cricoid ring
 6. Jugular notch

6. The Upper Airway

7. The Lower Airway
 1. Trachea
 Hollow tube which passes
air to the lower airways
 Supported by cartilage
rings
 2. Carina
 The bifurcation of the
trachea into the two main
stem bronchi
 3. Bronchi
 Hollow tubes which
further divide into lower
airways of the lungs
 Supported by cartilage
 Alveoli
 4. Lungs
 a. Bronchioles
 i. thin hollow tubes leading to the
alveoli
 ii. remain open through smooth
muscle tone
 Bronchial smooth muscle
 Beta2 adrenergic receptors
 b. Alveoli
 i. the end of the airway
 ii. millions of thin walled sacs
 iii. each alveolus surrounded by
capillary blood vessels
 iv. site where oxygen and carbon
dioxide (waste) are exchanged
 c. Pulmonary capillary beds
 i. blood vessels that begin as capillary
surrounding each alveolus
 ii. with adequate blood volume and
blood pressure, the vessels return
oxygenated blood to the heart

8. The Lower Airway

9. The Lower Airway
9

10. The Lower Airway
10

13. Key Point
 It takes approximately 150-200 cc
of air movement to reach the
terminal bronchus and the
aveoli…
 This is called “Dead Air Space”
 Tidal volumes less than 200 cc typically
do not oxygenate/ventilate at the
aveolar level.

14. The Lower Airway

15. The Chest Cavity
 Thoracic skin,
muscle, and bones
 Similarities to other
regions
 Also unique features to
allow for ventilation

16. Pulmonary Circulation

17. The Thoracic “Cage”
Credit: wikipedia.com

18. The Rib
Credit: wikipedia.com

20. The Chest Cavity
 The neurovascular bundle lies closely along the
lowest margin of each rib.
 The pleura covers each lung and the thoracic cavity
 The visceral pleura covers the lungs and the parietal pleura
covers the thoracic cavity.
 There is also a negative pressure between the two that keeps
them stuck together yet not actually attached.
 Surfactant allows the lungs to move freely against the inner
chest wall during respiration.

21. Intercostal Muscles and Diaphram
 The Intercostal Muscles
are several groups of
muscles that run
between the ribs
 The diaphragm is a
muscle that separates
the thoracic cavity from
the abdominal cavity.
 Together they help the
“Mechanical Bellows”

22. Mechanics of Ventilation
 The intercostal muscles (between the ribs) contract
during inhalation.
 The diaphragm contracts at the same time.
 The intercostal muscles and the diaphragm relax
during exhalation.
 The body should not have to work to breathe when
in a resting state.

23. Mechanics of Ventilation
 Patients with a spinal
injury below C5 can
still breathe from the
diaphragm.
 Patients with a spinal
injury above C3 may
lose the ability to
breathe altogether.

24. The Mechanical Bellows?

25. The Mechanical Bellows
 The muscles of the ribs
expand the size of the
chest, creating a (relative)
negative pressure.
 Air (with O2) moves in to
fill the void.
 Commonly thought of as
Oxygenation.
 Actual oxygenation takes
place at the cellular level.
Special Thanks to Charlie Miller for this Graphic.

26. The Mechanical Bellows
 The intercostals muscles
relax, allowing the chest
to return to its neutral
position, expelling air out
of the lungs (and CO2
with it.)
 Commonly thought of as
Ventilation.
 Actual ventilation takes
place at the cellular level.
Special Thanks to Charlie Miller for this Graphic.

27. The Mechanical Bellows
 Example of a
Compromised Bellows
 Positional Asphyxia
Special Thanks to Charlie Miller for this Graphic.

28. Key Point:
 A comprehensive understanding
of the Anatomy of the airway and
thorax is essential to managing
the airway and respiratory
functions of your patient.

