C191 w3tc cmast advanced airway techniques

Advanced Airway TechniquesAdvanced Airway Techniques

COMBAT MEDIC ADVANCED SKILLS TRAINING (CMAST)

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IntroductionIntroduction

One of the most critical skills for the soldier One of the most critical skills for the soldier medic.medic.

Without proper airway management and Without proper airway management and ventilation techniques, casualties may die.ventilation techniques, casualties may die.

Must be able to choose and effectively Must be able to choose and effectively utilize the proper equipment for ventilation utilize the proper equipment for ventilation in a tactical environment.in a tactical environment.

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Review the PhysiologyReview the Physiology Inhalation (an active process):Inhalation (an active process):

– Initiated by contracting of respiratory system musclesInitiated by contracting of respiratory system muscles– Diaphragm contracts and drops downwardDiaphragm contracts and drops downward– Intercostal muscles contract, chest expands Intercostal muscles contract, chest expands – Intrathoracic pressure falls, pulling air into lungsIntrathoracic pressure falls, pulling air into lungs

Exhalation (a passive process):Exhalation (a passive process):– Respiratory muscles relax; diaphragm moves upwardRespiratory muscles relax; diaphragm moves upward– Chest wall recoilsChest wall recoils– Intrathoracic pressure risesIntrathoracic pressure rises– Air is pushed outAir is pushed out

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Gas ExchangeGas Exchange Alveoli supply OAlveoli supply O² to, and remove CO² from ² to, and remove CO² from

the lungs.the lungs. Exchange is made by diffusion across the Exchange is made by diffusion across the

cell wall of the alveoli and capillaries.cell wall of the alveoli and capillaries.

InhalationInhalation ExhalationExhalation

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Sources of Airway ObstructionSources of Airway Obstruction Tongue:Tongue:

– Most common cause of airway obstructionMost common cause of airway obstruction Foreign body airway obstruction (FBAO).Foreign body airway obstruction (FBAO). Trauma/Combat:Trauma/Combat:

– Loose teeth, facial bone fractures, fractured larynxLoose teeth, facial bone fractures, fractured larynx Laryngeal spasm:Laryngeal spasm:

– Edema can severely obstruct airflowEdema can severely obstruct airflow Aspiration.Aspiration.

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Nasopharyngeal AirwayNasopharyngeal Airway Insert a nasopharyngeal airway (NPA) adjunct.Insert a nasopharyngeal airway (NPA) adjunct.

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Nasal Airway AdjunctNasal Airway Adjunct Do not use if roof of mouth is fractured or Do not use if roof of mouth is fractured or

brain matter is exposed.brain matter is exposed.

Purpose:Purpose:– To maintain an artificial airway for oxygen To maintain an artificial airway for oxygen

therapy or airway managementtherapy or airway management

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Nasal Airway AdjunctNasal Airway Adjunct Indications:Indications:

– Conscious, semi-conscious or has an active Conscious, semi-conscious or has an active gag reflexgag reflex

– Injuries to mouthInjuries to mouth– Seizure casualtiesSeizure casualties– Likely vomitingLikely vomiting

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Nasal Airway AdjunctNasal Airway Adjunct Contraindications:Contraindications:

– Injuries to roof of mouth Injuries to roof of mouth – Exposed brain matterExposed brain matter– Drainage of CSF from nose, mouth or earsDrainage of CSF from nose, mouth or ears

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Nasal Airway AdjunctNasal Airway Adjunct Complications:Complications:

– Nasal traumaNasal trauma– Bloody nose, minor tissue trauma (most Bloody nose, minor tissue trauma (most

common)common)– May trigger gag reflex if NPA is too longMay trigger gag reflex if NPA is too long

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Nasopharyngeal InsertionNasopharyngeal Insertion Procedures:Procedures:

– Supine position on firm surface – C-spine Supine position on firm surface – C-spine stabilizedstabilized

