EMS Airway Management - Lungs Sounds

EMS Providers should have a solid understanding of normal lung sounds and be able to recognize those that are adventitious lung, as these can provide crucial information about a patient's respiratory status. 

Here’s an overview of the key points regarding lung sounds:

1. Normal Lung Sounds

• Vesicular Breath Sounds: These are the standard breath sounds heard over most of the lung fields. They are soft, low-pitched, and have a longer inspiratory phase than expiratory phase.
  • Characteristics: "Gentle rustling" sound, more prominent in the bases of the lungs.
  • Cause: Normal airflow through the large and small bronchi and alveoli.

2. Adventitious (Abnormal) Lung Sounds

Adventitious Sounds are additional lung sounds superimposed on normal breath sounds. They indicate an underlying pathology. They include:

Stridor

• Description: A high-pitched, harsh sound heard during inspiration.
• Cause: Caused by a partial obstruction of the upper airway (i.e., larynx).
• Common Conditions:
• Croup: Typically in children, caused by a viral infection that leads to inflammation.
• Epiglottitis: Life-threatening condition caused by bacterial infection.
• Airway Obstruction: Foreign body or severe anaphylaxis.
  
• Sound File: Stridor

Wheezing

• Description: High-pitched, musical sounds, typically heard during expiration (but can be heard on inspiration as well).
• Cause: Narrowing or obstruction of the lower airway (i.e., trachea)
• Common Conditions:
  • Asthma: Due to bronchospasm and inflammation.
  • COPD: From chronic airway obstruction.
  • Bronchiolitis: Inflammation of the small airways, common in infants.
• Sound File: Wheezing

Rhonchi

• Description: Low-pitched, snoring or gurgling sounds, often cleared with coughing.
• Cause: Secretions or mucus in the larger airways (i.e., bronchi; bronchioles)
• Common Conditions:
  • Chronic Bronchitis: Increased mucus production and obstruction.
  • Pneumonia: Accumulation of mucus and fluids.
  • Bronchiectasis: Chronic enlargement and inflammation of bronchi.
• Sound File: Rhonchi

Rales (Crackles)

• Description: Fine or coarse, popping or crackling sounds, more prominent during inspiration.
  • Fine Crackles: High-pitched, short, and intermittent.
  • Coarse Crackles: Low-pitched, bubbling or rattling.
• Cause: Fluid in the small airways (i.e., alveoli)
• Common Conditions:
  • Heart Failure (Pulmonary Edema): Fluid accumulation in the alveoli.
  • Pneumonia: Fluid or pus within alveoli due to infection.
  • Fibrosis: Stiffening of lung tissue.
• Sound File: Fine & Course

Pleural Friction Rub

• Description: Low-pitched, grating sound, like creaking leather, heard during both inspiration and expiration.
• Cause: Inflammation of the pleural layers causing them to rub together.
• Common Conditions:
  • Pleuritis: Inflammation of the pleura, often due to infection or autoimmune disorders.
  • Pulmonary Embolism: Can lead to pleuritic inflammation and pain.
• Sound File: Pleural Friction Rub

3. Other Abnormal Lung Findings

Pleural Effusion

• Description: Presence of fluid in the pleural space, usually causing a decrease in normal lung sounds over the affected area.

• Common Conditions:

  • Heart Failure: Increased hydrostatic pressure causes fluid leakage into the pleural space.
  • Infection (e.g., Pneumonia): Inflammatory fluid accumulation.
  • Cancer: Malignant pleural effusions.

• Physical Exam Findings:

  • Decreased breath sounds over the affected area.
  • Dullness to percussion due to fluid presence.

Key Points for EMS Providers

• Stridor is a red flag indicating upper airway obstruction — immediate airway assessment is critical.

• Wheezing typically suggests lower airway narrowing; listen carefully to both inspiratory and expiratory phases.

• Rhonchi may indicate the need for airway clearance (e.g., suctioning).

• Crackles (rales) suggest fluid in the lungs — think about causes like heart failure or infection.

• Pleural Friction Rub can indicate pleuritic pain and requires assessment for underlying conditions like pleuritis or PE.

• Assess for Patient Symptoms: Correlate lung sounds with symptoms (e.g., shortness of breath, cough, sputum production, chest pain) for a more complete clinical picture.

Recognizing and differentiating these sounds can help EMS providers make critical early decisions about management and transport.

Further Reading:

Alexander, M. & Belle, R. (2017) Advanced EMT: A Clinical Reasoning Approach (2nd Ed). Hoboken, New Jersey: Pearson Education

Bickley, L. S., & Szilagyi, P. G. (2020) Bates' Guide to Physical Examination & History Taking (13th Ed). Philadelphia, Pennsylvania: Wolters Kluwer.

Bohadana, A., Izbicki, G., & Kraman, S. S. (2014) Fundamentals of Lung Auscultation. New England Journal of Medicine, 370(8): 744-751. Accessed October 8, 2024

Brown, C. A. (2022) Walls Manual of Emergency Airway Management (5th Ed). Philadelphia, Pennsylvania: Lippincott, Williams & Wilkins.

Bledsoe, B. E., Cherry, R. A. & Porter, R. S (2023) Paramedic Care: Principles and Practice (6th Ed) Boston, Massachusetts: Pearson

Mistovich, J. J. & Karren, K. J. (2014) Prehospital Emergency Care (11th Ed). Hoboken, New Jersey: Pearson Education

Sarkar, M., Madabhavi, I., Niranjan, N., & Dogra, M. (2015) Auscultation of The Respiratory System. Annals of Thoracic Medicine 10(3):158-168. Accessed October 8, 2024

EMS Airway Management - iGel Supraglottic Airway Device

The iGel supraglottic airway device is an essential tool for EMS providers when managing a patient's airway, especially in situations where endotracheal intubation may be difficult or not immediately feasible.

