Chapter 11: Respiratory Emergencies and Airway Management

Overview

In this chapter, you will learn how to manage a patient’s airway and how to care for respiratory emergencies. Because oxygen is vital to life, you must always ensure that the patient has an open airway and is breathing effectively. Airway and respiratory problems should be apparent when you check the patient’s ABCs during your primary assessment.

A respiratory emergency can occur in two ways: Respiration becomes difficult or ineffective, or respiration stops entirely. A patient who is having difficulty breathing (dyspnea) is in respiratory distress. A patient who has stopped breathing is in respiratory arrest.

Airway management and ventilation can contribute significantly to the survival and recovery of a seriously ill or injured patient. A number of devices can help you maintain an open airway, perform ventilations, and/or increase the oxygen concentration in a patient’s bloodstream. In addition, some of these devices limit the potential for infection.

Techniques for Opening the Mouth

There are two common methods of opening a patient’s mouth to assess the upper airway, insert an OPA, or provide suction. If the patient has facial trauma, use caution when inserting your fingers to avoid injury from sharp edges of broken teeth or dental appliances.

The Crossed-Finger Technique. This method is preferred in most situations.

  1. Cross the thumb and index finger of one hand.
  2. Place the thumb on the patient’s lower front teeth and the index finger on the upper front teeth.
  3. Open the mouth using a scissor motion.

The Tongue-Jaw Lift Technique. The tongue-jaw lift can provide a better view of the oral cavity and upper airway than the crossed-finger technique. However, it requires you to place your thumb between the patient’s teeth, so it exposes you to the risk of being bitten. If the patient is fully unresponsive, this risk is mitigated, so this technique may be used interchangeably with the crossed-finger technique.

  1. Place your index finger beneath the patient’s chin.
  2. Insert the thumb of the same hand into the patient’s mouth and grasp the tongue, pinning it between your thumb and finger.
  3. Gently lift the mandible to open the patient’s mouth.

Airway Obstructions

There are two types of airway obstruction:

  1. Anatomical airway obstruction. Occurs when the airway is blocked by an anatomical structure, which may result from injury to the neck or a medical emergency such as anaphylaxis. The most common obstruction in an unresponsive patient is the tongue, which may drop to the back of the throat and block the airway. This occurs because muscles, including the tongue, relax when deprived of oxygen.
  2. Foreign-body airway obstruction. Occurs when the airway is blocked by a foreign object, such as food, toys, or by fluids such as vomit, blood, mucus, or saliva. This may also be referred to as a mechanical obstruction.

If you see an object, carefully pick it out with your finger.

Partial FBOA – Mild Choking. A person that can still move air to and from the lungs. Have the patient cough forcefully. Usually the patient’s coughing will clear the object without the need for interventions. Coughing is usually more effective when the patient is in a seated position and leaning forward slightly. Sitting down also reduces the risk of injury if the patient becomes unresponsive. Purple call emergency. Partial choking can cause a great deal of anxiety, which can aggravate an underlying condition such as angina or asthma. Monitor the patient closely.

Complete FBOA – Severe Choking. Immediately have patient lean forward and administer five back blows. If that doesn’t work, 5 abdominal thrusts. If that doesn’t work, vertical CPR. Once unconscious, CPR with attempts to ventilate and manually remove the foreign object.

  • Back Blows.Stand to the side and just behind a choking adult. For a child, kneel down behind. Place one arm across the person’s chest for support. Bend the person over at the waist so that the upper body is parallel with the ground. Deliver five separate back blows between the person’s shoulder blades with the heel of your hand.
  • Abdominal Thrusts. Sand behind the person. Place one foot slightly in front of the other for balance. Wrap your arms around the person’s waist. Tip the person forward slightly. If the person is a child, kneel down behind the child. Make a fist with one hand and position it slightly above the person’s navel. Grasp the first with the other hand and press hard into the abdomen with a quick, upward thrust – as if trying to lift the person.

  • Pregnant or obese person. Position your hands a little bit higher than with a normal abdominal thrust, just above the joining of the lowest ribs.
  • Unconscious person. Lower the person on their back onto the floor, arms to the side. Clear the airway, being careful not to push the object deeper into the airway. Begin CPR, which may dislodge the object. After each set of 30 chest compressions, check the mouth, remove any objects you see, and attempt to ventilate. If your breath goes in, give a second breath. If it does not, resume the CPR sequence.
  • Children older than 1 and conscious. Give abdominal thrusts only. Be careful not to use too much force to avoid damaging ribs or internal organs.
  • Infants younger than 1. Sit down and hold the infant face down on your forearm, which is resting on your thigh. Support the infant’s head and neck with your hand, and place the head lower than the trunk. Thump gently but firmly 5 times on the middle of the back using the heel of your hand. The combination of gravity and back blows should release the blocked object. If the infant still isn’t breathing (check by turing the infant faceup on your forearm), Use two fingers placed at the centre of the infant’s breastbone to give 5 quick chest compressions, pressing down about 1.5 inches. Begin infant CPR if one of these techniques opens the airway but the infant doesn’t resume breathing.

Respiratory Emergencies

Allergic Reaction. An allergic reaction is non-life threatening, however it may develop into Anaphylaxis which is. Help the patient into the most comfortable position. Keep them calm. Sitting is better than lying. Remove the stinger using a credit card to flick stinger off patient. If patient is able to swallow, administer maximum dose of oral antihistamines. Hydrate patient. Monitor breathing for 30+ minutes – if the patient can only speak in 2 to 4 word sentences, administer an EpiPen and evacuate immediately as they are having Anaphylaxis.

