Airway Positioning

INDICATION
To estabish and maintain a patent airway to relieve a partial or total airway obstruction due to
displacement of the tongue into the posterior pharynx and/or the epiglittis at the level of the
lariynx. These positions are indicated for unconsious patients who do not have an adequate
airway.
CONTRAINDICATIONS AND CAUTIONS
1. In an unconscius trauma patient or a patient with a known or suspected neck injury, the
head and neck should be maintained in a neutral position without neck hyperextension.
Use the jaw-thrust or chin-lift maneuver to open the airway in this situasion. In
resuscitation, maintaining a patent airway is a priority; the head-tilt/chin-lift maneuver
may be used if the jaw thrust does not open the airway (AHA, 2005)
2. Positioning alone may be insufficient to arcieve and maintain an open airway. Additional
interentions, such as suctioning, oral/nasal airway insertion, and intubation, may be
indicated.
PROCEDURAL STEPS
1. Place the patient in a supine position.
2. For the head-tilt/chin-lift maneuver, lift the chin forward to displace the mandible
anteriorly while tilting the head back with a hand on the forehead (Figure 3-1). This
maneuver results in hyperextention of the neck and is contraindicated when a neck injury
is suspected or known to be present.

FIGURE 3-1 Head-tilt/chin-lift maneuver. (From Sanders, M. [2003].Mosbys

paramedic textbook [2nd ed].St. Louis: Mosby, p. 397.)
3. If the head-tilt/chin-lift maneuver is unsuccessful or contraindicated, use either the jawthrust of the chin-lift maneuver.
a. Jaw-thrust maneuver: lift the mandible forward with your index fingers while
pushing againt the zygomatic arches with your thumbs (Figure 3-2). Your thumbs
provide counterpressure to prevent movement of the head when the mandible is
pushed forward.

FIGURE 3-2 Jaw Thrust. (From Emergency Nurses Assosiation.[2002].Trauma

nursing core course:Provide manual [5th ed]. Des Plaines, IL: Author,p.364.)

b. Chin-lift menuver: place one hand on the forehand to stabilize the head and neck.
Grab the mandible between the thumb and index finger of the other hand. Lift the
mandible forward (Figure 3-3).

FIGURE 3-3 Chin lift. (From Emergency Nurses Assosiation.[2002].Trauma

nursinh core course:Provider manual [5th ed]. Des Plaines, IL: Author,p.364.)
4. Reassess airway patency after any maneuver.
AGE-SPECIFIC CONSIDERATIONS
3. For the head-tilt/chin-lift maneuver in the infart or child, place one hand on the patients
forehand and tilt the head gently back into a neutral position. The nect should be sligtly
extended. This is known as the sniffing position. Hyperextension of an infants neck
may cause airway compromise or obstructon due to the relative flexibility of their
trachea. Place fingers under the bony part of the lower jaw at the chin and lift the
mandible upward and outward. Use caution no to close the mouth or push on the soft
tissues under the chin because these maneuver may obstruct the airway.
1. All children should be allowed to maintain a position of comfort. This is particularly
important in children presenting with symptoms of epiglottitis, such as high fever,
drooling, and respiratory distress. Forcing them into a supine position could obstruct the
airway. Allow the child to maintain a position of comfort until definitive airway
management is available.
COMPLICATIONS
1. If the airway remains obstructed, suctioning should be completed, and then an
oropharyngeal or nasopharyngeal airway shoud be inserted. (See Procedures 5, 6, and
29).
2. Injury the spinal cord may occur if the head/or beck is moved in the patient with cervical
spine injuries.
3. If your fingers press deeply into the soft tissue under the chin, blood vessels or the airway
could be obstructed.
REFERENCE
American Heart Assosiation (AHA). (2005).Basic life support for healthcare providers.Dallas:
Author.

Airway Foreign Object Removal

Abdominal thrusts are also known as the Heimlich maneuver.
INDICATION
To relieve upper airway obstruction caused by foreign objects. Signs and symptoms of airway
obstruction are characterized by some or all of the following:
1.
2.
3.
4.
5.
6.
7.
8.

Sudden inability to speak or cry

Poor or no air exchange
Universal sign for choking: clutching the neck (AHA, 2005a)
Noisy airflow (high-pitched sounds) during inspiration
Accessory muscle use during respiration and increasing work of breathing
Weak or ineffective cough or an inability to cough
Absence of spontaneous respirations or cyanosis
Infants or children with a sudden onset of respiratory distress associated with coughing,
gangging, stridor, or wheezing (AHA, 2005a)

CONTRAINDICATIONS AND CAUTIONS

1. In the conscious patient, a voluntary cough generates the greatest airflow and may relieve
the obstruction. Do not interfere with the patients attempts to cough up the obstruction.
2. Chest thrust should not be used in the patient who has a chest injury, for example, flail
chest, cardiac contusion, or sternal fractures.
3. In the advanced stages of pregnancy or in the markedly obese, chest thrusts are
recommended (AHA, 2005b).
4. Correct hand placement is essential to avoid injury to underlying organs during the
delivery of abdominal thrusts.
EQUIPMENT
Oral suction, if available
Magill or kelly forceps ang laryngoscope (optional for the removal of a forieign object that can
be visualized in the upper airway)
PATIENT PREPARATION
1. The patient may be sitting, standing, or supine.
2. Suction any blood of mucus you can visualize in the patients mouth.
3. Remove broken or loose-fitting dentures.
4. Be prepared to perform more definitive airway management, sucs as cricothyrotomy (see
Procedure 15).

5. Before performing abdominal thrusts on a conscious adult or child, ask the person if he or
she is choking. If the victim nods yes sng cannot talk, communicate that you are going to
help.
PROCEDURAL STEP (ADULT OR CHILD OLDER THAN AGE 1)
1. Stand or kneel behind the victim and wrap your arms around the victims waist.
2. Make a fist with one hand and place the thub side of your fist against the abdomen of the
victim, just above the navel but below the xiphoid process.
3. Grasp your fist with your other hand and press into the victims abdomen with a quick
upward thrust (Figure 4-1).

FIGURE 4-1 abdominal thrust for the standing or sitting victim of choking.
4. Thrusts should be reparated, each as a separate, distinct movement, until the object is
expelled or the victim becomes unresponsive.
5. For the pregnant or obese patient, the chest thrust may be performed. The patient may be
supine, sitting, or standing. Put one hand directly over yhe other and positio the bottom
hand at the midsternal area above the xiphoid process (mid-nipple line, the same position
used in external cardiac massage). Thrust straight down toward the spine. If necessary,
repeat chest thrusts several times to relieve airway obstruction (Figure 4-2).

FIGURE 4-2 Chest thrust for the pregnant or obese victim of choking.
6. If the victim become unresponsive, open the airway, remove any object you can see, and
begin cardiopulmonary resuscitation (CPR). Each time the airway is opened for breasths,
assess for an object and remove it if seen. If nothing is seen, continue with CPR (AHA,
2005c) (Figure 4-3).

FIGURE 4-3 Abdominal thrust for supine, unconscious victim of choking.

7. *For complete obstruction in an unconscious patient, where thrusts are ineffective, use
Magill forceps with direct laryngoscopy before ventilation to facilitate removal ot the
obstruction (Walls, 2004) or surgical cricothyroidotomy.
__________________
*indicates portions of the procedure ussually performed by a physician or an advanced practice nurse.

