2016 Continuing Education
Airway Management and
Concepts in Pulmonary Care
Table of contents
Learning Objectives. . . . . . . . . . . . . . . . . . . . . . . . 1
Respiratory Assessment. . . . . . . . . . . . . . . . . . . . 1
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Module Completion and Evaluation. . . . . . . . 2
Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Anatomy and Physiology. . . . . . . . . . . . . . . . . . 3
Upper Airway Management. . . . . . . . . . . . . . . . 10
Airway Obstruction. . . . . . . . . . . . . . . . . . . . . 10
Basic Airway Management. . . . . . . . . . . . . . 10
Patient Positioning. . . . . . . . . . . . . . . . . . . 10
Insertion of Airway Adjunct. . . . . . . . . . 10
Suctioning the Airway . . . . . . . . . . . . . . . 10
Oxygenation. . . . . . . . . . . . . . . . . . . . . . . . . 10
Ventilation . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Review. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
The Difficult and Failed Airway . . . . . . . . . 11
Pressure and Partial Pressure . . . . . . . . . . . . 3
Difficult Bag Mask Ventilation
— MOANS. . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Normal Anatomical Structure . . . . . . . . . . . 4
Mechanism of Breathing. . . . . . . . . . . . . . . . 4
Lung Volumes. . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Anatomic Dead Space. . . . . . . . . . . . . . . . . . . . 5
Physiologic Dead Space. . . . . . . . . . . . . . . . . . 5
Gas Exchange . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Extraglottic Airway Ventilation
— RODS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Difficult Laryngoscopy — LEMON. . . . . 11
Failed Airway. . . . . . . . . . . . . . . . . . . . . . . . 12
Endotracheal Intubation (ETI). . . . . . . . . . . 12
The Alveolar Gas Equation. . . . . . . . . . . . . . . 6
Delayed Sequence Intubation
Versus Rapid Sequence Intubation. . . . 12
Hypoxemia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Additional Resources. . . . . . . . . . . . . . . . . . . 13
Reduction in Inspired Oxygen. . . . . . . . . 7
Articles for Review.. . . . . . . . . . . . . . . . . . . . . . . . 13
Hypoventilation . . . . . . . . . . . . . . . . . . . . . . 8
Inhalation Injuries. . . . . . . . . . . . . . . . . . . . . . 13
Diffusion Impairment . . . . . . . . . . . . . . . . . 8
Acute Respiratory Distress Injuries. . . . . . 13
Shunt . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Obesity and Asthma. . . . . . . . . . . . . . . . . . . . 13
Ventilation–Perfusion Mismatch. . . . . . . 9
Capnography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Advanced Study for EMR/EMT
but Mandatory for EMT-Ps . . . . . . . . . . . . 9
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Alberta College of Paramedics • 2016 Continuing Education • Airway Management and Concepts in Pulmonary Care
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Learning Objectives
By the end of this module, learners of all designations will be able to do the following:
1. Search for medically relevant videos online
2. Access research articles via EBSCO
3. Define the concepts of pressure and partial pressure
4. Describe how atmospheric pressure is measured
5. Describe the relevance of Dalton’s law to inspired oxygen
6. Provide a descriptive overview of the entire respiratory system
7. Describe normal upper and lower airway anatomy
8. Describe the normal mechanism of breathing
9. Define dead space and differentiate between physiologic dead space and anatomic dead space
10.Describe and relate the various types of lung volumes and capacities
11. Describe the processes by which gas exchange in the lungs occurs
12. Use the alveolar gas equation to determine different values for the variables in the equation
13. Define hypoxemia
14. Explain how a reduction in inspired oxygen contributes to hypoxemia
15. Explain how hypoventilation contributes to hypoxemia
16. Explain how diffusion impairment contributes to hypoxemia
17. Explain how shunt contributes to hypoxemia
18. Explain how ventilation–perfusion mismatch contributes to hypoxemia
19. Describe the oxygen hemoglobin dissociation curve and how it varies under certain conditions
20.Describe a thorough respiratory assessment
21. Explain the signs of airway obstruction
22.Describe some of the concepts of basic airway management
23.List the devices used in basic airway management
EMTs and EMT-Ps will be able to do the following:
24.Differentiate between a difficult and failed airway attempt
25.Explain the mnemonic LEMON
26.Explain the mnemonic RODS
27.Explain the mnemonic MOANS
EMT-Ps will be able to do the following:
28.Describe the pathophysiology and treatment of inhalation injuries
29.Describe the pathophysiology and treatment of obese and asthmatic patients
30.Describe the pathophysiology and treatment of acute respiratory distress syndrome
31. Describe the purposes of capnography and capnometry
32.Identify the normal morphology of a capnographic waveform
33.Identify some typically abnormal capnographic waveforms
Respiratory Assessment
To review respiratory assessment, read the following two articles. Access these by using the College
EBSCO research database. Login details are in the Module Completion and Evaluation section.
Massey, D., & Meredith, T. (2010). Respiratory assessment 1: Why do it and how to do it? British
Journal of Cardiac Nursing, 5(11), 537-541.
Massey, D., & Meredith, T. (2011). Respiratory assessment 2: More key skills to improve care.
British Journal of Cardiac Nursing, 6(2), 63-68.
Alberta College of Paramedics • 2016 Continuing Education • Airway Management and Concepts in Pulmonary Care
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Introduction
You might think airway management is all about hands-on tasks like intubating and inserting OPAs.
While these tasks certainly involve skill, the most important skill in airway management is knowing
when to do something, and in order to know when you need to take a certain action, you must
understand why.