Signs include: mild to no breathing difficulty, local swelling near the sting site, swelling around face, lips, and extremities, hives, runny nose, and itchy, swollen eyes.

Administering an Epipen.

  1. Grasp with orange tip pointing downward. Remove blue safety cap by pulling straight up – do not bend or twist.
  2. Place the orange tip against the middle of the outer thigh. Swing and push the auto-injector firmly into the thigh until it “clicks”. Hold firmly in place for 3 seconds – count slowly, “1, 2, 3”.

The effects of epinephrine can wear off or you could have a second reaction, so call 911, or go to the emergency room right after using EpiPen.

Do not inject more than 2 injections right after each other. Too much epinephrine can cause dangerously high blood pressure, stroke, or death. Signs of an overdose include:

  • Irregular heartbeat
  • Difficulty breathing caused by a buildup of fluid in your lungs

Anaphylaxis. Anaphylaxis is a life-threatening allergic reaction that causes the air passages to constrict. It occurs suddenly, within seconds or minutes of contact with the substance, though it may occur 30 minutes or more after exposure. Help the patient into the most comfortable position. Keep them calm. Sitting is better than lying. Remove the stinger using a credit card to flick stinger off patient. Administer an EpiPen asap. EpiPen lasts 10-15 minutes. If patient is able to swallow, administer maximum dose of oral antihistamines. Hydrate patient. Evac asap, and stand by with patient’s second EpiPen.

Signs include: respiratory distress, patient speaking in 2 to 4 word sentences, swollen face, lips, tongue, airway, extremities, and hives.

Chronic Obstructive Pulmonary Disease (COPD) (Emphysema & Chronic Bronchitis). The lungs are receiving low oxygen, resulting in a loss of lung function. They need oxygen. It may trigger an asthma attack. Types of COPD:

  • Emphysema: Alveoli in the lungs lose elasticity. Pink puffers. Exhaling is difficulty.
  • Chronic Bronchitis: Excessive mucus production and inflammation of lungs. Blue bloaters. Short of breath with productive cough.

Signs include: shortness of breath, gasping for air with sudden onset; sitting upright, leaning forward; a barrel-chested appearance; distended neck veins; cyanosis; prolonged exhalation through pursed lips.

Asthma. During an asthma attack, the air passages become constricted or narrowed by a spasm of the muscles lining the bronchi or by a swelling of the bronchi themselves, making breathing difficult. People usually become anxious or frightened by this. First, seat the patient and open their throat. Relax them. Administer inhaler to stop the muscle spasm (see inhaler information below). Blue inhalers and green inhalers are rescue puffers. Blue inhalers are ok for everyone, whereas white inhalers and green inhalers are not ok for a blue patient due to possible allergy. Blue, white, and green inhalers are rescue inhalers, while all other colors are preventer inhalers and do not help in an asthma attack. Shake the inhaler before use. After administering inhaler, attempt Pursed Lip Breathing (see below). Crushed caffeine tablets can work if an inhaler is not available. An EpiPen works if the patient is unresponsive or the puffer doesn’t work. Give oxygen, if available. Stop aspirin, ibuprofen, and other NSAIDs.

Signs include: wheezing during exhalations.

Using Inhalers. An Inhaler can deliver the following medications:

  • A bronchodilator, which helps open up your airways and increase airflow.
  • A corticosteroid, which helps reduce inflammation in your airways.
  • A combination of different bronchodilators.
  • A combination of a bronchodilator and corticosteroid.

Inhalers deliver these medication in three different types nd five different products, and a responder should know how to use all of them.

  1. MDIs (Metered Dose Inhalers) deliver a liquid medication that is inhaled slowly using a spacer in a single burst. MDIs are more effective with a spacer.

    An MDI (Metered Dose Inhaler)

  2. DPIs (Dry Powder Inhalers) deliver a dry powder medication that is inhaled without a spacer by wrapping lips around the mouthpiece. DPIs do not need a spacer.

 

Types of DPIs (Dry Powder Inhaler). From left to right, DISKUS, Turbuhaler, Diskhaler

      3. SMIs (Soft Mist Inhalers) deliver the medication in a slow mist that does not depend on how fast the medication is inhaled. SMIs do not need a spacer.

An SMI (Soft Mist Inhaler)

To use an MDI:

  1. Shake the puffer well before use (three or four shakes) Remove the cap.
  2. Breathe out, away from your puffer.
  3. Bring the puffer to your mouth. Place it in your mouth between your teeth and close your mouth around it.
  4. Start to breathe in slowly. Press the top of your puffer once, and keep breathing in slowly until you’ve taken a full breath.
  5. Remove the puffer from your mouth, and hold your breath for about 10 seconds, then breathe out.

To use a DISKUS:

  1. Open your DISKUS: Hold it in the palm of your hand, put the thumb of your other hand on the thumb grip and push the thumb grip until it “clicks” into place.
  2. Slide the lever until you hear a click. Your medication is now loaded.
  3. Breathe out away from the device.
  4. Place the mouthpiece gently in your mouth and close your lips around it.
  5. Breathe in deeply until you have taken a full breath.
  6. Remove the DISKUS from your mouth.
  7. Hold your breath for about ten seconds, then breathe out slowly.

