Paramedic Airway Study Guide

 Establishing and maintaining a patient airway and ensuring effective oxygenation and ventilation are vital to patient care.
 Failure to manage the airway is a major cause of preventable death in the prehospital setting

Question Answer
All airway interventions must begin with Good positioning and hyper oxygenation
Vallecula Pocket between base of tongue and epiglottis;
important landmark for ET intubation
Arytenoid cartilages Posterior attachment of vocal cords; valuable
guides for ET intubation
Laryngospasm Spasmodic closure of the vocal cords
Larynx Formed by two plates “laryngeal prominence”
Adams apple
Cricothyroid membrane  Ligament between the thyroid and
cricoid cartilage Site for emergency
surgical and nonsurgical access to the airway
(cricothyrotomy)

Cricothyrotomy Surgical and nonsurgical access to airway

through the cricothyroid membrane
Trachea Conduit for air entry into lungs
Where does the esophagus lie Posterior to the trachea
Trachea divides into what Right and left mainstem bronchi
 Goblet cells Secrete mucous to help protect the lining of
bronchus; traps microorganisms
Cilia Hair-like structures that sweep fluids and
particles out of airway to keep out of lungs
Where are Beta-2 adrenergic receptors located Located in the bronchioles of lungs and arteries
of the skeletal muscles
What happens when Beta-2 adrenergic Increase the diameter of the bronchioles to let
receptors are stimulated more air in/out during breathing
Alveoli Functional site for the exchange of oxygen and
CO2
What lines the alveoli to prevent collapse Surfactant
Lungs consist of what Smaller bronchi, bronchioles, and alveoli
Surfactant Phospholipid compound
Normal air pressure 760 mmHg
Inhalation Thoracic cage expands during inhalation and air
pressure in thorax decreases
When does negative-pressure ventilation When atmospheric pressure is equalized
inhalation stop
Breathing is due to Changing pressure in the lungs
Air flows from --- pressure to ---pressure Higher; lower
Thoracic cage Like a bell jar in which balloon are suspended
Why does breathing become deeper Tidal volume responds to increased demand for
oxygen
Alveolar volume Volume of air that reaches the alveoli
 Tidal volume Amount of air moved in/out of respiratory tract
during 1 breath
What is the average tidal volume for 6-8mL/kg
infants/kids
What is the average tidal volume for adults 5-7mL/kg
Dead space volume Portion of tidal volume that does not reach the
alveoli
Minute volume Amount of air moved through the respiratory
tract in 1 minute
Why would minute ventilation increase Exercise as tidal volume and breathing rate
increase
Is exhalation a passive or active process Passive process
Which feedback loop is used to prevent over- Herring-Breuer reflex
inflation of the lungs
What primarily regulates ventilation pH of CSF
Central chemoreceptors (medulla oblongata) CO2 and hydrogen ion changes in the CSF
sense what to regulate ventilation
Peripheral chemoreceptors (carotid/aortic Changes in blood oxygen levels and increased
bodies) sense what to regulate ventilation breathing rate
A rising O2 level will do what to breathing Suspends breathing
A rising CO2 level will do what the breathing Stimulate breathing
Patients with COPD have trouble eliminating CO2
what with exhalation
Hypoxic drive Secondary control; backup system that
 stimulates breathing when arterial oxygen level
falls
What other factors control ventilation Fever, certain medications, pain, strong
emotions, narcotic analgesics, hypoxia, acidosis,
and metabolic rate
What if fraction of inspired oxygen (FIO2) % of oxygen in inhaled air
When does FIO2 increase With supplemental oxygen
Oxyhemoglobin dissociation curve represents Represents the % of hemoglobin that are
what saturated with oxygen depending on PO2 in
blood
What shape is the oxyhemoglobin diss. Curve Sigmoidal shape (S-shape)
A RIGHT shift in the curve does what DECREASES oxygen’s affinity for hemoglobin
A LEFT shift in the curve does what INCREASES oxygens affinity for hemoglobin
What does acidosis and increased CO2 do to Shift to the RIGHT; hemoglobin gives up O2
the oxyhemoglobin diss. Curve faster
Alkalosis and decreased CO2 do what to the Curves to the LEFT; hemoglobin holds on to
oxyhemoglobin diss. Curve more O2
Metabolism Process of cells taking energy from nutrients
Respiration Process of exchanging oxygen and CO2
External respiration Exchange of O2 and CO2 between alveoli and
blood in pulmonary capillaries
Internal respiration Exchange of oxygen and CO2 between the
systemic circulation and cells
Aerobic metabolism The mitochondria of cells convert glucose to
 energy (ATP)
Anaerobic metabolism Without O2, cells do not completely convert
glucose to energy
Perfusion Circulation of blood in adequate amounts to
meet the cells needs
Hypoxia Tissues/cells do not receive enough O2
Intrinsic factors that affect ventilation Infection, allergic reactions, and
