• Divided into 2 sections
• Upper Airway:
  • nose
  • mouth
  • throat (pharynx)
  • Epiglottis
• Lower Airway:
  • Larynx (voice box)
  • Trachea
  • Bonchioles
  • Alveoli

Chest

(Thoracic Cage)

• Contains:
  • Lungs
  • mediastinum (space between the lungs)
  • heart
  • Great Vessels
  • Esophagus
  • Trachea
  • Major Bronchi

16% Oxygen

3% - 5% Co2

19 - 12% Nitrogen

• Body tissues do not have enough Oxygen
• Develops quickly in the vital organs of patients who are not breathing or who are breathing inadequately

• The primary disease is influenced by a low level of oxygen in the blood (Sensors in the brain become accustomed to low levels of Oxygen)
• Found in patients with:
  • Chronic respiratory diseases:
  • Emphysema
  • COPD
  • Chronic Bronchitis

• Restlessness
• Irritability
• Apprehension
• Tachycardia (fast heart rate)
• Anxiety

• Mental status change
• Weak (thready) pulse
• Cyanosis (blue, grey, color)
• Dyspnea - Shortness of breath (in conscious patients) 
• Best to give Oxygen before signs of hypoxia

• Hearth Attack (myocardial Infraction) - Ischemia - inadequate oxygen-carrying blood to the heart
• Pulminary Edema - fluid in the lungs
• Acute Narcotic or Sedative Overdose
• Inhalation of smoke and/or toxic fumes
• Stroke (Cerebrovascular Accident)
• Chest Injury
• Shock (Hypoperfusion)
• COPD
• Asthma
• Premature Birth

• Normal Rate (12 - 20 Adult, 15 -30 children, 25 - 50 infants))
• Regular pattern of inhalation and exhalation
• Clear and equal lung sounds on both sides of the chest
• Regular and equal rise and fall of the chest
• Adequate depth (Tidal Volume)

• Labored breathing - use of accessory muscles
• Breathing less than 12 breaths/min - Adults
• Irregular rhythm
• Auscultated breath sounds are diminished, absent, or noisy
• Reduced flow of exhaled air at nose and mouth
• Unequal or Inadequate chest expansion (Low tidal volume)
• Shallow depth (Tidal Volume)
• Skin is pale, cyanotic, cool, clammy
• Retractions - Skin pulling in around the ribs or above the clavicle during inhalation

• Agonal breaths - gasping
• Cheyne-Stokes Respirations - irregular respiratory pattern in which the patient breaths with an increasing rate and depth of rspiration that is followed by a period of:
• Apnea - lack of spontaneous breathing
• Ataxic Respirations - ineffective respirations that may or may not have a regular pattern
• Serious head injuries may cause irregular breathing

Opening the Airway of a patient with suspected spinal injury

Step 1

• Kneel beside the patient
• Have partner kneel far enough away so that the patient, when rolled toward, you does not rest in your lap
• Place your hands behind the patient's head and neck to provide in-line-stabilization of the cervical spine as your partner straightens the patient's legs

• As you call the count to control movement, have your partner turn the patient toward you by pulling on the far shoulder and hip
• Control the head and neck so that thay move as a unit with the rest of the torso
• Apply the cervical collar

• Tongue
• Dentures
• Blood
• Vomitus
• Mucas
• Food
• Foreign Objects

Head Tilt-Chin Lift Manuever

Steps

• With the patient in supine position, position yourself behind the patient's head
• Place 1 hand on the patient's forehead, and apply firm backward pressure with your palm to tilt the patient's head back
• Place the tips of your fingers of your other hand under the lower jaw
• Lift the chin upward, bringing the entire lower jaw with it, helping to tilt the head back

Jaw Thrust Manuever

(Suspected Cervical Spine Injury)

• Kneel above the patient's head
• Place your fingers behind the angles of the lower jaw, and move jaw upward
• Use your thumbs to help position the lower jaw to allow breathing
• The completed maneuver should Open the airway with the mouth slightly open and the jaw jutting forward

Oropharyngeal Airways

2 Principle Purposes

1^st - to keep the tongue from obstructing the upper airway

2^nd - to make it easier to suction the oropharynx, if necessary

• Unconscious patient without a gag reflex
• Any apneic patient being ventilated with BVM device

• Conscious patient
• Any patient (conscious or unconscious) who has an intact gag reflex

Inserting an Oropharyngeal Airway

Steps 1 & 2

• 1) To select to Proper Size -
  • Measure from the patient's earlobe or angle of the jaw to the corner of the mouth on the side of the face
• 2) Open the Patient's Mouth -
  • with the cross-finger technique
  • Hold the airway upside down with your other hand
  • Insert the airway with the tip facing the roof of the mouth and slide it in until it touches the roof of the mouth