AGE-SPECIFIC CONSIDERATIONS
Infant (Younger Than Age 1 Year)
1. Kneel or sit with the infant in your lap, and hold the infant prone with the head slightly
lower than the chest. Support the infants head and jaw with your hand (Figure 4-4).

FIGURE 4-4 Back blows and chest thrust for foreign body obstruction in an infant.
2. Deliver up to five forceful back slaps between the shoulder blades using the heel of your
hand.
3. Turn the infant supine, supporting the head and neck and keeping the infants head lower
than the trunk.
4. Give up to five quick downward chest thrusts in the same location as for chest
compressions, just below the nipple line. Thrusts should be delivered at a rate of about
one per second with enough force to dislodge the foreign body (AHA, 2005b, 2002c;
ACEP and AAP, 2004)
5. Step 1 through 4 are continued until the object is expelled or the infant loses
consciousness.
6. If the infant becomes unresponsive, open the airway, remove any object you can see, and
begin CPR. Each time airway is opened for breaths, assess for an object and remove it if
seen. If nothing is seen, continue with CPR (AHA, 2005).
7. *For complete obstruction in which ventilation is not possible, use Magill forceps with
laryngoscopy removal of the obstruction (ACEP and AAP, 2004) or perform a
cricothyroidotomy (see Procedure 15).
COMPLICATIONS
1. Abdominal pain, ecchymosis
2. Nausea, vomiting
3. Fractured ribs
4. Injury to underlying abdominal or chest organs
__________________
*indicates portions of the procedure ussually performed by a physician or an advanced practice nurse.
REFERENCES
American College of Emergency Physicians (ACEP) and American Academy of Pediatrics
(AAP).(2004).APLS: The Pediatric emergency medicine resource (4th ed.). Boston: Jones and
Barlett Publishers.
American Heart Assosiation (AHA). (2005a).Advance pediatric life support: Instructors
manual.Dallas: Author.

American Heart Assosiation (AHA). (2005b).Basic life support for healthcare providers.Dallas:
Author.
American Heart Assosiation (AHA). (2005c).ACLS provider manual.Dallas: Author.
Walls, R. (2004). Foreign body in the adult airway. In R. Walls, M. Murphy, R. Luten, & R.
Schnieder (Eds.), Manual of emergency airway management (2nd ed., pp. 307-311).New
York:Lippincott Williams &Wilkins.

Oral Airway Insertion

The oral airway is also known as an oropharyngeal airway, OPA, Guedel airway, or Berman
airway.
INDICATIONS
To maintain airway for patients in the following situations:
1. An unconscious spontaneously breathing patient with an airway obstruction caused by an
impaired gag reflex an a loss of tone to the submandibular muscles.
2. Unsuccessful airway opening by other maneuvers, such as the head tilt, the chin lift, and
the jaw thrust.
3. A patient ventilated by a bag-mask device. The oral airway elevates the soft tissues of the
posterior pharynx, easing ventilation and minimizing gastric insufflation.
4. An orally intubated patient who bites/clenches the endotracheal tube; the oral airway is
used as a bite block.
5. An unconsious patient during suctioning, to facilitate the removal of a patients oral
secretions (AHA, 2005).
CONTRAINDICATIONS AND CAUTIONS
1. Insertion of an oral airway in a conscious or semiconscious patient stimulates the gag
reflex and may stimulate airway spasm or cause the patient to retch and to vomitt (AHA,
2005).
2. Incorrect placement of an oral airway may compress the tongue into the posterior
pharynx and cause further obstruction (Vrocher & Hopson, 2004).
3. An airway that is too small may push the tongue into the oropharynx and cause an
obstruction, and an airway that is too large may obstruct the trachea (Vrocher & Hopson,
2004).
4. Failure to clear the oropharynx of foreign material before insertion of the airway may
result in aspiration.
5. To avoid vomiting and aspiration, the oropharyngeal airway should be removed
immediately after the patient regains a gag reflex.
EQUIPMENT
1. Oropharyngeal suction equipment
2. Oropharyngeal airway
3. Tongue blade

TABLE 5-1
ORAL AIRWAY SIZING BY AGE
Age
Premature infant
Neonate
Full-term infant
1-3 yr
3-8 yr
Large child, small adult
Medium adult
Large adult

Oral Airway Size

000
00
0
1
2
3
4
5,6

PATIENT PREPARATION
1. Place the patient i a supine position.
2. Suction blood, secretions, or other foreign material from the patients oropharynx.
3. Select the appropriately sized oropharyngeal airway. Table 5-1 lists usual airway sizes by
age. Align the tube on the side ot the patients face, so the airway extends from the level
of the central incisors with the bite block portion parallel to the hand palate. The tip of the
appropriate size airway will meet the angle of the jaw (AAP, 2006).
PROCEDURAL STEPS
1. Use a tongue blade to depress and displace the tongue forward. Insert the airway with the
curve pointing up, and advance it over the tongue into the oropharynx (Figure 5-1).

FIGURE 5-1 Correct placement of oropharyngeal airway using a tongue blade to

displace the tongue.
2. As an alternative procedure for adults and adolescents, insert the airway upside down
(with the curve pointing toward the back of the patients head) into the mouth. As the tip
of the airway reaches the posterior wall of the pharynx, rotate the airway 180 degrees to
the proper position.
3. The distal tip of the airway should lie between the base of the tongue and the back of the
throat. The flange of the tube should sit comfortably on the lips.
4. Reassess the airway patency, and auscultate the lung for equal and clear breath sounds
during ventilation.
AGE-SPECIFIC CONSIDERATION
For pediatric patients, depress and displace the tongue forward with a tongue blade and insert the
airway (described in step : 1 above). Do not insert an upsidedoen airway and then rotate it
(described in step : 2 above), because this technique may injure the soft tissue of the oropharynx
(AAP, 2006).

COMPLICATIONS
1. Trauma to the lips, tongue, teeth, and oral mucosa
2. Vomiting and aspiration (Vrocher & Hopson, 2004)
3. Complete airway obstruction (AHA, 2005)
REFERENCES
American Academy of Pediatrics (AAP).(2006).Pediatric
professionals(2th ed.). Boston: Jones and Barlett.

education

for

prehospital

American Heart Assosiation (AHA). (2005).Textbook of advance cardiac life support.Dallas:

Author.
Vrocher, D. & Hopson, L. (2004). Basic airway management and desicion-making. In J. R.
Roberts, & J. R. Hedges (Eds.), Clinical procedures in emergency medicine (4th ed., pp. 53-68).
Philadelphia:Saunders.

