Emergency lectures - Emergency airway management

Emergency Airway ManagementEmergency Airway Management

Rob Dickson, M.D. FAAEM, FACEP

Good Shepherd Health System

Longview, Texas

Rob Dickson, M.D. FAAEM, FACEP

Good Shepherd Health System

Longview, Texas

Clinical QuestionsClinical Questions

• What is different about emergency airways from those done in the anesthesia suite?

• Are there reliable signs of airway compromise and at what point do we intervene?

• How can we screen for potential airway disasters?

• What are the best management strategy for difficult airways?

• What are the newest airway devices and are they worth the investment?

Unique issues in the Emergency DepartmentUnique issues in the Emergency Department

Unique issues in the Emergency DepartmentUnique issues in the Emergency Department

We don’t pre-select casesWe don’t pre-select cases

Unique issues in the Emergency DepartmentUnique issues in the Emergency Department

We don’t pre-select cases

Can never cancel a case

We don’t pre-select cases

Can never cancel a case

The patient we wantThe patient we want

The patients we getThe patients we get

Closed claims paperClosed claims paper

• Review paper of closed anesthesia claims resulting in death or disability

• Take home points• Emergency airways are the riskiest!• Difficult BVM ventilation increased risk of

bad outcome• Highest predictor of bad outcome was

persistent attempts before rescue method employed- have a plan B!

Peterson GN. Management of the difficult airway: A closed claims analysis.Anesthesiology 2005; 103:33.

Unique issues in the Emergency DepartmentUnique issues in the Emergency Department

Unique issues in the Emergency DepartmentUnique issues in the Emergency Department

• Deteriorating cardio -respiratory status

Unique issues in the Emergency DepartmentUnique issues in the Emergency Department

• Deteriorating cardio -respiratory status• High aspiration risks

Unique issues in the Emergency DepartmentUnique issues in the Emergency Department

• Deteriorating cardio -respiratory status• High aspiration risks• Altered mental states

Unique issues in the Emergency DepartmentUnique issues in the Emergency Department

• Deteriorating cardio -respiratory status• High aspiration risks• Altered mental states• Anatomical variants

Unique issues in the Emergency DepartmentUnique issues in the Emergency Department

• Deteriorating cardio -respiratory status• High aspiration risks• Altered mental states• Anatomical variants• Upper airway structural and mechanical

considerations (vomit, angioedema)

Clinical signs of airway compromiseClinical signs of airway compromise

• Snoring respirations• Inspiratory stridor• Drooling• Hoarseness• Retractions/tracheal tugging/paradoxical

breathing patterns• Mass effects

When to intervene?When to intervene?

• Hypoxic/hypercapnic respiratory failure• Shock states (decreases cardiac load)• Altered mental states and unable to maintain

patent airway• Potential decompensation

Continuum of airway management Continuum of airway management

• Upper airway obstruction (airway positioning)

• Head positions- jaw thrust, head tilt-chin lift• Oropharyngeal/nasopharyngeal airway• Bag-valve-mask ventilation• Supra-glottic airways- LMA, combitube, king

device• Difficult intubations- bougie, video assisted

laryngoscopy, cricothyrotomy, needle cricothyrotomy

Predictors of difficult AirwayPredictors of difficult Airway

• History of airway problems- tracheostomy scars

• Physical assessment- obesity• Mouth opening• Tongue to pharyngeal size• Hyo-mental distance• Neck flexion/head extension(mobility issues)

Mallampatti/Cormack-LehaneMallampatti/Cormack-Lehane

Mallampatti viewsMallampatti views

Bag-valve maskBag-valve mask

• Essential skill to managing the airway• The most important airway skill• Almost every case can be managed or

rescued with good BVM technique• Never abandon until using a 2 person

technique with NP/OP airway• This skill is necessary before attempting to

master other techniques/devices

One person BVMOne person BVM

Two person BVMTwo person BVM

Direct laryngoscopy Direct laryngoscopy

Rapid Sequence IntubationRapid Sequence Intubation

• Use of sedation and chemical paralysis to facilitate intubation

• 70-84% of all intubations• High success rates for experience operators• In comparison to non-paralysis intubations

RSI had 15% less aspiration, 25% less airway trauma, 3% less death

Steps in RSISteps in RSI

• Preparation: T-10 minutes• Preoxygenation: T-5m• Premedication: T-3m• Paralysis: T-0• Placement of tube T+45s• Post intubation management:T+2m

BladesBlades

• Miller (straight)• Macintosh(curved)• Main criteria is blade long enough to

effectively fit into the valecula space (curved) • Reach the epiglottis to lift (straight)

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Best laryngoscopy techniquesBest laryngoscopy techniques

• Proper alignment auditory meatus with suprasternal notch

• Flex neck by placing pillow under occiput• Extend head maximal• Insert laryngoscope, visualize epiglottis by

sweeping tongue to the left• Must see this landmark• Glottic opening lies just distal to this

structure

Proper alignment Proper alignment

Picture correct axis positioningPicture correct axis positioning

Positioning in the obese patientPositioning in the obese patient

Technique for difficult airwayTechnique for difficult airway

Bimanual laryngoscopy

What is looks like in a perfect worldWhat is looks like in a perfect world

Supraglottic airwaysSupraglottic airways

LMALMA

• Peripharyngeal sealers• Seats over the pyriform fossae• Sizes 1(infant) to 5(large adult)• At least as effective as other airway

management choices in CPR• Does not prevent aspiration

Laryngeal Mask AirwaysLaryngeal Mask Airways

King airwayKing airway

• Isolates the hypopharynx and laryngeal inlet• Pediatric sizes 2 and 2.5• Adult sizes 3-5 (sized by height 4-5 ft,5-6,