29. A K A : H O W W E B R E A T H … . .
Physiology of Respiration

30. Key Definitions
 Tidal Volume (Vt)
 Typically 500-700 cc
 Minute Volume (Vm)
 Tidal Volume X Respiratory Rate = Minute Volume
 Functional Reserve Capacity (FRC)
 Typically 2,400 cc in a 70 kg Human
 Inspired Oxygen (FiO2)
 Fraction of Inspired Oxygen
 Expressed as a decimal, i.e. 80% is 0.8 FiO2. 100% is 1.0
FiO2
 Work of Breathing (WOB)

31. Respiratory Rate
times x
Tidal Volume
(amount of air exchanged
in one breath)
equals =
Minute Ventilation
Minute Ventilation
RR x TV = minute volume

32. Physiology of Respiration
 Diffusion of O2 from the lung to the blood is by the
binding of O2 to the hemoglobin (Hgb)
 This is dependant on a pressure gradient.
 This is a Passive transport system.
 It is also dependant on available surface area and distance
it must travel to cross the threshold.
 Capillaries and Alveoli are where the real
Oxygenation and ventilation take place.

33. Alveolar Ventilation
Minute Ventilation
minus –
Dead Air Space
equals =
Alveolar Ventilation
Dead Air Space: the
trachea, bronchi, and
bronchioles.
There is NO gas exchange in
these areas.

34. Key components of an intact respiratory system
 An appropriate Drive to Breath
 Airway and respiratory tract
 Mechanical Bellows
 A diffusion friendly place for gas exchange to
happen.
 An O2 friendly RBC with hgb.
 An intact circulatory system to carry the gasses
and waste through out the body.
 Must have enough of a pressure to promote diffusion.
 An intact capillary bed
 Its like a truck shipping company.

35. Drive to breath
 Controlled by the CNS through information
gathered from receptors in the body.
 Located in the pons region of the brainstem
 Detects increases in CO2 or decreases in pH and
informs the brain to increase the respiratory rate.
 Increased respiratory rate reduces CO2 and will
increase pH.
 Other things can effect our drive to breath

36. “Hypoxic Drive”
 Develops in some patients with Chronic Lung
Disease
 Pons region of brain becomes sensitized to constant
increased CO2 state
 Regulation is now based on O2 level in blood
 Increased oxygen level states may tell the brain to
stop breathing

37. Diffusion

38. An O2 friendly RBC with hgb.
 Hemoglobin is an Iron Based compound essential
to the transport of O2.
 Anemia
 Cyanide Poisoning
 CO Poisoning

39. An intact circulatory system
 Blood Loss
 Shock
 Pump Problem
 Volume Problem
 Fluid issue
 O2 carrying issue
 Vessel Problem

40. KEY POINT:
Must have enough of a pulmonary perfusion pressure
to promote diffusion.
Conditions like Hypotension
cause secondary hypoxia by
promoting low perfusion.

41. Physiology of Respiration
 The primary function of the respiratory system is
gaseous exchange.
 Ventilation and Oxygenation.
 Air is composed of a mixture of gases.
 Breathing is largely controlled by the Autonomic
Nervous system, in response to changes sensed
in all parts of the body. The biggest part of this is
the “Hypoxic Drive”.

42. Physiology of Respiration
 Ventilation is the body’s ability to move gas (usually
atmospheric air) in and out of the chest and lung
tissue.
 Respiration is the exchange of gases in the alveoli of
the lung tissue.

43. Physiology of Respiration
 Oxygen exchange can be hindered by:
 Condition in the airway
 Disease processes- COPD, asthma, pneumonia, pulmonary edema
 Traumatic conditions
 Abnormalities in pulmonary vessels
 Altitude
 Closed environment
 Toxins or poisonous environment
 Drowning
 Occupational exposure

44.  All cells need a constant supply of oxygen to survive.
Physiology of Respiration

45.  Inhalation
 The active part of breathing
 Focused on delivering oxygen to the alveoli
 Tidal volume is the amount of air that moves into or out of
the lungs during a single breath.
 Minute ventilation (minute volume) is the amount of air
moved through the lungs in 1 minute minus the dead space.
Ventilation

