Chapter 9



Chapter 6

Airway Management

Unit Summary

After students complete this chapter and the related coursework, they will understand the need for proper airway management. Topics covered in airway management include recognizing adequate and inadequate breathing; maintaining an open airway; providing artificial ventilation; and understanding the use of airways, suction equipment, ventilation devices, and techniques for relieving airway obstruction.

National EMS Education Standard Competencies

Airway Management, Respiration, and Artificial Ventilation

Applies knowledge (fundamental depth, foundational breadth) of general anatomy and physiology to assure a patent airway, adequate mechanical ventilation, and respiration while awaiting additional EMS response for patients of all ages.

Airway Management

Within the scope of practice of the EMR:

• Airway anatomy (p 91)

• Airway assessment (pp 92–93)

• Techniques of ensuring a patent airway (pp 93–97)

Respiration

• Anatomy of the respiratory system (pp 90–92)

• Physiology and pathophysiology of respiration (p 91)

o Pulmonary ventilation (p 92)

o Oxygenation (p 92)

o Respiration (p 92)

▪ External (p 91)

▪ Internal (pp 91–92)

▪ Cellular (p 92)

• Assessment and management of adequate and inadequate respiration (p 102)

• Supplemental oxygen therapy (p 119)

Artificial Ventilation

Assessment and management of adequate and inadequate ventilation

• Artificial ventilation (p 103)

• Minute ventilation (p 92)

• Alveolar ventilation (p 92)

• Effect of artificial ventilation on cardiac output (p 92)

Pathophysiology

Uses simple knowledge of shock and respiratory compromise to respond to life threats.

Medicine

Recognizes and manages life threats based on assessment findings of a patient with a medical emergency while awaiting additional emergency response.

Respiratory

Anatomy, signs, symptoms, and management of respiratory emergencies including those that affect the:

• Upper airway (pp 102–109)

• Lower airway (pp 102–109)

Knowledge Objectives

1. Identify the anatomic structures of the respiratory system and state the function of each structure. (pp 90–92)

2. State the differences in the respiratory systems of infants, children, and adults. (p 92)

3. Explain how to check a patient’s level of responsiveness. (p 93)

4. Describe how to perform the head tilt(chin lift maneuver. (p 93)

5. Describe how to perform the jaw-thrust maneuver. (pp 93–95)

6. Explain how to check for fluids, solids, and dentures in a patient’s mouth. (p 95)

7. List the steps needed to clear a patient’s airway using finger sweeps and suction. (p 95)

8. Describe the steps required to maintain a patient’s airway using the recovery position, oral airways, and nasal airways. (pp 97–102)

9. Describe how to check a patient for the presence of breathing. (p 103)

10. Describe the signs of adequate breathing, the signs of inadequate breathing, the causes of respiratory arrest, and the major signs of respiratory arrest. (p 102)

11. Describe how to perform rescue breathing using a mouth-to-mask device, a mouth-to-barrier device, mouth-to-mouth techniques, and a bag-mask device. (pp 103–109)

12. Describe, in order, the steps for recognizing respiratory arrest and performing rescue breathing in infants, children, and adults. (pp 109–112)

13. Describe the differences between the signs and symptoms of a mild airway obstruction and those of a severe or complete airway obstruction. (p 112)

14. List the steps in managing a foreign body airway obstruction in infants, children, and adults. (pp 113–117)

15. Describe the special considerations of airway care and rescue breathing in children and infants. (pp 109–110)

16. Describe the indications for using supplemental oxygen. (pp 117–118)

17. Describe the equipment used to administer oxygen. (pp 118–119)

18. Describe the safety considerations and hazards of oxygen administration. (p 119)

19. Explain the steps in administering supplemental oxygen to a patient. (p 119)

20. Describe the function and operation of a pulse oximeter. (pp 120–121)

21. List the special considerations needed to perform rescue breathing in patients with stomas. (p 121)

22. Describe the hazards that dental appliances present during the performance of airway skills. (p 123)

23. Describe the steps in providing airway care to a patient in a vehicle. (p 124)

Skills Objectives

1. Demonstrate how to check a patient’s level of responsiveness. (p 93)

2. Demonstrate the head tilt–chin lift maneuver for opening blocked airways. (p 93)

3. Demonstrate the jaw-thrust maneuver for opening blocked airways. (pp 93–95)

4. Demonstrate how to check for fluids, solids, and dentures in a patient’s airway. (p 95)

5. Demonstrate how to correct a blocked airway using finger sweeps and suction. (pp 95–97)

6. Demonstrate how to place a patient in the recovery position. (p 97)

7. Demonstrate the insertion of oral and nasal airways. (pp 100–101)

8. Demonstrate how to check for the presence of breathing. (p 103)

9. Demonstrate how to perform rescue breathing using a mouth-to-mask device, a mouth-to-barrier device, mouth-to-mouth, and a bag-mask device. (pp 103–109)

10. Demonstrate the steps in recognizing respiratory arrest and performing rescue breathing on an adult, a child, and an infant. (pp 109–111)

11. Demonstrate the steps needed to remove a foreign body airway obstruction in an infant, a child, and an adult. (pp 113–116)

12. Demonstrate administration of supplemental oxygen using a nasal cannula and a nonrebreathing mask. (p 120)

13. Demonstrate the operation of a pulse oximeter. (pp 120–121)

14. Demonstrate rescue breathing on a patient with a stoma. (p 121)

15. Demonstrate airway management on a patient in a vehicle. (p 124)

Readings and Preparation

Review all instructional materials, including Emergency Medical Responder, Fifth Edition, Chapter 6, and all related presentation support materials.

• Instruct students to review respiratory system notes from Chapter 5, “The Human Body,” to better prepare for reading Chapter 6, “Airway Management,” and expanding on existing knowledge.