To use a Turbuhaler:

  1. Unscrew the cap and take it off. Hold the inhaler upright.
  2. Twist the coloured grip of your Turbuhaler as far as it will go. Then twist it all the way back. You have done it right when you hear a “click”.
  3. Breathe out away from the device.
  4. Put the mouthpiece between your teeth, and close your lips around it. Breathe in forcefully and deeply through your mouth.
  5. Remove the Turbuhaler from your mouth before breathing out.
  6. Always check the number in the side counter window under the mouthpiece to see how many doses are left. For the Turbuhalers that do not have a dose counter window, check the window for a red mark, which means your medication is running out. When finished, replace the cap.

To use a Diskhaler:

  1. Remove the cover and check that the device and mouthpiece are clean.
  2. If a new medication disk is needed, pull the corners of the white cartridge out as far as it will go, then press the ridges on the sides inwards to remove the cartridge.
  3. Place the medication disk with its numbers facing up on the white rotating wheel. Then slide the cartridge all the way back in.
  4. Pull the cartridge all the way out, then push it all the way in until the highest number on the medication disk can be seen in the indicator window.
  5. With the cartridge fully inserted, and the device kept flat, raise the lid as far as it goes, to pierce both sides of the medication blister.
  6. Move the Diskhaler away from your mouth and breathe out as much as you can until no air is left in your lungs.
  7. Place the mouthpiece between your teeth and lips, making sure you do not cover the air holes on the mouthpiece. Inhale as quickly and deeply as you can. Do not breathe out.
  8. Move the Diskhaler away from your mouth and continue holding your breath for about 10 seconds.
  9. Breathe out slowly.
  10. If you need another dose, pull the cartridge out all the way and then push it back in all the way. This will move the next blister into place. Repeat steps 5 through 9.
  11. After you have finished using the Diskhaler, put the mouthpiece cap back on.

To use an SMI:

  1. Open the cap, after you’ve prepared the device following the manufacturer’s instructions.
  2. Breathe out slowly and fully.
  3. Close your mouth around the mouthpiece. Don’t cover the air vents on the side of the device.
  4. Take a slow deep breath while you press the dose release button. Inhale the mist.
  5. Hold your breath for 10 seconds.
  6. Repeat if necessary to get the dose your doctor prescribed.

Attempt Pursed Lip Breathing as follows:

  • Breathe in slowly through your nose, making sure to keep your mouth closed. Some people find it helpful to count to themselves, “one, two, three.”
  • Purse your lips as if you were going to whistle or gently blow out a candle, and then breathe out all of the air in your lungs through your mouth slowly and gently through pursed lips. Try to breathe out longer than your inhale. Some people find it helpful to count to themselves, “four, five, six, seven”
  • Continue to repeat this exercise of slowly inhaling through the nose and exhaling through pursed lips until your breath becomes normal.

Use a reliever with a spacer as follows:

  • 4 puffs (each separated by 4 breaths), re-assess in 4 minutes. If no improvement:
  • 4 puffs (each separated by 4 breaths), reassess in 4 minutes. If no improvement:
  • 10 puffs (each separated by 4 breaths), reassess in 20 minutes. If no improvement, continue with 10 puffs every 20 minutes until improvement occurs.

Using a spacer (only for MDIs). A spacer greatly improves the action of asthma sprays. to make one, cut a hole in the side of a plastic bottle (up to 1-litre) to loosely fit around the spray’s mouthpieces (do not have it so tight that it creates a seal). The patient puts the neck of the bottle in their mouth, activates the spray once and takes four breaths of the now invisible vapour.

If improvement occurs at any point in the above protocol, give ongoing treatment as follows:

  • Mild Attack: 4 puffs every hour
  • Moderate Attack: 10 puffs every hour
  • Severe Attack: 10 puffs every 10 minutes

Acute pulmonary Edema (APE). A buildup of fluid in the lungs, caused by heart or lung damage. For example, a number of heart disorders, pneumonia, smoke or toxin inhalation, narcotic overdose, drowning, and high-altitude sickness. Congestive heart failure (CHF) is the most common condition to cause APE. Patients are often found sitting upright, leaning forward. If you find a person lying down, instruct them to sit up and dangle their legs to encourage fluid to pool in the lefts. You should give oxygen to anyone with APE, and you may need to assist ventilation.

Signs include: shortness of breath, sudden onset, rapid and laboured breathing, and cyanosis, restlessness, anxiety, exhaustion, rapid pulse, cool, clammy skin, frothy sputum (in the later stages).

Pulmonary Edema – Caused by a buildup of fluid in the lungs

Pulmonary Embolism. Caused by a blockage of a pulmonary artery by a clot or other foreign material that has travelled from another part of the circulatory system. If you suspect someone has a pulmonary embolism, help them into a comfortable position and administer oxygen. Definitive care requires hospitalization.

Signs include: chest pain, anxiety, fainting, hypotension, tachycardia, short breath, fever, distended neck vein.

Pulmonary Embolism – Caused by a blockage of the pulmonary artery.

Pneumonia. A group of illness characterized by lung infection and fluid- or pus-filled alveoli, resulting in inadequate oxygen in the blood. Have the patient assume a comfortable position. Drink plenty of water. Control fever with anti-inflammatory drugs such as ibuprofen or naproxen.

Signs include: dyspnea, tachypnea, pleuritic chest pain, which usually worsens while breathing, productive cough with flem in the sputum, fever, usually exceeding 38 degrees Celsius, and chills. White phlegm = virus, yellow phlegm = bacterial.