46.  Exhalation
 Passive process
 Diaphragm and intercostal muscles relax.
 Smaller thorax compresses air out of the lungs.
 Vital capacity is the amount of air that can be forcibly
expelled from the lungs after breathing deeply.
 Residual volume refers to the air that remains after maximal
expiration.
Ventilation

47.  Regulation of ventilation
 The body’s need for oxygen is constantly changing.
 Failure to meet the need may result in hypoxia.
 For most people, the drive to breathe is based on pH
changes in blood and cerebrospinal fluid.
Ventilation

48. Q U I C K R E V I E W
A L S O R E V I E W E D I N M E D I C A L E M E R G E N C I E S
Respiratory Compromise

49. Pneumothorax
 Commonly called a collapsed lung
 Accumulation of air in the pleural space
 Blood passing through the collapsed portion of the lung is not
oxygenated.
 You may hear diminished, absent, or abnormal breath
sounds.

50. Pneumothorax

51. Pneumothorax
Open chest wound
Often called an open
pneumothorax or a
sucking chest wound.

52. Tension Pneumothorax
 Tension pneumothorax
 Results from significant air accumulation in the pleural space
 Increased pressure in the chest causes:
Complete collapse of the affected lung
Mediastinum to be pushed into the opposite pleural
cavity

53. Tension Pneumothorax

54.  Blood collects in the
pleural space from
bleeding around the
rib cage or from a lung
or great vessel.
Hemothorax

55. Pulmonary Edema
 Heart muscle can’t circulate blood properly.
 Left ventricle is compromised resulting in “backflow.”
 Fluid builds up within alveoli and in lung tissue.
 Usually result of congestive heart failure
 Pulmonary trauma
 Chemical exposures

56. Pulmonary Edema
The fluid and
thicker tissue makes
exchange of gasses
less efficient.

57. Chronic Obstructive Pulmonary Disease
(COPD)
 Slow process of constriction and disruption of
airways and alveoli
 Caused by chronic bronchial obstruction
 Tobacco smoke can create chronic bronchitis.

58. Chronic Obstructive Pulmonary Disease
(COPD)
 Emphysema is another type of COPD.
 Loss of elastic material around air spaces
 Causes include inflamed airways and smoking.
 Most patients with COPD have elements of both
chronic bronchitis and emphysema.

59. Chronic Obstructive Pulmonary Disease
(COPD)

60. Chronic Obstructive Pulmonary Disease
(COPD)
 “Wet lungs” vs. “dry lungs”
 “Wet lungs” sounds—pulmonary edema
 “Dry lungs” sounds—COPD
 Can be easily confused with congestive heart failure

61. Asthma, Hay Fever, and Anaphylaxis
 Result of allergic reaction to inhaled, ingested, or
injected substance
 In some cases an allergen cannot be identified.
 Asthma is acute spasm of smaller air passages
(bronchioles).

62.  Asthma is acute spasm of
smaller air passages
(bronchioles).
Asthma

63. Signs of Mechanical Ventilation Impairment
 Abnormal sounds include wheezing, rales,
rhonchi, and stridor.

64. Management & Interventions
 Insure adequate airway and ventilation
 Either assisted or on patient’s own
 Use of adjuncts
 Pulse oximetry
 Provide supplemental oxygen
 NRB, NC, Nebulizer with Albuterol
 Reference ACP SWO Appendix A
 Provide positive pressure ventilations if indicated
 BVM
 Demand valve
 Automatic transport ventilator (ATV)

65. Assessment

66. What do we assess?
 Primary Assesment
 Presence or absence?
 Rate
 Quality
 “Doorway Test”

67. First Impressions
 Air Hungry
 Nasal Flaring
 Tripoding
 Rocking with respirations
 Pursed Lip Breathing
 Barrel or Sparrow Chest
 Home O2

