Airway Management

Basic before Advance

Ed Strapp, ATC-L, EMT-P, FP-C Trooper/Flight Paramedic, Maryland State Police

Lecture Goals

•Examine and discuss the current scientific guidelines and treatment recommendations regarding prehospital airway management of the injured athlete.

• Identify and discuss the current evidence for the use of and the interrelatedness of emergency airway management equipment in the prehospital setting.

•Compare and contrast the roles, characteristics, and advantages /disadvantages for progression from Basic to advanced airways in the prehospital setting

What I want you to know……

• Airway Anatomy

• Oxygenation vs. Ventilation

• Equipment available

• Techniques

• Athletic Considerations

– Helmet vs. Facemask removal

– Shoulder Pads

– Other Protective equipment

NATA Competencies

1. Differentiate the types of airway adjuncts (oropharyngeal airways [OPA], nasopharyngeal airways [NPA] and supraglottic airways [King LT-D or Combitube]) and their use in maintaining a patent airway in adult respiratory and/or cardiac arrest. (AC-9)

This is what THEY want you to know……..

NATA Competencies

2. Establish and maintain an airway, including the use of oro- and nasopharyngeal airways, and neutral spine alignment in an athlete with a suspected spine injury who may be wearing shoulder pads, a helmet with and without a face guard, or other protective equipment. (AC-10)

This is the newest Standard of Care ……..

Why are we here

• NATA Position Statements

Current NATA Position Statement Recommendations

“If rescue breathing becomes necessary, the person with the most

training and experience should establish an airway and begin rescue

breathing using the safest technique.”

Current NATA Position Statement Recommendations

“The jaw-thrust maneuver is recommended over the head-tilt technique,

which produces unnecessary motion at the head and in the cervical spine.”

“Advanced airway management techniques (e.g., laryngoscope,

endotracheal tube) are recommended when appropriately trained and

certified rescuers are present.”

“If rescue breathing becomes necessary, the individual with the most

training and experience should establish an airway and commence rescue

breathing using the safest technique(s).”

“During airway management, rescuers should cause as little motion as

possible.”

Airway Anatomy

• Upper and Lower Airway

– Why is this important? • What impact does patient position have

• What impact does my adjunct have?

• Where is my adjunct working?

Airway Anatomy

• Oxygen is required for metabolism

• A patient’s air movement is a window into the cells of the patient

• LOOK at your patient to see this process

Anatomy Review

• Air movement requires an open airway – Airway begins at mouth and nose

• Upper airway: – Begins at nose and lips and ends at vocal

cords

• Lower airway: – Begins at vocal cords and ends at

alveolar—capillary membrane

Up

per

Air

way

Upper Airway

Lower Airway

Adult vs. pediatric

• Pediatric airway smaller and more flexible than adult

• Pediatric vocal cords more anterior & closer to base of tongue

• Narrowest part of pediatric airway is cricoid cartilage, glottic opening is narrowest in adults

• Tongue is larger in pediatrics compared to adults

Adult vs. pediatric

Most important challenge:

Assessing and assuring adequate Ventilation and Oxygenation

Oxygenation vs. Ventilation

• Ventilation

– Mechanical Process that moves air in and out of the lungs

• Oxygenation

– The exchange of gases between a living organism and the environment

Bronchioles and Alveoli

Pulse Oximetry

• Measures saturation of RBCs with O2

• Normal saturation = 97%+

Capnography

• Measures concentration of carbon dioxide in the expired air.

• How much CO2 you breath out

• Measures Oxygenation

• Normal should be 35-45

• Will keep at 35 if signs of herniation or serious head injury

• Best Indicator of Oxygenation and Metabolism

Airway Management – The Basics

Manual Maneuvers

• Chin Lift

• Jaw Lift

• Jaw Thrust

• Head Tilt – Chin Lift

• Modified Jaw thrust

Airway Management – The Basics

Mechanical Airways

• NPA’s

• OPA’s

• Description

• Advantages

• Disadvantages

• Indications

• Contraindications

• Methods of Insertion

Airway Management – The Basics

Ventilation

• Mouth to Mask

• BVM

• Description

• Advantages

• Disadvantages

• Indications

• Contraindications

• Methods of Use

BVM Ventilation

• The most important airway skill

• Always the first response to inadequate oxygenation and ventilation

• “ Anybody ( almost ) can be oxygenated and ventilated with a bag and a mask “

• Delays the collapse and the urgency to intubate

BVM Ventilation

• Requires practice to master

• One hand to

– maintain face seal

– position head

– maintain patency

• Other hand ventilates

• This can be a 2 or 3 person skill

– Use 2 people when ever possible

(Tip: Pull Chin Into Mask, Don’t Push Mask down onto Face)

Hyperventilation

• DO NOT HYPERVENTILATE, ESPECIALLY WITH A HEAD INJURY

• Hyperventilation will cause vasoconstriction and allows more blood into the cranial vault worsening the injury.

• ONLY if they show signs of Herniation

Opening the Airway

• Check the airway

• Open the airway, place one hand on the victims forehead and gently tilt head back

• Use Modified Jaw Thrust in Trauma Pt.

• Remove any visible obstruction from the victims mouth, including mouth pieces or teeth.

• DO NOT ATTEMPT ANY FINGER SWEEPS

Opening the airway

Jaw thrust technique may be needed if C-spine injury

Jaw Thrust

Simple airway adjuncts

Nasopharyngeal airway insertion

Oropharyngeal airway insertion

We Have Options

Why Progress beyond NPA/OPA

This is on a continuum

•Can you mask ventilate?