unresponsiveness
What is the most common obstruction in an The tongue
unresponsive patient
Extrinsic factors that affect ventilation Trauma and foreign bodies and airway
obstructions
What are external factors affecting High altitudes, closed environments, and toxic
oxygenation and respiration gases
Internal factors affecting oxygenation and Nonfunctional alveoli or fluid in alveoli; inhibits
respiration gas exchange, hypoglycemia, infection,
hormonal imbalances
What is considered adequate breathing Patients responsive and alert, rate between 12-
20 bpm, adequate depth, regular pattern and
clear/equal breath sounds
What is considered inadequate breathing Rate <12 bpm or >20 bpm, cyanosis, or
preferential positioning
Evaluation of inadequate breathing includes Observation, palpation, and auscultation
What things should you note with inadequate Position, orthopnea, chest rise/fall, skin, flared
 breathing nostrils, pursed lips, retractions, use of
accessory muscles, asymmetric chest wall, quick
breaths, and labored breathing
What are some protective airway reflexes Coughing, sneezing, gagging, sighing, and
hiccupping
How does air reach the lungs (through what Only through the trachea
structure)
Laryngeal edema Glottic opening narrow or totally closes
What can cause a laryngeal spasm Intubation trauma or extubating
What can cause laryngeal edema Epiglottitis, anaphylaxis, or inhalation injury
Laryngeal injury Fracture of the larynx increases airway
resistance by decreasing airway size
What does the abdominal thrust (Heimlich) Creates an artificial cough, expelling an
maneuver do obstructive object
Normal ventilation Diaphragm contracts and negative pressure in
chest cavity draws air in
Positive-pressure ventilation Generated by a device and forces air into the
chest cavity from the external environment
The bag-mask device and deliver nearly 100% Mask seal integrity
O2 and provide adequate tidal volume
depending on what
What is the total amount of gas in an adult 1200-1600mL
bag-mask device
Bag valve mask is only effective as what The mask seal to the patient’s face
What happens when there is air leakage in the Decreased tidal volume and hypoventilation
bag valve mask
Why must you allow the patient to exhale Can lead to air trapping, pleural barotrauma,
between breaths while using a bag valve mask subsequent pneumothorax
Continuous positive airway pressure Noninvasive means of providing support for
patients with respiratory distress
What does continuous positive airway pressure Increases pressure in lungs, opens collapsed
do alveoli, pushes O2 across alveolar membrane,
and forces interstitial fluid back into circulation
How is continuous positive airway pressure Through face mask secured with a strapping
typically delivered system
Esophageal tracheal combi-tube (ETC) A dual-lumen airway with a ventilation port for
each lumen
Laryngoscope Required to perform orotracheal intubation by
direct laryngoscopy
Straight (Miller and Wisconsin) blades Useful with infants/small kids; damage adults’
teeth
Curved (Macintosh) blade Curve conforms to tongue and pharynx; tip
placed in vallecula
Blade sizes 0-2 Infants and children
Blade sizes 3-4 Adult sizes
What anatomical clues can help determine Internal diameter of the nostril approximates
endotracheal tube size diameter of glottic opening
Diameter of little finger or thumbnail size
 approximates airway size
What is critical before intubating Preoxygenation
How long should you oxygenate for apneic or 2-3 minutes
hyperventilating patients
What are the 3 axes of the airway Mouth, pharynx, and larynx
Capnography Graphic representation of exhaled CO2;
ventilation
Pulse oximetry Measures O2 and oxygenation
Capnography use is limited with what Cardiac arrest
Capnography can do what 2 things Indicate effectiveness of chest compressions
and detect return to spontaneous circulation
External laryngeal manipulation (ELM) can do Assist with better visualization of the glottis and
what airway structures
In nasotracheal intubation, which direction Toward the nasal septum
should the bevel face during placement
What equipment do you need for a scalper Scalpel, bougie, and ETTube
cricothyroidotomy
Scalpel cricothyroidotomy Most reliable method and fastest
A cuffed tube in the trachea does what Protects the airway from aspiration
Provides secure route for exhalation
Allows low-pressure ventilation using standard
breathing systems
Permits end-tidal CO2 monitoring
What characteristics have decreased O2 Elderly
 storage capacity Obesity
Pregnancy
Lung disease
Chest trauma
Baseline hypoxia
What characteristics have increased 02 Fever/sepsis
consumption Severe pain
Alcohol withdrawal
Cocaine/methamphetamine intoxication
Tachycardia
Shock
Children
What can make bag valve mask ventilation Facial trauma/ facial hair
difficult Obesity
Lack of teeth
History of snoring
Severely limited jaw protrusion
Thyromental distance less than 6mm