In some instances, paramedics (and from here on in this module, the term paramedic encompasses
EMR and EMT designations) focus only on the treatment of symptoms. They rely on being told or
on following protocols in order to know what to do; for example, treat chest pain this way or treat
shortness of breath that way. In Alberta, paramedics are expected to have the ability to understand
underlying illness, recognize the illness when assessing the patient, think critically, and use clinical
decision-making and judgment to establish a safe patient-care plan.
Respiratory emergencies make up a significant part of what paramedics deal with on a daily basis.
More importantly, many of these emergencies respond positively to the treatments paramedics are able
to provide. But if improperly performed, some of the treatments can increase patient morbidity and
mortality. Furthermore, advances in pulmonary care are ongoing and continuous. It was not that long
ago that capnography was unheard of in paramedic services. Some will even remember the arrival of
the peripheral saturation monitor, the appearance of LMAs, the development of RSI protocols, and the
implementation of Combitubes and King LTs.
One approach to airway management is to simply focus on upper airway management. There is nothing
wrong with this approach, but this is not the approach taken here. This module is designed to relate
specific aspects of pulmonary care to both upper and lower airway management (lower airways are
considered anything below the level of the glottis). This module combines written information with
video lessons and podcasts to create a varied approach to the review of the topic, as well as appeal
to different learning styles. Note that this module will not include practical training or a practical
evaluation component in airway management.
This module will also allow you to use the skills you learned in 2014’s research module to gather,
read, and review evidence related to the topic of airway management. Unless otherwise stated, the
information in this module is intended for all EMR, EMT, and EMT-P practitioners to review.
This module is not an exhaustive review of the topic. It is designed to help focus a review, encourage
further learning, and expose you to alternate study methods. For example, Rapid Sequence Intubation
(RSI) is deliberately not included in this module, simply to keep the module from being too long. It is
always a valid criticism that a module like this contains not enough of some things and too much of
others. You might well be overly tired of hypoxemia and yearn for a detailed discussion of hypoxia.
The College encourages you to explore topics that catch your attention and interest, or ones you feel
you need to review.
The expectation of the patient, the employer, and other paramedics in practice is that competence
in decision-making and clinical judgment is developed and maintained for the benefit of the patient.
Module Completion and Evaluation
The College created this module presuming you possess knowledge of anatomy and physiology and an
understanding of medical terminology appropriate to your level of practice. If you are unsure of
particular terms or concepts, there are a number of resources you can turn to, such as the Internet,
medical dictionaries, and literature, as well as your peers. You can also look for the
symbol throughout
this module for suggested additional resources.
This module also includes video and audio links throughout to support the written content — just look
for the
symbol. The majority of the videos come from three different sources: Armando Hasudungan
Alberta College of Paramedics • 2016 Continuing Education • Airway Management and Concepts in Pulmonary Care
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(armandoh.org), MedCram (youtube.com/user/MEDCRAMvideos), and AnatomyZone (anatomyzone.com).
The videos indicated in this module are all short (mostly 2-10 minutes) and concise.
You can view the videos in any order you choose, and you may even find alternate videos that explain
the same concepts. If you find that a link is broken, try using a different browser or searching for
another video, and at the same time, the College will continue to update any links in this module. If
you have a thorough knowledge of the subject, you may choose not to view the videos at all; however,
you’re expected to know the information provided in the module, the videos, and some of the
literature. The evaluation includes questions pertaining to the information found in all of these areas.
In order to complete this module, you will be required to access and read journal articles, indicated
by a
symbol. The information contained in the journal articles will be included in the evaluation.
The previous Continuing Education module on research provided you with information on how to
search and review literature. If you are new to practice, this knowledge will have been a part of your
education program. The journal articles can all be accessed through a search of the College-funded
EBSCO research database.
Go to search.ebscohost.com to log in to the database.
User ID: ns233491main
Password: main
In order to be able to view all of the articles
referenced in this module, you will have to
click on both the MEDLINE Complete and
the CINHAL Complete databases.
Evaluation
Each designation (EMR, EMT, and EMT-P) has its own specific multiple-choice test. The pass mark is
100%. We recommend that you look at the evaluation first and see what information you will be looking
for in the module. It is meant to be an open-book evaluation, which allows you to review all the
information in the module and evaluate how well you understood the material. You will not be able to
save your answers and go back to the module, then go back to the evaluation; however, you can keep
two browser windows open and flip back and forth between them, or you can print off the module and
reference it while completing the evaluation.
EMR Airway Evaluation: classmarker.com/online-test/start/?quiz=ggh55ce4a00212b1
EMT Airway Evaluation: classmarker.com/online-test/start/?quiz=kxb55ce4af667b56
EMT-P Airway Evaluation: classmarker.com/online-test/start/?quiz=vd955ccc7ea105bd
Anatomy and Physiology
Review
This section will provide an overview of the respiratory system.
Respiratory System — Overview by Armando Hasudungan:
youtube.com/watch?v=x5x19lwPnbo
Pressure and Partial Pressure
Pressure is the force exerted on an object. The atmosphere exerts a pressure on everything within
it. At sea level, the pressure the air exerts is about 14.7 psi. In metric, this is 10,000 kg per square
metre. An equivalent measurement is 760 mm of mercury (mm Hg), which means the pressure exerted
by air will force mercury to travel up an evacuated tube 760 mm. Barometers are used to measure
atmospheric pressure.
