Airway and Ventilation
Because oxygen is vital to life, you must maintain an open airway for the patient, provide ventilations if the patient cannot breathe on his or her own, work to establish and preserve patient breathing, and provide oxygen if available
The airway is the passage from the mouth and nose to the lungs. Without an open airway and breathing, the patient will die. A patient who can speak or cry has an open airway, is breathing, and has a pulse. If a patient is unconscious, you must assess airway and breathing and may need to provide artificial ventilations or CPR.
The Respiratory System
The respiratory system consists of the mouth, nose, pharynx, larynx, trachea, bronchi, and lungs. Each bronchus attaches to a lung where the bronchial tree further divides into bronchioles that lead to the alveoli where the exchange of oxygen and carbon dioxide takes place.
Once oxygen-exchange has taken place, the circulatory system transports the oxygen-rich blood back to the heart where it is pumped to the brain and other parts of the body. Some organs, like the heart and brain, are very sensitive to oxygen deprivation. Other vital organs can be adversely affected unless oxygen supplies are restored quickly.
Breathing requires coordination of the respiratory, circulatory, musculoskeletal, and nervous systems. Injuries or illnesses that affect any of these systems may cause respiratory distress or arrest.
Respiratory Emergencies/Airway Management
A respiratory emergency occurs when the body is deprived of oxygen due to airway blockage, respiratory problems, or issues with ventilation.
- Airway issues
- Conscious choking
- Foreign body airway obstruction (FBAO)
- Opening the unconscious patient’s airway
- Unconscious choking
- Respiration issues
- Pulmonary issues
- Ventilation issues
- Chest injuries
- Poisoning/drug abuse
- Airway adjuncts
- Bag-valve-mask (BVM) resuscitator
- Resuscitation masks/face shields
Determining the presence of adequate breathing requires you to observe the patient closely. If the patient is conscious or semi-conscious, he or she is also breathing and has a pulse. Even an unconscious patient may be breathing and have a pulse. The American Red Cross still advocates look, listen, feel (i.e., looking at the chest, listening for sounds of respiration, and feeling for air escaping from the patient’s mouth) for unconscious patients; the American Health Association advocates looking for signs of life, such as movement, obvious breathing, etc.
Even if a patient is breathing, the breathing must be adequate before the patient can be considered stable. Adequate breathing means sufficient and normal in terms of rate, depth, and effort. Sufficient breathing rate differs by age:
- Adults: 12 to 20 breaths per minute
- Children: 15 to 30 breaths per minute
- Infants: 25 to 50 breaths per minute
The depth of breathing must be sufficient to bring air into the lungs so it can pass to the bloodstream. Problems of respiration and ventilation can affect breathing depth and breathing effort. A healthy person with adequate breathing will be calm and clear thinking with normal skin color.
Signs of inadequate breathing include:
- Shallow, rapid breathing
- Struggling to breathe
- Excessive use of the muscles to inhale or exhale
- Inability to “catch one’s breath”
- Noisy breathing (i.e., crackles, stridor, wheezing, etc.)
- Nausea or vomiting
- Altered mental status (i.e., restless, anxious, confused, and agitated)
- Cool, clammy, and/or mottled skin
Artificial ventilation refers to the various mechanical ways to breathe for the patient when the patient’s respiratory system is not functioning but a pulse is present. When delivering artificial ventilations, make sure the force of air is consistent and just deep enough to cause the patient’s chest to clearly rise during each breath.
- Artificial ventilation procedures - continue artificial ventilations for 2 minutes between each check
- BVM resuscitator ventilation
- Direct contact ventilation
- Mouth-to-mask ventilation
- Older ventilation methods
- Retention of ventilation training
- Ventilation complications
- Air in the stomach - When providing ventilations, blow slowly with just enough force to make the chest clearly rise. Excess air can enter the stomach, causing gastric distention. This interferes with care and can cause the patient to vomit.
- Vomiting - Artificial ventilations may cause the patient to vomit. If this occurs, quickly turn the patient onto his or her side to allow the vomit to drain out of the mouth so it does not block the airway or enter the lungs. After vomiting stops, clear the patient’s airway using finger sweeps or suctioning and then continue ventilations. More examples of lateral turning the victim: 8-rescuer log roll and lift; NLS Canada Vomit roll
- Dentures - Leave dentures in place unless they become loose and block the airway. Dentures actually help support the mouth and cheeks, making it easier to make a seal with your mouth or a mask.
- Suspected spinal injury - If you suspect a spinal injury, use the jaw thrust without head extension to open the airway and give ventilations.
When someone has a breathing or cardiac emergency, supplying emergency oxygen can be crucial. During such an emergency, the amount of oxygen carried by the blood cells to the heart, brain, and remainder of the body is reduced, resulting in hypoxia. The air we breathe contains approximately 21% oxygen. When you use a BVM, you deliver 21% oxygen to the patient. The amount of oxygen we exhale contains about 16% oxygen. This is the amount of oxygen delivered when you use a face shield or resuscitation mask or give mouth-to-mouth or mouth-to-nose resuscitation. These percentages, while adequate for resuscitation, are not optimum for the hypoxic patient.
Emergency oxygen can be given in many breathing or cardiac emergencies to increase the percentage of oxygen delivered to the patient. According to the US Food and Drug Administration (FDA), emergency oxygen units are available without prescription for first aid, provided they contain at least a 15-minute supply of oxygen and are designed to deliver a preset flow rate of at least 6 liters of oxygen per minute (LPM).
Different delivery devices provide different percentages of oxygen. For example:
- Nasal cannulae can delivery oxygen at 1 to 6 LPM to achieve a concentration of 24% to 44% oxygen for breathing patients only
- Resuscitation masks with O2 inlets can deliver oxygen at 6 to 15 PM to achieve a concentration of 25% to 55% for breathing and nonbreathing patients
- Non-rebreather masks can deliver oxygen at 10 to 15 LPM to achieve a concentration of up to 90% for breathing patients only
- BVMs can deliver oxygen at 15 LPM or higher to achieve a concentration of 90% oxygen or higher for breathing or nonbreathing patients