–Does an NPA Help? Do they accept OPA?

•Athlete presentation

–Are they getting better or worse

•Do I need to move the patient?

•Where is the equipment?

•How comfortable are you with the skill?

Indications for Supraglottic Airways

•Irreversible respiratory arrest

–Narcotic OD, Hypoglycemia

•Cardiac Arrest

•Ventilation support with the absence of a gag reflex.

Attributes of the KLTD/KLTSD

• Easier to place and use.

▪ One port to inflate ▪ One tube to ventilate ▪ Does not require extensive skill

training

• Can be placed quickly.

• Limits Gastric Inflation and aspiration of vomit

• No interruption of CPR necessary.

• Little or no spinal movement necessary.

• Lower incidence of sore throat and trauma.

Sizes KLTD/KLTSD

• Comes in various sizes.

– #3: 4–5 feet

– #4: 5–6 feet

– #5: Greater than 6 feet

King

Comparison of Tube Sizes

Range: 45–60

ml

Range: 60–80

ml

Range: 70–90

ml

Attributes of the Combitube

• Easy to place and use.

▪ 2 port to inflate each cuff individually ▪ Two tube to ventilate

▪ Tube 1 if in Esophagus ▪ Tube 2 if in the Trachea

▪ Does not require extensive skill training

• Can be placed quickly.

• Limits Gastric Inflation and aspiration of vomit

• No interruption of CPR necessary.

• Little or no spinal movement necessary.

• Lower incidence of sore throat and trauma.

Combitube

Combitube Sizes

• Comes in various sizes.

– 37 fr: 4–6 feet

– 41 fr: Greater than 5 feet

Expected Placement

• Presence of gag reflex.

• Caustic ingestion.

• Obstructed airway.

• Esophageal trauma or disease.

• Cancer, Varices, expanding neck hematoma, obvious trauma

• Patient Size not within range

• Latex Allergies.

Contraindications

Same contraindications for both Supraglottic Airways

• Have all equipment ready prior to attempt.

• Test cuff inflation system for leaks.

• Apply a water-soluble lubricant to the posterior distal tip of the device.

• Hold airway device in dominant hand at proximal connector.

• Use a superior (to patient’s head) approach.

• Perform tongue-jaw lift while keeping head in a neutral position. ▪ Head can be slightly extended or placed

in the “sniffing” position if needed to facilitate placement.

Insertion Procedure

• With the device rotated

laterally 45-90 degrees such that the blue orientation line is touching the corner of the mouth, introduce tip into mouth and advance behind base of the tongue.

• As the tube passes under the tongue, rotate the tube back to midline (blue orientation line faces chin).

Insertion Procedure continued…

Insertion Procedure

• Without excessive force, advance tube until connector is aligned with teeth and/or gums.

It is important that that the King is advanced all the way.

Insertion Procedure

• Using a syringe, inflate the cuffs with the appropriate volume of air.

• Special (reusable) color-coded syringes can be utilized.

Insertion Procedure continued…

#3: 45–60 ml

#4: 60–80 ml

#5: 70–90 ml

• Attach BVM to 15 mm connector.

• While ventilating, simultaneously withdraw until ventilation is easy and free-flowing.

▪ There should be good tidal volume with minimal resistance.

Insertion Procedure

• Perform standard evaluation of lung sounds while ventilating through the inserted device.

• Attach and utilize end-tidal CO2 monitoring while the device is in place.

• Re-adjust cuff inflation as needed.

• Consider securing with tape or ET tube holder.

▪ Securing with tape or ET tube holder not required, but recommended.

▪ With cuffs inflated, device tends to fit snugly and securely.

SECURE YOUR TUBE, CHECK AFTER EVERY MOVEMENT

Insertion Procedure

Proper Position of the KLTD/KLTSD

Combitube

• Dual-lumen airway – Two tubes laminated together – Ventilation port for each airway

• Tracheal and esophageal tubes – Tracheal tube

• Has open distal end • If Combitube placed in trachea, acts as endotracheal tube

– Esophageal tube • Has closed distal end with fenestrations • If Combitube placed in esophagus, trachea ventilated

through fenestrations

• Insert the combitube so that it curves in the same direction as the natural curvature

• If resistance is met,

withdraw tube and attempt to reinsert

• Advance tube until patients teeth are between the two black lines

Insertion Procedure

• INFLATE the #1 blue pilot cuff with 100 ml of air from the large syringe (85ml for 37 fr)

• INFLATE the #2 white

pilot cuff with 15ml of air from the small syringe (12ml for 37 fr)

Insertion Procedure

• Begin Ventilation through the longer blue tube ( #1)

• Auscultation of lung sounds and gastric sounds

• If no gastric sounds with lung sounds and chest rise, Continue thru Blue Tube (#1)

Insertion Procedure

• IF: • Auscultation of breath

sounds is absent and gastric inflation is positive

• Begin ventilation through the shorter clear tube (#2)

• Assume Tracheal placement

Insertion Procedure

Insertion Procedure

• Do not ventilate the patient more than needed – May drop blood pressure

– especially if already in shock – Can cause worsening head injury and

promote herniation

• In cardiac arrest, ventilate more slowly

Questions?

•Reminder

–Airway management is a mechanical

skill that MUST be mastered by properly

trained prehospital care providers

–Airway management is a Perishable skill and must be maintained through regular training