• Review the local protocols for airway management. In particular, note any specific equipment that may be mandated or prohibited locally.

• Review current airway management techniques and/or equipment presented in a locally approved CPR training course.

• Review the most current CPR and ECC guidelines.

• Review operation of airway adjuncts, suction machines, and ventilation devices used in this chapter.

Support Materials

• Lecture PowerPoint presentation

• Skill Drill PowerPoint presentations

- Skill Drill 6-1, Clearing the Airway Using Finger Sweeps PowerPoint presentation

- Skill Drill 6-2, Inserting an Oral Airway PowerPoint presentation

- Skill Drill 6-3, Inserting a Nasal Airway PowerPoint presentation

- Skill Drill 6-4, Performing Mouth-to-Mask Rescue Breathing PowerPoint presentation

- Skill Drill 6-5, Performing Mouth-to-Barrier Rescue Breathing PowerPoint presentation

- Skill Drill 6-6, Using a Bag-Mask Device With One Rescuer PowerPoint presentation

- Skill Drill 6-7, Performing Infant Rescue Breathing PowerPoint presentation

- Skill Drill 6-8, Managing Airway Obstruction in a Conscious Patient PowerPoint presentation

- Skill Drill 6-9, Performing Cricoid Pressure PowerPoint presentation

• Airway training manikins (adult, child, and infant)

• Assorted airways (oral/nasal, adult/pediatric) and lubricant

• Rescue breathing devices

• Suctioning unit and assorted catheters

• EMR life support kit

• Skill Evaluation Sheets

- Skill Drill 6-1, Clearing the Airway Using Finger Sweeps

- Skill Drill 6-2, Inserting an Oral Airway

- Skill Drill 6-3, Inserting a Nasal Airway

- Skill Drill 6-4, Performing Mouth-to-Mask Rescue Breathing

- Skill Drill 6-5, Performing Mouth-to-Barrier Rescue Breathing

- Skill Drill 6-6, Using a Bag-Mask Device With One Rescuer

- Skill Drill 6-7, Performing Infant Rescue Breathing

- Skill Drill 6-8, Managing Airway Obstruction in a Conscious Patient

- Skill Drill 6-9, Performing Cricoid Pressure

Enhancements

• Direct students to visit the companion web site to the Fifth Edition at EMR. for online activities.

• Contact a local hospital respiratory therapy department or respiratory specialist for guest speakers to present the most current information regarding airway management.

• Consider directing students to view this brief video, which provides an animation of diaphragmatic movement during the ventilatory cycle: .

Teaching Tips

• Airway management is the most fundamental skill of basic life support care. It is also one of the trickiest. Be sure to provide students with ample practice time and carefully monitor their performance.

• This lesson includes several skill drills associated with airway management. After you initially demonstrate the skills and allow students to practice them, use airway management scenarios to give students an opportunity to approach the scene, assess it, and take action.

• If some students complete a CPR course prior to the beginning of the EMR course, they may have varying levels of proficiency. Some may need to review selected skills.

• Make manikins and other airway equipment available for student practice before or after class.

Unit Activities

Writing assignments:

• Assign students a brief respiratory assessment of a fictitious patient and have each student write a short scenario of the situation leading to this breathing problem. Include such facts as respiratory rate, depth, and any additional sounds (or absence of sounds). Keep in mind that students will learn more about respiratory emergencies in subsequent chapters. Your provided information might, for example, include the following statements: “A 35-year-old man is found in a restaurant with inadequate, weak breathing. His lips are blue and he is lethargic.” Student responses might vary from “He was eating shrimp and is now having an allergic reaction” to “He was eating a piece of bread and now has an obstructed airway.” Have students make a possible list of clues to look for to aid in the diagnosis and treatment.

Student presentations: Ask students to give a presentation to the class on each airway adjunct, describing its use, indications, and contraindications.

Group activities: Have students work in teams of four. Provide each student group with a manikin and airway equipment, including various sizes of oral and nasal airways, oxygen tubing, masks, a bag-valve mask, a pocket mask, and an oxygen regulator and tank. One student in each group is the blindfolded provider, and another student is the helper. The manikin is the patient. The remaining members of the group act as observers to evaluate the effectiveness of the blindfolded provider’s treatment. The blindfolded provider must approach the manikin and check for breathing. The helper informs the provider, “The patient (manikin) is not breathing.” The blindfolded provider must measure, select, and properly insert an oropharyngeal airway, assemble the bag-mask device, and provide adequate ventilations. Upon completion of 2 minutes of effective ventilation, the blindfolded provider should demonstrate proper removal of the oropharyngeal airway. Allow each student a turn at being the blindfolded provider.

Medical terminology review:

• Give students a handout of airway anatomy, and instruct them to label each portion of the airway and to relate its importance.

• After students complete the reading, evenly divide the words/terms from the chapter vocabulary and any student-generated terminology lists among student groups. Ask each group to devise a way to remember the words; examples might include making index cards, a crossword puzzle, or cards with the word and a diagram to link understanding to the word or term.

Pre-Lecture

You are the Provider

“You are the Provider” is a progressive case study that encourages critical thinking skills.

Instructor Directions

1. Direct students to read the “You are the Provider” scenario found throughout Chapter 6.

2. You may wish to assign students to a partner or a group. Direct them to review the discussion questions at the end of the scenario and prepare a response to each question. Facilitate a class dialogue centered on the discussion questions.

3. You may also use this exercise as an individual activity and ask students to turn in their comments on a separate piece of paper.