The History of the Barometer (and How it Works) by Asaf Bar-Yosef:
ed.ted.com/lessons/the-history-of-the-barometer-and-how-it-works-asaf-bar-yosef
Alberta College of Paramedics • 2016 Continuing Education • Airway Management and Concepts in Pulmonary Care
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The atmosphere really does exert quite a lot of pressure. In fact, the weight of air actually helps
to hold the oceans down. Theoretically, a reduction in air pressure by only 1 inch of mercury could
correspond to a 13-inch rise in sea level. Ocean currents mitigate this and other factors but the effects
of air pressure can become noticeably evident in big low-pressure storms like hurricanes. See the older
but excellent article by Harris (1963, p.4) for a more thorough explanation. Air pressure is enough to
crush a metal can if you can find a way to remove the air from the can. The air inside an empty metal
can splints the can and allows it to hold its shape by exerting the same atmospheric pressure from the
inside as is exerted upon it from the outside.
This example illustrates what happens inside our lungs: the nitrogen in air has the same effect on the
shape of the alveoli in the lungs. It splints them and allows them to retain their shape, thereby helping
to prevent atelectasis.
Atmospheric pressure is the force that drives air into the lungs and ultimately drives oxygen across
the alveolar-capillary membrane. This is a critical point. Without a difference in pressure between the
atmosphere and the inside of the lung, ventilation cannot occur. Anatomically, the expansion of the
chest causes an increase in intrathoracic volume, which allows the atmospheric pressure to push air
into the lungs. Chest expansion only causes a difference in pressure of about 4 mm Hg, but even this
small pressure gradient is enough to allow air to flow into the lungs.
So far, the discussion has been about pressure in the general sense. However, partial pressure is also
an important aspect of pressure to understand. Gas laws describe the nature of gases and how they
interact, and the relevant law here is Dalton’s law, which states that the total pressure of a mixture of
gases is the sum of the partial pressures of the various component gases. This is written as PT = P1 + P2
+ P3 + … where P means pressure, PT means the total pressure of the gas and P1 means the pressure of
one of the gases in the mixture. The consequence of this law is that since oxygen makes up 21% of the
atmosphere, oxygen will exert a pressure equal to 21% of the atmospheric pressure. At sea level, 21%
of 760 mm Hg is 160 mm Hg, so at sea level, 160 mm Hg is the starting pressure normally available to
force oxygen across the alveolar membrane. Note that we have not yet taken into account the watervapour pressure present in the lung.
One more point before we move on: PO2 means the pressure of oxygen, and PN2 is the pressure of
nitrogen. These are often referred to as the partial pressure of oxygen and the partial pressure of
nitrogen. The term partial is used to make clear that it is only one of several gases in a mixture.
Normal Anatomical Structure
There are many references in textbooks and many good videos on the Internet dealing specifically with
anatomy.
Respiratory System Introduction — Part 1 (Nose to Bronchi) — 3D Anatomy Tutorial by Anatomy
Zone: youtube.com/watch?v=OIU7Mdx4DTg
Respiratory System Introduction — Part 2 (Bronchial Tree and Lungs ) — 3D Anatomy Tutorial
by Anatomy Zone: youtube.com/watch?v=TQ24-WCsYN4
Mechanism of Breathing
The dynamics of breathing are illustrated in every paramedic textbook. Also, there are many good
videos on the Internet that explain the mechanism of breathing.
Mechanism of Breathing by Armando Hasudungan:
youtube.com/watch?v=GD-HPx_ZG8I
Control of Respiration by Armando Hasudungan:
youtube.com/watch?v=9j6BpanhpKY
Alberta College of Paramedics • 2016 Continuing Education • Airway Management and Concepts in Pulmonary Care
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Lung Volumes
In normal breathing, the amount of air entering and leaving the lungs is about 500 ml. This is called
tidal volume. Fortunately, the lungs contain some reserve capacity for times when the body calls for
more oxygen, like during exercise. The capacity to breathe in more air than tidal volume is defined
as the inspiratory reserve volume. The maximum air that can be exhaled after tidal volume has been
exhaled is called the expiratory reserve volume.
If an individual takes a maximum breath and breathes out as much as possible, the volume of air
exhaled is called vital capacity. However, it is not possible to breathe out all of the gas in the lungs—
this is a good thing, as the lungs would then collapse. The amount of gas residing in the lungs after
maximal expiration is the residual volume.
The volume of air remaining in the lungs after a normal exhalation is called functional residual capacity
(FRC). FRC is very important; the larger the FRC, the bigger the oxygen reserve. An adult with a smaller
FRC cannot hold her breath for as long without becoming hypoxic. Diseases that affect FRC affect gas
exchange, as does the patient’s position. An awake adult who is lying supine loses about 1000 ml of
FRC because the diaphragm is pushed upward about 4 cm by the abdominal contents (Whitten, 2012).
Morbid obesity can also dramatically reduce FRC when a person is in the supine position. Anaesthesia
and unconsciousness can further reduce FRC by about 400 ml (Whitten, 2012).
You can improve a patient’s FRC by altering his position. In respiratory emergencies where FRC is
compromised, positioning the patient to a 45-degree-angle sitting position can be life-saving. This will
allow gravity to pull the abdominal contents away from the diaphragm. Assisting ventilation with a bag
valve mask (BVM) will also be easier and safer because the abdominal contents are not pushed out of
the way as the BVM forces air into the lungs. While on the topic of BVMs, it is worthwhile remembering
that squeezing the bag too hard can cause a pneumothorax, especially in those already susceptible
because of a pre-existing disease. It is usually best to increase the rate of ventilation rather than the
tidal volume when the need for increased ventilation presents itself.
