Introduction

(Needs to written to be consistent with other chapters) 

Airway Management

Airway Anatomy and Physiology

Without oxygen, the body cannot function properly. An adequate airway is essential to assuring the body has what it needs to function properly. We will start with the basics, understanding the anatomy and physiology of the respiratory system.

Anatomy of the Upper Airway

The upper airway is the initial pathway for air to enter the respiratory system, a complex and vital process for life. It begins with the nose, the primary entry point for air. The nasal passages filter, warm, and humidify inhaled air, preparing it for the lungs. Inside the nose, specialized cells and structures like cilia and mucous membranes trap dust, pollen, and other foreign particles, preventing them from reaching the lower respiratory tract. This filtration process is necessary for maintaining respiratory health.

The mouth is an alternative airway, especially in emergencies when the nasal passages are obstructed. It also plays a role in the digestive system, as it’s the entry point for food and liquids. Beyond respiration and digestion, the mouth is essential for speech production. The tongue, a muscular organ located within the mouth, manipulates food during chewing and swallowing, as well as for forming sounds during speech. Its position and movement significantly impact the quality and clarity of spoken language.

The jaw, composed of the mandible (lower jaw) and maxilla (upper jaw), provides the bony framework for the mouth and supports the teeth used for chewing. The jaw’s movement, facilitated by muscles and joints, allows for biting, chewing, and speaking. Proper jaw alignment is necessary for both oral function and facial structure. Any injury or misalignment can impact breathing, eating, and/or speech.

In the back of the mouth and the nasal cavities lies the throat, or pharynx. The pharynx is divided into three regions: the oropharynx, nasopharynx, and laryngopharynx. The oropharynx is located directly behind the mouth, while the nasopharynx is behind the nose. The laryngopharynx is the lower part of the pharynx and connects to the esophagus and larynx. The epiglottis, a leaf-shaped flap of cartilage, sits at the entrance to the larynx. During swallowing, the epiglottis closes over the glottis, the opening to the trachea, preventing food and liquids from entering the lungs.

The larynx, also known as the voice box, is a cartilaginous structure located in the anterior neck. It houses the vocal cords, which vibrate to produce sound. The vocal cords are two folds of tissue that can be tightened or relaxed to change the pitch of the voice. The larynx also contains the thyroid cartilage, which protects the front of the larynx and forms the Adam’s apple, and the cricoid cartilage, a ring-shaped structure that forms the lower portion of the larynx. The larynx’s primary function is to protect the lower airway and facilitate sound production.

Maintaining a patent airway is the priority in emergency medical care. Knowledge of these structures enables EMS providers to effectively assess and manage airway issues, whether through basic maneuvers like the head-tilt/chin-lift or more advanced techniques such as endotracheal intubation. A thorough understanding of the upper airway’s anatomy is fundamental for providing effective prehospital care and ensuring patient survival.

Anatomy of the Lower Airway

The lower airway begins with the trachea, commonly known as the windpipe. This hollow tube serves as the connection between the pharynx, located in the upper airway, and the lungs, the primary organs of respiration. The trachea’s structure is reinforced by a series of C-shaped cartilage rings, which provide support and prevent the trachea from collapsing, ensuring a continuous and open passageway for air to travel to the lungs. This open airway is essential for effective breathing and gas exchange.

Distributing air throughout the lungs is the bronchi. These hollow tubes branch off from the trachea and further subdivide into a complex network of progressively smaller airways, much like the branches of a tree. Similar to the trachea, the bronchi are also supported by cartilage, ensuring their patency and facilitating the efficient transport of air into the deeper structures of the lungs. The branching pattern of the bronchi allows for a wide distribution of inhaled air, maximizing the surface area available for gas exchange.

The lungs themselves are complex organs containing millions of tiny air sacs called alveoli. The bronchi eventually lead to smaller and thinner tubes called bronchioles. These bronchioles, unlike the bronchi, are not supported by cartilage rings but instead maintain their open state through smooth muscle tone. This smooth muscle can constrict or relax, influencing airflow to the alveoli. The alveoli, located at the very end of the airway, are the functional units of the lung. These microscopic, thin-walled sacs are where the exchange of oxygen and carbon dioxide takes place.

Each alveolus is surrounded by a dense network of capillary blood vessels. The proximity of the alveoli and capillaries allows for rapid diffusion of oxygen from the inhaled air into the bloodstream, while carbon dioxide, a waste product of cellular metabolism, diffuses from the blood into the alveoli to be exhaled. This intricate system of airways and alveoli within the lungs ensures the efficient delivery of oxygen to the body’s tissues and the removal of carbon dioxide. Understanding both the anatomy of the upper and lower airways is important to understanding their function within the body.

Age-Related Respiratory System Variations in Pediatric Patients

The unique anatomical and physiological characteristics of pediatric patients is important to understand. Age-related variations in pediatric patients significantly impact assessment, treatment, and overall outcomes. This section highlights key differences in pediatric airway anatomy that necessitate special considerations during emergency medical interventions.

Infant vs. Adult Airway Differences

Not only is the size of the airway different, the shapes and locations of the structures also vary between the infant and the adult. The table and illustration summarize the major anatomical differences in the infant and toddler airways compared to the older child and adult. The younger the child, the more different the airway.

One notable distinction lies in the size and structure of the pediatric airway. Infants and young children have a smaller nose and mouth compared to adults. This seemingly minor difference can pose challenges when implementing airway maneuvers or using airway adjuncts. Additionally, the jaw of a pediatric patient is smaller, while their tongue is proportionally larger, occupying more space in the oral cavity. This anatomical feature contributes to infants being nose breathers, as their oral cavity is primarily occupied by the tongue.

The trachea, or windpipe, in pediatric patients, also exhibits distinct characteristics. It is more pliable and has a smaller diameter compared to adults. The increased pliability makes the trachea susceptible to compression or kinking during neck movements, potentially leading to airway obstruction. The smaller diameter implies that even minimal swelling or foreign objects can significantly compromise airflow.

Furthermore, the cricoid cartilage, a ring-like structure that helps maintain the trachea’s patency, is less rigid and less developed in children. This immaturity increases the risk of airway collapse, especially in cases of increased airway resistance or external pressure. Consequently, airway structures in pediatric patients are generally more easily obstructed due to a combination of these anatomical differences.

The epiglottis, a flap of cartilage that covers the trachea during swallowing, also differs in pediatric patients. In infants and toddlers, the epiglottis is longer, floppier, and narrower, extending at a 45-degree angle into the airway. This unique shape and position can increase the risk of airway obstruction.

These age-related variations in pediatric airway anatomy necessitate careful consideration during airway management. EMS professionals must be knowledgeable about these distinctions and adapt their techniques accordingly. For instance, when positioning a pediatric patient for airway management, gentle maneuvers are necessary to avoid hyperextension or hyperflexion of the neck, which can lead to airway compromise.

As an EMS provider, it is important to understand age-related variations in pediatrics to provide effective and safe care. Recognizing the unique anatomical and physiological characteristics of pediatric airways enables prompt and appropriate interventions, ultimately improving patient outcomes.

Age-Related Respiratory System Variations in Geriatric Patients

Geriatric patients present unique challenges in the prehospital setting due to age-related physiological changes. One significant alteration occurs in the respiratory system. The chest wall loses elastic recoil, leading to air-trapping and a subsequent increase in both lung capacity and residual volume. This means that while the total volume of air the lungs can hold might increase, the efficiency of gas exchange is compromised. Simultaneously, there is a loss of alveoli, the tiny air sacs where oxygen and carbon dioxide exchange takes place. This reduction in surface area further diminishes the body’s ability to effectively oxygenate tissues and remove waste products. These changes contribute to a decline in overall respiratory function, making geriatric patients more vulnerable to respiratory distress.

Adding to these challenges, the aging respiratory system experiences a reduction in the exchange of oxygen and carbon dioxide. This diminished exchange capacity, coupled with the structural changes already mentioned, means that geriatric patients may present with lower baseline oxygen saturation levels and a reduced ability to compensate for respiratory difficulties. Furthermore, the body’s ability to respond to respiratory distress is often reduced. A key physiological response to declining oxygen levels or increasing carbon dioxide is an increase in respiratory rate. However, geriatric patients often exhibit an inability to significantly increase their respiratory rate in response to these stressors. This limited ability to compensate can mask the severity of respiratory problems and delay recognition of critical illness.

Beyond the changes in lung tissue and gas exchange, the body’s defense mechanisms within the respiratory system also weaken with age. The cough reflex, a vital protective mechanism that helps clear the airway of foreign material, is often diminished in geriatric patients. This makes them more susceptible to aspiration pneumonia and other respiratory infections. Compounding this issue is the decreased ability of cilia, the tiny hair-like structures lining the respiratory tract, to effectively move mucus upward and out of the lungs. This impaired mucociliary clearance further contributes to the increased risk of pneumonia and other respiratory complications in the elderly population.

In the prehospital setting, EMS providers must be acutely aware of these age-related respiratory changes in geriatric patients. A seemingly minor respiratory complaint may quickly escalate into a life-threatening situation due to the reduced reserve capacity and impaired compensatory mechanisms. A thorough assessment, including careful observation of respiratory rate and effort, pulse oximetry, and auscultation of lung sounds, is crucial. Early recognition of respiratory distress and prompt intervention, including supplemental oxygen and potentially assisted ventilation, are essential to improving outcomes for geriatric patients experiencing respiratory compromise.

Airway Assessment

Adequate Airway

A patent airway is essential for ensuring oxygen delivery to the lungs and the removal of carbon dioxide. Several key indicators suggest an adequate airway. First and foremost, the airway is open. This can be assessed by visually inspecting the oral cavity for obstructions and by listening and feeling for the movement of air at the patient’s mouth and nose. This simple step confirms that air is flowing. Beyond simply being open, the quality of the airway is assessed through other signs.

A patient’s ability to speak in full sentences without difficulty is a strong indicator of an adequate airway. This demonstrates that air is moving freely through the upper airway and into the lungs, allowing for the complex process of speech. The ability to articulate full sentences suggests sufficient airflow and adequate respiratory effort. This assessment is particularly useful in conscious patients and provides a rapid gauge of airway patency. However, it’s important to remember that a patient who is initially speaking full sentences can deteriorate quickly, so continuous monitoring is essential.

The sound of the patient’s voice also provides valuable information about the airway. A normal voice, consistent with the patient’s baseline, suggests that the vocal cords are vibrating freely. Changes in voice quality, such as hoarseness, muffled speech, or stridor (a high-pitched whistling sound), can indicate airway compromise. These changes may be due to swelling, obstruction, or other issues affecting the larynx and vocal cords. Therefore, noting the quality of the patient’s voice is an important part of the airway assessment.

Observing the chest rise and fall is another component of airway evaluation. Equal and symmetrical chest expansion indicates that both lungs are receiving adequate ventilation. Unequal chest rise can be a sign of various problems, including pneumothorax (collapsed lung), hemothorax (blood in the chest cavity), or flail chest (multiple rib fractures). Asymmetrical movement can also suggest airway obstruction in one lung. Therefore, careful observation of chest movement provides information about the effectiveness of the patient’s breathing.

Finally, auscultating (listening) breath sounds using a stethoscope provides data about the patient’s airway. Clear breath sounds heard bilaterally (on both sides of the chest) indicate that air is moving freely through the lungs. Diminished or absent breath sounds can be a sign of airway obstruction, atelectasis (alveoli collapse), or other respiratory issues. Adventitious (abnormal) breath sounds, such as wheezing or crackles, can also provide clues about the underlying cause of respiratory distress. Auscultation is a skill that needs to be practiced and used on all patients.

While these five signs are key indicators of an adequate airway, it’s important to remember that they represent a snapshot in time. A patient’s condition can change rapidly, and continuous monitoring of the airway and breathing is essential, especially in critical patients. Furthermore, these assessments should be integrated with other vital signs, such as pulse rate, respiratory rate, and oxygen saturation, to provide a comprehensive picture of the patient’s condition.

Inadequate Airway

Recognizing the signs and symptoms of an inadequate airway is critical for prompt intervention. An inadequate airway can manifest in a variety of ways, ranging from subtle indicators to overt signs of respiratory distress. One of the most alarming signs of an inadequate airway is the absence of breathing or air movement. This can be readily assessed by observing the patient’s chest for rise and fall or by placing a hand near the patient’s mouth to feel for exhaled air. If no breathing or air movement is detected, immediate intervention is necessary.

Another sign of an inadequate airway is the presence of foreign bodies in the airway. These foreign bodies can include blood, vomit, or other objects, such as broken teeth. The presence of such foreign bodies can obstruct the flow of air, leading to respiratory distress or arrest.

In some cases, an inadequate airway may not be immediately apparent. In such instances, you will need to assess the amount of air exchange at the nose and mouth. If no air can be felt or heard, or if the amount of air exchange is below normal volume, an inadequate airway should be suspected.

Patients with an inadequate airway may also exhibit difficulty speaking. They may be unable to speak full sentences or may speak with difficulty. This difficulty in speaking can be attributed to the reduced airflow through the airway.

Unusual lung sounds can also indicate an inadequate airway. These lung sounds may include wheezing, stridor, or crackles. Such sounds can be indicative of airway obstruction or other respiratory problems.

In addition to the aforementioned signs and symptoms, an inadequate airway can also manifest as minimal, absent, or uneven chest rise and fall. This can be observed by carefully examining the patient’s chest during breathing. If the chest rise and fall is minimal, absent, or uneven, it may indicate an inadequate airway.

Finally, gurgling, gasping, snoring, or stridor are all sounds that can be heard during breathing in patients with an inadequate airway. These sounds are indicative of airway obstruction or other respiratory problems. An inadequate airway can manifest in a variety of ways, ranging from subtle indicators to overt signs of respiratory distress. EMS professionals must be vigilant in recognizing these signs and symptoms to ensure prompt intervention and patient safety.

Airway Swelling

When assessing a patient with swelling, EMS providers must differentiate between swelling due to trauma or infection. Trauma-related swelling is often accompanied by other signs of injury, such as bruising, open wounds, or deformities. The swelling may also be localized to the injured area. Infection-related swelling, on the other hand, may be accompanied by redness, warmth, tenderness, and pus. The swelling may also be more diffuse and may involve multiple areas of the body.

