Lesson 05

Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Lesson 5Lesson 5

Airway, Oxygenation, Airway, Oxygenation, and Ventilationand Ventilation

Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 2

ObjectivesObjectives As a result of active participation in this lesson As a result of active participation in this lesson

you should be able to:you should be able to: Recognize the need for early management of airway, Recognize the need for early management of airway,

oxygenation, and ventilation in trauma patientsoxygenation, and ventilation in trauma patients Discuss advantages, disadvantages, indications, and Discuss advantages, disadvantages, indications, and

contraindications of basic and advanced methods contraindications of basic and advanced methods and devices for management of the trauma patient’s and devices for management of the trauma patient’s airway, oxygenation, and ventilationairway, oxygenation, and ventilation

Discuss the need for on-going assessment Discuss the need for on-going assessment of the trauma patient’s airway, oxygenation,of the trauma patient’s airway, oxygenation,and ventilationand ventilation


ScenarioScenario

It is a pleasant spring morning. You and your partner have been dispatched to a residence to assist a man injured by a falling tree. As you approach the residence, a middle-aged man directs you to the back yard where you see two men kneeling next to a third man, who is sitting on the ground, leaning against a large fallen tree.


ScenarioScenario

The men had been cutting down a tree The men had been cutting down a tree damaged in a storm. As the tree fell, the injured damaged in a storm. As the tree fell, the injured man was unable to get out of the way. The man was unable to get out of the way. The trunk of the tree missed him, but he was hit by a trunk of the tree missed him, but he was hit by a large branch and knocked to the ground. His large branch and knocked to the ground. His co-workers cut the branch away before your co-workers cut the branch away before your arrival.arrival.


Scenario: Scene Size-UpScenario: Scene Size-Up

What are the considerations for scene What are the considerations for scene safety?safety?

What are the potential injuries associated What are the potential injuries associated with this mechanism?with this mechanism?


Scenario: General ImpressionScenario: General Impression

The patient is awake with labored ventilations The patient is awake with labored ventilations and an increased respiratory rate. One of the and an increased respiratory rate. One of the co-workers is holding a towel to the patient’s co-workers is holding a towel to the patient’s right posterior chest, just below the scapula. right posterior chest, just below the scapula. There is a moderate amount of blood on the There is a moderate amount of blood on the towel and on the patient’s shirt.towel and on the patient’s shirt.


Scenario: Primary SurveyScenario: Primary Survey

Awake, anxiousAwake, anxious Shallow, labored ventilations; rate faster than Shallow, labored ventilations; rate faster than

normalnormal Skin is cool, radial pulse is rapidSkin is cool, radial pulse is rapid



What do the findings suggest?What do the findings suggest? Is there evidence of compromised Is there evidence of compromised

respiration?respiration?


Scenario: Critical ThinkingScenario: Critical Thinking

What is happening to this patient?What is happening to this patient? What else do we need to know from the What else do we need to know from the

primary survey?primary survey?



Breath sounds are decreased on the right Breath sounds are decreased on the right sideside

There is an open wound to the right There is an open wound to the right posterior chestposterior chest

External bleeding is controlledExternal bleeding is controlled No air is entering the woundNo air is entering the wound It appears that a 1-inch (2.5-cm) diameter It appears that a 1-inch (2.5-cm) diameter

stick is broken off in the woundstick is broken off in the wound


Respiratory CompromiseRespiratory Compromise

A state of impaired ventilation and/or oxygenationA state of impaired ventilation and/or oxygenation resulting in resulting in inadequate cellular oxygenation to meet metabolic needsinadequate cellular oxygenation to meet metabolic needs

Cells have different levels of sensitivity Cells have different levels of sensitivity to hypoxiato hypoxia

Brain cells begin to die in 4 to 6 minutes without oxygenBrain cells begin to die in 4 to 6 minutes without oxygen

Organ Tolerance to Ischemia


Ventilation and RespirationVentilation and Respiration

Fick conceptFick concept Airway, ventilation, Airway, ventilation,

oxygenation, and oxygenation, and circulation are allcirculation are allneeded for respirationneeded for respirationto occurto occur



VentilationVentilation Adequate movement of air into and Adequate movement of air into and

out of the lungsout of the lungs OxygenationOxygenation

Delivery of ODelivery of O22 to the cells via RBCs to the cells via RBCs



RespirationRespiration External = ventilationExternal = ventilation Internal = the use of OInternal = the use of O22 by the cells to form ATP by the cells to form ATP

for energy and convert lactic acid to Hfor energy and convert lactic acid to H22O and COO and CO22, ,

which can be eliminated through ventilationwhich can be eliminated through ventilation