If you are unclear as to how the different lung volumes compare to each other, please watch this video:
Lung Volumes and Capacities Explained Under Five Minutes by Arzoo Sadiqi:
youtube.com/watch?v=QJcAJHFqXZg
Anatomic Dead Space
Not every part of the lung contributes directly to gas exchange. The lung is more than alveoli; it
consists of bronchi and bronchioles, which serve as passageways for airflow. Dead space is the portion
of the tidal volume that never makes it to the alveoli and includes the volume of air in the trachea.
The volume that cannot contribute to gas exchange is typically about 150 ml. Dead space depends
on the posture and size of the individual. It also increases with deep inspiration as the airways are
expanded slightly when the lungs expand. A rule of thumb is that dead space is equal to about 2 ml per
kg of ideal (i.e., normal) body weight (Whitten, 2012). So a 90-kg male has about 180 ml of anatomic
dead space. Ventilating this person via a BVM with 150 ml of tidal volume will not ventilate his alveoli
very well. Such a patient would become hypercarbic and possibly hypoxic.
Physiologic Dead Space
Physiologic dead space consists of anatomic dead space plus the alveoli that are ventilated but
not perfused. In other words, the alveoli are getting fresh air but blood is not flowing through the
capillaries that surround them. Physiologic dead space can change based on disease processes; for
example, a pulmonary embolism can block the flow of blood to certain parts of the lung. If no blood
flows to the capillaries that reach the alveoli, gas exchange at the alveolar membrane cannot occur.
Physiologic dead space will also increase due to hypovolemic shock because there may not be enough
blood to fill the capillary bed that perfuses the entire lung.
Alberta College of Paramedics • 2016 Continuing Education • Airway Management and Concepts in Pulmonary Care
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Gas Exchange
Oxygen and carbon dioxide move between the lung (specifically the alveoli) and the blood in the
circulatory system by simple diffusion: in areas where oxygen molecules are found in greater
concentration, they will naturally move to areas of lower concentration until they even out. While we
cannot directly count the number of molecules, we can measure the pressure they exert. The more
molecules there are, the greater the pressure they exert. It is important to recognize that oxygen will
flow from the alveolus to the capillary because the concentration of the oxygen (and therefore the
pressure) is greater in the alveolus than in the capillary. Oxygen flows from the alveoli to the capillaries
in the same way that water flows down a hill. The same is true of carbon dioxide, but in this case the
direction will be out of the capillary into the alveolus.
Several unique aspects of anatomy allow for diffusion to occur. First, the distance between an oxygen
molecule in an alveolus and the capillary lumen to which it diffuses can be as little as 0.3 micrometres
(West, 2012). There are a million micrometres in a metre, so this is a very small distance. Also, the
blood-gas barrier is very thin. There are about 500 million alveoli in a single lung, each about 1/3 of a
mm in diameter. This corresponds to a surface area for gas exchange of about 85 m, even though the
lungs occupy a volume of only about 4 L (West, 2012).
The diameter of a capillary is about 7-10 micrometres, which is just sufficient to allow a red blood cell
(RBC) to pass through. Each RBC spends about ¾ of a second in the capillary network in a position to
receive the diffusion of oxygen, and during this time contacts 2 or 3 alveoli. Yet only about 1/3 of this
time is required for the actual diffusion to occur.
Respiration Gas Exchange by Armando Hasudungan:
youtube.com/watch?v=qDrV33rZlyA
Blood Gases (O2, CO2, ABG) by Armando Hasudungan:
youtube.com/watch?v=KudrLakBgeU
The Alveolar Gas Equation
There is a handy equation that can help you understand and figure out the relationship between
inspired oxygen and atmospheric pressure. This equation is somewhat of an approximation, but the
results will be close to real values:
PAO2 = FiO2 (Patm – PH2O) – PACO2 / R
PAO2 is the pressure of oxygen within the alveoli.
FiO2 is the fraction of inspired oxygen. It is the percentage of oxygen in the total gas mixture. In this
case, the total gas mixture is all of the gases in the atmosphere. Oxygen makes up 21% by volume of
these gases, so FiO2 = 0.21 for room air. If the patient is intubated and breathing 100% oxygen, the
fraction of inspired air is 100% or 1.
Patm is the atmospheric or barometric pressure.
PH2O is the pressure that water vapour exerts in the lung. Because the lung is humid, it saturates the
inspired air with water vapour. This has the net effect of reducing the pressure of the other gases. The
effect is too big to ignore. The pressure of water vapour in the lung is about 47 mm Hg. This must be
subtracted from the atmospheric pressure.
PACO2 is the alveolar pressure of carbon dioxide, which must get washed out of the lung.
R is the respiratory quotient, a constant which can be assumed to be of value 0.8.
Alberta College of Paramedics • 2016 Continuing Education • Airway Management and Concepts in Pulmonary Care
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In an equation like this you calculate what is inside the parentheses first, then do the multiplication
and division, and finally do the addition and subtraction.