Nasal Airway Isertion

Nasal airway are also known as nasopharyngeal airways and nasal trumpets.
INDICATIONS
The nasal airway is indicates in the following situations:
1. There is a question of patency of the posterior nasopharynx with intact upper airway
reflexes.
2. Bag-mask ventilation is ineffective because of difficulty maintaining a patent airway; use
of a naso pharyngeal airway may facilitate ventilation. The nasal airway may be used in
combination with the oropharyngeal airway in this setting.
3. Insertion of an oropharyngeal airway is technically difficult or impossible because of
massive trauma when frequent nasotracheal suctioning is necessary (AHA, 2005;
Vrocher & Hopson, 2004).
CONTRAINDICATIONS AND CAUTIONS
1. The insertion of a nasal airway may stimulate the gag reflex and cause the patient to
vomit.
2. If the tube is too long, it may enter the esophagus and cause gastric insufflation and
hypoventilation (AHA, 2005).
3. Epistaxis may occur and may lead to aspiration of blood.
4. Nasal airway should not be used in patients who have extensive facial trauma or a basilar
skull fracture.
EQUIPMENT
1. Nasopharyngeal suction equipment
2. Water-soluble lubricant or anesthetic jelly
3. Nasopharyngeal airway
PATIENT PREPARATION
1. Place the patient in a supine position or high Fowlers position.
2. Select the nostril that appears to be the largest ang most open. Assess the nasal passages
for trauma, foreign body, septal deviation, or polyps.
3. Prepare suction equipment for use.
PROCEDURAL STEPS
1. Select an appropriately size nasal airway. Use the largest airway that will pass easily
through the naris. Sizing is labeled by a number indicating the inside diameter in
milimeters, and sizes are available for neonates through adults. An endotracheal tube can
be used if the correct size nasopharyngeal airway is not available. Measure the length of
the nasopharyngeal airway from the tip of the nose to tragus or the ear (ENA, 2004).

2. Vasocontristriction ot the mucous membranes may be indicated. Agents commonly

prescribed for this purpose include phenleprine (Neo-Synephrine) or cocaine spray or
liquid (Vrocher & Hopson, 2004).
3. Lubricate the tube with water-soluble gel or anasthetic jelly.
4. Pass the airway along the floor ot the tnostril with the bevel facing the nasal septum
(Figure 6-1). Direct the airway posteriorly and rotate if slightly toward the ear until the
flage rests against the nostril. Note that all nasal airway have a bevel that is angled for
insertion into the right naris. The airway may be used in the left naris. Place the airway in
the left naris with the bevel facing the nasal septum. The nasopharyngeal airway
curvature will be opposite of the natural nasal curvature. Once the airway tiphas reached
the correct position, rotate the airway 180 degrees.

FIGURE 6-1 Correct placement of nasopharyngeal airway. (Courtesy of P. Rosen, MD.)

5. If resistance is met, a slight rotation of the tube may facilitate passage as the device
reaches the hypopharynx. Insertion should never be forced.
6. Reassess the airway patency.
COMPLICATIONS
1. Epistaxis
2. Aspiration
3. Hypoxia secondary to aspiration or improper placement.
4. Contraindications include suspected basilar skull fracture, facial trauma, or nasal
obstruction that prevents easy insertion of airway (ENA, 2004).
REFERENCES
American Heart Assosiation (AHA). (2005).American Heart Association Guidelines for
cardiopulmonary resucitation and emergency cardiovascular care.Circulation,112 (suppl. IV).
Emergency Nurses Association (ENA). (2004). Emergency nursing pediatric course provider
manual (3rd ed.). Des Plaines, IL. Author.
Vrocher, D. & Hopson, L. (2004). Basic airway management and desicion-making. In J. R.
Roberts, & J. R. Hedges (Eds.), Clinical procedures in emergency medicine (4th ed., pp. 53-68).
Philadelphia:Saunders.

General Principles of Endotracheal Intubation

Endotracheal Intubation refers to the procedure of inserting a tube directly into the trachea. The
endotracheal (ET) tube (ETT) may be placed through the nose or the mouth. Methods of
insertion include visual (using laryngoscopy), blind (through the nose), digital (also blind), or
facilitated using a flexible fiberoptic bronchoscope, the eschmann tracheal tube introducer, a
gum elastic bougie, or a lighted stylet. Details of oral nasal intubation procedures are included in
Procedures 10 and 11.
INDICATIONS
The purpose of intubation is to secure a patent and effective airway. Intubation is the preferre
means of airway control because it has the following benefits:
1. Protects the trachea and lungs from aspiration of gastric contents, saliva, or blood and
fluid into the upper airway (Vrocher & Hopson, 2004).
2. Provides an airway for mechanical ventilation in the presence of failure of ventilation or
oxygenation (Walls, 2004).
3. Allows direct access to the lungs for removal or suctioning of secretions (Walls, 2004).
4. Alows trachea administration of emergency medications for rapid absorption through the
pulmonary tree (AHA, 2005).
CONTRAINDICATIONS AND CAUTIONS
1. There are no absolute contraindications to endotracheal intubation; however, the
procedure should be considered carefully when it is performed in a patient with any of
the following (Lutes & Hopson, 2004;Vrocher & Hopson 2004; Wall, 2004):
a. Intact gag reflex
b. Potential or actual cervical spine injury
c. Head trauma, increased intracranial pressure, or both
d. Facial factures
2. Epiglittitis complicates any intubation attempt because of the potential for laryngospasm
and complete airway obstruction. Ideally, intubation of the patient with epiglottitis should
be performed in the most controled setting with the most skilled intubator. Contingency
planning should include set-up for the performance of a surgical airway.
3. Specific precautions exist for each method of endotracheal intubation. These are
discussed in the procedures devoted to nasal and oral intubation.
EQUIPMENT
1. Endotracheal tubes
2.5 to 5 mm, uncuffed; 4.5 to 9 mm, cuffes
2. Laryngoscope handle
3. Laryngoscope blades

 Curved (sizes 2 to 4)
Straight (sizes 1 to 4)
4. Stylets to fit each size of endotracheal tube
5. 10-ml syringe for inflating the cuff of the tube
6. Lubricating or lidocaine jelly for nasal intubation
7. Benzocaine, cocaine, or phenylephrine hydrochloride (Neo-Synephrine) drop or spray for
nasal intubation (optional)
8. Medication as prescribed for paralysis and sedation (see Procedure 9)
9. Tube-securing device (commercially manufactured device or tape)
10. Stethoscope
11. Adjuncts as indicated, e.g., bronchoscope, lighted stylet, or elastic gum bougie
12. Bag-mask device with reservoir connected to 100% oxygen
13. Additional supportive equipment
Suction, complete with tonsil and catheter tips
Extra laryngoscope bulbs and batteries
End-tidal carbon dioxide detector for tube position confirmation (optional)
Esophageal detector device for tube position confirmation (optional) (Figure 8-1)
Pulse oximeter to monitor oxygen saturation during intubation and to help confirm
tube placement (optional)
Limb restraints (optional)

FIGURE 8-1 Flotec Esophageal Detector Device. (Courcesy of Flotec, Inc,

Indianapolis, IN.)
PATIENT PREPARATION
1. Preoxygenate the patient with 100% oxygen by using a nonrebreather oxygen mask or a
bag-mask device as indicated
2. Administer sedative, paralytic agents, or topical anasthesia as prescribed (see Procedure
9, Rapid Sequence Intubation).
3. Restrain the patient as indicated to prevent inadvertent extubation.
PROCEDURAL STEPS
Intubate
The specific steps of intubation depend on the method of insertion used. See Procedure 10 and
11 for specific directions for oral and nasal intubation.

