Review of Respiratory Arrest
Respiratory Arrest simply means cessation of breathing. In ACLS, respiratory arrest typically means that a patient’s respirations are completely absent or inadequate to maintain oxygenation, but a pulse is present.
Management of respiratory arrest includes the following interventions:
Open the airway
Provide basic ventilation
Provide respiratory support with the use of artificial airways (OPA and NPA)
Suction to maintain a clear airway
Maintain airway with advanced airways
During respiratory arrest, the ACLS provider should avoid hyperventilation of the patient. Hyperventilation is providing too many breaths per minute or too large of a volume per breath during ventilation. Hyperventilation may lead to increased intrathoracic pressure, decreased venous return to the heart, diminished cardiac output, and increased gastric inflation, all of which can decrease the likelihood of positive outcomes.
For patients with a perfusing rhythm deliver 1 breath every 5 to 6 seconds.
The most common cause of airway obstruction in a patient that is unresponsive is the loss of tone in the throat muscles. When loss of throat muscle tone occurs the tongue can fall back and obstruct the airway.
This type of obstruction is easily prevented with a basic airway opening technique called the head tilt-chin lift. In the case that spinal injury is suspected, the jaw thrust maneuver can be utilized. This jaw thrust maneuver allows the BLS/ACLS provider to maintain a stable cervical spine.
There are 5 basic airway skills used to ventilate a patient. Basic ventilation skills are discussed in the BLS course and will not be discussed in detail here. The following is a list of the 5 basic airway skills: 1.) Head tilt-chin lift; 2.) Jaw thrust without head extension for possible cervical spine injury; 3.) Mouth-to-Mouth ventilation; 4.) Mouth-to-Barrier device (using a pocket mask); and 5.) Bag-mask ventilation.
Bag-Mask ventilation is the most common method of providing positive-pressure ventilation. Both the oropharyngeal airway and the nasopharyngeal airway may be used as adjuncts to improve effectiveness of patient ventilation. The oropharyngeal airway may only be used on the unconscious patient because it can stimulate gagging and vomiting in a conscious patient. The nasopharyngeal airway may be used on the unconscious patient or on the semiconscious patient and is also indicated if a patient has massive trauma around the mouth or wiring of the jaws.
If the airway is being maintained with the basic airway skills listed above, blood, secretions, and vomit become the primary causes of an obstructed airway in the unconscious patient. Suctioning should be used to clear the airway if it becomes occluded with these body fluids.
Limit suctioning to 10 seconds or less to reduce the risks of hypoxemia. Monitor for changes in heart rate as oropharyngeal suctioning can cause vagal stimulation resulting in bradycardia.
Advanced Airways used during ACLS include Combitube, LMA (Laryngeal mask airway), and ET tube (endotracheal tube). Once an advanced airway is in place, chest compressions are no longer interrupted for ventilations. 1 breath should be given every 6-8 seconds (8-10 breaths per minute).
You should be given adequate time to practice with these devices during your ACLS training before ACLS megacode testing.