Airway Management for Emergency Medical Technicians
- Airway Mechanisms and Anatomy
- Upper and Lower Airways
- Inhalation and Exhalation
- The Physiology of the Respiration Process
- Determining Normal Breathing
- Breathing Rate
- Respiration Rhythm
- Chest Characteristics
- Breathing Volume
- Abnormal/Inadequate Breathing
- Characteristics of Inadequate Breathing Conditions
- Cheyne-Stokes Respirations
- Biot Respirations
- Kussmaul Respirations
- How to Determine Inadequate Breathing
- Considerations for Airway in Children and Infants
- Artificial Ventilation
- How to Ascertain Inadequacy and Adequacy in Artificial Ventilations
- Airway Management Techniques
- Mouth Opening
- Abdominal Thrusts
- Back Slaps
- Oral Adjuncts
- Recovery Position
- How to Open the Airway
- Works Cited
In any profession, there are essential factors to consider before anything else. For instance, in real estate business, an essential thing to consider is location. For emergency medical technicians (EMT) or practitioners, airway management is the most crucial aspect. Airway management involves ensuring the passage of air is open to allow the patient to breath. Before embarking on other aspects, such as stopping bleeding or arresting some burns, one must ensure that the patient is breathing well. Airway management is the first essential task in patient treatment because a patient who is not breathing is dead. Since one cannot waste time treating a dead person, it is crucial to prevent death first by managing airway passage before focusing on another area. Airway management is thus a basic course every medical practitioner should have, and this paper will explore the topic in details.
Airway Mechanisms and Anatomy
An airway is essentially a route through which respiratory gasses passes during respiration. Respiration, in this case, involves exhalation and inhalation process. Understanding its anatomy is thus the key to understanding how to manage a patient with breathing difficulties.
Upper and Lower Airways
The physical breathing process is achieved through the respiration system. The system is divided into two distinct regions; the lower airway, and the upper airway. These regions are shown in figure 1
Figure 1: Upper and Lower Airway (Asher, Knight and Reasor 1)
The upper airway is the section above the vocal cords. It includes the epiglottis, nasal air passages, mouth, oropharynx, nasopharynx, uvula, and parts above the epiglottis. The lower airway in the respiratory system involves the vocal cords and respiratory structures below it. The lower airway is dominated by the lungs and the trachea. The lungs form the bulk of airway as they house essential airway features, including the alveoli, carina, and bronchi among others. For one to understand airway management he or she must be aware of the anatomy involved and this includes the lower and upper airway (Limmer, Hafen and Karren 97).
Inhalation and Exhalation
The airway mechanism involves coordination of the lower and upper airways to bring about inhalation and exhalation. During inhalation process, the mouth and nose open to allow air to pass through the pharynx and proceeds to oropharynx down to the nasopharynx. The air proceeds further down beyond the epiglottis via the vocal cords and the larynx. It then moves down the trachea and to the carina. From the carina, the air divides into the right and the left bronchi whereby sizeable quantities move into each section. The air, after that, moves into the bronchioles and finally to the alveoli (American Medical Association 31).
The exhalation process is the reverse process of inhalation and involves the action of the intercostal and diaphragm muscles. During inhalation, the intercostal and diaphragm muscles contracts thereby increasing thoracic cavity size. During this process, the muscle action brings about the downward movement of the diaphragm and the outward and upwards movement of the rib following ribcage flaring. When exhalation starts, the ribs move inward and downward following the upward movement of the diaphragm resulting from its relaxation. This movement causes air to move out of the lungs. The air movement, in this case, is passive as it is not forced (American Heart Association 52).
The Physiology of the Respiration Process
Airway allows air to enter the body through inhalation and to move out through exhalation. However, exhalation and inhalation is not the only process taking place in the airway. When air consisting of mostly oxygen is inhaled, it is utilized in the body before being released as waste during exhalation. The process taking place in the body that involves oxygen utilization consist the physiology of respiration. It is a complex process involving the exchange of oxygen and carbon dioxide gasses across the cell. The air reaching alveoli during inhalation is loaded with oxygen and brings about respiration. Oxygen reaches the alveoli through diffusion whereby it moves from high to low concentration areas at capillary level across the cell wall (American Academy of Orthopedic Surgeons 112).