Confirm Tube Placement

No single confirmation technique is completely reliable; therefore, both clinical assessment and
other methods should be used to assess appropriate tube placement immediately after insertion as
well as after moving the intubated patient (AHA, 2005; Walls, 2004).
1. Epigastric sound/chest rise: With the first ventilation, auscultate over the epigastric area
while observing for chest rise (AHA, 2005). Te presence of burping sounds over the
epigastrium in the absence of chest rise suggests esophageal placement. Remove the tube
immediately, and reoxygenate the patient before attempting intubation again.
2. Breath sound: Auscultate the right and left axilla, and then the right and left anterior
chest for equal bilateral breath sound. Unilaterally absent or dexreased breath sound
(usually on the left) suggest that the tube was advance into a mainstem broncus.
Withdraw the tube slightly and reassess until breath sound are equal bilaterally.
3. End-tidal carbon dioxide detection and/or monitoring also helps cofirm tube placement
(See Procedure 24). These device are recommended as a secondary technique of tube
confirmation in patients with adequate perfusion (AHA, 2005). If the patient is poorly
perfused or in cardiac arrest, there may be minimal CO2 expiration even when the tube is
properly placed.
4. Esophageal detector device: These devices are attached to the ETT, and suction is
applied with a bulb or syringe device. If the ETT is in the esophagus, the tissue will
collapse around the tube when suction is applied and there will be resistance to filling of
the bulb or syringe. If the ETT is in the trachea, the bulb or syringe will fill eith air easily.
These devices are recommended for secondary confirmation of tube placement for the
adolescent or adult patient arrest (AHA, 2005)
5. Direct visualization of the tube passing through the cord with the laryngoscope.
6. Bag comliance: Ventilation of the stomach is easier than ventilation of the lungs, where
as tube obstruction, bronchospasm, or tension pneumothorax make ventilation more
difficult.
7. Considensation in the ETT on exhalation suggests that the tube is positioned in the
trachea.
8. Transillumination of the neck using a lighted stylet: If thr neck glows after intubation
with the lighted stylet, the tube is placed correctly in the trachea (Murphy & Hung, 2004)
9. Pulse oximetry: Maintenance of adequate oxygen saturation helps confirm tube
placement.
10. Presence of gastric contents in the ETT: Material resembling food present in the tube
may indicate esophageal intubation.
11. Cuff palpation may be used to verify the appropriate placement within the trachea in
references to the carina and the bronchi. After the cuff is inflated, and with the patients
head in a neutral position, gently palpate at the suprasternal notch while holding the pilot
balloon is maximally distended in response to pressure at the suprasternal notch, the tube

is appropriately positioned within the trachea (Kaur & Heard, 2003; Pollard & Lobato,
1995).
12. Chest radiographic documentation of the tube location in the trachea just above the
carina.
Secure the Endotracheal Tube
To prevent inadvertant extubation, the ETT must be secured carefully. Although several
techinques can be used for this maneuver, many principles apply to all of them:
1. A bite block or oral airway should be inserted after oral intubation to prevent the patient
from biting the tube and occluding the airway.
2. To allow suctioning and mouth care, the mouth must not be completely occluded by tape
or other devices.
3. The method used should prevent the inadvertant advancement or withdrawal of the tube.
4. When possible, the methode used should minimize pressure points on the skin to prevent
long-term complications.
5. When tape is used, it should encircle the head completely for maximum security.
6. When possible, the makings on the tube should be noted at the patients teeth and
documented so that movement of the tube can be checked visually.
7. The commonly used methods include commercial tube-securing devices (follow the
manufacturers directions) or tape (Figure 8-2). Apply tape as follows:
a. Tear off approxinately 24 inches of 1-inches at each end.
b. Split the tape in half for the last 4 inches at each end.
c. Slide the tape under the middle of the neck, adhesive side up.
d. Bring each end of the tape alongside the patients head and wrap the split ends
securely around the tube. Split the tape farther if necessary.
8. Reconfirm the tube position after it has been secured.
AGE-SPECIFIC CONSIDERATIONS
1. Several methods exist for estimating the correct tube size (Table 8-1), usually based on
age and weight. Other methods include the following:
a. Estimates based on the size of the patients little finger. Men usually require a 7.5 to
9 mm tube, where as women usually require a 7 to 8 mm tube. Nasal intubation
generally requires a tube that is 0.5 to 1 mm smaller than the tube used for oral
intubation (Lutes & Hopson, 2004).

TABLE 8-2
USUAL ENDOTRACHEAL TUBE SIZE BY AGE ANG WEIGHT
Age
Premature
Newborn-3 months
6-12 months
2 years
4 years
6 years
8 years
10 years
12 years
14 years

Weight (kg)
1.5-2
3-6
7-10
12
16
20
25
34
40
50

Endotracheal tube size

(internal diameter)
3
3.5
4
5
5.5
6
6.5
6.5
6.5-7
7

b. The following formula may be used to calculate the appropiately sized ETT for
children aged 2 years or older (Cole, 1957; Luten & Kissoon, 2004):
16 + age in years
= ETT size
4

2. The depth to which the ETT should be advanced into the trachea varies with the age and
size of the patient. Adult women require an average depth (from the central incisors) of
21 cm, and adult men require 23 cm (Lutes & Hopson, 2004). The following formula
estimates the required length of the oral tracheal tube from lip to midtrachea for children
(Luten & Kissoon, 2004):
Tracheal tube depth cm = Internal diameter of the tube3

3. Oral intubation is the preferred method for intubation in the pediatric population (Luten
& Kissoon, 2004).
4. Children younger than age 8 are generally intubated with uncuffed ETTs (Luten &
Kissoon, 2004). The narrowest region of the airway in children is the cricoid cartilage.
This area forms a physiologic cuff around the uncuffed ETT (Luten & Kissoon, 2004). In
the hospital setting cuffed tubes may be used in infants beyond the newborn period and in
young children. The cuff pressure should be kept at less than 20 cm H2O. in the pediatric
patient with poor lung compliance or high airway resistance, the cuffed tube may be
necessary in order to provide adequate ventilation (AHA, 2005).
5. In infant and small children, transmittal of breath sounds across the chest may result in
equal breath sounds, even in the presence of mainstem bronchus intubation or

pneumothorax. A chest radiograph is indicated to help ascertain appropriate position of

the tube.
6. Take care to maintain neutral head position in intubated infants and toddlers. Because the
airway is shorter and the tubes are uncuffed in this population, head movement may
result in significant tube movement. Flexion may withdraw the tube, resulting in
extubation. Extension may advance the tube into the right mainstem bronchus.
7. Esophageal detector deviced are unreliable in children less than 1 year old, morbidly
obese patients, and patients in late pregnancy. There is insufficient evidence to support
their use in children younger than age 1 at this time (AHA, 2005).
8. In infant and children with a perfusing rhythm, assessing end-tidal CO2 via a colorimetric
device or capnography should be used to confirm tube lacement. Appopriately sized
colorimetric device can be used on any patient weighing over 2 kg (AHA, 2005).
COMPLICATION
1. Esophgeal intubation: This is a serious complication, because the patients lungs are not
ventilated and gastric distention may occur. Gastric distenton increases the risk of
vomiting and may decrease the tidal volume.
2. Dislodgment of the tube: Frequent reassesment of the tube position is necessary,
especially after the patient is moved.
3. Damage to teeth, nasal mucosa, posterior pharynx, or larynx (depending on the method of
insertion) may occur.
PATIENT TEACHING
1. You will not e able to speak while the tube is in place.
2. Swallowing may help diminidh gagging.
3. Do not move or manipulate the tube in any way.
REFERENCES
American Heart Assosiation (AHA). (2005).American Heart Association Guidelines for
cardiopulmonary resucitation and emergency cardiovascular care.Circulation,112 (suppl. IV).
Core, F.(1957).Pediatric formulas for the anesthesiologist.American journal of Disease in
Children, 94,472.
Kaur, S. Heard, S. O. (2003).Airway management and endotracheal intubation. In R. S. Irwin, &
J. M. Rippe (Eds.). Irwin and Rippes intensive care medicine (5th ed.,pp. 416).Philadelphia:Lippincott williams & Wilkins.
Luten, R. S. & Kissoon, N. (2004). Approach to the pediatric airway. In R. Walls, M.Murphy, R.
Luten & R. Schneider (Eds.), Manual of emergency airway management (5th ed., pp. 212-227).
Philadelphia:Lippincott Williams &Wilkins.