• 3)  Rotate the airway 180^o
• When inserted properly, the airway will rest in the mouth with the curvature of the airway following the contour of the airway
• The flange should rest against the lips or teeth, with the other end opening into the pharynx

• 1) Use a Bite Stick to depress the tongue, ensuring that the tongue remains forward
• 2) Insert the Oral Airway Sideways from the corner of the mouth, until the flange reaches the teeth
• 3)  Rotate the Oral Airway at a 90o angle, removing the bite stick as you exert gentle backward pressure on the oral airway, until it rests securely in place against the lips and teeth

Nasopharyngeal Airways

Used for Patients who:

• Have an intact gag reflex
• Unable to maintain spontaneous breathing
• Patients with an altered mental status
• Patients whom have just had a seizure
• Patient has severe head or face trauma - Consult Medical Control, 1st
• Coat the airway with water-soluable lubricant before inserted

• Semiconscious or unconscious patients with an intact gag reflex
• Patients who otherwise cannot tolerate an oropharyngeal airway

• Severe head injury or blood drainiing from the nose
• History of fractured nasal bones

Steps to Ensure Correct Placement of the Nasopharyngeal Airway

Steps 1 & 2

• 1) Before Inserting the Airway
  • Be sure you have selected the proper size
  • Measure from the tip of the patient's nose to the earlobe
  • 2) The Airway should be Placed in the larger nostril, with the curvature of the device following the curve of the floor of the nose
  • If using the right nare - the bevel should face the septum
  • If using the left nare - insert the airway with the tip of the airway pointing upward, which will allow the bevel to face the septum

• 3) Advance the Airway Gently
  • If using the left nare, insert the nasopharyngeal airway until resistance is met
  • Rotate the nasopharyngeal airway 180^o into position
  • This rotation is not needed if using the right nare

• 4) When Completely Inserted
  • The flange rest against the other nostril
  • The other end of the airways opens into the posterior pharynx

• Portable
  • Must provide enough vacuum pressure and flow to allow proper suctioning
• Hand-operated (with disposable chambers)
  • Reliable, effective, cost-efficient
• Fixed (mounted)
  • Should generate a vacuum of more than 33 mm Hg when tubing is clamped

• Wide-Bore, thick walled, nonkinking tubing
• Plastic, rigid pharyngeal suction tips (Tonsil Tips, Yankauer Tips)
• Norigid plastic catheters (French Whistle-Tip Catheters)
• A Nonbreakable, disposable collection bottle
• A Supply of water for rinsing tips

• A hollow, cylindrical device that is used to remove fluids from the patient's airway
• A Tonsil-Tip Catheter is the best kind of catheter for suctioning the oropharynx of adults, preferred in infants and children

• Tips with a curved contour allow easy, rapid placemnet in the orophynx
• Soft plastic (French Whistle-Tip Catheters) are used to suction the nose and secretions in the back of the mouth and in situations where you cannot use a rigid catheter, as with patient's with a stoma (thrach)

Techniques of Suctioning

General steps to operate the suctioning unit

1) Check the unit for proper assembly of all its parts

2) Turn on the suctioning unit and test to ensure a vacuum pressure of more than 33 mm Hg

3) Select and attach the appropriate suction catheter to the tubing

Techniques of Suctioning

Cautions

Suctioning removes oxygen = Hypoxia

• Never suction the mouth or nose for more than 15 seconds at one time for an adult
• Never suction the mouth or nose for more than 10 seconds at one time for a child
• Never suction the mouth or nose for more than 5 seconds at one time for an infant

1) Turn on the assembled Suction Unit
2) Measure the catheter to the correct depth by measuring the catheter from the corner of the patient's mouth to the edge of the earlobe or an angle of the jaw
3) Open the patient's mouth using the cross-finger technique or the tongue-jaw lift, and insert the tip of the catheter to the depth measured
Insert the catheter to the premeasured depth and apply suction in a circular motion as you withdraw the catheter.

