Module I: Airway / Ventilation

NREMT PRACTICE ANALYSIS TASK ITEM
•	Provide ventilatory support for a patient. 

COGNITIVE OBJECTIVES
At the completion of this unit, the paramedic will be able to:
1.1	Describe the indications, contraindications, advantages, disadvantages, complications, and technique for ventilating a patient by: (C-1) / 2-1.43 
•	Mouth-to-mouth 
•	Mouth-to-nose 
•	Mouth-to-mask 
•	One person bag-valve-mask 
•	Two person bag-valve-mask 
•	Three person bag-valve-mask 
•	Flow-restricted, oxygen-powered ventilation device 	
1.2	Compare the ventilation techniques used for an adult patient to those used for pediatric patients. (C-3) / 2-1.45	
1.3	Describe indications, contraindications, advantages, disadvantages, complications, and technique for ventilating a patient with an automatic transport ventilator (ATV). (C-1) / 2-1.46	
1.4	Define how to ventilate with a patient with a stoma, including mouth-to-stoma and bag-valve-mask-to-stoma ventilation. (C-1) / 2-1.54	
1.5	Describe the special considerations in airway management and ventilation for patients with facial injuries. (C-1) / 2-1.55	
1.6	Describe the special considerations in airway management and ventilation for the pediatric patient. (C-1) / 2-1.56	
PSYCHOMOTOR OBJECTIVES
At the completion of this unit, the paramedic will be able to:
1.7	Demonstrate ventilating a patient by the following techniques: (P-2) / 2-1.95 
•	Mouth-to-mask ventilation 
•	One person bag-valve-mask 
•	Two person bag-valve-mask 
•	Three person bag-valve-mask 
•	Flow-restricted, oxygen-powered ventilation device 
•	Automatic transport ventilator 
•	Mouth-to-stoma 
•	Bag-valve-mask-to-stoma ventilation 	
1.8	Ventilate a pediatric patient using the one and two person techniques. (P-2) / 2-1.96	
1.9	Perform bag-valve-mask ventilation with an in-line small-volume nebulizer. (P-2) / 2-1.97	
1.10	Perform assessment to confirm correct placement of the endotracheal tube (P-2) / 2-1.103	
1.11	Intubate the trachea by the following methods: 
•	Orotracheal intubation 
•	Nasotracheal intubation 
•	Multi-lumen airways 	
1.12	Perform transtracheal catheter ventilation (needle cricothyrotomy). (P-2) / 2-1.107	

DECLARATIVE
I.	Ventilation 
A.	Mouth-to-mouth 
1.	Most basic form of ventilation 
2.	Indications 
a.	Apnea from any mechanism when other ventilation devices are not available 
3.	Contraindications 
a.	Awake patients 
b.	Communicable disease risk limitations 
4.	Advantages 
a.	No special equipment required 
b.	Delivers excellent tidal volume 
c.	Delivers adequate oxygen 
5.	Disadvantages 
a.	Psychological barriers from 
i.	Sanitary issues 
ii.	Communicable disease issues 
a.	Direct blood/ body fluid contact 
b.	Unknown communicable disease risks at time of event 
6.	Complications 
a.	Hyperinflation of patient's lungs 
b.	Gastric distention 
c.	Blood/ body fluid contact manifestation 
d.	Hyperventilation of rescuer 
B.	Mouth-to-nose 
1.	Ventilating through nose rather than mouth 
2.	Indications 
a.	Apnea from any mechanism 
3.	Contraindications 
a.	Awake patients 
4.	Advantages 
a.	No special equipment required 
5.	Disadvantages 
a.	Direct blood/ body fluid contact 
b.	Psychological limitations of rescuer 
6.	Complications 
a.	Hyperinflation of patient's lungs 
b.	Gastric distention 
c.	Blood/ body fluid manifestation 
d.	Hyperventilation of rescuer 
C.	Mouth-to-mask 
1.	Adjunct to mouth-to-mouth ventilation 
2.	Indications 
a.	Apnea from any mechanism 
3.	Contraindications 
a.	Awake patients 
4.	Advantages 
a.	Physical barrier between rescuer and patient blood/ body fluids 
b.	One-way valve to prevent blood/ body fluid splash to rescuer 
c.	May be easier to obtain face seal 
5.	Disadvantages 
a.	Useful only if readily available 