Lecture

I. Introduction

A. This chapter introduces the two most important lifesaving skills:

1. Airway care

2. Rescue breathing

B. Patients must have an open airway passage and must maintain adequate breathing to survive.

C. By using simple skills, you can often make a difference between life and death.

D. The “ABCs”

1. Airway

2. Breathing

3. Circulation

E. Remember the check-and-correct process for both airway and breathing skills.

II. Anatomy and Function of the Respiratory System

A. To maintain life, all humans must have food, water, and oxygen.

1. Lack of oxygen, even for a few minutes, can result in irreversible damage and death.

2. If brain cells are deprived of oxygen and nutrients for 4 to 6 minutes, they begin to die.

3. Brain death is followed by the death of the entire body.

B. The main purpose of the respiratory system is to provide oxygen and to remove carbon dioxide from the red blood cells as they pass through the lungs.

C. Parts of the body used in breathing

1. Mouth (oropharynx)

2. Nose (nasopharynx)

3. Throat

4. Trachea (windpipe)

5. Lungs

6. Diaphragm (dome-shaped muscle between the chest and the abdomen)

7. Numerous chest muscles

D. In an unconscious patient lying on his or her back, the passage of air through both nose and mouth may be blocked by the tongue.

1. The tongue is attached to the lower jaw (mandible).

2. A partially blocked airway often produces a snoring sound.

E. Other parts of the respiratory system

1. At the back of the throat are two passages:

a. The esophagus (the tube through which food passes)

b. The trachea

2. The epiglottis is a thin flapper valve that allows air to enter the trachea but helps prevent food or water from entering the airway.

3. Below the trachea, the airway divides into the bronchi (two large tubes supported by cartilage).

4. The lungs are located on either side of the heart and are protected by the sternum at the front of the body and by the rib cage at the sides and back.

5. The smaller airways that branch from the bronchi are called bronchioles.

6. The bronchioles end as tiny air sacs called alveoli.

7. The actual exchange of gases takes place across a thin membrane that separates the capillaries of the circulatory system from the alveoli of the lungs.

a. The exchange of oxygen and carbon dioxide that occurs in the alveoli is called alveolar ventilation.

b. The amount of air pulled into the lungs and removed from the lungs in 1 minute is called minute ventilation.

F. When a patient is not breathing, artificial ventilation is necessary to supply oxygen to the heart and the rest of the body.

G. The lungs consist of soft, spongy tissue with no muscles.

1. Movement of air into the lungs depends on movement of the rib cage and the diaphragm.

2. When the diaphragm contracts during inhalation, it flattens and moves downward.

3. On exhalation, the diaphragm relaxes and once again becomes dome shaped.

III. “A” Is for Airway

A. In healthy individuals, the airway automatically stays open.

B. An injured or seriously ill person is not able to protect the airway, so it may become blocked.

1. You must check the condition of the patient’s airway and correct any problem to keep the patient alive.

C. Check for responsiveness.

1. Determine whether the patient is responsive or unresponsive by asking, “Are you okay? Can you hear me?”

2. If you get a response, you can assume that the patient is conscious and has an open airway.

3. If there is no response, gently shake the patient’s shoulder and repeat your questions.

4. If the patient is unresponsive, call 9-1-1 first before doing anything for the patient.

5. After calling 9-1-1, position the patient by supporting the patient’s head and neck and placing the patient on his or her back.

D. Correct the blocked airway.

1. An unconscious patient’s airway is often blocked because the tongue has dropped back and is obstructing it.

a. Simply opening the airway may enable the patient to breathe spontaneously.

2. Head tilt–chin lift maneuver

a. Place the patient on his or her back and kneel beside the patient.

b. Place one hand on the patient’s forehead and apply firm pressure backward with your palm.

c. Place the tips of the fingers of your other hand under the bony part of the lower jaw near the chin.

d. Lift the chin forward to help tilt the head back.

3. Jaw-thrust maneuver

a. Use this technique if you suspect a neck injury.

b. Place the patient on his or her back and kneel at the top of the patient’s head.

c. Place your fingers behind the angles of the patient’s lower jaw and move the jaw forward with firm pressure.

d. Tilt the head backward to a neutral or slight sniffing position.

e. Use your thumbs to pull down the patient’s lower jaw, opening the mouth enough to allow breathing through the mouth and nose.

E. Check for fluids, foreign bodies, or dentures.

1. After you have opened the patient’s airway, look into the patient’s mouth to see if anything is blocking the airway.

2. Potential blocks include:

a. Secretions such as vomitus, mucus, or blood

b. Foreign objects such as candy, food, or dirt

c. Dentures or false teeth

3. If you find anything in the patient’s mouth, remove it.

4. If the patient’s mouth is clear, consider using one of the devices described in the section on airway devices.

F. Correct the airway using finger sweeps or suction.

1. Vomitus, mucus, blood, and foreign objects must be cleared from the patient’s airway.

2. Finger sweeps

a. Finger sweeps can be done quickly and require no special equipment except a set of medical gloves.

b. To perform a finger sweep, follow the steps in Skill Drill 6-1.

3. Suctioning

a. Suction machines can be helpful in removing secretions such as vomitus, blood, and mucus from the patient’s mouth.

b. Manual suction devices

i. These devices are relatively inexpensive and are compact enough to fit into EMR life support kits.

ii. Insert the end of the suction tip into the patient’s mouth and squeeze or pump the hand-powered pump.

c. Mechanical suction devices

i. Use either a battery-powered pump or an oxygen-powered aspirator to create a vacuum.

ii. Such a device draws the obstructing materials from the patient’s airway.

iii. Clear the patient’s mouth of large pieces of material with your gloved finger.

iv. Turn on the suction device and use the rigid tip to remove most of the remaining material.

v. Do not suction for more than 15 seconds at a time because the suction also draws air out of the patient’s airway.

vi. Change to the flexible tip and clear out material from the deeper parts of the patient’s throat.