• Suction the (adult) patient for 15 seconds
• Ventilate for 2 minutes
• Continue this pattern until all secretions have been cleared

Maintaining the Airway

Recovery Position

• Used to help maintain a clear airway in a patient who is not injured and is breathing on his/her own with a normal rate and adequate Tidal Volume
• To prevent the aspiration of vomitus
• Not appropriate for patients with suspected spinal injury or unconscious patients who require ventilation

1)  Roll the patient onto the left side so that the head, shoulders, and torso move at the same time without twisting

2) Place the patient's extended left arm and right hand under his/her cheek

Supplemental Oxygen Equipment

Oxygen Cylinders

• Supplied in a compressed gas in green, seamless, steel, or aluminum containers
• Check to make sure the cylinder is labeled for medical oxygen
• Stamp marking month, year cylinder was last tested
• Several sizes (D & M most common)

• D (Super D 500 L Volume) can be carried from your unit to the patient
• 350 L Volume
• M Remains on board your unit as a main supply tank
• 3,000 L Volume
• E 625 L Volume
• G 5,300 L Volume
• H,A,K 6,900 L Volume

• Handle carefully - under pressure
• Fitted with pressure regulators to ensure that the patient receives the proper amount
• Do not handle the cylinder by the neck assembly alone
• Secured in brackets in the ambulance when not in use

Gauge pressure in PSI

Safe Residual Pressure 200 psi

D = 0.16 0 h 29 mins

E = 0.28 0 h 50 mins

M = 1.56 4 h 41 mins

G = 2.41 7h 14 mins

H = 3.14 9h 25 mins

K = 3.14 9h 25 mins

• For Potable Cylinders to prevent an oxygen regulator from being connected to a CO2 cylinder or a CO2 Cylinder to an Oxygen tank
• Features a series of pins on a yoke that must be matched with the holes on the valve stem of the gas cylinder
• Safety system for large tanks = American Standard System (threaded gas outlet valves)

• Pressure of gas in a full tank = 2,00 psi
• Pressure regulators reduce the pressure to a more useful range, 40 - 70 psi

• After the pressure is reduced to a more workable level, the final attachment for delivering the gas to the patient is usually:
• A quick-connect female fitting that will accept a quick-connect male plug from a pressure hose or ventilator, or resusitator
• A flowmeter that will permit the regulated release of gas measured in L/min

Flowmeters

Flowmeters are usually permanently attached to pressure regulators on emergency equipment

2 common types:

• pressure-compensated 
  • incorporates a float ball within a tapered calibrated tube
  • Affected by gravity - must be kept in the upright position for an accurate reading
• Bourbon-gauge
  • Not affected by gravity
  • Does not compensate for backpressure - it will usually record a higher flow rate when there is any obstruction to gas flow downstream

Oxygen Tank Operating Procedures

Step 1

• Inspect the Cylinder and its markings.
• Commercially sealed = plastic seal around valve stem & covering the opening
• Remove the seal & inspect the opening to make sure it is free from dirt and debris
• "Crack" the cylinder by slowly opening and then reclosing the valve (make sure its clean)
• Open the tank by attaching a tank key to the valve - rotate counterclockwise

• Attach the Regulator/flowmeter to the valve stem after clearing the opening
• 3 holes on 1 side - larger 1 ( on top) = true opening through which the Oxygen flows
• 2 smaller holes provide stability to the regulator
• Pin-Indexing system - these 2 holes are unique to oxygen cylinders
• Above the pins on the inside of the collar is the actual port through which oxygen flows from the cylinder to the regulator
• Metal/plastic o-Ring around oxygen port to optimize air seal between collar and valve stem

• Place the Regulator Collar over the Cylinder Valve with the Oxygen Port and Pin-Indexing Pins on the side of the Valve Stem that has the 3 holes
• Align the Regulator so that the pins fit snugly into the correct holes on the Valve Stem and hand tighten the regulator

• With the regulator firmly attached, open cylinder
• Check for leaking from the regulator/oxygen cylinder connection
• Read the Pressure level
• Attach the oxygen connective tubing to the flow meter

• Supports combustion
• Make sure area is adequately ventilated
• Careful in enclosed environment
• Never leave Oxygen Cylinder unattended

• Used in the filed - limited to
  • nonrebreathing masks
  • BVM Devices
  • Nasal Cannulas

• Nasal Cannula = Flow Rate 1 - 6 L/min = 24% - 44%
• Nonrebreathing Mask = 10 - 15 L/min = up to 90%
• BVM Device w/ reservoir = 15 L/min flush = Nearly 100%

Nonrebreathing Masks

(Exhaled gas escapes through flapper valve ports, at the cheek area of the mask)

• Preferred way to deliver oxygen in prehospital care to patient's experiencing difficulty breathing or showing signs of Hypoxia
• Combination mask & reservoir bag system
• Oxygen fill the bag
• Be sure the reservoir bag is full before placing on the patient
• Adjust the flow rate so bag does not fully collapse when the patient inhales (2/3 bag volume or 10 - 15 L/min)

• Delivers oxygen through the nostrils
• 24% - 44% inspired oxygen when flow meter is set at 1 - 6 L/min (don't exceed 6 L/min for the patient's comfort)
• Delivers dry oxygen - can irritate the lining of the nose
• Limited use in prehospital setting
• Not for Hypoxic patients