Lutes, M. & Hopson, L. R. (2004). Tracheal intubation. In J. R. Roberts, & J. R. Hedges (Eds.),
Clinical procedures in emergency medicine (4th ed., pp.69-99). Philadelphia:Saunders.
Murphy, M. & Hung, O. (2004). Lighted stylet intubation. In R. Walls, M. Murphy, R. Luten, &
R. Schneider (Eds.), Manual of emergency airway management (2nd ed.,pp.120-126).
Philadelphia: Lippincott Williams &Wilkins.
Pollard, R. J. & Lobato, E. B. (1995).Endotracheal tube location verified reliably by cuff
palpation.Anasthesia and Analgesia,81,135-138.
Vrocher, D. & Hopson, L.(2004). Basic airway management and decision-making. In J. R.
Roberts & J. R. Hedges (Eds.), Clinical procedures in emergency medicine (4th ed.,pp. 53-68).
Philadelphia:Saunders.
Walls, R. (2004). The decision to intubate. In R. Walls, M. Murphy, R. Luten, & R. Schnieder
(Eds.), Manual of emergency airway management (2nd ed., pp. 1-7). Philadelphia:Lippincott
Williams &Wilkins.

Rapid Sequence Intubation

The intubation in this procedure should be used in conjunction with the information in Procedure
8 and 10.
Rapid sequence intubation is also known as RSI, crash intubation, paralytic intubation, and
neuromuscular blockade intubation.
INDICATIONS
1. To facilitate intubation of a critically ill or injured patient when the ability of the patient
to protect his airway is in question and trismus or a gag reflex is present (Walls, 2004).
2. To augment intubation of combative head-injured patients (Semonin Holeran, 2003).
3. To minime the risk of aspiration in non-fasting patients with complex airway
emergencies (Walls, 2004).
CONTRAINDICATIONS AND CAUTIONS
1. Neuromuscular blocking agents (NMBAs) are the foundation of emergency airway
management. They allow placement of the oral endotracheal tube while minimizing
potential complications, such as aspiration. There are two classes of NMBAs. One class
is the noncompetitive depolarizing agents, of which succinylcholine is the most common.
The second class is the competitive, nondepolarizing NMBAs, which is made up of two
categories of agent: Benzylisoquinolone compounds and aminosteroid compounds.
Benzylisoquinolone compounds include atracurium and mivacurium, and aminosteroid
compounds include veuronium, pancuronium, and rocuronium (Schneider & Caro,
2004b).
2. The most common methid of RSI uses succinycholine. Succinycholine is absoutely
contraindicated in patients who have a family history of malignant hyperthermia, burn
injuries that are greater than 24 hours old, or crush injuries greater than 7 days old. These
patients are at risk for developing life-threatening hyperkalemia (Schneider & Caro,
2004b). There are many other conditions in which succinylcholine must be given with
care, if at all. Consult a pharmacist or medication reference material for details.
3. Penetrating eye injuries are considered relative contraindications to RSI because of the
increased intraocular pressure resulting from some of the medications; alternatives may
need to be considered (Schneider & Caro, 2004b; Kelly et al., 1993).
4. RSI requires rapid administration of several medications. Keeping the medications,
needles, and syringes together in a kit facilitates rapid administration. Box 9-1 lists a
sample kit inventory.

BOX 9-1
SAMPLE LIST OF RSI CONTENTS
MEDICATIONS
SYRINGES/NEEDLES
Atropine 1-mg vial prefilled syringe
5-ml syringes with attached needle
Lidocaine 100-mg vial prefilled syringe
10-ml syringes
Succinycholine 200-mg vial
18-G needles
Vecuronium 10-mg vial
Syringes caps
MISCELLANEOUS
Sterile water 10-ml vial
Alcohol wipes
Rocuronium 50-mg vial
Medication labels for each medication
Etomidate 40-mg vial
RSI worksheets
Normal saline 10-ml vial
Courtesy of Dartmouth-Hitchcock Medical Center Emergency Department, Lebanon, NH.

EQUIPMENT (Walls, 2004; Schneider & Caro, 2004a; Schneider & Caro, 2004; Schneider &
Caro, 2004c)
Endotracheal intubation and ventilation supplies (see Procedure 8)
Cricothyrotomy supplies (see Procedure 15)
Syringes and needles
Premedication(s) (Schneider & Caro, 2004a):

Lidocaine (1.5 mg/kg) 3 minutes before induction

Fentanyl (3 mcg/kg) 3 minutes before induction in all who will be negatively imacted by
the systemic catecholamine release caused with the intubation
Artopine (0.02 mg/kg) 3 minutes before induction for all children 10 years of age or
younger
Some sources suggest a defasciculating dose of a competitive neuromuscular blcking
agent; e.g., 10% of the paralyzing dose of vecuropatients who will be receiving
succinylcholine except in children

Induction agen(s) (Schneider & Caro, 2004b):

Thiopental (3-6 mg/kg)

Midazolam (0.2-0.3 mg/kg)
Etomidate (0.3 mg/kg)
Methohexital (1-3 mg/kg)

Neuromuscular blocking agent(s) (Schneider & Caro, 2004c):

Succinylcholine (1.5-2 mg/kg)

Vecuronium (0.15 mg/kg)
Rocuronium (1 mg/kg)

PATIENT PREPARATION
1. Complete a brief neurologic assessment.
2. Maintain the patient in a supine position with spinal stabilization, if indicated.
3. Preoxygenate the patient with 100% oxygen. Deliver assisted ventilation in coordination
with patient efforts. Avoid virgorous bag-mask ventilation to prevent gastric distention,
which increases the risk of vomiting and aspiration.
4. Initiate an interavenous line (see procedure 60)
5. Attach oxygen saturation and cardiac monitors (see procedure 21 and 55)
6. Draw up all pharmacologic agent in individual syringes and label clearly. A worksheet
can help with dosing and sequencing of medications. See Figure 9-1 for a sample
worksheet.

