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AIRWAY MANAGEMENT
CHRIS POULSEN, D.O.
MEDICAL DIRECTOR, REACH AIR MEDICAL SERVICES
OBJECTIVES
At the conclusion the participant will
• 1.Understand airway anatomy applicable to airway management devices and techniques.
• 2.Verbalize an understanding of airway management devices and theory.
• 3.Verbalize indications and contraindications of airway pharmacology.
• 4.Understand the impact on scene time when Rapid Sequence Airway is performed at the scene.
• 5.Recognize the signs of a potentially difficult airway.
Introduction
Anatomy / Physiology
Positioning
Basics - Adjuncts
ALS - Intubation
AIRWAY MANAGEMENT
Children are different than adults !!!
ANATOMY
ANATOMY
PEDIATRIC AIRWAYS
Epiglottis:
• Relatively large size in
children
• Omega shaped
• Floppy – not much
cartilage
ANATOMY: ADULT vs PEDIATRIC
AIRWAY ANATOMY - SHAPE
ANATOMY
POSITIONING
AIRWAY POSITIONING FOR CHILDREN <2yrs
POSITIONING
SIGNS OF RESPIRATORY DISTRESS
Poiseuille’s law
pedi adult
When radius is halved ----
Resistance increases 16 fold
R =8 n l
r4
PHYSIOLOGY: EFFECT OF EDEMA
Breathing should always be divided in two!
Oxygenation Ventilation
In with the new Out with the old
(Inhalation) (Exhalation)
• It’s not a ventilator --- it’s an oxygenator/ventilator
Priority 1) Oxygen Delivery
Priority 2) Not to hyperventilate
Priority 3) Adequate ventilation
BREATHING
Big tidal volumes and rates don’t increase oxygenation
For Hypoxemia: turn up the FiO2, or the pressure
• D - O - P - E (dislodged - obstructed - PTX - Equipment)
• Use a PEEP valve!
• If still dropping……..
EPIC study (Dan Spaite - Arizona)
Hypoxia is REALLY BAD for TBI:
• 500 cases of hypoxia/10,000 = 4 X mortality!
• A single sat <90 doubles mortality in severe TBI!
• Always utilize 100% O2 on TBI patients!
BREATHING: OXYGENATION
“the quantity of a gas dissolved in liquid is proportional to the partial pressure of the gas in contact with the liquid…”
- So higher FIO2 = higher pO2
- Higher PEEP or PIP = higher pO2
Oxygen (Hg) saturation is dependent on pO2
(Note: Rate / TV have no effect here ---- “minute ventilation”)
OXYGENATION: HENRY’S LAW
Adjuncts: High Flow Nasal Canula
Preoxygenation and Prevention of Desaturation
During Emergency Airway Management
Scott D. Weingart, MD Richard M. Levitan, MD
AIRWAY MANAGEMENT
Remember tidal volume x rate = minute ventilation
Minute Ventilation RAPIDLY affects pCO2
Medical Providers all Hyperventilate! **
• We want to feel the lungs inflate!
• Use a 1 liter BVM
• 1 breath every 5 seconds
• And flow control / counter
BREATHING: VENTILATION
Remember tidal volume x rate = minute ventilation
Follow ETCO2 in all critical patients
• ETCO2 is about 5mmhg less that PCO2
• Waveform capnography is best!
• All that is ETCO2 is not ventilation
It’s only “accurate” if there is adequate Cardiac Output
If blood is not pumped to the lungs, CO2 will not off-gas
(CPR, Shock, etc)
EMMA Colorimetric
BREATHING: VENTILATION
Do Not Hyperventilate TBI Patients! *
We were taught to do this in the 80’s and 90’s
• We killed thousands based on “expert opinion”
• Goal ETCO2: 35-40
• TBI patients begin to drop off at pCO2 < 35*
*Davis, et al and Dumont, et al
BREATHING VENTILATION
We manage airways so we can manage breathing
Less is More!
• Utilize the least invasive method that solves the problem
Positioning
NPA (over OPA)
BVM
SGA (LMA type devices)
ETT
Cricothyrotomy
AIRWAY MANAGEMENT
AIRWAY MANAGEMENT BASICS: BLS
• Positioning – head tilt/chin lift or jaw thrust
• Effective BVM - most important skill
– Get a good seal (two person better)
– Don’t over ventilate
• Adjuncts
– OPA - good choice if tolerated – (no gag)
– NPA – better tolerated – new better materials
• SUCTION!!!
