Advanced Airway Management

Airway Management: Airway management is the most important skill for the Pre-hospital/Hospital Clinician. ABC’S Timely, effective, and decisive management of the airway can literally make the difference between life and death or between ability and disability. Its important for crew to have the skill, confidence, knowledge, and equipment to effectively manage the airway. TRAINING IS KEY!!

ANATOMY WE GOT TO KNOW THIS:

WHAT MAKES UP THE UPPER AIRWAY? Nose-cartilaginous, bony structure in the midline of face that warms and humidifies inspired air. Mouth-begins at the lips and ends with the oropharynx. Contains the tongue which is attached to the mandible and teeth. Pharynx- U-shaped tube that begins at the base of the skull and extends to lower border of cricoid cartilage near the esophagus. Nasopharynx Oropharynx Hypopharnyx

WHAT MAKES UP THE LOWER AIRWAY Trachea- beginning at the inferior border to the cricoid ring and ending at the carina. Lungs- when the trachea divides into the right and left mainstem bronchi, these bronchi lead into the right and left lobes of the lung. Right has 3 lobes and Left has 2 lobes. This is the site of gas exchange.

PUTTING IT ALL TOGETHER

What’s in my mouth?

WHY IS KNOWING ANATOMY SO IMPORTANT?

Why? Because… You can not manage what you do not understand! Airway management is not just being able to identify who needs additional airway assistance but knowing the landmarks and anatomical aspects of an airway so the assistance can be given. Burns, Edema, Blood, Vomit, Foreign Bodies in the Airway will distort view so knowing what things should look like and where they should be is very beneficial. Ex. IV in the A/C

Patient and Airway Assessment Now since we know what an airway looks like lets assess.

Breathing Process Unfortunately we all realize there are many factors that prevent many people from breathing properly.. COPD Asthma Cystic fibrosis Asbestosis Mesotheolioma Pneumonia Trauma, Head Injury Drug Overdose Foreign Body Obstruction Airway edema Congenital Abnormality

Patient Assessment But… Just because a patient has one or more of these issues does not mean the patient has an acute problem needing intervention. We first must assess the patient and see if advanced intervention is necessary or if less invasive but helpful application will work.

Patient Assessment Who needs an Airway? Pt with diminished level of consciousness with loss or airway control. Absent or diminished gag reflex??? How about ability to swallow secretions! Glasgow Coma Scale of 8 or less (Pt Hx Dependent) Potential for aspiration Respiratory Failure (hypoxemia, hypercarbia) Cardiac arrest, after adequate CPR or bag mask ventilations have been provided.

Airway Assessment

Airway Assessment There are many ways we can assess an airway and some techniques have been proven very successful such as the Visual Inspection, Auscultation, Lemon Law, Mallampati Classification, and 3-3-2 Rule.

Airway Assessment Lemon Law L – Look externally E – Evaluate the 3-3-2 rule M – Mallampati O – Obstruction N – Neck Mobility

Look Externally Evaluate patients general apperance: LOC Skin Color Skin Temperature Skin texture Patient Posture Tripod Position

Look Externally Visibly is the patient having difficulty breathing? Goldilocks Logic is it Slow, Fast, Just Right Normal Ranges RR Adult/Child (6-12 years) = 12-20 bpm RR Child 1-5 years = 20-30 bpm RR Infant 6-12 months = 24-30 bpm RR Infant Newborn to 6 months = 30-60 bpm

Airway Assessment: Look Externally

Airway Assessment: Look Externally

Airway Assessment: Look Externally Look for things that could make intubating or ventilating a patient difficult. Beards False Teeth Secretions Obesity Trauma to Facial area

Airway Assessment: 3-3-2 Rule The mouth should be at least three patient fingers wide or 5 cm when open. Less than 3 fingers indicates a possible difficult airway. The space from the tip of chin to hyoid bone should be three fingers wide. Smaller mandibles have less room for displacement of tongue and epiglottis. The distance from the hyoid bone to the thyroid notch should be at least two fingers wide.

Airway Assessment: Mallampati/Cormack and Lehane

Airway Assessment: Obstruction Obstruction is anything that might interfere with visualization or tracheal tube placement. Foreign Body Hematoma Masses

Airway Assessment: Obstruction

Airway Assessment: Obstruction

That Airway Makes Me Nervous

Airway Assessment: Neck Mobility Ideally we want our patients in a sniffing position for better visualization with the adult head slightly elevated and extended. This may be impossible with the Elderly and Trauma patients Does patient have a c-collar in place? Does patient have osteoporosis or arthritis?

Airway Assessment Our Goal: Our assessments will ultimately determine whether a patient has a open and patent airway and wither a patients breathing is sufficient on its own or if it needs some form of intervention to assist.

Airway Management Lets say our assessment has been performed and we determine that intervention is necessary? Basic Management Advanced Management

Basic Airway Management Although intubation is considered the GOLD STANDARD for airway management, basic airway skills are the starting point in the initial patient assessment and treatment and what we fall back on in times of difficulty.

Basic Airway Management Basic skills may be as simple as positioning the non-trauma victim in the recovery position or using the head tilt-chin lift or jaw thrust maneuver to maintain airway patency. Other basic skills may use other adjuncts such as the OPA and NPA.

Basic Airway Management

So….. What is an Advanced Airway

Advanced Airway Management Advanced Airway Management is Definitive Airway Management. The placement of a ET tube or tracheostomy tube in the trachea is definitive airway management because it facilitates adequate oxygenation and ventilation of the patient.

