Management of Airway and

Breathing
Emergency Medical Technician -
Basic

1
Airway Functions
• Passage that allows air to move from
atmosphere to alveoli
• Must remain patent (open) at all times
• Anything that blocks airway will cause
decrease in oxygen available to body
• Size of obstruction affects available air
exchange

2
Airway Anatomy

QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.

3
Opening the Airway
• Techniques
– Head-tilt/Chin-lift
– Jaw Thrust
– Suctioning
– Nasopharyngeal airway (through nose)
– Oropharyngeal airway (through mouth)

4
Head-Tilt/Chin-Lift
• Used when no neck injury is suspected
• Temporary procedure
• Must be replaced with an airway adjunct
unless patient begins adequate spontaneous
ventilation

5
Head-Tilt/Chin-Lift
• Technique
– Place one hand on patient’s forehead
– Apply firm, backward pressure with palm
causing head to tilt backward
– Place fingers of other hand under bony part of
patient’s lower jaw near chin
– Lift jaw upward to bring chin forward

6
Head-Tilt/Chin-Lift
• Patients needing head-tilt/chin-lift
– Unresponsive patient without history of trauma
– Cardiac arrest patients without signs of trauma
– Apneic patients without signs of trauma

7
Jaw Thrust
• Used when spinal injury suspected
• Temporary procedure
• Must be replaced with airway adjunct
unless patient begins adequate spontaneous
ventilation

8
Jaw Thrust
• Technique
– Place one hand on either side of patient’s head,
resting elbows on surface on which victim is
lying
– Grasp angles of patient’s lower jaw, lift with
both hands
– If patient’s lips close, retract lower lips with
thumbs

9
Jaw Thrust
• Patients needing jaw thrust
– Unresponsive trauma patient
– Unresponsive patient with undetermined
mechanism of injury

10
Suctioning
• Purpose
– Remove blood, vomit, other liquids, food
particles from airway
– May not be adequate for removing large, solid
objects (teeth, foreign bodies, food)
– Should be performed immediately when
gurgling is heard with spontaneous or artificial
ventilation

11
Suctioning
• Suction devices
– Mounted in ambulance
– Portable
• Electrical
• Hand operated
– Should generate 300mm Hg vacuum
– Ensure batteries in units remain properly
charged
12
Suctioning
• Rigid Suction Catheter
– Used to suction mouth, oropharynx (back of
throat) of unresponsive patient
– Inserted only as far as you can see
– Take caution not to touch back of airway,
particularly in infants and children (can cause
heart rate to drop)

13
Suctioning
• Soft Suction Catheter
– Useful for suctioning nasopharynx (through
nose) or tracheostomy tubes
– Should be inserted only as far as base of tongue
or end of tracheostomy tube

14
Suctioning
• Techniques
– Turn on unit
– Attach catheter
– Insert catheter into oral cavity without suction
– Insert only to base of tongue
– Apply suction, move catheter from side to side
– Suction no longer than 15 seconds in adults, 10 seconds
in children, 5 seconds in infants
– Rinse catheter with saline or water to prevent
obstruction

15
Nasal Airways
• Used on responsive patients who need help
keeping tongue out of airway
• Insertion is uncomfortable for responsive
patients sometimes
– When inserting, aim towards back of head, not
up towards top of nose

16
Nasal Airways
• Technique
– Measure from tip of nose to earlobe
– Ensure airway will fit through nostril
– Lubricate with water-soluble lubricant
– Insert with bevel toward base of nostril or septum
– If resistance is met, try other nostril
– Do not use in patients with mid-face trauma or possible
basilar skull fractures

17
Nasal Airways
• Patients needing nasal airway
– Unresponsive patients who are snoring
– Unresponsive patients with gag reflex

18
Oral Airways
• Used on unresponsive patients without gag
reflex
• Helps hold tongue away from back of throat

QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.

19
Oral Airways
• Technique
– Measure from corner of mouth to earlobe or angle of
jaw
– Open patient’s mouth
– In adults insert with tip facing roof of patient’s mouth,
advance until resistance encountered, turn 180o until
flange comes to rest on patient’s teeth
– Or in adults can try and insert right side up, being
careful not to p[ush the tongue back, often easier with a
jaw thrust
– In infants and children use tongue depressor to lift
tongue, insert oral airway right side up 20
Oral Airways
• Patients needing oral airway
– Unresponsive, apneic patients (no breathing)
with or without trauma
– Any apneic patient being ventilated with a
BVM (bag valve mask)

21
Airway Limitations
• Nasal/oral airways are not definitive devices
• Manual maneuvers must be used with nasal/oral
airways to ensure airway stays open
• Patients may require frequent suctioning to
remove blood, vomit, other secretions from airway
• Definitive devices such as endotracheal tubes are
required to completely protect the airway