Respiratory Anatomy Respiratory Anatomy and Physiologyand Physiology

Upper airwayUpper airway NoseNose MouthMouth PharynxPharynx


Respiratory PathophysiologyRespiratory Pathophysiology

Upper airwayUpper airway

obstructionobstruction TongueTongue Teeth, bone, soft Teeth, bone, soft

tissuetissue BloodBlood VomitVomit Foreign bodyForeign body


Assessment: AirwayAssessment: Airway

Level of consciousnessLevel of consciousness General appearance and level of distressGeneral appearance and level of distress Air movementAir movement

BreathingBreathing Ability to speakAbility to speak

Work of breathingWork of breathing Noisy ventilationsNoisy ventilations


Airway Management: Airway Management: Essential SkillsEssential Skills

Manual clearing of the airwayManual clearing of the airway Manual maneuversManual maneuvers

Head-tilt chin-liftHead-tilt chin-lift Jaw thrustJaw thrust

SuctionSuction Basic adjunctsBasic adjuncts

Oropharyngeal airwayOropharyngeal airway Nasopharyngeal airwayNasopharyngeal airway


Airway ManagementAirway Management

Dual lumen/ Dual lumen/ nonvisualized airwaysnonvisualized airways CombitubeCombitube Laryngeal mask airwayLaryngeal mask airway



Endotracheal airwaysEndotracheal airways Placement under direct laryngoscopyPlacement under direct laryngoscopy Pharmacologically assisted Pharmacologically assisted

intubationintubation Face-to-face intubationFace-to-face intubation Blind nasotracheal placementBlind nasotracheal placement Digital placementDigital placement Retrograde intubationRetrograde intubation



Surgical airwaysSurgical airways Used in “can’t intubate, Used in “can’t intubate,

can’t ventilate” scenarioscan’t ventilate” scenarios Needle cricothyrotomyNeedle cricothyrotomy Surgical cricothyrotomySurgical cricothyrotomy





Lower airwayLower airway EpiglottisEpiglottis LarynxLarynx TracheaTrachea BronchiBronchi LungsLungs



Lower airwayLower airway LungsLungs

• BronchiBronchi

• BronchiolesBronchioles

• AlveoliAlveoli



VentilationVentilation Air moves in and out of Air moves in and out of

the lungsthe lungs RequiresRequires

• Intact conducting airwaysIntact conducting airways

• Intact chest wallIntact chest wall

• Contact between visceral Contact between visceral and parietal pleuraand parietal pleura

• Intact neurological Intact neurological functionfunction

• Intact diaphragmIntact diaphragm



VentilationVentilation Tidal volume Tidal volume ×× respiratory rate = minute volume respiratory rate = minute volume



Average adult tidal volume = 500 mLAverage adult tidal volume = 500 mL 150 mL remains in the airway above the level of 150 mL remains in the airway above the level of

the alveoli and is not available for gas exchangethe alveoli and is not available for gas exchange Adult respiratory rate = 12–20Adult respiratory rate = 12–20

RR of 14 RR of 14 ×× 500 mL tidal volume = 7000 mL/minute 500 mL tidal volume = 7000 mL/minute at restat rest• 4900 mL is available for gas exchange4900 mL is available for gas exchange• 2100 mL never reaches the alveoli2100 mL never reaches the alveoli



VentilationVentilation Hypoventilation = inadequate minute volumeHypoventilation = inadequate minute volume Trauma increases need for oxygen delivery and Trauma increases need for oxygen delivery and

carbon dioxide eliminationcarbon dioxide elimination



NeurologicalNeurological Traumatic brain injuryTraumatic brain injury High spinal cord injuryHigh spinal cord injury

Conducting airwaysConducting airways Lacerated or obstructed Lacerated or obstructed

trachea or bronchitrachea or bronchi Chest wallChest wall

Flail chestFlail chest



Pleural contactPleural contact PneumothoraxPneumothorax

• OpenOpen

• ClosedClosed

• TensionTension

HemothoraxHemothorax


Assessment: VentilationAssessment: Ventilation

General appearance and level of distressGeneral appearance and level of distress Air movementAir movement Depth of ventilationDepth of ventilation Respiratory rateRespiratory rate Evidence of tension pneumothoraxEvidence of tension pneumothorax Blunt or penetrating trauma to the thoraxBlunt or penetrating trauma to the thorax Chest excursion and symmetryChest excursion and symmetry Breath soundsBreath sounds Later: pulse oximetry, end-tidal COLater: pulse oximetry, end-tidal CO22 monitoring monitoring


ScenarioScenario

Our patient’s ventilatory rate is increased to Our patient’s ventilatory rate is increased to 24 per minute24 per minute


Critical ThinkingCritical Thinking

ExampleExample Minute volumeMinute volume

• 300 mL 300 mL ×× 24 bpm = 7200 mL/minute 24 bpm = 7200 mL/minute


Critical ThinkingCritical Thinking

However:However: Only 3600 mL is available for gas exchangeOnly 3600 mL is available for gas exchange Remaining 3600 mL never reaches the alveoliRemaining 3600 mL never reaches the alveoli Trauma patients have increased oxygen demands Trauma patients have increased oxygen demands


