basic airway management

Since CPR Started in the early sixties, it was meant to be only for basic Life Support . As time went on Advanced Cardiac Life support developed and became an integral part of the CPR.

Overview

CPR consists of:1. Airway Management2. Basic Life Support (BLS)3. Advanced Cardiac Life Support

(ACLS)4. Advanced Trauma Life Support

(ATLS)5. CPR in special situations6. Ethical Issues

,

AIRWAY MANAGEMENT

REVIEW & UPDATEDr. Salah Kamel ashourAlbada General Hospital

Tabuk [email protected]

0502617860

AIRWAY MANAGEMENT Basic & Advanced

ObjectivesReview airway anatomyIdentify important anatomical structures related to the intubation of a patientReview basic airway maneuversReview blind insertion airwaysReview advanced airway techniquesDescribe the process of opening the airway and maintaining itDescribe the indications, limitations, proper sizing, and contraindications of airway adjuncts

OBJECTIVESIdentify indications for intubation and prepare the necessary equipment.Identify the advantages and disadvantages of various devices for airway management. Refresh working knowledge of intubation equipment and airway support adjunctsDiscusse supraglottic and infraglottic a\w device ( LMA& COMBTUBE)Identify difficult airway. Identify equipment for difficult airway and know their use.

Objectives:

Discuss the ten commandments of airway management Review and demonstrate pediatric and adult basic/advanced airway techniquesReview techniques for confirmation of tube placement and ongoing monitoring Describe the indications, contraindications, advantages, disadvantages, complications and equipment for sedation procedures during intubation Perform needle and surgical cricothyroidotomy procedures

CONTENTS Introduction. Facts about A/W. Procedures of A/W management. Initial management of A/W.

Without Tracheal intubation. Advanced a/w management with tracheal

intubation. Management and protection of A/W. in patient with

head trauma. A/W. Management & chest trauma. Summary.

Regardless of certification level, to

Manage a patient's airway in the most effective way possible

It is the responsibility of every HEALTH CARE PROVIDER

Airway anatomy and function.Evaluation of airway.Maintenance and ventilation.Clinical management of the airway.How to open the A/W.

What should we know about“airway management?”

♥ A/W control is vital to improve pulmonary exchange , as well as , to protect patient's from aspiration .

♥ The most vital element in providing functional respiration is the AIRWAY .

INTRODUCTION

The A/W is the conduit through which air & o2 must pass before reaching the lungs .It include the anatomic structures extending from the nose and mouth to the larynx and trachea.

WHAT IS THE A / W?

Successful airway management requires

detailed understanding of upper and lower

airway structure (ANATOMY) and

function (PHYSIOLOGY)

Review of Upper and Lower

Airway ANATOMY

Upper and lower airway

ANATOMY

AnatomyUpper airway

The upper airway consists of the structures above the vocal cords. It is divided into the following regions:

Nose and oral cavity.. The nose, which is composed of bone cartilage, is the primary pathway for normal breathing. The oral cavity consists of the upper and lower teeth, the tongue and floor of the mouth, the hard palate and the openings of the major salivary glands. The floor of the mouth is supported by the mylohyoid muscles.

Pharynx. In normal size adult males, an approximately 13-cm long muscular tube located behind the oral and nasal cavities. It conducts food to the esophagus and air to the larynx, trachea and lungs. The pharynx is divided into three sections: Nasopharynx: extends from the back of the internal

nasal cavity to the soft palate. Contains the adenoids. Oropharynx: Begins at the soft palate and continues to

the level of hyoid bone. Serves as both respiratory and food passage. Contains the tonsils. The tongue is the principal source of obstruction, usually because of decreased muscle tone related to sedation drugs such that the tongue falls backward in a supine patient.

Laryngopharynx:  Begins at the level of the hyoid bone and extends downward where it branches into two passages: the larynx at the front which leads to the lungs; the esophagus at the back which leads to the stomach.

Innervation and blood supply

The motor and most of the sensory supply to the pharynx is by the pharyngeal plexus, is formed by the pharyngeal branches of the vagus and glossopharyngeal nerves

. The pharynx is supplied by branches of the external carotid (ascending pharyngeal) and subclavian (inferior thyroid) arteries

Lower airway The lower airway encompasses the structures of the respiratory system below the larynx.