6.	Complications 
a.	Hyperinflation of patient's lungs 
b.	Hyperventilation of rescuer 
c.	Gastric distention 
7.	Method for use 
a.	Position head by appropriate method 
b.	Position and seal mask over mouth and nose 
c.	Ventilate as appropriate 
D.	One person bag-valve-mask 
1.	Fixed volume self inflating bag can deliver adequate tidal volumes and O2 enrichment 
2.	Indications 
a.	Apnea from any mechanism 
b.	Unsatisfactory respiratory effort 
3.	Contraindications 
a.	Awake, intolerant patients 
4.	Advantages 
a.	Excellent blood/ body fluid barrier 
b.	Good tidal volumes 
c.	Oxygen enrichment 
d.	Rescuer can ventilate for extended periods without fatigue 
5.	Disadvantages 
a.	Difficult skill to master 
b.	Mask seal may be difficult to obtain and maintain 
c.	Tidal volume delivered is dependent on mask seal integrity 
6.	Complications 
a.	Inadequate tidal volume delivery 
b.	Poor technique 
c.	Poor mask seal 
d.	Gastric distention 
7.	Method for use 
a.	Position appropriately 
b.	Choose proper mask size - seats from bridge of nose to chin 
c.	Position, spread/ mold/ seal mask 
d.	Hold mask in place 
e.	Squeeze bag completely over 1.5 to 2 seconds for adults 
f.	Avoid overinflation 
g.	Reinflate completely over several seconds 
8.	Special considerations 
a.	Medical 
i.	Observe for 
a.	Gastric distention 
b.	Changes in compliance of bag with ventilation 
c.	Improvement or deterioration of ventilation status ( i.e., color change, responsiveness, air leak around mask) 
b.	Trauma 
i.	Very difficult to perform with cervical spine immobilization in place 
E.	Two-person bag-valve-mask ventilation method 
1.	Most efficient method 
2.	Indications 
a.	Bag-valve-mask ventilation on any patient 
i.	Especially useful for cervical spine immobilized patients 
ii.	Difficulty obtaining or maintaining adequate mask seal 

