Backup AirwaysBackup Airways

New HampshireNew Hampshire

Division of Fire Standards & Training andDivision of Fire Standards & Training andEmergency Medical ServicesEmergency Medical Services

Know Your Options!!!& Don’t hesitate to use them!

Purpose It is vital that the prehospital crew be

confident and comfortable with the rescue airways approved for their level of licensure.

During this module you will review and practice the back up airways for your level of licensure.

Purpose

Review Backup Airway Devices (Rescue Airways) BVM LMA King-LT-D Combitube Cricothyrotomy

The Basics

Position OPA BVM Suction

Most difficult airways will still be manageable using basic airway

maneuvers!

The Need for Oxygen

0 – 1 minute: cardiac irritability 0 – 4 minutes: brain damage not likely 4 – 6 minutes: brain damage possible 6 – 10 minutes: brain damage very likely > 10 minutes: irreversible brain damage

Oxygen and Carbon Dioxide Exchange

Oxygen-rich air is inhaled to alveoli

O2 exchanged at alveolocapillary level

Perfusion to capillary beds O2/CO2 exchange at

cellular level Perfusion from capillary

beds CO2 exhanged at

alveolocapillary level CO2 exhaled

Assessment of Respiration

Patients level of consciousness Respiration quality Pulse quality Respiratory rate Pulse rate SPO2 EtCO2 Blood pressure Glasgow coma score

Every TRUE life saving intervention performed by EMS reverses one or more failing components of respiration

BVM is the most essential intervention in RSI

Inadequate Breathing

Fast or slow rate Irregular rhythm Abnormal lung sounds Reduced tidal volume Use of accessory muscles Cool, pale, diaphoretic, cyanotic skin

Head Tilt-Chin Lift

One hand on the forehead Apply backward pressure

Tips of fingers under mandible Lift the chin

Jaw-Thrust Maneuver

Place fingers behind the angle of the jaw Use thumbs to open mouth

Look, Listen, and Feel

Assess that Airway!

Basic Airway Adjuncts

Oropharyngeals Keeps tongue from blocking oropharynx Eases suctioning Used with BVM Patients without gag reflex

Nasopharyngeals Maintains patency of oropharynx Patients with gag reflex Should not be used with head trauma

Oxygen

Nonrebreathing mask– Provides up to 90% oxygen– Used at 10 to 15 L/min

Nasal cannula– Provides 24% to 44% oxygen– Used at 1 to 6 L/min

Oxygen

Nasal cannula 24-40% at 1-6 liters

Non-rebreather mask Up to 90% at 15 liters

BVM 21% atmosphere Up to 100% at 15 liters with reservoir

Artificial Ventilation

Mouth to mask BVM – one person BVM – two person

Ventilation Rates

Adults: 8 - 10 breaths per minute Approximately one breath every 6 – 8 seconds

Pediatric: 12 – 20 breaths per minute Approximately one breath every 3 – 6 seconds

Bag Valve Mask

Delivers > 90% oxygen Requires practice and proficiency Use with airway adjuncts and/or advanced

airways

O2 ReservoirBag

Valve

Mask

BVM-Problems encountered

Inattentiveness Poor mask seal = poor ventilatory ability Varying ventilatory rates Varying expiration rates Varying tidal volumes Often excessive airway pressure Often hyper-ventilation

Mastering the BVM overcomes these obstacles!

BVM – One person

Insert an oral/nasal airway Seal mask by placing the apex over the bridge of

the nose and lower portion of the mask over the mouth and upper chin.

Make a “C” with your index finger and thumb around the mask.

Maintain the airway with your middle, ring and little finger, creating a “E”, under the jaw to maintain the chin lift.

Squeeze the bag with your other hand slowly at a rate of one breath every 6–8 seconds.

Monitoring SpO2

BVM – Two Person Insert oral/nasal airway First provider hold the bag portion of the BVM

with both hands. Second provider seals the mask with apex over

the bridge of the nose and base at the upper chin.

Using two hands the second provider places his/her thumbs over the top half of the mask; index and middle finger over bottom half; ring and little finger under jaw.

Second provider also maintains chin-lift First provider squeezes bag every 6–8 seconds Monitoring SpO2.

Adequate Ventilation

Equal chest rise and fall Appropriate rate Heart rate returns to normal

Inadequate Ventilation

Minimal or no chest rise Ventilating too fast or too slow Heart rate does not return to normal

Asthma and COPD

These patients complicate the traditional RSI approach due to the difficulty encountered when mask ventilating

Alveolar hyperinflation secondary to underlying pathophysiology must be considered and adequate passive ventilation time must be ensured

Tidal volumes should be reduced, initially, to reduce likelihood of barotrauma and air trapping

Gastric Distention

Air fills the stomach from too forceful or too frequent ventilations

Airway may be blocked and ventilations are re-routed to stomach

Decreases lung capacity May cause patient to vomit

Airway Obstructions

Tongue Vomit Blood, clots, traumatized tissue Swelling Foreign objects

Recognizing an Obstruction

Partial or complete? Can patient speak? Cough? If unconscious, deliver artificial ventilation Does air go in? Does the chest rise?