G. Maintain the airway.

1. For unconscious patients, you must continue holding the patient’s head to maintain the head tilt–chin lift or the jaw-thrust position.

2. If the patient is breathing adequately, you can keep the airway open by placing the patient in the recovery position.

3. You can also insert an oral or nasal airway to keep the patient’s airway open.

H. Recovery position

1. If an unconscious patient is breathing and the patient has not suffered trauma, place the patient in the recovery position.

a. The recovery position helps keep the patient’s airway open by allowing secretions to drain out of the mouth instead of draining into the trachea.

b. It also uses gravity to help keep the patient’s tongue and lower jaw from blocking the airway.

2. To place a patient in the recovery position:

a. Roll the patient onto one side, as you support the patient’s head.

b. Place the patient’s face on his or her side so any secretions drain out of the mouth.

I. Airway adjuncts

1. Oral airway

a. Two primary purposes:

i. Maintains the patient’s airway

ii. Functions as a pathway through which you can suction

b. Oral airways can be used for unconscious patients who:

i. Are breathing

ii. Are in respiratory arrest

iii. Do not have a gag reflex

c. These airways can be used with mechanical breathing devices such as the pocket mask or a bag-mask device.

d. There are two styles of oral airways:

i. One style has an opening down the center.

ii. The other has a slot along each side.

e. Before you insert the airway, you need to select the proper size.

i. Choose the proper size by measuring from the earlobe to the corner of the patient’s mouth.

f. Follow the steps in Skill Drill 6-2 to insert an oral airway.

2. Nasal airway

a. This device is inserted into the patient’s nose.

b. Nasal airways can be used in both unconscious and conscious patients who are not able to maintain an open airway.

c. Nasal airways are not as likely as oral airways to cause vomiting.

d. You cannot suction through a nasal airway.

e. Be sure to select the proper size nasal airway for the patient.

i. Measure from the earlobe to the tip of the patient’s nose.

ii. Coat the airway with a water-soluble lubricant before inserting it.

iii. The airway is fully inserted when the flange or trumpet rests against the patient’s nostril.

f. Follow the steps in Skill Drill 6-3 to insert a nasal airway.

IV. “B” Is for Breathing

A. After you have checked and corrected the patient’s airway, you will next check and correct the patient’s breathing.

B. Signs of adequate breathing

1. Use the look, listen, and feel technique to assess if an unconscious patient is breathing adequately.

a. Look for the rise and fall of the patient’s chest.

b. Listen for the sounds of air passing into and out of the patient’s nose or mouth.

c. Feel the air moving on the side of your face.

2. Normal adults have a resting breathing rate of approximately 12 to 20 breaths per minute.

3. One breath includes both an inhalation and an exhalation.

C. Signs of inadequate breathing

1. Noisy respirations, wheezing, or gurgling indicate a partial blockage or constriction somewhere along the respiratory tract.

2. Rapid or gasping respirations may indicate that the patient is not receiving an adequate amount of oxygen as a result of illness or injury.

3. The patient’s skin may be pale or even blue.

4. The most critical sign of inadequate breathing is respiratory arrest, which is characterized by three signs:

a. Lack of chest movements

b. Lack of breath sounds

c. Lack of air against the side of your face

5. Causes of respiratory arrest include:

a. Heart attacks

b. Mechanical blockage or obstruction caused by the tongue

c. Vomitus, particularly in a patient weakened by a condition such as a stroke

d. Foreign objects such as broken teeth, dentures, balloons, marbles, pieces of food, or hard candy (especially in small children)

e. Illness or disease

f. Drug overdose

g. Poisoning

h. Severe loss of blood

i. Electrocution by electrical current or lightning

D. Check for the presence of breathing.

1. After establishing the loss of consciousness and opening the airway of the unconscious patient, check for breathing by looking, listening, and feeling.

a. Look for the rise and fall of the patient’s chest.

b. Listen for the sound of air moving in and out of the patient’s nose and mouth.

c. Feel for the movement of air on the side of your face and ear.

2. Continue to look, listen, and feel for at least 5 seconds.

E. Correct the breathing.

1. As you perform rescue breathing, keep the patient’s airway open by using the head tilt–chin lift maneuver (or the jaw-thrust maneuver).

a. Pinch the patient’s nose with your thumb and forefinger, take a deep breath, and blow slowly into the patient’s mouth for 1 second.

b. Remove your mouth and allow the patient’s lungs to deflate.

c. Breathe for the patient a second time.

d. After these first two breaths, breathe once into the patient’s mouth every 5 to 6 seconds.

2. Mouth-to-mask rescue breathing

a. Enables you to perform rescue breathing without mouth-to-mouth contact with the patient

b. A mouth-to-mask ventilation device consists of three parts:

i. Mask that fits over the patient’s face

ii. One-way valve

iii. Mouthpiece through which the rescuer breathes

c. Because mouth-to-mask devices prevent direct contact between you and the patient, they reduce the risk of transmitting infectious diseases.

d. To use a mouth-to-mask ventilation device for rescue breathing, follow the steps in Skill Drill 6-4.

3. Mouth-to-barrier rescue breathing

a. Some of these devices are small enough to carry in your pocket.

b. Most of these devices consist of a port or hole that you breathe into and a mask or plastic film that covers the patient’s face.

c. These devices provide variable degrees of infection control.

d. To perform mouth-to-barrier rescue breathing, follow the steps in Skill Drill 6-5.