22
Laryngeal Mask Airways (LMA)

23
Laryngeal Mask Airways (LMA)
• Although endotracheal intubation is the definitive way of
controlling the airway, as AMT-basic, you are not qualified to
use it yet. (later EMT course will qualify you to do so)
• LMA’s are excellent for many patients, as they are easy to
place usually, and often work very well for short-term use
• Unfortunately LMA’s DO NOT protect the lungs from
secretions, blood vomit etc.
• LMA’s also do not protect from air getting into the stomach,
therefore use the MINIMUM amount of pressure to ventilate
adequately

24
Laryngeal Mask Airways (LMA)
• Choose the correct size for the patient.
– Normal Indonesian adult male: size 3
– Normal Indonesian adult female: size 2
– Large adult male: size 4
– Children sizes depend on age: size 1/2 to 1 1/2
• To place LMA, cover with small amount of water soluble lubricant, open
airway (jaw thrust or head tilt as appropriate; scissor hand technique
helps), and insert LMA similarly to oral airway
– Can insert with curved side up, then when reach resistance turn 180 degrees
and push into place
– Can insert with right side down (like a C that follows the mouth to neck) until
meet resistance
– Do not push when resistance is met
– Make sure you get good ventilation once inserted correctly
– LMA is usually inflated 3/4 of the way to have a good seal 25
Adequate Breathing
• Normal Rate
– Adult: 12 to 20/minute
– Child: 15 to 30/minute
– Infant: 25 to 50/minute
• Regular Rhythm
• Adequate Quality
– Movement of air at mouth, nose
– Chest expansion adequate, symmetrical (equal)
– Breath sounds present, equal
– Minimum effort of breathing
– Adequate tidal volume (depth)

26
Inadequate Breathing
• Abnormal Rate
– Adult: <12 to >20/minute
– Child: <15 to >30/minute
– Infant: <25 to >50/minute
• Irregular Rhythm
• Inadequate Quality
– Absent or reduced at mouth, nose
– Chest expansion inadequate or asymmetrical (unequal)
– Breath sounds diminished, unequal, noisy, absent
– Increased effort of breathing, use of accessory muscles
– Inadequate (shallow) tidal volume

27
Inadequate Breathing
• Skin changes
– Pale, cool, clammy: Early sign
– Cyanosis: Late, unreliable sign
• Retractions of soft tissues above clavicles,
between ribs, below rib cage
• Flaring of nostrils
• “Seesaw” breathing in infants

28
Ventilation Techniques
(In order of preference)
1. Mouth-to-mask with supplemental oxygen
2. Two-person bag-valve mask with oxygen
reservoir and supplemental oxygen
3. Flow restricted, oxygen-powered
ventilation device (manually-triggered
ventilator)
4. One-person bag-valve mask with oxygen
reservoir and supplemental oxygen
29
Ventilation Techniques
• Mouth-to-Mouth (safety risk!, so almost
never done)
– Open airway
– Pinch nose closed or seal nose with cheek
– Take deep breath
– Seal lips around patient’s mouth to create
airtight seal
– Blow into patient’s mouth slowly over 2
seconds until patient’s chest rises
30
Ventilation Techniques
• Mouth-to-Mask
– Connect mask to oxygen at 15 liters per minute
– Kneel directly above patient’s head
– Apply mask to patient’s face
– Place thumbs along sides of mask, index fingers of both
hands under patient’s mandible
– Lift jaw into mask, tilt head if neck injury not suspected
– Blow into one-way valve slowly over 2 seconds until
patient’s chest rises

31
Ventilation Techniques
• Bag-valve mask (BVM)
– Self-inflating bag
– One-way valve
– Face mask
– Oxygen reservoir

Must be connected to oxygen to perform

most effectively
32
Ventilation Techniques
• BVM Issues
– Provides less volume than mouth-to-mask
– 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
33
Ventilation Techniques
• BVM Technique (Two Rescuer)
– Open airway, insert oral or nasal airway
– Position thumbs over top half of mask, index and
middle fingers over bottom half
– Place apex of mask over bridge of nose, lower mask
over mouth/upper chin
– Use ring and little fingers to bring jaw up to mask
– Have assistant squeeze bag with two hands until chest
rises
– Ventilate every 5 seconds for adults, every 3 seconds
for infants and children
34
Ventilation Techniques
• BVM Technique (One Rescuer)
– Open airway, insert oral or nasal airway
– Form a “C” around ventilation port with thumb,
index finger
– Use middle, ring, little fingers under jaw to
maintain chin lift, complete seal
– Squeeze bag with other hand until chest rises
– Ventilate every 5 seconds for adults, every 3
seconds for infants and children
35
Ventilation Techniques
• BVM Technique (Suspected Trauma)
– Open airway, insert oral or nasal airway
– Have assistant hold patient’s head or use your knees to prevent
movement
– Position thumbs over top half of mask, index and middle fingers
over bottom half
– Place apex of mask over bridge of nose, lower mask over
mouth/upper chin
– Use ring and little fingers to bring jaw up to mask without tilting
head or neck
– Have assistant squeeze bag with two hands until chest rises
– Ventilate every 5 seconds for adults, every 3 seconds for infants
and children continue to hold jaw up without moving head or neck
36
Ventilation Techniques
• If chest does not rise, reevaluate
– If abdomen rises, reposition head or jaw
– If air escapes under mask, reposition fingers
and mask
– Check for obstruction
– If chest still does not rise and fall use another
method of ventilation

