Respiratory Assessment SkillsNormal Breathing

Normal Rate
Adults Children Infants 12 20 breaths/min 15 30 breaths/min 25 50 breaths/min

Respiratory Assessment SkillsNormal Breathing

Normal Rhythm
Regular pattern of inhalation and exhalation

Normal Lung Sounds

Clear and equal bilaterally

Normal Chest Expansion

Regular rise and fall of the chest that is equal bilaterally

Normal Tidal Volume

Respiratory Assessment SkillsAbnormal Breathing

Abnormal (Inadequate)Rate
Apnea Bradypnea Tachypnea

Abnormal Rhythm
Apnea Cheyne-Stokes

Respiratory Assessment SkillsAbnormal Breathing

Accessory Muscle Use
Supraclavicular or intercostal retractions Neck Muscle use Belly breathing

Lung Sounds
noisy breathing is obstructed breathing diminished unequal

Respiratory Assessment SkillsAbnormal Breathing

Chest Expansion/ Tidal Volume
Absent Unequal Shallow

Basic Airway Management Review

Positioning BVM Ventilation Use of oropharyngeal airways Use of nasopharyngeal airways Use of suction

Review of Oxygen Therapy

Nasal Cannula Simple Oxygen Mask Non-rebreather Mask Manually Triggered Ventilation Devices

Session 1 Review
EMT-C Accreditation/Reaccreditation EMT-C Skills Proficiency Demonstrations Respiratory System Anatomy and Physiology Respiratory Assessment Basic Airway Management Review Review of Oxygen Therapy

Role of the ETAD in Airway Management

Initiate basic airway management first
positioning OPA/NPAs Suction

Defibrillate as appropriate
(if certified to do so)

Assure adequate ventilation and CPR

100% O2 BVM

Hyperventilate patient and prepare to use ETAD

Combitube Kit Contents

Combitube Syringes
140 cc syringe 20 cc syringe

Elbow

Other Required Supplies and Equipment

Personal Protective Equipment
Gloves Goggles/Glasses Mask

Portable Suction Unit

Yaunkauer tip Flexible Catheter

Water Soluble Lubricant

Bag-Valve-Mask Oxygen Source Toomey Syringe

ETAD Indications
Pt. Unconscious No Purposeful Response Gag reflex absent Apnea or respiratory rate < 6/minute
All indications must be present

Appears 16 years old or older Appears at least 5 feet tall

ETAD Contraindications
Age Less than 16 Height less than 5 feet tall Ingestion of caustic substances Known esophageal disease

ETAD Precautions
Do not attempt insertion for more than 30 seconds Do not use excessive force

ETAD Special Information

ETAD placement esophageal 85% so ventilation via tube #1 usual If ventilating via tube #2 (tracheal placement) then ALS personnel may:
administer medications via ET route perform tracheal suctioning

ETAD must be removed for endotracheal intubation

ETAD Insertion Procedure

Wear appropriate Personal Protective Equipment Assemble equipment Inflate each cuff and check for leaks Deflate cuffs and Apply emesis diverter to Tube #2 Apply water soluble lubricant to distal end of tube

ETAD Insertion Procedure

Hyperventilate patient Place patients head in a neutral position (maintain C-Spine immobilization if appropriate) Grab lower jaw and tongue and lift away from posterior pharynx Insert tube gently until black rings straddle the teeth/gums

ETAD Insertion Procedure

Inflate pharyngeal cuff with 100 cc air via port #1 Inflate distal cuff with 15 cc air via port #2 Realign airway Ventilate through Tube #1

ETAD Insertion Procedure

Assess Ventilation
Chest rise and fall Bilateral breath sounds Epigastric sounds Verify esophageal placement with Toomey Syringe

If esophageal placement confirmed Continue ventilation via Tube #1 Secure Tube with a tube holder or tape

The ETAD will enter the esophagus approximately 85% of the time.

ETAD Insertion Procedure

If esophageal placement is not confirmed Remove emesis diverter and ventilate through Tube #2 Re-assess ventilation
Chest rise and fall Bilateral breath sounds Epigastric sounds Verify esophageal placement with Toomey Syringe

ETAD Insertion Procedure

If ventilation now effective tube placed in the trachea continue to ventilate through Tube #2 secure tube If unable to confirm either esophageal or tracheal placement remove Combitube resume ventilations via mask with OPA or NPA in place

ETAD Removal Indications

Unable to auscultate lung sounds Patient becomes combative or gag reflex returns Mechanical failure of tube ALS/LALS arrives and assumes patient care and determines need for:
ET medication administration or ET Suctioning and ETAD is in the esophagus

ETAD RemovalProcedure
Deflate Pharyngeal and Esophageal cuffs using Port #1 and Port #2 Turn on suction and roll pt. onto Left side Gently remove ETAD suctioning as needed

ETAD Reporting Form

Complete and deliver to NCEMS within five days of any attempt to use the ETAD Provider Information Provider Agency STAR Date Date of Call Phone # (707) 574-6616

ETAD Reporting Form

Times Call Received Patient Contact Estimated Down Time ETAD Placement ALS

ETAD Reporting Form

Patient Information Name Age Sex Patient Condition Apneic Pulseless Bystander Airway Management Bystander CPR

Probable cause of arrest (if known)

ETAD Reporting Form

AED Use Was AED Placed? Shock Delivered Total Number of Shocks Initial Airway Management OPA NPA BVM Other

ETAD Reporting Form

ETAD Inserted Successfully # of Attempts ETAD Location Placement confirmed by Chest Rise Lung Sounds Epigastric Sounds Esophagus (Ventilation Confirmation Device
tube #1) Trachea (Ventilation tube #2) Toomey syringe Other

ETAD Reporting Form

ALS ETAD removal Patient Destination Transport Provider

Small Group Practice- Scenario #1

Small Group Practice- Scenario #2

Small Group Practice- Scenario #3

Summary- Did we:

Review respiratory system anatomy and physiology Review and develop skills for respiratory assessment Review basic airway management techniques

Summary- Can we:

State the indications and contraindications for ETAD use and its role in the sequence of airway management Demonstrate competency in use of the ETAD by correctly placing it in a mannequin in a simulated respiratory emergency

Where to get more information

Crosby, Lynn A.; Lewallen, David G. eds. 1998. Ch 4, 7, 38 in Emergency Care and Transportation of the Sick and Injured. Seventh Edition. Ochs, Mel MD, Cooper Gail. 1997. Combitube Study 1995 - 1997. County of San Diego. Department of Health Services. Division of Emergency Medical Services.

Where to get more information

North Coast EMS Policies and Procedures 3308, 4407, 4408, 4409, 5206, Combitube/ ETAD Skills Proficiency Checklist, ETAD Reporting Form Title 22, Division 9, Chapter 2 100064(a)(3) California Health and Safety Code, Division 2.5

NCEMS ETAD Written and Skills Examination

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