Detailed Lesson Plan

Chapter 10

Airway Management, Artificial Ventilation,

and Oxygenation

480–540 minutes

Chapter 10 objectives can be found in an accompanying folder.
These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.
Minutes / Content Outline / Master Teaching Notes
5 / I.Introduction
A.During this lesson, students will learn special considerations of assessment and management of the airway and breathing status and techniques of oxygen administration.
B.Case Study
  1. Present The Dispatch and Upon Arrival information from the chapter.
  2. Discuss with students how they would proceed.
/ Case Study Discussion
  • Are there any obvious reasons to suspect problems with the patient’s airway, breathing, and circulation?
  • What actions will you take to determine any problems with the patient’s airway, breathing, and circulation?

10 / II.Respiration
  1. Respiration refers to the gas exchange process that occurs between the alveoli or cells and the capillaries, or to the utilization of glucose and oxygen during normal metabolism in cells.
  2. Respiration has four distinct components.
  1. Pulmonary ventilation—The mechanical process of moving air in and out of the lungs
  2. External respiration—The gas exchange process that occurs between the alveoli and the surrounding pulmonary capillaries
  3. Internal respiration—The gas exchange process that occurs between the cells and the systemic capillaries
  4. Cellular respiration and metabolism—The process through which glucose is broken down in the presence of oxygen to produce ATP, carbon dioxide, and water
/ Teaching Tip
Ask students to explain back to you the four components of respiration to ensure their understanding before moving to the next section.
Critical Thinking Discussion
Without glucose circulating in the blood, what component or components of respiration will be affected? Why?
20 / III.Respiratory System Review—Anatomy of the Respiratory System
  1. The upper airway—Extends from the nose and mouth to the cricoid cartilage
  1. Nose and mouth
  2. Pharynx
  3. Epiglottis
  4. Larynx
  5. The lower airway—Extends from the cricoid cartilage to the alveoli of the lungs
  1. Trachea
  2. Bronchi and bronchioles
  3. Lungs
  4. Diaphragm