Ventilation: ManagementVentilation: Management

Needle chest Needle chest decompression for tension decompression for tension pneumothoraxpneumothorax

Stabilization of flail segmentStabilization of flail segment Pocket maskPocket mask Bag-valve-maskBag-valve-mask


Ventilation: ManagementVentilation: Management

Bag-valve device with Bag-valve device with nonvisualized airway or nonvisualized airway or endotracheal tubeendotracheal tube

Manually triggered (oxygen Manually triggered (oxygen powered) ventilation devicepowered) ventilation device

High-pressure oxygen delivery High-pressure oxygen delivery via needle cricothyrotomy via needle cricothyrotomy (percutaneous transtracheal (percutaneous transtracheal ventilation)ventilation)



Decreased ATP (energy) for cell membrane Decreased ATP (energy) for cell membrane functionfunction Low pH results in release of cellular enzymes that Low pH results in release of cellular enzymes that

autodigest cellsautodigest cells Cellular edemaCellular edema Loss of intravascular volumeLoss of intravascular volume



OxygenationOxygenation Pulmonary circulationPulmonary circulation Capillary-alveolar Capillary-alveolar

interfaceinterface



Capillary-alveolarCapillary-alveolar

interface = theinterface = the

respiratory membranerespiratory membrane


Oxygenation: PathophysiologyOxygenation: Pathophysiology Impaired pulmonary or systemic circulationImpaired pulmonary or systemic circulation

Pulmonary embolismPulmonary embolism ShockShock

Increased distance for gas diffusion across the Increased distance for gas diffusion across the respiratory membranerespiratory membrane Pulmonary contusionPulmonary contusion Pulmonary edemaPulmonary edema

Inability of RBCs to off-load oxygenInability of RBCs to off-load oxygen AlkalosisAlkalosis CO poisoningCO poisoning


Oxygenation: AssessmentOxygenation: Assessment

MechanismMechanism General appearanceGeneral appearance CyanosisCyanosis AirwayAirway VentilationVentilation Circulatory compromiseCirculatory compromise


ScenarioScenario

RecallRecall MechanismMechanism General appearanceGeneral appearance Increased respiratory rateIncreased respiratory rate Decreased tidal volumeDecreased tidal volume Increased heart rateIncreased heart rate Decreased breath soundsDecreased breath sounds


Scenario: Critical ThinkingScenario: Critical Thinking

What is/are the likely cause(s) of the patient’s What is/are the likely cause(s) of the patient’s respiratory compromise?respiratory compromise?

How do you know?How do you know?


Assessment: Critical ThinkingAssessment: Critical Thinking

What factors may affect a patient’s ability to What factors may affect a patient’s ability to respond to and compensate for respiratory respond to and compensate for respiratory compromise?compromise? AgeAge Preexisting medical conditionsPreexisting medical conditions


Management: Airway, Management: Airway, Ventilation, and OxygenationVentilation, and Oxygenation

Prehospital care providers must address all Prehospital care providers must address all physical and physiological causes of physical and physiological causes of inadequate cellular respirationinadequate cellular respiration Patent airwayPatent airway Adequate Adequate

• Rate and depth of ventilationRate and depth of ventilation• Inspired oxygen/on-loadingInspired oxygen/on-loading• Circulation of RBCsCirculation of RBCs• Off-loadingOff-loading• Elimination of carbon dioxideElimination of carbon dioxide


Management: ScienceManagement: Science

Studies have shown a tendency toward Studies have shown a tendency toward patient hyperventilation by prehospital patient hyperventilation by prehospital personnelpersonnel

Hyperventilation Hyperventilation Increases intrathoracic pressure, which impedes Increases intrathoracic pressure, which impedes

blood return to the heart, reducing cardiac outputblood return to the heart, reducing cardiac output Reduces COReduces CO22

How are your ventilation techniques?How are your ventilation techniques?


Management: ScienceManagement: Science

Endotracheal intubation does not necessarily Endotracheal intubation does not necessarily improve patient survival over the use of BVM improve patient survival over the use of BVM ventilationsventilations

RSI does not necessarily benefit patientsRSI does not necessarily benefit patients


Management: Airway,Management: Airway,Ventilation, and OxygenationVentilation, and Oxygenation

Guiding principlesGuiding principles What is the cause of respiratory compromise in What is the cause of respiratory compromise in

this patient?this patient? What is the care for this problem?What is the care for this problem? Where/how can the patient get this care?Where/how can the patient get this care? What can be done between now and the time the What can be done between now and the time the

patient reaches definitive care?patient reaches definitive care?


