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Flashcards in Manual Ventilation Deck (75)

Functions of the Nose

  1. Humidify Air
  2. Transport Air
  3. Heating and Warming Air
  4. Sense of Olfactory
  5. Filter Air


External Nose

External Nares-There are two flared openings called alae

Vestibule-The most anterior portion of the nasal cavity before the alae

Anterior Nares-Located posterior to the vestibules are openings to the internal nose 


Internal Nose

AKA nasal cavity

The nasal cavity extends from the anterior nares to the internal nares

The nasal cavity is tilted slightly downwards (10-15 degrees) from the front to the back



Protects the airway by preventing food from entering


Little’s Area (Kiesselbach’s Plexus)

A highly vascular area located on the anterior aspect of the nasal septum in each nostril

Most nosebleeds will often originate from this area



A tube connecting the nasal cavity, mouth, larynx, and esophagus

Approximately 13 cm in length (in adults)

Extends from the base of the skull to the cricoid cartilage (at level of C)

Muscular wall is composed of skeletal muscle-This means that there is voluntary control which allows us to hold our breath



In theory it is a passage for air alone

Extends from the base of the skull to the uvula

Contains pharyngeal tonsils (adenoids) and tubal tonsils


5 Openings to Nasopharynx

The nasopharynx contains 5 openings which is important during intubation as we can have infection

These openings are

  • 2 eustachian tubes
  • 2 Internal nares
  • 1 opening to the oropharynx



Extends from tip of uvula to upper rim of the epiglottis

Common pathway for food and air

Contains palatine tonsils, which are commonly removed during tonsillectomy



Conducts air into the lungs

Acts a switch mechanism to ensure that food bypasses the trachea and proceeds down the esophagus

Larynx is the most heavily sensory inervated organ in the body.

Stimulation of unaesthetized larynx causes very strong sympathetic response-HR and BP may double.



True vocal cords located in larynx will vibrate as air passes between them through the glottis


Defenses in the Larynx

Pseudostratified ciliated columnar epithelial cell sit below the vocal cords and sweep mucus up into the pharynx continually


Larynx-Breath Hold, Effort closure and cough

Muscular vestibular folds (false vocal cords help to close the glottis tightly)

Valsalva Maneuver-performed by moderately forceful attempted exhalation against a closed airway, usually done by closing one's mouth, pinching one's nose shut while pressing out as if blowing up a balloon


Cartilage of the Larynx

There is 9 Cartilages of the Larynx

  • 2 Arytenoid Cartilages
  • 2 Cuneiform Cartilages
  • 2 Corniculate Cartilages
  • 1 Thyroid Cartilage
  • 1 Cricoid Cartilage
  • 1 Epiglottis Cartilage



When we are intubating we want to go into the trachea we have to manipulate things because if we don’t manipulate things then the path of least resistance for intubation is through the esophagus

If doing an emergency cricoid cartilage you don’t have to go through the cric you can go through a ring that is not continuous but C shaped



Thyroid Cartilage

Thryroid cartilage forms anterior wall of larynx


Functions of the Trachea

  • Conducts air in and out of the lungs
  • Contraction of trachealis muscle can accelerate expired air to excel mucous during a cough


Trachea Measurements

Extends from the larynx to the main stem bronchi 12-15 cm in length and ~2 cm in diameter 16-20 C-shaped cartilage rings


Carina Topography

Carina sits behind “angle of Louis” anteriorly and level of T4 posteriorly


Patent Airway

Airway Patency is the state or quality of the airway being open, expanded, or unblocked

If you are bagging and not ventilating the patient reapply the mask and that is the most common cause


Loss of Airway Patency

Causes of loss of airway patency can be divided into 2 general categories

Central Causes-Any condition that leads to a depression of the CNS (i.e. <8)

Peripheral Causes-Airway obstruction caused by something originating outside the body


Jaw Thrust

The jaw thrust will move the tongue from the back of the throat


Central Causes-Decrease in Cardiac Output

Acute myocardial infarction (MI)

Cardiac tamponade-But when cause through a infection it is considered to be a peripheral cause