The diffusion process in the alveoli facilitates oxygen movement to the capillaries, after that, to the arterioles, and finally to the arteries. The blood in the arteries carries oxygen to the rest of the body. The diffusion process also ensures that carbon dioxide, which is the waste product after oxygen has been used in the body, is moved from the venous system. Since carbon dioxide is in high concentration in the venous system, it diffuses into the venules, after that, to the capillaries into the alveoli and the lungs (Asher, Knight and Reasor par. 3). From the lungs, carbon dioxide is exhaled out through muscle action.
Figure 2: alveoli (Asher, Knight and Reasor 1)
Determining Normal Breathing
Breathing must be adequate for a patient to survive. The medical practitioner ought to determine if the patent’s breathing is adequate by assessing the quality, depth, rhythm, and rate of respiration. Signs such as shallow breath, distress, or laboring during breathing should be key signs to observe (American Heart Association 29).
Assessing the airway of the patient should involve the assessment of the breathing rate, which is essentially the number of breaths a patient is taking in every minute. According to the American Heart Association (54), breathing rate for an infant should be 25-50 times per minutes. The rate for a child should be 15-30, whereas, the rate for an adult should be 12-20 times per minute.
Respiration rhythm is also crucial when determining adequate breathing. Rhythm can be irregular or regular. For a regular breathing pattern, the volume entering and coming out is almost the same. The chest rises and falls in equal patterns. A deviation from this pattern is deemed inadequate breathing (Limmer, Hafen and Karren 112).
Normal breathing is further ascertained by the sound of breathing, effort applied during breathing, and adequate expansion of the chest. Abdominal muscles are used more by infants and children during breathing than in the adult and thus this should not be considered as an abnormality (Margolis 69).
Regular breathing should also be enhanced by breathing volume. Breathing volume is also termed as tidal volume, which is the amount of air being inhaled. It is sometimes difficult to ascertain tidal volume but one should observe sings of visible chest rise. Based on the visible chest rises, one can ascertain if the volume of air being inhaled is adequate. Margolis (69) states that tidal volume should be observed based on chest rise. In general, normal breathing should be determined by rhythm, rate, and depth.
Abnormal breathing is caused by a number of issues including inadequate rate, insufficient chest expansion, and blockage of airway by chest fluids. Inadequate breathing may include epiglottis, swollen tongue, and trauma, among other obstructions. Trauma is not the only cause of obstruction; some infectious diseases may also be a cause. Inadequate rate and chest expansion are normally caused by injuries or diseases affecting the nerves. Airway filed with fluids is a factor in inadequate breathing and is caused by drowning, burns in the upper airway, and blood from trauma (Limmer, Hafen and Karren 109).
Improper functioning of the respiratory system affects the ability of the patient to exchange oxygen to the parts of the body. When not corrected in time, inadequate breathing can lead to cellular death or death of the patient. Rhythm, rate, and depth of breathing should be considered when determining inadequate breathing (Limmer, Hafen and Karren 109).
Characteristics of Inadequate Breathing Conditions
Refers to a condition whereby the rate is below 12 respirations per minute.
Refers to a condition caused by high breathing rates.
Refers to a condition of irregular respiration patterns whereby there is an increase in breathing depth and rate followed by a decrease in depth and rate and thereafter a moment of apnea. It is common in patients suffering from strokes or head injuries.
Biots results from abnormal breathing patterns whereby there is shallow and rapid breathing followed by apnea.
This type of respiration is characterized by deep breathing rate caused by some conditions such as diabetic ketoacidosis.
Apneustic is a respiration condition characterized by prolonged inspirations with difficult expirations.
Ataxic is an irregular breathing pattern coupled with apnea period.
How to Determine Inadequate Breathing
It is pertinent to ascertain what is normal in order to determine abnormal breathing in a patient. Breathing sound is the most essential aspect used. In this case, history of the patient should be the guiding factor since it will help one to gauge normal from abnormal.
Unequal expansion of the chest wall is also a factor used to determine inadequate breathing. Performing this visual check is crucial and should include palpation of the thoracic region. Skin color, temperature, and the condition of the patent can be affected by a patient’s respiratory pattern and thus should be observed. A person with inadequate breath may exhibit cyanotic, clammy, and cool skin. Skin is affected because inadequate breathing forces the body to extract more oxygen from red blood cells resulting in tissue perfusion (American Heart Association 56).