37
Ventilation Techniques
• Flow Restricted, Oxygen-Powered Ventilation Devices
(Manually-Triggered Ventilator)
– Peak flow of 100% oxygen at maximum of 40 lpm
– Pressure relief valve that opens at 60 cm H2O
– Audible alarm that sounds when relief valve pressure is exceeded
– Trigger so both hands remain on mask to maintain seal

Do NOT use on children or infants!!!

38
Ventilation Techniques
• Manually-Triggered Ventilator
– Open airway, insert oral or nasal airway
– Position thumbs over top half of mask, index/middle
fingers over bottom half
– Place apex of mask over bridge of nose, lower mask
over mouth and chin
– Use ring/little fingers to bring jaw up to mask
– Trigger device until chest rises
– Repeat every 5 seconds

39
Ventilation Techniques
• Manually-Triggered Ventilator (Suspected Trauma)
– Open airway, insert oral or nasal airway
– Have assistant hold head manually or use knees to prevent
movement
– Position thumbs over top half of mask, index/middle fingers over
bottom half
– Place apex of mask over bridge of nose, lower mask over mouth
and chin
– Use ring/little fingers to bring jaw up to mask without tilting head
and neck
– Trigger device until chest rises
– Repeat every 5 seconds

40
Assisting Patients Who Are Breathing

• Who needs assistance?

– A patient who is not breathing
– A patient who has reduced respiratory rate and
tidal volume
– A patient whose breathing rate is increased, but
whose tidal volume is inadequate

41
Assisting Patients Who Are Breathing

• Patients with rapid, shallow breathing

– Explain procedure to patient
– Place mask over patient’s mouth and nose
– Initially assist ventilations at rate at which
patient is breathing. Squeeze bag as patient
inhales
– Slowly adjust rate and tidal volume until
adequate ventilations are achieved
42
Assisting Patients Who Are Breathing

• Patients with slow, shallow breathing

– Place bag over patient’s mouth and nose
– Squeeze bag each time patient inhales
– Adjust rate and tidal volume until adequate
ventilations are achieved

43
Special Considerations
• Stoma or tracheostomy tube
– Attach BVM to tube, or use infant/child mask
to make seal over stoma
– Seal mouth/nose if air is escaping when
ventilating at stoma
– If unable to ventilate
• Suction stoma or tracheostomy tube
• Seal stoma, attempt to ventilate through mouth/nose

44
Special Considerations
• Infants and children
– Place infant’s head in neutral position
– Extend child’s head slightly past neutral
– Avoid excessive hyperextension
– Avoid excessive ventilation, just make chest
rise
– Gastric distension is more common in children
– Do not use BVMs with pop-off valves
45
Special Considerations
• Dentures
– Leave in place unless obviously loose
– Remove if loose
– Be prepared to remove if displacement occurs

46
Oxygen
• Oxygen cylinder sizes
– D cylinder 350 liters
– E cylinder 625 liters
– M cylinder 3,000 liters
– G cylinder 5,300 liters
– H cylinder 6,900 liters
• Contents under pressure
• Should be positioned to prevent falling, blows to
valve-gauge assembly

47
Oxygen
• Operating procedures
– Remove protective seal
– Quickly open, then shut valve
– Check if tank is full, or has adeqaute amount of
oxygen/pressure for trip. Make sure back-up is available
– Attach regulator-flow meter to tank
– Select proper size of oxygen mask for patient
– Attach oxygen mask to flow-meter
– Open flow-meter to desired setting
– Apply device to patient
– When complete, remove device from patient, turn off
48
device, remove all pressure from regulator
Oxygen
• Non-rebreather mask (NRB mask)
– Preferred method of giving oxygen to
prehospital patients
– Up to 90% oxygen can be delivered
– Non-rebreather bag must be full before mask is
placed on patient
– Flow rate should be adjusted so when patient
inhales, bag does not collapse (~15 lpm)
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Oxygen
• Nasal cannula
– Rarely best method for giving adequate oxygen
in emergency care settings
– Should be used only if patient will not tolerate
non-rebreather mask in spite of coaching
– Usually use 6 lpm or less oxygen flow

50
Oxygen
• Concerns about giving too much oxygen to
patients with COPD, infants, and children
are NOT valid during short-term emergency
administration
• Patients with COPD, infants, and children
who require oxygen should be given high
concentration oxygen.

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