Removing an Obstruction

Heimlich maneuver Suction Magills (paramedics)

Suctioning

Turn on unit and ensure proper suctioning pressure (300 mmHg)

Select proper tip and measure Insert with suction off Suction on the way out Suction for no more than 15 seconds

Continuous Positive Airway Pressure (CPAP)

Is the patient a candidate for CPAP?

CPAP Indications

Any patient in respiratory distress associated with CHF with any of the below obvious signs and symptoms or a history of CHF: Bibasilar or diffuse rales Respiratory rate greater than 25 Pulse oximetry below 92% Retractions or accessory muscle use Abnormal capnography (rate, waveform, CO2 levels)

RSI Indication

Immediate severe airway compromise in the context of trauma, drug overdose, status epilepticus, etc. where respiratory arrest in imminent.

Always have a back-up plan.

Plans “A”, “B”, and “C” Know the answers before you begin

Plan “A”: (ALTERNATIVES) Different:

Size of blade Type of blade

Miller Macintosh Specialty

Position (patient & provider) Hockey stick bend in ETT or Directional tip ETT Remove the stylette as you pass through the cords “BURP” (aka “ELM”) Gum Elastic Bougie 2-person technique

“cowboy” or “skyhook” Have someone else try

Viewmax Scope

Easy of use Can be used like a Mac or Miller Should improve your view by one grade

“BURP” – a.k.a. “External Laryngeal Manipulation”

Backward, Upward, Rightward Pressure: manipulation of the trachea

90% of the time the best view will be obtained by pressing over the thyroid cartilage

Differs from the Sellick Differs from the Sellick ManeuverManeuver

Plan “B”: (BVM and BACK UP Airways)

Can you ventilate with a BVM?

(Consider two NPA’s and an OPA, +

Cricoid pressure w/ gentle ventilation)

KING–LT-D

Combitube

LMA

King-LT-D

King LT-D

Combitube

CombiTube

Insertion Technique

• Tongue-Jaw Lift• Anatomical

Insertion• Black rings will lie

between teeth or alveolar ridges

• Bending the tip prior to use may ease insertion

CombiTube• Inflate Blue

Balloon• Inflate White

Balloon• The

CombiTube may reposition as the oropharyngeal is inflated.

Esophageal Placement

• Ventilate Blue Tube

• Visualize• Auscultate• EtCO2

Tracheal Placement

• Ventilate Clear Tube

• Visualize• Auscultate• EtCO2

Laryngeal Mask AirLMA

LMA

The LMA was invented by Dr. Archie Brain at the London Hospital in Whitechapel in 1981

The LMA consists of two parts: The mask The tube

The LMA has proven to be a very effective management tool for the airway

Introduction continued

The LMA design: Provides an “oval seal around

the laryngeal inlet” once the

LMA is inserted and the cuff

inflated.

Once inserted, it lies at the

crossroads of the digestive

and respiratory tracts.

Indications

Situations involving a difficult mask (BVM) fit.

May be used as a back-up device where endotracheal

intubation is not successful.

May be used as a “second-last-ditch” airway where a

surgical airway is the only remaining option.

Contraindications

Greater than 14 to 16 weeks pregnant

Patients with multiple or massive injury

Massive thoracic injury

Massive maxillofacial trauma

Patients at risk of aspiration

NOTE: Not all contraindications are absolute

Complications

Throat soreness

Dryness of the throat and/or mucosa

Complications due to improper placement vary based on

the nature of the placement

Equipment for LMA Insertion

Body Substance Isolation equipment Appropriate size LMA Syringe with appropriate volume for LMA cuff

inflation Water soluble lubricant Ventilation equipment Stethoscope Tape or other device(s) to secure LMA

Preparation

Step 1: Size selection

Step 2: Examination of the LMA

Step 3: Check deflation and inflation of

the cuff

Step 4: Lubrication of the LMA

Step 5: Position the Airway

Step 1: Size Selection

Verify that the size of the LMA is correct for the patient

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/poor seal with size 4

Step 2: Examine the LMA

Visually inspect the LMA cuff for tears or other

abnormalities Inspect the tube to ensure that it is free of blockage

or loose particles Deflate the cuff to ensure that it will maintain a

vacuum Inflate the cuff to ensure that it does not leak

Step 3: Deflation & Inflation Slowly deflate the cuff to form a smooth flat

wedge shape which will pass easily around the back of the tongue and behind the epiglottis.

During inflation the maximum air in cuff should not exceed: Size 1: 4 ml Size 1.5: 7 ml Size 2: 10 ml Size 2.5: 14 ml Size 3: 20 ml Size 4: 30 ml Size 5: 40 ml

Step 4: Lubrication

Use a water soluble lubricant to lubricate the LMA Only lubricate the LMA just prior to insertion Lubricate the back of the mask thoroughly Important Notice: Avoid excessive amounts of lubricant

on the anterior surface of the cuff or in the bowl of the mask.

Inhalation of the lubricant following placement may result in coughing or obstruction.

Step 5: Positioning of the Airway Extend the head and flex the

neck

Avoid LMA fold over: Assistant pulls the lower

jaw downwards. Visualize the posterior oral

airway. Ensure that the LMA is not

folding over in the oral cavity as it is inserted.