68. Respiratory Rate
 Decreased by:
 Depressant Drugs
 Sleep
 Increased by:
 Fever
 Fear
 Exertion

69. Respiratory Quality
 Irregular: Neuro Insult.
 Shallow:
 Respiratory Depressants
 CNS Depressants
 Neuro Insult
 Deep:
 Hyperglycemia with Acidosis (DKA): “Kussmal
Respirations
 Electrolyte Imbalances
 Neuro Insult

70. Skin Signs
 Cyanosis
 Nail Beds
 Lips
 Ears
 Mottling
 Chest
 Lower Ext
 Abd

71. Noisy breathing is obstructed breathing
 Snoring: obstruction by tongue
 Gurgling: Funky Junk in upper airway
 Grunting: Physiologic PEEP
 Stridor: harsh, high pitched sound on inhalation:
 Laryngeal edema
 Epiglotitis
 FBAO

72. Speech Dyspnea
 Inability to speak more than a few syllables in a
sentence between breaths.

73. Breath Sounds
 Listening by comparison
 Listening anterior
 Listening posterior
 Fremitus

76. Abnormal breath sounds
 Rales (crackles): fine bubbling sound of fluid in
alveoli (“Rice Krispies”: snap, crackle and pop)
Alveoli popping open.
 Rhonchi: fluid in larger airways, obstructing object
in the bronchus
 Wheezes: high pitched whistling, air through
narrowed airways
 SILENCE IS BAD NEWS

77. Causes of respiratory abnormalities
 Brain damage: trauma, drugs, stroke
 Spinal cord damage: trauma, polio
 Upper airways: tongue, swelling, foreign body,
trauma
 Lower airways: asthma, chronic bronchitis
 Alveoli: atelectasis, obstruction
 Impaired pulmonary circulation: embolism

78. Signs/symptoms of distress
 Dyspnea
 Restlessness/anxiety
 Tachypnea/Bradypnea
 Cyanosis (core)
 Abnormal sounds
 Retractions
 Diminished ability to speak

79. More S/S
 Retractions and/or use of accessory muscles
 Abdominal breathing
 Nasal flaring
 Productive cough
 Color?
 Irregular breathing
 Tripod position
 Pursed-lip breathing

80. Take another look ….What do you see?

81. Hows this?
Pursed Lips
Sparrow Chest
Tripoding
Retractions
Abd retractions
Kewl Haircut
O2

82. Inadequate Breathing: Infants and
Children
Retractions
Nasal Flaring
See-Saw
Breathing
Diaphragmatic Breathing

83.  A pulse oximeter measures the percentage of
hemoglobin saturation.
 Should be 95% to 100% while breathing room air.
 AHA recommendations are to maintain a saturation of
greater than 94%.
 A saturation of 75% is extremely low. Approximately the
level of oxygen that should be returning from the tissues.
Assessment

84.  Inaccurate pulse oximetry readings may be caused by:
 Hypovolemia
 Anemia
 Severe peripheral vasoconstriction (including cold)
 Nail polish (turn sensory sideways)
 Dirty fingers
 Carbon monoxide poisoning
Assessment

85. Assessment
 Assess for:
 Gag reflex
 Airway obstruction
 Soft tissue obstruction
 Foreign bodies
 Complete or incomplete
 Upper vs. lower
 Work of breathing
 Laryngospasm
 Laryngeal edema
 Penetrating injuries.

86. Basic Airway Interventions

87. Basic Airway Interventions
 Manual Airway maneuver
 Head tilt/chin lift
 Jaw thrust
 Airway devices
 OPA
 NPA
 IOM (NuMask)
 BVM
 Relief of foreign body airway obstruction
 (per AHA guidelines)
 Upper airway suctioning
 Lower airway suctioning
 After placement of advanced airway

88. Airway Obstruction
Most common cause: tongue and/or epiglottis

89. Manual Opening the Airway
Jaw thrust Head tilt–chin lift

90. The Oropharyngeal Airway

91. Malposition of
Oropharyngeal Airway
Too short

92. Nasopharyngeal Airway
Insertion technique

93. The Bag Valve mask

94. The Sniffing Position

98. KEY POINTS
 BVM ventilation is a perishable skill and
surprisingly difficult on mannequins, as well
as many patients. A number of studies have
demonstrated the difficulties performing
BVM ventilation on real patients in field
situations.
 The “weak link” in using the BVM is the “Face
Mask Seal”.

