Case Evaluation

• How do you think you did?

• What do you think you did well?

• What would you have done differently?

• How do you think your colleagues did?

Diagnosis?

• Status Asthmaticus with respiratory failure

• Spontaneous iatrogenic pneumothorax developing of a tension pneumothorax

General Assessment of the Dyspneic Patient

• Ability to speak• Mental status• Position – Lying back, upright and forward or

slumped back• Cyanosis – Central or acrocyanosis• Pulmonary exam – Inspection, percussion

auscultation• Cardiovascular• Extremities

Advanced Airway Management Techniques

• Definitive – Oral awake– Nasotracheal– RSI

• Rescue– LMA– Combitube– Cricothyrotomy– Others

Factors Predictive of a Difficult Airway

• Mallampati class

• Neck mobility

• Jaw size

• Laryngeal trauma

• Tongue size

• Prominent incisors

• Combativeness

Mallampati Classes

• I – The tonsillar pillars, fauces, soft pallet and uvula are visualized

• II – The fauces, soft pallet and uvula are visualized

• III – The soft pallet and the base of the uvula are visualized

• IV – Only the hard pallet is visualized

Risks Associated with Intubation

• Inability to intubate

• Aspiration

• Misplacement of the tube

• C-spine injury

• Increased ICP

• Hemodynamic changes

Orotracheal Intubation Technique

• Chose appropriate sized tube & blade• Check equipment• Sniffing position if no C-spine injury• Identify Cricoid cartilage for BURP maneuver• Laryngoscope in left hand, open mouth with right hand• Advance blade on dorsal surface of tongue to ID

epiglottis and position blade• Pass tube through cords to 2 cm beyond cuff• Remove stylet, inflate cuff, confirm tracheal placement• Secure Tube (22-24 cm at teeth)

Six Ps of RSIProcess Timing

Preparation Early

Preoxygenation - 5 Min

Pretreatment - 3 Min

Paralysis (with induction, cricoid pressure)

- 1 Min

Placement of tube 0

Postintubation Management

+…..

Contraindications to RSI

• Clinical and/or anatomical considerations that predict difficulty intubating the patient

Nasotracheal Intubation Technique

• Select and Prep both tube and nares• Place tube bevel flat against nasal septum• Gentle consistent pressure• When in the nasopharynx, position ear at end of

tube, advance tube to loudest point• As patient inspires, advance tube 2-3 cm• Assess tube position and reposition if needed• If in trachea, inflate cuff, confirm placement, and

secure tube

Contraindications to Nasotracheal Intubation

• Absolute – Apnea

• Relative – Midface/basilar skull fracture– Coagulation defects– Potential altered airway anatomy– Impaired airway reflexes– Closed head injury– Myocardial ischemia

Nonpulmonary Causes of Dyspnea

• Is it true dyspnea?– Thoracic pain– Hyperventilation

• CHF

• ACS/MI

• Decreased oxygen-carrying capacity

• Acid-base disorders

Pulmonary Causes of Dyspnea

• Asthma

• Pneumonia

• COPD– Emphysema– Chronic Bronchitis

• Pulmonary Embolus

• Pneumothorax

Asthma

• Etiology – Bronchospasm, increased mucous production and inflammation

• Hx – Prior episodes, precipitating factors• PE – Tachypnea, tachycardia, wheezing,

prolonged expiratory phase• Tests – Spirometry, pulse ox (?CXR, ABG)• Rx – Oxygen, Inhaled bronchodilators, Steroids,

rehydration, SC epinephrine, magnesium, active airway control in nonresponders

Pneumothorax

How do you treat a pneumothorax?

• Chest tube

• Pleuricath

• Needle aspiration

• When do you need to drain the air?

What is the major complication you have to be aware of?

• Tension pneumothorax– When would this occur?

Time to Practice Chest Tubes