Lisbon Fire Department Standard Operating Guidelines and Policies

– AIRWAY AND RESPIRATORY MANAGEMENT

2. To provide the proper positioning of an unconscious patient for the purpose of maintaining patency of the patient’s airway

3. To facilitate the patency of a patient’s airway through the use of basic and advanced airway adjuncts

4. To create a properly functioning suction system, through the assembly of individual system components, capable of removing foreign materials, blood, fluids and bodily secretions from the upper airway

5. To facilitate the removal of foreign body and/or displaced body tissues from the patient’s upper airway through appropriate use of the Magill forceps and laryngoscope

6. To provide adequate resuscitation and/or ventilatory assistance through the use of adjunct airway devices to include: the bag-valve-mask, pocket mask, and flow restricted oxygen powered ventilation device (FROPVD)

2. Always position the patient properly to assure an open airway

3. Open the airway using the head-tilt/chin lift or jaw thrust maneuvers

4. Modifications for maintaining the airway may be necessary due to the patient’s injuries and/or condition

5. Confirm a patent airway by observing chest rise and fall, and air exchange

6. Artificial ventilation should never be delayed if airway adjuncts are not readily available

1. 
   Oxygen cylinders must be handled carefully since the contents are under high pressure
   
2. 
   Selection of a delivery device will depend on the patient’s condition
   
3. 
   Regulators reduce the cylinder’s pressure to a safe level and regulate the flow of gas in liters per minute
   

1. 
   Identify oxygen cylinder by color, correct pin code and 100% USP marking
   
1. 
   Remove protective cap or tape
   
2. 
   Quickly open and close cylinder valve to “crack” so as to remove any impurities, which may have accumulated on the mating surfaces between the tank and regulator
   
3. 
   Attach regulator and flowmeter and insure a leakproof seal
   

7. 
   Turn on cylinder and check pressure gauge to insure adequate pressure
   
8. 
   Attach appropriate delivery device to flowmeter
   
9. 
   Adjust flow control to deliver recommended level
   
10. 
    Fit delivery device to patient
    
11. 
    Check adequacy of flow to patient
    

1. 
   Remove oxygen delivery device from patient
   
1. 
   Shut off cylinder and bleed regulator
   
2. 
   Return flowmeter control to “off” position
   

1. 
   This position may be useful for maintaining a patent airway and preventing aspiration in patients who are unable to properly protect their own airway
   
2. 
   Airway, ventilations and vital signs should be monitored continuously
   

1. 
   Roll the patient onto their side while supporting the head and neck
   
2. 
   Flex uppermost leg and position knee to support weight
   
3. 
   Position lower arm out behind patient or place lower arm and forearm under head for support
   
4. 
   Position upper arm along side patient’s face to assist in supporting weight
   
5. 
   Ease patient’s head back and jut chin to facilitate airway
   

1. 
   Use appropriate body substance isolation precautions
   
2. 
   Always measure airway
   
3. 
   Use jaw thrust without head-tilt for patients with possible cervical spine injury
   
4. 
   Tongue depressor or similar device may be used to ease insertion
   

B. Open mouth using cross-finger technique

1. 
   Adult only – with tip pointing toward roof of mouth, insert airway until point touches soft palette, rotate 180 degrees into position with flange resting against lips or teeth
   
2. 
   Adult, child or infant – Using a tongue depressor or similar device. Move the patient’s tongue forward and down. Insert airway in anatomical position so as to follow the normal curvature of the oropharynx until the flange rests against the lips or teeth
   

1. 
   Use appropriate body substance isolation precautions
   
2. 
   If resistance is felt, remove and try other nare
   

1. 
   Visualize the nares and select a nasopharyngeal airway slightly smaller in diameter than the patient’s largest nare
   
2. 
   Size the device by measuring from the tip of the patient’s nose to the tip of the earlobe or angle of the jaw
   
3. 
   Lubricate the distal surface of the airway with water or a water soluble lubricant
   
4. 
   Insert the airway into the nare
   

1. 
   If placed in the right nare, insert so as to follow the normal anatomical curvature of the nasopharynx with the bevel toward the septum. Direct it along the floor of the nose and into the oropharynx
   
2. 
   If placed in the left nare, invert the airway so the bevel of the airway follows the septum of the nose. Once the tip of the airway reaches the nasopharynx, rotate the airway 180 degrees to resume alignment with the normal anatomical curvature of the nasopharynx. Continue to insert the airway into the oropharynx
   