For example, consider an individual breathing normal air (21% or 0.21 oxygen) at sea level and
producing 40 mm Hg of CO2:
PAO2 = .21 (760 mm Hg – 46 mm Hg) – 40 mm Hg / 0.8
PAO2 = .21 (714 mm Hg) – 50 mm Hg
PAO2 = 150 mm Hg – 50 mm Hg
PAO2 = 100 mm Hg
The above is the typical “normal” case. See what happens when you give the patient 100% (FiO2 = 1)
oxygen:
PAO2 = 1 (760 mm Hg – 46 mm Hg) – 40 mm Hg / 0.8
PAO2 = 1 (714 mm Hg) – 50 mm Hg
PAO2 = 714 mm Hg – 50 mm Hg
PAO2 = 664 mm Hg
The oxygen pressure is very significantly raised in this case just by adding 100% oxygen. You will see
how useful this equation can be when watching the videos in the hypoxemia section.
Hypoxemia
Hypoxemia is a low concentration of oxygen in the blood (as opposed to hypoxia, which is a low
concentration of oxygen in the tissues). In this module, we will concentrate on hypoxemia as a way of
confining the subject matter. There are five primary causes of hypoxemia: (a) a reduction in inspired
oxygen, (b) hypoventilation, (c) diffusion impairment, (d) shunt, and (e) ventilation–perfusion mismatch.
Reduction in Inspired Oxygen
It is self-evident that hypoxemia can be caused by breathing an atmosphere that contains a deficient
amount of oxygen. Imagine sleeping in a winter cabin where the heater has used all of the oxygen, or
being oxygen-deprived because of strenuous activity at a high altitude. First, let’s consider the simple
case of providing artificial respiration to an apneic individual.
Imagine you are providing artificial respiration to an apneic individual at sea level. Given that exhaled
air contains about 17% oxygen, what is the maximum oxygen partial pressure that you are providing?
The way to figure this out is to determine 17% of 760 mm Hg, which is 129 mm Hg. In this case, the
pressure available to push oxygen is much reduced.
Now imagine you are hiking up Mount Kilimanjaro. At 10,000 ft of altitude, the atmospheric pressure
is much less than the atmospheric pressure at sea level—approximately 523 mm Hg. It is important to
note that even at this altitude, oxygen still makes up 21% of the air. So again the question is “what is
the pressure of oxygen?” To rephrase, what is 21% of 523 mm Hg? The answer is 110 mm Hg—a drastically
lower value than the 169 mm Hg we started with at sea level. As we will soon see, this may not be
enough oxygen. In any case, the take-away point is that it is oxygen pressure and not the percentage of
oxygen that typically matters most. Note that the above calculations represent the pressure of oxygen in
the atmosphere and do not take into account the pressure of water vapour from moist airways.
Hypoxemia Explained Clearly by MedCram:
youtube.com/watch?v=hKACkc5aUTE
Alberta College of Paramedics • 2016 Continuing Education • Airway Management and Concepts in Pulmonary Care
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Hypoventilation
Many practitioners worry that the key problem with hypoventilation is hypoxemia, but this is not quite
correct. Hypoxemia is certainly an outcome of untreated hypoventilation; however, supplementary
oxygen can correct the hypoxemia even in the presence of moderate hypoventilation. The more pressing
problem is that alveolar and arterial PCO2 rise in the presence of hypoventilation and the addition of
supplemental oxygen will not alter this. A rise in PCO2 rapidly leads to an increase in acidosis, which
actually increases the required pressure needed for oxygen to bind with hemoglobin. It also directly affects
the amount of alveolar oxygen as revealed in the alveolar gas equation. It is worthwhile to note here that
hyperventilation in the normal healthy patient has no substantive effect on oxygenation, but it can have a
harmful effect on the patient by “blowing off” too much carbon dioxide, resulting in respiratory alkalosis.
At the risk of being overly simplistic, it is sometimes useful to consider oxygenation and ventilation as
performing two different functions. Oxygenation is the process by which inspiration provides sufficient
PAO2 and PaO2 (the partial pressure of oxygen in the pulmonary capillary; note that “A” means alveolar
and “a” means arterial), while ventilation is the process that clears the carbon dioxide from the
respiratory system.
This video gives a good example of why you cannot just rely on the SpO2 monitor:
Hypoventilation Explained Clearly by MedCram:
youtube.com/watch?v=wm1BA7EjYzU
Diffusion Impairment
The blood-gas barrier is so thin it can be easily damaged, which can result in diffusion impairment and
hypoxemia. Diffusion impairment can be caused by pneumonia, pulmonary fibrosis, asbestosis, cancer,
etc., but also by pathological increases in right-side blood pressure.
It is a common misunderstanding that blood pressure is the same on both the left and right sides of
the heart. A normal blood pressure of 120/80 mm Hg is a left-sided blood pressure measurement of the
pressure arising from the left ventricle. If this reading were to occur on the right side where circulation
flows from the right ventricle to the lung, it would blow the blood-gas barrier apart. Typical systolic
pressure on the right side is 25 mm Hg. A systolic blood pressure over 40 mm Hg is a sign of malignant
right-side hypertension.
The PO2 of a red blood cell entering a capillary approaching the alveolus is about 40 mm Hg. The PO2 in the
alveolus is about 100 mm Hg. This is a significant pressure gradient and oxygen will flow from the alveolus
to the RBC. Even though the blood is in close contact with the alveoli for ¾ of a second, it only needs
about ¼ of a second to move the oxygen across the membrane and reach equilibrium. In most cases, by
the time the blood leaves the vicinity of the alveoli, the PAO2 will be very close to the PaO2—the PaO2 will
usually be a fraction of 1 mm Hg less than the PAO2. Even during severe exercise where pulmonary blood
flow is much increased and where the flow of the blood through the capillary may only be ¼ of a second,
there is still enough time for PO2 equalize and there will be no measurable drop in PaO2.