• BROSELOW!!!
BROSELOW TAPE
Pediatric Resuscitation Palm Pedi
BROSELOW TAPE…there’s an app for that
• Nasal airway
• Oral airway
AIRWAY ADJUNCTS
BASIC AIRWAY MANAGEMENT TECHNIQUES
AIRWAY MANAGEMENT ADJUNCTS (NPA)
Wrong size: Too Long
ADJUNCTS: ORAL AIRWAY
Wrong size: Too Short
Adjuncts: Oral Airway
Correct size
Adjuncts: Oral Airway
BAG VALVE MASK (BVM)
BAG VALVE MASK VENTILATIONPro’s
• Effective adjunct
• Non invasive
• Feel compliance
Give Slow Small Breaths: 6-8 cc/kg (smallest aprop. bag)
Rate: Adults: 12 Child: 16-20 Infant: 20-30
ADJUNCTIVE & RESCUE AIRWAYS
• King LT (Periglottic Airways)
• Supraglottic Airways (SGAs = LMAs)
• The SGA was invented byDr. Archie Brain at theLondon Hospital inWhitechapel in 1981
• The SGA consists of twoparts:– The tube– The mask
SGA’s (LMA’s)
• The SGA design:
– Provides an “oval seal around thelaryngeal inlet” when cuff inflated.
– Lube only the outside – not insidethe cup area
– Direct it posteriorly and upwards –past the posterior tongue (jawthrust will help)
Then Bury It!(avoid a “flipped tip”)
– Don’t overinflate (or don’t inflate!)
SGA’s (supraglottic airways)
• Failed less invasive techniques
• Failed more invasive techniques
• May be used as a:
– Rescue Device
– Bridging Device
– Destination Device
SGA INDICATIONS
• Intact Gag Reflex
• Patients requiring definitive airway protection:
(Swollen cords, burn, anaphylaxis, vomiting, high pressures, etc)
• Massive maxillofacial trauma
• Patients at High risk of aspiration
CONTRAINDICATIONS
• Step 1: Size selection
• Step 2: Examination of the LMA
• Step 3: Check the cuff
• Step 4: Lubrication of the LMA
• Step 5: Position the Airway
PREPARATIONS
• Verify that the size of the LMA is correct for the patient –(Broselow or pckg insert)
• Recommended Size guidelines:
– Size 1: under 5 kg
– Size 1.5: 5 to 10 kg
– Size 2: 10 to 20 kg
– Size 2.5: 20 to 30 kg
– Size 3: 30 kg to small adult
– Size 4: adult
– Size 5: Large adult
STEP 1: SIZE SELECTION
THE i-Gel SGA…… no inflation
Manage the airway – don’t secure it !
Should we be intubating at all?
PRE HOSPITAL INTUBATION
Studies showing WORSE outcomes with ETIStiell: CMAJ 2008;178:1141-52Davis: J Trauma 2003;54:444-53Davis: J Trauma 2005;58:933-9Davis: J Trauma 2005;59:486-90Denninghoff: West J Emerg Med 2008;9:184-9Murray: J Trauma 2000;49:1065-70Wang: Ann Emerg Med 2004;44:439-50Wang: Prehosp Emerg Care 2006;10:261-71Eckstein: Ann Emerg Med 2005;45:504-9Bochicchio: J Trauma 2003;54:307-11Arbabi: J Trauma 2004;56:1029-32
Studies showing BETTER outcomes with ETI
¡ Winchell: Arch Surg 1997;132:592-7¡ Klemen: Acta Anaesthesiol Scand 2006;50:1250-4¡ Warner: Trauma 2007;9:283-89¡ Davis: Resuscitation 2007;73:354-61¡ Davis: Ann Emerg Med 2005;46:115-22¡ Bulger: J Trauma 2005;58:718-23¡ Bernard: Ann Surg 2010;252:959-965
The Debate on Prehospital Intubation Continues…
• Failure to oxygenate
• Failure to ventilate
– (Failure to remove CO2 = hypercarbic respiratory failure)
• Failure to protect the airway
- (or expected failure to protect the airway (GCS <8, etc)
• Expected Course Demands ETT (prior to TOC)
INTUBATION: INDICATIONS
INTUBATION: PREPARATION
• Preoxygenate
– Monitors - ECG, pulse ox
– BLM (Sellick’s)
– Good basics
• Equipment selection
– Miller (< 4) vs. Mac
– Cuffed vs. uncuffed
– ETT size
• Positioning
• 3-5 minutes of 100% oxygen - non-rebreather mask
• Hi Flow Nasal Cannula 15 L adults, 1 L/kg peds
• Avoid positive pressure ventilation if possible
6 full volume ventilations via BVM if needed
• Establishes O2 reserve via nitrogen washing
• Permits prolonged apnea w/o desaturation
Healthy 70kg adult >90% for over 10 minutes
Healthy10kg child >90% for over 4 minutes
But! The Airway must be open!
