AIRWAY MANAGEMENT DAN MUSE, MD

INFORMATION FOR THIS TOPIC WAS LARGELY OBTAINED FROM AIRWAYCAM.COM

OXYGENATION/ VENTILATION Provides oxygen to the cells in the body including the brain. Hypoxia or lack of oxygen results in the death of cells in the body including the brain. Profound hypoxia or anoxia can result in brain death in less than 10 minutes

OXYGENATION/ VENTILATION The exchange of oxygen and CO2 (carbon dioxide) Occurs at the alveoli in the lungs Lack of ventilation results in increase of CO2 in the body and hypercarbia (elevated carbon dioxide in the blood) Hypercarbia causes acidosis and sedation. VENTILATION IS A BETTER MEASURE OF HOW THE PATIENT IS BREATHING.

OXYGENATION/ VENTILATION VENTILATION IS A BETTER MEASURE OF HOW THE PATIENT IS BREATHING.

OXYGENATION/ VENTILATION RESPIRATORY DRIVE Breathing normally occurs because CO2 increases in the body. When the brain receptors recognize the increased CO2, it causes the body to exhale A secondary mechanism is driven by hypoxia

OXYGENATION/ VENTILATION “CO2 RETAINERS” In CO2 retainers, the normal mechanism has “burned out” These people need to be hypoxic in order to have the drive to breath. If they receive to much oxygen, the body will think it’s fine and not breath resulting in poor ventilation CO2 builds up and……..

OXYGENATION/ VENTILATION PULSE OXYMETRY Measures the percentage of the bodies hemoglobin that is saturated with oxygen. There is no substantial difference in hemoglobin saturation from 90% and above Saturations below 90% substantially increase the degree of hypoxia

OXYGENATION/ VENTILATION

OXYGENATION/ VENTILATION END TIDAL CO2 Measures the level of carbon dioxide that is exhaled. A tachypnic patient should have a low CO2. CO2 will increase as the patient tires and indicates poor ventilation.

OXYGENATION/ VENTILATION END TIDAL CO2 End tidal CO2 confirms tube placement since the lungs exchange CO2 and the esophagus does not. VERY LOW OR LACK OF CO2 IN THE INTUBATED PATIENT INDICATES AN ESOPHAGEAL INTUBATION. Normal values: 35-45

OXYGEN DELIVERY NASAL CANULA Low flow delivery directly into the nose No longer necessary for chest pain when the patient has no respiratory issues

OXYGEN DELIVERY NON REBREATHER VENTURI MASK Provides high flow 100% oxygen Used in respiratory distress Has fenestrations so that the CO2 is disbursed VENTURI MASK Provides a set percentage of oxygen. Amount is adjusted by changing the valve

OXYGEN DELIVERY CPAP Continuous Positive Airway Pressure. Mask creates a positive pressure gradient and keeps the lungs open. Reduces the work of inhaling. Allows for rest of the intercostal muscles.

BAG VALVE MASK

MASK VENTILATION 2 PERSON TECHNIQUE BAG VALVE MASK MASK VENTILATION 2 PERSON TECHNIQUE Used to assist in breathing when the patient cannot breath adequately on their own. Can result in gastric distention, emesis and aspiration. Provides adequate oxygenation and ventilation is a code.

MASK VENTILATION 2 PERSON TECHNIQUE BAG VALVE MASK MASK VENTILATION 2 PERSON TECHNIQUE Proper positioning – ear-to-sternal notch alignment, unless contraindicated by cervical spine immobilization. Jaw thrust – lift up on mandible and submandibular tissues. Fully insert oral and/or nasal airways. Press mask down on the face and make a tight seal.

MASK VENTILATION 2 PERSON TECHNIQUE BAG VALVE MASK MASK VENTILATION 2 PERSON TECHNIQUE Small, slow, easy squeeze of bag: 6-7 cc/kg, over 1- 2 seconds, using low pressure. Rate should not exceed 12 breaths per minute in adults. Over-ventilation, high volume, and high pressure increase regurgitation.

OXYGEN DELIVERY

AIRWAY ANATOMY

ANATOMY OF THE AIRWAY

ANATOMY OF THE AIRWAY Epiglottis is the “beacon” to the vocal cords. It is at the base of the tongue, connected to the tongue and at the midline of the airway.