When determining inadequate breathing, the quality of breathing must be considered. Quality involves the sound of lungs and chest expansion. Lung sounds should be ascertained in an environment with minimal noise level. Abnormal breathing sounds may include wheezing, stridor, crackles, rhonchi, and pleural frictional rub
Inadequate breathing signs in children are different from those in adults. For children, common sign is flaring of the nose to increase air intake. Other signs in children are sea saw breathing whereby the abdomen and the chest seem to compete with each other among others (American Heart Association 56).
Considerations for Airway in Children and Infants
Apart from the differences in size, the upper airway in children is different compared to the adults. The nose and mouth of a child are smaller compared to the head and thus head positioning during breathing is essential in children than in adults.
The differences in the airway in children are mainly caused by structural differences. For instance, the tongue of a child is larger than in adults and thus takes much of the space in the pharynx. Also, the trachea is less rigid and narrow. In addition, children mostly use their diaphragm for breathing because they have a soft chest wall. This means there are chances of inflating the chest during artificial ventilation and thus care must be taken during this process. Children too have small reserves of oxygen and high metabolic rate. This means hypoxia is a likely issue (Margolis 68).
Artificial ventilation is vital to patients with breathing adequacies; either when the volume or the rate is inadequate or even both. It can be applied mouth to mouth or mouth to -mask, whereby a pocket mask is used. There are two types of Bag-valve mask (BVM) that can be used. The first one is the Bag-valve mask which is operated by one person by holding the face-mask seal with one hand and using the other hand to squeeze the bag. The other Bag-valve mask is done by two people with one person holding the face-mask seal while the other person squeezes the bag (Limmer, Hafen and Karren 112).
Chest compressions (CPR) are used to ease circulation and are mostly coupled to Bag-valve masks when dealing with a non-breathing and pulse-less patient. A flow-restricted and oxygen-powered ventilation gadget also known as a demand-valve device is used in artificial ventilation. This provides 100% oxygen, and therefore, there is no need for squeezing.
Cricoid pressure is also used in artificial ventilation and is also known as the Sellick maneuver. The cricoid cartilage uses commands abbreviated as BURP meaning backward, up, right pressure. This chunks the esophagus at the cricoid, and avoids stomach aspirations or inflation during the process. For patients suspected to have spinal injury, the C-spine should be held through spinal stabilization (Limmer, Hafen and Karren 114).
Stoma is required for patients undergoing laryngectomy or tracheostomy. This is a hole created on the patient’s neck to serve as the airway opening. Artificial ventilation and suctioning are performed through the stoma (Limmer, Hafen and Karren 115).
How to Ascertain Inadequacy and Adequacy in Artificial Ventilations
An airway may fail to function naturally thus necessitating the use of external aid. The external aid involves using masks and ventilators. Artificial ventilation must be done properly. The person administering the procedure must be able to tell whether ventilation is adequate or inadequate and thus adjust appropriately.
To ensure ventilation is adequate, a number of factors must be considered. In the first place, chest behavior should be normal. The chest should be rising and falling with ventilation as an indication that air is reaching the alveoli. Heart rate should also be a factor whereby if it returns to normal, the artificial ventilation is adequate. Ventilations rates should also be in line with the existing standards to be considered adequate. According to the American Academy of Orthopedic Surgeons (38), the rate of assisted ventilation should be about 10 to 12 times per minute. For children, the rate should be between 12 and 20 times per minute.
Inadequate artificial ventilation is deadly and is detected by improper rise and fall of the chest of the patient. If the chest fails to rise as expected, it means that oxygen is not reaching the alveoli as expected and is an indication that the airway has been blocked. Also, if the ventilation rate is outside the acceptable limits, the artificial ventilation is not adequate.
Airway Management Techniques
A number of techniques can be applied to facilitate the proper functioning of the airway. One of such techniques is opening a patient’s mouth. This can be done by laying the patient on a prostrate position and standing behind the patience and thereafter opening his or her mouth using overlapped thumb-forefinger. The mouth should be opened by the teeth by the use of a scissors motion (American Academy of Orthopedic Surgeons 56).