V fib or V tach

Hypovolemic Shock

Septic Shock

Massive Pulmonary Embolism


Mechanisms of Upper Airway Obstruction

Decrease in tone of submandibular muscles leads to posterior displacement of tongue against the posterior pharyngeal wall

While in a comatose state the position of the chin will worsen the obstruction

C-spine adopts a semi flexed position, narrowing the distance between the tongue and posterior pharyngeal wall

Epiglottis gravitates towards the larynx partially occluding the airway

Negative pressure cause by respiratory efforts in presence of obstruction draws tongue towards the airway


Peripheral Causes

  • Peripheral causes come from outside of the body  
  • Infection
  • Abscess
  • Neoplastic (carcinomas)
  • Physical and Chemical Agents
  • Thermal
  • Caustic Injuries- Can cause swelling
  • Inhaled toxins
  • Allergic/Idiopathic
  • Traumatic 


Signs of Loss of Airway Patency

• Tachypnea and dyspnea • Noisy snoring respirations • Paradoxical breathing • Tracheal tug or retractions • Nasal flaring o Usually seen in babies • Expiratory Grunting o Is a compensation for collapse o Usually seen in babies o Cardiac dysrhythmias • Pressure in chest and low oxygen levels will affect the heart • Stridor • Absence of breath sounds or visible chest movement • Cyanosis o Can be misleading due to polycythemia or hypothermia o Will be check at the inside of the lips


Peripheral Causes-Infection

Viral and bacterial infection laryngotracheobronchitis (e.g. croup)

Parapharyngeal and retropharyngeal abscess

Lingual tonsillitis

Hematomas or abscess of the tongue or floor of the mouth

Epiglottitis (also known as supraglottitis)

Similar to croup but the patient will have low energy and is very serious and in this case we do not manipulate the airway


Peripheral Causes-Neoplastic

Laryngeal carcinomas Hypopharyngeal and lingual (tongue) carcinomas


Peripheral Causes-Physical and Chemical Agents

Foreign bodies Chocking something shoved up a nose Thermal injuries-Can cause swelling Caustic Injuries- Can cause swelling Inhaled toxins


Peripheral Causes- Allergic/Idiopathic

Angiotensin converting enzymes inhibitors induced angioedema


Peripheral Causes- Traumatic

Blunt and penetrating neck and upper airway trauma


Central Causes of Loss of Airway Patency

When the CNS is depressed and comes from within the body

The causes of CNS depression varies

Most common cause of upper airway obstruction is the tongue

Includes-Decrease in cardiac output, TBI, Anesthesia, drug overdose, hypoxemia/hypercarbia, hypothermia/hyperthermia, metbolic derrangements


Central Causes-Hypoxemia/Hypercarbia

COPD, Asthma, ARDS, Pneumonia, moderate PEs 


Central Causes-Metabolic Derangements



hypokalemia (lead to heart malfunction)

metabolic acidosis

hepatic encephalopathy


Signs of Loss of Airway Patency

Tachypnea and dyspnea

Noisy snoring respirations

Paradoxical breathing

Tracheal tug or retractions

Nasal flaring-Usually seen in babies

Expiratory Grunting-Is a compensation for collapse and usually seen in babies

Cardiac dysrhythmias-Pressure in chest and low oxygen levels will affect the heart


Absence of breath sounds or visible chest movement

Cyanosis-Can be misleading due to polycythemia or hypothermia, will be check at the inside of the lips


Presentation of Obstructed Airway 


Hot Potato Voice- Horse Voice

Difficultly in Swallowing Secretions

Drooling is a very serious sign


STRIDOR-Means a complete obstruction is imminent




High pitched inspiratory sound

Indicated that airway has already lost at least 50% of its usual caliber

Complete obstruction may be imminent

The volume and pitch are related to the velocity of air flow-Air flow is dependent on patient’s level of consciousness and inspiratory muscle strength

Often audible but may be detected early via auscultation over the trachea-Can normally be heard without a stethoscope

If it is epiglottitis don’t place the stethoscope near the throat just keep them calm