Respiratory Distress (Breathing Too Fast (>30 RPM)). Occurs due to anxiety and may lead to unconsciousness. Calm the patient and try to slow their breathing. Be very reassuring and kind to the patient. Holding their hand helps. Assist the patient in taking any prescribed medication for the condition. It can take longer than 10 minutes to control.

Respiratory Distress (Breathing Too Slow (<6 RPM)). Ventilate the patient with rescue breaths. Monitor the patient’s skin color (blue = low oxygen), and evacuate the patient to hospital immediately.

          Ventilation Rates:

  • Adults: 1 breath every 5-6 seconds
  • Children: 1 breath every 3-5 seconds

Respiratory Arrest. Respiratory arrest is a life-threatening condition in which respiration ceases. It may be caused by illness, injury, or an obstructed airway. During respiratory arrest, the patient’s body is not independently acquiring oxygen. Without oxygen, the heart will quickly stop functioning, which causes the circulatory system to fail. However, you can simulate the function of the patient’s respiratory system with assisted ventilation.

If possible, monitor the patient’s pulse as you provide ventilations. After every 2 minutes of assisted ventilation, check whether the patient has begun to breathe spontaneously. You should also re-check the patient’s carotid pulse (for adults and children) or brachial pulse (for infants) to confirm that the heart is still beating. If the patient still has a pulse but is not breathing, continue to provide ventilations.

Continue to provide assisted ventilation until one of the following occurs:

  • The patient begins to breathe.
  • The patient’s pulse is absent. In this case, begin CPR.
  • You transfer care to another person with the same or a higher level of qualification.
  • You are too exhausted to continue.
  • The scene becomes unsafe.

Airway Management

Assisted Ventilation

Assisted ventilation is a technique for delivering atmospheric air and/or oxygen into a patient’s lungs when his or her breathing is inadequate. When performing assisted ventilation, you are actively pushing air into the patient’s lungs, not just supplying it for the patient to inhale.

Assisted ventilation is indicated for patients who are in respiratory arrest or who require assistance regulating their respiratory rates. A respiratory rate lower than 10 breaths per minute or higher than 30 breaths per minute indicates a need for assisted ventilation.

The most common devices used for assisted ventilation are the resuscitation mask and the bag-valve-mask (BVM) resuscitator. The best practice is to use supplemental oxygen in conjunction with your ventilation device, though atmospheric air can also be effective if supplemental oxygen is unavailable.

While ventilating a patient, maintain an open airway using the head-tilt/chin-lift or jaw thrust manoeuvre. Always provide an appropriate tidal volume for the patient: The amount of air given in each ventilation should be comparable to that of one normal breath. Watch the patient’s chest. You should see it begin to rise with each ventilation. If it does not, the patient’s airway may be obstructed. If re-tilting the patient’s head does not open the airway, obstructed airway interventions will be necessary before ventilations can be effective.

Your goal is to reproduce the natural respiratory rate of the patient. Provide 1 ventilation every 5 to 6 seconds for an adult and every 3 to 5 seconds for a child or an infant. If the patient is breathing too slowly (bradypnea), provide one ventilation as the patient inhales and a second ventilation in between the patient’s breaths, maintaining the natural respiratory rate (every 5 to 6 seconds for an adult and every 3 to 5 seconds for a child or an infant).

If the patient is breathing too quickly (tachypnea), provide one ventilation on every second inhalation, trying again to maintain a steady rate that mirrors the patient’s natural respiratory rate. If the patient is responsive, he or she may resist the ventilations or even begin to panic. Try to calm and reassure the person and explain what you are doing. Providing supplemental oxygen can help to reduce anxiety caused by hypoxia.

Because ventilations are given through a mask that covers the patient’s mouth and nose, the procedure is the same even if the patient’s mouth is compromised. Your ventilations will enter the lungs through the nasal passages.

In some cases, assisted ventilation will cause a patient to spontaneously resume a normal respiratory rate, even if that patient was initially in respiratory arrest. Otherwise, the ventilations will maintain a steady supply of oxygen to the patient’s lungs until additional interventions can be performed.

Special Considerations for Assisted Ventilation

Air in the Stomach (Gastric Distension). When you perform assisted ventilation, air sometimes enters the patient’s stomach instead of their lungs. This can cause serious problems because it can cause the patient to vomit. When an unresponsive patient vomits, the stomach contents can be inhaled, impairing breathing and creating the risk of an airway obstruction. If the patient vomits, you must clear the airway immediately.

There are several reasons why gastric distention may occur. First, overinflating the lungs by providing too much air in a ventilation may cause the extra air to enter the stomach. Second, ventilations that are given with too much force (aggressive ventilations) can also force air into the stomach. If the patient’s head is not tilted back adequately, the airway will not open completely and the chest may only rise slightly when you ventilate normally. This can lead you to provide ventilations with more force. Third, if your ventilation rate is too high, pressure can build up in the airway and cause air to enter the stomach.

To avoid forcing air into the stomach, be sure to keep the patient’s head tilted to an appropriate angle. Give ventilations with just enough volume to make the chest start to rise and maintain a steady rhythm of 1 breath every 5 to 6 seconds (every 3 to 5 seconds for infants and children).

Mouth-To-Stoma-Breathing. Some patients have had an operation to remove all or part of the larynx. They breathe through an opening in the front of the neck called a stoma. Air passes directly into the trachea through the stoma instead of through the mouth and nose.