99. The E-C Technique

100. “Double C” or “two Hand Technique
Pirated from www.emsbasics.com

102. Poor seal, esp. in victims with:
•Obesity
•Facial hair
•The elderly
•Lack of teeth
•Facial Trauma
Current masks are fragile
and cumbersome
Easy to learn, difficult to retain
Often needs 2 providers
for adequate seal on difficult patients
Why traditional facemasks can be problematic
All Rights Reserved. © 2007-2011 NuMask®, Inc.

103. Predictors of difficult ventilation…
 In addition to the psycho-motor and provider difficulties of retaining
this vital skill, research has shown us that the patient themselves
present many predictable difficulties to successful BVM ventilation.
Some of the major ones are:
 a body mass index of 30 kg/square meter or more
 Presence of a beard
 Mallampati score of three or four
 Age of 57 or older
 Severely limited jaw protrusion
 Snoring.
 Maxillo-Facial Trauma
 Short thyromental distance
 The edentulous, and obese patients.
 Of these 9 co-morbid factors, 5 of which are directly dependant on face
mask seal, and therefore these five which would be mitigated if not
eliminated with the use of the IOM.
Kheterpal S, Han R, Tremper KK, et al. Incidence and predictors of
difficult and impossible mask ventilation. Anesthesiology. 2006 Nov;
105(5):885-91.

104. Nu-Mask
 Nu-Mask is a new alternative to the BVM.
 It is for patients whom a getting a face mask seal is
problematic.
 It is the only device for difficult aiways that can be
used by both BLS and ALS providers.
 ACP/ACEMSS is deploying these to all BLS and ALS
units in the system.

105. NuMask IOM® and IOM® w/ OPA in Place
NuMask IOM NuMask IOM with OPA
All Rights Reserved. © 2007-2011 NuMask®, Inc.

106. An air tight seal in 1/10th the space
of a traditional mask
All Rights Reserved. © 2007-2011 NuMask®, Inc.

107. KEY POINT
 The IOM uses internal oral tissue to
obtain a superior “wet seal”. Because
hand placement, hand size, and hand
position are not as crucial, the IOM is
easier to use.

108. Key Points about suction…
 300 mm hg for adults
 No more than 120 mm hg for pediatrics
 Intervals
 Prefer < 10 seconds (2010 ECC Guidelines for CPR)
 Devices
 Soft tip
 Yankour/Big Stick
 In Line

109. Types of Portable Suction
Courtesy of Laerdal Medical Corporation, Armonk, NY

110. Supra-glottic Airways

111. AEMT “Supraglottic” airway devices
 Indications
 To promote airway management by providing a patent airway
in the unconscious, and/or apneic patient.
 Contraindications
 Responsive patients with an intact gag reflex.
 Patients with known esophageal disease, i.e. esophageal
varices.
 Patients known or suspected to have ingested caustic
substances.

112. KEY POINT
 THE NEW AEMT SCOPE OF PRACTICE DOES
NOT CONTAIN ETT.
 Discussion: Is this a god idea or bad?
 This doesn’t mean that the AEMT shouldn’t have a
working understanding of the ETT so as to be a
better clinical provider and member of the overall
health care team.