Here’s some thing EMS providers need to know about the iGel:

1. Indications and Contraindications

- Indications: Emergency airway management in unconscious patients with absent or inadequate respiratory effort.

• Alternative to endotracheal intubation during cardiac arrest, respiratory arrest, or when intubation is not possible.
• Can be used in prehospital settings in combination with anesthesia, sedation, or other airway management situations requiring a secure airway.

- Contraindications:Conscious or semi-conscious patients with intact gag reflex.

• Patients with known esophageal disease or pathology, such as esophageal varices.
• Patients with a high risk of aspiration or who have ingested a large meal recently.
• Severe airway trauma or obstruction that may prevent insertion.

2. Device Design and Features

• Supraglottic Airway: The iGel is designed to sit above the glottis, creating a seal around the laryngeal inlet without inflating a cuff.
• Gel-Like Cuff: The cuff is made of a soft, gel-like material that molds to the patient’s anatomy, minimizing trauma and reducing the need for precise sizing.
• Integral Bite Block: Built-in bite block helps prevent the patient from biting down and occluding the airway.
• Gastric Channel: The device includes a gastric channel that allows for the insertion of a gastric tube to decompress the stomach and reduce the risk of aspiration.
• Sizing: The iGel comes in multiple sizes, typically based on patient weight, ranging from neonates to large adults.

3. Preparation and Insertion

• Sizing: Select the appropriate size based on the patient’s weight.
• Typical Ranges:
• Size 1: Neonates (2-5 kg)
• Size 2: Pediatric (10-25 kg)
• Size 3: Small adult (30-60 kg)
• Size 4: Medium adult (50-90 kg)
• Size 5: Large adult (90+ kg)
• Lubrication:Cover the back, sides, and cuff of the device with a water-based lubricant.
• Avoid over-lubricating the front of the device to prevent blocking the airway opening.
• Insertion Technique: Position the patient’s head in a neutral or slightly extended position.
• Open the patient’s mouth and gently insert the iGel along the natural curve of the airway until resistance is felt, indicating it is seated correctly.
• Avoid excessive force during insertion to prevent trauma.
• Confirmation: Confirm placement by observing chest rise, listening for bilateral breath sounds, and using capnography (if available).
• Security: Secure the device with a strap or tape to prevent dislodgement.

4. Maintenance and Monitoring

• Ongoing Assessment: Continuously monitor for effective ventilation, chest rise, and oxygen saturation.
• Regularly check for signs of dislodgement, obstruction, or leakage.
• Gastric Decompression: If necessary, insert a gastric tube through the gastric channel to decompress the stomach and reduce the risk of regurgitation and aspiration.
• Ventilation: Connect the device to a bag-valve mask (BVM) or ventilator, ensuring adequate tidal volume and oxygen delivery.

5. Complications and Troubleshooting

• Airway Obstruction: If ventilation is inadequate, reassess the device placement, and consider repositioning or reinsertion.
• Aspiration Risk: Despite the gastric channel, there is still a potential risk of aspiration; be prepared to manage this complication if it occurs.
• Device Dislodgement: Regularly check the device's position and secure it properly to avoid dislodgement, especially during patient movement or transport.
• Trauma or Discomfort: Monitor for signs of airway trauma or discomfort, particularly if insertion was difficult.

6. Removal

• Timing: The iGel should be removed once the patient regains consciousness and airway reflexes, or if endotracheal intubation is indicated.
• Technique: Gently withdraw the device while monitoring for any signs of obstruction, aspiration, or respiratory distress.
• Prepare to manage the airway immediately if complications arise during removal.

7. Training and Proficiency

• Simulation Training: Regular practice with the iGel device in simulated scenarios to maintain proficiency in its use.
• Familiarization: EMS providers should be familiar with the different sizes and specific features of the iGel, including the gastric channel and the appropriate insertion technique.
• Continuing Education: Stay updated on best practices, new developments, and guidelines related to supraglottic airway management.

8. Legal and Ethical Considerations

• Scope of Practice: Ensure the use of the iGel is within the provider’s scope of practice as defined by their certification level and local protocols.
• Informed Consent: While typically used in emergencies where consent cannot be obtained, providers should be aware of the ethical considerations in airway management.
• Documentation: Document the size of the device used, time of insertion, confirmation methods, patient response, and any complications encountered.

Conclusion

The iGel supraglottic airway device is a valuable tool in the EMS provider’s airway management arsenal. Proper selection, insertion, and management are crucial to ensure effective ventilation and patient safety. 

It was invented by Dr. Muhammed Aslam Nasir and is manufactured by Intersurgical.

Continuous training and familiarity with the device will enhance the provider's ability to use the iGel effectively in emergency situations.

Further Reading:

Alexander, M. & Belle, R. (2017) Advanced EMT: A Clinical Reasoning Approach (2nd Ed). Hoboken, New Jersey: Pearson Education

Bledsoe, B. E., Cherry, R. A. & Porter, R. S (2023) Paramedic Care: Principles and Practice (6th Ed) Boston, Massachusetts: Pearson

Brown, C. A. (2022) Walls Manual of Emergency Airway Management (5th Ed). Philadelphia, Pennsylvania: Lippincott, Williams & Wilkins

Chinn, M., Engel, T., & Sinclair, P. R. (2022) Supraglottic Airways: A Look From Above. EMS Airways. Accessed August 1, 2024

Intersurgical (ND) I-Gel® Supraglottic Airway. Accessed August 1, 2024