3.	Contraindications 
a.	Awake, intolerant patients 
4.	Advantages 
a.	Superior mask seal 
b.	Superior volume delivery 
5.	Disadvantages 
a.	Requires extra personnel 
6.	Complications 
a.	Hyperinflation of patient's lungs 
b.	Gastric distention 
7.	Method for use 
a.	First rescuer maintains mask seal by appropriate method 
b.	Second rescuer squeezes bag 
8.	Special considerations 
a.	Observe chest movement 
b.	Avoid overinflation 
c.	Monitor lung compliance with ventilations 
F.	Three-person bag-valve-mask ventilation 
1.	Indications 
a.	Bag-valve-mask ventilation on any patient 
i.	Especially useful for cervical spine immobilized patients 
ii.	Difficulty obtaining or maintaining adequate mask seal 
2.	Contraindications 
a.	Awake, intolerant patients 
3.	Advantages 
a.	Superior mask seal 
b.	Superior volume density 
4.	Disadvantages 
a.	Requires extra personnel 
b.	"Crowded" around airway 
5.	Complications 
a.	Hyperinflation of patient’s lungs 
b.	Gastric distention 
6.	Method for use 
a.	First rescuer maintains mask seal by appropriate method 
b.	Second rescuer holds mask in place 
c.	Third rescuer squeezes bag and monitors compliance 
7.	Special considerations 
a.	Avoid overinflation 
b.	Monitor lung compliance with ventilations 
G.	Flow-restricted, oxygen-powered ventilation devices 
1.	The valve opening pressure at the cardiac sphincter is approx 30 cm H2O 
2.	These devices operate at or below 30 cm H2O to prevent gastric distention 
3.	Indications 
a.	Delivery of high volume/ high concentration of O2 (1 L/ sec) 
b.	Awake compliant patients 
c.	Unconscious patient with caution 
4.	Contraindications 
a.	Non-compliant patients 
b.	Poor tidal volume 
c.	Small children 
5.	Advantages 
a.	Self administered 
b.	Delivers high volume/ high concentration O2 
c.	O2 delivered in response to inspiratory effort (no O2 wasting) 
d.	O2 volume delivery is regulated by inspiratory effort minimizing overinflation risk 
a.	O2 volume delivery is also restricted to less than 30 cm H2O 
1.	Disadvantages 
a.	Cannot monitor lung compliance 
b.	Requires O2 source 
2.	Complications 
a.	Gastric distention 
b.	Barotrauma 
3.	Method 
a.	Mask is held manually in place 
b.	Negative pressure upon inspiration triggers O2 delivery or medic triggers release button 
c.	Patient is monitored for adequate tidal volume and oxygenation 
A.	Automatic transport ventilators 
1.	Volume/ rate controlled 
2.	Indications 
a.	Extended ventilation of intubated patients 
b.	In situations in which a BVM is used 
c.	Can be used during CPR 
3.	Contraindications 
a.	Awake patients 
b.	Obstructed airway 
c.	Increased airway resistance 
i.	Pneumothorax (after needle decompression) 
ii.	Asthma 
iii.	Pulmonary edema 
4.	Advantages 
a.	Frees personnel to perform other tasks 
b.	Lightweight 
c.	Portable 
d.	Durable 
e.	Mechanically simple 
f.	Adjustable tidal volume 
g.	Adjustable rate 
h.	Adapts to portable O2 tank 
5.	Disadvantages 
a.	Cannot detect tube displacement 
b.	Does not detect increasing airway resistance 
c.	Difficult to secure 
d.	Dependent on O2 tank pressure 
B.	Cricoid pressure - Sellick’s maneuver 
1.	Pressure on cricoid Ring 
2.	Occludes esophagus 
3.	Facilitates intubation by moving the larynx posteriorly 
4.	Helps to prevent passive emesis 
5.	Can help minimize gastric distention during bag-valve-mask ventilation 
6.	Indications 
a.	Unconscious patients receiving BVM ventilations 
b.	Patient cannot protect own airway 
7.	Contraindications 
a.	Use with caution in cervical spine injury 
8.	Advantages 
a.	Noninvasive 
b.	Minimizes risk of aspiration as long as pressure is maintained 