4. Mouth-to-mouth rescue breathing

a. This technique requires no equipment.

b. There is a somewhat higher risk of contracting a disease when using this method.

c. Follow these steps:

i. Open the airway with the head tilt–chin lift maneuver.

ii. Pinch the patient’s nostrils together with your thumb and forefinger.

iii. Keep the patient’s mouth open with the thumb of whichever hand you are using to lift the patient’s chin.

iv. Take a deep breath and then make a tight seal by placing your mouth over the patient’s mouth.

v. Breathe slowly into the patient’s mouth for 1 second.

vi. Remove your mouth and allow the patient to exhale passively.

vii. Repeat this rescue breathing sequence 10 to 12 times per minute for adults and about 12 to 20 times per minute for children and infants.

5. Bag-mask device

a. The bag-mask device has three parts:

i. A self-inflating bag

ii. One-way valves

iii. A face mask

b. To use this device:

i. Place the mask over the face of the patient and make a tight seal.

ii. Squeezing the bag pushes air through a one-way valve, through the mask, and into the patient’s mouth and nose.

iii. As the patient passively exhales, a second one-way valve near the mask releases the air.

c. The bag-mask device delivers 21% oxygen without supplemental oxygen attached; however, supplemental oxygen is usually added to the bag-mask device.

d. Many bag-mask devices are designed to be discarded after a single use.

e. A single rescuer may find it difficult to maintain an adequate seal between the patient’s face and the mask with one hand.

f. Bag-mask technique

i. To use a bag-mask device, follow the steps in Skill Drill 6-6.

ii. Use of a bag-mask device is best accomplished as a two-person operation if additional rescuers are present.

V. Airway and Breathing Review

A. You should assume that all patients may be in respiratory arrest until you can assess them and determine whether they are breathing adequately.

B. Airway

1. Check for responsiveness by shouting, “Are you okay?”, and gently shaking the patient’s shoulder.

2. If the patient is unresponsive and the EMS system has not been notified, activate the EMS system.

3. Place the patient on his or her back.

4. Correct a blocked airway by using the head tilt–chin lift maneuver or the jaw-thrust maneuver.

5. Check the mouth for any secretions, vomiting, or solid objects. If found, clear the mouth.

6. Correct a blocked airway, if needed, by using finger sweeps or suction to remove foreign substances.

7. Maintain the airway by manually holding it open or by using an oral or nasal airway.

C. Breathing

1. Check for the presence of breathing.

a. Look for the rise and fall of the patient’s chest.

b. Listen for the sound of air moving in and out of the patient’s nose and mouth.

c. Feel for air moving on the side of your face and ear.

2. Correct the lack of breathing by performing rescue breathing using a mouth-to-mask or mouth-to-barrier device, if available.

D. Performing rescue breathing on children and infants

1. Rescue breathing for children

a. Children are smaller and you will not have to use as much force to open their airways and tilt their heads.

b. The rate of rescue breathing is slightly faster for children.

i. Give 1 rescue breath every 3 to 5 seconds (about 12 to 20 rescue breaths per minute).

2. Rescue breathing for infants

a. An infant is tiny and must be treated extremely gently.

b. The steps in rescue breathing for an infant are shown in Skill Drill 6-7.

VI. Foreign Body Airway Obstruction

A. Causes of airway obstruction

1. The most common airway obstruction is the tongue.

a. If the tongue is blocking the airway, the head tilt–chin lift maneuver or jaw-thrust maneuver should open the airway.

b. If a foreign body is lodged in the air passage, you must use other techniques.

2. Food is the most common foreign object that causes an airway obstruction.

3. Children may put small objects in their mouths and inhale such things as tiny toys or balloons.

4. Vomitus may obstruct the airway of a child or an adult.

B. Types of airway obstruction

1. The first step in caring for a conscious person who may have an obstructed airway is to ask, “Are you choking?”

a. If the patient can reply to your question, the airway is not completely blocked.

b. If the patient cannot speak or cough, the airway is completely blocked.

2. Mild airway obstruction

a. The patient coughs and gags.

b. The patient may even be able to speak, although with difficulty.

c. To treat a mildly constructed airway, encourage the patient to cough.

d. If the patient is unable to expel the object by coughing, you should arrange for the patient’s prompt transport to an appropriate medical facility.

3. Severe airway obstruction

a. The patient is unable to breathe in or out and, because he or she cannot exhale air, speech is impossible.

b. Other symptoms may include:

i. Poor air exchange

ii. Increased breathing difficulty

iii. A silent cough

iv. Loss of consciousness in 3 to 4 minutes

c. The currently accepted treatment for conscious patients involves abdominal thrusts (Heimlich maneuver).

i. Abdominal thrusts compress the air that remains in the lungs, forcing the object out.

C. Management of foreign body airway obstructions

1. Relieving a foreign body airway obstruction requires no special equipment.

2. Airway obstruction in an adult

a. If the patient is conscious, stand behind the patient and perform the abdominal thrusts while the patient is standing or seated in a chair.

b. To assist a patient with a complete airway obstruction, follow the steps in Skill Drill 6-8.

c. Performing CPR on a patient who has become unresponsive has the same effect as performing the Heimlich maneuver on a conscious patient.

3. Airway obstruction in a child

a. When opening the airway of a child or infant, tilt the head back just past the neutral position.

b. If you are by yourself and a child with an airway obstruction becomes unresponsive, perform CPR for five cycles (about 2 minutes) before activating the EMS system.

4. Airway obstruction in an infant

a. An infant’s airway structures are very small, and they are more easily injured than those of an adult.

b. If the infant has an audible cry, the airway is not completely obstructed.

c. Use a combination of black slaps and chest thrusts.

d. To assist a conscious infant with a severe airway obstruction, you must:

i. Assess the infant’s airway and breathing status.

ii. Place the infant in a face-down position over one arm so that you can deliver five back slaps.

iii. Turn the infant face up and deliver five chest thrusts in the middle of the sternum.

iv. Repeat the back slaps and chest thrusts until the foreign object is expelled or until the infant becomes unresponsive.

e. If the infant becomes unresponsive, continue with the following steps:

i. Ensure that the EMS system has been activated.

ii. Begin CPR.

iii. Continue CPR until more advanced EMS personnel arrive.