Trachea. Rigid tube approximately 10-15 cm length in the midline of the neck that provides a passage for air into the lungs.

Bronchial tree. Branched tree-like tube system leading from the trachea that conducts air into the lungs. It is made up of increasingly smaller tubes terminating in the alveoli.

Lungs. Paired organs consisting of millions of small sacs (alveoli) gas exchange occurs.  The lungs occupy most of the space of the thoracic cavity.

The Larynx

The Larynx• The larynx is a 5-7

cm long structure. • Its upper boundary

starts at the tip of the epiglottis, opposite the 3rd to 4th, cervical vertebra.

• Its lower end is at the lower border of the cricoid cartilage.• This lies opposite the

6th cervical vertebra.

www.phon.ox.ac.uk

Larynxn vocal cords

'true vocal folds'

n The false folds are also called vestibular folds and ventricular folds The 40th edition of Gray's Anatomy

was published in September 2008

AB

C

D

The Larynx

Superior surface anatomy :

Major Landmarks

The glottisThe

opening between the vocal cords at the upper part of the larynx.

Larynx . Enlargement at the top of the

trachea which houses the vocal cords.

The structure contains muscles, ligaments, and cartilages.

The epiglottis is a fibrous leaf-like cartilage that hangs over the laryngeal inlet that closes during swallowing to prevent aspiration of gastric contents into the trachea. 

.

Larynx The triangular opening between the

vocal cords is called the glottic opening and is the entry point to the larynx, It is the adult airway’s narrowest point. Patency of the glottic opening is dependent upon muscle tone

The glottis: open for inspiration and closed for

swallowing

Open Closed

Larynx The vocal cords of

the larynx as seen by a doctor using a laryngeal mirror. Note that the inside of the trachea can be seen through the open vocal cords and the opening to the esophagus can be seen lying behind the larynx. ©

Nerve SupplyVagus (X)

Superior Laryngeal

Recurrent Laryngeal

Continues in Thorax/Abdo to supply Heart, Trachea,

Lungs, GI Tract (to midgut)

Internal

BranchExterna

l Branch

Meningeal BranchAuricular Branch

Pharyngeal Branch

Nerve SupplyVagus (X)

Superior Laryngeal

Recurrent Laryngeal

Continues in Thorax/Abdo to supply Heart, Trachea,

Lungs, GI Tract (to midgut)

Cricothyroid

Internal

BranchExterna

l Branch

All other Intrinsic Muscles

MotorMeningeal BranchAuricular Branch

Pharyngeal Branch

Nerve SupplyVagus (X)

Superior Laryngeal

Recurrent Laryngeal

Continues in Thorax/Abdo to supply Heart, Trachea,

Lungs, GI Tract (to midgut)

Above cords

Below cords

Cricothyroid

Internal

BranchExterna

l Branch

All other Intrinsic Muscles

Sensory

MotorMeningeal BranchAuricular Branch

Pharyngeal Branch

Larynx Unilateral damage of a recurrent

laryngeal nerve results in paralysis of all the intrinsic muscles of the larynx except the cricothyroid, which will tend to adduct the vocal cord

The larynx has arterial supply by

(1) the superior laryngeal artery (from the superior thyroid), which accompanies the internal laryngeal nerve,

(2) the inferior laryngeal artery (from the inferior thyroid), which accompanies the recurrent laryngeal nerve

Pediatric Airway Infant and Child Considerations

5 Differences between Pediatric and Adult Airway

• More rostral larynx• Relatively larger tongue• Angled vocal cords• Differently shaped epiglottis• Funneled shaped larynx-narrowest part of

pediatric airway is cricoid cartilage

Pediatric Airway Pediatric vs Adult Upper

Airway Larger tongue in comparison to

size of mouth Floppy epiglottis Delicate teeth and gums Larynx is more superior Funnel shaped larynx due to

undeveloped cricoid cartilage Narrowest point at cricoid ring

before 10 yoa

Pediatric Airway Pediatric vs Adult Upper

Airway Trachea -

Infants and children have narrower tracheas that are obstructed more easily by swelling.

Trachea is softer and more flexible in infants and children.

