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Anatomy and Physiology Review
- Upper and lower airway
- Alveoli and pulmonary capillaries
Key Concepts: Respiratory Physiology
- Perfusion: Adequate blood flow to the body cells that allows the proper delivery of oxygen and nutrients and the adequate removal of waste products
- Oxygen is transported on the red blood cell by the hemoglobin molecule
- Minute volume: Tidal volume × Rate
- Alveolar ventilation: The amount of air that reaches the alveoli during ventilation
- External respiration: The exchange of oxygen and carbon dioxide from air to blood at the level of the alveoli
- Requires adequate alveolar ventilation
- Requires adequate blood flow to pulmonary capillaries
- Internal respiration: The exchange of oxygen and carbon dioxide from blood to the cells of the body
- Requires adequate external respiration
- Requires adequate blood flow to the cells (perfusion)
Pathophysiology of the Airway
- Upper airway obstruction
- Mental status: Decreasing mental status can cause structures of the airway (such as the tongue and epiglottis) to relax and obstruct air flow. Remember, this is a dynamic condition that can change rapidly.
- Foreign body airway obstruction from liquids (such as blood, vomit) and/or objects (foreign bodies, as in choking)
- Swelling of airway structures, as in anaphylaxis or trauma
- Disruption of alveolar ventilation
- Obstruction of air flow in the lower airways—example: bronchoconstriction
- Changes in the alveoli and small airways—example: pulmonary edema
- Inadequate breathing
- Rate problems leading to inadequate minute volume—example: very slow breathing as with narcotic overdose
- Volume problems leading to inadequate breathing—example: collapsed lung (pneumothorax)
- Disordered control of breathing
- Conditions such as seizures or brain injury that challenge the ability to keep an airway open or maintain adequate breathing
- Respiratory decompensation after prolonged compensation for a respiratory challenge
- Failure of the muscles of respiration as increased demand and overall respiratory challenge outpace the ability to supply oxygen to them
- Exhaustion
Recognizing Airway Problems
- Airway trauma
- Obvious airway obstruction (foreign bodies or liquid)
- Altered mental status
- Can cause airway failure
- Can be caused by hypoxia and high levels of carbon dioxide (consider a broad spectrum of mental status changes, from agitation/anxiety to lethargy and unconsciousness)
- Dyspnea and respiratory distress
- Inability to speak/move air
- Hoarse or raspy voice
- Accessory muscle use
- Stridor: the sound of restricted air movement in the upper airway
- Cyanosis
- Signs of compensation: tachypnea, tachycardia
- Lung sounds
- The sounds of diminished air movement
- The sound of no air movement (silent chest)
- Adventitious sounds: stridor, wheezing, rales and rhonchi
- Pulse oximetry less than 94%
- Capnography: increased exhaled carbon dioxide (readings greater than 45 mmHg)
Key Airway Interventions: Opening the Airway
- Head-tilt, chin-lift: Create the “sniffing” position
- Beware excessive neck movement in trauma
- Jaw-thrust: Move mandible forward to adjust soft tissues of the airway and clear the pathway for air
- Used for trauma patients
- Oral pharyngeal airways
- Used to maintain an airway
- Indicated in unconscious patients without gag reflex (beware stimulating gag reflex on insertion—have suction ready)
- Measure from corner of mouth to earlobe
- In adults, insert upside down and rotate 180 degrees following natural curvature of the airway
- In pediatric patients, insert following the natural curvature of the airway (rotation is unnecessary)
- Nasal pharyngeal airways
- Used to maintain an airway
- Indicated in situations where oral airways are contraindicated—can be used on patients who have intact gag reflex (although may still cause gag reflex)
- Use caution in patients with head/facial trauma and possible basilar skull fractures
- Measure from tip of the nose to earlobe
- Lubrication is necessary
- Insert in a backwards/downward direction using gentle twisting motion to pass nasal turbinates; DO NOT force insertion
Key Airway Interventions: Clearing the Airway
- In situations of obstruction by a liquid (blood/vomit), use position to clear the airway—roll patient onto side, allowing gravity to aid removal (always consider the need for spinal motion restriction)
- The recovery position (patient in lateral recumbent position) is designed to prevent obstruction
- Portable Suction (can be mechanical or manual) and Onboard Suction (uses power from ambulance)
- Beware power failures and have a manual backup
- Must be capable of generating 300 mmHg pressure when occluded
- Suction catheters
- Rigid (Yankauer)
- Insert only as far as is visible
- Avoid posterior hypopharynx—can cause bradycardia and decreased blood pressure
- Soft (French)
- Used when rigid tip is inappropriate
- Insert only as far as is visible
- Avoid posterior hypopharynx—can cause bradycardia and decreased blood pressure
- Rigid (Yankauer)
Important Concepts: Airway Care
- Recognition of an airway problem is a critical concept that anchors the primary assessment. Always look for signs and symptoms (both dramatic and subtle) of airway problems.
- Remember that airway problems are dynamic and often develop over time. A patent airway now is no guarantee that it will remain patent.
- Airway problems often will require advanced capabilities to resolve. Consider the early activation of ALS and rapid transport to an appropriate destination hospital.
- Study Tip: Consider each of the pathophysiologies listed here. How would you recognize each one, and what steps would be necessary to treat it?
- Study Tip: Consider each skill and intervention in context. How would you use the device or intervention in a real person? In what type of situation would you use the device/intervention?
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