Establishing and Maintaining Patient Airways Manuevers

Head-tilt/ Chin-Lift

Jaw Thrust Maneuver

Occasionally opening the airway is all that is require to re-establish the airway


Head-Tilt/ Chin-Lift

Used when no c-spine injury is evident

Performed with patient on his back and unconscious

Place palm across patient forehead, and firmly tilt head backwards. Fingers of other hand placed under ye bony part of lower jaw to bring chin forward and teeth almost to occlusion

Supports jaw and helps tilt head back

Mouth should not be completely closed, and rather should be slightly open

This maneuver elevates the tongue off the posterior pharyngeal wall, hopefully relieving obstruction

If fingers press too deeply into the soft tissue under chin, may obstruct airway by oving the tongue

If dentures are not too loose the head tilt chin lift with make the mouth to mouth seal easier. If denture can not be kept in placed though they must be removed

Babies have a large occiput and when putting them in this position make sure to not do the full chin lift but rather put them in the sniffing position 


The Jaw Thrust

The jaw thrust is the safest initial approach to opening the airway with suspected neck injury as it is accomplished without extending the neck. The head is supported without tilting it backwards or tuning it side to side

Used to accomplish the forward displacement of mandible

Grasp the angle of the patient lower jaw and lifting with both hands, one on each side, displace mandible forward while titling the head backwards

This will elevate the tongue and hopefully relieve the obstruction

If the lips are closed, retract the lower lip with thumb 


Patient is Breathing but Airway is Obstructed What To Do?




Devices used to elevate the tongue off the posterior pharyngeal wall and away from the hard and soft palates, thereby establishing a patent airway through which spontaneous ventilation can be achieved

Breath stacking will occur when you do not fully allow them to exhale 


Oropharyngeal Airways (OPAs)

Rigid, curved devices with an air passage, placed through the mouth with the end resting distal to the tongue above the glottis opening


Oropharyngeal Airways (OPAs) Indication for Use

  • Used in patients with decreased submandibular tone
    • Obtunded 2 degrees to any of the central cause of airway obstruction
    • Anesthesia
    • Deep sedation
  • Used when manually ventilating a patient
  • Used as aid for deep suctioning
  • Used as a bite block
  • Some model used to facilitate intubation


OPA Contraindications for Use

Patients with obvious oral trauma

Awake or semi-conscious patients

May cause vomiting or gagging

IMPORTANT-If a patent is awake enough to spit or tongue the device out then they are too awake for the device to be used



OPA Sizing

Proper sizing

Place the airway next to the face with the flange at the mouth and the tip of the airway should reach the angle of the jaw (tragus of the ear)



Complications of OPA

May cause trauma to the lips, mouth, or teeth-Rare

May cause pressure necrosis

Difficult to perform mouth care

May cause gagging and vomiting-May push the tongue back


Nasopharyngeal Airways (NPAs)


AKA nasal trumpet

Soft or semi-rigid hollow tube placed through the nares, the tip lying distal to the tongue above the glottic opening

May be sized in mm I.D. or French sizes


NPA Indications for Use



  • Semi-awake patients who require some airway maintenance and do not tolerate the OPA
  • Ay be used when insertion of OPA is difficult or contraindicated
  • Maybe used to facilitate deep suctioning
  • Pierre-Robin Syndrome (in neonates)
    • Micrognathia-Tiny Chin
    • Mandibular hypoplasia


Contraindications of NPA



Obvious nasal trauma

Deformities of the nose

Basal fractures of the nose (Racoon eyes and battle sign)-This may indicate skull fractur but use history to help determine

Coagulation disorder-NPA can cause nosebleeds


Complication from Use of NPA


If too long can enter into the esophagus causing gastric distension and hypoventilation

May cause vomiting and laryngospasm (big issue with infection) in semi-conscious patient

Injury of nasal mucous with bleeding


Bypassing natural defenses

Otitis Media (ear infection)

Intubation of meninges (basal skull fracture)

Occlusion of airway by secretions

Tissue necrosis



Used when pt. is not breathing on their own

Manual Resuscitator

Bag-Valve-Mask (BVM)

Bag-Mask Ventilator (BMV)