In either case, it is important to assess the patient’s airway to determine if the swelling is causing any compromise. This can be done by listening for stridor, which is a high-pitched whistling sound that indicates a narrowing of the airway. If stridor is present, the patient may need immediate intervention to secure the airway.

Here are some additional tips for differentiating between swelling due to trauma or infection:

• Ask the patient about the onset of the swelling. Swelling due to trauma typically occurs immediately or shortly after the injury, while swelling due to infection may develop over days.
• Inspect the area of swelling. Look for any signs of injury, such as bruising, open wounds, or deformities. Also, look for signs of infection, such as redness, warmth, tenderness, and pus.
• Palpate the area of swelling. Feel for any warmth, tenderness, or swelling.
• Auscultate the patient’s lungs. Listen for stridor, which indicates the narrowing of the airway.
• Obtain vital signs. Take the patient’s temperature, pulse, respiration rate, and blood pressure. Fever is a common sign of infection.
• Consider the patient’s medical history. Some medical conditions, such as allergies or autoimmune diseases, can increase the risk of swelling.
• If you are unsure of the cause of the swelling, it is always best to err on the side of caution and treat the patient as if they have a serious condition.

Remember, prompt recognition and management of airway compromise is critical in patients with swelling. If you are unsure of the cause of the swelling or if the patient’s airway is compromised, it is always best to consult with a medical professional.

Airway Maneuvers

Manual airway maneuvers are fundamental skills for managing a patient’s airway. These techniques aim to alleviate airway obstruction caused by the tongue falling back against the posterior pharynx, a common occurrence in unconscious or semi-conscious individuals. Two primary maneuvers are employed: the head-tilt/chin-lift and the jaw-thrust. Understanding their proper application, indications, and contraindications is paramount for effective airway management.

The head-tilt/chin-lift maneuver is a basic technique used to open the airway by extending the patient’s neck and lifting the chin. The purpose of this maneuver is to align the oral, pharyngeal, and tracheal axes, creating a clear pathway for air to flow. It is indicated for any patient with a non-patent airway unless a cervical spine injury is suspected. Contraindications include suspected neck, spine, or head injury, as manipulating the neck in these situations could exacerbate the injury. While generally safe, complications can arise. Multiple attempts may be needed to achieve a patent airway, and the position must be maintained to ensure continued airway patency. The procedure itself involves placing one hand on the forehead to tilt the head back while the other hand lifts the chin.

The jaw-thrust maneuver is an alternative technique specifically designed for patients with suspected head, neck, or spine injuries. Its purpose, like the head-tilt/chin-lift, is to open the airway by aligning the airway structures. It is indicated in patients with a non-patent airway and a suspected or unknown mechanism of injury that could involve the cervical spine. There are no absolute contraindications when a patient cannot maintain their airway. However, if the jaw thrust is ineffective, it can be augmented by mechanical tools such as an oral airway.

The key difference between these two maneuvers lies in their application concerning potential spinal injuries. The head-tilt/chin-lift, while effective in opening the airway, involves neck extension, which is contraindicated in suspected spinal injuries. The jaw-thrust maneuver, on the other hand, minimizes neck movement, making it the preferred technique in such situations. However, it’s important to recognize that maintaining a patent airway is the priority. If the jaw thrust is unsuccessful, the head-tilt/chin lift should be used, even with a suspected spinal injury, as a compromised airway poses a more immediate threat to life.

While both maneuvers aim to achieve the same outcome – a patent airway – their specific applications differ. The head-tilt/chin-lift is a first-line approach in most cases of airway obstruction, while the jaw-thrust is reserved for situations where cervical spine injury is a concern. This distinction is important to understand, as it directly impacts patient safety and the potential for further injury.

The ability to quickly and accurately assess a patient’s airway and select the appropriate manual maneuver can significantly impact patient outcomes. Regular training and practice are essential to ensure competency in these life-saving techniques.

Manual Airway Maneuvers — Procedures

1. Head-Tilt/Chin-Lift Maneuver

The head-tilt/chin-lift is a first-line maneuver for opening the airway when cervical spine injury is not suspected. It involves tilting the patient’s head back by placing one hand on the forehead and gently applying pressure while simultaneously lifting the chin with the other hand. This action lifts the tongue away from the back of the throat, effectively opening the airway.

2. Modified Jaw-Thrust Maneuver

The modified jaw thrust is the preferred technique when cervical spine injury is suspected. It involves grasping the angles of the mandible (jawbone) and lifting them upward, effectively moving the tongue forward and opening the airway without manipulating the neck. This technique requires practice and precision to avoid causing further injury.

Additional Considerations:

• Both maneuvers should be performed gently and with caution, especially in patients with potential head or neck injuries.
• It is important to assess the patient’s breathing and responsiveness before and after performing either maneuver.
• These techniques are often used in conjunction with other airway management tools, such as oropharyngeal or nasopharyngeal airways.

Airway Adjuncts

Mechanical Airway Devices

Mechanical airway devices are tools used for managing a patient’s airway, ensuring adequate ventilation and oxygenation. These devices range from simple adjuncts like nasopharyngeal (NPA) and oropharyngeal (OPA) airways to more advanced techniques like endotracheal intubation. Each device serves a specific purpose, with its own set of indications, contraindications, complications, procedures, and limitations.

The nasopharyngeal airway adjunct is a soft, flexible tube inserted through the nostril into the nasopharynx. It is indicated for unconscious patients who retain a gag reflex, as it is generally better tolerated than an OPA in these patients. However, it is contraindicated in patients with a suspected basilar skull fracture (evidenced by severe facial trauma, with cerebrospinal fluid leakage from the ears or nose), epistaxis (nosebleed), or nasal trauma. Complications can include nasal ulcers, further nasal trauma or bleeding, and airway obstruction if improperly sized. The NPA is measured from the nasal septum to the angle of the jaw or from the nostril to the earlobe. It should be lubricated with a water-based lubricant before insertion, and the bevel should be directed towards the septum. If resistance is met, the other nostril should be attempted. A key limitation of the NPA is its unsuitability for patients with significant facial trauma, which may distort nasal anatomy and hinder insertion.

The oropharyngeal airway, also known as a Berman or Guedel airway, is a curved plastic device inserted into the mouth to prevent the tongue from obstructing the airway. It is indicated for unconscious patients without a gag reflex. It is strictly contraindicated in conscious patients or those with an intact gag reflex, as it can stimulate vomiting and laryngospasm. Other contraindications include patients with a foreign body airway obstruction. Complications can include inducing vomiting, laryngospasm (especially with improper sizing), oral trauma, and difficulty inserting due to lockjaw or excessive facial bleeding. The OPA is measured from the corner of the mouth to the angle of the jaw. It is inserted with the tip pointing towards the roof of the mouth, advanced past the uvula, and then rotated 180 degrees into the pharynx. Alternate insertion techniques involve anatomical placement with the aid of a tongue depressor. The flange should rest against the patient’s teeth. Like the NPA, the OPA has limitations, particularly in patients with significant facial trauma or bleeding, which can impede insertion and visualization.

While both NPA and OPA airways are valuable for basic airway management, they are considered adjuncts and do not provide a definitive airway. They are often used as a first step in airway management or in conjunction with other techniques. They are designed to maintain airway patency by preventing the tongue from falling back and obstructing the pharynx. However, they do not protect against aspiration, and they do not provide a means for delivering positive pressure ventilation.

The choice between an NPA and OPA depends primarily on the patient’s level of consciousness and the presence or absence of a gag reflex. The NPA is generally preferred for patients who retain a gag reflex, while the OPA is used for patients who are completely unconscious and have lost their gag reflex. It’s important to remember that these are general guidelines.

It is important to ensure proper sizing. An improperly sized airway can be ineffective or even cause harm. Too small an NPA may not reach the oropharynx, while too large an NPA can cause trauma. Similarly, an OPA that is too small may not effectively displace the tongue, while an OPA that is too large can impinge on the epiglottis and obstruct the airway.

Continued monitoring of the patient’s airway is necessary after any airway insertion. This includes monitoring for signs of airway obstruction, such as stridor, retractions, and cyanosis. It also includes ensuring that the airway device remains properly positioned and secured. Again, continuous monitoring is vital to ensure that the patient’s airway remains patent and that adequate ventilation and oxygenation are maintained.

Understanding the indications, contraindications, complications, procedures, and limitations of each airway device is essential for effective airway management. The choice of device depends on the patient’s condition, the available resources, and the skill level of the provider.

Insertion of Airway Adjunct Devices

Review these videos on the insertion of airway adjuncts.

Relief of Airway Obstructions

Relief of Foreign Body Airway Obstructions (FBAO)

Foreign body airway obstruction (FBAO) is a medical emergency that requires immediate intervention. Prompt recognition and appropriate treatment are necessary to prevent serious complications, including death. The techniques used to relieve an FBAO vary depending on the patient’s age (adult, child, or infant) and the severity of the obstruction. Effective management hinges on quickly assessing the situation and applying the correct procedures.

Recognizing an FBAO is the first step. The AHA distinguishes between severe and non-severe obstructions. A severe FBAO is characterized by the inability to speak, cough, or breathe. There will be no air movement, and the patient may be clutching their throat (the universal choking sign). They might also exhibit signs of increasing distress, such as cyanosis (bluish discoloration of the skin) and eventually, loss of consciousness.

A non-severe obstruction, on the other hand, allows for some air exchange. The patient may be able to speak, cough, wheeze, or gasp. While concerning, a non-severe obstruction doesn’t necessitate the immediate, forceful interventions required for a complete blockage. However, it’s vital to monitor the patient closely as a partial obstruction can quickly become complete.

Treatment for FBAO differs based on the patient’s age. For adults and children over 1 year old with a severe obstruction, the abdominal thrusts (Heimlich maneuver) are the recommended technique. These involve delivering quick, upward thrusts to the abdomen, just below the rib cage to dislodge the object. Chest thrusts are used for pregnant or obese individuals. Back blows are also part of the management algorithm. For infants under 1 year old with a severe obstruction, the approach is different. Back blows and chest thrusts are used instead of abdominal thrusts. It’s important to support the infant’s head and neck during these maneuvers. For non-severe obstructions in all age groups, encouraging the patient to cough forcefully is the first line of treatment. This natural mechanism is often effective in expelling the foreign body.

Techniques of Upper Airway Suctioning

Upper airway suctioning clears the airway of obstructions like fluids, secretions, or foreign materials. The primary indications for suctioning include audible gurgling sounds, which strongly suggest the presence of liquid in the airway, and visual evidence of such materials in or around the patient’s mouth and airway. Effectively removing these obstructions can significantly improve a patient’s respiratory status and oxygenation.

However, suctioning is not appropriate in all situations. Conscious patients typically have intact airway reflexes and can manage their secretions, making suctioning unnecessary and potentially uncomfortable. Specific conditions like epiglottitis and croup, which involve inflammation and swelling in the upper airway, are also contraindications. Suctioning in these cases can exacerbate the swelling and worsen the patient’s condition. Furthermore, patients with severe hemodynamic instability or bronchospasm may experience further deterioration with the procedure, making it contraindicated. Careful assessment of the patient’s overall condition is essential before attempting suctioning.

Complications associated with upper airway suctioning, though usually avoidable with proper technique, can be serious. Hypoxia, a deficiency in oxygen reaching the tissues, is a major concern, especially if suctioning is prolonged or performed without adequate pre-oxygenation. Bradycardia, a slow heart rate, can also occur due to vagal nerve stimulation during the procedure. Trauma to the airway, including tissue damage and bleeding, is another potential complication, particularly if the suction catheter is inserted too forcefully or manipulated roughly.

The proper procedure for upper airway suctioning involves several key steps. First, attach the appropriate suction catheter to the suction unit and test it to ensure proper function. If using a portable power unit, turn it on and confirm adequate suction pressure. Position yourself at the patient’s head and turn the patient’s head (or entire body if necessary) to the side to facilitate access to the airway. Measure the catheter from the corner of the patient’s mouth to the tip of their ear to estimate the appropriate insertion depth. This helps prevent excessively deep insertion and potential trauma.

After measuring the catheter, open the patient’s airway using the cross-finger technique (scissoring the teeth open with the index finger and thumb). Carefully insert the suction catheter, without applying suction, to the predetermined measured point or only as far as you can visualize. Applying suction during insertion can traumatize the airway. Once the catheter is in place, apply suction and gently withdraw the catheter, using a sweeping motion to remove secretions. The entire suctioning process should be brief, with a maximum duration of 10 seconds per attempt. Prolonged suctioning can lead to hypoxia.

Finally, it’s important to recognize the limitations of upper airway suctioning. In some cases, the patient may require pre-oxygenation before suctioning to prevent hypoxia. This is especially true for patients with pre-existing respiratory compromise or those who require multiple suctioning attempts. Additionally, suctioning may not be effective in removing thick, tenacious secretions or solid foreign body obstructions. In these situations, alternative airway management techniques, such as manual extraction or advanced airway procedures, may be necessary. Continuous reassessment of the patient’s condition is crucial to determine the effectiveness of suctioning and the need for additional interventions.

Skills for Relief of an Airway Obstruction

Review these videos on relief of foreign body airway obstruction.

Relieving Choking in Adults (Conscious)

1. Assess the Situation: If an adult is conscious and choking, they may be unable to speak or cough. Look for the universal choking sign (hands clutching the throat).
2. Call for Help: If someone is nearby, have them call 911 or your local emergency number.
3. Back Blows: Stand behind the choking person and slightly to one side. Place one arm across their chest for support. Bend them forward at the waist and give five distinct back blows between their shoulder blades with the heel of your hand.
4. Abdominal Thrusts (Heimlich Maneuver): If the back blows are unsuccessful, perform abdominal thrusts. Stand behind the person and wrap your arms around their waist. Make a fist with one hand and place the thumb side against the abdomen, just above the navel. Grasp your fist with your other hand and give five quick, upward thrusts (in a “J” motion).
5. Alternate Between Back Blows and Abdominal Thrusts: Continue alternating between five back blows and five abdominal thrusts until the object is dislodged or the person becomes unconscious.