What can make Extraglottic airway insertion/ Limited mouth opening

ventilation difficult Massive secretions
Morbid obesity
Severe pulmonary disease
What can make laryngoscopy and orotracheal Facial trauma or anomalies
 intubation more difficult Short thyromental distance
Short sternomental distance
Limited mouth opening
Limited neck mobility
Obesity
Buckteeth
What can make a surgical airway more difficult Cricothyroid membrane cannot be located
(morbid obesity, anterior neck trauma, prior
radiation therapy, and Ludwig’s angina)
Tube insertion prevented by conditions in
airway (tumor, infection, swelling, or foreign
body)
A rapid airway exam uses which acronym and L-Look externally
what does it stand for E-Evaluate 3-3-2
M-Mallampati score
O- airway Obstruction
N- Neck mobility
S- Saturations
Mallampati score: Class I Considered EASY
Visualize soft palate, fauces, uvula, and
anterior/posterior pillars
Mallampati score: Class II Considered MILDLY DIFFICULT
Visualize soft palate, fauces, and uvula
Mallampati score: Class III Considered MODERATELY DIFFICULT
 Visualize soft palate and base of uvula
Mallampati score: Class IV Considered DIFFICULT
Soft palate not visible at all
 Chapter 15: Airway Management and Ventilation
 Airway management and ventilation are the first and most critical steps in the primary assessment of every patient you will encounter.
 ABC: airway, breathing, ventilation
 CAB: compressions, airway, breathing
 Your deliberate and precise use of simple, basic airway skills is the key to successful and a good patient outcome
 Respiration = gas exchange between a living organism and it’s environment
 Upper airway: mouth and nose to larynx
 Fractures of the upper sinuses (sphenoid’s) can occasionally cause CSF to leak from the cranial cavity into the nasal cavity
 Eustachian tubes = auditory tubes
 Nasolacrimal ducts: drains tears and debris from the eyes into the nasal cavity
 Pharynx: muscular tube that extends vertically from the back of the soft palate to the superior aspect of the esophagus
 Upper airway components include:
o Nasal cavity
o Oral cavity
o Pharynx
 Three regions:
 Nasopharynx -back of nasal opening to plane of soft palate
 Oropharynx – plane of soft palate to hyoid bone
 Laryngopharynx (Hypopharynx) – extends posteriorly from hyoid bone to esophagus anteriorly to larynx
 Larynx: complex structure that joins the pharynx with the trachea
o Epiglottis: located anteriorly in the hypopharynx (laryngopharynx), leaf shaped, prevents food from entering respiratory tract
o Vallecula: anterior and superior to epiglottis; fold formed by base of tongue and epiglottis (Book)/pocket between base of tongue and
epiglottis (PowerPoint) Important landmark for intubation