35 / IV.Respiratory System Review—Mechanics of Ventilation (Pulmonary Ventilation) Review
A.Ventilation is the passage of air into and out of the lungs.
1.Inhalation, or inspiration, is the process of breathing air in.
2.Exhalation, or expiration, is the process of breathing air out.
B.Inhalation
1.The diaphragm and the intercostals muscles contract.
2.The diaphragm moves slightly downward.
3.The size of the chest cavity increases.
4.Negative pressure is created inside the chest cavity.
5.Air is drawn in by way of the nose, mouth, trachea, and bronchi into the lungs.
C.Exhalation
1.The diaphragm and the intercostals muscles relax.
2.The diaphragm moves slightly upward to its resting position.
3.The size of the chest cavity is reduced.
4.The pressure in the chest cavity becomes positive.
5.Air is forced out of the lungs.
D.Control of respiration
1.Respirations are controlled by the nervous system.
2.The respiratory centers that control impulses sent to respiratory muscles include the dorsal respiratory group (DRG), ventral respiratory group (VRG), apneustic center, and pneumotaxic center in the brain stem.
3.Chemoreceptors monitor levels of oxygen, carbon dioxide, and pH in arterial blood.
  1. Patients with chronic obstructive pulmonary disease (COPD) have chronically elevated carbon dioxide levels in arterial blood.
  2. Chemoreceptors in COPD patients become insensitive to changes in carbon dioxide and instead rely on oxygen levels to regulate breathing.
/ Teaching Tip
Allow students to demonstrate and increase learning by asking them to explain concepts first, and then fill in gaps and correct inaccuracies.
30 / V.Respiratory System Review—Respiratory Physiology Review
A.Oxygenation is the process by which the blood and the cells become saturated with oxygen.
B.Hypoxia is an inadequate amount of oxygen being delivered to the cells.
1.Causes
  1. Occluded airway
  2. Inadequate breathing
  3. Inadequate delivery of oxygen to cells by the blood
  4. Inhalation of toxic gases
  5. Lung and airway diseases
  6. Drug overdose that suppresses respiratory center
  7. Stroke
  8. Injury to the chest or respiratory structures
  9. Head injury
2.Signs
  1. Tachypnea
  2. Dyspnea
  3. Pale, cool, clammy skin
  4. Tachycardia
  5. Elevation in blood pressure
  6. Restlessness and agitation
  7. Disorientation and confusion
  8. Headache
  9. Cyanosis
  10. Loss of coordination
  11. Sleepy appearance
  12. Head bobbing
  13. Slow reaction time
  14. Altered mental status
  15. Bradycardia
3.Response to signs of hypoxia
  1. If airway is open and breathing is adequate, apply a nonrebreather mask and administer high-flow, high-concentration oxygen.
  2. If breathing status is inadequate, begin positive pressure ventilation.
C.Alveolar/capillary exchange (external respiration)
1.Deoxygenated blood moves into the capillaries surrounding the alveoli.
2.Oxygen-rich air moves into the alveoli.
3.Oxygen diffuses into the capillaries and carbon dioxide diffuses into the alveoli.
4.Hemoglobin in the blood picks up most of the oxygen.
5.The blood carries oxygen through the arterial system to the capillaries of the body.
6.Carbon dioxide is exhaled from the alveoli and out of the lungs.
7.Despite adequate oxygenation, cellular hypoxia may still result from any disturbance in the delivery or the off-loading of the oxygen.
D.Capillary/cellular exchange (internal respiration)
1.Oxygenated blood moves into the capillaries surrounding the body cells.
2.Cells have high levels of carbon dioxide and low levels of oxygen.
3.Oxygen diffuses into the cells and carbon dioxide diffuses into the blood.
4.Deoxygenated blood moves into the venous system, where it is transported back to the lungs for has exchange. / Discussion Questions
  • What is the process by which body cells receive oxygen?
  • What are signs of early hypoxia and late hypoxia?
Critical Thinking Discussion
A trauma patient has an injury to the lung that has allowed air to separate the pleural layers (pneumothorax). How will this affect ventilation?
25 / VI.Respiratory System Review—Pathophysiology of Pulmonary Ventilation and External and Internal Respiration
A.A disturbance in pulmonary ventilation, oxygenation, external respiration, internal respiration, or circulation can lead to cellular hypoxia and anaerobic metabolism.
  1. Anaerobic metabolism is associated with insufficient energy production and the buildup of lactic acid.
  2. A severe alteration in perfusion can decrease glucose delivery to cells.
  3. Without fuel, cells will eventually die.
B.Causes for disruption in the mechanical process of pulmonary ventilation
  1. Interruption of nervous system’s control
  2. Structural damage to the thorax
  3. Increased airway resistance
  4. Disruption of airway patency
C.The exchange of gas can be disrupted.
  1. Pneumonia, pulmonary edema, and drowning cause fluid to hinder the movement of oxygen from the alveoli to the capillaries.
  2. Diseases such as emphysema distort the alveoli and change the surface for effective gas exchange.
  3. Inhaled toxic gases interfere with oxygen use by the cell.
  4. Poor perfusion or a decreased ability to carry blood can lead to cellular hypoxia.
  5. Pulmonary embolism
  6. Tension pneumonthorax
  7. Heart failure
  8. Cardiac tamponade
  9. Anemia
  10. Hypovoemia
/ Discussion Question
What are some illnesses and injuries that can impair oxygenation?
Knowledge Application
Describe patient situations with various cardiac, cardiovascular, respiratory, or nervous system problems. Have students explain how each problem can lead to hypoxia and anaerobic metabolism.
10 / VII.Respiratory System Review—Airway Anatomy in Infants and Children
A.Mouth and nose
  1. Mouths and noses are smaller and more easily obstructed.
  2. Infants are obligate nose breathers.
B.Pharynx
  1. Children are more prone to posterior displacement of tongue at level of pharynx.
  2. Epiglottis can protrude into the pharynx, causing obstruction.
C.Trachea and lower airway
  1. Passages are narrow, softer, and more flexible than those of adults.
  2. Obstructions are more likely with flexion or extension.
  3. Padding under the shoulders is necessary to keep trachea open.
D.Cricoid cartilage
  1. Cartilage is less developed and less rigid.
  2. Under ten years of age, cricoid is narrowest portion of upper airway.
E.Chest wall and diaphragm
  1. Chest wall is softer and more pliable, leading to greater compliance.
  2. Infants and children rely more on diaphragm than intercostals muscles.
  3. If chest does not rise easily during artificial ventilation, assume an airway is not open, the airway is occluded by an obstruction, or the ventilation volume is inadequate.
F.Oxygen reserves
  1. Less oxygen is available during periods of inadequate breathing or apnea.
  2. Twice the metabolic rate of adults
  3. Become hypoxic more rapidly than adult patients
/ Discussion Question
What are differences in pediatric respiratory systems as compared to adults’?
.
10 / VIII. Airway Assessment—Airway Functions and Considerations
A.A patent airway is an open airway.
B.Airway functions and considerations
  1. Airway and respiratory tract is the conduit that allows air to move from the atmosphere into the alveoli.
  2. The airway must remain patent.
  3. Any obstruction of the airway will lead to poor gas exchange and potential hypoxia.
  4. The degree of obstruction will directly affect the amount of air available for gas exchange.
C.Mental status of a patient typically correlates with the status of the airway.
  1. An alert, responsive patient has an open airway.
  2. A patient with an altered mental status or who is unresponsive has the potential for airway occlusion.
/ Discussion Questions
  • What are indications that a patient has a patent airway?
  • Why is opening the airway the first step in the primary survey?