Note the location of the esophagus behind the trachea ANATOMY OF THE AIRWAY Note the location of the esophagus behind the trachea

ANATOMY OF THE AIRWAY FIRST ROW SECOND ROW THIRD ROW Uvula Tonsils Epiglottis SECOND ROW Moving beyond the epiglottis to the glottic opening THIRD ROW Vocal cords. Open, closed and open again

ANATOMY OF THE AIRWAY

INTUBATION

INTUBATION INDICATION CPR Respiratory distress Altered mental status with hypoventilation / airway protection Facial trauma Angioedema of the airway Airway infection i.e. Epiglottis

INTUBATION PRE-OXYGENATION Pre-oxygenation helps prevent hypoxia during the intubation. BVM 15 LPM Non-rebreather face mask 15 LPM Nasal cannula 15 LPM in addition to the face mask

USE NASAL CANNULA 15 LPM IN CONJUNCTION WITH THE BVM AT 15 LPM INTUBATION PRE-OXYGENATION USE NASAL CANNULA 15 LPM IN CONJUNCTION WITH THE BVM AT 15 LPM Leave the nasal cannula on during intubation Nasal cannula will expel co2 build up in the nasopharynx It will also maintain 02 saturations during the intubation

INTUBATION FIRST PASS SUCCESS Goal is to intubate on first pass Studies indicate that complications increase with increasing attempts.

STANDING ORDER Re: Airway management Airway assessment must include vital signs, oxygen saturation measurements and physical exam. The appropriate airway modalities will be based on the vitals, exam, respiratory status and the patient’s mental status. When available, capnography will be utilized in cases of respiratory distress and advanced airway management. In the case of intubations, one attempt will be made at an endotracheal intubation. If unsuccessful, a supraglottic tube should be inserted or the patient should be ventilated with a BVM. Exceptions to this rule would be cases where there is epiglottic or glottic edema and there is an obvious need to insert a tube beyond the level of the swelling.

INTUBATION EPIGLOTTIS Epiglottis is the “beacon” leading to the glottis and trachea It is midline in the posterior pharynx and attached to the base of the tongue.

INTUBATION FIRST PASS TECHNIQUE Initial blade insertion is with the laryngoscope handle pointed at the patient’s feet. The tongue and jaw are distracted downward to insert the blade. Minimal force is required for downward jaw distraction, assuming the head is not overextended. AIRWAYCAM.COM

INTUBATION FIRST PASS TECHNIQUE The tip of the blade gets around base of tongue, permitting change in angle of lifting and better mechanical advantage. Epiglottis edge is lifted off the pharyngeal wall. The epiglottis is often camouflaged against the mucosa of the posterior pharynx. AIRWAYCAM.COM

INTUBATION FIRST PASS TECHNIQUE With full insertion of the curved blade into the vallecula the angle of lifting changes to ~40 degrees from the horizontal. Once the tip is fully in the vallecula, the lifting force can be increased as needed. TIP POSITION (NOT FORCE) IS THE MAIN DETERMINANT OF GLOTTIC EXPOSURE AIRWAYCAM.COM

INTUBATION PROGRESSION OF LANDMARKS IN INTUBATION (1) Tongue and Uvula (2) Epiglottis (3) Posterior Cartilages (4) Glottic Opening (5) Vocal Cords

INTUBATION

INTUBATION

INTUBATION

EPIGLOTTIS CAMOUFLAGE INTUBATION EPIGLOTTIS CAMOUFLAGE In the supine position, poor muscle tone and sedation can cause the epiglottis to flop back and rest against the posterior pharyngeal wall It is easy in this position to go past the epiglottis and overshoot the glottis

EPIGLOTTIS CAMOUFLAGE INTUBATION EPIGLOTTIS CAMOUFLAGE Maintain the head at the ear-sternal notch position. Extending the head at the base of the skull will only cause the epiglottis to push further against the posterior pharynx Lifting the head can better expose the epiglottis

BIMANUAL LARYNGOSCOPY INTUBATION BIMANUAL LARYNGOSCOPY Allows for the curved blade to slip completely into the vallecula. When only partially inserted, the epiglottis cannot be adequately lifted.

BIMANUAL LARYNGOSCOPY INTUBATION BIMANUAL LARYNGOSCOPY Using the right hand and pushing down on the thyroid cartilage will allow for the curved blade to slip fully into the vallecula This will cause the epiglottis to “pop up” and expose the vocal cords.

INTUBATION

LMA, COMBITUBE, KING TUBE SUPRAGLOTTIC AIRWAY LMA, COMBITUBE, KING TUBE Provides a reliable rescue airway by sealing off the supraglottic area. Application takes less than 20 seconds.