 Lower airway components include:

o Trachea
o Bronchi
o Alveoli
o Lung parenchyma
o Pleura
 Pulmonary respiration: (external) occurs in the lungs when the respiratory gases are exchanged between the alveoli and the RBC’s in the
pulmonary capillaries through the capillary membranes
 Cellular respiration: (internal) occurs in the peripheral capillaries; between the RBC’s and various body tissues
o Produces carbon dioxide
 Ventilation: mechanical process that moves air into and out of the lungs; necessary for respiration to occur
 Partial pressure: the pressure exerted by each component of a gas mixture
o % of the mixture’s total pressure
 Diffusion: is the movement of a gas from an area of higher concentration (partial pressure) to an area of lower concentration, attempting to
reach equilibrium.
 Oxygen diffuses into the blood plasma, where most of it combines with hemoglobin and is measured as oxygen saturation (SaO2)
 CaO2 = arterial oxygen concentration
 SaO2 = hemoglobin oxygen saturation
 SpO2 = oxygen saturation %
o Varies between 96-99% at sea level
o 91-95% indicate mild hypoxemia: supplemental O2
o 86-90% indicate moderate hypoxemia; high concentration supplemental O2 using nonrebreather
o <85 indicates severe hypoxemia; immediate intervention, high concentration O2, ventilatory assistance, or CPAP
 Hgb = amount of hemoglobin present (g/dL)
o 1.34 is a constant: represents the amount of oxygen bound to one gram of hemoglobin at 1 atmosphere pressure and the partial
pressure of oxygen dissolved in the plasma
 Factors affecting oxygen concentration in the blood:
o Decreases hemoglobin concentration: anemia, hemorrhage
o Inadequate alveolar ventilation due to low inspired oxygen concentration, respiratory muscle paralysis, and pulmonary conditions:
emphysema, asthma, and pneumothorax
o Decreased diffusion across the pulmonary membrane
o Perfusion/ventilation mismatch that occurs when alveoli collapses
 Correcting oxygen derangements:
o Increase ventilation
o Administer supplemental oxygen
o Administer medications to correct underlying problems
 Hypercarbia = increased CO2 levels
 Respiratory rate -= the number of times a person breathes in 1 minute
 Main respiratory center lies in the medulla; located in the brainstem
o Additional center in the pons: apneustic center assumes respiratory control when the medulla fails
 o Pneumotaxic center: third center, also in the pons, controls expiration
 Hering-Breuer reflex prevents overexpansion of the lungs
 Hypoxemia: decrease partial pressure of oxygen in the blood
 Causes of airway obstruction:
o Tongue: most common cause
o Foreign bodies
o Trauma
o Laryngeal spasm and edema
o Aspiration: vomitus is the most common
 Dyspnea: abnormality of breathing rate, pattern, or effort
o May cause or be caused by hypoxia
o Prolonged can lead to anoxia: absence or near absence of oxygen

 Pulsus paradoxus: a drop in BP of greater than 10 torr Patients with severe chronic obstructive pulmonary disease may sustain a drop in
blood pressure during inspiration. This drop is due to increased pressure within the thoracic cavity that impairs the ability of the ventricles
to fill.
 Compliance: refers to the stiffness or flexibility of the lung tissue, and is indicated by how easily air flows into the lungs
 Hyperoxia = excess concentrations of O2
 Capnography: recording or display of the exhaled CO2 levels
o Used to verify proper endotracheal tube placement in the trachea
 CO2 is the normal end product of metabolism and is transported by the venous system to the right side of the heart and on to the lungs
where it diffuses into the alveoli and is removed via exhalation
 Ear-to-sternal-notch position: a supine patient’s head is elevated to the point where the ear and the sternal notch are horizontally aligned
o Referred to as sniffing position in non-obese patients
o Referred to as ramped position in obese patients; elevate entire portion of the upper body
 Oxygen delivery Devices:
o Nasal cannula: catheter places at the nares; low-moderate oxygen requirements
o Venturi mask: high-flow face mask delivers precise oxygen concentrations, regardless of patients’ rate/depth of breathing
o Simple face mask: for patients requiring moderate oxygen concentrations
o Partial rebreather mask: patients requiring moderate-high oxygen concentrations
o Nonrebreather mask: provides the highest oxygen concentration of all devices
 Patients should be monitored for hypoxemia
o Small volume nebulizer: delivery of medications in aerosol form
o Oxygen humidifier: provide humidified O2; often given to pediatric patients with upper airway problems (croup)
 o Positive airway pressure: PAP; maintains a constant level of pressure within the airway; prevents collapse of the airway during
inhalation
 Effective ventilatory support requires a tidal volume of 6-8 mL/kg of ideal body weight at a rate of 12 breaths per minute
 Cricoid pressure: posterior pressure on the cricoid cartilage
o Only complete ring in the trachea