FIGURE 9-1 RSI worksheet. (Countesy of Dartmouth-Hitchcock Medical Center Emergency

Department, Lebanon, NH.)
PROCEDURAL STEPS (Walls, 2004; Hopson & Dronen, 2004)
1. Administer premedications as prescribed:
a. Give lidocaine to attenuate the increase in intracranial pressure assosiated with
intubation. Lidocaine is usually used in patients with head injuries (Walls, 2004).
Administer the lidocaine approximately 3 minutes before administering
succinylcholine.
b. Give atropine to minimize the bradycardic impact of succinylcholine for children
younger than 10 years of age (Schneider & Caro, 2004a) or bradycardiac adults.
c. Give vecuronium or another nondepolarizing paralytic agent at one tenth of paralytic
dose. This is a defasciculating dose and may be used for adolescent and adult patients
when succinylcholine is the prescribed paralytic.
2. As soon as the defasciculating dose is administered or the patient begins to lose
consciousness (Hopson & Dronen, 2004), apply cricoid pressure, that is, the Sellick
menuver.
a. Cricoid pressure is applie by placing your thumb and index finger on the cricoid
cartilage.
b. Firmly press the cricoid cartilage backward to occlude the esophagus. This helps
prevent regurgitation and may improve visualization of the vocal cords.
c. Maintain cricoid pressure throughout backward to occlude the esophagus. Cheal tube
placement is verified and the cuff is inflated.
3. Administer the induction agent of choice.
4. Administer the neuromuscular blocking agent od choice.
5. *Perform laryngoscopy and intubate the trachea.
6. Verify the endotracheal tube placement, inflate the cuff, and ventilate the patient with
100% oxygen while manually maintaining the tube placement (see procedure 8).

7. Release the cricoid pressure. Have suction immediately available in case of regutgitation
when the cricoid pressure is released.
8. Secure the endotracheal tube.
9. Assure adequate sedative/analgesia in conjunction with MNBAs.
10. Decompress the stomach with a gastric tube (see procedure 98).
11. If intubation is unsuccessful and an alternative airway must be established, consider a
laryngeal mask airway (see procedure 7), needle cricothyrotomu (see procedure 16), or
surgical cricothyrotomy (see procedure 15) (Murphy, 2004).
__________________
*indicates portions of the procedure ussually performed by a physician or an advanced practice nurse.
AGE-SPECIFIC CONSIDERATIONS
1. Most sources recommend that children younger than age 11 receive premedication with
atropine to prever bradycardia associated with intubation and the administration of RSI
agents (Schneider & Caro, 2004a; Luten & Kissoon, 2004).
2. A defasciculating dose of a nondepolarizing paralytic agent is not used in childen because
dosing errors may result in earlier than intended paralysis.
3. Uncuffed endotracheal tubes are recommended for children younger than age 8 in many
sources (Luten & Kissoon, 2004). In the 2005 AHA/AAP Pediatric Advance Life Support
guidelines, cuffer endotracheal tubes are suggested for children age 1 and older in
hospital setting provided that the tube cuff pressure is maintained at less than 20 cm H2O
(AHA, 2005).
4. Surgical cricothyrotomy is not recommended in children younger than age 12 because of
the small size of the cricothyroid membrane; needle cricothyrotomy is the procedure of
choice (Vissers & Bair, 2004).
COMPLICATIONS
Complications are related to the medications administered or to the intubation procedure (see
procedure 8). Vasodilation results from many of the medications and may result in profound
hypotension, especially in the kemodynamically instable patient.
PATIENT TEACHING
1. We have given your medications that relax your muscles temporarily so the machine can
breathe for you. We are here to take care of you and keep you safe.
2. Reassure the family that the patients paralysis and any new decrease in level of
conciousness the desires effect of the medications.
3. See procedure 8.

REFERENCES
American Heart Assosiation. (2005).Guidelines for cardiopulmonary resuscitation (CPR) and
emergency cardiovascular care (ECC) of pediatric and neonatal patients.Pediatric,117,989-1004.
Hopson, R. L. & Dronen, S. (2004). Pharmacologic adjuncts to intubation. In J. R. Robert, & J.
R. Hedges (Eds.), Clinical procedures in emergency medicine (4th ed., pp. 100-114).
Philadelphia:Saunders
Kelly, R. E., et al. (1993). Succinycholine increases intraocular pressure in the human eye with
extraocular muscle detached.Anesthesiology,79,948-952.
Luten, R. & Kissoon, N. (2004). The difficult pediatric airway. In R. Walls, M.Murphy, R. Luten
& R. Schneider (Eds.), Manual of emergency airway management (2nd ed., pp. 236-244).
Philadelphia:Lippincott Williams &Wilkins.
Murphy, M.(2004). Laryngeal mask airway. In R. Walls, M.Murphy, R. Luten & R. Schneider
(Eds.), Manual of emergency airway management (2nd ed., pp. 97-109). Philadelphia:Lippincott
Williams &Wilkins.
Schneider, R. & Caro, D. A. (2004a). Pretreatment agents. In R. Walls, M.Murphy, R. Luten &
R. Schneider (Eds.), Manual of emergency airway management (2nd ed., pp. 181-188).
Philadelphia:Lippincott Williams &Wilkins.
Schneider, R. & Caro, D. A. (2004b). Sedatives and induction agents. In R. Walls, M.Murphy, R.
Luten & R. Schneider (Eds.), Manual of emergency airway management (2nd ed., pp. 189-198).
Philadelphia:Lippincott Williams &Wilkins.
Schneider, R. & Caro, D. A. (2004a). Neuromuscular blocking agents. In R. Walls, M.Murphy,
R. Luten & R. Schneider (Eds.), Manual of emergency airway management (2nd ed., pp. 200211). Philadelphia:Lippincott Williams &Wilkins.
Semonin-Holleran, R.(2003).Air and surface patient transport: Principle and practice (3rd ed),
St. Louis: Mosby.
Vissers, R., & Bair, A. (2004). Surgical airway technigues. Schneider, R. & Caro, D. A. (2004a).
Pretreatment agents. In R. Walls, M.Murphy, R. Luten & R. Schneider (Eds.), Manual of
emergency airway management (2nd ed., pp. 158-182). Philadelphia:Lippincott Williams
&Wilkins.
Walls, R. (2004). Rapid sequence intubation. In R. Walls, M. Murphy, R. Luten, & R. Schnieder
(Eds.), Manual of emergency airway management (2nd ed., pp. 22-31). Philadelphia:Lippincott
Williams &Wilkins.

Oral Endotracheal Intubation

The information in this procedure should be used in conjunction with the information found in
Procedure 8.
INDICATIONS
To place an endotracheal tube (ETT) via the mouth. The oral route is usually used for comatose,
apneic, sedated, or chemically paralyzed patients. Indications include the following:
1.
2.
3.
4.

To maintain an adequate, patent airway

To facilitate mechanical ventilation
To provide a route for pulmonary secretion evacuation
To provide a route for medication administration for a patient in cardiac arrest

CONTRAINDICATIONS AND CAUTIONS

There no absolute contraindications to oral intubation; however, the procedure should be
considered carefully if performed when the patient has either of the following:
1. An intact reflex.
2. Potential or actual cervical spine injury. Laryngoscopy is known to cause spinal
movement (Aprahamian et al., 1984). Many studies have examined the impact of
orotracheal intubation on servical spine movement and resulting neurologic sequelae. No
conclusive data have been published that slearly state the safety of endotracheal
intubation in the presence of a cervical spinal injury, but there is literature supporting the
safety of this procedure (Schneider & Murphy, 2004).
EQUIPMENT
See procedure 8.
PATIENT PREPARATION
1. Place the patient int the supine position with the head in the sniffinf position unless there
is a potential cervical spine injury. Provide manual stabilization of the head if spinal
movement is contraindicated.
2. If necessary for an apneic or hypoventilating patient, initiate oxygenation with 100%
ocygen using a bag-mask (see Procedure 33).
3. Apply cardiac and oxygen saturation monitors (see Procedure 21 and 55).
4. Administer sedative, paralytic agents, or topical anesthesia as prescribed (see Procedure
9).
5. Restrain the patient as indicatedto prevent inadvertent extubation (see Procedure 190).