VII. Oxygen Administration

A. Administering supplemental oxygen to a patient who is showing signs and symptoms of shock increases the amount of oxygen delivered to the cells of the body and often makes a positive difference in the patient’s outcome.

B. Oxygen equipment

1. Oxygen cylinders

a. Oxygen is compressed to 2,000 pounds per square inch (psi) and stored in portable cylinders.

b. The portable oxygen cylinders used by most EMS systems are either D or E size.

i. Size D cylinders hold 350 liters of oxygen.

ii. Size E cylinders hold 625 liters of oxygen.

c. Oxygen cylinders must be marked with a green color and be labeled as medical oxygen.

d. Depending on the flow rate, each cylinder should last for at least 20 minutes.

2. Pressure regulator/flowmeter

a. The regulator and the flowmeter are a single unit attached to the outlet of the oxygen cylinder.

b. Once the pressure has been reduced, you can adjust the flowmeter to deliver oxygen at a rate of 2 to 15 liters per minute.

c. A gasket between the cylinder and the pressure regulator/flowmeter ensures a tight seal and maintains the high pressure inside the cylinder.

3. Nasal cannulas and face masks

a. These devices ensure that oxygen is delivered to the patient and is not lost in the air.

b. Nasal cannulas are used to deliver medium concentrations of oxygen (35% to 50%).

c. A face mask is placed over the patient’s nose and mouth to deliver oxygen through the patient’s mouth and nostrils.

d. Nonrebreathing masks are most commonly used by EMRs.

C. Safety considerations

1. Oxygen actively supports combustion and can quickly turn a small spark or flame into a serious fire.

a. All sparks, heat, flames, and oily substances must be kept away from oxygen equipment.

b. Smoking is never safe around oxygen equipment.

2. The high pressure in an oxygen cylinder can cause an explosion if the cylinder is damaged.

a. Oxygen cylinders should be kept inside sturdy carrying cases.

b. Handle the cylinder carefully to guard against damage.

D. Administering supplemental oxygen

1. Place the regular/flowmeter over the stem of the oxygen cylinder and line up the pins on the pin-indexing system correctly.

2. Tighten the securing screw firmly by hand.

3. Turn the cylinder valve two turns counterclockwise to allow oxygen from the cylinder to enter the regulator/flowmeter.

4. Check the gauge on the pressure regulator/flowmeter.

5. To administer oxygen, you must adjust the flowmeter to deliver the desired liter-per-minute flow of oxygen.

6. When the oxygen flow begins, place the face mask or nasal cannula onto the patient’s face.

7. Nasal cannula

a. A cannula delivers low-flow oxygen at 2 to 6 liters per minute and in concentrations of 35% to 50% oxygen.

b. Adjust the liter flow to 2 to 6 liters per minute and then apply the cannula to the patient.

8. Nonrebreathing mask

a. Consists of connecting tubing, a reservoir bag, one-way valves, and a face piece

b. Used to deliver a high flow of oxygen at 8 to 15 liters per minute

c. Can deliver concentrations of oxygen as high as 90%

d. Should be used for patients who require higher flows of oxygen, including those experiencing:

i. Shortness of breath

ii. Severe chest pain

iii. Carbon monoxide poisoning

iv. Congestive heart failure

v. Signs and symptoms of shock

e. To use a nonrebreathing mask:

i. Adjust the oxygen flow to 8 to 15 liters per minute to inflate the reservoir bag before putting it on the patient.

ii. Place the mask over the patient’s face.

iii. Adjust the straps to secure a snug fit.

iv. Adjust the liter flow to keep the bag at least partially inflated while the patient inhales.

E. Hazards of supplemental oxygen

1. Supplemental oxygen must be used carefully so that you, your team, and the patient will remain safe.

2. You will need additional class work and practical training before you are ready to administer oxygen in emergency situations.

VIII. Pulse Oximetry

A. Pulse oximetry is used to assess the amount of oxygen saturated in the red blood cells.

B. The machine that performs this function is called a pulse oximeter.

1. A pulse oximeter consists of a sensing probe and a monitor.

2. To operate the pulse oximeter, turn on the monitor.

3. Once you know that the monitor is operating correctly, place the sensing probe over the patient’s fingertip or earlobe.

4. The monitor should then display the percent saturation of the patient’s blood.

a. In a healthy patient, the oxygen saturation should be between 95% and 100% when breathing room air.

b. If a patient has difficulty breathing as a result of injury or a disease process, the percent of oxygen saturation may be much lower than 95%.

5. The pulse oximeter cannot tell you what is wrong with the patient, but it can help you:

a. Recognize that the patient is having a problem

b. Determine whether your treatment is helping the patient

C. A pulse oximeter has certain limitations.

1. It will not give an accurate reading if the patient is wearing nail polish or if the patient’s fingers are very dirty.

2. If the patient is cold and the blood vessels in the fingertips or earlobes are constricted, the pulse oximeter reading will not be accurate.

3. Patients who have lost a lot of blood will have inaccurate readings.

4. Patients who have experienced carbon monoxide poisoning will have false readings.

D. There is no machine that can replace a careful patient assessment, including a good medical history.

IX. Special Considerations

A. Rescue breathing for patients with stomas

1. Some people have had surgery that removed part or all of the larynx.

2. In these patients, the upper airway has been rerouted to open through a stoma (hole) in the neck.

3. Rescue breathing must be given through the stoma, in a technique known as mouth-to-stoma breathing.

a. Check every patient for the presence of a stoma.

b. If you locate a stoma, keep the patient’s neck straight.

c. Examine the stoma and clean away any mucus in it.

d. If there is a breathing tube in the opening, remove it to be sure it is clear.

e. Place your mouth directly over the stoma and use the same procedures as in mouth-to-mouth breathing.

f. If the patient’s chest does not rise, seal the mouth and nose with one hand and then breathe through the stoma.