When assessing the patient’s breathing, put the side of your face over the stoma rather than the mouth and nose. For ventilations, place the mask directly over the stoma and ensure that there is a good seal on the neck. It may be easier to create the seal if you use an infant- or child-sized mask. Otherwise, provide ventilations as usual. If the chest does not rise when you give ventilations, this may indicate that the patient has had only part of the larynx removed. This means that some air continues to flow through the larynx to the lungs during normal breathing. When providing ventilations into the stoma, air may leak through the nose and mouth, diminishing the amount that reaches the lungs. If this occurs, seal the nose and mouth with your hand to prevent air from escaping.

Patients with Dentures. Dentures help with assisted ventilation by supporting the patient’s  mouth and cheeks. If the dentures are loose, the head-tilt/chin-lift may help keep them in place. Remove the dentures only if they become so loose that they obstruct the airway or make it difficult to provide ventilations.

Resuscitation Devices

Resuscitation devices are used when providing assisted ventilation for a patient in respiratory distress or arrest. They are also a form of barrier protection, reducing the risk of direct contact between the patient and the responder.

Resuscitation Masks. Resuscitation masks are the simplest and most readily available resuscitation devices. They are much easier to use than BVM masks without a partner, and are small enough to be carried on your person. Adult and pediatric mask sizes are available. They can be susceptible to damage however: small parts such as valves can detach and become lost, and if stored for long periods in a collapsed state, can crack or split open.

When selecting a resuscitation mask, it should meet the following criteria:

  • Be made of transparent, pliable material that allows you to form a tight seal on the patient’s face.
  • Have a one-way valve for redirecting a patient’s exhaled air.
  • Contain a biofilter to keep fluids from entering the valve.
  • Have an inlet for the delivery of supplemental oxygen.
  • Work well under a variety of environmental conditions.
  • Be easy to assemble and use.

Using a Resuscitation Mask. To use a resuscitation mask, begin by expanding the mask and attaching the one-way valve. Next, place the mask so that it covers the patient’s mouth and nose. Position the lower rim of the mask between the patient’s lower lip and chin. The upper end of the mask should cover the nose. The figure below shows how to position the mask.

When using the mask, you must maintain a good seal to prevent air from leaking at the edges of the mask. Use both hands to hold the mask in place, and maintain an open airway by tilting the patient’s head back and lifting the jaw upward into the mask. The figures below show two different methods for holding the mask correctly, either besides the patient or above the patient’s head.

If you suspect the patient has a head or spinal injury, use the jaw thrust technique to maintain an open airway while holding the mask in position. The figure below shows how to do this.

Bag-Valve-Mask (BVM). BVMs are hand-held devices that allow you to ventilate the patient without using your own mouth. It can be adapted for use with certain airway adjuncts, and can be easily shared between responders without risk of infection. When used with an oxygen reservoir bag, it can deliver a higher concentration of oxygen than a resuscitation mask.

The device has three main components: a bag, a one-way valve, and a mask. The bag is self inflating and refills automatically when it is released. The one-way valve allows air to move from the bag to the patient’s airway but prevents exhaled air from entering the bag. The mask is similar to the resuscitation mask. Adult and pediatric mask sizes are available. An oxygen reservoir bag should be attached to the BVM when supplemental oxygen is administered.

The principle of the BVM is simple. By placing the mask on the patient’s face and compressing the bag, you open the one-way valve, forcing air from the bag into the patient’s lungs. When you release the bag, the valve closes and air from the atmosphere refills the bag. At approximately the same time, the patient exhales. This exhaled air is diverted into the atmosphere.

Using a Bag-Valve-Mask. When using a BVM on a non-breathing patient, ensure that the patient’s airway is open. Inserting an airway adjunct as soon as possible will assist in maintaining the patient’s airway.

The BVM is best used by two responders, however a single responder may be able to use a BVM effectively.

  • Using a BVM with Two Responders. The first responder positions the mask and opens the patient’s airway. The first responder should be positioned at the top of the patient’s head, with a view of the patient’s chest. The first responder maintains a tight seal with one thumb on each side of the mask facing the chest. The second responder provides ventilations by squeezing the bag. The bag should always be squeezed smoothly, giving just enough air to make the patient’s chest rise. This is generally about one-third of the bag’s capacity.
  • Using a BVM with One Responder. When using a BVM alone, you must maintain the mask seal, monitor the airway, and provide ventilations simultaneously. Position yourself above the patient’s head, facing the chest. Make a ‘C’ with the thumb and index finger of one hand and place it around the mask seal, with the index finger on the chin. Place the other three fingers of the same hand along the patient’s cheek, with your fingertips hooked under the patient’s mandible to maintain the angle of the head, protecting the airway. With your other hand, provide ventilations by squeezing the bag. The bag should always be squeezed smoothly, giving just enough air to make the patient’s chest rise. This is generally about one-third of the bag’s capacity.

BVM for Infants and Children. Some BVMs are designed specifically for children and infants. These devices have a smaller mask for a better fit on the face. The bag is designed to hold a smaller volume of air and limit the amount of air that is squeezed into the lungs. A number of these BVMs also include a valve that stops the forced entrance of air once a certain pressure has been reached, avoiding overinflation of the lungs. As always, ventilate until the chest just starts to rise.

