Respiratory Emergencies Case 1 Respiratory Emergencies © 2001 American Heart Association No notes for this case. 1

Case Presentation Patient = 69-year-old man, smoker (4 packs/day) PMHx = severe COPD CC = severe shortness of breath; “hungry for air!” VS = not obtained; patient suddenly becomes unresponsive

Learning and Skills Objectives Describe ACLS Approach (Primary and Secondary ABCD Surveys) in CPR Describe and demonstrate the “airway hierarchy”: Supplemental oxygen: Nasal cannulae Face masks Noninvasive airway devices: Nasopharyngeal airway Oropharyngeal airway

Learning and Skills Objectives The airway hierarchy (cont’d) Recommended invasive airway devices: Laryngeal mask airway (LMA) Esophageal-tracheal (Combitube) tube Tracheal tube Primary/secondary confirmation of tracheal tube placement: Physical exam criteria End-tidal CO2 detection Devices to detect esophageal placement Devices to prevent TT dislodgment

Primary ABCD Survey Focus: Basic CPR and Defibrillation Check responsiveness Activate emergency response system Call for defibrillator A = Airway: open the airway B = Breathing: check breathing, provide positive-pressure ventilations C = Circulation: check circulation, give chest compressions D = Defibrillation: assess for and shock VF/pulseless VT

Secondary ABCD Survey A = Airway: insert advanced airway device as soon as able (new: 3 types) B = Breathing: confirm placement by PE (primary tube confirmation) PLUS B = Breathing: confirm placement with esophageal detector device or end-tidal CO2 detector or both (secondary tube confirmation) B = Breathing: use a commercial tube holder to prevent dislodgment B = Breathing: confirm effective oxygenation/ventilation by 02 sat, CO2 levels, pH

Anatomy of Airway

Airway Obstruction Most common cause: tongue and/or epiglottis

Opening the Airway Jaw thrust Head tilt–chin lift

The Oropharyngeal Airway

Malposition of Oropharyngeal Airway Too short

Nasopharyngeal Airway Insertion technique

Oral airway: inserts in patient Barrier Devices Oral airway: inserts in patient

Pocket-Mask Devices 1-way valve Port to attach O2 source

Mouth-to-Mask Ventilation Advantages Eliminates direct contact Enables positive-pressure ventilation Oxygenates well if O2 attached Easier to perform than bag-mask ventilation Best for small-handed rescuers 1-rescuer technique; performed from side Rescuer slides over for chest compressions Fingers: head tilt–chin lift

Mouth-to-Mask Ventilation Fingers: jaw thrust upward Fingers: head tilt–chin lift

Bag-Mask Ventilation Key—ventilation volume: “enough to produce obvious chest rise” 1-Person: difficult, less effective 2-Person: easier, more effective

Cricoid Pressure Thyroid Cartilage Cricoid

Bag-Mask Ventilation Advantages Provides immediate ventilation and oxygenation Operator gets sense of compliance and airway resistance May provide excellent short-term support of ventilation High oxygen concentrations are possible Can be used to assist spontaneous respirations Potential complications Hypoventilation Gastric inflation

Airway Adjunct Devices Nasal cannula 24%-44% O2 concentration Face mask with O2 reservoir, 60%-100% O2 concentration

Types of Portable Suction Courtesy of Laerdal Medical Corporation, Armonk, NY

Equipment for Intubation Laryngoscope with several blades Tracheal tubes Malleable stylet 10-mL syringe Magill forceps Water-soluble lubricant Suction unit, catheters, and tubing

Curved Blade Attaches to Laryngoscope Handle

Curved Blade Attached to Laryngoscope Handle

Curved Blade Laryngoscope Inserted Against Epiglottis

Straight-Blade Laryngoscope

Straight-Blade Laryngoscope Inserted Past Epiglottis

Cricothyroid Membrane With Horizontal Cricothyrotomy Incision

Aligning Axes of Upper Airway Mouth A A B B C C Pharynx Trachea Extend-the-head-on-neck (“look up”): aligns axis A relative to B Flex-the-neck-on-shoulders (“look down”): aligns axis B relative to C

Visualization of Vocal Cords Anatomy Tongue Vallecula Epiglottis Vocal cord Glottic opening Arytenoid cartilage

Tracheal Intubation Advantages Protects airway from aspiration of foreign material Facilitates ventilation and oxygenation Facilitates suctioning of trachea and bronchi Provides route for drug administration Prevents gastric inflation if used with cuff Allows faster chest compressions

Tracheal Intubation Indications Inability to ventilate the unconscious patient After insertion of pharyngeal airway Inability of patient to protect own airway (coma, areflexia, or cardiac arrest) Need for prolonged mechanical ventilation

Tracheal Intubation Recommendations Intubate as soon as possible after ventilation and oxygenation in cardiac arrest Intubation should be done by most experienced person Do not take longer than 30 seconds per attempt Auscultate the thorax and epigastrium after intubation

Tracheal Intubation Complications Trauma—teeth, lips, tongue, mucosa, vocal cords, trachea Esophageal intubation Vomiting and aspiration Hypertension and arrhythmias

Esophageal-Tracheal Combitube A = esophageal obturator; ventilation into trachea through side openings = B C = tracheal tube; ventilation through open end if proximal end inserted in trachea D = pharyngeal cuff; inflated through catheter = E F = esophageal cuff; inflated through catheter = G H = teeth marker; blindly insert Combitube until marker is at level of teeth E Distal End A C H Proximal End B D F G

Esophageal-Tracheal Combitube Inserted in Esophagus F A = esophageal obturator; ventilation into trachea through side openings = B D = pharyngeal cuff (inflated) F = inflated esophageal/tracheal cuff H = teeth markers; insert until marker lines at level of teeth

Laryngeal Mask Airway (LMA) The LMA is an adjunctive airway that consists of a tube with a cuffed mask-like projection at distal end.

LMA Introduced Through Mouth Into Pharynx

Once the LMA is in position, a clear, secure airway is present. LMA in Position Once the LMA is in position, a clear, secure airway is present.

Anatomic Detail

Esophageal Detector Device (Bulb-Type)

Confirmation: Tracheal Tube Placement End-tidal colorimetric CO2 indicators

Tracheal Tube Holders: Adult and Infant 1 4 2 3

Qualitative End-Tidal CO2 Detector What should the operator’s next action be? 1