LMALMAInsertionInsertionTechniqueTechnique

Step 1

Step 5

Step 4

Step 2

Step 3

LMA Insertion Step 1

Grasp the LMA by the

tube, holding it like a pen

as near as possible to the

mask end

Place the tip of the LMA

against the inner surface

of the patient’s upper

teeth

LMA Insertion Step 2

Under direct vision: Press the mask tip upwards

against the hard palate to flatten it out.

Using the index finger, keep pressing upwards as you advance the mask into the pharynx to ensure the tip remains flattened and avoids the tongue.

LMA Insertion Step 3

Keep the neck flexed and head extended:

Press the mask into the posterior pharyngeal wall using the index finger.

LMA Insertion Step 4

Continue pushing with your index finger.

Guide the mask downward into position.

LMA Insertion Step 5

Grasp the tube firmly with the other hand

Then withdraw your index finger from the pharynx.

Press gently downward with your other hand to ensure the mask is fully inserted.

LMA Insertion Step 6

Inflate the mask with the

recommended volume of air. Do not over-inflate the LMA. Do not touch the LMA tube while it

is being inflated unless the position

is obviously unstable. Normally the mask should be

allowed to rise up slightly out of the

hypopharynx as it is inflated to find

its correct position.

Verify Placement of the LMA

Connect the LMA to a Bag-Valve Mask device or

low pressure ventilator

Ventilate the patient while confirming equal

breath sounds over both lungs in all fields and the

absence of ventilatory sounds over the

epigastrium

Securing the LMA

Insert a bite-block or roll of gauze to prevent

occlusion of the tube should the patient bite down.

Now the LMA can be secured utilizing the same

techniques as those employed in the securing of

an endotracheal tube.

Verify

During ventilation observe end-tidal CO2 monitor or

pulseoximetry to confirm oxygenation

Waveform Capnometry

Prerequisite Requirement

Becoming a standard of care

Easy to Use Good measure of

Pulmonary Perfusion

Relates well to PaCO2

Does have limitations

Problems with LMA Insertion

Failure to press the

deflated mask up against

the hard palate or

inadequate lubrication or

deflation can cause the

mask tip to fold back on

itself.

Problems with LMA Insertion

Once the mask tip has

started to fold over, this

may progress, pushing the

epiglottis into its down-

folded position causing

mechanical obstruction

Problems with LMA Insertion

If the mask tip is deflated forward

it can push down the epiglottis

causing obstruction

If the mask is inadequately

deflated it may either push down the epiglottis

penetrate the glottis

Plan C: Cricothyrotomy

Last resort!

Equipment Endotracheal or tracheostomy tube (or commercial device)

Scalpel

Curved hemostats

Suction apparatus

Oxygen Supply

BVM

Securing device

Bandaging materials

Procedure

Have all supplies (including suction) available and ready.

A commercially available device may be desirable.

Commercial Cricothyrotomy Kits

Must perform to recommendation of manufacturer and Medical Director’s satisfaction for proficiency.

                                                                                                       

Find the persons Adam's apple (thyroid cartilage)

Move your fingers about one inch down the neck until you find another bulge.

This is the cricoid cartilage. The indentation between the two is the cricothyroid membrane, where the incision will be made.

Procedure

Locate the cricothyroid membrane utilizing correct anatomical landmarks. Thyroid Cartilage

Cricothyroid Membrane

Cricoid Cartilage

Thyroid Gland

Tracheal Rings

Procedure

Prep the area with an antiseptic swap (e.g. Betadine).

Procedure

Using your non-dominant hand, stabilize the thyroid cartilage and secure the cricothyroid membrane.

Procedure

Make a 1-inch vertical incision through the skin and subcutaneous tissue using a scalpel.

Procedure

Using blunt dissection technique, expose the cricothyroid membrane.

This is a bloody procedure.

Procedure

Some protocols recommend stabilizing the cricothyroid membrane with a skin or trach hook.

Procedure

Make a horizontal, transverse incision approximately ½ inch long through the membrane.

Procedure

Using a dilator, hemostat, or gloved finger to maintain surgical opening, insert the cuffed tube into the trachea.

Cric tube from the kit of a 6.0 ETT is usually sufficient.

Procedure Using a dilator,

hemostat, or gloved finger to maintain surgical opening, insert the cuffed tube into the trachea.

Cric tube from the kit of a 6.0 ETT is usually sufficient.

Procedure

Inflate the cuff with 5-10cc of air and ventilate the patient while manually stabilizing the tube.

Procedure

All of the standard assessment techniques for ensuring tube placement should be performed (auscultation, chest rise and fall, end-tidal CO2 detector, etc..

Secure the tube.

Complications

Incorrect tube placement/ false passage

Thyroid gland damage

Severe bleeding

Subcutaneous emphysema

Laryngeal nerve damage

Always expect the unexpected!

RSI Procedure: The Seven P’s

1. Preparation2. Preoxygenate the patient3. Premedicate the patient4. Paralyze the patient5. Pass the tube6. Proof of placement7. Post intubation care