Relieving Choking in Adults (Unconscious)

1. Assess the Situation: If an adult is unconscious, check for responsiveness. If they are unresponsive, call for help immediately.
2. Position the Person: Carefully lay the person on their back on a firm, flat surface.
3. Open the Airway: Use the head-tilt/chin-lift maneuver to open the airway. Place one hand on the forehead and gently tilt the head back while lifting the chin with your other hand.
4. Look for an Object: Look into the person’s mouth. If you see an obstruction, carefully remove it with your fingers.
5. Begin CPR: If the person is not breathing or is only gasping, begin CPR. Chest compressions may help dislodge the object.

Relieving Choking in Children (Conscious)

1. Assess the Situation: If a child is conscious and choking, they may be unable to speak or cough. Look for the universal choking sign (hands clutching the throat).
2. Call for Help: If someone is nearby, have them call 911 or your local emergency number.
3. Back Blows: For a child over 1 year old, stand or kneel behind them. Place one arm across their chest for support. Bend them forward at the waist and give five distinct back blows between their shoulder blades with the heel of your hand. For a child under 1 year old, hold them face down on your forearm, supporting their head and neck. Give five back blows between their shoulder blades with the heel of your hand.
4. Abdominal Thrusts: If the back blows are unsuccessful, perform abdominal thrusts on a child over 1 year old. Stand or kneel behind them and wrap your arms around their waist. Make a fist with one hand and place the thumb side against the abdomen, just above the navel. Grasp your fist with your other hand and give five quick, upward thrusts using a “J” motion. For a child under 1 year old, perform chest thrusts instead of abdominal thrusts. Place two fingers on the breastbone, just below the nipple line, and give five quick, downward thrusts.
5. Alternate Between Back Blows and Abdominal Thrusts: Continue alternating between five back blows and five abdominal or chest thrusts until the object is dislodged or the child becomes unconscious.

Relieving Choking in Children (Unconscious)

1. Assess the Situation: If a child is unconscious, check for responsiveness. If they are unresponsive, call for help immediately.
2. Position the Person: Carefully lay the child on their back on a firm, flat surface.
3. Open the Airway: Use the head-tilt/chin-lift maneuver to open the airway. Place one hand on the forehead and gently tilt the head back while lifting the chin with your other hand.
4. Look for an Obstruction: Look into the child’s mouth. If you see an object/obstruction, carefully remove it with your fingers.
5. Begin CPR: If the child is not breathing or is only gasping, begin CPR. Chest compressions may help dislodge the object.

Upper Airway Suctioning

Upper airway suctioning is a technique used to remove secretions or foreign material from the upper airway. It is often used in conjunction with other airway management techniques, such as the Heimlich maneuver, to relieve FBAO.

1. Equipment: Gather the necessary equipment, including a suction catheter, suction tubing, and a suction device.
2. Prepare the Catheter: Select a catheter that is the appropriate size for the patient.
3. Insert the Catheter: Gently insert the catheter into the patient’s mouth or nose, advancing it until you reach the oropharynx or nasopharynx.
4. Apply Suction: Apply suction by placing your finger over the suction control port on the catheter. Suction for no more than 10-15 seconds at a time.
5. Remove the Catheter: Suctioning is done as the catheter is removed from the oropharynx or nasopharynx.
6. Repeat as Needed: Repeat the suctioning procedure as needed until the airway is clear.

Additional Considerations:

• If the patient is conscious, explain the procedure to them before you begin.
• Use appropriate personal protective equipment (PPE), such as gloves and a mask, when performing airway suctioning.
• Be careful not to suction for too long or with too much force, as this can damage the airway tissues.

Non-Visualized Advanced Airway

Airway Anatomy and Non-Visualized Airways

The airway – the pathway for gas exchange – begins at the nose and mouth, leading to the pharynx, larynx, trachea, bronchi, and finally, the alveoli in the lungs. Understanding the anatomy of the airway is important to understanding the use of a non-visualized airway. The pharynx, divided into the nasopharynx, oropharynx, and laryngopharynx, is an intersection of both the respiratory and digestive tracts. The larynx, containing the vocal cords, marks the entrance to the trachea, which then branches into the bronchi and bronchioles within the lungs. This airway network culminates in the alveoli, where the exchange of oxygen and carbon dioxide takes place between the air and the bloodstream.

A key concept in airway management is dead space. This refers to the portion of the tidal volume (the volume of air inhaled or exhaled in a single breath) that does not participate in gas exchange. Consider it the amount of air left in the lungs after exhalation of a breath. Anatomical dead space includes the air residing in the conducting airways – the nasal and oral cavities, pharynx, larynx, trachea, bronchi, and bronchioles. This air fills these spaces but doesn’t reach the alveoli, so no gas exchange occurs. In essence, dead space is the air we breathe that doesn’t contribute to the body’s oxygenation.

When a non-visualized airway, such as a blind insertion device like a King LTD™ or a laryngeal mask airway (LMA), is placed, it can impact both dead space and tidal volume. These devices are designed to create a seal in the pharynx, directing airflow into the trachea. However, their placement can inadvertently increase dead space if the device isn’t properly positioned, as air can leak into the esophagus or other areas of the pharynx. This means that a larger portion of the delivered tidal volume may remain in the non-gas-exchanging areas, reducing the effective volume reaching the alveoli. Furthermore, the device itself can add to the anatomical dead space.

The importance of a non-visualized airway on ventilations is significant. Because these devices don’t provide a direct view of the glottic opening, confirming proper placement relies on auscultation of breath sounds and observing chest rise. If the device is malpositioned, effective ventilation can be compromised. This can lead to inadequate oxygen delivery and potentially life-threatening complications. Understanding the relationship between airway anatomy, dead space, tidal volume, and the use of non-visualized airways is important to understand.

Components and Accessories of Non-Visualized Airways

There are three popular non-visualized airways. These are the Combitube®, King Laryngeal Tube Suction-D™ (King LTS-D™), and i-gel® supraglottic airways. Let’s cover these three devices and understand their components are essential for effective and safe use.

The Combitube® is a double-lumen airway device designed for blind insertion. It features two lumens, each connected to a separate cuff. One lumen inflates a pharyngeal cuff, while the other inflates a distal tracheal cuff (or if the device is inadvertently placed in the trachea, the esophageal cuff). Each lumen has a corresponding pilot balloon to indicate cuff inflation. The Combitube® kit typically includes syringes for cuff inflation and a water-soluble lubricant to facilitate insertion. A soft catheter may also be included for suctioning through either lumen.

The King LTS-D™ is another extraglottic airway device. It has a single lumen and a large pharyngeal cuff. Inflation of this cuff creates a seal against the base of the tongue and the soft palate. Like the Combitube®, the King LTS-D™ utilizes a pilot balloon to indicate cuff inflation status. The kit also includes a syringe for cuff inflation and water-soluble lubricant. A soft catheter may be included for suctioning secretions from the pharynx.

The i-gel® is a supraglottic airway device distinguished by its unique gel-like cuff. This cuff conforms to the patient’s anatomy, creating a seal without the need for inflation. The i-gel® consists of a single tube connected to the preformed cuff. Because it doesn’t require inflation, there are no pilot balloons or syringes associated with the device itself. However, lubricant is essential for insertion.

For all these devices, proper securing is vital. While the devices themselves provide some degree of stability, additional securing is necessary to prevent dislodgement. This can be achieved using adhesive tape, commercially available securing devices (like a Thomas clamp) or specialized manufacturer-provided securing mechanisms. The chosen method should be appropriate for the device and the clinical situation.

Water-soluble lubricant is also necessary for all these non-visualized airways. It reduces friction during insertion, minimizing the risk of trauma to the airway structures. Using a non-water-soluble lubricant is contraindicated, as it can be harmful to the tissues.

Soft catheters are often used in conjunction with these devices. They allow for suctioning of secretions from the pharynx or trachea, helping to maintain a clear airway. The catheter is typically passed through the lumen of the Combitube®, King LTS-D™, or alongside the i-gel®.

Syringes are necessary for inflating the cuffs of the Combitube® and King LTS-D™. They should be appropriately sized for the cuff volumes specified by the manufacturer. Using the correct inflation volumes is crucial for achieving an effective seal and minimizing the risk of complications.

In summary, each of these non-visualized airway devices has specific components and accessories that contribute to its function. Understanding these components and their proper use is essential for EMS professionals to effectively manage patients’ airways in emergencies. Proper training and adherence to established protocols are crucial for safe and successful airway management.

Indications and Contraindications for the Use of Non-Visualized Airways

The primary indications for the use of non-visualized airway insertion center around situations where a patient is unable to maintain their own airway or is in respiratory arrest. Regardless of the underlying cause, respiratory insufficiency necessitates immediate airway management, making non-visualized airways an appropriate intervention. Similarly, respiratory arrest, often identified by the absence of spontaneous breathing, demands prompt action to secure the airway. In unconscious patients, particularly those without a gag reflex, inadequate respirations further emphasize the need for airway support, making these devices essential. The absence of a gag reflex is particularly important as it reduces the risk of aspiration during insertion.

Conversely, several contraindications exist that preclude the use of non-visualized airways. Patient size is a critical factor; the device must be appropriately sized to ensure a proper seal and avoid complications. Manufacturers provide sizing guidelines, and local protocols often specify minimum height requirements. An active gag reflex is a strong contraindication, as it increases the risk of vomiting and aspiration during insertion. Ingestion of caustic substances is another contraindication, as these substances can damage the esophagus and airway, and insertion of an airway device could exacerbate the injury.

Pre-existing esophageal disease, whether known or suspected, represents a contraindication to non-visualized airway use. These conditions can make insertion difficult or increase the risk of complications like perforation. Similarly, any known or suspected obstruction of the larynx or trachea, such as from a foreign body or swelling, makes these devices inappropriate as they may worsen the obstruction. Attempting to force an airway past an obstruction can cause further injury and compromise the patient’s airway.

Finally, patients with a tracheostomy or laryngectomy present a unique situation. These patients typically breathe through the stoma in the neck, and inserting a non-visualized airway through the mouth or nose would bypass the established airway. In these cases, airway management should focus on the existing stoma. Recognizing these contraindications is as important as understanding the indications, as it ensures patient safety and optimizes the chances of successful airway management.

Insertion and Use of Non-Visualized Airways

The insertion and use of a non-visualized airway is an important skill for EMS providers managing patients requiring advanced airway management. Before any attempt at any airway insertion, appropriate PPE is essential. This includes gloves, eye protection, and a face shield to minimize the risk of exposure to bodily fluids. If required by local protocols or medical direction, permission must be obtained from medical control before proceeding with the procedure. The chosen supraglottic airway device (SGA) should then be prepared according to the manufacturer’s instructions, ensuring it is ready for immediate insertion.

Before inserting any SGA, the patient should be thoroughly preoxygenated using a bag-valve-mask (BVM) with high-concentration oxygen. This step maximizes the patient’s oxygen reserves, providing a safety buffer during the procedure. Effective preoxygenation involves ensuring a good mask seal and delivering adequate tidal volumes. Once the patient is adequately preoxygenated, the non-visualized airway can be inserted following the manufacturer’s recommended guidelines. These guidelines typically involve specific head positioning and insertion techniques to facilitate proper placement of the device.

Following insertion, primary confirmation of correct placement is essential. This involves auscultating for the presence of bilateral lung sounds, indicating that the device is correctly positioned in the trachea or esophagus (depending on the type of SGA) and ventilation is reaching the lungs. Simultaneously, auscultating over the epigastrium (stomach) is crucial to confirm the absence of gurgling sounds, which would suggest esophageal placement. If lung sounds are present and epigastric sounds are absent, the device is likely in the correct position.

Once primary confirmation is achieved, the SGA must be secured according to the manufacturer’s recommendations. This typically involves using a securing device or tape to prevent dislodgement of the airway. After securing the device, secondary confirmation of placement is performed. This is most commonly done using capnometry, capnography, or a colorimetric CO2 detector. These tools provide objective measures of exhaled carbon dioxide, confirming proper placement within the trachea and providing continuous monitoring of airway effectiveness during ventilation.

Finally, with the SGA securely in place and confirmed, ventilation of the patient can begin. It is vital to ventilate the patient at an age-appropriate rate and tidal volume. Over-ventilation or under-ventilation can have detrimental effects on the patient. Continuous monitoring of the patient’s respiratory status, including chest rise, lung sounds, and capnography readings, is essential to ensure adequate ventilation and oxygenation are maintained throughout transport and further management.

Gastric Distention/Decompression

Non-visualized airway insertion is an important tool for EMS providers when managing patients who are unresponsive or have a compromised airway. These devices, including the Combitube®, King LTS-D™, and i-gel®, are designed to create a patent airway without direct visualization of the vocal cords. Proper insertion technique maximizes the effectiveness and minimizes complications. Occasionally, because they are blindly inserted, there can be gastric distention that occurs. Gastric distention can fill the stomach causing expansion and reducing the ability of the lung to expand fully during ventilation.

Combitube®:

The Combitube® is a double-lumen airway device that can be inserted blindly into the esophagus or trachea. Interestingly, it functions regardless of which tube enters which passage. If the Combitube® is placed in the esophagus, which occurs more frequently, ventilation is typically performed through the larger, blue tube (#1). A key advantage of the Combitube® is its ability to facilitate gastric decompression. This is accomplished by inserting a soft-tip “whistle tip” catheter through the smaller, clear tube (#2), attaching it to a portable or on-board suction unit, and applying suction. This process helps to remove stomach contents, reducing the risk of aspiration, especially in patients who may have ingested food or liquids before their medical emergency.

1. Confirm Placement:

• To confirm placement, ventilate through both tubes and listen for breath sounds and epigastric sounds.
• If breath sounds are heard over the lungs when ventilating through the longer (blue) tube, the Combitube® is likely in the trachea, and you would use this tube to ventilate the patient.
• If breath sounds are heard over the lungs when ventilating through the shorter (white) tube, the Combitube® is in the esophagus, which is the more common placement.

2. Decompression:

• If the Combitube® is in the esophagus, you can use the shorter (white) tube for gastric decompression.
• Attach a suction device to the white tube and gently aspirate stomach contents.