SUPRAGLOTTIC AIRWAY

SUPRAGLOTTIC AIRWAY LMA 1) Wedge-shaped inflatable mask fits over larynx, creating seal within upper airway. Patient must have absent gag reflex. 2) Tip of wedge fits into upper esophagus and bowl of mask covers laryngeal inlet. 3) Numerous sizes from pediatric to adult; typical adult female requires #4 LMA, typical adult male #5 LMA.

SUPRAGLOTTIC AIRWAY LMA 4) Recommended insertion technique (LMA Unique, Classic): With mask deflated, lubricate undersurface, using fingers at base of bowl, push mask down throat, up against palate, and backward to posterior hypopharynx, until bowl is around curvature of tongue. 5) Best seal pressure is with under-inflation of mask; recommended volume is 30 cc for #4 , and 40 cc for #5--many users start with half this volume and listen over the neck for a cuff leak. If cuff leak, try smaller mask volume or larger LMA. 6) Cricoid pressure prevents optimal placement and pushes tip out of upper esophagus

SUPRAGLOTTIC AIRWAY COMBITUBE Combitube has two balloons with fenestrated ports between them. The proximal balloon is supraglottic and in the pharynx The distal balloon will enter either the trachea or esophagus 95% of the time, the tube goes into the esophagus and ventilation is via the fenestrated ports.

SUPRAGLOTTIC AIRWAY COMBITUBE In most cases ventilation is through the blue connector which connects to the fenestrated ports. Tube placement must always be confirmed with a CO2 detector

SUPRAGLOTTIC AIRWAY COMBITUBE

SUPRAGLOTTIC AIRWAY COMBITUBE

SUPRAGLOTTIC AIRWAY KING TUBE Supraglottic tube that has only one ventilation port. Inflation fills up both the supraglottic and esophageal balloons. It is possible, but unlikely for the esophageal tip to go into the trachea. Always check placement both clinically and with end tidal Co2

NEEDLE CRICOTHYROTOMY

NEEDLE CRICOTHYROTOMY

COMPLICATIONS NEEDLE CRICOTHYROTOMY 1. Asphyxia 2. Aspiration 3. Cellulitis 4. Esophageal perforation 5. Exsanguinating hematoma 6. Hematoma 7. Posterior tracheal wall perforation 8. Subcutaneous and/or mediastinal emphysema 9. Thyroid perforation 10. Inadequate ventilations leading to hypoxia and death

CCR OEMS PROTOCOL

PURPOSE To improve survival for out of hospital cardiac arrests. (OHCA).

CONTRAINDICATIONS DNR/Dni Clinically dead Under the age of 18.

COMPRESSIONS First provider assesses and initiates compressions. Compressions are 2.5 – 3 inches deep. Rate is 100-120/minute. They are done in 2 minute intervals without stopping. IT IS ABOUT THE COMPRESSIONS.

COMPRESSIONS Never interrupt the compressions in the 2 minute cycle. After a two minute cycle, change the person performing the compressions.

Standard CPR (with breaths) vs. CC alone Blood pressure Time = chest compression Berg et al, 2001

Standard CPR (with breaths) vs. CC alone Blood pressure Time = chest compression Berg et al, 2001

ALS PROCEDURES IV’s, medications and oxygen is instituted by the second EMT. Pads for AED or defibrillator are placed WITHOUT interfering with the CARDIAC COMPRESSIONS.

ANALYSIS After 200 compressions or 2 minutes, analysis of pulse and assess for “shock” is done. This should not go longer then 10 SECONDS. If an AED is used, compressions should continue during charging of machine After 10 second analysis (even if defibrillated), 200 compressions resume. Assess for pulse after the 200 compressions.

OXYGEN DELIVERY Initial oxygen delivery is 100 % non rebreather or BVM 100 % non rebreather provides passive ventilation with out gastric insufflations BVM will cause gastric insufflation……leads to vomiting.

OXYGEN DELIVERY No advanced airway is attempted until after 4 cycles of compressions; 8 minutes. THERE CAN BE ABSOLUTELY NO INTERRUPTION OF THE COMPRESSIONS. ETT is acceptable but cannot interrupt the compressions THINK SUPRAGLOTTIC TUBE.

OXYGEN DELIVERY HYPERVENTILATION KILLS! Hyperventilation results in alkalosis and vasoconstriction. This reduces the blood flow to the brain

OXYGEN DELIVERY Rate of oxygen delivery is 8 to 12 breaths per minute.

VENTILATION Use of nasal capnography can help assess the CPR performance and return to spontaneous circulation (ROSC)