1. 
   Use appropriate body substance isolation precautions
   
2. 
   Ventilate the patient per AHA guidelines for a minimum of thirty (30) seconds prior to attempting placement.
   
3. 
   Patient must have inadequate or absent breathing
   
4. 
   Patient must not have a gag reflex and no foreign body airway obstruction
   
5. 
   All contraindications for airway use must be considered prior to insertion
   
6. 
   A maximum of thirty (30) seconds should be allowed for each airway attempt
   
7. 
   A maximum of three (3) attempts per patient to place airway may be made
   
8. 
   The patient should be ventilated per AHA guidelines for a minimum of thirty (30) seconds between airway placement attempts
   
9. 
   Definitive assurance of placement through proper auscultation of breath and gastric sounds must be made.
   

10. 
    Removal, when necessary, should not be delayed by repeated attempts to contact medical control
    
11. 
    The ability to suction the airway must be constantly available when inserting or removing the airway
    
12. 
    Obtaining baseline breath sounds prior to advanced airway placement can assist with evaluation of tube placement
    

Gastric distention should be relieved by using gentle pressure to the abdomen. Suctioning of the oropharynx should be done according to suctioning S and P.

1. 
   INSERTION
   

b. Determine cuff integrity

1. 
   Inflate cuffs
   
2. 
   Disconnect syringes
   
3. 
   Carefully inspect pharyngeal and distal cuffs
   
4. 
   Carefully inspect valves and pilot cuffs
   
5. 
   Deflate both cuffs
   

1. 
   Preset inflation syringes to 100 mL and 15 mL (For Small Adult [SA] Model – Preset at 85 mL and 12 mL)
   
2. 
   Bag-valve-mask with supplemental oxygen
   
3. 
   Water soluble lubricant
   
4. 
   Suction device
   
5. 
   Stethoscope
   

5. 
   Ventilate for a minimum of thirty (30) seconds
   
6. 
   Lubricate airway with water soluble lubricant as necessary
   

5. 
   Position the patient supine with head in the neutral position. Do not hyperextend the patient’s head
   
6. 
   Remove oropharyngeal or nasopharyngeal airway if previously inserted
   
7. 
   Inspect patient’s airway for obstructions, broken teeth, dentures, dental appliances or other items that could damage cuffs
   

5. 
   While holding the patient’s tongue and lower jaw to facilitate insertion:
   

1. 
   Insert Combitube airway following the normal anatomical curvature of the oropharynx
   
2. 
   Insert firmly but gently until the insertion markers (two black lines which encircle the proximal end of the airway) are aligned on opposite sides of the patient’s teeth or gums
   
   1. 
      Do not use force – If airway does not insert easily, withdraw and reattempt
      
   2. 
      Ventilate for a minimum of thirty (30) seconds between attempts
      
   3. 
      Maximum of thirty (30) seconds for each attempt
      
   4. 
      Maximum of three (3) attempts
      
   5. 
      Suction as necessary between attempts
      

5. 
   When Combitube is positioned
   
   1. 
      Inflate the pharyngeal cuff with 100 mL of air using large syringe (85 mL for Small Adult [SA] Model) through line #1 (blue)
      
   2. 
      Insure Combitube has remained in proper position. (Combitube will move slightly with inflation)
      
   3. 
      Remove syringe and insure pharyngeal cuff inflation has occurred by observing pilot balloon
      

4. 
   Inflate distal cuff with 15 mL of air using smaller syringe (12 mL for Small Adult [SA] Model) through line #2 (white)
   
5. 
   Remove syringe and insure distal cuff inflation has occurred by observing pilot balloon
   

5. 
   Ventilate the patient
   
   1. 
      Attach bag-valve-mask (BVM) to primary tube #1 (blue) and ventilate patient
      
   2. 
      While ventilating, confirm tube placement by auscultation of breath and epigastric sounds
      

1. 
   Assess breath and epigastric sounds
   

1. 
   Esophageal placement
   

1. 
   Breath sounds present high axillary
   
2. 
   Breath sounds present bilaterally
   
3. 
   Epigastric sounds are absent
   
4. 
   Continue to ventilate through tube #1 (blue)
   

1. 
   Tracheal placement
   

1. 
   Breath sounds are not present high axillary
   
2. 
   Breath sounds are not present bilaterally
   
3. 
   Epigastric sounds are present
   
4. 
   Discontinue ventilation through primary tube #1 (blue)
   
5. 
   Ventilate through secondary tube #2 (clear)
   
6. 
   Reassess breath and epigastric sounds to confirm tracheal placement
   

Local protocols may alter the sequence in which breath and epigastric sounds are checked.