“Portable handheld devices that provide a means of delivering positive pressure to a patient’s airway”

“Deliver room air (R/A), oxygen air-oxygen mixtures via a mask or through an adapter that attaché directly to a patients ET”

You will know you are giving enough air if there is chest rise 


Manual Resuscitator

Hand squeezing a bag provides the mechanical force necessary to generate a positive pressure

Requires an oxygen source to deliver FiO2 greater than 0.21

In the baby and child versions they will have pop off valves


Commonalities in Bag

  • Universal connector (15/22 mm)
    • This allows them all to be connected to trachs
  • Requires an O2 sources for FiO2 >0.21
    • Oxygen flow meter
    • 50 psi source
      • Wall outlet
      • Cylinder
  • Originally designed for use during CPR


Self Inflating Manual Resuscitator 

Does not require a compressed gas source for operation

Re-usable or disposable


Self Infalting Resuscitator Parts

  • Self –inflating bag
    • (volume depends on patient population)
  • Air inlet/Oxygen Reservoir attachment site
  • Oxygen Inlet
  • Patient Outlet
  • Valve assembly
    • One way, non-rebreathing
  • Oxygen reservoir  (required for high FiO2)
  • Pressure release (pop-off) valve (optional)
  • Pressure Gauge / Guage attachment site (optional)


Classess of Non-Rebreathing Valves

  • Spring-Loaded
  • Diaphragm
    • Duckbill (most common)
    • Leaf-type
    • Fishmouth


Pneumatic Resuscitators

  • Used when unable to bag
  • Commonalities
  • Universal connector (15/22 mm)
    • This allows them all to be connected to trachs
  • Requires an O2 sources for FiO2 >0.21
    • Oxygen flow meter
    • 50 psi source
      • Wall outlet
      • Cylinder


Safety Mechanisms of Resuscitators

  • Non-Rebreathing Valve (Self-Inflating)
    • Prevents rebreathing of exhaled gases
  • High Pressure Pop-Off Valves (self-Inflating)
    • Prevents delivery of overly high pressure to patient (infant and children only)
  • Maximum circuit pressure control (T-Piece Resuscitator)
    • Will take away the variability of the pressure delivered in a breath
  • Standard 15/22 mm connectors
    • Allows for easy connection and disconnection


Quality Control Mechanisms

  • Operation manual should specify
    • BVM device underwent safety and standard testing
    • Criteria was met


Stamdard Construction for Resuscitators

  • Resuscitators capable of delivering FiO2 > or = 0.95
  • Must be able to operate at-Extreme temperatures and Relative humidity 40-96%
  • Deliver Vt > or equal to 600 ml into test lung for adult baggers
    • With compliance of 0.2L/cmH2O
    • With resistance of 20 cmH2O/L/sec
  • Non-rebreathing valve withstand oxygen flow rate up to 30lpm
  • If valve malfunctions due to foreign obstruction (e.g. vomitus), must be restored within 20 seconds
  • Must have standard 15/22 mm connectors
  • Adult resuscitators not have pressure limiting system
  • Resuscitators for infants and children have pressure relief valve that limits PIP to:
    • 40  +/- 10 cmH2O for children
    • 30  +/-  5 cmH2O for infants
  • When incorporating pressure limiting system, override capability must exist and must be apparent to operator
  • Resuscitator able to operate after being dropped from height of 1 meter on to concrete floor
  • Easily disassembled for sterilization and disinfection purposes
  • Should not be possible to accidentally interchange parts
    • making unit malfunction
    • not function at all 


Mask Seal

Hand Positioning-Single Hand

Lift chin up to the mask


Proper Ventilation

Connect bag to mask and O2

Should not use entire volume of bag

Assess for mask seal

Should feel some resistance in the bag.

Does the chest rise?

Can you hear a leak?





Steps to improve mask seal

Remove mask and reseat to face

Is airway patent

Head tilt chin lift?


Suction oropharynx

Two hand mask seal

Reinserting patient's false teeth


Assessment of effective ventilation.