PRE-OXYGENATION PRIOR TO RSA (RSI)
The Oxygen Dissociation Curve
PO2 up
to 400
On 100%
• Suction, Suction, Suction
• Zofran
• Pedi Bougie (4-6)
• Adult Bougie (6-8.5)
• Stylet
• ETT +/- one size (Parker flex tip ETT)
• Tube check and securing devices
• Magill forceps
AIRWAY EQUIPMENT
ENDOTRACHEAL TUBE INTRODUCER (GUM ELASTIC BOUGIE)
• Bougie Replaces the stylet
• Able to use with poor view
• Feel tracheal rings
• If it goes in all the way =
esophagus
• Fold it in ½ - in line with
coudet tip
• Don’t preload it
ENDOTRACHEAL TUBE INTRODUCER (GUM ELASTIC BOUGIE)
Large study June 2018:
Effect of Use of a Bougie vs Endotracheal Tube and Stylet on FirsAttempt Intubation Success Among Patients With Difficult AirwayUndergoing Emergency Intubation: A Randomized Clinical Trial.
757 patients:
1st pass success went from 82% to 96%
ENDOTRACHEAL TUBE (ETT)
Age kg ETT Length
Newborn 3.5 3.5 9
3 mos 6.0 3.5 10
1 yr 10 4.0 11
2 yrs 12 4.5 12
TUBE SIZE
• ETT size
– (Age + 16) / 4
– Diameter of nare
– Diameter of pinky
– Broselow tape
– Have one size smaller and larger
TUBE PLACEMENT – TIP TO LIP
• ETT depth – use the black line
• ETT size x 3
• Infants: wt (kg) + 6
BACK-UP PLAN
• Can’t ventilate or basics not working
– Consider adjuncts (OPA/NPA/positioning)
– Intubation?
• Can’t intubate
– Rescue devices
• Can’t rescue
– Surgical procedure
• Okay to stick with basics if working
Macintosh
Miller
LARYNGOSCOPE BLADES
LARYNGOSCOPE BLADES
Better in younger
children with a
floppy epiglottis
(<2-4)
LARYNGOSCOPE BLADES
Better in adults
and older
children (stiffer
epiglottis)
INTUBATION - CONFIRMATION
• Visualize tube passing through cords (video?)
• Breath sounds and no epigastric sounds
• End Tidal CO2 (ETCO2)
– Waveform better than colorimetric (not reliable in CPR)
Masimo EMMA Device
(mainstream ETCO2)
AIRWAY MANAGEMENT CHALLENGES
AIRWAY MANAGEMENT CHALLENGES
DETERIORATION OF INTUBATION: “DOPE”
• Displaced
• Obstructed
• PTX
• Equipment
• Same as adults
– Lidocaine
– Etomidate
– Succinylcholine
– Rocuronium
• Atropine not “required”
• Consider ketamine
RSI MEDICATIONS
IN CLOSING• There is airway management……and there is everything else
• Know your equipment and supporting policies
• Manage the airway – don’t “stabilize”
• A failed airway should never be unanticipated – consider all airways potentially difficult!
• Have plan B before proceding with plan A
• Practice! Practice! Practice!
It’s Not Okay to Continue with Failed Techniques
“HOPE is not an airway strategy”
QUESTIONS
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