Diaphragm - chest wall is softer, infants and children tend to depend more heavily on the diaphragm for breathing

Pediatric Airway The Cricoid cartilage

like other cartilage in the infant and child, the cricoid cartilage is less developed and less rigid. It is the narrowest part of the infant’s or child’s airway.

Cricothyroid membrane

Thyroid glandThyroid

cartilageCricoid cartilage

Blood Supply The lungs are very vascular organs, meaning they

receive a very large blood supply. This is because the pulmonary arteries, which

supply the lungs, come directly from the right side of the heart.

They carry blood which is low in oxygen and high in carbon dioxide into the lungs so that the carbon dioxide can be blown off, and more oxygen can be absorbed into the bloodstream.

The newly oxygen-rich blood then travels back through the paired pulmonary veins into the left side of the heart. From there, it is pumped all around the body to supply oxygen to cells and organs.

Basic Physiology

http://www.biology.eku.edu/RITCHISO/301notes6.htm

Airway Functions

Passage that allows air to move from atmosphere to alveoliMust remain patent (open) at all timesAnything that blocks airway will cause decrease in oxygen available to bodySize of obstruction affects available air exchange

Respiratory Physiology The physiology of respiration is a complex

process of gas exchange at the cellular level (CO2 and O2). When air loaded with oxygen reaches the alveoli, cellular respiration occurs. Oxygen inhaled into the lungs is moved into the alveoli through diffusion at the capillary level. This oxygen diffuses from areas of higher concentration to areas of lower concentration across the cell wall.

Respiratory Physiology Oxygenation - blood and the cells become

saturated with oxygen Hypoxia - inadequate oxygen being delivered to

the cells Signs of Hypoxia

Increased or decreased heart rate Altered mental status (early sign) Agitation Initial elevation of B.P. followed by a decrease Cyanosis (often a late sign)

Alveolar/Capillary Exchange

Oxygen-rich air enters the alveoli during each inspiration.

Oxygen-poor blood in the capillaries passes into the alveoli.

Oxygen enters the capillaries as carbon dioxide enters the alveoli.

Capillary/Cellular Exchange

Cells give up carbon dioxide to the capillaries.

Capillaries give up oxygen to the cells.

Airway managementdoes

not mean intubation

SO WHAT DOES

IT MEAN?

It means to ensure Patency, provide adequate Ventilation and maintain appropriate Oxygenation. 

Many times we forget the basics.  Merely providing a chin lift or jaw thrust

can open and/or salvage many airways. 

The proper use of adjuncts (oral/nasal airways), can convert a difficult-to-ventilate patient into a stable, well-ventilated one. 

The appropriate administration of high-flow oxygen, with properly fitted masks, is enormously beneficial. 

We must never forget that airway management is a collection of skills and techniques, not just an attempt to place a tube or device into the patient’s mouth or trachea

Remembering that: oxygenation is more important than tracheal Intubation .This can be done by: administering O2 via mask& bag to improve oxygenation prior to intubation

1. Relieve airway obstruction (e.g. head tilt-jaw thrust, finger sweep, suctioning)

2. Prevent aspiration (e.g. blood, foreign materials, stomach contents > leads to pneumonitis > 50% mortality rate

3. Maintain adequate ventilation/gas exchange

Goals of Airway Management

The Ten Commandments of Airway Management

1) Oxygenation and ventilation are the top priorities 2) Airway management does not mean intubation :-It means

to ensure patency, provide adequate ventilation and maintain appropriate oxygenation.  Many times we forget the basics. 

3) Be an expert at bag-valve-mask (BVM) ventilation . 4) Know your equipment

1) That daily check sheet is there for a reason.  Airway equipment is one of the most important items you carry.  Having backups (laryngoscope blades, bulbs, handles, adjuncts) and the ability to troubleshoot equipment are also important.  Assume personal responsibility for all airway equipment and its proper functioning.

5) Know at least one rescue ventilation technique and use it Rescue ventilation can best be described as a ventilation attempt to

use in the face of a failed airway (can’t intubate/can’t ventilate) scenario.  The most basic rescue technique is two-person BVM ventilation  Next, the use of the CombiTube® and LMSis recommended.  It is easy to use, can be inserted quickly and safely, and can accomplish ventilation when previous airway attempts fail.  It allows for blind insertion in the most difficult of patients and situations and provides some protection against aspiration and higher airway pressures.