– Select proper size NPASelect proper size NPA• Diameter – smaller than the casualty’s Diameter – smaller than the casualty’s

nostril; approximately diameter of nostril; approximately diameter of casualty’s little finger casualty’s little finger

• Length - Measure from tip of nose to Length - Measure from tip of nose to earlobeearlobe

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– Lubricate the NPA with a water soluble Lubricate the NPA with a water soluble lubricantlubricant

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– Place head into a neutral position; extend Place head into a neutral position; extend nostril nostril

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– Insert tip of the NPA through the R nostril; if Insert tip of the NPA through the R nostril; if resistance is met, resistance is met, do not force, try do not force, try

the other nostrilthe other nostril

– Place casualty Place casualty In recovery In recovery

positionposition

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CombitubeCombitube Esophageal-tracheal double Esophageal-tracheal double

lumen airway.lumen airway. Blind insertion. Blind insertion. Successful in casualties with:Successful in casualties with:

– TraumaTrauma– Upper airway bleeding and Upper airway bleeding and

vomitingvomiting Effective in cardiopulmonary Effective in cardiopulmonary

resuscitation.resuscitation.

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CombitubeCombitube Double-lumen design allows for effective Double-lumen design allows for effective

ventilations regardless if in the trachea or ventilations regardless if in the trachea or esophagus.esophagus.

Comes in two sizes:Comes in two sizes:– 37 Fr37 Fr– 41 Fr41 Fr

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CombitubeCombitube Indications:Indications:

– Adult casualties in respiratory distressAdult casualties in respiratory distress– Adult casualties in cardiac arrestAdult casualties in cardiac arrest

Contraindications:Contraindications:– Intact gag reflexIntact gag reflex– Casualties less than 5 feet in heightCasualties less than 5 feet in height– Known esophageal diseaseKnown esophageal disease– Caustic substance ingestionCaustic substance ingestion

CMASTCMAST 1818

CombitubeCombitube Side effects and complications:Side effects and complications:

– Sore throatSore throat– DysphagiaDysphagia– Upper airway hematomaUpper airway hematoma

Esophageal rupture (rare).Esophageal rupture (rare). Preventable by avoiding over-inflation of Preventable by avoiding over-inflation of

the distal and proximal cuffs. the distal and proximal cuffs.

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CombitubeCombitube Intubation procedures:Intubation procedures:

– Inspect the upper airway for visible Inspect the upper airway for visible obstructionsobstructions

– Hyperventilate (> 20/min) for 30 secondsHyperventilate (> 20/min) for 30 seconds– Casualty in neutral Casualty in neutral

head position head position– Test both cuffs:Test both cuffs:

• 15 ml (white)15 ml (white)• 100 ml (blue)100 ml (blue)

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– Insert in same direction as the natural curvature of Insert in same direction as the natural curvature of the pharynxthe pharynx• Grasp tongue and lower jaw between thumb Grasp tongue and lower jaw between thumb

and index finger, lift upward (jaw-lift)and index finger, lift upward (jaw-lift)• Insert gently but firmly until black rings are Insert gently but firmly until black rings are

positioned between casualty’s teethpositioned between casualty’s teeth• Do not force – if does not insert easily, withdraw Do not force – if does not insert easily, withdraw

and retryand retry• Hyperventilate between attemptsHyperventilate between attempts

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– Inflate #1 (blue) pilot balloon with Inflate #1 (blue) pilot balloon with 100 ml100 ml of air of air (100 ml syringe)(100 ml syringe)

– Inflate #2 (white) pilot balloon with Inflate #2 (white) pilot balloon with 15 ml15 ml of air of air (20 ml syringe) (20 ml syringe)

– Ventilate through the Ventilate through the primary #1 blue tube; if primary #1 blue tube; if auscultation of breath sounds auscultation of breath sounds is positive (gastric sounds is is positive (gastric sounds is negative), continue to ventilate negative), continue to ventilate