• Nonbreathing patient
• breathing inadequately (with some form of + pressure ventilation)
• Too fast
• Too Slow
• Reduced Tidal Volume 
• Irregular breathing pattern
• Can't speak a whole sentence

Methods of Artificial Ventilation

(EMT-B)

• Mouth - Mask (1 way valve)
• 2 person BVM device w/ reservoir and supplemental oxygen
• Flow Restricted Oxygen Powered Ventilation Device (Manually triggered ventilator) not on most ambulances - not for children
• 1 Person BVM Device w/ Oxygen reservoir and supplemental oxygen

Mouth to Mask

With oxygen Inlet

• Provides oxygen during mouth to mask ventilation to supplement the air from my lungs (16% oxygen)
• Gets more oxygen enrichment
• Frees both my hands - keep airway open and better seal

1) Once the patient's head is properly positioned and an airway adjunct is inserted

Place the mask on the patient's face

Seal the mask to the face using 2 hands

2) Breath into the 1 way valve until you note visible chest rise

3) Remove my mouth and watch for chest fall during expiration

• Almost 100% oxygen 
• Only as much Tidal Volume as you can squeeze
• Most common Device in the field
• Need to deliver high concentrations of oxygen
• Respiratory arrest
• Cardio-Pulmonary Arrest
• Respiratory Failure
• Use in conjunction w/ Oral or nasal airway adjunct

BVM Device Components

1,200 - 1,600 ml (adult)

500 - 700 ml (pediatric)

150 - 240 (infant)

• Disposible, self- refilling bag
• No pop-off valve (or capability of disabling valve)
• Outlet valve that is a true value for nonrebreathing
• oxygen reservoir that allows for delivery of high concentration Oxygen
• A 1 way no-jam inlet valve system that provides an oxygen inlet flow at a max. of 15L/min w/ standard 15/22 mm fittings for face mask and endotracheal tube connection
• Transparent face mask
• Ability to perform under extreme environmental conditions

Assisted Breathing

Cautions

• Too Forcefully:
  • Gastric Distention
  • Vomiting and aspiration
• Decreased blood return to the heart
  • increased intrathoracic pressure

Ventilation Rates

Apneic with pulse

• Adults = 1 breath/ 5 - 6 secs.
• Children = 1 breath/ 3 - 5 Secs.
• Infants = 1 breath/ 3 -5 secs

• Work w/ a partner when possible
• 1 maintains a good mask seal
• Other squeezes the bag

• High incidence of gastric Distention
• Possible damage to structures within the chest cavity
• Not be used on:
  • Infants or children
  • COPD
  • Suspected Cervical spine or chest injuries
• Cricoid press must be maintained

• Peak Flow Rate of 100% Oxygen at up to 40L/min
• Inspiratory Pressure Release valve - open at about 60 cm of water and vent any remaining volume to the atmosphere, or stops the flow of Oxygen
• Audible alarm - when you exceed the relief valve pressure
• Ability to operate under normal and varying conditions
• A Trigger (level) positions so both hands can remain on the mask - airtight seal, head tilt

Special Considerations for Assisted Ventilation

Gastric Distention

• Occurs when too much artificial ventilation fills the stomach with air
• When air is pushed too forcefully or too often
• When the airway is obstructed
• Causes vomiting with increased risk of aspiration
• Can significantly reduce lung volume (esp. infants and young children)
• Apply pressure to upper abdomen - likely result in vomiting

• Ignore any opening other than the midline Tracheal Stomas - only opening to put air into the patient's lungs
• Ventilate through the tracheostomy tube, if they have 1, as the standard 2/15 adapter on the BVM will fit (100% oxygen)
• Stoma - no tube use infant or child mask with BVM - Seal patient's nose and mouth w/ 1 hand and release the patient's nose and mouth for exhalation

• Most common obstruction in an unconscious patient is the tongue
• Swelling (infection, accute allergic reaction)
• Rapid Transport is critical
• Trauma - tissue damage from an injury

Early Recognition of Airway Obstruction

Mild obstruction (foreign body)

• Mild - partially obstructed
• cough forcefully
• may wheeze
• Don't interfer w/ the patient to clear the airway on their own
• Monitor
• Encourage coughing
• No Heimlich

• Can't breath, talk, cough
• Sudden inability to speak or cough (immediately after eating)
• Universal Distress Signal
• Turn Cyanotic
• Make frantic attempts to breath
• little - no air movement
• Ask conscious person if choking - perform heimlich
• Any person found unconscious must be managed as if he/she has a compromised airway

• Relaxation of the tongue in an unconscious patient
• Aspirated vomitus
• Foreign Object
• Trauma
  • Blood clots
  • bone fragments
  • damaged tissue
• Airway tissue swelling due to infection or allergic reaction