6) Develop a personal airway algorithm Each provider should have an algorithm specific to their skill level and approved scope

of practice.  Not all patients and situations you encounter are going to be the same.  Having only one or two airway skills in your repertoire can lead to a potentially dangerous approach to airway management.  Everyone’s algorithm should begin with the basics.  For example, start with BVM ventilation, advance to ET intubation, then place a Combitube®, and finally perform a surgical cricothyrotomy.  This plan should be calmly practiced and mastered.

7) Don’t let your ego get in the way This can be dangerous for your patient, your partner or colleagues, and your career. 

Remember, your goal is excellent patient care and a positive outcome, not skill accumulation or personal success. .  Don’t ever forget to ask for assistance when you need it. 

8) Invest time in learning airway skills Regularly devote training and practice time to airway management. 

Try not to limit yourself to manikin airway trainers if possible.  Work on gaining access to the simulator lab, operating room or emergency department.   Also, read about the latest techniques and advances in airway management.  Attend conferences and

airway obstacle courses for more hands-on training.  :  9) Use CAPNOGRAPH & an end tidal CO2 detector and/or

esophageal detector device to assist you in confirming every intubation . 

10)When seconds count, don’t count on seconds Each airway maneuver or intubation attempt should be your best

effort.  Often, our best chance at getting a decent airway is the first attempt.  Maximize your chances by leaving nothing to chance.  Being prepared often means the difference between success and failure.

Procedures of A/W

managementA/W Cane be managed

With(Advanced) or without

Basic))tracheal Intubation

ALWAYS REMEMBER THE BASICS

These skills should be used prior to initiating any

advanced airway techniqueHead-tilt/chin liftJaw thrustModified jaw thrust (for trauma patients)Sellick’s maneuver

Basic Airway Maneuvers

[

to open the A/W

Use head tilt & chin left or jaw

thrust

Techniques of Basic Airway Management

Non-invasive-Head positioning

-Removal of foreign body-Suctioning

-Mask ventilation

Opening and head positioning

• Jaw thrust

• Head Tilt Chin lift

• Combined

•Remember : C-spine stabilization

Airway managementManual methods:

Head tilt & Chin liftJaw Thrust ( Trauma)

Head-tilt/chin-liftHead-Tilt/Chin-Lift

Head-Tilt/Chin-Lift

TechniquePlace one hand on patient’s foreheadApply firm, backward pressure with palm causing head to tilt backward Place fingers of other hand under bony part of patient’s lower jaw near chinLift jaw upward to bring chin forward

Head-Tilt/Chin-Lift

♥Loss of consciousness is often accompanied by loss of submandibular muscle tone .

♥Occlusion of the A/W. by tongue can be relived by a head- tilt chin lift ( if no evidence of c.spine injury,

Head-Tilt/Chin-Lift

Falling of tongue backward ( during loss of consciousness) is the most common cause of U/A/W/ obstruction. which can be relieved by a head-tilt /chin lift or jaw- thrust.

Head-Tilt/Chin-Lift

Airway adjuncts

Oropharyngeal airwayNasopharyngeal airway

Airway adjunctsOropharyngeal airwayNasopharyngeal airway

Airway Adjuncts

• Oropharyngeal Airway (OP)– Helps prevent tongue from obstructing

posterior pharynx – Potential use in unconscious patient– Cannot use in patients with intact gag reflex– SIZING: measure from corner of mouth to

angle of jaw– PLACEMENT: direct method vs rotation

method.

Airway Adjuncts

• Nasopharyngeal Airway (NP)– Unconscious or depressed mental status– SIZING: Measure from the tip of the nares to

the tragus of ear– CONTRAINDICATIONS: basilar skull fracture,

midface fractures, bleeding disorders– Relative contraindication: children < 1 year

old

Oropharyngeal Airways

•Features: -single use

-rounded edges -bite block

-colour coding -airway path in centre

How do you size oral

airways?:

The correct size will vary Oral Airways with each patient.

To size the OPA, it is measured against the distance from the corner of the patient's mouth to the patient's earlobe.