Goal is for visible chest rise

Chest rise and fall with ventilation

Breath sounds with ventilation

Improving SpO2

Capnograph waveform-end tidal CO2 (confirmation of intubation and can tell us about effectiveness of CPR by seeing if you are pumping enough blood through the body)


Ventilating the Patient

  • 12 breaths per minute
    • Every 5 seconds
  • Target 500-600 mls for an adult
  • Ti 1.0s
    • Decrease insufflation of stomach with gentle ventilation
    • Esophageal sphincter opening pressures ~25cmH2O


BMV Golden Rules

Manual ventilation skill with proper equipment is a fundamental premise of advanced airway management

Anybody (almost) can be oxygenated and ventilated with a bag and a mask

The art of bagging should be mastered before the art of intubation


What Will Make Resuscitation Difficult



  • M- Mask Seal
    • Bushy beards, trauma
  • O- Obesity/Obstruction
    • ↑ weight of chest, ↓ diaphragmatic excursion
    • ↑ Resistance 2° to swelling, adipose tissue
  • A- Age
    • Older than age 55 (not a hard,fast rule)
  • N- No Teeth
    • Face tends to cave in
  • S- Stiff, Snoring Hx
    • Lungs resistant to ventilation (asthma, COPD)


Describe three major hazards associated with manual resuscitation. Which is the most common?

  • Delivery of excessive high airway pressure (most common)
    • Common in intubated patients
  • Defective nonrebreathing valve
    • Can cause an inspiratory leak and tidal volume escaping through the exhalation port and not delivered to the patient
  • Faulty pressure-relief valves
    • Can cause gas delivery at excessively high pressures and increases the risk of barotrauma


1. What is the difference between tracheotomy and tracheostomy?


A tracheostomy is a surgically created hole at the front of the neck into the trachea. The procedure of creating this hole and placing a tube within it (through which the patient breathes) is called a tracheotomy.



List factors considered when determining whether the patient should have a tracheotomy/tracheostomy.

Indications of a tracheotomy include:

-Upper airway obstruction or trauma

-Continuing need for artificial airway after a prolonged period of oro/nasotracheal intubation

-To facilitate removal of secretions from tracheobronchial tree when patient is unable to raise secretions

-Inability to wean from artificial airway even after being weaned off of mechanical ventilation

-Long term care patients with neuromuscular disease

-Obstructive sleep apnea



Briefly describe the two main methods of tracheotomy.

Cricothyroidotomy is a surgical incision to the trachea which passes through the cricothyroid membrane and results in the insertion of an endotracheal tube or a tracheostomy tube. Under this method, a single horizontal incision is done through the skin to the trachea.


Percutaneous dilatory tracheostomy (PDT) is the more common method of tracheotomy due to its effectiveness, simplicity, and low incidence of complications. This method is performed mostly in the ICU if the patient is in the unit and intubated for more than 7 days. PDT is performed mostly with the Ciaglia method: a guide wire is placed between the first and second or second and third tracheal rings and plastic dialators is pushed through the soft tissue until the appropriate size is met. This method is usually aided with the use of a bronchoscopy.



Describe the four mechanisms of airway emergencies in patients with artificial airways and how to troubleshoot these situations. Which mechanism is the most common?


Displacement: Reposition (if possible) or remove tube and bag until reintubation is possible.


Obstruction: (Most Common!) Many different causes, but move patient’s head/neck to reposition, deflate cuff, suction catheter through tube, or flush tube with saline or mucus shaving device


Pressure: The pressure of the cuff on the ETT can cause issues if under-inflated or over-inflated. If under-inflated, air and secretions can leak around the cuff and cause ventilation issues. Over-inflation can cause the trachea to become inflamed and cause further ventilatory issues.  


Equipment: Anything that causes a stoppage in the flow of oxygen to the patient. Check the tubing or vent to see if any kinks have developed, and have back-ups. You can also remove tube and bag patient until they can be reintubated.



Humidification and Warming Provided by the Mouth

The mucosal cavity of the mouth will provide humidification and warming of inspired air

Much less efficient than nose



A passage way from the epiglottis of the esophagus to cricoid cartilage (C6)