 The rule of 3’s for optimal BVM ventilation:

o 3 providers
o 3 inches
o 3 fingers
o 3 airways
o 3 PSI
o 3 PEEP (positive end expiratory pressure)
 Extraglottic airway devices (EGA): inserted blindly into the airway to facilitate oxygenation and ventilation via a self-inflating bag or
transport ventilator, but do not enter the glottis
o Glottis: space between the vocal cords
o Retroglottic: placed behind vocal cords
o Supraglottic: placed above vocal cords
 Endotracheal intubation indicators include
o Respiratory arrest
o Cardiac arrest
o Airway swelling (anaphylaxis; airway burns)
 Laryngoscope: instrument for lifting the tongue and epiglottis out of line of sight so that you can see the vocal cords
 Endotracheal tube (ETT): flexible translucent tube open at both ends and available lengths
o Stylet: plastic-covered metal wire that may be placed inside the ETT, stopping short of the distal end, to allow the tube to be
stiffened and maintained in the optimal shape
o Endotracheal tube introducer: gum-elastic bougie; straight, semi-rigid stylet like device with a distal bent tip covered in protective
resin; facilitates intubations when only the epiglottis may be visualized
 Complications of endotracheal intubation:
o Equipment malfunction
o Tooth breakage and soft tissue lacerations
o Aspiration: the entry of stomach contents, blood, or secretions into the lungs
o Elevated intracranial pressure
 o Transport delays
o Hypoxemia
o Esophageal intubation
o Endobronchial pneumothorax
o Tension pneumothorax: any tear in the lung parenchyma; excessive pressure applied to healthy lung or normal pressures applied to
abnormal lung
 Retrograde intubation: technique in which a needle is inserted into the airway through the cricoid membrane, from the outside, directed
superiorly.
 Maximizing rapid success with endotracheal intubation:
o Good initial training
o Ongoing practice
o Using the endotracheal tube introducer
o Managing neck pressure
o Optimal positioning
o Video laryngoscopy
o RSI
 Blind nasotracheal intubation: through nose and into trachea
 Airway management in children important differences:
o Structures are smaller and more flexible
o Nasal openings are small and adenoids are large
o nasal airway diameters are inadequate
o Cricoid pressure can worsen the situation; less rigid than an adult’s
o Surgical airways are unavailable; use restricted to patients older than 6-10 years
o Tube size is critical
 ETT size (mm) = (Age in years + 16) / 4
o Depth of ETT insertion is different
o The occiput is relatively large
o The epiglottis is floppy and round
o Tongue is larger in relation to the oropharynx
o The glottic opening is higher and more anterior in the neck
o Narrowest part of the airway is the cricoid cartilage, not the glottic opening as in adults
o Greater vagal tone
o Higher basal metabolism combined with led functional residual capacity
 Needle cricothyrotomy: (transtracheal jet ventilation/ transtracheal jet insufflation); generally, the easier procedure but make providing
adequate ventilation more difficult; generally reserved for pediatric patients
o Place large bore needle with plastic cannula through the membrane into trachea
o Barotrauma, including pneumothorax, is a potential complication
 Open cricothyrotomy: more difficult procedure; allows for more effective oxygenation and ventilation
o Both provide access to airway through the cricothyroid membrane
 Medication assisted intubation (MAI): drug-assisted intubation
o Includes RSI and sedation facilitated
o Gives the option to manage the airway that you couldn’t otherwise due to patient to too awake or has trismus
o RSI: intended to minimize the risk of aspiration in a high-rick population
 Administer a neuromuscular blocking drug