SIZING THE OPA:

correct size :

• it is measured against the distance from the corner of the patient's mouth to the patient's earlobe.

incorrect size :

• If an airway

is too small ,it may obstruct the airway.

incorrect size :

• If an airway is too large ,it may obstruct the airway.

Incorrect insertion of an OPA

can displace the tongue into hypopharynx ,

causing air-way obstruction

OPAImproper placement of oropharyngeal airway

INSERTION OF THE OPA :

• It is the responsibility of every provider, regardless of certification level, to manage a patient's airway in the most effective way possible

• Position the casualty on his back.• Place your thumb and index finger of one hand on the

casualty's upper and lower teeth near a corner of his mouth so the thumb and finger will cross when the casualty's mouth is opened.

• Push your thumb and index finger against the casualty's upper and lower teeth in a scissors-like motion until his teeth separate and his mouth opens.

• If the teeth do not separate, wedge your index finger behind the casualty's back molars and force the teeth apart.

INSERT THE OROPHARYNGEAL AIRWAY :

Place the tip end of the airway into the casualty's mouth. Make sure the tip is on top of the tongue. Point the tip of the airway up toward the roof of the casualty's mouth.

Slide the airway along the roof of the casualty's mouth, following the natural curvature of the tongue.

When the tip of the airway reaches the back of the tongue past the soft palate, rotate the airway 180 degrees so the tip of the airway points toward the casualty's throat.

INSERT THE OROPHARYNGEAL AIRWAY :

Advance the airway until the flange rests against the casualty's lips.

The airway should now be positioned so the tongue is held in place and will not slide to the back of the casualty's throat.

INSERT THE OROPHARYNGEAL AIRWAY :

INSERTION OF THE OPA• Using a head-tilt-

chin-lift, a modified jaw-thrust, or by grasping the tongue and jaw by placing your thumb in the patient's mouth, move the tongue forward.

INSERTION OF THE OPA :

• Position the OPA as shown with the tip in the patient's mouth and slowly insert the OPA

INSERTION OF THE OPA :

• At the point resistance is met, insertion should continue while simultaneously rotating the OPA 180°.

INSERTION OF THE OPA :

• Advance the OPA until the flange is resting on or just above the patient's teeth .

INSERTION OF THE OPA :

Blindly inserting the O/A/W upside down and turning it 180 ْonce it is in the mouth may push the tongue against the post. Pharynx which help to open A/W.

Check the casualty's respirations to make sure he is still breathing adequately and the oropharyngeal airway is not blocking his airway.Adjust the position of the oropharyngeal airway, if needed

MONITOR A CASUALTY WITH ANOROPHARYNGEAL AIRWAY IN PLACE

:

♥ The position of the airway in the patient’s mouth and breath sounds should be assessed frequently

♥ The oral cavity should be suctioned as needed.   ♥ Mouth care should be done every two to four

hours and as needed. ♥ Mouth care can be done with a moistened

swab.

some tips to care for a patientwith an oropharyngeal airway

If the airway is coated with secretions, it can be removed and insert a clean airwayIf the patient has the oropharyngeal airway as a long-term measure, the airway should be cleaned and replaced at  least once every eight hours.

some tips to care for a patientwith an oropharyngeal airway

Oropharyngeal airway

Contraindicated in patients with

gag reflex.

Oropharyngeal Airway

SIZEPROPER

POSITION

Image from: http://www.hadassah.org.il/NR/rdonlyres/59B531BD-EECC-4FOE-9E81-14B9B29D139B1945/AirwayManagement.ppt

Question:Should you tie or tape the airway in place?

Response:No.

Question:What should you do if the casualty begins

to regain consciousness?

Response:Remove the airway .

2.Nasopharyngeal AirwaySoft plastic or rubber tube that is designed to pass just inferior to the base of the tonguePassed through one of the nares and can be used in patients with an intact gag reflexCONTRAINDICATED in cases of suspected or possible basilar skull fractureSizes range from 17-26 cm in length and 6-9 mm internal diameterMeasured from tip of the nose to the corner of the patients ear

Nasal Airway continuedThe nasal airway is lubricated with a water soluble lubricantThe beveled tip is inserted directed towards the septum, with the airway directed perpendicular to the faceIf resistance is met, rotating the airway may help or the other nare may be used

Nasopharyngeal airway

Contraindicated in patients with basal skull #

Naso-pharyngeal A/W

Nasal A/W ( Naso-pharyngeal A/W)

The length is 2 – 4 cm longer than oral A/W Used to relieve upper A/W obstruction caused by

tongue or soft palate falling against posterior wall of the pharynx .

