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Airway Care Study Guide

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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

Click for larger image

Click for larger image

  • 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

      Click for larger image

      Click for larger image

  • 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

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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