 Premedications are drugs given early during RSI to mitigate anticipated complications
o Lidocaine: blunt the rise in intracranial pressure associated with succinylcholine and laryngoscopy
o Atropine: prevent bradycardia associated with succinylcholine in children
 Induction agent: renders the patient unaware during the procedure
o Etomidate: rarely causes a rise/drop in BP/pulse
o Midazolam: benzodiazepine sedative/hypnotic
o Ketamine: dissociative agent; predictable dose response, does not cause hypotension, and provides analgesia and sedation
o Propofol
 Neuromuscular blocking agents (paralytics): drugs that temporarily stop skeletal muscle function without affecting cardiac or smooth
muscle
o Succinylcholine: prototype noncompetitive depolarizing neuromuscular blocker
 Fast onset (45 sec) and short duration (8 min)
 Not recommended for maintaining paralysis; must carry 2nd competitive agent
o Rocuronium: most used competitive agent in emergency medicine/EMS
 Onset time (60 sec) and may last 30 min or longer
 Few adverse effects; may be used for ongoing paralysis
o Vecuronium: competitive agent commonly used to maintain paralysis after succinylcholine
 Long onset time (usually 2nd or 3rd line agent
 Sedative and Analgesics: essential for keeping a patient comfortable after intubation
 o Narcotics: critical to provide analgesia; Fentanyl most commonly used because of rapid onset and minimal effect on BP; morphine
can be used cautiously
o Benzodiazepines: optimal for keeping patients sedated while intubated; Midazolam is a favorite; lorazepam and diazepam also used
o Propofol: infusions are commonly used in intensive care units and during critical care transport to maintain sedation
 Difficult airway factors include
o Difficult BVM ventilation
o Difficult Extraglottic airway placement
o Difficult intubation
o Difficult cricothyrotomy
 Difficult airway scoring system: Mallampati classification system (not useful in unconscious patient)
o Class I: entire tonsil clearly visible
o Class II: upper half of tonsil fossa visible
o Class III: soft and hard palate clearly visible
o Class IV: only hard palate visible
 Cormack and LeHane grading system:
o Grade 1: entire glottic opening and vocal cords seen
o Grade 2: epiglottis and posterior portion of glottic opening may be seen with partial view of cords
o Grade 3: only epiglottis and posterior cartilages seen
o Grade 4: neither epiglottis nor glottis seen
 LEMONS: acronym that can be used to remember assessments and findings associated with difficult airway
o L: look externally
o E: evaluate 3-3-2 rule
o M: Mallampati score
o O: obstruction
o N: neck mobility
o S: saturation
 First line of defense against aspiration should be gravity; turn patient/ head on side
 Accurate and thorough documentation of airway management is critical for clinical care after the patient is transported, for quality
assurance, and for medical-legal defense.
 Always reassess the airway to ensure patient has not decompensated requiring additional airway procedures
 TERMS AND EXTRA NOTES:

 Lung Volumes Calculations

o Tidal volume - quiet respiration 500mL in and out of lungs
o

Review Questions/Answers: remember double check because I am not answering for a grade and the book is not always right 😊
1. The depression between the epiglottis and the base of the tongue is the vallecula
2. The average volume of gas inhaled or exhaled in one respiratory cycle is the tidal volume
3. A drop in BP of greater than 10 torr during inspiration is pulsus paradoxus
4. To avoid hypoxemia during intubation, limit each intubation attempt to no more than 30 seconds before reoxygenating the patient
5. Which medication is not preferred neuromuscular blocking agent for emergency RSI? Pancuronium
6. The nasal cavity is the most superior part of the airway
7. The hyoid is the only bone in the axial skeleton that does not articulate with any other bone
8. The alveoli comprise the key functional unit of the respiratory system
9. The paramedic can correct oxygen derangements by administering supplemental O2
10. The dead-space volume is the amount of gas in the tidal volume that remains in the air passageways unavailable for gas exchange
11. Dysphonia- difficulty speaking
12. An irregular pattern of rate and depth with sudden, periodic episodes of apnea, indicating increased intracranial pressure describes
Cheyne-Stokes respirations
13. Pulse oximetry is often called the 5th vital sign
a. Measures hemoglobin oxygen saturation in peripheral tissues
14. The visual representation of expired CO2 waveform is the capnogram
15. An advantage to the nasopharyngeal airway is it can be used on patients with a gag reflex
16. Advantages to the endotracheal intubation include all of the above (below)
a. It eliminates the need to maintain a mask seal
b. Isolates the trachea and permits complete control of the airway
c. Impeded gastric distention by channeling air directly into trachea
17. Which medication is generally the 2nd line paralytic when succinylcholine is contradicted: Rocuronium
18. Relative contradictions for blind nasotracheal intubation include all the above/below
a. Suspected elevation of intracranial pressure
b. Suspected basilar skull fracture
c. A combative patient
19. Which airway can work properly regardless of the tip being in the esophagus or the trachea: ETC
20. Open cricothyrotomy is contradicted in children under the age of 8 because the membrane is small and underdeveloped