Types of Advanced Airway Equipment and Procedures Combitube (double lumen airway) LMA (supraglottic airway) King LT (supraglottic airway) Endotracheal Tube Needle Cricothyrotomy Surgical Cricothyrotomy Pertrach (Emergency Cric) Rapid Sequence Intubation

Rapid Sequence Intubation Originally developed in 1946 to facilitate airway management in ob patients requiring intubation for c-section with full stomach By definition involves the co-administration of both anesthetic agents and neuromuscular blocking agents to produce a state of unconsciousness and paralysis to allow tracheal intubation.

Rapid Sequence Intubation Indications Actual/impending respiratory failure Actual/impending inability to protect the airway Combative secondary to presumed head injury Hypoxemia despite supplemental oxygen and medications

Rapid Sequence Intubation Contraindications Anticipated difficult intubation Anticipated difficult BVM Crash Airway Situation Cardiac Arrest These Patients should have no muscle tone

Rapid Sequence Intubation Steps to RSI Preparation Pre-oxygenate Pre-medicate Paralyze Intubate and Confirm Maintain paralysis and sedation

Rapid Sequence Intubation Preparation When preparing for RSI procedure we should gather all medications used in procedure, get them drawn up, labeled, and ready for administration. Gather all necessary equipment and make sure it is in working order. We should also prepare for worst case scenario which means having different sized laryngoscope blades and ET tubes available. We also need our back up airways very close by and ready for use if necessary.

Rapid Sequence Intubation Preparation

Rapid Sequence Intubation Preparation

Rapid Sequence Intubation Pre-oxygenate Oxygen 21% and Nitrogen 78% 100% Oxygen delivered for at least 3 minutes in an attempt to achieve NITROGEN WASHOUT. We do this in hopes to increase the amount of oxygen and develop a reserve in order to help patient desaturate less quickly while intubation attempt is being made.

Rapid Sequence Intubation Pre-medicate The first medications given should help the patient’s adverse physiologic responses to the subsequent medications and laryngoscopy. All pre-medications require at least 3 minutes to work before laryngoscopy.

Rapid Sequence Intubation Pre-medicate Anesthetize the airway reflexes that lead to elevate ICP. Dose: 1-1.5 mg/kg Peak : 3 mins Duration: 20 mins Adverse: Hypotension, Allergy, Seizures, Bradydysrhythmias

Rapid Sequence Intubation Induction Used to render the patient unconscious and unresponsive: Isn’t that what you would want? Have a Rapid Onset/Short duration Induce unconsciousness and unresponsiveness Provide amnesia Typically have minimal hemodynamic and adverse effects

Rapid Sequence Intubation Induction Dose: 0.2-.04 mg/kg Peak: 30 seconds Duration: 10 minutes Adverse: Adrenal Suppression – reduces the glands ability to secrete stress hormones,

Rapid Sequence Intubation Induction Benzodiazepine Dose: 0.2-0.4 mg/kg but be careful with hypotensive patients Peak: 3 mins Duration:Varies

Rapid Sequence Intubation Defasciculating Agent Non-Depolarizing 1/10 th of paralyzing dose Used to help prevent fasciculations caused by succinylcholine

Rapid Sequence Intubation Paralytics Non-competitive Depolarizing Agent Neuromuscular Blocking Agent Dose: 1-2 mg/kg Peak: 45 seconds Duration: 8 minutes Adverse: Hyperkalemia, Neuromuscular Diseases, Burns greater than 24-48 hrs old, Malignant Hyperthermia, increased intraocular pressure, Rhabdomyolysis

Long term Paralytic Non-Depolaring Neuromuscular Blocking Agent Regular Dose: 0.1-0.3 mg/kg Peak: 90 seconds Duration: 30-90 minutes depending on dose Adverse: Minimal

Pass the Tube Now once you have sedated and paralyzed the patient, you are ready to pass the tube. Don’t forget to wait until patient is full paralyzed… we do not want to cause patient to vomit and aspirate

Rapid Sequence Intubation Intubate and Confirm Once patient is paralyzed and intubation has taken place it’s very important to confirm your ET tube is in the correct position. Objective ways to confirm: Pulse Oximetry ETCO2 EDD Chest X-Ray Subjective ways to confirm: Direct visualization Tube misting Breath sounds

Pertrach If your at this point… it’s not a good day Tater!! Indicated for a can’t intubate/can’t ventilate situation.

Pertrach Contraindication: Complications: Inability to identify landmarks for procedure. Complications: Hemorrhage Subcutaneous Emphysema Infection Accidental removal Tracheal and esophageal laceration

Pertrach Most important step is to identify need for Pertrach device. Equally as important is making sure you find the correct landmark for procedure.

Pertrach If you can not find landmarks… you have no business attempting to perform the procedure.

Pertrach If appropriate to continue Open kit and assemble equipment Position patient as appropriate and find landmarks Cleanse site of insertion

Pertrach

We got the Airway.. I think? Remember before we celebrate we first have to confirm that our intervention is in the right place and working. Also note with sudden movements or transferring of patient, airway should always be reassessed for patency. Airways can be gained and Airways can be lost.

Failed Airway

Advancements in Equipment

Ranger Glide Scope Used during difficult intubation so better visualization is needed.

Gum Elastic Bougie Of great use when patient has a anterior larynx that cannot be visualized despite optimal positioning and external manipulation.

ETCO2 Monitoring The New Standard

Conclusion: Airway management is a very important skill for all clinicians to have. Assess, Reassess, and Reassess again! TRAIN! Because your next airway may be difficult.