King LTS-D™

The King LTS-D™ is a single-lumen supraglottic airway device. It is designed to seal against the base of the tongue and the soft palate, creating a channel for ventilation. Similar to the Combitube®, the King LTS-D™ also offers a port for gastric decompression. To utilize this feature, a soft-tip “whistle tip” catheter is inserted into the rear suction port of the device. This catheter is then connected to a portable or on-board suction unit, and suction is applied. This allows for the removal of gastric contents, mitigating the risk of aspiration and improving the patient’s overall condition.

1. Confirm Placement:

• The King LTS-D™ is a supraglottic airway device that is inserted blindly into the pharynx.
• To confirm placement, ventilate through the King LTS-D™ and listen for breath sounds and epigastric sounds.
• If breath sounds are heard over the lungs, the King LTS-D™ is likely in the correct position.

2. Decompression:

• The King LTS-D™ has a separate channel for gastric decompression.
• To decompress the stomach, insert a gastric tube (up to 18 French) through the gastric channel of the King LTS-D™.
• Attach a suction device to the gastric tube and gently aspirate stomach contents.

i-gel®

The i-gel® is another type of supraglottic airway device that utilizes a gel-like cuff to create a seal in the pharynx. Its design aims to minimize pressure on surrounding tissues. Like the other devices mentioned, the i-gel® also includes a port for gastric decompression. A soft-tip “whistle tip” catheter is inserted into the designated suction port of the i-gel®. This catheter is then connected to a suction source, enabling the removal of gastric contents and reducing the risk of aspiration.

1. Confirm Placement:

• The i-gel® is a supraglottic airway device that is inserted blindly into the pharynx.
• To confirm placement, ventilate through the i-gel® and listen for breath sounds and epigastric sounds.
• If breath sounds are heard over the lungs, the i-gel® is likely in the correct position.

2. Decompression:

• The i-gel® has a gastric channel that can be used for gastric decompression.
• To decompress the stomach, insert a nasogastric (NG) tube through the gastric channel of the i-gel®.
• Attach a suction device to the NG tube and gently aspirate stomach contents.

Non-visualized airway devices like the Combitube®, King LTS-D®, and i-gel® are standard airways for EMS providers in managing patients with compromised airways. A key feature of all three devices is the capability for gastric decompression. By inserting a soft-tip catheter through a designated port and applying suction, these devices allow for the removal of stomach contents, minimizing the risk of aspiration and potentially improving patient outcomes.

Removal of a Non-Visualized Airway

Several situations may necessitate the removal of a non-visualized airway, such as a nasopharyngeal airway (NPA) or oropharyngeal airway (OPA). The most common reasons include the patient regaining consciousness, the return of a protective gag reflex, or if ventilations are inadequate despite the presence of the airway adjunct. In the case of returning consciousness, the patient may begin to fight the airway or be at increased risk of aspiration. Similarly, a returning gag reflex indicates the patient’s ability to protect their airway, making the artificial airway unnecessary and potentially stimulating vomiting. Finally, if ventilations remain inadequate despite proper placement and confirmation of the airway, it may be necessary to remove and reassess the situation, possibly requiring a more advanced airway technique.

The procedure for removing a non-visualized airway requires careful preparation and execution. The first step, if your local protocols require it, is to contact medical control to inform them of the situation and receive any specific orders. While awaiting a response or if direct communication isn’t required, gather and prepare suctioning equipment. This is essential as the patient may have secretions or vomitus present, and immediate suctioning may be necessary upon removal of the airway. Next, if feasible and time allows, position the patient on their left side. This helps to minimize the risk of aspiration should vomiting occur during or immediately after removal.

The actual removal of the non-visualized airway should be performed according to the manufacturer’s guidelines for the specific device being used. Generally, this involves gently and carefully withdrawing the airway while observing the patient closely for any signs of distress or airway compromise. It is essential to avoid any forceful manipulation that could cause trauma to the nasal or oral passages. For an OPA, you may need to rotate it slightly as you pull it out to minimize trauma. For an NPA, it is usually a straight pull.

Immediately following the removal of the airway, be prepared to suction as needed. This is a critical step to ensure the patient’s airway remains clear and to prevent aspiration. Listen for gurgling sounds or observe for any visible secretions that may obstruct breathing. If suctioning is required, use appropriate techniques and equipment to clear the airway effectively. Continue to monitor the patient’s respiratory status closely, including their breathing rate, depth, and oxygen saturation.

Post-removal, it is vital to reassess the patient’s overall condition and continue appropriate management. This may include administering supplemental oxygen, monitoring vital signs, and preparing for further intervention if necessary. Document the entire procedure, including the reason for removal, the technique used, the patient’s response, and any post-removal interventions. This documentation serves as a valuable record for continued patient care and communication with other healthcare providers.

Supraglottic Airway Removal

Removing a Combitube®:

1. Prepare for Removal: Gather necessary equipment, including suction, oxygen, and a bag-valve-mask (BVM). Explain the procedure to the patient if they are conscious.
2. Preoxygenate: Administer 100% oxygen to the patient for a few minutes before removal.
3. Suction: Suction the oropharynx to remove any secretions or debris.
4. Deflate Cuffs: Deflate both cuffs of the Combitube® completely.
5. Remove the Tube: Gently remove the Combitube® while applying gentle suction.
6. Monitor the Patient: Closely monitor the patient’s respiratory status, including oxygen saturation, breathing rate, and chest movement.
7. Provide Oxygen: Administer supplemental oxygen as needed.
8. Consider Airway Replacement: If the patient requires ongoing airway support, consider replacing the Combitube® with an endotracheal tube or other definitive airway.

Important Considerations:

• Potential Complications: Combitube® removal can potentially cause complications such as bleeding, airway trauma, or aspiration. Careful technique and monitoring are essential.

Removing King LTS-D™

Preparation:

• Gather necessary equipment: suction, oxygen source, bag-valve-mask (BVM), and equipment for potential endotracheal intubation.
• Explain the procedure to the patient if they are conscious.
• Preoxygenate the patient with 100% oxygen for a few minutes before removal.

Removal:

1. Suction: Thoroughly suction the oropharynx to remove any secretions or debris.
2. Deflate Cuff: Completely deflate the cuff of the King LTS-D™.
3. Remove the Tube: Gently remove the King LTS-D™ while applying gentle suction to prevent aspiration.
4. Monitor the Patient: Closely monitor the patient’s respiratory status, including oxygen saturation, breathing rate, and chest movement.
5. Provide Oxygen: Administer supplemental oxygen as needed.
6. Consider Airway Replacement: If the patient requires ongoing airway support, consider replacing the King LTS-D™ with an endotracheal tube or other definitive airway.

Important Considerations:

• Potential Complications: King LTS-D™ removal can potentially cause complications such as bleeding, airway trauma, or aspiration. Careful technique and monitoring are essential.

Removing an i-gel®

Preparation:

• Gather necessary equipment: suction, oxygen source, bag-valve-mask (BVM), and equipment for potential endotracheal intubation.
• Explain the procedure to the patient if they are conscious.
• Preoxygenate the patient with 100% oxygen for a few minutes before removal.

Removal:

1. Suction: Thoroughly suction the oropharynx to remove any secretions or debris.
2. Deflate Cuff (if Applicable): Some i-gel® models have a cuff that can be deflated. If present, deflate the cuff completely.
3. Remove the Tube: Gently remove the i-gel® while applying gentle suction to prevent aspiration.
4. Monitor the Patient: Closely monitor the patient’s respiratory status, including oxygen saturation, breathing rate, and chest movement.
5. Provide Oxygen: Administer supplemental oxygen as needed.
6. Consider Airway Replacement: If the patient requires ongoing airway support, consider replacing the i-gel® with an endotracheal tube or other definitive airway.

Important Considerations:

• Potential Complications: i-gel® removal can potentially cause complications such as bleeding, airway trauma, or aspiration. Careful technique and monitoring are essential.

Respiration, Ventilation, and Oxygenation

Anatomy, Physiology, and Pathophysiology of Respiration and Ventilation

Airway Anatomy Review

The upper airway, consisting of the nasal cavity, pharynx, and larynx, is responsible for warming, humidifying, and filtering inhaled air. The nasal cavity, lined with mucosa and cilia, traps particles and pathogens while the pharynx serves as a passageway for both food and air. The larynx, containing the vocal cords, regulates airflow and produces sound. The lower airway, comprising the trachea, bronchi, and bronchioles, facilitates gas exchange. The trachea, a flexible tube reinforced with cartilage rings, leads to the right and left bronchi, which further divide into smaller bronchioles. These terminate in alveoli, tiny air sacs where oxygen and carbon dioxide exchange occurs between the lungs and bloodstream.

Vascular Structures Supporting Respiration

The intricate process of respiration, essential for life, relies heavily on a network of vascular structures that facilitate gas exchange. At the core of this network are the pulmonary capillaries, tiny blood vessels that intertwine with the alveoli, the microscopic air sacs in the lungs. These capillaries are the primary site of oxygen and carbon dioxide exchange. As deoxygenated blood flows through the pulmonary capillaries, it comes into proximity with the oxygen-rich air within the alveoli. Through simple diffusion, oxygen from the alveoli crosses the capillary walls and binds to hemoglobin in red blood cells, effectively “picking up” the life-sustaining gas. Simultaneously, carbon dioxide, a waste product of cellular metabolism, diffuses from the blood within the capillaries into the alveoli, ready to be exhaled.

The heart plays a critical role in driving the circulation of blood to and from the lungs, ensuring a continuous supply of oxygen and removal of carbon dioxide. The right side of the heart receives deoxygenated blood from the body and pumps it through the pulmonary arteries to the lungs. This blood, low in oxygen and high in carbon dioxide, travels through the branching network of pulmonary arteries, and arterioles, and finally reaches the pulmonary capillaries surrounding the alveoli. It is here, as described previously, that the vital gas exchange takes place.

Once the blood has been oxygenated in the pulmonary capillaries, it flows back to the heart, this time rich in oxygen and depleted of carbon dioxide. The oxygenated blood travels from the capillaries to venules, which merge into larger pulmonary veins. These pulmonary veins are unique in that they carry oxygenated blood, then empty into the left atrium of the heart. From the left atrium, the blood flows into the left ventricle, the heart’s strongest pumping chamber. The left ventricle then propels the oxygenated blood out into the systemic circulation, delivering it to all tissues and organs of the body.

This oxygen-rich blood nourishes cells, providing them with the necessary fuel for their metabolic processes. As cells consume oxygen and produce carbon dioxide, the blood gradually becomes deoxygenated. This deoxygenated blood then returns to the right side of the heart, completing the circulatory loop and beginning the process of pulmonary gas exchange anew. This continuous cycle, driven by the heart and facilitated by the pulmonary capillaries, ensures the delivery of oxygen to the body’s tissues and the removal of carbon dioxide, sustaining life.

Physiology and Pathophysiology of Ventilation

Maintaining a patent airway is necessary for effective ventilation. Obstructions at either the upper or lower airway can drastically reduce or even halt airflow. Upper airway patency can be compromised by various factors. Unconsciousness, often due to trauma, drug overdose, or medical conditions, leads to a loss of muscle tone, causing the tongue to fall back and obstruct the airway. FBAO, burns (which can cause swelling), trauma to the face or neck, and infections like epiglottitis can also impede airflow in the upper airway. These obstructions prevent air from reaching the lungs, thereby disrupting the critical gas exchange process.

Lower airway patency is equally vital. Bronchoconstriction, the narrowing of the bronchial tubes, can significantly restrict airflow. This is a common occurrence in conditions like asthma and chronic obstructive pulmonary disease (COPD). Lung tissue diseases, such as pneumonia, where the alveoli become inflamed and filled with fluid, also hinder gas exchange. In these conditions, the vascular structures within the lungs may still be functional, but the ability of oxygen to diffuse into the bloodstream and carbon dioxide to diffuse out is severely compromised due to the diseased lung tissue.

The nervous system plays a crucial role in controlling respiration. Disordered control of breathing can arise from various neurological insults. Drugs, particularly opioids, can depress the respiratory centers in the brain, leading to slow and shallow breathing or even apnea. Trauma to the head or brain, resulting in injury to these respiratory control centers, can also disrupt normal breathing patterns. Similarly, the postictal state following a seizure can temporarily impair respiratory drive. These neurological issues highlight the importance of the brain’s control over the vascular structures supporting respiration. Even if the lungs and blood vessels are healthy, the lack of proper neurological signals will prevent effective breathing.

Certain medical conditions can further complicate respiration. Bronchoconstriction, as mentioned earlier, is a common problem in asthma and COPD, limiting airflow and impacting gas exchange. The production of excess mucus, often seen in respiratory infections and cystic fibrosis, can also obstruct the airways, reducing the effectiveness of ventilation. These conditions impact the functionality of the vascular structures by reducing the amount of oxygen that can reach the blood and increasing the amount of carbon dioxide that remains.

Finally, structural damage to the thorax, or chest wall, can severely impair the mechanics of breathing. Injuries such as rib fractures, flail chest (multiple rib fractures), or pneumothorax (air in the pleural space) can restrict the expansion of the lungs, reducing tidal volume and impacting the ability to ventilate effectively. These injuries can also damage the underlying vascular structures, further compromising respiration. In these cases, the vascular network may be intact, but the chest wall’s inability to expand restricts the lungs’ ability to fill with air, thus preventing the necessary gas exchange.

Physiology and Pathophysiology of Respiration

Respiration, the fundamental process of gas exchange, is essential for life and can be broadly defined as the exchange of gases between the cardiopulmonary system and the body’s cells. This complex process is typically divided into external, internal, and cellular respiration, each playing a crucial role in maintaining homeostasis. External respiration, occurring in the lungs, involves the exchange of oxygen and carbon dioxide between the alveoli and the pulmonary capillaries. This exchange is critically dependent on the availability of sufficient oxygen in the inhaled air and the integrity of the alveolar-capillary membrane, which allows for the efficient diffusion of gases. Factors such as altitude, lung disease, or airway obstruction can impair external respiration, leading to hypoxemia (low blood oxygen levels).