If some diffusion impairment occurs, such as from fibrosis, then exercise could significantly lower
PaO2. Another way of stressing the system is to reduce PAO2, which can happen at altitude. So exercise
at altitude can also result in a lower PaO2. A related issue is the time it takes for oxygen to bond
to hemoglobin. When oxygen is added to hemoglobin, it typically bonds in about 0.2 seconds. This
reaction is fast but finite, and certain factors can slow it down. This is precisely where the somewhat
infamous oxygen–hemoglobin dissociation curve comes into play; for example, the higher the PO2, the
more saturated hemoglobin becomes. Similarly, an increase in acidity requires higher PO2 to obtain
hemoglobin saturation.
Pulmonary Diffusion Explained Clearly by MedCram:
youtube.com/watch?v=47u3-GamoII
Alberta College of Paramedics • 2016 Continuing Education • Airway Management and Concepts in Pulmonary Care
8
Shunt
This section pertains to pulmonary shunts. Unventilated alveoli, which continue to be perfused,
contribute to the condition of shunt. This blood will return to the heart in an unoxygenated state
where it will then mix with oxygen-saturated blood. It is as if the blood simply goes from the right
ventricle directly to the left atrium (right to left shunt) without passing through the lungs. Obviously,
if all the blood shunts, death will follow in short order. However, many large shunts may be seen in
acute respiratory distress syndrome. Consolidation from pneumonia may also contribute to shunt as the
alveoli become filled and therefore do not ventilate. Other causes of shunt are atelectasis (collapsed
alveoli), pulmonary edema, and lung-tissue trauma.
Shunts are somewhat unique in one particular aspect: a patient breathing room air will have a reduced
PaO2. This is because the poorly oxygenated blood coming back from the lungs will always drop the
PaO2 when it mixes with the oxygenated blood. Now give the patient 100% oxygen. The oxygen pressure
in the alveoli (PAO2) will be about 600 mm Hg, but the PaO2 will still not rise to what is “normal”
because of the mixing of blood. The added oxygen cannot overcome the mixing of blood. Only shunts
behave in this way. The other causes of hypoxemia, such as hypoventilation, diffusion impairment, and
ventilation–perfusion inequality, will all respond to 100% oxygen with a rise in the PaO2 approaching
normal, so even small shunts can be detected using 100% oxygen.
Shunting Explained Clearly by MedCram:
youtube.com/watch?v=pRIkwjlFRgo
Ventilation–Perfusion Mismatch
In order for body systems to work properly, the ventilation of the alveoli must “match” the perfusion
of blood through the capillary blood in the lungs. If everything is matched, the ventilation-to-perfusion
ratio is 1 (V/Q = 1 where V is ventilation and Q is perfusion—remember that P means pressure). At the
extreme, if there is ventilation but no perfusion (as with the trachea, bronchi, and bronchioles), you
have dead space. In the opposite case, where you have perfusion but no ventilation, you have shunt.
All lungs have some degree of V/Q mismatch. In a normal standing individual, there will be variation
in the ventilation-to-perfusion ratio between the base and apex of the lung. However, this variation
becomes noticeable when disease processes break down the normal relationship of ventilation to
perfusion throughout the lung. In these cases, gas transfer becomes inefficient. V/Q mismatch is the most
common cause of hypoxemia. The causes of V/Q mismatch tend to be COPD, fibrosis, asthma, pulmonary
embolism, pulmonary hypertension, pulmonary infarction, pneumonia, and cardiogenic shock. Some of
these conditions will cause high V/Q and others low V/Q. Can you figure out which would be which?
It is beyond the scope of this module to go further, but this video provides more detail:
Ventilation Perfusion (V/Q) Mismatch Explained Clearly by MedCram:
youtube.com/watch?v=RJ-H8_0-8wk
Advanced Study for EMR/EMT but Mandatory for EMT-Ps
EMT-Ps are already aware of the oxygen–hemoglobin dissociation curve. However, if you are an EMR
or EMT then you might want to go the next step and watch the following three videos. They contain
different information, so you should watch all three.
Oxygen Hemoglobin Dissociation Curve by Andrew Wolf:
youtube.com/watch?v=OT7WqGb8rz8
Oxygen Hemoglobin Dissociation Curve Explained Clearly by MedCram:
youtube.com/watch?v=HYbvwMSzqdY
Bohr Effect vs. Haldane Effect by Khan Academy:
youtube.com/watch?v=dHi9ctwDUnc
Alberta College of Paramedics • 2016 Continuing Education • Airway Management and Concepts in Pulmonary Care
9
Upper Airway Management
Airway Obstruction
When evaluating the upper airway, the first assessment should be to determine the adequacy of the
airway and whether it is deteriorating. If the patient can answer questions, she has an airway that is
adequate at the time. But the airway could still be deteriorating, and it might still not be optimal.
Four signs of upper airway obstruction are a muffled voice, an inability to swallow, stridor, and
dyspnea. Assessment should be followed by careful inspection and palpation (e.g., feel for
subcutaneous emphysema). Listen to the stridor. If it is inspiratory, it is usually coming from the upper
airway. If it is expiratory, it often reveals some lower airway obstruction. If the stridor is becoming
worse, the airway might be progressing to full occlusion. You should then auscultate the chest and
assess oxygenation and ventilation. If you need to clear an airway obstruction, start basic measures,
then continue with advanced procedures if possible. It is critical throughout this process to consider
the patient’s position, as a conscious person with an airway compromise will seek to maintain the best
position possible. Do not overlook this!
