Advanced Airway Management University of Colorado Medical School Rural Track 2013

Advanced Airway Management Basic Airway Management Airway Suctioning Oxygen Delivery Methods Laryngeal Mask Airway ET Intubation Oropharyngeal Airway Nasopharyngeal Airway Cricothyrotomy

Basic Airway Management For patients unable to protect their own airway Jaw thrust/head tilt technique This technique itself can open the airway If concern for c-spine injury, use jaw thrust without head tilt Excessive head tilt can occlude trachea in infants, consider padding under shoulders Jaw thrust without head tilt. The jaw is lifted without tilting the head. This is the airway maneuver of choice for a victim suspected of having sustained a cervical spine injury.

Basic Airway Management

Basic Airway Management Padding under shoulders for infant

Airway Suctioning Obstruction of airway by secretions, blood, vomitus can lead to aspiration Rigid catheters (Yankeur), soft catheters (Y suction) Complications include airway trauma, coughing or gagging, delay in ventilation, vagal stimulation  bradycardia, hypotension

Airway Suctioning Yankeur Rigid Catheter Y Suction Catheter

Oropharyngeal Suctioning- Procedure Adults Preoxygenate Check connection to tubing Occlude side port to test for adequate suction Insert catheter into oropharynx under direct visualization Neonates Insert y-suction catheter into nasopharynx Occlude sideport while withdrawing catheter Repeat for oropharynx

Oxygen Delivery Methods Nasal Cannula: flow rate 1-6 LPM (FiO2 24-40%) Simple face mask: flow rate 5-10 LPM (FiO2 40-60%) Non-rebreather mask: flow rate 10-15 LPM (FiO2 60-90%) BiPAP/CPAP Nasal cannula: flow rate 1-6 LPM, 24-44 percent oxygen concentration, (one source says 25-45%) victims with difficulty breathing, sometimes used for victims unable to tolerate a mask. Available in adult and pediatric sizes. Resuscitation mask: flow rate 6 -15 LPM, 35-55 percent oxygen concentration, victims with difficulty breathing and non-breathing victims
Non-rebreather mask: flow rate 10-15 LPM, up to 90 percent oxygen concentration, (one source says 60 to 95%) breathing victims only
BVM: flow rate 15 LPM or more, 90+ percent oxygen concentration, victims with difficulty breathing and non-breathing victims

Oxygen Delivery Methods Bag Valve Mask- flow rate >15 LPM (FiO22 >90%)

Laryngeal Mask Airway Supraglottic airway Doesn’t require laryngeal visualization Can precipitate vomiting or aspiration Size Weight guide Population 1 <5 kg Infant 2 10-20 kg Small Child 3 30-50 kg Small Adult 4 50-70 kg Average Adult 5 70-100 kg Large Adult

Laryngeal Mask Airway Prepare LMA: ensure patent cuff, apply water-based lubricant Place patient in sniffing position Insert tip of LMA into mouth Advance into laryngopharynx until resistance is met Ensure black line on tubing in line with upper lip Inflate cuff Confirm tube misting, auscultation, EtCO2 Consider placement of bite block

Other Airways King Tube Combitube

Endotracheal Intubation Placing orotracheal tube under direct vision through larynx into trachea Protects airway, enables ventillation Complications of laryngoscopy direct trauma to mucous membranes, teeth, larynx bradycardia from vagal stimulation Raised intracranial pressure

Endotracheal Intubation Complications of Intubation Prolonged apnea  hypoxia Esophageal or right mainstem bronchus intubation Inadequate tube size  excessive leak, high pressures Aspiration Complications of Ventilation Barotrauma  pneumothorax Hypoventilation  hypoxia, hypercarbia Hyperventilation  hypocarbia, cerebral hypoxia Reduction in preload  hypotension

Endotracheal Intubation Preparation Pre-oxygenation Ensure IV access and patency, cardiac monitoring Assess for predictors of technical difficulty (LEMON) Look (obesity, pregnancy, airway, facial, neck trauma) Evaluate 3-3-2 rule (small mouth, receding jaw, short neck) Manual inline stabilization/Mallampati score Obstruction (airway burn, protruding teeth, foreign body) Neck mobility

Endotracheal Intubation Preparation of equipment Suction Oxygen BVM device Airway adjuncts: OP airways, LMA Laryngoscope with appropriate blade, check light source ETT: right size Bougie Monitoring and EtCO2

Endotracheal Intubation Tools: Laryngoscope Macintosh blade- curved blade, rests on epiglottic vallecula Miller blade- straight blade, lifts epiglottis directly Blade Size Patient Miller Infant 1 Small child Macintosh 2 Large child 3 Small adult 4 Large adult

Endotracheal Intubation Tools: ET tube Age Uncuffed ETT (mm) Cuffed ETT (mm) Depth at lips (cm) Newborn 3.0-3.5 3.0 9-10 1-5 mths 3.5 10 6-11 mths 3.5-4 11 1 yr 4.0-4.5 4.0 12 2-3 yrs 4.5-5.0 12-13 4-5 yrs 5.0-5.5 13-15 6-9 yrs 5.5-6.0 15 10-12 yrs 6.5-7.0 6.0-6.5 17 13+ 7.0-7.5 19

Endotracheal Intubation Place head in sniffing position (MILS if c-spine injury) Open mouth, inspect oral cavity Remove dentures or debris Place laryngoscope with left hand into the right side of patient’s mouth, sweeping tongue to left Lift mandible without levering on teeth until direct visualization of the larynx

Endotracheal Intubation

Endotracheal Intubation Introduce bougie through cords Advance ET tube over bougie until cuff passes through cords ETT length at lips for women 20-21, men 22-24 Remove bougie Connect BVM, commence ventilation Inflate cuff Confirm placement EtCO2 capnography, attach detector proximal to filter Auscultation in axillae and over stomach

Glidescope

Post-intubation management Secure ETT with a cloth tie Manually ventilate for EtCO2 35-40 mmHg Post-intubation sedation as needed Continue comprehensive monitoring and ETCO2

Oropharyngeal Airway Prevents the tongue from occluding the airway, bite block Should reach from the mouth to the angle of the jaw Insertion (Adults) Ensure concavity facing roof of the mouth Insert 1/3, rotate 180 degrees over the tongue Advance until flange against lips Insertion (Pediatrics) Concavity follows the curve of the tongue to avoid hard and soft palate trauma

Oropharyngeal Airway Size Color Suggested Population 000 Clear Neonate (under 6 wks) 00 Blue Infant (1-6 months) Black Older infants/toddlers 1 White Small child (3-10 years) 2 Green Adolescent/adult female 3 Yellow Adult male 4 Red Large adult male

Nasopharyngeal Airway Useful in patients with airway obstruction, especially if oropharyngeal airway is inappropriate Correct size reaches from tip of patient’s nose to ear lobe Sizes 6,7 & 8 mm Lubricate end of tube with lubricating jelly Insert into nostril (usually right) with bevel facing nasal septum Advance device along floor of nasopharynx, following curvature until flange rests against the nostril

Nasopharyngeal Airway

Cases

References Queensland EMS Clinical Practice Procedures: https://ambulance.qld.gov.au/medical/pdf/02_cpp_airway. pdf http://www.thoracic.org/clinical/copd-guidelines/for- health-professionals/exacerbation/inpatient-oxygen- therapy/oxygen-delivery-methods.php