Suction via this A/W less traumatic than oral A/W.

Better tolerated than orally A/W. in awake or lightly anaesthetized patient.

After it is lubricated it can be gently inserted down at an angle to the face to avoid traumatizing the turbinate or the roof of the nose

Nasal Airways• Patients needing nasal airway

–Unresponsive patients who are snoring

–Unresponsive patients with gag reflex

It should be alternated every 24 h. between R& L. nares to minimize complication .

Should not be used in : *Anticoagulant patient . * Children with prominent adenoids

Absolute contraindication in skull fracture base

Sinusitis , otitis media , nasal necrosis , are possible complication of its use

SIZING THE NPA• The correct size will vary with

each patient. To size the NPA, it is measured against the distance from the patient's nose to the patient's earlobe

CORRECT SIZE INCORRECT SIZE

INSERTION OF AN NPAFirst, check the nostril for signs of fracture or obstruction then apply generous amounts of a water-based lubricant to the NPA taking care

not to fill the tip with the lubricant

Orient the bevel end so that it will pass along the inside of the nasal cavity with minimal effort and insert the NPA until

the flange (the large end of the tube) is seated on the patient's nose as shown below

Two NPA's can be inserted to provide even better ventilation. Placing the second is similar in fashion with one difference: The bevel of the second

NPA must be oriented to the nasal septum as was the first but the curvature of the NPA itself indicates that while being inserted, it must be

turned 180° when about 1/2 way into the nasal cavity

SPECIAL CONSIDERATIONS Another acceptable sizing technique is

to match the diameter of the NPA to that of the patient's little finger

If significant resistance is felt upon insertion of the NPA, remove it and attempt placement in the opposite nostril

Be prepared for bleeding that may occur with the placement of the NPA

Always make efforts to be prepared with suction devices at the ready with all airway procedures in the event the patient should vomit

Potential Hazards Involved in the Use of Nasopharyngeal airways airways• Using an airway that is too long; this

may cause the tip to enter the esophagus.

• Injuring the nasal mucosa causing bleeding. This can lead to aspiration of blood or clots.

• If nasal airway doesn’t have flange at the nasal end can lose airway in nose and the airway.

Q1. An NPA shouldn't be used if _______ has been found in the patient's

nose.A. Blood.B. Vomitus.C. Cerebrospinal fluid.D. Soft-tissue damage

Q2. As you are inserting an oropharyngeal airway, your patient begins to gag. You

should: A. Continue placing the airway, as the

gagging will cease when it is completely inserted.

B. Roll the patient on his side and continue inserting the airway.

C. Apply cricoid pressure to prevent vomiting.immediately

D. Remove the airway and prepare to suction.

Q. 12.Which airway adjunct can be used if the

patient has a gag reflex?

A. Nasopharyngeal airway B. Oropharyngeal airway C. Pharyngeal lumen

airway D. Nasal cannula

Q4. The preferred method of inserting an

oropharyngeal airway in a child is A. by using a tongue depressor to press the

tongue down while inserting the airway.B. by inserting the airway so that the tip is

pointing towards the roof of the mouth, and rotating it 180 degrees as you insert it

C. .by inserting the airway with the tip towards the side of the patient's mouth, rotating it 90 degrees as you insert it.

D. None of the above. Oropharyngeal airways are not recommended for children.

Q23.Which of the following statements is true

regarding the oropharyngeal airway? A. The oral airway may be used in any

conscious patient who needs airway control.

