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Copyright 2006 © Pearson Education Canada 27:2-1
Chapter 27, Part 2Airway
Management and Ventilation
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Copyright 2006 © Pearson Education Canada 27:2-2
Airway management and ventilation are the first
and most critical steps in the initial assessment of every patient you will encounter.
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Lecture Outline
Respiratory Problems
Respiratory System Assessment
Airway Management
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Respiratory Problems
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Airway Obstruction Immediate threat to life and true
emergency Interference with air movement through
the upper airway Tongue is the most common cause Other causes:
Foreign bodies Trauma Laryngeal spasm and edema Aspiration
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The Tongue as an airway obstruction
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Partial Airway Obstruction
Adequate air exchange Effective cough
Poor air exchange Ineffective cough Stridor (high-pitched noise while inhaling) Cyanosis Gagging, choking Dysphonia (difficulty speaking)
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Inadequate Ventilation Compromise oxygen intake and
carbon dioxide removal Hypoxia Hypercarbia
Caused by reduction of rate or tidal volume
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Respiratory System
Assessment
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Is the airway patent? Is breathing adequate? Look, listen, and feel. If patient is not breathing
Open the airway Assist ventilations as necessary
Primary Assessment
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Look
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Listen
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Feel
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Bag-valve-mask ventilation
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Onset Symptom development Associated symptoms Past medical history Recent history Does anything make symptoms
better or worse?
Focused History
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Skin color Patient’s position Dyspnea Modified forms of respiration Rate Pattern Mentation
Inspection
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Modified Forms of Respiration Coughing
Forceful exhalation of large volume of air from lungs
Protects airway from irritants Sneezing
Forceful exhalation from nose Caused by nasal irritation
Hiccoughing Spasmodic contraction of diaphragm Occasionally associated with inferior myocardial
infarction
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Modified Forms of Respiration
Sighing Slow deep involuntary inspiration and
expiration Re-expands the alveoli
Grunting Forceful expiration against partially
closed glottis Usually an indication of respiratory
distress
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Abnormal Respiratory Patterns
Kussmaul’s respirations Cheyne-Stokes respirations Biot’s respirations Central neurogenic hyperventilationCentral neurogenic hyperventilation Agonal respirationsAgonal respirations
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Auscultation Listen at the mouth and nose
for adequate air movement. Listen with a stethoscope for
normal or abnormal air movement Right and left apices Right and left bases Right and left back or midaxillary
Posterior surface is preferable Heart sounds do not interfere
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Position for auscultating breath sounds
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Airflow Compromise Snoring
Partial airway obstruction by the tongue Gurgling
Accumulation of fluid in airway Stridor
Associated with laryngeal edema or constriction Wheezing
Associated with bronchiolar constriction Quiet
Ominous finding indicating a serious problem
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Compromise of Gas Exchange
Crackles Fine bubbling noises heard on inspiration Associated with fluid in smaller
bronchioles
Rhonchi Coarse rattling noise heard on inspiration Associated with inflammation, mucous or
fluid in the bronchioles
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Palpation Air movement through mouth and nose Palpate chest for rise and fall Palpate chest wall
Tenderness Symmetry Abnormal motion Crepitus Subcutaneous emphysema
Assess for compliance
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Compliance
Refer to stiffness or flexibility of lungs
Good Airflow meets minimal resistance
Poor Ventilation is harder to achieve Occurs in diseased lungs, chest wall
injuries or tension pneumotharx
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Compliance and Ventilation
Airway open Head properly positioned Tension pneumothorax ET tube in right mainstem ET tube displaced into esophagus Ventilation equipment functioning
properly
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Non-Invasive Respiratory Monitoring
Pulse oximetry Capnography Esophageal detector device Peak expiratory flow testing
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Pulse Oximetry
Widely used in prehospital setting Measure hemoglobin saturation in
peripheral tissues Correlates with PaO2
Accurate and continually reflect changes in oxygenation
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Pulse Oximeter
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Sources of Error
False readings infrequent Carbon monoxide poisoning High intensity lighting Absence of pulse in extremity
Hypovolemia Hypothermia
Severely anaemic patients
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Capnography Measure exhaled carbon dioxide
concentrations Reflects adequacy of ventilation Colorimetric or waveform monitoring Most commonly for placement
confirmation for intubation Absence of ETCO2 strongly suggests esophageal
placement
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Colorimetric End-Tidal CO2 Detector
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Electronic End-Tidal CO2 Detector
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Combined devices check SpO2, ETCO2 BP, pulse,
respiratory rate, and temp.