4. A bag-mask or pocket-mask device can also be used to ventilate a patient with a stoma.

B. Gastric distention

1. Gastric distention occurs when air is forced into the stomach instead of the lungs.

2. It increases the chance that the patient will vomit.

3. Breathe slowly into the patient’s mouth, just enough to make the chest rise.

4. Remember that the lungs of children and infants are smaller and require smaller breaths during rescue breathing.

5. Cricoid pressure

a. You can reduce gastric distention and minimize the risk of vomiting by applying posterior pressure to the trachea at the level of the cricoid cartilage.

b. The cricoid cartilage is located at the bottom of the larynx just below the Adam’s apple.

c. Cricoid pressure compresses the esophagus between the spine and the trachea, thereby reducing the amount of air that enters the stomach.

d. Cricoid pressure is also called the Sellick maneuver.

e. Use cricoid pressure only when the patient is unresponsive and not breathing and you are performing rescue breathing with a positive-pressure device.

f. Skill Drill 6-9 shows the steps for performing cricoid pressure.

C. Dental appliances

1. Do not remove dental appliances that are firmly attached.

a. They may help keep the patient’s mouth full so you can make a better seal between the patient’s mouth and your mouth or a breathing device.

2. Loose dental appliances may cause problems.

a. Partial dentures may become dislodged during trauma or while you are performing airway care and rescue breathing.

b. Remove the dentures and try to put them in a safe place.

D. Airway management in a vehicle

1. If the patient is lying on the floor or seat of the car, apply the standard jaw-thrust maneuver.

2. Use the jaw-thrust maneuver if there is any possibility that the crash could have caused a head or spine injury.

3. When the patient is in a sitting or semireclining position:

a. Approach the patient from the side by leaning in through the window or across the front seat.

b. Grasp the patient’s head with both hands.

c. Put one hand under the patient’s chin and the other hand on the back of the patient’s head, just above the neck.

d. Maintain a slight upward pressure to support the head and cervical spine.

4. This technique has several advantages:

a. You do not have to enter the automobile.

b. You can easily monitor the patient’s carotid pulse and breathing patterns by using your fingers.

c. This technique stabilizes the patient’s cervical spine.

d. It opens the patient’s airway.

X. Summary

A. The main purpose of the respiratory system is to provide oxygen and to remove carbon dioxide from the red blood cells as they pass through the lungs. The structures of the respiratory system in children and infants are smaller than the corresponding structures in adults. As a consequence, the air passages of children and infants may be more easily blocked by secretions or by foreign objects.

B. When a patient experiences possible respiratory arrest, check for responsiveness; open the blocked airway using the head tilt–chin lift or jaw-thrust maneuver; check for fluids, solids, or dentures in the mouth; and correct the airway, if needed, using finger sweeps or suction.

C. Maintain the airway by continuing to manually hold the airway open, by placing the patient in the recovery position, or by inserting an oral or a nasal airway. Check for breathing by looking, listening, and feeling for air movement, and correct any problems by using a mouth-to-mask or mouth-to-barrier device, by using a bag-mask device, or by performing mouth-to-mouth rescue breathing. It is important to use the correct sequence for adults, children, and infants.

D. If the airway is obstructed in a conscious adult or child, kneel or stand behind the patient and perform the Heimlich maneuver. Give abdominal thrusts until the obstruction is relieved or the patient becomes unconscious. For an unconscious adult or child with an airway obstruction, perform chest compressions. Move to the head, open the airway, and look in the patient’s mouth. Do not perform a finger sweep—regardless of the patient’s age—unless you can see the object. Attempt rescue breathing again. If the airway is still obstructed, repeat chest compressions, visualization of the mouth, and ventilation attempts until the obstruction is relieved.

E. Administering supplemental oxygen to patients who show signs and symptoms of shock increases the amount of oxygen delivered to the cells of the body and often makes a positive difference in the patient’s outcome. Patients who have experienced a heart attack or stroke or patients who have chronic heart or lung disease may also benefit from receiving supplemental oxygen.

F. Pulse oximetry is used to assess the amount of oxygen saturated in the red blood cells.

Post-Lecture

This section contains various student-centered end-of-chapter activities designed as enhancements to the instructor’s presentation. As time permits, these activities may be presented in class. They are also designed to be used as homework activities.

Assessment in Action

This activity allows the student an opportunity to analyze an emergency care scenario and develop responses to critical-thinking questions. This scenario is designed to assist the student in gaining a further understanding of the issues surrounding airway management.

Instructor Directions

1. Direct students to read the “Assessment in Action” scenario located in the Prep Kit at the end of Chapter 6.

2. Direct students to read and individually answer the quiz questions at the end of the scenario. Facilitate a class review and discussion of the answers, allowing students to correct their responses as needed. Use the quiz question answers noted here to assist in building this review.

3. You may wish to ask students to complete the activity on their own and turn in their answers on a separate piece of paper.

Answers to Assessment in Action Questions

1. Answer: C check for breathing.

2. Answer: B Attempt the jaw-thrust maneuver again and try to ventilate.

3. Answer: B 12 to 20 times a minute

4. Answer: B Log roll her onto her side while making sure her head, neck, and spine are aligned.

5. Answer: C A pressure regulator and flowmeter

6. Answer: Because of the potential for a neck injury, you should use the jaw-thrust maneuver to open the airway.

7. Answer: Once the patient is breathing at a normal rate, continue with your assessment and address the bleeding.

8. Answer: The mouth (oropharynx), the nose (nasopharynx), and the throat (trachea) are used in breathing.

9. Answer: Signs of inadequate breathing include noisy respirations, wheezing, gurgling, or the patient’s skin turning pale or blue, especially around the lips and fingernail beds.