Internal respiration takes place at the cellular level, where oxygen and carbon dioxide are exchanged between the systemic capillaries and the body’s tissues. This exchange is driven by the concentration gradients of these gases between the blood and the cells. Oxygen, transported by hemoglobin in red blood cells, diffuses from the capillaries into the interstitial fluid and then into the cells, while carbon dioxide, a byproduct of cellular metabolism, diffuses from the cells into the capillaries for transport back to the lungs

The efficiency of internal respiration is influenced by factors such as blood flow, capillary permeability, and the metabolic demands of the tissues. Impaired circulation or tissue hypoxia can disrupt internal respiration, leading to cellular dysfunction and potentially organ damage.

Cellular respiration, the final stage, refers to the cells’ utilization of oxygen for metabolism. Within the mitochondria, oxygen serves as the final electron acceptor in the electron transport chain, a crucial process that generates ATP, the cell’s primary energy currency. This process also produces carbon dioxide as a waste product. Cellular respiration is dependent on the cell’s ability to effectively utilize oxygen. For example, in cyanide poisoning, cyanide binds to the cytochrome oxidase enzyme in the electron transport chain, preventing the cells from using oxygen, even if it is available. This effectively halts ATP production and leads to rapid cellular death. This highlights the critical dependence of cellular function on the proper delivery and utilization of oxygen.

Pathophysiological processes affecting any stage of respiration can have profound consequences. Conditions like pneumonia, pulmonary edema, or acute respiratory distress syndrome (ARDS) can impair external respiration by damaging the alveolar-capillary membrane or reducing lung surface area.  Anemia, where there is a reduced number of red blood cells or hemoglobin, can hinder oxygen transport, affecting both internal and cellular respiration. Furthermore, conditions like sepsis can lead to tissue hypoperfusion, impairing the delivery of oxygen to cells and disrupting internal respiration. Understanding the intricate physiology and potential pathophysiology of respiration is crucial for EMS professionals to effectively assess and manage patients with respiratory distress and provide timely interventions to support oxygenation and ventilation.

Physiology and Pathophysiology of Oxygenation

Oxygenation, the process of loading oxygen molecules onto hemoglobin in the bloodstream, is necessary for cellular function and survival. Physiologically, oxygen from inhaled air diffuses across the alveolar-capillary membrane in the lungs and binds to hemoglobin molecules within red blood cells. This process is driven by the partial pressure gradient of oxygen, moving from the higher concentration in the alveoli to the lower concentration in the blood. The amount of oxygen dissolved in the blood and other body fluids is directly related to the partial pressure of oxygen (PaO2). While this dissolved oxygen is essential, it represents only a small fraction of the total oxygen carried in the blood. The vast majority of oxygen is bound to hemoglobin, forming oxyhemoglobin, which is then transported throughout the body to tissues and cells. The percentage of hemoglobin saturated with oxygen is known as oxygen saturation (SpO2), a key clinical measurement.

Each iron ion in the heme can bind to one oxygen molecule; therefore, each hemoglobin molecule can transport four oxygen molecules. An individual erythrocyte may contain about 300 million hemoglobin molecules and therefore can bind to and transport up to 1.2 billion oxygen molecules.

Well-oxygenated blood, often described as saturated with oxygen, is vital for maintaining aerobic metabolism. This means that cells have a sufficient supply of oxygen to efficiently produce energy through cellular respiration. Adequate oxygen delivery is essential for all organ systems, particularly the brain, which is highly sensitive to hypoxia (oxygen deficiency). Factors affecting oxygenation include the concentration of oxygen in the inhaled air, the efficiency of gas exchange in the lungs, the amount of hemoglobin available to carry oxygen, and the cardiac output, which determines how effectively oxygenated blood is delivered to the tissues. The oxygen-hemoglobin dissociation curve illustrates the relationship between PaO2 and SpO2, demonstrating how changes in PaO2 affect hemoglobin’s affinity for oxygen.

Disruptions in either ventilation (the movement of air into and out of the lungs) or respiration (the gas exchange process) can lead to decreased oxygenation, resulting in hypoxemia. Ventilation problems can arise from conditions such as airway obstruction, neuromuscular disorders affecting respiratory muscles, or chest wall injuries. These conditions impair the ability to bring fresh air into the alveoli, reducing the oxygen available for diffusion. Respiration issues can stem from diseases affecting the lung parenchyma, like pneumonia, pulmonary edema, or acute respiratory distress syndrome (ARDS). These conditions thicken the alveolar-capillary membrane or reduce the surface area available for gas exchange, hindering oxygen diffusion into the blood.

Hypoxemia can have severe consequences, ranging from mild symptoms like shortness of breath and fatigue to life-threatening complications such as organ damage, cardiac arrest, and death.

The body attempts to compensate for hypoxemia through various mechanisms, including increasing respiratory rate and depth, as well as increasing cardiac output to deliver more oxygen to tissues. However, these compensatory mechanisms can become overwhelmed in severe or prolonged hypoxemia. In clinical practice, supplemental oxygen therapy is often administered to increase the fraction of inspired oxygen (FiO2) and improve oxygenation. Monitoring SpO2 using pulse oximetry is a crucial tool for assessing oxygenation status and guiding treatment interventions.

Understanding the Mechanics of Respiration

The mechanics of respiration involve the intricate interplay of muscles, pressure gradients, and the elastic properties of the lungs and chest wall. Inspiration, the active phase, begins with the contraction of the diaphragm, the primary muscle of respiration. This contraction flattens the diaphragm and increases the volume of the thoracic cavity. Simultaneously, the external intercostal muscles contract, lifting the rib cage up and outward, further expanding the chest cavity. These actions create a negative pressure within the lungs, drawing air in until the pressure equalizes with the atmosphere. Expiration, typically a passive process, occurs when the diaphragm and intercostal muscles relax.

The elastic recoil of the lungs, along with the weight of the chest wall, causes the thoracic cavity to decrease in volume. This leads to an increase in pressure within the lungs, forcing air out until the pressure equalizes with the atmosphere. In situations requiring forceful exhalation, such as during exercise or respiratory distress, the abdominal muscles can actively contract to further reduce the thoracic cavity volume and expel air more rapidly.

Reasons for Inadequate Respiration

Inadequate respiration, or respiratory failure, occurs when the lungs can’t effectively exchange oxygen and carbon dioxide. This can stem from various underlying issues. One major category is ventilation problems, where the body struggles to move air in and out of the lungs. This could be due to weakened respiratory muscles, airway obstructions like asthma or choking, or central nervous system issues affecting breathing control. Another category involves gas exchange problems, where the lungs struggle to transfer oxygen into the blood and remove carbon dioxide. This can be caused by conditions like pneumonia, where the air sacs are filled with fluid, or pulmonary embolism, where blood clots block lung circulation.

Beyond these direct lung issues, inadequate respiration can also arise from problems elsewhere in the body. For example, heart failure can lead to fluid buildup in the lungs, hindering gas exchange.

Neurological conditions like spinal cord injuries or muscular dystrophy can impair the nerves and muscles responsible for breathing. Even severe obesity can restrict lung expansion and contribute to respiratory problems.

Assessment and Management of Issues Related to Respiration and Ventilation

Assessment and Management of Airway Patency

Ensuring a patent airway is the first step in patient care. Assessment begins with observing for signs of airway compromise, such as stridor, gurgling, or an inability to speak. If the patient is unresponsive or has an altered mental status, manual airway maneuvers should be used. The head-tilt/chin-lift is the primary technique for opening the airway in non-trauma patients, effectively lifting the tongue away from the posterior pharynx. In patients with suspected cervical spine injury, the jaw-thrust maneuver is preferred, as it minimizes neck movement while still lifting the mandible and opening the airway. Once the airway is open, it’s essential to maintain it and address any obstructions.

Relieving airway obstructions involves several key interventions. FBAO in a conscious patient is managed with abdominal thrusts (Heimlich maneuver), while in an unconscious patient, chest compressions are used. Suctioning is vital for removing liquids or secretions that may be obstructing the airway. If manual maneuvers and suctioning are insufficient, airway adjuncts should be considered. An oropharyngeal airway (OPA) is useful for unresponsive patients without a gag reflex, helping to maintain an open airway by preventing the tongue from falling back. A nasopharyngeal airway (NPA) is an alternative for patients who are semi-conscious or have a gag reflex, as it is better tolerated. The appropriate size and insertion technique are crucial for both OPAs and NPAs to ensure effectiveness and avoid complications.

Adequate and Inadequate Ventilation

Adequate ventilation ensures the body receives sufficient oxygen and eliminates carbon dioxide effectively. It’s characterized by a respiratory rate within the normal range for the patient’s age: 12-20 breaths per minute (1 breath every 3-5 second) for adults, 15-30 (1 breath every 2-4 second) for children, and 25-50 (1 breath every 1-2 seconds) for infants. The breathing rhythm should be regular, and the quality should be noise-free, meaning no adventitious sounds like gurgling (often due to fluid in the airway), stridor (a high-pitched sound indicating upper airway obstruction), or wheezing (a whistling sound associated with lower airway constriction) are present. Equal bilateral chest rise indicates that both lungs are expanding properly. Normal tidal volume, the amount of air inhaled or exhaled with each breath, ensures adequate oxygen delivery. Finally, adequate ventilation is achieved with minimal effort; there should be no signs of respiratory distress, such as accessory muscle use, nasal flaring, or abnormal positioning.

In contrast, inadequate ventilation signifies that the patient is not effectively exchanging gases. The respiratory rate might be outside the normal range, either too fast (tachypnea) or too slow (bradypnea) for the patient’s age. The rhythm may be irregular, indicating an underlying respiratory problem. The quality of breathing is often compromised, with noisy respirations. These noises can include gurgling, stridor, or wheezing. Unequal chest rise suggests a problem with one lung or the chest wall. Decreased tidal volume, resulting in shallow breathing, limits the amount of oxygen reaching the tissues.

Visible signs of increased work of breathing are crucial indicators of inadequate ventilation. These include the use of accessory muscles (muscles in the neck, chest, and abdomen) to assist with breathing, nasal flaring (widening of the nostrils), and abnormal patient positioning, such as the tripod position (leaning forward with hands on knees), which helps to maximize lung expansion. These signs indicate that the patient is struggling to breathe and requires immediate intervention.

Other critical signs of inadequate ventilation include unresponsiveness, which suggests that the brain is not receiving enough oxygen; cyanosis, a bluish discoloration of the skin and mucous membranes due to low oxygen levels; absent breathing; and gasping or agonal respirations, which are ineffective, irregular breaths that often precede respiratory arrest. These are late signs of respiratory compromise and necessitate immediate and aggressive treatment, including assisted ventilation.

Differences Between Adequate and Inadequate Respiration

Adequate ventilation, reflecting proper respiration and oxygenation, is characterized by a patient exhibiting a normal mental status appropriate for their age and baseline condition. Their skin color should be normal, indicating good perfusion. A pulse oximeter (SpO2) reading should ideally be greater than 94%. These combined factors suggest the patient is effectively exchanging gases and maintaining appropriate oxygen levels.

In contrast, inadequate ventilation signifies compromised respiration and oxygenation, often presenting as respiratory distress, failure, or even arrest. A hallmark of inadequate ventilation is an abnormal or altered mental status, ranging from confusion and lethargy to unresponsiveness or unconsciousness. Visual signs can include cyanotic (bluish) or pale (ashen) skin, indicating poor oxygenation and circulation. Pulse oximetry (SpO2) readings will typically be less than 95%, reflecting decreased oxygen saturation.

Recognizing the difference between adequate and inadequate ventilation is important to proper medical care. A patient with adequate ventilation requires ongoing monitoring to ensure their status remains stable. This includes reassessing vital signs, including respiratory rate and depth, and continually evaluating their mental status. Maintaining a patent airway and providing supplemental oxygen are essential to immediate treatment.

Conversely, a patient exhibiting signs of inadequate ventilation requires immediate intervention. This may involve assisting ventilations with a bag-valve-mask (BVM) device, potentially followed by advanced airway management such as endotracheal intubation. Prompt recognition and treatment of inadequate ventilation are essential to prevent further deterioration and potentially life-threatening consequences such as hypoxia and cardiac arrest.

Managing Issues of Ventilation and Oxygenation

Effective management of ventilation and oxygenation is essential for good patient care. For patients exhibiting adequate ventilation and oxygenation, the primary focus shifts to continuous monitoring. This includes assessing respiratory rate and depth, ensuring clear and equal breath sounds bilaterally, and confirming adequate chest rise and fall. Pulse oximetry provides a non-invasive measure of oxygen saturation (SpO2), ideally maintained above 94% in most patients. Maintaining a patent airway is crucial, and interventions such as suctioning or the use of oral or nasal airways may be necessary. Finally, understanding the underlying cause of the patient’s condition is vital, as this will inform further treatment strategies.

When a patient presents with inadequate ventilation and oxygenation, immediate intervention is required. Positioning the patient in a position of comfort, often semi-Fowler’s or upright, can optimize chest expansion and improve breathing. Supplemental oxygen should be administered to all patients experiencing dyspnea, respiratory distress, respiratory failure, or respiratory arrest. The method of oxygen delivery will depend on the patient’s condition, ranging from nasal cannula for mild distress to non-rebreather masks for more significant hypoxia. High-flow oxygen may be considered in certain situations.

For patients with inadequate ventilation, assisting ventilations or providing positive pressure ventilation (PPV) with supplemental oxygen is crucial. This can be accomplished using a BVM device, ensuring a proper seal over the mouth and nose. The appropriate ventilation rate and volume should be delivered, avoiding hyperventilation which can have detrimental effects. If available, advanced airway adjuncts like a supraglottic airway can be placed to secure the airway and facilitate PPV.

Addressing ventilation and oxygenation issues requires a systematic approach. First, ensure scene safety and take appropriate standard precautions. Rapidly assess the patient’s airway, breathing, and circulation (ABCs). Determine the need for supplemental oxygen and initiate administration based on the patient’s condition. If ventilations are inadequate, begin assisted or controlled ventilations with a BVM and supplemental oxygen. Continuously reassess the patient’s response to interventions, adjusting treatment as needed. Early notification of the receiving hospital is crucial, providing them with a concise and accurate report of the patient’s condition and the interventions performed.

Respiratory Distress, Failure, and Arrest

Respiratory distress, failure, and arrest represent a spectrum of progressively worsening conditions, each requiring distinct interventions. Understanding the differences between these states is essential to provide timely and effective patient care. These conditions are differentiated primarily by changes in ventilation, which encompasses the rate, rhythm, quality, and volume of breathing, as well as the body’s compensatory mechanisms.