Supplemental Oxygen

The normal concentration of oxygen in the air is approximately 21%, which is more than enough to sustain life under normal conditions. However, when serious injury or illness occurs, the body’s tissues may not receive sufficient oxygen from atmospheric air, resulting in hypoxia (a condition in which the body’s cells receive insufficient oxygen). Hypoxia can cause an increase in respiration and heart rate, restlessness, cyanosis, chest pain, and changes in responsiveness.

Supplemental oxygen is indicated in the following situations:

  1. The patient has been exposed to carbon monoxide.
  2. The patient is experiencing decompression sickness or injury.
  3. The patient is suffering from asphyxiation.
  4. The patient is suffering from dyspnea.
  5. The patient is hypoxic.
  6. The patient’s SpO2 is lower than 95% (hypoxemia)

In order to deliver supplemental oxygen, a responder must have the following equipment:

  • An oxygen cylinder. Oxygen cylinders have a distinctive green or white colour and a yellow diamond marking that says “oxidizer.” Depending on their size, those used in the pre-hospital setting typically hold between 350 and 625 litres of oxygen. These cylinders have internal pressures of approximately 2,000 psi. Portable oxygen cylinders are also available.
  • An oxygen regulator. A regulator controls the rate at which oxygen flows through the oxygen delivery device, which is measured in litres per minute (LPM). Regulators normally deliver between 1 and 25 LPM. Also, by checking the gauge, you can determine if the cylinder is full (2,000 psi), nearly empty (200 psi), or somewhere in between. An oxygen regulator has two metal prongs that fit into a valve at the top of the oxygen cylinder. Regulators and cylinders are pin indexed, meaning that a regulator will only fit into a cylinder that it was designed for. To ensure a tight seal between the regulator and the cylinder, a gasket (commonly referred to as an O-ring) must be used. These come in both single-use and multi-use forms.
  • A delivery device. To deliver oxygen from the cylinder to the patient requires a delivery device. There are a variety of delivery devices available, applicable in different situations. A section of tubing is attached to the device at one end and to the oxygen regulator at the other.

Supplemental Oxygen Precautions. Depending on the environment, supplemental oxygen is not always safe to use. Oxygen supports combustion; therefore, it cannot be used in environments where there is a risk of fire or explosion, or around sparks or flames. You may need to caution bystanders against smoking. The responder needs to remain vigilant of the environment any time oxygen is being administered.When using supplemental oxygen, safety is a primary concern. Remember the following precautions:

  • Do not operate oxygen equipment around an open flame, sparks, or in close proximity to an AED.
  • Do not stand oxygen cylinders upright unless they can be well secured If a cylinder falls, it could damage the regulator or loosen the cylinder valve.
  • Handle oxygen cylinder carefully: Do not drop, drag, or roll a cylinder.
  • Do not use grease, oil, tape, or petroleum products to lubricate any pressure regulator parts.
  • When disinfecting an oxygen regulator, take care to prevent any material from entering the inlet port.

Oxygen Cylinder Precautions. When working with oxygen cylinders, always:

  • Use pressure gauges and regulators designed for use with oxygen.
  • Ensure that all hardware is in good condition.
  • Use medical-grade (USP) oxygen.
  • Store oxygen in a cool, ventilated room when not in use.
  • Have cylinders hydrostatically tested every 5 years (or per manufacturer’s specifications)

Calculating How Long an Oxygen Cylinder Will Last. The size of an oxygen cylinder is designated by a letter. If you know the size of your oxygen cylinder and the reading on the pressure gauge, you can calculate how long the supply will last. There are various protocols as to when to change your tank; however, in all cases, 200 psi is known as the safe residual pressure, and the tank should always be changed around this point. Note that this is the oxygen remaining under ideal conditions: The general best practice is to monitor the oxygen supply while it is being administered to ensure that it does not run out unexpectedly.

If a patient who is receiving supplemental oxygen is being transported, you must include the extrication and transportation time when calculating how much oxygen will be required and ensure that you are prepared to meet the demands. It is better to have more oxygen than you need than torun out while providing care.

The calculation is as follows:

Using Oxygen Delivery Devices

Nasal Cannula. A nasal cannula is a plastic tube with two small prongs that are inserted into the patient’s nostrils to deliver oxygen. It is commonly used to manage patients with minor respiratory difficulties who do not require high-flow oxygen. Because it leaves the mouth clear, it also facilitates communication with the patient. A nasal cannula is only suitable for a breathing patient.

The use of a nasal cannula is limited to a flow rate of 1 to 4 LPM. Under these conditions, it delivers a peak oxygen concentration of approximately 36%. Flow rates above 4 LPM are not commonly used because of their tendency to quickly dry out mucous membranes. This can cause epistaxis (nosebleeds) and headaches. After longer periods of use, patients can experience irritation around the nostrils. Adding moisture to oxygen by attaching an oxygen humidifier to the regulator can help decrease irritation of the respiratory tract, which can result when a patient receives supplemental oxygen over a long period of time. The humidifier forces oxygen through sterile water, which allows it to pick up moisture before being delivered to the patient. Generally, a humidifier is not used in a prehospital setting, although it may be used during a long transfer.

To use a nasal cannula, connect the cannula to an oxygen source and start the oxygen flow. Place the cannula’s prongs into the patient’s nostrils. Hold the prongs in place (or have the patient hold them) while you loop the cannula tubing over the patient’s ears with the excess hanging in front of the patient’s chest. Adjust the collar on the tubing to gather it in front of the patient’s chest and hold the cannula in place.