113. Terms
 Supra-glottic
 Double/Single Lumen
 Peri-glottic
 Esophageal orburtrator airways

114. Lots of devices over the years
 Esophageal obturation
 Esophageal Gastric Tube Airway (EGTA)
 Esophageal Orbturator Airway (EOA)

115. Dual Lumen Supra-Glotic Airways
 Pharyngeal-tracheal Lumen Airway (PTLA)
 AKA: The PTL
 Esophageal-Tracheal Combitube (ETC)
 AKA: The Combi-tube
 AKA: Rush Easy Tube

116. “Peri-Glottic” Airways
 Laryngeo-Mask Airways (LMA)
 Air-Q
 I-Gel

117. Laryngeo-Mask Airways

118. I Gel

120. Single Lumen Airways
 King LTD
 COBRA Peri-Laryngeal Airway (PLA)

121. Cobra PLA

122. King Airway
 Size determined
by Pt’s height:
 Yellow: 4-5 ft
 Red: 5-6 ft
 Purple: > 6 ft

123. Instructions for use
 Choose appropriate size based on patient’s height.
 Test cuffs by inflating to recommended volume of
air and deflate cuffs completely before attempting
to insert. 60-90ml air based on device size.
 Generously lubricate tube using a water based
lube.
 Pre-oxygenate patient with 100% O2
 Have suction available.

124. Insertion:
 Position the head in a slightly sniffing position,
unless spinal injury is known or suspected. Then
maintain cervical alignment and keep the head in a
neutral position.
 Insert King rotated 45-90 degrees laterally and
insert into mouth
 As you gently advance the tube rotate tube to
midline.
 Advance tube until base of connector aligns with
teeth or gums.

125. Cuff inflation:
 Inflate cuffs with minimum volume necessary to
seal the airway according to tube size.
 “SEAT THE TUBE”
 GENTLY tug on the tube to appropriately place it…
 Attach to resuscitator bag and ventilate using 100%
O2 source.
 Assure chest rise and fall. Auscultate breath
sounds.
 Secure tube, using a commercially approved
device, noting depth of tube placement.
 Monitor end tidal CO2 if available.

126. ARTIFICIAL
VENTILATION
Management Techniques

127.  Probably the most important skills in EMS at any
level.
 Basic airway and ventilation techniques are
extremely effective.
 Airway management is the one advanced skill that
can have the greatest impact on patient mortality
and morbidity.
 It is imperative that you become experts at basic
and advance airway management.
Assisted and Artificial Ventilation

128. Basic Airway Adjuncts
 Chin lift
 Jaw thrust
 Positioning/suctioning
 Oropharyngeal airway (OPA)
 Nasopharyngeal airway (NPA)
 EGTA/Combi-tube/King LT

129. Oxygen Delivery Adjuncts
 Nasal Cannula: 2-6 LPM 24-44%
 Simple mask: 6-10LPM 35-60%
 Non-Rebreather Mask: 10-15LPM 80-95%
 Bag-valve-mask 15LPM 95-100%

130.  When assisting with a bag-mask device:
 Explain the procedure to the patient.
 Place the mask over the nose and mouth.
 Squeeze the bag each time the patient breathes.
 Maintain an adequate minute volume.
Assisted and Artificial Ventilation

131.  Artificial ventilation
 Devices include:
Pocket face masks
Bag-mask device
CPAP/BiPAP
Manually triggered ventilation device
Automatic transport ventilator
Assisted and Artificial Ventilation

132. Assisted and Artificial Ventilation
 Pocket Masks
 Includes IOM/NEW MASK
 Advantages:
 Small, easy to use
 Easy to use two handed technique
 Oxygen optional
 Disadvantages
 Down near the patients face---YUCK
 High FiO difficult

133. Assisted and Artificial Ventilation
 Bag Valve Mask
 Advantages
 Self inflating
 Can be used with or without an oxygen source
 Can be used with the IOM/NuMask
 Disadvantages
 Difficult to obtain a mask seal at times (dentures removed,
facial hair, etc. )
 Best results if used with more than one rescuer

134.  Manually triggered ventilation devices
 Advantages:
 Also known as flow-restricted, oxygen-powered ventilation device
 Allows single rescuer to use both hands to maintain mask-to-face seal while
providing positive-pressure ventilation
 Should not be used routinely
 Disadvantages
 Difficult to maintain adequate
ventilation without assistance
 Requires oxygen. Typical adult ventilation
consumes 5 liters per minute O2 versus
15-25 liters per minute for a bag-valve-mask
 Typically used on adult patients only
 Requires special unit and additional
training for use in pediatric patients
 The rescuer is unable to easily assess lung
compliance
 High ventilator pressures may damage lung tissue
Assisted and Artificial Ventilation