Respiratory distress signifies a state where the patient is working harder than normal to breathe but is still effectively compensating. Changes in ventilation are evident, often reflecting either the body’s attempt to compensate for respiratory system dysfunction or the dysfunction itself. The ventilatory function is altered, with noticeable changes in the rate, rhythm, and quality of breathing. The respiratory rate is typically increased, often accompanied by an elevated pulse rate. Despite these changes, the patient usually maintains a normal mental status, and oxygen saturation (SpO2) remains within acceptable limits.

A patient in respiratory distress may present with obvious signs of increased work of breathing, such as nasal flaring, accessory muscle use, and retractions. However, their mentation remains appropriate for the patient, and their SpO2 is generally normal. Management at this stage focuses on supporting the patient’s breathing and addressing the underlying cause. Supportive oxygenation should be used to include devices such as a nasal cannula or non-rebreather mask. Rapid assessment and transport to a definitive care facility are also essential.

Respiratory failure occurs when the body’s compensatory mechanisms for respiratory distress begin to fail. This failure is marked by further deterioration in ventilatory function. While the respiratory rate may initially be high, it can become shallow and ineffective as the patient fatigues. The pulse rate may remain elevated or begin to decrease. A significant change is a decrease in the patient’s level of consciousness, ranging from confusion to lethargy. Oxygen saturation (SpO2) will begin to fall.

In respiratory failure, other signs may include diminished or absent lung sounds, indicating reduced airflow. Tidal volume, the amount of air inhaled and exhaled with each breath, also decreases. The patient’s presentation may include increased respiratory rate and pulse rate initially, but as failure progresses, these rates may decline. Decreased mentation is a key sign of respiratory failure. Management shifts to more aggressive interventions, including assisted positive-pressure ventilation using a BVM device.

Respiratory arrest represents the complete cessation of breathing. Ventilation is absent, and the patient is unresponsive or has an altered level of consciousness. Breathing is either absent or agonal (gasping). The pulse may be bradycardic (slow) or absent. Oxygen saturation (SpO2) plummets and capnometry will show a rapid decline. Lung sounds are typically absent.

Respiratory arrest is a life-threatening emergency requiring immediate intervention. The patient will be unresponsive or have an altered level of consciousness. Ventilations are absent or agonal. Bradycardia or an absent pulse is common. Oxygen saturation will be significantly decreased. Management requires immediate initiation of basic life support (BLS) protocols, including cardiopulmonary resuscitation (CPR) and ventilation with a BVM.

Recognizing the progression from respiratory distress to failure and arrest is essential. Early intervention in respiratory distress can often prevent progression to failure. Prompt recognition of respiratory failure and initiation of assisted ventilation can be life-saving. In respiratory arrest, immediate CPR and ventilatory support are essential for survival.

Maintenance of Adequate Respiration through the use of Non-invasive Positive Pressure

Non-invasive positive pressure ventilation (NPPV) is used to maintain ventilation in a patient that is not breathing adequately or not at all. The benefits of NPPV in EMS extend to a wide range of conditions, including acute pulmonary edema, COPD exacerbations, and asthma attacks. By increasing intrathoracic pressure, NPPV helps to recruit collapsed alveoli, improve gas exchange, and reduce the workload on the respiratory muscles. This can lead to rapid symptom relief, improved patient comfort, and a reduced need for hospital admission. The timely application of NPPV can significantly improve patient outcomes, potentially averting critical situations and facilitating faster recovery.

Assessment and Management of Ventilation and Respiration in EMS

Initial Assessment:

Upon arrival at the scene, EMS providers must immediately assess the patient’s airway, breathing, and circulation (ABCs). This involves evaluating the patient’s level of consciousness, respiratory rate, depth, and pattern. Look for signs of respiratory distress, such as nasal flaring, accessory muscle use, and retractions. Listen for abnormal breath sounds, such as wheezing, stridor, or crackles. Assess the patient’s skin color and temperature, as well as their oxygen saturation using a pulse oximeter.

Ventilation Assessment:

Ventilation refers to the movement of air into and out of the lungs. Assess the patient’s chest rise and fall, and determine if the chest expands symmetrically. Look for any signs of chest trauma or deformity that may impair ventilation. Evaluate the patient’s ability to speak or cough, as this can indicate the adequacy of their ventilation.

Respiration Assessment:

Respiration refers to the exchange of gases (oxygen and carbon dioxide) between the lungs and the blood. Assess the patient’s oxygen saturation level, and look for signs of cyanosis (bluish discoloration of the skin) which may indicate inadequate oxygenation. Consider the patient’s medical history and any potential causes of respiratory distress, such as asthma, pneumonia, or pulmonary embolism.

Management of Ventilation and Respiration Issues:

If the patient is not breathing or is breathing inadequately, EMS providers must immediately intervene. This may involve providing supplemental oxygen, assisting with ventilations using a BVM device, or securing the airway with an advanced airway.

Ongoing Monitoring:

Throughout the patient’s care, EMS providers must continuously monitor their ventilation and respiration status. This includes reassessing their respiratory rate, depth, and pattern, as well as their oxygen saturation level. Any changes in the patient’s condition should be promptly addressed, and appropriate interventions should be initiated as needed.

Documentation:

Accurate and thorough documentation of the patient’s ventilation and respiration assessment and management is necessary. This includes documenting the patient’s initial presentation, any interventions performed, and their response to treatment. This information ensures continuity of care and facilitates communication between EMS providers and other healthcare professionals.

Supplemental Oxygen Therapy

Oxygen Safety Considerations

Oxygen, while essential for life, is also classified as a medication and must be treated with the same respect and caution as any other drug. It should only be administered when medically necessary. Unnecessary or inappropriate oxygen administration can have detrimental effects on patients, potentially leading to oxygen toxicity or other complications. Therefore, a thorough patient assessment and understanding of their respiratory status are crucial before initiating oxygen therapy. Dosage, delivery method, and duration of therapy should be carefully considered and regularly reassessed.

A critical safety consideration regarding oxygen is its ability to enhance combustion. While oxygen itself is not flammable, it acts as a powerful oxidizer, meaning it significantly accelerates the burning process. In the presence of oxygen, even small sparks or flames can quickly ignite and spread, posing a serious fire hazard. Therefore, it is imperative to avoid open flames, smoking, or any potential ignition sources when oxygen is in use. This includes ensuring that oxygen equipment is kept away from heat sources and that all electrical devices in the vicinity are properly grounded and functioning correctly.

Oxygen is stored and transported as a pressurized gas, typically in cylinders. These cylinders are under significant pressure, and any damage, such as a crack or break, can cause them to become dangerous projectiles. A ruptured cylinder can cause serious injury or even death. To prevent such incidents, oxygen cylinders should always be handled with care. They should never be dropped, dragged, or rolled. Furthermore, cylinders should be stored securely, in designated racks or secured with straps to prevent them from falling over. When transporting cylinders, ensure they are properly secured in a cart or vehicle to prevent movement during transport. Never stand an unsecured cylinder upright, as it could easily tip over and cause damage or injury.

Finally, petroleum-based products, such as grease, oil, and adhesive tapes, should never come into contact with oxygen cylinders, regulators, or other oxygen equipment. These substances can react violently with oxygen, creating a fire or explosion hazard. Specifically, petroleum products should never be used as lubricants or sealants on oxygen equipment. Instead, only oxygen-compatible lubricants and sealants, specifically designed for use with high-pressure oxygen, should be used. Similarly, adhesive tapes should not be used to secure or repair oxygen equipment, as they may contain petroleum-based adhesives. Regular inspection and maintenance of oxygen equipment are essential to ensure its integrity and prevent potential hazards.

Parts of an Oxygen Cylinder

Oxygen cylinders are essential tools for EMS professionals. The cylinder itself is a high-pressure container designed to hold a specific volume of oxygen. In EMS, common sizes include the D cylinder, holding approximately 350 liters of oxygen, and the E cylinder, which contains around 635 liters. These sizes offer a balance between portability and sufficient oxygen supply for patient care. Understanding the capacity of each cylinder size is important to ensure an adequate supply throughout a patient care encounter.

Oxygen cylinders are considered full when the internal pressure reaches 2,000 pounds per square inch (psi). This high pressure is necessary to store a usable amount of oxygen in a relatively compact container. However, you should not allow a cylinder to get empty. A minimum safe residual level of 200 psi should be maintained. This ensures that there is always enough pressure to deliver oxygen to the patient and prevents potential issues with the cylinder itself.

Attached to the oxygen cylinder is the regulator, a device specifically designed for use with oxygen. It is vital to never attempt to force a regulator onto a tank it is not designed for, as this can cause damage or even serious injury. The primary function of the regulator is to reduce the high pressure of the oxygen within the cylinder to a safe level for patient administration. Without a regulator, the oxygen would be delivered at an extremely high pressure, potentially causing harm.

Connected to the regulator is the flow meter, which allows for precise control of the oxygen flow rate delivered to the patient. This is important, as different medical conditions require varying amounts of oxygen. The flow meter enables EMS personnel to adjust the oxygen flow in liters per minute, ensuring the patient receives the appropriate and prescribed amount of oxygen for their specific needs. This controlled delivery of oxygen is essential for effective respiratory support and patient safety.

Assembly and Use of a Portable Oxygen Cylinder

Portable oxygen cylinders are a crucial tool in EMS for providing supplemental oxygen to patients in need. Proper assembly and usage are necessary for patient safety and effective treatment. This process involves several key steps, beginning with preparing the oxygen tank for use.

The first step in preparing an oxygen tank is identification. Oxygen cylinders are typically identified by their green or green and silver color. The tank will be labeled as “Oxygen USP” marking on the cylinder to ensure it contains the correct medical-grade oxygen. Once identified, remove the protective cap or tape covering the cylinder valve. A quick “crack” of the cylinder valve (briefly opening and closing it) is next to remove any impurities that might have accumulated on the valve’s mating surfaces. Before attaching the regulator, ensure a gasket is present; this ensures a leak-proof seal.

With the gasket in place, carefully attach the regulator and flowmeter to the cylinder valve, ensuring a tight, leak-proof seal. Once attached, slowly turn on the cylinder valve and check the pressure gauge. The gauge should indicate adequate pressure, typically above 500 psi, to ensure sufficient oxygen supply.

The next phase involves oxygen administration. Attach the appropriate oxygen delivery device, such as a nasal cannula or mask, to the flowmeter. Adjust the flow control on the flowmeter to deliver the prescribed oxygen level, as determined by the patient’s condition and medical orders. Carefully place the delivery device on the patient, ensuring a proper fit and comfortable placement. Continuously monitor the patient and check the adequacy of the oxygen flow, observing for any signs of distress or changes in their respiratory status.

Discontinuing oxygen administration is as important as initiating it. Begin by removing the oxygen delivery device from the patient. Next, shut off the cylinder valve completely. Bleed the regulator of any remaining pressure by opening the flowmeter until the gauge reads zero. Finally, return the flowmeter control to the “off” position. This ensures the system is safely depressurized.

Cylinder discontinuance involves removing a cylinder from service when it reaches a certain pressure level, typically between 200 and 500 psi, or as dictated by local protocols. Before removal, ensure the cylinder valve is completely shut off and the regulator is free of any pressure. Only then should the regulator be carefully detached from the cylinder.

Proper securing and handling of oxygen cylinders are essential for safety. Cylinders should never be left freestanding, as they can easily tip over and cause injury. Standing cylinders must be secured with an appropriate base, secured to a stable structure, or secured to multiple other cylinders for stability. Smaller cylinders should be secured with a base or laid down during use to prevent them from falling.

Dropping oxygen cylinders is strictly prohibited. Dropping a cylinder can cause scratches or damage that weakens the integrity of the metal, potentially leading to a rupture. Furthermore, dropping a cylinder can damage the valve, potentially turning it into a dangerous projectile. Always handle cylinders with care and use appropriate equipment for transport.

Finally, remember that oxygen supports combustion. Keep oxygen cylinders away from open flames, sparks, and other sources of ignition. No smoking should be allowed near oxygen cylinders or during oxygen administration. Following these guidelines for assembly, use, discontinuance, handling, and securing oxygen cylinders ensures safe and effective oxygen therapy for patients in need.

Oxygen Delivery Devices

Oxygen delivery devices are important tools in EMS for managing patients experiencing hypoxia, a condition characterized by insufficient oxygen reaching the body’s tissues. Different devices cater to varying levels of oxygen need, and EMS professionals must be proficient in selecting and utilizing the appropriate device for each patient. This requires a thorough understanding of each device’s purpose, indications, proper procedure, and limitations.

The nasal cannula is a common oxygen delivery device designed to provide low-concentration oxygen to patients. It is indicated for patients experiencing mild hypoxia, where supplemental oxygen can improve their condition without requiring high flow rates. The procedure for applying a nasal cannula involves attaching it to an oxygen regulator and setting the flowmeter between 1 and 6 liters per minute (LPM), with 2 LPM often used as a starting point. The nasal prongs are carefully placed in the patient’s nostrils, and the cannula is secured around the ears and under the chin. A key limitation of the nasal cannula is that administering oxygen at rates greater than 6 LPM can lead to the drying of the nasal membranes and potentially cause bleeding.

For patients requiring higher concentrations of oxygen, the nonrebreather mask is a more suitable option. This device is designed to deliver high-concentration oxygen and is indicated for patients with moderate hypoxia. The procedure for applying a nonrebreather mask includes attaching it to an oxygen regulator and setting the flowmeter to 12-15 LPM. It is essential to inflate the reservoir bag before placing the mask on the patient’s face, ensuring a readily available supply of oxygen. The mask is placed over the mouth and nose, and the strap is tightened to secure it in place. A critical limitation of the nonrebreather mask is the need to maintain a sufficiently high flow rate to keep the reservoir bag inflated, ensuring the patient receives the intended oxygen concentration.

Patients with a tracheostomy or stoma, a surgically created opening in the trachea, require specialized oxygen delivery. The trach mask is specifically designed for these individuals, providing oxygen directly to the airway. It is indicated for patients with mild to moderate hypoxia who have a tracheostomy or stoma. The procedure involves attaching the trach mask to an oxygen regulator and setting the flowmeter to 10-15 LPM. The mask is placed over the stoma, and the strap is tightened to secure it. While generally well-tolerated, the trach mask may require adjustments or alternative devices depending on the patient’s specific anatomy and needs.