A nasal cannula is not appropriate for patients experiencing serious respiratory emergencies, since they need a device that can supply a greater concentration of oxygen. In addition, the nasal cannula can be ineffective if the patient has a nasal airway obstruction, nasal injury, or illness causing blocked sinus passages.

Resuscitation Mask. Resuscitation masks have a port that can be connected to supplemental oxygen. If a breathing patient requires supplemental oxygen and no other delivery device is available, you can connect oxygen directly to the mask and use it as you would use a standard oxygen mask. The oxygen flow rate is 6–10 LPM and can supply an oxygen concentration of approximately 35 to 55%. Some resuscitation masks have elastic straps that can be placed over the patient’s head and tightened to secure the mask in place. If the mask does not have a strap, either you or the patient can hold it in place.

Standard Mask. A standard mask (also referred to as a medium-concentration mask) is an oxygen mask that fits over a patient’s mouth and nose to supply oxygen. It is usually made of a pliable material to increase patient comfort. Standard masks are available in both adult and pediatric sizes. The flow rate is usually 6 to 10 LPM, delivering an oxygen concentration of 40 to 60%.

Non-Rebreather Mask. A non-rebreather mask (also referred to as a high-concentration mask) is an oxygen face mask with low-resistance check valves along its sides. It is used with an oxygen cylinder and reservoir bag (usually 750 ml) to provide supplemental oxygen. A non-rebreather mask needs to have a flow rate of 10 LPM or more to ensure the proper reservoir bag inflation. This device allows the patient to inhale air from the reservoir bag and exhale through the check valves. The non-rebreather mask, when used in conjunction with a pulse oximeter, can be utilized on a patient with SpO levels under 95%, with flow rates from 10 to 15 LPM. Monitor the oxygen reservoir bag, and increase the oxygen flow rate as necessary to ensure that the bag remains full.

Bag-Valve-Mask (BVM). The BVM resuscitator with an oxygen reservoir is capable of supplying an oxygen concentration of 90 to 100%. A flow rate of 15 LPM is sufficient to keep the reservoir full. To deliver oxygen through a BVM, you must first attach an oxygen reservoir bag to the back of the BVM bag. Next, connect the oxygen cylinder tubing to the BVM through the oxygen port. After setting the oxygen flow rate and opening the cylinder, block the outlet port on the resuscitation mask with your finger or thumb. This will fill the oxygen reservoir. When you compress the BVM bag, the patient will receive close to 100% oxygen. When you release the BVM bag, it will refill with oxygen from the reservoir.

Administering Oxygen

Begin by checking the cylinder to confirm that it contains medical oxygen (figure 1). Next, check the oxygen gauge to ensure that the quantity of oxygen in the cylinder is sufficient. A full cylinder will come with a protective covering over the tank opening. Remove this covering and save the O-ring. While pointing the cylinder’s valve away from yourself and others, and wearing proper ear and eye protection, quickly open the cylinder’s valve (for a maximum of one second) (figure 2). This will remove any dirt or debris from the cylinder valve.

Next, examine the pressure regulator. Ensure that the gasket is positioned properly within the regulator inlet port (figure 1). Confirm that the pin index on the regulator corresponds to the oxygen cylinder you are using (figure 2). Attach the pressure regulator to the cylinder, seating the prongs inside the holes in the valve stem (figure 3). Hand-tighten the screw until the regulator is snug. To avoid damaging the assembly, do not use a wrench or other tool to tighten the regulator. Using an appropriate oxygen wrench, open the cylinder by giving the valve one full turn, and listen for leaks.

Check the gauge to determine how much pressure is in the cylinder (figure 1). A full cylinder should have approximately 2,000 psi. Attach the chosen delivery device to the oxygen port on the regulator using the appropriate tubing. Set the regulator to the appropriate flow rate. Listen and feel to make sure that oxygen is flowing into the delivery device. If using a delivery device with a reservoir bag, ensure that it is full (Figure 2), and then place the delivery device on the patient.

Airway Adjuncts

An airway adjunct is a tube that is inserted into an patient’s upper airway to assist in keeping it open. It can also facilitate assisted ventilations. Airway adjuncts are especially useful for patients with decreased levels of responsiveness, whose tongues can otherwise become anatomical obstructions. The most common adjuncts in wilderness first aid are oropharyngeal airways (OPAs) and nasopharyngeal airways (NPAs).

Note that any airway obstructions must be cleared before any airway adjuncts can be inserted. Also note that even after inserting an adjunct, you must continue to monitor the patient’s respirations and use manual techniques such as the head-tilt/chin-lift to maintain an open airway.

After inserting an airway adjunct for an unresponsive breathing patient, check the patient’s breathing to confirm that the airway has not been obstructed.

Oropharyngeal Airways (OPAs). An OPA inserts into the mouth of an unconscious patient, where the curved design fits the natural contour of the mouth and throat. When properly sized, it will not interfere with assisted ventilations or oxygen delivery.

Sizing and Inserting an OPA. Measure the device against the side of the patient’s face to ensure that it extends from the earlobe to the corner of the mouth (figure 1). Open the patient’s mouth using the crossed-finger technique, and then insert the OPA by gently sliding the tip along the roof of the mouth (figure 2). When the device is approximately one-half to three-quarters of the way into the patient’s mouth (as the tip approaches the back of the throat), rotate it a half-turn (figure 3). The OPA should drop into the throat without resistance. The flange end should rest on the patient’s lips (figure 4).