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– If auscultation of breath sounds is negative If auscultation of breath sounds is negative and gastric sounds is positive, immediately and gastric sounds is positive, immediately begin ventilations through the shorter (white) begin ventilations through the shorter (white) connecting tube (#2)connecting tube (#2)

– Confirm tracheal ventilation Confirm tracheal ventilation of breath sounds and absence of breath sounds and absence of gastric insufflation of gastric insufflation

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– If auscultation of breath sounds and auscultation of If auscultation of breath sounds and auscultation of gastric insufflation is negative, the Combitubegastric insufflation is negative, the Combitube may may have been advanced too far into the pharynxhave been advanced too far into the pharynx

– Deflate the #1 balloon/cuff, and move the CombitubeDeflate the #1 balloon/cuff, and move the Combitube approx. 2-3 cm. out of the casualty’s mouthapprox. 2-3 cm. out of the casualty’s mouth

– Re-inflate the #1 balloon and ventilate through the Re-inflate the #1 balloon and ventilate through the longer (#1) connecting tube; if auscultation of breath longer (#1) connecting tube; if auscultation of breath sounds is positive and auscultation of gastric sounds is positive and auscultation of gastric insufflation is negative – continue to ventilate.insufflation is negative – continue to ventilate.

– If breath sounds are still absent – extubate If breath sounds are still absent – extubate

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CombitubeCombitube Combitube removal.Combitube removal. Should not be removed unless:Should not be removed unless:

– Tube placement cannot be determinedTube placement cannot be determined– Casualty no longer tolerates the tubeCasualty no longer tolerates the tube– Casualty vomits past either distal or Casualty vomits past either distal or

pharyngeal tubepharyngeal tube– Palpable pulse and casualty breathing on Palpable pulse and casualty breathing on

their owntheir own– Physician or PA is present to emplace ETTPhysician or PA is present to emplace ETT

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CombitubeCombitube Combitube removal.Combitube removal.

– Have suction available and readyHave suction available and ready– Logroll casualty to side (unless spinal-injured)Logroll casualty to side (unless spinal-injured)– Deflate the pharyngeal cuff (#1 pilot balloon)Deflate the pharyngeal cuff (#1 pilot balloon)– Deflate the distal cuff (#2 pilot balloon)Deflate the distal cuff (#2 pilot balloon)– Gently remove CombitubeGently remove Combitube while suctioning while suctioning

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Emergency CricothyrotomyEmergency Cricothyrotomy

Indications:Indications:– Inability to ventilate a casualty with NPA or Inability to ventilate a casualty with NPA or

Combitube secondary to:Combitube secondary to:• Severe maxillofacial injury, airway Severe maxillofacial injury, airway

obstruction and structural deformities obstruction and structural deformities • Emergency airway catheters with a 6 mm Emergency airway catheters with a 6 mm

diameter allow for spontaneous breathing diameter allow for spontaneous breathing and adequate oxygenation in adultsand adequate oxygenation in adults

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Emergency CricothyrotomyEmergency Cricothyrotomy When maxillofacial, cervical spine, head or When maxillofacial, cervical spine, head or

soft tissue injuries are present, several soft tissue injuries are present, several factors may prevent ventilation:factors may prevent ventilation:– Gross distortionGross distortion– Airway obstructionAirway obstruction– Massive emesisMassive emesis– Significant hemorrhageSignificant hemorrhage

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Emergency CricothyrotomyEmergency Cricothyrotomy Complications:Complications:– Incorrect tube placementIncorrect tube placement– Blood aspirationBlood aspiration– Esophageal lacerationEsophageal laceration– HematomaHematoma– Tracheal wall perforationTracheal wall perforation– Vocal cord paralysis, hoarsenessVocal cord paralysis, hoarseness

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LarynxLarynx

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Cricothyroid MembraneCricothyroid Membrane