The nebulizer is a versatile device used to provide humidified oxygen and administer bronchodilator medications. It is indicated for patients requiring humidified oxygen or those needing nebulized medications. The procedure involves attaching the nebulizer chamber to a T-connector or mask, depending on the chosen delivery method. Oxygen tubing is connected to the nebulizer chamber and the oxygen regulator. Saline or medication, as prescribed by a physician and prepared by an EMT, AEMT, or paramedic, is placed in the chamber. The flowmeter is set to 6-8 LPM to create a mist. The administration of medications through the device falls within the scope of practice of the state in which you practice.

Understanding the differences between these oxygen-delivery devices is important. Accurate assessment of the patient’s oxygenation status, coupled with knowledge of the capabilities and limitations of each device, ensures the delivery of appropriate and effective oxygen therapy. This expertise is essential for optimizing patient outcomes and ensuring their safety during emergency medical situations.

The Delivery of Supplemental Oxygen

Setting up an oxygen cylinder for use involves several steps to ensure safe and effective oxygen delivery. First, confirm the oxygen cylinder is the correct type and size prescribed by the healthcare provider. Verify the cylinder’s label to ensure it contains the intended medical-grade oxygen. Next, inspect the cylinder for any visible damage or leaks, such as dents, cracks, or hissing sounds. If any issues are detected, do not use the cylinder and report it to the supplier immediately.

Once the cylinder is deemed safe, attach the oxygen regulator to the cylinder valve. Ensure the regulator is compatible with the cylinder type and has the necessary gauges and flow rate controls. Before attaching the regulator, briefly open the cylinder valve to clear any debris from the valve outlet. Then, carefully align the regulator with the cylinder valve and tighten the connection securely.

After the regulator is attached, connect the oxygen delivery device, such as a nasal cannula or oxygen mask, to the regulator outlet. Ensure the device is clean and free from obstructions. Adjust the flow rate on the regulator to the prescribed level, as determined by the healthcare provider. Finally, before administering oxygen to the patient, test the oxygen flow by briefly opening the valve and checking for any leaks or malfunctions.

Oxygen Delivery Devices

There are several common oxygen delivery devices used in healthcare. The following is a quick overview of these devices.

• Nasal Cannula: Delivers 24-44% oxygen at flow rates of 1-6 liters per minute (LPM). It is a comfortable option for patients who require low to moderate amounts of supplemental oxygen.
• Simple Face Mask: Delivers 35-60% oxygen at flow rates of 6-10 LPM. It provides a higher concentration of oxygen than a nasal cannula and is useful for patients with moderate oxygenation needs.
• Venturi Mask: Delivers a precise oxygen concentration of 24-60% by using a venturi system that mixes oxygen with room air. It is ideal for patients with chronic lung conditions who require a consistent and controlled oxygen level.
• Non-Rebreather Mask: Delivers 60-90% oxygen at flow rates of 10-15 LPM. It is used for patients who require high concentrations of oxygen, such as those with severe respiratory distress.
• Bag-Valve-Mask (BVM): Provides up to 100% oxygen when used with supplemental oxygen and proper technique. It is used for patients who are not breathing adequately on their own.
• Continuous Positive Airway Pressure (CPAP): Delivers a constant level of positive pressure throughout the breathing cycle, which can help improve oxygenation and reduce the work of breathing. It is used for patients with conditions such as congestive heart failure and sleep apnea.

Artificial Ventilation

Review Adequate and Inadequate Ventilation

Adequate ventilation is characterized by a normal respiratory rate, rhythm, and quality. A normal respiratory rate falls within age-specific ranges (see chart below). The rhythm should be regular and consistent. Normal respiratory quality includes equal bilateral chest rise, indicating adequate tidal volume and lung expansion. The depth and volume of each breath should be appropriate, and the effort of breathing should be minimal and unlabored. These combined factors ensure that the patient is effectively moving air in and out of the lungs, facilitating proper gas exchange.

Inadequate ventilation, conversely, presents with deviations from these normal parameters (outside the range of the chart below). The rate of breathing may be too fast (tachypnea) or too slow (bradypnea) for the patient’s age. The respiratory rhythm can become irregular, with inconsistent intervals between breaths. Respiratory quality is often compromised. Abnormal respiratory noises, such as stridor (a high-pitched whistling sound indicative of upper airway obstruction) or wheezing (a whistling or musical sound suggesting lower airway constriction), are common signs. Chest wall movement may be unequal, indicating potential lung collapse or other thoracic issues, or paradoxical, where the chest moves inward during inhalation and outward during exhalation, a sign of serious respiratory compromise. The depth of breathing can be shallow, limiting tidal volume, or markedly increased, potentially indicating a compensatory mechanism for respiratory distress.

Finally, abnormal effort is often observed, with retractions (skin pulling between the ribs or above the clavicle), accessory muscle use (in the neck and abdomen), nasal flaring, and the patient assuming a tripod position (leaning forward with hands on knees) or other abnormal postures to maximize lung expansion – all signs of increased work of breathing and impending respiratory failure.

Normal Respiratory Rates

• Infants (Birth to 1 year):
  • 30 to 60 breaths per minute.
  • Newborns may have even faster rates, sometimes up to 40-60 breaths per minute, which can slow down when they sleep.
• Toddlers (1 to 3 years):
  • 24 to 40 breaths per minute.
• Preschoolers (3 to 6 years):
  • 22 to 34 breaths per minute.
• School-Age Children (6 to 12 years):
  • 18 to 30 breaths per minute.
• Adolescents (12 to 18 years):
  • 12 to 16 breaths per minute.
• Adults:
  • 12 to 20 breaths per minute.

Management of a Patient with Adequate Ventilation

Managing a patient with adequate ventilation involves several key steps:

• Assess the Patient’s Airway: Ensure the airway is patent and free from obstructions. Look for signs of airway compromise, such as stridor, wheezing, or difficulty speaking.
• Monitor the Patient’s Breathing: Observe the rate, depth, and rhythm of the patient’s respirations. Look for signs of respiratory distress, such as retractions, nasal flaring, or use of accessory muscles.
• Administer Supplemental Oxygen: If the patient is hypoxic, administer supplemental oxygen via nasal cannula or mask. Titrate the oxygen flow rate to maintain an oxygen saturation of 94% or higher.
• Position the Patient: Position the patient in a comfortable position that promotes optimal breathing. This may include sitting the patient up or placing them in the recovery position.
• Provide Reassurance: Reassure the patient and keep them calm. Anxiety can worsen respiratory distress.
• Transport the Patient: Have the patient transported to the hospital for further evaluation and treatment.

Management of a Patient with Inadequate Ventilation

Managing a patient with inadequate ventilation is an important skill for EMS providers. If a patient is breathing but exhibiting signs of respiratory distress or respiratory failure, characterized by inadequate ventilation (shallow, rapid, or irregular breathing), assisting with their ventilation is important. This can be necessary whether the patient is conscious or unconscious.

In the case of a patient who is apneic (not breathing) but has a palpable pulse, the immediate priority is to provide rescue breathing. For adults, this involves administering one breath every 6 seconds. For pediatric patients, the rate is one breath every 2 to 3 seconds. It’s also important to remember that gasping or agonal respirations, often described as “fish breathing,” should be treated as if the patient is not breathing at all, requiring immediate intervention with rescue breathing or assisted ventilation.

Positive pressure ventilation devices (PPVDs) help to manage patients with inadequate ventilation. Their primary purpose is to provide ventilatory support, effectively moving air into and out of the lungs. Indications for PPVD use include inadequate ventilation, apnea, and cardiac arrest. While PPVDs are highly effective, they do have limitations. They require the presence of the equipment, can be challenging to maintain a proper seal, and may be difficult to use on patients with altered mental status or facial trauma.

Furthermore, there are various types of PPVDs available, including mouth-to-mouth with a barrier device, pocket masks, and bag-valve-masks (BVMs). Choosing the appropriate device and being proficient in its use is essential for effective patient care. The BVM is often considered the most versatile and effective PPVD, allowing for high concentrations of supplemental oxygen to be delivered simultaneously.

Pathophysiology of Normal Ventilation Versus Positive Pressure Ventilation

Normal ventilation and positive pressure ventilation (PPV) impact the body’s systems in distinctly different ways. Understanding these differences is crucial for effective patient care, especially in emergencies.

During normal ventilation, the body creates negative pressure within the chest cavity. This negative pressure “sucks” air into the lungs. Simultaneously, this process assists with venous return, meaning blood is “pulled” back towards the heart. This efficient exchange of gases and blood flow supports the body’s oxygenation needs. The esophagus, connecting the throat to the stomach, remains closed during normal breathing, preventing air from entering the stomach.

Positive pressure ventilation, on the other hand, uses external force to push air into the lungs, creating positive pressure within the chest. While this can be life-saving, it can also have unintended consequences. The increased pressure in the chest can impede venous return, reducing the amount of blood returning to the heart.  This, in turn, can decrease the amount of blood the heart pumps out to the body, potentially leading to lower blood pressure.

Furthermore, when using a pocket mask or BVM for PPV, there’s a risk of air being pushed into the stomach, especially if the ventilation is too forceful or the airway isn’t properly sealed.  This gastric insufflation can lead to vomiting during CPR.  Excessive rates or depths of ventilation can also be harmful, contributing to low blood pressure, vomiting, and decreased blood flow during chest compressions.

Ventilation of a Patient

Mouth-to-mouth resuscitation with a barrier device:

1. Check for Responsiveness and Breathing: Gently tap the person on the shoulder and shout, “Are you okay?” If there is no response, check for breathing for no more than 10 seconds.
2. Call 911 or Your Local Emergency Number: If the person is unresponsive and not breathing normally, immediately call emergency medical services (EMS).
3. Position the Person: Carefully place the person on their back on a firm, flat surface.
4. Open the Airway: Use the head-tilt/chin-lift maneuver to open the airway. Place one hand on the forehead and gently tilt the head back. Place the fingers of your other hand under the chin and lift the chin forward.
5. Check for Breathing Again: Look, listen, and feel for normal breathing for no more than 10 seconds.
6. Give Rescue Breaths: If the person is not breathing normally, give two rescue breaths. Use a barrier device, such as a pocket mask or face shield, if available. Pinch the person’s nose shut and create a tight seal over their mouth with your mouth or the barrier device. Give each breath over 1 second, watching for the chest to rise.
7. Check for a Pulse: Check for a pulse for no more than 10 seconds. If you cannot find a pulse, begin chest compressions.
8. Continue CPR: Continue giving rescue breaths and chest compressions.

Steps for performing mouth-to-mouth ventilations with a barrier device:

1. Check for Responsiveness and Breathing: Gently tap the person on the shoulder and shout, “Are you okay?” If there is no response, check for breathing for no more than 10 seconds.
2. Call 911 or Your Local Emergency Number: If the person is unresponsive and not breathing normally, immediately call emergency medical services (EMS).
3. Position the Person: Carefully place the person on their back on a firm, flat surface.
4. Open the Airway: Use the head-tilt/chin-lift maneuver to open the airway. Place one hand on the forehead and gently tilt the head back. Place the fingers of your other hand under the chin and lift the chin forward.
5. Check for Breathing Again: Look, listen, and feel for normal breathing for no more than 10 seconds.
6. Give Rescue Breaths: If the person is not breathing normally, give two rescue breaths. Use a barrier device, such as a pocket mask or face shield, if available. Pinch the person’s nose shut and create a tight seal over their mouth with your mouth or the barrier device. Give each breath over 1 second, watching for the chest to rise.
7. Check for a Pulse: Check for a pulse for no more than 10 seconds. If you cannot find a pulse, begin chest compressions.
8. Continue CPR: Continue giving rescue breaths and chest compressions.

Two-person bag-valve-mask (BVM) ventilation with supplemental oxygen:

Two-person BVM ventilation with supplemental oxygen is a technique used to provide assisted breathing to patients who are not breathing adequately on their own. It requires two rescuers: one to hold the mask and maintain a seal, and the other to squeeze the bag. This method is generally more effective than one-person BVM ventilation as it allows for a better mask seal and more consistent tidal volumes.

The first rescuer, often referred to as the “mask holder,” is responsible for ensuring a proper mask seal. They position themselves at the head of the patient, placing the mask over the patient’s nose and mouth. Using the “EC” technique, they form a “C” with their thumb and index finger around the mask, while using the remaining fingers to lift the patient’s jaw and create an “E” to help maintain an open airway. Maintaining a tight seal is crucial to prevent air leaks and ensure effective ventilation. They should also be monitoring the patient’s chest rise with each breath.

The second rescuer, the “bag squeezer,” is positioned at the side of the patient. They are responsible for squeezing the bag at a rate of 10-12 breaths per minute for adults, and 12-20 breaths per minute for children, while also observing the chest rise to ensure adequate ventilation. The breaths should be delivered slowly and evenly, each over approximately 1 second, aiming for a visible chest rise. They also coordinate with the mask holder, ensuring the mask remains properly sealed throughout the procedure. Supplemental oxygen should be connected to the BVM, with a flow rate of at least 15 liters per minute, to deliver the highest possible concentration of oxygen to the patient.

Effective two-person BVM ventilation requires coordination and communication between the two rescuers. They should communicate about the patient’s condition, the effectiveness of the ventilation, and any changes in the patient’s status. If the chest is not rising adequately, the mask seal should be checked and adjusted, and the airway patency should be re-evaluated. This technique is a critical skill for EMS professionals and requires regular practice to maintain proficiency.

Performing stoma ventilation with a bag-valve-mask (BVM) ventilation:

Ventilating a patient with a stoma requires a modified approach to BVM ventilation. Since the stoma provides a direct opening to the trachea, the usual method of ventilating through the mouth and nose is bypassed. The primary goal remains the same: to deliver adequate tidal volume and oxygenation, but the technique is adapted to the patient’s unique anatomy. A patient with a stoma may have a laryngectomy, meaning their upper airway is surgically separated from their lower airway. Therefore, ventilating through the mouth or nose will be ineffective.