>6)• Pass tube exchanger/bronchoscope through

ports• No documented tracheal placements• Insertion technique

King airwayKing airway

CombitubeCombitube

• High success rates of 98-100 %• Esophageal and oropharyngeal balloons• Most common placement in the esophagus• Tracheal placements ventilate thru distal port• No pediatric sizes• Distal cuff #2(white)-15cc air• Proximal cuff #1(blue)-85 cc air

OTHER AIRWAY ADJUNCTSOTHER AIRWAY ADJUNCTS

Gum Elastic BougieGum Elastic Bougie

• Used to facilitate endotracheal intubation• Essentially a plastic ETT changer with

curved tip• For use when unable to visualize the glottic

opening or the view is impaired• Place the tip up and aim just past the

epiglottis• “Feel bumps” or hit resistance• Continue using laryngoscope and slide tube

over the bougie for placement

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What is a difficult airway?What is a difficult airway?

• Three components may co-exist• Difficult BVM ventilation• Difficult laryngoscopy• Difficult surgical airway

ASA Difficult Airway Task Force. Anesthesiology 2003; 93:1269-1277.

Failed airwayFailed airway

• Occurs when one or mores exists• Inability to ventilate or intubate paralyzed

patients• 3 or more attempts at intubation by most

experienced operator

ASA Difficult Airway Task Force. Anesthesiology 2003; 93:1269-1277.

Failed emergency airwaysFailed emergency airways

• NEAR database• N= 7212• Patients were enrolled if first technique failed

and a rescue was required• Overall 2.7% failed airways• Surgical airway in 0.5% of cases

Bair AE. The failed intubation attempt in the emergency department: analysis ofprevalence, techniques, and personnel. Journal of Emergency Medicine 2002; 23:131.

Failed airway algorithmFailed airway algorithm

Normal anatomy and oxygen Abnormal anatomy normal oxygen

Normal anatomy abnormal oxygen Abnormal anatomy abnormal oxygen

Failed airway algorithmFailed airway algorithm

Normal anatomy and oxygen

•Obese overdose patient with unfavorable anatomy- able to BVM to 95% saturation

•First choice: video laryngoscope•Second choice: bougie or supraglottic device

Abnormal anatomy normal oxygen

Normal anatomy abnormal oxygen Abnormal anatomy abnormal oxygen

Failed airway algorithmFailed airway algorithm

Normal anatomy and oxygen

•Obese overdose patient with unfavorable anatomy- able to BVM to 95% saturation

•First choice: video laryngoscope•Second choice: bougie or supraglottic device

Abnormal anatomy normal oxygen

Normal anatomy abnormal oxygen

•Obese paralyzed RSI patient with failed intubation and falling sats, unable to oxygenate with BVM

•First choice: Supraglottic device or limited attempt with video device•Second choice: Cricothyrotomy

Abnormal anatomy abnormal oxygen

Failed airway algorithmFailed airway algorithm

Normal anatomy and oxygen

•Obese overdose patient with unfavorable anatomy- able to BVM to 95% saturation

•First choice: video laryngoscope•Second choice: bougie or supraglottic device

Abnormal anatomy normal oxygen

•Severe angioedema with normal oxygen saturation

•First choice: Intubating bronchoscope or video device•Second choice: Cricothyrotomy

Normal anatomy abnormal oxygen

•Obese paralyzed RSI patient with failed intubation and falling sats, unable to oxygenate with BVM

•First choice: Supraglottic device or limited attempt with video device•Second choice: Cricothyrotomy

Abnormal anatomy abnormal oxygen

Failed airway algorithmFailed airway algorithm

Normal anatomy and oxygen

•Obese overdose patient with unfavorable anatomy- able to BVM to 95% saturation

•First choice: video laryngoscope•Second choice: bougie or supraglottic device

Abnormal anatomy normal oxygen

•Severe angioedema with normal oxygen saturation

•First choice: Intubating bronchoscope or video device•Second choice: Cricothyrotomy

Normal anatomy abnormal oxygen

•Obese paralyzed RSI patient with failed intubation and falling sats, unable to oxygenate with BVM

•First choice: Supraglottic device or limited attempt with video device•Second choice: Cricothyrotomy

Abnormal anatomy abnormal oxygen

•Obese patient with severe angioedema and falling oxygen saturation with bradycardia

•First choice: cricothyrotomy

Difficult airway algorithmDifficult airway algorithm

• 2674 pre-hospital intubations (France)• Difficult airway algorithm BAI, ILMA,

Cricothyrotomy• 6% failed airways• 98% adherence to algorithm• BAI successful rescue in 114/151 attempts• Remainder successfully managed with ILMA• Cricothyrotomy in 1 patient

Anesthesiology:January 2011 - Volume 114 - Issue 1 - pp 105-110

Back to our questionsBack to our questions

• What is different about emergency airways from those done in the anesthesia suite?

• Are there reliable signs of airway compromise and at what point do we intervene?

• How can we screen for potential airway disasters?

• What are the best management strategy for difficult airways?

• What are the newest airway devices and are they worth the investment?

DISCUSSIONDISCUSSION