PROCEDURAL STEPS
1. Ensure that all larygoscopic equipment is in appropriate working order. Inflate the ETT
cuff to test for air leaks and deflate after testing.
2. Insert the stylet into the ETT and apply a water-solube lubricant to allow easy
advancement of the tube. Confirm appropriate placement of the stylet within the ETT.
Ensure that the stylet has not been advanced beyond the end of the tube.
3. Turn on the suction and place the tonsil-tip suction next to the patients head
4. *Insert the laryngoscope with hthe left head. The patients tongue should be swept to the
left side and the laryngoscope inserted and lifted up and away from the intubator (Figure
10-1). Do not rock the laryngoscope against the patients teeth or gums. Advance the
laryngoscope blade under the epiglottis when using a straight blade into the vallecula
when using a curved blade.

FIGURE 10-1 The laryngocope is lifted uo and away from the intubator ro align the
airway structures.
5. *Visualize the epiglottis and the vocal cords (Figure 10-2).

FIGURE 10-2 After the cords are visualized, the tube should be advanced through the
cords until the cuff disappears.
6. If the cords are not visible, downward cricoid pressure (also known as the Sellick
maneuver) may move the glottis into view (Schneider & Murphy, 2004). This maneuver
is performed by placing the index finger and thumb on cricoid membrane and applying
posterior pressure to occlude the esophagus. The cricoid pressure may also prevent
aspiration of emesis by occluding the esophagus during intubation (Sellick, 1961). If
applied, cricoid pressure should be maintained until tube placement is verified and the
cuff inflated.
7. *Using the right hand, pass the ETT through the cords. The tube should be advance until
the cuff moves forward 1 to 2 cm through the cords.
8. *Remove the laryngoscope while maintain a grip on the ETT to Keep it in place.
9. *Remove the stylet.
10. The gum elastic bougie is an aid for oral intubation, especially if difficulty is encountered
during the initial attempts with a laryngoscope.
a. The bougie is a solid or hollow, partially malleable stylet that serves as an introducer
for the ETT. The bougie helps the intubator manipulate the ETT when the larnyx
cannot be visualized during laryngoscopy (Rosenblatt, 2006).
b. The ETT is threaded over the bougie and advanced into the trachea. The bougie
extends beyond the ETT and is more easily manipulated to enter the trachea.

c. Once the bougie is placed between the vocal cords, the ETT is advanced and
positioned normally.
d. Once the ETT is in position, the bougie is then removed and the tube assessed and
secures as usual.
__________________
*indicates portions of the procedure ussually performed by a physician or an advanced practice
nurse.
AGE-SPECIFIC CONSIDERATIONS
Oral intubation is the preferred of intubation in the pediatric population (Luten & Kissoon,
2004).
COMPLICATIONS
See Procedure 8.
PATIENT TEACHING
See Procedure 8.
REFERENCES
Aprahamian, C., et al.(1984). Experimental cervical spine injury model: Evaluation or airway
management and splinting technique.Annals of Emergency Medicine, 13, 584-587.
Luten, R. & Kissoon, N. (2004). Approach to the pediatric airway. In R. Walls, M.Murphy, R.
Luten & R. Schneider (Eds.), Manual of emergency airway management (2nd ed., pp. 212-235).
Philadelphia:Lippincott Williams &Wilkins.
Rosenblatt, W. H. (2006).Airway managent. In P. G. Barash, B. F. Cullen, & R. K. Stoelting
(Eds.), Clinical anesthesia(5th ed., pp. 596-642). Philadelphia:Lippincott Williams &Wilkins.
Schneider, R. E. & Murphy, M.(2004). Bag/mask ventilation and endotrachea intubation. In R.
Walls, M.Murphy, R. Luten & R. Schneider (Eds.), Manual of emergency airway management
(2nd ed., pp. 43-69). Philadelphia:Lippincott Williams &Wilkins.
Sellick, B. A.(1961).Cricoid pressure to control regurgitation of stomech contents during
induction of anesthesia. Lanct,2, 404-408.

General Principles of Oxygen Therapy and

Oxygen Deliver Device
INDICATION
To provide supplemental oxygen (O2) to partient with adequate and spontaneus respirations
(ventilation) but inadequate oxygenation. The need for supplemental O2 may be determined by
clinical asessment of the patient, pulse oximetry, and arterial blood gas analysis. Supplemental
O2 is defined a d delivery of O2 concentration greater than room air O2 concentration of 21% or
Fi O2 (fraction of inspired O2) of 0.21. the provision of supplemental O2 should be treated with
same respect and caution as when administering any drug. Oxygen delivery has safe dosing
ranges and may produce adverse effects, and toxic effects are possible, especially with delivery
of high concentrations or with prolonged use.
CONTRAINDICATIONS AND CAUTIONS
1. In ill injured patient, O2 is never contraindicated. Insufficient O2 administration may lead
to hypoxia, which is a significant risk to the patient. Hypoxia may lead to cardiac
arrhythmias and may damage tissues and organs. Supplemental O2 should be delivered to
maintain an O2, once the hemoglobin has fully saturated (SpO2 99% to 100%), increases
the risk of toxic effects.
2. Oxygen-induced hypoventilation, from suppression of the hypoxic respiratory drive, may
occur in a small set of patient. Administration of O2 the these patients may result in
hypoventilation, further hypercapnia, and possibly hypoxia and apnea. This class of
patients; often with underlying COPD, cystic fibrosis, sedation from medications for
procedures, neuromuscular disease, morbid obesity, and extensive previous chest disease,
requres more agressive monitoring of their respiratory status during O2 delivery. Oxygen
therapy should be titrated to maintain an SpO2 between 90% and 92% in these patients. If
hypoxia persists, then invasive or noninvasive mechanical ventilation may be necssary.
3. A significant physical hazard of O2 therapy is fire. Oxygen supports combustion, and
smoking should no be permitted anywhere O2 is being used. Spark producing appliance
and volatile or flammble substances should also be removed from area. Patients may nee
to be searched to ensure that they do not have any mathces or lighters.
4. Absorption atelectasis may occur with use of high concentrations of O2. The usually more
abundant nitrogent gas is wash out of the alveolus may collapse, further worsening the
ability to axygenate and ventilate the patient (Pierce, 2007).
5. Exposure of lung tissue of high O2 concetrations can lead to pathologic changes in the
tissue. After only a few hours of exposure to high O2 levels (generally an FiO2 greater
than 0,5) mucus clearance from the lung is depressed. More prolonged exposure may lead
to change that are similar to acute respiratory distrees syndrom (ARDS). The lowest FiO2

capable of creating suficient SpO2 should be used in an attempt to avoid O2 toxicity

