EMT BasicAdvanced Airway

ManagementPharyngeal Esophageal Airway Device

(PEAD)

A.K.A. Combitube©

PowerPoint developed by Jennifer Stanislaw, EMT-P, EMS Training Officer West Valley Fire District, Willamina, OR

The Cat Fan (No Pun Intended)

Agenda Review Objectives Lesson 1

Respiratory Anatomy & Physiology

Lesson 2 Respiratory Volume and Management

Lesson 3 Assessing Respiratory Problems

Agenda cont’d Lesson 4

Respiratory/Cardiac Arrest Basic Airway Management

Lesson 5 Suctioning

Lesson 6 Dual-Lumen Airway Devices

Agenda cont’d Demonstration Practical Stations

Basic Airway Management Manual Maneuvers and Simple Adjuncts Supplemental Oxygen Ventilation Suctioning

Combitube Insertion

Practical Testing must be done with the Physician

Advisor (or another Physician of his / her choosing)

Objectives Describe the anatomy and function of the upper

and lower airways Describe respiratory volumes and capacities in

relationship to the need for assisted ventilations Identify the specific observations and physical

findings commonly found in patients presenting in respiratory and/or cardiac arrest.

Identify the basic principles of airway management

Objectives (cont’d) Describe the indications for suctioning. Identify rigid and flexible suction catheters

and the indications for use. Identify indications and contraindications for

use of the PEAD’s. Identify the advantages and disadvantages

of using PEAD’s.

Objectives (cont’d) Identify those situations in which PEAD’s

may be removed. Demonstrated placement of PEAD’s. Demonstrate methods of assuring and

maintaining correct placement of PEAD’s. Demonstrate re-ventilation for missed

placement of PEAD’s.

Objectives (cont’d) Demonstrate on a manikin the proper

technique for the use and maintenance of the following airway adjuncts: Nasal cannula Non-rebreather mask Bag-Valve-Mask

Demonstrate sterile suctioning techniques on a manikin with a PEAD in place.

Lesson 1Respiratory Anatomy & Physiology

Respiratory Anatomy & Physiology

Function of the Respiratory System Removes carbon

dioxide from the blood Transfers oxygen to

the blood

The Upper AirwayEpiglottis

Mandible

Frontal Sinus

Soft Palate

Trachea

Glottis

Esophagus

Vocal Cords

A

B

C

D

E

F

G

H

The Upper Airway Other Structures

Nasopharynx Oropharynx Hypopharynx Larynx

Functions

Functions of the Upper Airway Passageway for air Warm Filter Humidify Protection

Gag Reflex Cough

Speech

The Lower AirwayPrimary Bronchi

Hyoid Bone

Right Lung

Secondary Bronchi

Tracheal Ligament

Trachea

Larynx

Esophagus

Left Lung

Trachea

A

B

C

D

E

F

G

H

I

J

Alveoli Gas Exchange

Lungs Structure Lobes Pleura

Physiology of Respiration Define Respiration

The exchange of gases between a living organism and the environment

Define Ventilation Mechanical Process that moves air in and out of

the lungs

Muscles of Breathing Intercostal Muscles Diaphragm

Regulation of RespirationWhere is the Respiratory Center Controlled? Brainstem

Medulla Apeustic Center (pons) Pneumotaxic center (pons)

Stretch receptors Hering-Breuer reflex

Chemoreceptors CSF Blood

Voluntary or Involuntary Both

Humans can override body’s urge to breathe But only for so long

Respiratory Cycle Inspiration

Active phase Lasts 1-2 seconds

Expiration Passive phase Lasts 5 seconds

Lesson 2Respiratory Volume and

Management

Drinking Straw Exercise Breathe through

straws for 1 minute

Carbon Dioxide & The Respiratory System

High CO2 Increases respiratory rate

Low CO2 Decreases respiratory rate

Hypoxic Drive Chronic COPD patients

Normal Respiratory Rates Adult Children Infants Newborns

12 – 20 / min 18 – 24 / min 22 – 36 / min 40 – 60 / min

Factors Affecting Respiratory Rate Fever Depressant Drugs Anxiety Insufficient Oxygen Stimulant Drugs Sleep

Respiratory Volumes Lung Capacity Tidal Volume Dead Space Alveolar Air

6000 mL of air 500 mL at rest 150 mL 350 mL

Minute Volume Total air moved per minute Rate X Volume = Minute volume Important Assessment Item

Factors Affecting Minute Volume Head, neck, chest injury Shock Diabetes CO2 / O2 rapid changes

Maintaining the A in ABC Patient positioning Suctioning Supplemental Oxygen Mechanical Assistance

Pulse Oximetry Measures amount of oxygen in the blood. Gives percent of hemoglobin saturated

Tool only, do not rely on totally Why?