9.	Disadvantages 
a.	May have extreme emesis if pressure is removed 
b.	Second rescuer required for bag-valve-mask ventilation 
c.	May further compromise injured cervical spine 
10.	Complications 
a.	Laryngeal trauma with excessive force 
b.	Esophageal rupture from unrelieved high gastric pressures 
c.	Excessive pressure may obstruct the trachea in small children 
11.	Method 
a.	Locate the anterior aspect of the cricoid ring 
b.	Apply firm, posterior pressure 
c.	Maintain pressure until the airway is secured with an endotracheal tube 
C.	Artificial ventilation of the pediatric patient 
1.	Flat nasal bridge makes achieving mask seal more difficult 
2.	Compressing mask against face to improve mask seal results in obstruction 
3.	Mask seal best achieved with jaw displacement (two person bag-valve-mask) 
4.	Bag-valve-mask ventilation 
a.	Bag size 
i.	Full-term neonates and infants - minimum of 450 ml tidal volume (pediatric BVM) 
ii.	Children up to eight years of age - pediatric BVM preferred but adult-sized BVM (1500 ml) may be used 
iii.	Children over eight years of age require adult-sized BVM for adequate ventilation 
iv.	Proper mask fit 
v.	Length based resuscitation tape 
vi.	Bridge of nose to cleft of chin 
b.	Proper mask position and seal (EC-clamp) 
i.	Place mask over mouth and nose; avoid compressing the eyes 
ii.	Using one hand, place thumb on mask at apex and index finger on mask at chin (C-grip) 
iii.	With gentle pressure, push down on mask to establish adequate seal 
iv.	Maintain airway by lifting bony prominence of chin with remaining fingers forming an "E"; avoid placing pressure on the soft area under chin 
v.	May use one or two rescuer technique 
c.	Ventilate according to current standards 
d.	Obtain chest rise with each breath 
i.	Begin ventilation and say "squeeze"; provide just enough volume to initiate chest rise; DO NOT OVERVENTILATE 
e.	Allow adequate time for exhalation 
i.	Begin releasing the bag and say "release, release" 
f.	Continue ventilations using "squeeze, release, release" method 
g.	Assess BVM ventilation 
i.	Look for adequate chest rise 
ii.	Listen for lung sounds at third intercostal space, midaxillary line 
iii.	Assess for improvement in color and/ or heart rate 
h.	Apply cricoid pressure to minimize gastric inflation and passive regurgitation 
i.	Locate cricoid ring by palpating the trachea for a prominent horizontal band inferior to the thyroid cartilage and cricothyroid membrane 
ii.	Apply gentle downward pressure using one fingertip in infants and the thumb and index finger in children 
iii.	Avoid excessive pressure as it may produce tracheal compression and obstruction in infants 
D.	Ventilation of stoma patients 
1.	Mouth-to-stoma 
a.	Locate stoma site and expose 
b.	Pocket mask to stoma preferred 
i.	Seal around stoma site, check for adequate ventilation 
ii.	Seal mouth and nose if air leak evident 
2.	Bag-valve-mask to stoma 
a.	Locate stoma site and expose 
b.	Seal around stoma site, check for adequate ventilation 
c.	Seal mouth and nose if air leak evident 
E.	Translaryngeal cannula ventilation 
1.	High volume/ high-pressure ventilation of lungs through cannulation of trachea below the glottis 
a.	Oxygen delivery differs from other methods 
b.	Delivers a large volume of O2 through a small port 
c.	Delivers a very high pressure to the lungs compared to other methods (50 psi versus less than 1 psi through a regulator) 
2.	Indications 
a.	Apnea 
b.	Delayed or inability to ventilate the patient by other means 
3.	Contraindications 
a.	Total airway obstruction (both inspiratory and expiratory) 
b.	Equipment not immediately available 
4.	Advantages 
a.	Rapidly performed 
b.	Provides adequate ventilation when performed properly 
c.	Does not manipulate the cervical spine 
d.	Does not interfere with subsequent attempts to intubate 
5.	Disadvantages 
a.	Requires jet ventilator 
b.	Expends high volumes of oxygen more rapidly 
c.	May not protect against aspiration 
6.	Equipment 
a.	Large bore IV catheter (14-16 gauge) 
b.	10 cc syringe 
c.	3 ccs of water or saline (optional) 
d.	Oxygen source (50 psi) 
e.	Jet ventilator 
7.	Method 
a.	Prepare equipment 
b.	Identify cricothyroid membrane 
c.	Insert needle with syringe midline through cricothyroid membrane at a slight angle towards sternum 
d.	Withdraw on syringe plunger until air is freely withdrawn (bubbles if fluid is in syringe) 
e.	Advance additional 1 cm 
f.	Hold needle steady, advance catheter to hub 
g.	Attach jet ventilator 
h.	Ventilate once per five seconds 
i.	Exhalation is passive through the glottis 
8.	Complications 
a.	Bleeding 
i.	From improper catheter placement 

b.	Subcutaneous emphysema 
i.	From excessive air leak around catheter site or undetected laryngeal trauma 
c.	Airway obstruction 
i.	Result of excessive bleeding or subcutaneous air which compresses trachea 
d.	Barotrauma 
i.	Resulting from overinflation 
e.	Hypoventilation 
II.	Airway Techniques 
A.	Endotracheal intubation techniques 
1.	Medical patient 
a.	Orotracheal intubation by direct laryngoscopy 
2.	Trauma patient 
a.	Orotracheal intubation by direct laryngoscopy 
b.	Nasotracheal intubation techniques 
i.	Indications 
3.	Confirming placement 
a.	Direct re-visualization 
b.	Tube condensation 
c.	Auscultation 
d.	Palpation of balloon cuff at sternal notch 
e.	Pulse oximetry 
f.	Expired CO2 
g.	Bag-valve ventilation compliance 
4.	Field extubation 
5.	Endotracheal tube securing device 
B.	Multi-lumen airways 
1.	Pharyngo-tracheal lumen airway 
a.	Indications 
b.	Advantages 
c.	Disadvantages 
d.	Method 
e.	Complications 
f.	Special considerations 
2.	Combitube 
a.	Indications 
b.	Advantages 
c.	Disadvantages 
d.	Method 
e.	Complications 
f.	Special considerations