(Pierce, 2007).
6. Oxygen masks may impede care in patients with facial burns or trauma or who need
frequnt nursing care to facial area. Gastric tubes may interfere with obtaining an adequate
mask seal.
7. Aspiration is a potential hazard when an O2 delivery mask is in use. Elevating the head of
the bed may reduce this risk.
8. Oxygen concentration delivery is highly variable, and factors such as O2 flow rate,
ventilatory rate and depth, mask seal, and anatomic dead spase all contribute to this
variability (Tabel 25-1).
9. To deliver high O2 concentration, masks must have a tight seal. This tight seal may be
uncomfortable an irritating to the skin.
10. Masks may interfere with patients speech and must be removed for patients to eat meals.
11. all O2 delivery device must be monitored to ensure they are functioning correctly and
delivering the desirering the desired concentration of O2.
EQUIPMENT
Appopriate O2 delivery device (see Table 25-1)
Oxygen delivery system (extra tubing, connectors)
Flowmeter or regulator
Nut and tailpiece (Christmas tree adapter, green nipple connector)
Oxygen source (O2 tank or wall delivery system)
Humidification delivery adjunct (used only in select patients)

TABLE 25-1
OXYGEN DELIVERY DEVICE
O2 Delivery Device
Nasal Cannula

O2 Flow
(L/min)
1
2
3
4
5
6

Fi O2
24%
28%
32%
36%
40%
44%

Advantages
Well tolerated and
comfortable
Patient may eat and drink
without removing
May be used with humidy

Disvantages
May cause pressure sores
around nose and ears. This
can be minimize by
placing padding between
the cannula tubing and the
skin
Decreased effectivess with
mouth breathing
May dry an irritate nasal
mucosa

5-6
6-7
7-8

40%
50%
60%

Simple and lightweight

May be used with humidity
Effective for mouth breathers
ot those with nasal
obstructon

Insufficient O2 flow may lead

to rebreathing of CO2; use
a flow rate of at least 5-6
L/min
Considered confning by
some patients
Aspiration of vomitus
possible
Difficulty with fitting when a
gastric tube is present
May cause drying of eyes

Nasal cannula in place, attached to an O2 flowmeter

Simple Mask

Simple face mask attached to an O2 flowmetes

Partial Rebreather mask

(Top) Partial rebreather mask in place, attached to an

O2 flowmeter (Bottom)Arrows indicate the direction
of gas movement on (A) inhalation and (B) exhalation

7
8-15

65%
70%-80%

FiO2 of greater than 60% is

delivered for treatment of
moderate to severe
hypoxia.

Insulfficient O2 flow may

lead to rebreathing of CO2;
reservoir bag should never
completely collapse
Considered confininf by
some patients
Limits access to face for
coughing, eating, drinking,
blowing nose, and delivery
of oral and facial nursing
care
Aspiration of vomitus
possible
Difficulty with fitting when a
gastric tube is present
May cause drying of eyes

TABLE 25-1
OXYGEN DELIVERY DEVICE-contd
O2 Flow
O2 Delivery Device
(L/min)
Fi O2
Advantages
Disvantages
Set
rate
high
enough
to
Highest
FiO
delivery
for
a
Insufficient
O2 flow may
Nonrebreathing mask
2
(Note that mask labeled nonrebreather by some
prevent collapse of
nonintubated patient
lead to reabreathing of
manufacturers are actually partial rebreathers.)
fecervoir bag.
CO2;reservoir bah should
Delivers an FiO2 of
never
completely
80% of greater.
collapse
Considered confining by
some patients; mask
must fit snugly for
optimal FiO2
Limits access to face for
coughing,
eating,
drinking, blowing nosee,
and delivery of oral and
facial nursing care
Aspiration of vomitus
possible
Difficulty with fitting
when a gastric tube is
present
May cause drying of eyes
Possible sticking drying of
valves, limiting benefit
and
causing
CO2
rebreathing
(Top) Nonrebreathing mask in place, attached to an O2
flowmeter (Bottom)Arrows indicate the direction of
gas movement on (A) inhalation and (B) exhalation

Air Entertaiment Mask

(Also known as a Venturi mask or Venti mask)

FiO2
changed
by Precise control of FiO2
Considered confining by
adjsting the air Useful in patients with COPD
some patients
entrainment port and
where excessive O2 delivery Limits access to face for
O2 flw rate (per
may suppress respiratory
coughing,
eating,
directions on each
drive
drinking,
blowing
device)
nosee, and delivery of
Provides FiO2 of 24%
oral and facial nursing
to 50%
care
Aspiration of vomitus
possible
Difficulty with fitting
when a gastric tube is
present
May cause drying of eyes

Oxygen flowing rapidly through narrowed orifice

creates an area of low pressure that entrains room ait
through the air entrainment port.
Tracheal Collar
(Also known as a Puritan collar)

FiO2 of 28 % to 100%; High humidity prevents airway Collar can accumulate

varies with flow rate
drying and maintains ciliary
secretoins
and fit of mask
funcion
Tubing can accumulate
Device is lightweight and
water, which could
comfortable
block delivery of O2
could cause the collar
to become dislodged, or
could drain into the
airway when the patient
changes position

Tracheostomy collar over a tracheostomy tube

attached to a flowmeter and humidification device
Figures from Pierce, L. (2007).Management of the mechanically ventilated patient.St. Louis: Saunders

PROCEDURAL STEPS
1. Attach flowmeter or regulator to O2 source.
2. Attach the nut and tailpiece to the flowmeter. If humidified O2 is required, attach the
humidifier to the flowmeter. Humidification is not required for short-term use.
3. Attach the flaired vinyl tip of the O2 tubing to the tailpiece or humidifier.
4. Adjust the O2 to the flw rate as directed by equipment recommendations to deliver the
prescribed amount of O2. The float bal on the flowmeter should be positioned so that the
flow rate line is in the middle of the ball.
5. Check to see that O2 is flowing through the cannula or mask.
6. For nonrebreather masks, the reservoir must be filles with O2 before it is applied to the
patient. When using an O2 mask with a reservoir bag. Adjust the flow rate so that the bag
does not collaps, even with a deep inspiration. These masks require q tight seal in order to
deliver the highest concentration of oxygen.
7. Place the cannula prongs into the nares or apply the mask to the face. Oxygen masks have
a malleable metal nose strip that can be adjusted for a better and more comfortable fit.
Monitor to ensure that the mask side port do not become blocked.
8. Padding straps with gauze or cotton may prevent irritation or discomfort.
9. If humidification is being used, periodically check and drain tubing of excess water as
needed.
AGE-SPECIFIC CONSIDERATIONS
1. Allow an alert child to maintain a position of comfort.
2. Allow parents or caregivers to remain in the room with child. Allow the parent or
caregiver to hold the child if not contraindicated by patient condition.
3. Introduce O2 delivery devices in a nonthreatening manner. A parent or caregiver may
hold the O2 delivery device to decrease the childs anxiety.
4. If a child becomes too upset by the O2 delivery device, alternative methods may be
attempted. A drinking cup decorated with colorful stickers and O2 supply tubing inserted
through the bottom of the cum is one such alternative.
COMPLICATION
1. Mask or cannula be easily dislodged or removed.
2. Masks are standard size and may not fit all patients adequately and comfortably.
3. Facial irritation and skin breakdown may result if a mask is too tight.
4. Some patients may be poorly tolerant of tight fitting masks.
5. Mask must be removed for the patient to eat, drink, expectorate, or blow the nose.
PATIENT TEACHING
1. No smoking ia allowed while O2 is in the room.
2. Remove the mask only to eat, drink, blow nose, expectorante, or vomit. Repalce the mask
immediately.

3. Explain the proper position of mask and the importance of a snug fit. Explain taht both
prongs of the cannula must be in the nose.
REFERENCE
Pierce, L. (2007).Management of the mechanically ventilated patient.St. Louis: Saunders