Cricoid Cartilage

CricothyroidMembrane

ThyroidCartilage

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Procedure:Procedure:– Identify and palpate Identify and palpate

the cricothyroid the cricothyroid membranemembrane

– Make a 1 ½-inch Make a 1 ½-inch vertical incision in the vertical incision in the midline using a #15 midline using a #15 or #10 scalpel bladeor #10 scalpel blade

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Procedure:Procedure:– Stabilize the larynx with Stabilize the larynx with

one hand; using a one hand; using a scalpel or hemostat, cut scalpel or hemostat, cut or poke through the or poke through the cricothyroid membranecricothyroid membrane

– A rush of air may be felt A rush of air may be felt through the openingthrough the opening

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Insert the end of the ET tube Insert the end of the ET tube into the trachea directed into the trachea directed towards the lungs and inflate towards the lungs and inflate the cuff with 5-10 ml of airthe cuff with 5-10 ml of air

Advance the tube no more Advance the tube no more than 2-3 inches; further than 2-3 inches; further intubation could result in intubation could result in right main stem broncus right main stem broncus inubation onlyinubation only

CMASTCMAST 3535


Check for air exchange and tube Check for air exchange and tube placement:placement:

– Listen and feel for air passing in and out of Listen and feel for air passing in and out of tubetube

– Look for bilateral rise and fall of the chestLook for bilateral rise and fall of the chest– Ascultate the abdomen and both lung fields Ascultate the abdomen and both lung fields

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Emergency CricothyrotomyEmergency Cricothyrotomy Indications of proper placement:Indications of proper placement:

– Unilateral breath sounds and rise and fall Unilateral breath sounds and rise and fall of the chest (right main stem intubation); of the chest (right main stem intubation); deflate cuff and retract 1-2 inches and deflate cuff and retract 1-2 inches and recheck airwayrecheck airway

– Air coming out of the casualty’s mouth Air coming out of the casualty’s mouth (tube pointing away from lungs); remove (tube pointing away from lungs); remove tube and reinsert with tube facing lungs tube and reinsert with tube facing lungs

CMASTCMAST 3737

Emergency CricothyrotomyEmergency Cricothyrotomy If casualty is not breathing spontaneously If casualty is not breathing spontaneously

direct someone to perform rescue direct someone to perform rescue breathing:breathing:– Connect tube to BVM and ventilate at 20 Connect tube to BVM and ventilate at 20

breaths per minutebreaths per minute– No BVM available, perform mouth-to-tube No BVM available, perform mouth-to-tube

resuscitation at 20 breaths per minute resuscitation at 20 breaths per minute – Tube must be secured once rescue Tube must be secured once rescue

breathing has startedbreathing has started

CMASTCMAST 3838

Emergency CricothyrotomyEmergency Cricothyrotomy Apply dressing to protect the tube and Apply dressing to protect the tube and

incision site:incision site:– Cut two 4x4 gauze sponges halfway Cut two 4x4 gauze sponges halfway

through and place on opposite sides of through and place on opposite sides of tube; tape securelytube; tape securely

– Or apply two 4x4 gauze dressing in a “V” Or apply two 4x4 gauze dressing in a “V” shape fold at the edges of the cannula and shape fold at the edges of the cannula and tape securely tape securely

CMASTCMAST 3939

Emergency CricothyrotomyEmergency Cricothyrotomy Monitor casualty’s respirations on a Monitor casualty’s respirations on a

regular basis.regular basis.– Reassess air exchange and tube placement Reassess air exchange and tube placement

every time the casualty is movedevery time the casualty is moved– Assist with respirations if rate falls below 10 Assist with respirations if rate falls below 10

or above 24 per minuteor above 24 per minute

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SummarySummary Airway compromise is a small Airway compromise is a small

percentage of combat casualties.percentage of combat casualties. Airway management must be readily Airway management must be readily

available and rapidly applied.available and rapidly applied. Airway compromise is the third leading Airway compromise is the third leading

cause of preventable death on the cause of preventable death on the battlefield.battlefield.

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Questions?Questions?

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C191 w3tc cmast advanced airway techniques