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Esophageal Detector Device
Simple tool for ET tube placement confirmation
Bulb or syringe style Trachea is a rigid tube, esophagus
is collapsible If air is easily withdrawn, confirms
placement in trachea
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Squeeze device then attach it to the ET tube
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If the bulb refills easily on release, it indicates correct
placement
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If the bulb does not refill, the tube is improperly
placed
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Manual Airway Maneuvers
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Personal Protective Equipment
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Head Tilt/Chin Lift
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Modified Jaw Thrust in Trauma
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Jaw-Thrust Maneuver
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Jaw-Lift Maneuver
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Sellick’s Maneuver (Cricoid Pressure)
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Airway before applying Sellick’s
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Airway with Sellick’s applied (note compression on the
esophagus)
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Basic Mechanical Airways
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Nasopharyngeal airway, inserted
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Nasopharyngeal Airway
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Insert oropharyngeal airway with tip facing palate
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Rotate airway 180º into position
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Improper placement of oropharyngeal airway
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Advanced Airway Management
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Endotracheal intubation is clearly the preferred
method of advanced airway
management in prehospital emergency care.
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Engaging laryngoscope blade and handle
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Activating laryngoscope light source
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Laryngoscope Blades
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Placement of Macintosh blade into vallecula
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Placement of Miller blade under epiglottis
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Endotrol ETT
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ETT, stylet, and syringe, unassembled
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ETT and Syringe
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ETT, Stylet, and Syringe, assembled for intubation
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Magill Forceps
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Indications Respiratory or cardiac arrest. Unconsciousness. Risk of aspiration. Obstruction due to foreign bodies,
trauma, burns, or anaphylaxis.
Respiratory extremis due to disease. Pneumothorax, hemothorax,
hemopneumothorax with respiratory difficulty.
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Advantages Isolates trachea and permits
complete control of airway. Impedes gastric distention. Eliminates need to maintain a mask
seal. Offers direct route for suctioning. Permits administration of some
medications.
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Disadvantages Requires considerable training and
experience. Requires specialized equipment. Requires direct visualization of vocal
cords. Bypasses upper airway’s functions
of warming, filtering, and humidifying the inhaled air.
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Complications
Equipment malfunction Teeth breakage and soft tissue
lacerations Hypoxia Esophageal intubation Endobronchial intubation Tension pneumothorax
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Endotracheal Intubation
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Hyperoxygenate the patient
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Prepare the equipment
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Apply Sellick’s manoeuver (if required) and insert
laryngoscope
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Visualize the larynx and insert the ETT
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Glottis visualized through laryngoscopy
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Inflate the cuff, ventilate and auscultate
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Confirm placement with an ETCO2 detector or an EDD
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Secure the tube
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Reconfirm ETT placement
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Tube Placement Confirmation
Visualization Ausculation End tidal CO2
Esophageal detector device (EDD) Condensation inside the ETT Absence of vomitus in the tube Absence of vocal sounds
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Continuously recheck and reconfirm the placement
of the endotracheal tube.
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Lighted Stylet for Endotracheal
Intubation
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Insertion of lighted stylet/ETT
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Lighted stylet/ETT in position
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Transillumination of a lighted stylet
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Blind orotracheal intubation by digital method
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Digital Intubation Used when proper positioning is
difficult Trapped spinal injury patient Facial injuries
Increased risk to paramedic Patient may clamp down on teeth
Contraindicated Conscious patients Unconscious patients with a gag reflex
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Insert your middle finger into the patient’s mouth
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Walk your fingers and palpate the patient’s
epiglottis
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Insert the ETT
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Endotracheal Intubation with In-line
Stabilization
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Hyperoxygenate patient and apply C-spine stabilization
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Apply Sellick’s Maneuver and intubate
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Ventilate patient and confirm placement
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Secure ETT and apply a cervical collar
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Reconfirm placement
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Rapid Sequence Intubation
Patient requires intubation but condition makes success unlikely Altered mental status with hypoxia Conscious patient
RSI sedates and temporarily paralyzes patient to facilitate intubation
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Smaller and more flexible than an adult. Tongue proportionately larger. Epiglottis floppy and round. Glottic opening higher and more anterior. Vocal cords slant upward, and are
closer to the base of the tongue. Narrowest part is the cricoid cartilage.
The Pediatric Airway
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Pediatric Tube Size
ETT size (mm) = (age in years + 16) / 4
ETT size (mm) = (age in years / 4) + 4
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Endotracheal Intubation in a
Child
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Hyperoxygenate the child
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Position the head
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Insert the laryngoscope
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Insert the ETT and ventilate the child
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Confirm placement and secure the ETT
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Nasotracheal Intubation Blind procedure without direct
visualization of the cords Generally oral intubation preferred Consider in case of
Conscious patients Trismus Facial and airway swelling
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Advantages
The head and neck can remain in neutral position.
Better tolerated by awake patient Less stimulation of gag reflex
It can be secured more easily The patient cannot bite the ETT
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Disadvantages More difficult and time-consuming Potentially more traumatic for patients May kink or clog more easily Poses a greater risk of infection Improper placement is more likely Requires that the patient be breathing
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Blind Nasotracheal Intubation
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ETC Airway— tracheal placement
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ETC Airway-esophageal placement
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Other Intubation Devices
Esophageal CombiTube (ECT) Laryngeal mask airway (LMA) Pharyngo-tracheal lumen airway
(PtL)
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Advantages of ECT Provides alternate airway control
When conventional intubation techniques are unsuccessful or unavailable.