Normal Values 95% - 100% Normal 90% - 95% - Mild – Normal for COPD < 90 % Moderate – High Flow Oxygen

End-Tidal CO2 Detection Measured

Colorimetric and Digital

Tool to aid in determining correct placement

Lesson 3

Assessing Respiratory Problems

Patient Assessment

General Patient Assessment Primary Survey

LOC ABC’s Speech Pattern Obvious Respiratory Noise Patient Position

General Assessment (cont’d)

Secondary Assessment SAMPLE history Chief Complaint Pertinent Negatives Chest Pain (pleuritic vs cardiac) Cough History Edema Vitals

Respiratory Assessment Confusion, Agitation, Orientation Cyanosis (late sign) Diaphoresis Retractions Accessory Muscle Use Jugular Venous Distention Nasal Flaring / Pursed Lip Breathing

Palpation Skin

Turgor Color Temperature Diaphoresis

Pulse Rate Rhythm Quality

Chest Wall Pain Tracheal Deviation

Assessing Lung Sounds Methods Hand Out

Lung Sounds Normal Wheezes Rales (Crackles) Stridor Rhonchi Pleural Rub

Listen on every patient End of Expiration End of Inspiration During both phases Expiration End of Inspiration

Respiratory Diseases COPD Asthma Pneumonia Pulmonary Edema Pulmonary Embolus Trauma

COPD

Chronic Obstructive Pulmonary Disease

Pink Puffers and Blue Bloaters Frequently on Home oxygen Assessment

Typical Lung Sounds

Common Medications May or May not be Hypoxic Drive

Asthma

Asthma Bronchiole Constriction & Mucous

Production Lung Sounds

Wheezes Diminished None

Usually Diagnosed

Pneumonia

Pneumonia Fever Productive Cough

Colored Sputum

General Illness Elderly & Pediatric most at risk Lung Sounds

Rhonchi, Rales, Wheezes

Pulmonary Edema

Pulmonary Edema Congestive Heart Failure

Acute – Flash Pulmonary Edema Chronic – Heart Failure

Medications Orthopnea, PND

Lung Sounds Keep them upright with legs dangling

Pulmonary Embolus

Pulmonary Embolus Lung Sounds History

Surgery Bed Confined Long trip

Rapid Transport & High Flow Oxygen

Trauma

Trauma Maintain spinal control Airway Management High Flow Oxygen Rapid Transport Seal Chest Wounds Stabilize Impaled Objects

Lesson 4Respiratory/Cardiac Arrest

Basic Airway Management

Respiratory & Cardiac Arrest

Assessing the Patient First Steps of CPR Annie, Annie You Okay? Other Signs and Symptoms

Unconsciousness Cardiac Seizure Agonal respirations or apnea Cyanosis, Ashen, Mottled No signs of spontaneous respiration or circulation No Pulse

Combitube

When to Use the Combitube CPR

Remember to do CPR! Attach AED!

Respiratory Arrest Agonal Respirations without intact gag reflex Respiratory Arrest leads to Cardiac Arrest

Airway Management – The Basics

Manual Maneuvers Chin Lift Jaw Lift Jaw Thrust Head Tilt – Chin Lift Modified Jaw thrust

Airway Management – The BasicsMechanical Airways NPA’s

OPA’s

Description Advantages Disadvantages Indications Contraindications Methods of Insertion

Airway Management – The BasicsVentilation Mouth to Mask

BVM

Description Advantages Disadvantages Indications Contraindications Methods of Use

Evaluation of Effectiveness How do I know I am ventilating?

Chest movement Lung Sounds Epigastric sounds/Abdominal distention Patient Response

Lesson 5Suctioning

Reviewing Suctioning BSI – Scene Safety Equipment

Suction device Rigid or Soft Tip

Insert with Suction Off Withdraw while

Suctioning No more than 15

seconds before ventilating!

Oh, That Sucks! Vomitus

Food Protein dissolving

enzymes Hydrochloric Acid

Aspiration damage Alveolar Damage Increased fluid Obstruction Aspiration Pneumonia

Oh, Go Spit on It Saliva

Digestive enzymes Bacteria

Aspiration Damage Fills alveoli Pneumonia

Food Clogs airways Interferes with

ventilation Pneumonia

Blood Contents

Protein Fibrin Water Electrolytes

Aspiration Damage Clog small airways Creates chemical

reaction

Suction Catheters

Rigid Advantages Disadvantages Indications Contraindications Methods of Use

Flexible Advantages Disadvantages Indications Contraindications Methods of Use

Lesson 6Dual-Lumen Airway Devices

Combitube©

Description Other Similar Devices

Pharyngeal tracheal lumen airway (PTLA) EGTA EOA

What we use Combitube©

Indications for Combitube©

Respiratory Arrest Cardiac Arrest Unconscious, without a gag reflex

Contraindications for Combitube©

Gag Reflex Conscious Breathing Adequately Caustic Ingestion Known esophageal disease or varices Under 16 y/o Under 5 feet or over 6 feet 8inches

Advantages for Combitube©

Rapid Insertion Limits regurgitation, aspiration & distention Blind insertion High oxygen delivery Less training required Inserted in neutral position

Disadvantages for Combitube©

Patient must be unresponsive without gag reflex

Some are difficult to obtain adequate seal Some do not totally protect against

aspiration Most responsive patients will vomit when

removed May damage esophagus

Demonstration

When Can I Remove the Combitube?

Patient returns to full consciousness Patient able to maintain own airway Orders from OLMC

Procedure for Removing SUCTION READY! Deflate Tube #2 Deflate Tube #1 Tell patient to exhale Pull out quickly and in-line SUCTION

Demonstration

Skills Labs Basic Airway Management

Manual Maneuvers and Simple Adjuncts Supplemental Oxygen Ventilation Suctioning

Advanced Airway Management Combitube

Questions?