10. Answer: Rescue breathing would occur through the stoma in her neck rather than through her mouth and nose.

Lesson Review

A. Without oxygen, how long will it take the cells of the brain to die? (Lecture II-A)

B. True or false: An unconscious patient will not be able to keep his or her airway open. (Lecture III-D)

C. Mechanical suctioning of an adult should not last more than how many seconds? (Lecture III-F)

D. What are the two kinds of airways that can be used to keep a patient’s airway open? (Lecture III-I)

E. What are some of the signs of inadequate breathing? (Lecture IV-C)

F. Discuss the differences among mouth-to-mask, mouth-to-barrier, and mouth-to-mouth rescue breathing. (Lecture IV-E)

G. If a person is coughing or gagging, can you assume the airway is only partially obstructed? (Lecture VI-B)

H. Describe how abdominal thrusts can remove an object from an obstructed airway. (Lecture VI-C)

Assignments

A. Complete all the Student Workbook activities for Chapter 6.

B. Review all materials from this lesson and be prepared for a lesson quiz to be administered (date to be determined by the instructor).

C. Read Chapter 7: Professional Rescuer CPR for the next class session.

Unit Assessment Keyed for Instructors

1. In an unconscious patient, a blocked airway is most likely caused by:

A. a foreign object.

B. the tongue.

C. the epiglottis.

D. the larynx.

Answer: B

pp 91, 111

2. The first step in correcting a blocked airway is to:

A. shake the patient to determine responsiveness.

B. attempt to give rescue breaths.

C. position the head properly.

D. clear foreign matter from the throat.

Answer: C

p 93

3. To open the airway in an unconscious adult with no suspected spinal injury, you should use the:

A. jaw-thrust technique.

B. manual suction device.

C. head lift–chin tilt technique.

D. tongue–jaw lift technique.

Answer: C

p 93

4. An oral airway of proper size will extend from the:

A. corner of the patient’s mouth to the tip of the earlobe.

B. lips to the larynx.

C. nose to the angle of the jaw.

D. none of the above

Answer: A

p 99

5. When inserting a nasopharyngeal airway, lubricate the outside of the tube with:

A. petroleum jelly.

B. an oil-based lubricant.

C. a silicone-based lubricant.

D. a water-soluble lubricant.

Answer: D

p 100

6. When at rest, the normal breathing rate for an adult is ______ times per minute.

A. 12 to 20

B. 30 to 40

C. 60 to 80

D. 75 to 100

Answer: A

p 102

7. Signs of inadequate breathing in an adult include all of the following except:

A. respirations that are slowed.

B. a respiratory rate of 14 to 18 breaths per minute.

C. breathing is very shallow, is very deep, or appears labored.

D. the patient is unable to speak in full sentences.

Answer: B

pp 102–103

8. To correct breathing, the very first step you should take is to:

A. clear the mouth.

B. administer oxygen.

C. apply positive-pressure ventilation.

D. open the airway.

Answer: D

p 103

9. If a patient is coughing forcefully with something caught in the throat:

A. give abdominal thrusts.

B. sweep out the mouth.

C. check the pulse.

D. encourage the patient to cough.

Answer: D

p 112

10. If gastric distention occurs while you are doing CPR, it is probably caused by:

A. rescue breaths that are too small.

B. too much force while doing chest compressions.

C. air entering the patient’s stomach.

D. too much fluid in the patient’s stomach.

Answer: C

p 122

Unit Assessment

1. In an unconscious patient, a blocked airway is most likely caused by:

A. a foreign object.

B. the tongue.

C. the epiglottis.

D. the larynx.

2. The first step in correcting a blocked airway is to:

A. shake the patient to determine responsiveness.

B. attempt to give rescue breaths.

C. position the head properly.

D. clear foreign matter from the throat.

3. To open the airway in an unconscious adult with no suspected spinal injury, you should use the:

A. jaw-thrust technique.

B. manual suction device.

C. head lift–chin tilt technique.

D. tongue–jaw lift technique.

4. An oral airway of proper size will extend from the:

A. corner of the patient’s mouth to the tip of the earlobe.

B. lips to the larynx.

C. nose to the angle of the jaw.

D. none of the above

5. When inserting a nasopharyngeal airway, lubricate the outside of the tube with:

A. petroleum jelly.

B. an oil-based lubricant.

C. a silicone-based lubricant.

D. a water-soluble lubricant.

6. When at rest, the normal breathing rate for an adult is ______ times per minute.

A. 12 to 20

B. 30 to 40

C. 60 to 80

D. 75 to 100

7. Signs of inadequate breathing in an adult include all of the following except:

A. respirations that are slowed.

B. a respiratory rate of 14 to 18 breaths per minute.

C. breathing is very shallow, is very deep, or appears labored.

D. the patient is unable to speak in full sentences.

8. To correct breathing, the very first step you should take is to:

A. clear the mouth.

B. administer oxygen.

C. apply positive-pressure ventilation.

D. open the airway.

9. If a patient is coughing forcefully with something caught in the throat:

A. give abdominal thrusts.

B. sweep out the mouth.

C. check the pulse.

D. encourage the patient to cough.

10. If gastric distention occurs while you are doing CPR, it is probably caused by:

A. rescue breaths that are too small.

B. too much force while doing chest compressions.

C. air entering the patient’s stomach.

D. too much fluid in the patient’s stomach.

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