Insertion is rapid and easy Does not require visualization of the larynx No special equipment.
Pharyngeal balloon anchors the airway behind the hard palate
Patient may be ventilated regardless of tube placement
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Advantages of ECT Significantly diminishes gastric
distention and regurgitation Can be used on trauma patients
Neck can remain in neutral position during insertion and use.
If tube is placed in esophagus, gastric contents can be suctioned for decompression through the distal port
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Disadvantages of ETC Maintaining adequate mask seal is
difficult Suctioning tracheal secretions is
impossible when the airway is in the esophagus.
Cannot be used in conscious patients or in those with a gag reflex
Cuffs can cause esophageal, tracheal, and hypopharyngeal ischemia
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Disadvantages of ETC Does not isolate and completely
protect the trachea Cannot be used in patients with
esophageal disease or caustic ingestions
Cannot be used with pediatric patients
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Laryngeal Mask Airway
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Pharyngo-Tracheal lumen airway
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Advantages of PtL Airway
Can function in either the tracheal or esophageal position.
No face mask to seal. Does not require direct visualization. Can be used in trauma patient
Neck can remain in neutral position during insertion and use.
Helps protect the trachea from upper airway bleeding and secretions
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Disadvantages of PtL Airway Does not isolate and completely protect
the trachea The oropharyngeal balloon can migrate
out of the mouth anteriorly Intubation around the PtL is extremely
difficult Cannot be used in
Conscious patients or those with a gag reflex. Pediatric patients.
Can only be passed orally.
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Foreign body removal with direct visualization and Magill
forceps
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Surgical
Airways
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Anatomical Landmarksfor Cricothyrotomy
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Locate/palpate cricothyroid membrane
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Proper positioning for cricothyroid puncture
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Advance the catheter with the needle
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Cannula properly placed in trachea
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Jet ventilation with needle cricothyrotomy
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Open Cricothyrotomy
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Locate cricothyroid membrane
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Stabilize larynx and make a 1–2 cm skin incision over cricothyroid
membrane
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Make a 1 cm horizontal incision through the cricothyroid
membrane
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Using a curved hemostat, spread membrane incision
open
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Insert an ETT (6.0) or Shiley (6.0)
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Inflate the cuff
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Confirm placement
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Ventilate
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Secure tube, reconfirm placement,
evaluate patient
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Patients with Stoma Sites Laryngectomy or tracheostomy
Patients breathe through a stoma
Problems with a stoma Excess secretions Stoma may become plugged
Suctioning Prevents a simple vomiting episode from
becoming a life-threat
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Tracheostomy Cannulae
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Suctioning Technique BSI
Preoxygenate the patient. Determine depth of catheter
insertion. With suction off, insert catheter. Turn on suction
Suction while removing catheter (no more than 10 seconds)
Hyperoxygenate the patient
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Gastric Decompression Gastric distension
Common problem with ventilating a nonintubated patient
Occurs when the procedure’s high pressures trap air in the stomach
Gastric decompression Placement of a tube in the stomach to relieve
pressure Uses either orogastric or nasogastric approach
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Gastric Tube Placement Prepare patient
Head in neutral position Preoxygenate
Determine length of tube insertion Measure from epigastrum to the angle of the jaw,
then to the tip of the nares. If patient is awake, suppress the gag
reflex Topical anasthetic applied into the posterior
oropharynx IV lidocaine
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Gastric Tube Placement Lubricate the distal tip of the gastric tube
and gently insert Into the nares and along the nasal floor Into the oral cavity at midline
Advance tube gently If patient is awake, encourage swallowing to facilitate
tube’s passage Advance to predetermined mark on tube
Confirm placement Apply suction and note gastric contents that
pass through the tube Secure the tube in place
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Oxygenation
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Oxygenation
Supplemental oxygen Diminish hypoxia’s secondary effects
Oxygen should never be withheld Toxicity is rarely a concern
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Tank Duration
Tank life in minutes =
gauge pressure – safe residual pressure x tank constant
oxygen delivered in litres per minute
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Oxygen Delivery Devices Nasal cannula
Venturi mask Simple face mask Partial face mask Nonrebreather mask Small-volume nebulizer Oxygen humidifier
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Ventilation Methods
Mouth-to-mouth Mouth-to-nose Mouth-to-mask Bag-valve device Demand valve device Automatic transport ventilator
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Bag-valve-mask with built-in colorimetric ETCO2 detector
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Ventilation of Pediatric Patients
Mask seal can be more difficult Bag size depends on age of child Ventilate according to current standards Obtain chest rise and fall with each breath Assess adequacy of ventilations
Observe chest rise Listening to lung sounds Assessing clinical improvement
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Portable Mechanical Ventilator
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CARvent ALS Resuscitator
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Summary
Respiratory Problems
Respiratory System Assessment
Airway Management