Anything new in Airway Management? Dr Adrian Burger Emergency Medicine Senior Registrar UCT/US

So what do we do? A,B,C’s…… A is for clearing, opening and or securing the airway Clearing - turn on side - suction - no more blind finger sweeps!

Opening Jaw thrust Head Tilt Chin lift Combined Remember : C-spine stabilization

Opening or securing the Airway BMV OPA/NPA LMA Combitube® ETT

Mask Most basic piece of “airway” kit Different types - clear, black - cushion around edge Won’t maintain airway by self Needs head tilt/chin lift or jaw thrust Also needs Positive Pressure Ventilation

Mask

Positive Pressure Ventilation Rescuer’s breathing efforts and one-way valve Bag Mask Ventilation (BMV)

Mask with one-way valve

Oropharyngeal Airway/Guedel Different colours = different sizes Neonate to large adult SIZECOLOUR 000Violet OOBlue OBlack 1White 2Green 3Orange 4Red 5Yellow

Oropharyngeal Airways

Oropharyngeal Airway/Guedel Features: - single use - rounded edges - bite block - colour coding - airway path in centre

Oropharyngeal Airway/Guedel How to size it???? The size of the Guedel airway is the distance between the center of the incisors and the angle of the jaw (on the same side!)

Oropharyngeal Airway/Guedel How to put it in: Depress tongue Slip over spatula with curve caudal direction Place bite block between teeth NO TWISTING MOVEMENT

Oropharyngeal Airway/Guedel Indications: To open and maintain an airway in a patient with a depressed level of consciousness With FMO2 or BMV

Oropharyngeal Airway/Guedel Contra indications: Patient won’t accept it LOC Risk of vomiting & aspiration

Nasopharyngeal Airway For maintaining airway in “more awake” patients Sits in nasopharynx and opens airway Does NOT protect against aspiration

Nasopharyngeal Airway

How to size it? Estimate by comparing to patients little finger How to insert it? Lubricate Gently push posteriorly towards ear on same side Fix with a safety pin

Nasopharyngeal Airway Contra-indications: Base of skull fracture Serious midline facial fractures When definitive airway needed

LMA Advanced airway Useful alternative for “difficult intubation” Easy to use Sits on larynx - Protects lungs?

LMA

Have a range in unit Re-use ?20 times Part of kit Formula for Children: The combined widths of the patient's index, middle and ring fingers SIZEPATIENT 1<5 kg kg kg kg kg kg kg 6>100kg

LMA in Emergency Medicine Indications: Unconscious or anaesthetized patients AHA Guidelines for adults: BLS: alternative to BMV ACLS: Optional/alternative to BMV, failed ETT Aspiration? Paediatrics?

LMA in Emergency Medicine Aspiration? Less than with BMV Supraglottic device Aspirated from CPR or post LMA? Cricoid pressure during CPR

LMA Use in Emergency Paediatrics Little Data “Despite widespread use LMA, there is little data on its effectiveness during positive pressure ventilation in infants and young children “ Obstruction The LMA appears more likely to cause partial airway obstruction in infants ( < 10kg) than in older children. PALS®: Class Indeterminate Neonates: “Can’t intubate can’t ventilate”

LMA in Emergency Medicine Benefits: Ineffective BMV with failed ETT AHA: Alternative to ETT or BMV in CPR Blind ETT, by passing ETT through LMA Drugs - 27% efficacy

LMA in Emergency Medicine Disadvantages: Needs adequate training Risk of aspiration Limited Paediatric use Not always successful

LMA Insertion

Combitube®

Advantages: Protect airway from aspiration Easy to use AHA: alternative to ETT for CPR Disadvantages: Trauma to soft tissues Not available here in SA

Combitube® Head neutral or slightly flexed Hold tongue and jaw between thumb & forefinger and lift Gently insert Combitube® in a curved back and downward movement until black markers aligned with teeth Inflate (proximal) pharyngeal balloon Inflate (distal) tracheal balloon Confirm which one of #1 or #2 tube is in lungs by using bag ventilator

Combitube® Insertion

ETT

Equipment for ETT Mask and bag ventilator with O2 ETT - checked, lubricated, tape ready Laryngoscope Drugs: Induction agent & muscle relaxant McGills forceps, Bougie Primary detection tools Other advanced airways Surgical airway capability

ETT Advantages: Airway patent and protected Secretions suction O2 Medication Known tidal volume

ETT Disadvantages: Training Skill lost Interrupted CPR

Why ETT? For above benefits Inability to BMV or ineffective BMV Secure threatened airway Certain thoracic injuries

Anatomy

endotracheal tubes cuffed tubes uncuffed tubes

placement of ETT length of tube at the larynx (cm) = internal diameter of correct ETT for size

railroad techniques for changing tubes getting the curves right

Tube Placement Confirmation Clinical - visual - auscultation - laryngoscopy Detection devices - CO2 (2a) - EDD

Detection Devices Always clinical + device No single device specific or sensitive CO2 detector: 33%-100% sensitive : 97%-100% specific : only studied on ETT EDD: bulb compressed or syringe pulled : High sensitivity : Poor specificity CXR

Secure the ETT Record depth at front teeth Evidence is commercial=tape Re-evaluate 3 Rules - verify placement - asynchronous CPR - avoid excessive ventilation

BMV Best for last! Easy to master First line in CPR Every unit has one Effective

BMV

OLD: ETT ventilation adjunct of choice for CPR ETT complications - misplaced - displaced - interrupted CPR AHA: BMV or advanced airway for CPR Prehospital: BMV=LMA & Combitube®

Failed Intubation Can’t intubate, Can Ventilate Don’t panic, call for help Reassess need to intubate Reposition patient, airway Cricoid pressure Bougie Consider other advanced airways Call for help

Failed Intubation Can’t intubate, Can’t Ventilate Call for help, don’t panic Reassess airway, positioning Reassess equipment Two person ventilation Other advanced airway Surgical airway CALL FOR HELP

Remember Check your equipment before you need it Be prepared Don’t panic

Parting shot “Patients do not die from lack of intubation they die from lack of oxygenation”

References Currents, winter JAMA, Feb 9, 2000-Vol 283, No6 p Elective/airway/anatomywww.healthsystem.virginia.edu/Internet/Anesthesiology- Elective/airway/anatomy