135.  Automatic transport
ventilator (ATV)
 Manually triggered device
attached to a control box
 Allows the variables of
ventilation to be set
 Lacks the control of a hospital
ventilator
 Frees the EMT to perform other
tasks
Assisted and Artificial Ventilation
Courtesy of Impact Instrumentation, Inc.

136. CPAP
 Continuous Positive Airway Pressure
 Advantages
 Is a BLS intervention in many states
 May reduce the need for advanced airway management
 Reduces in hospital stays
 Better outcomes overall…
 Disadvantages
 Requires an EXCELLENT face-mask seal
 Will not provide ventilation, only assist the patients own ventilatory
effort
 May lower the blood pressure
 May promote gastric distention
 Can not be used if airway reflexes are compromised.

137. Automatic transport ventilator (ATV)
 Disadvantages
 requires oxygen. Typical adult ventilation consumes 5 liters
per minute 02 versus 15-25 liters per minute for a bag-valve-
mask
 may require an external power source
 must have bag-valve-mask device available
 may interfere with timing of chest compressions during CPR
 must monitor to assure full exhalation
 barotrauma

138.  Automatic transport ventilator (ATV)
 Generally consumes 5 L/min of oxygen
 May lead to hypoventilation in patients with:
 Poor lung compliance
 Increased airway resistance
 Airway obstruction
 Assess patient for full chest recoil.
Assisted and Artificial Ventilation

139.  Patients with tracheostomies do not breathe through their mouth and
nose.
 Tracheostomy masks may be available. A face mask may also be used.
 If the trach has a 15mm
adaptor, a standard BVM
will fit onto the adaptor. If
not you will need to us a pediatric
mask for a seal.
Tracheostomy

140. Changes in the body
 There are several changes in the bodies physiology
during positive pressure ventilation:
Air Movement
 Normal ventilation has a negative intrathoracic pressure
leading air to get “sucked” into the lungs.
 With positive pressure you are “pushing” the air into the cavity

141. Changes in the body
Blood Movement
 1. Normal ventilation
 a. Blood return from the body happens naturally
 b. Blood is pulled back to the heart during normal breathing
 2. Positive pressure ventilation
 a. Venous return is decreased during lung inflation
 Use caution to not overinflate
 b. Amount of blood pumped out of the heart is reduced

142. Changes in the body
Esophageal Opening Pressure
Positive pressure ventilation
 Air is pushed into the stomach during ventilation
 Gastric distention may lead to vomiting
 Sellick’s maneuver (cricoid pressure)
 Use during positive pressure ventilation
 Reduces amount of air in stomach
 Procedure
 identify cricoid cartilage
 apply firm backward pressure to cricoid cartilage with thumb and index finger
 Do not use if
 patient is vomiting or starts to vomit
 patient is responsive
 breathing tube has been placed by advanced level providers

143. Special patient population
 Use caution with artificial ventilation with geriatric
and pediatric patients.
 Geriatric
 Geriatric disease process break down lung tissue and elasticity
of their lungs, use caution with positive pressure ventilation.
 Pediatric
 Pediatric airways are significantly smaller (the size of THEIR
pinky finger) and require less volume.
 Large, floppy tongues
 Padding under shoulders
 Do not hyperextend pt neck, it will “kink” the trachea
 Gastric distention

144. Take Home Points….
 All pt’s with SOB get O2. Lots of O2.
 Listen to ALL lungs.
 Beware of the “silent chest”.
 Noisy Breathing is abnormal breathing
 Visible Breathing is abnormal breathing.
 Positional breathing is abnormal breathing.
 Abnormal Breathing gets O2.

145. Questions?