The procedure begins with confirming the stoma’s patency and ensuring it’s free of obstructions. Suctioning may be necessary to clear secretions or debris. Next, select a BVM mask that appropriately fits the stoma. A smaller mask, such as a pediatric or infant mask, may be necessary for some stomas. Secure the mask over the stoma, ensuring a tight seal to prevent air leaks. If a standard mask doesn’t fit well, a tracheostomy adapter or other specialized airway device may be required.

Once the mask is securely in place, connect the BVM to the mask and begin ventilations. The ventilation rate and volume remain similar to standard BVM ventilation: 10-12 breaths per minute for adults and 12-20 breaths per minute for children, with each breath delivered over approximately 1 second, while observing for chest rise. Supplemental oxygen should be connected to the BVM with a flow rate of at least 15 liters per minute. It’s essential to monitor the patient’s chest rise and lung sounds to ensure adequate ventilation. If breath sounds are absent or diminished, check the mask seal, the stoma’s patency, and consider alternative airway management techniques if necessary. Remember, the goal is to provide effective ventilation through the stoma, bypassing the upper airway entirely.

Glossary

• Alveoli: tiny air sacs in the lungs where gas exchange takes place.
• Apnea/Apneic: not breathing.
• BIAD: blind insertion airway device.
• Bronchi: hollow tubes branch off from the trachea.
• Bronchioles: thinner, smaller tube branching off the bronchi and connect to the alveoli.
• Cricoid cartilage: a ring-shaped structure that forms the lower portion of the larynx.
• Dead space: the portion of the tidal volume (the volume of air inhaled or exhaled in a single breath) that does not participate in gas exchange.
• Epiglottis: leaf-shaped flap of cartilage, sits at the entrance to the larynx.
• FBAO: foreign body airway obstruction.
• Flail chest: multiple rib fractures causing chest wall instability.
• Hemothorax: blood in the chest cavity.
• Hypoxemia: low oxygen levels in your blood.
• Hypoxia: low levels of oxygen in the tissues of your body.
• Larynx: voice box.
• LMA: laryngeal mask airway.
• Mandible: lower jaw.
• Maxilla: upper jaw.
• NPA: nasopharyngeal airway.
• OPA: oropharyngeal airway.
• Oxygenation: presence of or delivery of oxygen to blood or tissues.
• Pharynx: throat.
• Pneumothorax: collapsed lung.
• PPVD: positive pressure ventilation devices, including mouth-to-mouth with a barrier device, pocket masks, and bag-valve-masks (BVMs).
• SGA: supraglottic airway device.
• Stoma: opening in neck to the trachea to allow breathing.
• Stridor: a high-pitched whistling sound at the larynx and vocal cords, can indicate airway compromise.
• Thyroid cartilage: protects the front of the larynx and forms the Adam’s apple.
• Tidal volume: the volume of air inhaled or exhaled in a single breath.
• Trachea: the windpipe.
• Ventilation: exchange of oxygen and carbon dioxide.

References

Ball, M. (2023). Anatomy, airway. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK459258/

Boundless. (2024). 39.6: Gas exchange across respiratory surfaces – basic principles of gas exchange. Biology LibreTexts. https://bio.libretexts.org/Bookshelves/Introductory_and_General_Biology/General_Biology_(Boundless)/39%3A_The_Respiratory_System/39.06%3A_Gas_Exchange_across_Respiratory_Surfaces_-_Basic_Principles_of_Gas_Exchange

Boundless. (2024b). 39.8: Gas exchange across respiratory surfaces – gas exchange across the alveoli. Biology LibreTexts. https://bio.libretexts.org/Bookshelves/Introductory_and_General_Biology/General_Biology_(Boundless)/39%3A_The_Respiratory_System/39.08%3A_Gas_Exchange_across_Respiratory_Surfaces_-_Gas_Exchange_across_the_Alveoli#:~:text=The%20change%20in%20partial%20pressure,the%20tissue%20and%20the%20carbon

Bucher, J. T., Vashisht, R., Ladd, M., & Cooper, J. S. (2023). Bag-valve-mask ventilation. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK441924/

Charbek, E. (2024).  Normal vital signs. Medscape. https://emedicine.medscape.com/article/2172054-overview?form=fpf

Chourpiliadis, C., & Bhardwaj, A. (2022). Physiology, respiratory rate. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK537306/

Cleveland Clinic. (2024). What are your airways? https://my.clevelandclinic.org/health/body/airway

Cleveland Clinic. (2025). Respiratory system. https://my.clevelandclinic.org/health/body/21205-respiratory-system

Cleveland Clinic. (2025a). A guide to your kid’s vital signs. https://health.clevelandclinic.org/pediatric-vital-signs

CPR Select. (n.d.). What is bag valve mask: When and how to use BVM ventilation. https://www.mycprcertificationonline.com/bag-valve-mask

CPR Select. (2024). How to perform the head tilt-chin lift maneuver. https://www.mycprcertificationonline.com/courses/bls/head-tilt-chin-lift#:~:text=The%20head%20tilt%20chin%20lift,open%20airway%20in%20unconscious%20individuals

Di Cicco, M., Kantar, A., Masini, B., Nuzzi, G., Ragazzo, V., & Peroni, D. (2020). Structural and functional development in airways throughout childhood: Children are not small adults. Pediatric Pulmonology, 56(1), 240–251. https://doi.org/10.1002/ppul.25169

Ernstmeyer, K., & Christman, E. (Eds.). (2023). Nursing skills 2e. Open RN. https://wtcs.pressbooks.pub/nursingskills/

Frysh, P. (2025). Stridor. WebMD. https://www.webmd.com/lung/what-is-stridor#:~:text=4%20min%20read-,What%20Is%20Stridor%3F,narrow%20or%20partly%20blocked%20airway

Habrat, D. (2022). How to do bag-valve-mask (BVM) ventilation. Merck Manual Professional Edition. https://www.merckmanuals.com/professional/critical-care-medicine/how-to-do-basic-airway-procedures/how-to-do-bag-valve-mask-bvm-ventilation#:~:text=Bag%2Dvalve%2Dmask%20(BVM)%20ventilation%20is%20the%20standard,apnea%20or%20severe%20ventilatory%20failure

Mayo Foundation for Medical Education and Research. (2016). Critical airway management in kids. Mayo Clinic. https://www.mayoclinic.org/medical-professionals/trauma/news/critical-airway-management-in-kids/mac-20429698#:~:text=Jaw%20thrust%20and%20suction&text=This%20opens%20the%20airway%20by,blood%2C%20vomit%20and%20other%20secretions

Mayo Foundation for Medical Education and Research. (2024). Cardiopulmonary resuscitation (CPR): First aid. Mayo Clinic. https://www.mayoclinic.org/first-aid/first-aid-cpr/basics/art-20056600#:~:text=chin%2Dlift%20maneuver.-,Pinch%20the%20nostrils%20shut%20for%20mouth%2Dto%2Dmouth%20breathing%20and,to%20give%20two%20rescue%20breaths

Potchileev, I. (2023). Positive pressure ventilation. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK560916/

Rhodes, C. E. (2022). Physiology, oxygen transport. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK538336/#:~:text=Most%20oxygen%20in%20the%20blood,physically%20dissolved%20in%20the%20plasma.&text=Approximately%2098%25%20of%20total%20oxygen,is%20dissolved%20directly%20in%20plasma

Singh, K. (2020). Second generation supraglottic airway (SGA) devices. IntechOpen. https://www.intechopen.com/chapters/73593

Department of Health & Human Services, Victoria. (2014). Intern manual (4th edition) – Immediate management of surgical emergencies. https://www.health.vic.gov.au/publications/intern-manual-4th-edition-immediate-management-of-surgical-emergencies

The Royal Children’s Hospital Melbourne. (n.d.). How are children different? https://www.rch.org.au/trauma-service/manual/how-are-children-different/

Thim, T., Krarup, N. H. V., Grove, E. L., Rohde, C. V., & Lofgren, B. (2012). Initial assessment and treatment with the airway, breathing, circulation, disability, exposure (ABCDE) approach. International Journal of General Medicine, (5), 117–121. https://doi.org/10.2147/ijgm.s28478

U.S. Department of Health and Human Services. (2022). What breathing does for the body. National Heart Lung and Blood Institute. https://www.nhlbi.nih.gov/health/lungs/breathing-benefits#:~:text=Breathing%20in,-When%20you%20breathe&The%20muscles%20between%20your%20ribs,and%20outward%20when%20you%20inhale

U.S. National Library of Medicine. (2024). Aging changes in the lungs. MedlinePlus [Internet]. https://medlineplus.gov/ency/article/004011.htm

Whited, L. (2023). Abnormal respirations. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK470309/#:~:text=Respiratory%20disorders%20can%20significantly%20impact,a%20buildup%20of%20carbon%20dioxide

Images:

”2301_Major_Respiratory_Organs” by OpenStax College is licensed under CC BY 3.0

“2309 The Respiratory Zone.jpg” by OpenStax College is licensed under CC BY 3.0.

”Adult_and_pediatric_airway_anatomy” by Open Critical Care & World Health Organization is licensed under CC BY 4.0

”Head-tilt-chin-lift-maneuver” by Another-anon-artist-234 is licensed under CC0, Public Domain

”Jaw_thrust_maneuver” by Randhillon is licensed under CC BY-SA 4.0

Image modified from EMS Skills – Nasopharyngeal Airway Insertion [Video] by WCTCFire&EMS is licensed under CC BY 4.0

“Nasopharyngeal_Airway_2” by ICUnurses is licensed under CC BY-SA 4.0

Image modified from EMS Skills – Oropharyngeal Airway Insertion [Video] by WCTCFire&EMS is licensed under CC BY 4.0

“Oropharyngeal_Airways” by Hospital is licensed under CC BY-SA 3.0

”F15” by unknown author is licensed under CC BY 3.0. Access for free at https://www.intechopen.com/chapters/73593

“F17” by unknown author is licensed under CC BY 3.0. Access for free at https://www.intechopen.com/chapters/73593

“biad-king-airway-combitube-1936581” by kkirkemtp via Pixabay is licensed under CC0

”F14” by unknown author is licensed under CC BY 3.0. Access for free at https://www.intechopen.com/chapters/73593

“Tracheostomy NIH.jpg” by National Heart Lung and Blood Institute is in the Public Domain.

Alveolus” by Prina123 is licensed under CC BY-SA 3.0

“Dual System of the Human Blood Circulation” by OpenStax College is licensed under CC By 4.0

”Asthma_attack-illustration_NIH” by United States-National Institute of Health: National Heart, Lung, Blood Institute is in the Public Domain

”New_Pneumonia_cartoon” by Gambo7 is licensed under CC BY-SA 3.0

”Cellular_respiration_EN” by Zlir’a is licensed under CC BY-SA 4.0

”1904_Hemoglobin” by OpenStax College is licensed under CC BY 3.0

“Cynosis.JPG” by James Heilman, MD is licensed under CC BY-SA 3.0

”Bvm-with-two-medics” by Baedr-9439 is licensed under CC0, Public Domain

Videos:

WebMD. (2024, December 17). Compare the sound of healthy lungs to noises that indicate a bigger health issue like pneumonia, rales, and other conditions [Video]. Unknown player. https://www.webmd.com/lung/what-is-stridor

WCTSFire&EMS. (2013, July 30). EMS Skills – Manual Airway Techniques [Video]. YouTube. CC BY 4.0. https://www.youtube.com/watch?v=vLNzHcKNPtY

WCTSFire&EMS. (2013, July 30). EMS Skills – Oropharyngeal Airway Insertion [Video]. YouTube. All rights reserved. https://www.youtube.com/watch?v=vgqOrmBskaw

WCTSFire&EMS. (2013, July 30). EMS Skills – Nasopharyngeal Airway Insertion [Video]. YouTube. All rights reserved. https://www.youtube.com/watch?v=uALM3HqtTnI

American Red Cross. (2024, August 12). What to do when an adult is choking (responsive) [Video]. YouTube. All rights reserved. https://www.youtube.com/watch?v=8R3RWC-xx1I

American Red Cross. (2024, August 12). What to do when an adult is choking (Unresponsive) [Video]. YouTube. All rights reserved. https://www.youtube.com/watch?v=9pTnepZd5as

American Red Cross. (2024, August 12). What to do when an infant is choking (Responsive) [Video]. YouTube. All rights reserved. https://www.youtube.com/watch?v=ShaNuST_58A

American Red Cross. (2024, August 12). What to do when an infant is choking (Unresponsive) [Video]. YouTube. All rights reserved. https://www.youtube.com/watch?v=NF9oSpXt19c

WCTSFire&EMS. (2013, July 30). EMS Skills – Pharyngeal Suctioning (Flexible Tip) [Video]. YouTube. All rights reserved. https://www.youtube.com/watch?v=l_qL_tYVUMk

WCTSFire&EMS. (2013, July 30). EMS Skills – Pharyngeal Suctioning – Rigid Tip [Video]. YouTube. All rights reserved. https://www.youtube.com/watch?v=uALM3HqtTnI

LTC EMS Program. (2019, August 18). Combi Tube [Video]. YouTube. All rights reserved. https://www.youtube.com/watch?v=VL_Ux5Luxx8

LTC EMS Program. (2019, August 18). King LTS-D [Video]. YouTube. All rights reserved. https://www.youtube.com/watch?v=86OGtNofIUE

intersurgical. (2017, December 7). i-gel® supraglottic airway from Intersurgical – training and guidance [Video]. YouTube. All rights reserved. https://www.youtube.com/watch?v=Z0962B8axAY

A.D.A.M. (2024, July 15). Breathing [Video]. MedlinePlus. All rights reserved. https://medlineplus.gov/ency/anatomyvideos/000018.htm#:~:text=When%20the%20lungs%20exhale%2C%20the,the%20pressure%20within%20it%20increases.

DrBruce Forciea. (2015, May 13). Respiratory System Anatomy (v2.0) [Video]. YouTube. All rights reserved. https://www.youtube.com/watch?v=aqTwrdMS6CE

DrBruce Forciea. (2015, May 12). Anatomy and Physiology: Respiratory System: Breathing Mechanics (v2.0) [Video]. YouTube. All rights reserved. https://www.youtube.com/watch?v=X-J5Xgg3l6s