B. Even with the airway inserted it is necessary to maintain the position of the head.

C. Measure the oral airway by comparing the airway to the patient's little finger.

D. The preferred method of insertion in an infant or child is upside-down first.

Why is proper size important when using an

OPA or NPA? A. Too large may block the

airway B. Too large may damage tissue C. Too small may not adequately

control airway D. All of the above

You are considering use of an oropharyngeal airway

(OPA). You know that all of the following are true

EXCEPT?A. A too-large OPA may obstruct the larynxB. A too-small OPA may obstruct the airway by

pushing the tongue into the throatC. You should insert the OPA so that it curves

upward and then rotate it 180 degrees to match the curve of the tongue and throat

D. OPAs are safe to use in all patients

Bag-valve-mask

ventilation(BVM)

Be an expert at bag-valve-mask (BVM) ventilation

INDICATIONS: The BVM is a device used to

deliver positive pressure ventilations to patients :-who are breathing ineffectively or not breathing at all.

Bag-mask ventilation is a basic but critical airway management skill. It enables clinicians to provide adequate ventilation for patients requiring airway support and allows enough time to establish a more controlled approach to airway management,.Because the technique can be difficult to perform correctly, clinicians performing the procedure should continually practice and monitor their technique

Bag-valve-maskComponents of BVM VentilationSelf-inflating bagOne-way valveFace maskOxygen reservoirMust be connected to oxygen to perform

most effectively

Bag-valve-maskBy adding oxygen and a reservoir close to 100% oxygen can be delivered to the patientWhen using a BVM an OPA/NPA should be used if possibleVolume of approximately 1,600 millilitersProvides less volume than mouth-to-maskSingle Rescuer may have trouble maintaining seal Two Rescuer more effectiveAvailable in infant, child, and adult sizes

Bag and mask ventilation is an important clinical skill to

masterIn most resuscitation settings a self-reinflating bagwith nonrebreathing valves (such as that shown) isused to provide positive pressure ventilation, usually using100% oxygen. This bag fills spontaneously after being squeezed and can be used even when oxygen is unavailable.

Strategies for

Successful BVM

Ventilation

APPLYING THE BVM:

The mask of the BVM should be placed over the patient's nose and mouth to ensure an adequate seal between the patient's face and the mask itself. OPA/NPA's can be used in conjunction with the BVM to ensure adequate passage for each ventilation

Basics skill of BVM

Paying attention to the basics of this skill will make it maximally effective

Single person BVM

Two person BVM

Bag-mask ventilation

All healthcare providers should be familiar with the use of the bag- mask device for support of oxygenation and ventilation.

Successful bag-mask ventilation depends on three things: 

Patent airway :Airway patency can be established using basic airway maneuvers Adequate mask seal :In order to secure a good seal, the mask must be placed and held correctly Proper ventilation (ie, proper volume, rate )

In order to secure a good seal, the mask must be placed and held correctly Excessive tidal volumes: A volume just large enough to cause chest rise (no more than 8 to 10 cc/kg) should be used. During cardiopulmonary resuscitation (CPR), even smaller tidal volumes are adequate (5 to 6 cc/kg) due to the reduced cardiac output of such patients. Forcing air too quickly: The bag should not be squeezed explosively. It should be squeezed steadily over approximately one full second. Ventilating too rapidly. The ventilatory rate should not exceed 10 to 12 breaths per minute.

Ventilation TechniquesBVM Issues

Single rescuer may have difficulty maintaining air-tight seal

Two rescuers using device are more effective

Position yourself at top of patient’s head for best performance

Oral or nasal airway should be inserted

Ventilation Techniques BVM Technique (Two Rescuer)

Open airway, insert oral or nasal airwayPosition thumbs over top half of mask, index and middle fingers over bottom halfPlace apex of mask over bridge of nose, lower mask over mouth/upper chinUse ring and little fingers to bring jaw up to maskHave assistant squeeze bag with two hands until chest risesVentilate every 5 seconds for adults, every 3 seconds for infants and children

Bag-mask ventilation

two-person fitting technique; are more effective

one person secures the mask to the face while an assistant delivers breaths

Two hands method with one rescuer using two hands to hold the mask in place while another

rescuer applies PPV.with the BVMThe rescuer uses his/her thumb and index finger to hold the mask while the middle, ring, and pinky fingers are used to grasp the soft tissue under the patient's jaw. forming a seal as the patient's face is pulled up and into the mask.

Q25.When using a bag-valve-mask to ventilate a

non-breathing patient A. Position yourself to the side of the

patient's head.B. Use your ring and little finger to bring

the patient's jaw up to the mask.C. It is not necessary to use an airway

adjunct.D. Give one ventilation every 12 seconds.