#3 Intro to EM Airway Management- Assessment and SupraGlottic Airways (SGA) Andrew Brainard 1

#3 SupraGlottic Airway Learning Objectives: – Briefly describe plan, assign roles Declare “Crash Airway” Skip checklist Continue Chest Compressions Place SupraGlottic Airway – Proper sized LMA/AirQ – Proper insertion (<30sec) – Troubleshoot cuff leak – Tube confirmation Discuss – Crash vs Emergent vs Semi-elective – Advantages/Disadvantages of SGAs – Indications for SGA, RSI, ETT Safe removal of SGA – Formal Airway Assessment – MOANS/LEMON/RODS – Specific briefing for Plan A, B, C, & D – Suction – Leave Cuff Up – Remove under direct visualization Bell in Short Stay: – 60y/o M, chest compressions in progress on patient admitted with chest pain – On floor unresponsive – GCS 3, No pulse, CPR in progress, – Unobtainable SaO2 – Difficulty with BVM seal (beard, small jaw, no neck, emesis, high resistance) Crash SGA during compressions – Insert SGA – Oxygenate and Ventilate through SGA – Get ROSC – Transfer to resus – Intubate through SGA – Discuss removing SGA Formal Airway Assessment – MOANS – LEMON – RODS – SHORT

Using SuperGlottic Airways (SGA) Air Q Fastrack I-LMA Indications Predicting difficult (RODS) Sizing Insertion Procedure Troubleshooting Intubating through an SGA 3

Indication(s) – Rescue Airway – Rescue Oxygenation – Anywhere on the Algorithm – Replacing Inadequate BVM – During CPR/compressions – For Pre-Oxygenation before Laryngoscopy (Rapid Sequence Airway) – After unsuccessful Laryngoscopy – Before/during cric 4 SGA/LMA

Intubating LMA (Fastrack) #3- Small Adults 30-50kgs #4- Most Adults50-70 kgs #5- Large Adults kgs AirQ #1.0- Infant <7 kgs #1.5- Toddler 7-17 kgs #2.0- Child kgs #2.5- Small Adult30-50kgs #3.5- Most Adults50-70 kgs #4.5- Large Adult kgs Ideal Body Weight (height) 5

Predictors of Difficult SGA RODS – R: restricted mouth – O: obstruction – D: disrupted or distorted airway – S: stiff lungs or c-spine 6

AirQ Insertion – Lubricate – Leave red tag on pilot balloon – Lift tongue Finger/Laryngoscope/Tongue depressor – Can use finger to assist around the corner – Jaw lift – Position incisors between 2 insertion marks Add ~5 cc’s of air. Minimizing Leaks – Neutral head position – Use jaw lift – Don’t over-inflate – Check position While inflated, pull back 1-3cm – Change size – Check ETCO2 waveform How to use a AirQ 0a1KYwfDk0http:// 0a1KYwfDk0 (9 minutes) 7

Supraglottic Airway (SGA) Prepare/position airway Lubricate and deflate cuff Pull the jaw and tongue forward – Finger – Laryngoscope – Tongue depressor Insert the LMA – Press against hard palate – Advance until resistance Inflate the cuff – Poor seal may indicate over inflation. Ventilate the patient with PEEP Confirm placement – ETCO2 – Chest Rise – Listen for Leak 8

Troubleshooting SGAs Get best possible seal – Over-inflation is frequently the cause of leaks – Usually Too deep – Test airway pressures – Watch ETCO2 trace Chandy maneuver, – Rotate Sagittal Coronal – Lifting Toward ceiling 9

Intubating through the LMA Place LMA Ventilate – Relax Insert ETT Reattach BVM to ETT – Ventilate w/ETCO2 Size ETT/I-LMA – Lubricate tube – Test ETT fit Confirm placement – Ventilate w/ ETCO2 – Confirm tube placement – Inflate ETT cuff Advance ETT – Applying upward pressure on the LMA – Ventilate w/ ETCO2 – Advance ETT through cords Removing the LMA is optional Verify placement – ETCO2 – Listen for leak 10

Airway briefing and checklist CPR with chest compressions and BMV are in progress. We are having difficulty assuring oxygenation with a BVM This is a crash airway Continue Chest Compressions Place the I-LMA #5 Continue Chest Compressions Our plan is: A- Continue to attempt to BVM B- Place I-LMA #4 (now) C- Direct/bougie/7.5 tube once we have ROSC or some more time D- Cric if we get ROSC but can not get an airway Questions? Oxygenate the patient 11

SuperGlottic Airways (SGA) Indications Predicting difficult (RODS) Sizing Insertion Procedure Troubleshooting Intubating through an SGA 12

Brief SGA References: 13 Thomas C. Mort The Supraglottic Airway Device in the Emergent Setting: Its Changing Role Outside the Operating Room. Anesthesiology News, (accessed on 15/6/2014) Daniel J Cook, AirQ Tips and Techniques Youtube- Mercury Medical (accessed on 15/6/2014) Dr. Gallagher’s Neighborhood- Laryngeal Mask Airway: MICU Fellows Airway Course- f5qkGY&index=5&list=PLDvE6n0oI4ehBbTL_OAMeFQvJmJFz6tGU (accessed on 15/6/2014) f5qkGY&index=5&list=PLDvE6n0oI4ehBbTL_OAMeFQvJmJFz6tGU Nichole Bosson- Laryngeal Mask Airway, Emedicine: (accessed on 15/6/2014)