1. 
   Unknown placement
   

1. 
   Breath sounds are not present high axillary
   
2. 
   Breath sounds are not present bilaterally
   
3. 
   Epigastric sounds are not present
   
4. 
   Deflate cuffs (blue then white)
   
5. 
   Reposition airway – withdrawing approximately ½ inch
   
6. 
   Reinflate cuffs with appropriate volume of air (blue then white)
   

7. 
   Begin ventilations through primary tube #1 (blue) and reassess breath and epigastric sounds to confirm placement
   
8. 
   Ventilate as appropriate
   

1. 
   Placement remains unknown
   

1. 
   Follow removal procedures
   
2. 
   Ventilate patient for minimum of thirty (30) seconds
   
3. 
   Reattempt placement (maximum of three (3) attempts) starting at the beginning of the insertion steps
   

2. 
   REMOVAL
   

1. 
   Contact medical control (local protocol)
   

2. 
   Prepare suction and emesis collection devices
   
3. 
   Position patient in lateral recumbent position when feasible, observing appropriate C-spine precautions for trauma patients
   
4. 
   Use large syringe to deflate cuff #1 (blue) until pilot balloon is completely deflated
   

5. 
   Use small syringe to deflate cuff #2 (white) until pilot balloon is completely deflated
   
6. 
   Immediately withdraw airway with a smooth and steady motion while maintaining normal curvature of the pharynx
   
7. 
   Suction as necessary
   
8. 
   Monitor the patient’s airway and breathing closely
   
9. 
   Provide high-flow oxygen via non-rebreather mask
   
10. 
    Consider nasopharyngeal airway and assist ventilations as necessary
    

2. 
   KING LTS-D ADVANCED AIRWAY
   
   1. 
      INSERTION
      
      1. 
         Reconfirm assessment of absent or inadequate breathing without a gag reflex
         
      2. 
         Determine correct size airway based on patient’s height
         
      3. 
         Determine cuff integrity
         

2) Disconnect syringes

3) Carefully inspect pharyngeal and distal cuff

4) Carefully inspect valve and pilot cuff

5) Deflate cuffs

4. 
   Prepare all necessary accessories
   

2) Bag-valve-mask with supplemental oxygen

3) Water soluble lubricant

4) Suction device

5) Stethoscope

5. 
   Suction as necessary; inspect patient’s airway for obstructions, broken teeth, dentures, dental appliances, tongue piercings or other items that could damage cuffs
   
6. 
   Ventilate for a minimum of thirty (30) seconds
   
7. 
   Lubricate airway with water soluble lubricant as necessary
   

A chin lift or laryngoscope and tongue depressor can be used to lift the tongue anteriorly to allow easy advancement

8. 
   Position the patient supine with head in the neutral or sniffing position. Do not hyperextend the patient’s head
   

2. 
   Normal Insertion
   
   1. 
      Hold the King LTS-D at the connector with dominant hand
      
   2. 
      With non-dominant hand, hold mouth open and apply chin lift unless contraindicated by C-spine precautions or patient position
      
   3. 
      Using a lateral approach, introduce the tip into the corner of the mouth
      
   4. 
      Advance the tip behind the base of the tongue while rotating the tube back to midline so that the blue orientation line faces the chin of the patient
      
   5. 
      Without exerting excessive force, advance tube until base of connector is aligned with teeth or gums
      
   6. 
      Deeper placement and subsequent retraction is preferred
      
   7. 
      When the King LTS-D is positioned
      
      1. 
         Inflate cuffs to volume sufficient to seal the airway
         
      2. 
         Attach ventilation device to the connector of the King LTS-D
         
      3. 
         At the same time, gently bag the patient and withdraw the King LTS-D until ventilation is easy and free flowing
         
      4. 
         Readjust cuff inflation to “just seal” volume
         
      5. 
         Check breath sounds, epigastric sounds and chest rise and fall
         

Important that the tip of the device be maintained at midline to assure that the distal tip is properly placed in the hypopharynx/upper esophagus