If the patient appears unresponsive but gags when you attempt to insert the device, he or she may be partially responsive. If so, stop your attempt. Maintain an open airway using other methods and continue your assessment of the patient. The patient’s LOR can rapidly decline. Reattempt to insert the OPA frequently: A small change in the patient’s responsiveness may allow you to insert it without triggering the gag reflex.

OPAs in Children and Infants. Younger children and infants have delicate airways, so extra caution must be taken to avoid causing injury when inserting an OPA. Also, you must be careful not to hyperextend the patient’s neck, which could close or even damage the airway.

When inserting an OPA into a child’s mouth, you should gently slide the tip along the inside of the cheek, and then rotate it 90 degrees to place it into the throat (figure below).

When inserting an OPA for an infant, place some padding (e.g., a towel) under the infant’s shoulders to help maintain the neutral position of the head without hyperextending the neck. Hold the tongue against the bottom of the mouth with a tongue depressor. Place the OPA against the lower lip with the concave side facing down, and slide the OPA smoothly into place without rotating it, following the natural curvature of the mouth and throat.

Removing an OPA. To remove an OPA from a patient of any age, grasp the flange between your thumb and index finger and pull gently outwards and downwards (towards the chin). The OPA will slide out smoothly.

Nasopharyngeal Airways (NPAs). A nasopharyngeal (nasal) airway (NPA) is used to assist in maintaining an airway in an unresponsive adult. An NPA may also be used on a responsive adult who needs help keeping the tongue from obstructing the airway. Unlike an OPA, an NPA will not interfere with suctioning a patient’s airway, so it may be preferable in cases where a patient has fluid in the airway.

An NPA should not be used on a patient with a suspected skull fracture, active bleeding from the nose, or facial trauma. Insertion of an NPA may cause nosebleeds, which can cause blood to enter the airway. Monitor the patient and provide interventions as necessary.

Sizing and Inserting an NPA. NPAs are available in a variety of sizes. When choosing an NPA, confirm that you have selected the correct size by measuring the device against the patient’s cheek: The NPA should extend from the earlobe to the tip of the nose. Ensure that the diameter of the NPA is no larger than the diameter of the patient’s nostril (figure 1).

Lubricate the NPA with a water-soluble lubricant. Insert the NPA into the patient’s right nostril (which tends to be slightly larger than the left), with the bevel towards the septum. Gently advance the airway straight in (not upward) until the flange rests against the patient’s nostril (figures 2-3). If you feel even minor resistance, do not attempt to force the NPA into the airway. If the NPA does not pass easily, remove it and try the other nostril. Unlike the OPA, the NPA will not cause a patient to gag.

Removing an NPA. To remove an NPA, grasp the flange gently between your thumb and index finger and draw it gently out of the patient’s nose.

Suction

Injury or illness can cause materials such as mucus, vomitus, water, or blood to collect in a patient’s airway. In many cases, these materials can be removed by simply rolling the patient onto his or her side and sweeping the mouth clean with your finger. Because this technique involves moving the patient, it can aggravate existing injuries and therefore may not be appropriate for a person with a suspected spinal injury, for example. It may also not allow you to remove material that is farther back in the airway.

A safer and more effective method is to suction the airway clear. Suctioning is the process of removing foreign matter by means of a vacuum. Whenever you are providing assisted ventilations to an unresponsive patient, it is good practice to have the suction unit on standby so you can use it immediately if the patient vomits.

A variety of manual and mechanical vacuums are available. A bulb syringe is used to provide suction for an infant. Ensure that you deflate the bulb syringe before inserting it into the infant’s airway. Attached to the end of any suction device is a suction tip, also referred to as a catheter. These come in various sizes and shapes. Some are rigid and others are flexible. The two most common are the tonsil tip catheter and the French catheter. The tonsil tip catheter is used for clearing the mouth and throat, whereas a French catheter is used to clear the nose.

Suctioning devices are most effective when removing fluids: The catheter can be clogged by large pieces of material (e.g., pieces of food). If this happens, quickly pull a quantity of sterile water or saline through the device to clear the catheter. If this is not immediately effective, roll the patient carefully and attempt to clear the airway with a finger sweep.

If the patient vomits up a large quantity of material, it may exceed the capacity of the unit. If this happens, roll the patient immediately and clear the airway with a finger sweep.

If the patient has an OPA inserted that will interfere with suctioning the oral, remove the OPA prior to suctioning. If necessary, reinsert the OPA once the airway is clear.

Whether you are using a manual or mechanical suction device, the basic steps are the same. First, measure the distance of insertion, which is the distance from the patient’s earlobe to the corner of the mouth (figure 1). This indicates how far into the airway the vacuum can be safely inserted.

Open the patient’s mouth using the crossed-finger technique or tongue-jaw lift. Insert the catheter into the upper airway (figure 2) to the maximum depth measured earlier. Provide rapid suction until the airway is clear.

Using suction will draw air from the patient’s airway. After providing suction, give the patient supplemental oxygen to ensure that he or she does not become hypoxic.

If a mechanical suction device malfunctions or does not adequately clear the airway, roll the patient onto his or her side immediately and sweep the airway clear.

If a patient has a tracheostomy or stoma, suction through the tube or hole, as this is where the patient’s air passes. Do not insert the suction tip more than 5 cm beyond the lower edge of the opening.