Suction is also another airway technique. The suction should not be applied below the tongue base and it should always be done by the use of a catheter which should always be moved on its way out. For adults, suction should be done in 15 seconds per session and 5 seconds for children and infants. In case the suctioning process causes respiration inadequacy to a patient, oxygen and positive pressure ventilation (PPV) should be provided.
When suctioning the oral pharynx and the mouth, a rigid or hard catheter is used, as well as a tonsil sucker and a tonsil tip. To determine the right catheter size to be used on a patient it ought to be measured from the earlobe to the corner of the mouth of that particular patient. Suctioning the nasopharynx and the nose is done by use of a soft catheter which is also known as the ‘French’ catheter. In this case the catheter size is determined by the length between the nose and the earlobe of a patient.
For patients undergoing laryngectomy or tracheostomy, a hole is formed in the neck to serve as the airway opening. Such a hole is known as a stoma and it should be treated as the opening through which artificial ventilation and suction are performed (American Heart Association 57).
Another airway technique is abdominal thrusts. This helps in the removal of airway blockage, especially, when a conscious patient chokes on something. By standing behind the patient, one should squeeze and hold around the abdomen, and then push inward and upward.
Back slaps is also another useful airway technique and it is done on conscious and chocking infants mostly below a year old. The infant should be tilted downward and slapped at the back.
Another airway technique is oral adjuncts. There are two types of oral adjuncts and entails oropharyngeal airway also called the oral airway and the nasopharyngeal airway also called the nasal airway. Oral airway helps to hold the airway open through the mouth, protecting the tongue from obstructing the airway. Its measurement is done from the mouth corner to the earlobe, and it cannot be used on patients suffering from a gag reflex. On the other hand, for nasopharyngeal airway holds the airway open through the nostrils. Its measurements should be done from the ear tip to the earlobe, and it can work even to patients with a gag reflex (Limmer, Hafen and Karren 26).
Lastly, there is the recovery position, which is an airway technique that protects a patient from aspiration by placing them in a recovery position. It is also known as the coma position. The patient should be placed by their side, and it should always be ensured that the arm does not touch the ground. It should be folded such that the patient’s hand is beneath the head. This enables the patient to vomit as much as they like, and the vomit flows out easily. For pregnant and obese patients, the midline of the sternum should be grasped during the process (American Academy of Orthopedic Surgeons 117).
How to Open the Airway
The opening of the airway is essential in allowing enough ventilation in a patient. The process can be very simple and effective if done properly. Opening an airway should be preceded by careful consideration and assessment of the situation to ascertain the right procedure to use. There are two main techniques of opening the airway, and they include jaw thrust and head-tilt chin-lift.
Head-tilt chin-lift is performed to open airway in a situation where there is no head injury. It is performed when the victim is in the supine position. Several steps are followed during this process. First, the patient is placed in supine position and the person performing the test kneels beside the head. Second, the pressure is applied on the forehead. Third, the head is lifted gently and tilted upward. Lastly, an adjunct is applied to maintain an open airway.
The second method applied is the jaw thrust. This technique is applied in the situation where a patient is apneic, unconscious, or has cervical trauma. First, the head of a patient is held in a neutral position. Second, a finger is placed on the patient’s cheekbone and extended throughout the cheek. Third, the ring finger and middle finger of all hands are placed on the mandible angle and lifted gently. Lastly, the patient’s airway is opened gently when lifting the tongue gently. If the airway is not clear, suction is applied.
Emergency medical technicians have the obligations of ensuring the patient in critical care survives. The primary way of ensuring the survival of a patient is by ensuring that he or she is breathing. Breathing is enhanced through proper airway management techniques. There is some airway management techniques applied and is upon the EMT to consider which technique is the most suitable. When applying airway techniques, special considerations are made on children and infants because their airways are different from the adults.
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Asher, Ryan, et al. “EMT Basic – Airway Management.” n.d. CEU-EMT. 16 Oct 2015 <http://www.ceu-emt.com/airway-ceu.php>.
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Margolis, Greg. Paramedic: Airway Management. Sudbury, MA: Jones & Bartlett Publishers, 2004.