3. 
   Secure the airway
   
   1. 
      Disconnect the ventilation device
      
   2. 
      Aggressively tape the King LTS-D in the midline to the maxilla
      
   3. 
      Avoid taping over gastric access lumen
      
   4. 
      Reattach the ventilation device
      

4. 
   Removal
   
   1. 
      Remove the King LTS-D when protective reflexes have returned
      
   2. 
      Contact medical control (local protocol)
      
   3. 
      Prepare suction and emesis collection devices – suction as indicated
      
   4. 
      Position patient in lateral recumbent position when feasible, observing appropriate C-spine precautions for trauma patients
      
   5. 
      Deflate cuffs
      
   6. 
      Immediately withdraw airway with a smooth and steady motion while maintaining normal curvature of the pharynx
      
   7. 
      Monitor the patient’s airway and breathing closely
      
   8. 
      Provide high-flow oxygen via non-rebreather mask
      
   9. 
      Consider nasopharyngeal airway and assist ventilations as necessary
      

2. Always measure flexible catheter

3. Use cross-finger technique or tongue blade devices to prevent rescuer and/or patient injury

4. Apply suction after reaching insertion depth

5. Suction the mouth first, then the nose on infants

1. Attach suction tip to suction device

2. Measure flexible catheter from tip of earlobe to corner of mouth to determine insertion length

3. Switch on suction unit (or begin pumping) and insure suction is present

4. Open mouth using cross-finger technique or tongue blade device

6. Suction across oropharynx (maximum of 15 seconds for adult patient)

7. Remove device while maintaining suction

8. Flush system with water as necessary

9. Check for adequate air exchange

1. Squeeze air from bulb prior to insertion

2. Gradually reduce pressure on bulb to provide suction while removing from nose or mouth

3. Check for adequate air exchange

4. Repeat as necessary

2. The laryngoscope should never be pried or levered against the teeth

3. The Magill forceps should be held so the handle does not obstruct the view of the pharynx

4. This device is intended for use on unconscious patients

2. Assemble blade and handle, insure light is bright and tightly secured in the blade

3. Place the patient’s head in the “sniffing” position

4. Hold laryngoscope in left hand

A. Adult patient – Hold handle with entire hand

B. Infant patient – Hold handle with thumb, index and middle fingers

5. With the rescuer in the cephalic position, insert blade in right side of mouth and displace tongue to left by moving blade to midline

7. Lift tongue in direction of long axis of the handle without prying on teeth or gums

8. Visualize obstruction

9. Holding the Magill forceps in the right hand, remove obstruction

10. Visualize airway for further obstructions before removing laryngoscope blade

11. Check for adequate air exchange

2. This technique should be used with supplemental oxygen to deliver high concentrations of oxygen

3. Inflate only enough to make visible chest rise

5. This procedure should be performed as a two rescuer technique whenever possible

6. Appropriate C-spine considerations should be taken when managing patients with potential spinal injuries

2. Select adult, pediatric or infant size bag-valve-mask and assemble components

3. Attach oxygen supply to bag-valve-mask; adjust oxygen supply to recommended level

5. Squeeze bag, ventilating patient according to AHA guidelines

6. Observe chest rise and fall with each ventilation. If no chest rise, reassess equipment, technique and patient

7. If two rescuers are available, one rescuer uses two hands to maintain the airway and mask seal, while the second rescuer uses two hands to compress the bag to provide ventilations

2. Prolonged depression of ventilation button may result in gastric distention

3. Proper airway positioning minimizes the potential of gastric distention

4. The FROPVD is not recommended for use with pediatric or chest trauma patients

5. Must be reduced to deliver no more than 40 LPM of oxygen

6. May be used by spontaneously breathing patients

8. Appropriate C-spine considerations should be taken when managing patients with potential spinal injuries

2. Open cylinder and check for leaks

3. Select and insert appropriate airway adjunct, if indicated

4. Press ventilation button to clear line and check operation

6. Depress ventilation button until patient’s chest rises

7. Release ventilation button and observe patient’s exhalation

8. Ventilate per AHA guidelines

2. Oxygen concentrations will be increased by attaching supplemental oxygen

3. Appropriate C-spine considerations should be taken when managing patients with potential spinal injuries

2. Unfold pocket mask as appropriate and attach one-way valve

3. If available, attach oxygen delivery tube to oxygen source and to mask inlet

4. Turn on oxygen and adjust liter flow to recommended level

5. While maintaining head-tilt, chin-lift, seal mask on patient’s face

6. Ventilate patient through one-way valve attached to mask until chest rises

7. Allow patient to exhale while maintaining mask seal to face

8. Ventilate per AHA guidelines