10 / IX. Airway Assessment—Abnormal Upper Airway Sounds
A.When assessing the airway of a patient with a severely altered mental status
  1. Open the mouth manually.
  2. Perform a manual airway maneuver.
  3. Inspect the inside of the mouth.
  4. Listen for any abnormal sounds.
B.Sounds that indicate airway obstruction
1.Snoring—Upper airway is partially obstructed by the tongue or relaxed tissues in the pharynx.
2.Crowning—Muscles around the larynx spasm and narrow the opening into the trachea.
3.Gurgling—Blood, vomitus, secretions, or other liquids are present in the airway.
4.Stridor—Swelling in the larynx causes significant upper airway obstruction. / Discussion Question
What are indications that a patient’s airway is not patent?
10 /
  1. Airway Assessment—Opening the Mouth
A.Crossed-finger technique
1.Kneel above and behind the patient.
2.Cross the thumb and forefinger of one hand.
3.Place the thumb on the patient’s lower incisors and forefinger on the upper incisors.
4.Use a scissors motion to open the mouth.
B.Inspect the airway
  1. Suction any foreign substances.
  2. If suction equipment is not available and no spine injuries are suspected, turn the patient on his side and wipe the fluids or sweep the mouth to remove them.
/ Teaching Tip
Ensure all equipment necessary to demonstrate each skill is readily available.
10 /
  1. Airway Assessment—Opening the Airway
A.Open and maintain a patent airway.
1.Manual airway maneuvers
  1. Head-tilt, chin-lift
  2. Jaw-thrust
2.Suction
3.Mechanical airways
  1. Oropharyngeal airway
  2. Jaw-nasopharyngeal airway
B.Head-tilt, chin-lift maneuver
1.Usage
  1. Should be used when opening the airway in a patient who has no suspected spine injury
  2. Must be supplemented with a mechanical airway device if the airway cannot be adequately maintained
2.Procedure
  1. Apply pressure with one hand backward on patient’s forehead.
  2. Place tips of fingers of the other hand underneath the bony part of the lower jaw.
  3. Lift the jaw upward.
  4. Continue pressing on the forehead to keep the head tilted backward.
  5. Lift the chin and jaw so the teeth are brought nearly together.
C.Head-tilt, chin-lift maneuver in infants and children
1.Same as for adults except for a variation in head positioning
2.With an infant, head should be tilted back into a neutral position.
3.Place a pad behind the shoulders to keep the airway open.
4.Only the index finger of one hand lifts the chin and jaw.
5.Take care not to press on soft tissue beneath the chin.
D.Jaw-thrust maneuver
1.Usage
  1. Patient’s head and neck must be brought into a neutral, in-line position if a spine injury is suspected.
  2. This maneuver is used to open the airway without tilting back the head and neck.
  3. The jaw is displaced by the EMT’s fingers.
  4. Must be supplemented with a mechanical airway device if the airway cannot be adequately maintained
2.Procedure
  1. Kneel at the top of the patient’s head.
  2. Place your elbows on the surface upon which the patient is lying.
  3. Put your hands at the side of the patient’s head.
  4. Grasp the angles of the patient’s lower jaw on both sides.
  5. Use the thumb to retract the lower lip if the lips close.
E.Jaw-thrust maneuver in infants and children
1.Follow the same procedure as for adults.
2.Insert an airway adjunct if the jaw thrust does not open the airway.
F.Positioning the patient for airway control
G.Modified lateral position is used if patient has altered mental status and may be at risk for aspirating blood, secretions, or vomitus.
1.Place patient’s arm flat on the ground at a right angle to the body.
2.Log roll the patient onto his side.
3.Place the hand of the opposite arm under his lateral face and cheek.
4.Bend the leg at the hip and knee to stabilize.
5.If a spine injury is suspected, the patient must remain supine. / Discussion Question
Explain the steps used in opening and maintaining a patient’s airway.
Teaching Tip
Demonstrate each skill first in “real-time,” then step-by-step with explanations, and then in “real time” again.
Class Activity
Give students the opportunity for guided practice of airway management skills.
10 /
  1. Airway Assessment—Suctioning