Basic Airway Management
For basic airway management, there are a minimum of five skill sets to master: (a) patient positioning,
(b) insertion of airway adjunct, (c), suctioning the airway, (d) oxygenation, and (e) ventilation.
Patient Positioning
Most conscious patients who are short of breath will be found sitting (tripoding) or semi-sitting. As his
level of consciousness decreases, the patient may lose the ability to ventilate properly and ventilator
assistance may be required. Positioning the jaw becomes important in an unconscious patient.
Insertion of Airway Adjunct
In the initial stages of airway management, you will use an oropharyngeal airway (OPA) or a
nasopharyngeal airway (NPA). Many people forget the NPA and that you can actually insert two NPAs—one
in each nostril. A key tip to remember is that there is no correlation between the presence or absence of a
gag reflex and a patient’s GCS; this is a fallacy (Walls and Murphy, 2012). Another tip is that there is also no
correlation between aspiration and the presence or absence of a patient’s gag reflex (Bleach, 1993).
Suctioning the Airway
Suction can be done with a suction catheter, a Yankauer, a whistle-tip suction device, or, in the worstcase scenario, the suction tubing itself. A hospital-type suction catheter is the preferred device if you
have an option to choose. Suctioning longer than 10 to 15 seconds can induce hypoxia; however, if the
airway is occluded, the occlusion needs to be removed.
Oxygenation
Always consider oxygen early on to deter the primary cellular injury from anoxia and also the secondary
complication from continued anoxia.
Ventilation
The most common means of ventilation is via a BVM. The use of two hands on the mask is much more efficient
(Joffe, Hetzel, & Liew, 2010). In the ideal situation, this type of ventilation is a two-person procedure.
Becker, D., Rosenberg, M., & Phero, J. (2014). Essentials of airway management, oxygenation,
and ventilation: Part 1: Basic equipment and devices. Anesthesia Progress, 61, 78-83.
Alberta College of Paramedics • 2016 Continuing Education • Airway Management and Concepts in Pulmonary Care
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The Difficult and Failed Airway
Walls and Murphy (2012) provide an excellent description of difficult and failed airways. As they
point out, these two concepts are distinct. A difficult airway is one in which an initial examination
(intubation or otherwise) reveals that the use of a BVM, LMA, Combitube, King tube, or laryngoscopy
will be more difficult than what would typically be the case for a “normal” patient. A failed airway
means the airway cannot be secured or captured by any of the above means.
Walls and Murphy (2012) list some useful acronyms as memory aids assisting in identifying difficult
airways. These have been reproduced here.
Difficult Bag Mask Ventilation — MOANS
M — Mask/male/Mallampati score
ÎÎ Mask seal can be a problem
ÎÎ Beards can stop a seal
ÎÎ If you cannot see the entire uvula with the mouth open and the tongue stuck out, air flow might
be a problem
O — Obesity/obstruction
ÎÎ Obese patients may have compromised airways from the start
A — Age
ÎÎ Loss of muscle tone can make a seal more difficult
N — No teeth
S — Stiff
ÎÎ There might be some intrinsic resistance to ventilation (e.g., asthma)
Extraglottic Airway Ventilation — RODS
R — Restricted mouth opening
ÎÎ The mouth should open the width of three fingers; otherwise, it can be difficult to insert the
device
O — Obstruction/obesity
ÎÎ An upper-airway obstruction can prevent the device from seating properly
ÎÎ Obese patients may require more ventilation pressure, which can prevent a good seal of the
device
D — Disrupted or distorted airway
ÎÎ Will this affect the seal of the device?
S — Stiff
ÎÎ Same issue as for the MOANS mnemonic
Difficult Laryngoscopy — LEMON
L — Look externally
E — Evaluate 3-3-2
M — Mallampati score
O — Obstruction/obesity
N — Neck mobility
Alberta College of Paramedics • 2016 Continuing Education • Airway Management and Concepts in Pulmonary Care
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Airway Assessment – The LEMON Law*:
cmedownload.com/lecture/emlive-lemon-law
*There is one provision to this video. The video states that practitioners should NOT manipulate the
neck of a trauma patient; however, Walls and Murphy (2012) suggest that the collar can be opened at
the front and removed entirely for intubation purposes. In addition, the decision to do this should be
guided by the results of the neurologic examination.
Failed Airway
What you need to try to avoid is the “can’t intubate/can’t oxygenate” scenario. This is the worst
outcome. For BLS providers, this is essentially a “can’t oxygenate” scenario.
In this situation, there is not enough time to evaluate or attempt a series of rescue options and
no available device provides adequate oxygenation. In this case, if you are an EMR or EMT, use the
equipment available to you, trying to maintain the best patient airway position possible, as you move
the patient to more definitive care. If you are an ALS practitioner, this situation would typically warrant
consideration of a cricothyrotomy. The take-away point here is to make sure you do everything you
can not to end up in this situation. For ALS providers, the first intubation attempt should be the best
attempt, and setup/preparation is vital for success. A good practice is to apply a nasal cannula with
high-flow oxygen prior to attempting intubation (apneic oxygenation).
Endotracheal Intubation (ETI)
ETI is the gold standard for airway control. The literature is very clear. Benoit, Gerecht, Steurwald,
and McMullan (2015) did a meta-analysis of 10 observational studies comparing 34,533 endotracheally
intubated patients and 41,116 supraglottic airways. They concluded that “Patients with OHCA [out-ofhospital cardiac arrest] who receive ETI by paramedic services are more likely to obtain ROSC [return
of spontaneous circulation], survive to hospital admission, and survive neurologically intact when
compared to SGA” (Benoit et al., 2015).