Guiding principlesGuiding principles The best airway management and ventilation The best airway management and ventilation

technique is the one that provides adequate technique is the one that provides adequate ventilation and oxygenation with the fewest ventilation and oxygenation with the fewest complicationscomplications



Compromised oxygenation may be occurring Compromised oxygenation may be occurring before signs and symptoms are pronouncedbefore signs and symptoms are pronounced

Proper management improves the Proper management improves the oxygenation of RBCs, improves the delivery oxygenation of RBCs, improves the delivery of RBCs to the tissues, and off-loading of of RBCs to the tissues, and off-loading of oxygen at the cellular leveloxygen at the cellular level

What is the proper management?What is the proper management?



Scenario: AirwayScenario: Airway

What are the patient’s airway needs?What are the patient’s airway needs?


Scenario: VentilationScenario: Ventilation

Does the patient require assisted Does the patient require assisted ventilations?ventilations?


Scenario: OxygenationScenario: Oxygenation

What guides the What guides the

administration ofadministration of

oxygenation for this oxygenation for this

patient?patient?


Scenario: CirculationScenario: Circulation

What can be done to improve the patient’s What can be done to improve the patient’s circulation?circulation?


Transport ConsiderationsTransport ConsiderationsTransport without delay Transport without delay

does not mean “scoop does not mean “scoop and run.”and run.”

Anything that can be Anything that can be done to immediately done to immediately improve cellular improve cellular oxygenation must be oxygenation must be done.done.

How do decisions differ How do decisions differ based on transport based on transport time?time?


Scenario: Secondary SurveyScenario: Secondary Survey

After beginning transport you perform a After beginning transport you perform a secondary surveysecondary survey Minor lacerations and abrasions to the upper Minor lacerations and abrasions to the upper

extremitiesextremities No additional injuries to the chest No additional injuries to the chest Breath sounds remain decreased on the rightBreath sounds remain decreased on the right Abdomen is soft and nontenderAbdomen is soft and nontender No apparent injuries to the pelvis or lower No apparent injuries to the pelvis or lower

extremitiesextremities


Scenario: Secondary SurveyScenario: Secondary Survey

Vital signsVital signs RR 28RR 28 SaOSaO22 92% on 15 liters O 92% on 15 liters O22

HR 116HR 116 Blood pressure 132/90Blood pressure 132/90


Complications: Inadequate Airway, Complications: Inadequate Airway, Ventilation, and OxygenationVentilation, and Oxygenation

Prehospital care can make a difference in the Prehospital care can make a difference in the patient’s eventual outcomepatient’s eventual outcome Failure to maintain the airway and inadequate Failure to maintain the airway and inadequate

ventilation and oxygenation lead to tissue hypoxiaventilation and oxygenation lead to tissue hypoxia Overly aggressive ventilation leads to increased Overly aggressive ventilation leads to increased

intrathoracic pressure, poor preload, and intrathoracic pressure, poor preload, and inadequate perfusioninadequate perfusion


Minimizing ComplicationsMinimizing Complications

What is the best airway for the patient?What is the best airway for the patient?


Scenario: On-going AssessmentScenario: On-going Assessment

Breath sounds remain decreased on the rightBreath sounds remain decreased on the right Respiratory rate 28Respiratory rate 28 SaOSaO22 90% on 15 liters O 90% on 15 liters O22

Heart rate 118Heart rate 118 Blood pressure 134/90Blood pressure 134/90


Scenario: OutcomeScenario: Outcome Chest x-ray film confirmed a 70% right Chest x-ray film confirmed a 70% right

pneumothorax pneumothorax A chest tube was inserted in the EDA chest tube was inserted in the ED The impaled stick was surgically removedThe impaled stick was surgically removed A lacerated bronchus required surgical repairA lacerated bronchus required surgical repair A right pulmonary contusion evolved A right pulmonary contusion evolved

postoperativelypostoperatively The patient was released when the The patient was released when the

pulmonary contusion resolved pulmonary contusion resolved sufficiently to allow adequate sufficiently to allow adequate oxygenation on room airoxygenation on room air


SummarySummary

Respiratory compromise is a state of impaired Respiratory compromise is a state of impaired ventilation and/or oxygenation resulting in ventilation and/or oxygenation resulting in inadequate cellular oxygenation to meet inadequate cellular oxygenation to meet metabolic needs.metabolic needs.


SummarySummary

Prehospital care providers must address all Prehospital care providers must address all physical and physiological causes of physical and physiological causes of inadequate cellular respiration.inadequate cellular respiration. How do we do this?How do we do this?


QUESTIONS?QUESTIONS?

Lesson 05

Education

trauma patients airway

early management of

ventilation internal

respiratory compromise

increased respiratory

bronchi chest wall

patients shirt

injured man