A.Standard Precautions during suctioning
1.Protective eyewear, mask, and gloves should be worn.
2.An N-95 or high-efficiency particular air (HEPA) respirator should be worn if a patient is known to have tuberculosis.
B.Suction equipment
1.Mounted suction devices
2.Portable suction devices
3.Suction catheters
  1. Hard or rigid catheter—A Yankauer catheter, commonly known as a tonsil tip or tonsil sucker, is used to suction the mouth and oropharynx of an unresponsive patient.
  2. Soft catheter—Known as a French catheter, it is used in suctioning the nose and nasopharynx and in other situations where the rigid catheter cannot be used.
C.Technique of suctioning
1.Position yourself at the patient’s head.
2.Turn on the suction unit.
3.Select the appropriate catheter.
4.Measure the catheter and insert it into the oral cavity without suction.
5.Apply suction only on the way out of the airway.
6.If necessary, rinse the catheter with water to prevent obstruction of the tubing.
D.Special considerations when suctioning
1.Log roll the patient on his side and clear the oropharynx with a finger if secretions or vomitus cannot be removed quickly by suctioning.
2.If both suctioning and artificial ventilation are needed, apply suction for 15 seconds followed by positive pressure ventilation with supplemental oxygen for two minutes, and then repeat.
3.Monitor the patient’s pulse, heart rate, and pulse oximeter reading while suctioning to identify any decrease in blood oxygen levels due to the removal of the residual volume of air.
4.Before suctioning a patient who is being artificially ventilated, ventilate at a rate of 12 ventilations per minute for five minutes, then suction and resume ventilation. / Discussion Question
What precautions should be taken when suctioning?
Critical Thinking Discussion
What will happen if you ventilate a patient who has blood or vomit in the airway?
Teaching Tip
Cover all steps and criteria on the skill check-sheets used for later student testing. It is more difficult to change behaviors, once learned, than to teach them initially.
10 /
  1. Airway Assessment—Airway Adjuncts
A.Oropharyngeal (oral) airway
1.Consists of a semicircular device of hard plastic or rubber that holds the tongue away from the back of the airway.
2.Patient must be completely unresponsive and have no gag or cough reflex.
3.If the patient gags at any time during insertion, the device must be removed.
4.Size and method must be appropriate for the patient
  1. If the device is too long, it can push the epiglottis over the opening of the larynx.
  2. If the device is inserted improperly, it may push the tongue back into the airway.
B.Procedure
1.Select the proper size airway.
2.Open the patient’s mouth using the crossed-finger technique.
3.Gently rotate the airway 180 degrees when it comes in contact with the soft palate at the back of the roof of the mouth.
4.Alternate method involves the use of a tongue depressor (blade).
C.Nasophayngeal (nasal) airway
1.Consists of a curved hollow tube of soft plastic or rubber with a flange or flare at the top end and a bevel at the distal end.
2.Use of this device is indicated for patients in whom the oral airway cannot be inserted.
3.It can be used on a patient who is not fully responsive and needs assistance in maintaining an open airway.
4.Avoid using in patients with a suspected fracture to the base of the skull or severe facial trauma.
D.Procedure
1.Measure the airway.
2.Lubricate the outside of the airway well.
3.Insert the device in the larger or more open nostril, with the bevel facing the septum or floor of the nostril.
4.Check that air is flowing through the airway. / Discussion Question
What are advantages and disadvantages of oral and nasal airways?
Video Clip
Go to
and click on the mykit link for Prehospital EmergencyCare, 9th edition to access a video clip describing OPA insertion.
Animation
Go to
and click on the mykit link for Prehospital EmergencyCare, 9th edition to access an animation reviewing OPA, NPA, and suction techniques.
Knowledge Application
After students have practiced rote skills, put the skills in context by providing lab scenarios that call for decision-making.