This study certainly provides evidence to support prehospital intubation of cardiac arrest patients. The
article is listed as follows and an abstract* can be accessed from the EBSCO research database:
Benoit et al. (2015). Endotracheal intubation versus supraglottic airway placement in out-ofhospital cardiac arrest: A meta-analysis. Resuscitation, 93, 20-26.
*Only the abstract is available, but it contains the basic information that is presented in the full
article. The full article is not currently available through our EBSCO account, and it does not need to
be purchased for completion of the module.
Delayed Sequence Intubation Versus Rapid Sequence Intubation
An interesting article and podcast on both the concepts of pre-oxygenation (using a nasal cannula at 15
lpm) and delayed sequence intubation can be found on the EMCrit website:
“Delayed Sequence Intubation (DSI) [Episode 40]” — EMCrit Podcast by Scott D. Weingart:
emcrit.org/podcasts/dsi/
The podcast is based upon a paper by the same person:
“Preoxygenation, reoxygenation, and delayed sequence intubation in the emergency department”
by Scott D. Weingart (2010): hwcdn.libsyn.com/p/f/2/e/f2ed6a816e9f7044/preox_reox_article.
pdf?c_id=2523611&expiration=1437543200&hwt=d77c537654058a2de9ba339e5f373343
Alberta College of Paramedics • 2016 Continuing Education • Airway Management and Concepts in Pulmonary Care
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Additional Resources
This excellent textbook is highly recommended for additional study:
Walls, R., & Murphy, M. (2012). Manual of emergency airway management (4th ed.). New York:
Wolters Kluwer/Lippincott Williams & Wilkins.
The following course is also recommended:
The Difficult Airway Course: EMS
theairwaysite.com
Articles for Review
Using the College EBSCO research database, download and read the following articles. This will give
you a chance to review some of the concepts in this module.
Inhalation Injuries
Dries, D., & Endorf, F. (2013). Inhalation injury: Epidemiology, pathology and treatment
strategies. Scandinavian Journal of Trauma, 21, 1-15.
Acute Respiratory Distress Injuries
Gibbons, C. (2015). Acute respiratory distress syndrome. Radiologic Technology, 86(4),
419-436.
Obesity and Asthma
Mohanan, S., Tapp, H., McWilliams, A., & Dulin, M. (2014). Obesity and asthma: Pathophysiology
and implications for diagnosis and management of primary care. Experimental Biology and
Medicine, 239, 1531-1540.
Capnography
Capnography is the graphic representation of carbon dioxide in exhaled air. It is a tool that shows in
real time important aspects of ventilation and, indirectly, circulation. The tool is non-invasive and now
widely available. In EMS, it should be considered as the 6th vital sign—and in some ways, it is more
important than pulse oximetry. Yet while the importance of capnography is recognized worldwide and it
is used in many settings, it is still not used and embraced by all.
Capnography is accurate, and its reading can be compared to that of an ECG. Capnography is the
most reliable method of confirming tube placement in endotracheal intubation. Two resources on this
subject are particularly useful. Start by reading the following web page:
“Use of Capnography in Emergency Medicine and Prehospital Critical Care” by Bhavani Shankar
Kodali and Samuel Galvagno: capnography.com/new/outside-or/emergency-medicine
Please note that this website also has a page for 911 personnel, which is also worth reading; however,
the first link has more details applicable to the Alberta practitioner.
A second very valuable article on pre-hospital capnography is not available on our EBSCO research
database; however, the following link provides direct access:
“Capnometry in the prehospital setting: Are we using its potential?” by Dejan Kupnik and Pvel Skok:
ncbi.nlm.nih.gov/pmc/articles/PMC2464675
Alberta College of Paramedics • 2016 Continuing Education • Airway Management and Concepts in Pulmonary Care
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If interested, please take some time to read more about this topic. Paramedicine is one of the few
medical professions that use capnography on a regular basis.
Paramedic tip: Try putting an ETCO2 sampling line on the end of the endotracheal tube. As you
intubate, have your partner look for an ETCO2 reading as the tube is inserted.
Conclusion
Excellent airway management is always the priority for every practitioner in order to provide safe,
effective patient care. It is an area where there are many tools available. Don’t hesitate to seek out
help when you need it—for example, consider your resources and ask yourself if can you wait a few
more minutes until backup is available.
Continue to discover interesting, informative videos and share them with your colleagues and even with
the College. Using the EBSCO database as a resource is a great way to access the latest research and
continue to be an informed practitioner in the paramedic profession.
This topic area is fast-moving, and we encourage you not to rely solely upon your employer for
education. Ensure you are competent in all knowledge and skill areas, not just in airway management.
With a full understanding of the latest evidence within medicine, you are better prepared to make
sound clinical treatment decisions.
Alberta College of Paramedics • 2016 Continuing Education • Airway Management and Concepts in Pulmonary Care
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Benoit, J., Gerecht, R., Steurwald, M., & McMullan, J. (2015). Endotracheal intubation versus supraglottic
airway placement in out-of-hospital cardiac arrest: A meta-analysis. Resuscitation, 93, 20-26.
Dries, D., & Endorf, F. (2013). Inhalation injury: Epidemiology, pathology and treatment strategies.
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Alberta College of Paramedics • 2016 Continuing Education • Airway Management and Concepts in Pulmonary Care
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Alberta College of Paramedics • 2016 Continuing Education • Airway Management and Concepts in Pulmonary Care
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