Basic Emergency Airway Management Pat Melanson,MD - the most essential skill in EM - establishing or protecting on airway is frequently the essential maneuver for saving a person’s life - conversely, failure to do so is the fastest way to assure a patient’s demise - assessment and management of the airway have been appropriately assigned the A in the well known ABC’s of resuscitation for scientific reasons as well as alphabetic Basic Emergency Airway Management Pat Melanson,MD

Objectives Differentiate the Emergency Airway from elective intubation in the OR Assessment of airway compromise Indications for airway intervention Recognition of the difficult airway Bag-Mask Techniques Laryngoscopy

Emergency Airway Management : Unique Considerations Full stomach - high aspiration risk Altered level of consciousness Deteriorating cardiorespiratory physiology - (hypotension, hypoxia) Abnormal or distorted upper airway anatomy No time for “pre-op” assessment

Airway Assessment Assessment for airway compromise or threats and need for interventions Examination for the potentially difficult airway

Patency of Upper Airway Protection against aspiration The Three Pillars of Airway Management: ( Assessment of Compromises or Threats ) Patency of Upper Airway ( airflow integrity ) Protection against aspiration Assurance of oxygenation and ventilation

Indications for Active Airway Intervention: including intubation Failure to maintain patency Protection from aspiration Hypoxic/ hypercapnic respiratory failure Airway access for pulmonary toilet, drug delivery,therapeutic hyperventilation Intractable Shock Anticipated clinical deterioration

Indications for Intubation Is there failure of airway maintenance ? Is there failure of airway protection ? Is there failure of oxygenation or ventilation? What is the anticipated clinical course ? (i.e., expected deterioration, long transport, long time in radiology, etc.)

Clinical Signs of Airway Compromise : Threatened Patency Inspiratory stridor Snoring ( pharyngeal obstruction ) Gurgling ( blood/ secretions ) Drooling ( epiglottitis ) Hoarseness ( laryngeal edema/ vocal cord paralysis) Paradoxical chest wall movement Tracheal tug Mass - abscess, hematoma, angioedema

Clinical Signs of Airway Compromise: Inadequate Protection Blood in upper airway Pus in upper airway Persistent vomiting Loss of protective airway reflexes swallowing reflex is superior to gag reflex

Clinical Signs of Airway Compromise: Oxygenation and Ventilation Central cyanosis Obtundation and diaphoresis Rapid shallow respirations Accessory muscle use Retractions Abdominal paradox

Clinical Signs of Airway Compromise: Oxygenation and Ventilation The assessment of oxygenation and ventilation is a clinical one. Arterial blood gases should not be relied upon to assess whether intubation is necessary.

Techniques for the Compromised Airway Head Positioning Jaw Thrust, Chin lift Orophryngeal/ Nasopharyngeal airways Bag-Valve-Mask Ventilation Endotracheal Intubation Advanced techniques Cric, LMA, Combitube, Retrograde, Fibreoptic, Light wand, Bouge

The Difficult Airway Difficult Laryngoscopy poor visualization of cords Difficult bag-mask ventilation unable to oxygenate or ventilate Lower airway difficulty severe bronchospasm

Golden Rules of Bagging “ Anybody ( almost ) can be oxygenated and ventilated with a bag and a mask “ The art of bagging should be mastered before the art of intubation Manual ventilation skill with proper equipment is a fundamental premise of advanced airway Rx

BVM Ventilation The most important airway skill Always the first response to inadequate oxygenation and ventilation The first “bail-out” maneuver to a failed intubation attempt Attenuates the urgency to intubate Do not abandon bagging unless it is impossible with two people and both an OP and NP airway

BVM Ventilation Requires practice to master One hand to maintain face seal position head maintain patency Other hand ventilates

BVM Ventilation: Technique Insert oropharyngeal/nasopharyngeal “Sniffing”position if C-spine OK Thumb + index to maintain face seal Middle finger under mandibular symphysis Ring/little finger under angle of mandible Maintain jaw thrust/mouth open

Predictors of a Difficult Airway : BVM Upper airway obstruction Lack of dentures Beard Midfacial smash Facial burns, dressings, scarring Poor lung mechanics resistance or compliance

Difficult Airway : BVM degree of difficulty from zero to infinite Zero = no external effort or internal device required one person jaw thrust/ face seal oropharyngeal or nasopharyngeal AW two person jaw thrust / face seal both internal airway devices Infinite = no patency despite maximal external effort and full use of OP/NP

Algorithm for Difficulty “Bagging” Remove Foreign Bodies - Magill forceps Triple maneuver if c-spine clear Head tilt, jaw lift, mouth opening Nasal or oropharyngeal airways Two-person, four-hand technique

BVM Ventilation: Mask Seal Tips and Pearls Easier to get seals with masks too large than too small Inflate mask collar correctly Apply lubricant to beards to “mat down” hair If edentulous insert gauze sponges into cheeks

Prediction of the Difficult Airway: Laryngoscopy History of past airway problems check previous OR anesthesia records if time permits cricothyroidotomy scar Careful physical assessment mouth opening tongue to pharyngeal size hyo-mental distance Neck flexion, Head extension

Technique of Laryngoscopy “Sniffing” position to align oral-pharyngeal-laryngeal axis Flex neck by placing pillow beneath occiput ( raise 10 cm ) Extend head maximally With laryngoscope open mouth fully push tongue to left out of view pull upward at 45 degrees

Adducted vocal cords

Predictors of Difficult Laryngoscopy Short thick neck Receding mandible Buck teeth Poor mandibular mobility/ limited jaw opening Limited head and neck movement ( including trauma )

Difficult Airway : Laryngoscopy Tumor, abscess or hematoma Burns Angioneurotic edema Blunt or penetrating trauma Rheumatoid arthritis, ankylosing spondylitis Congenital syndromes Neck surgery or radiation

Predictors of Difficult Laryngoscopy 3 fingerbreadths mentum to hyoid 3 fb chin to thyroid notch 3 fb upper to lower incisors Head extension and neck flexion Mallimpadi classification Previous history of difficult intubation

Mallimpadi Classification (Tongue to Pharyngeal Size) I - soft palate, uvula, tonsillar pillars visible 99 % have grade I laryngoscopic view II - soft palate, uvula visible III - soft palate, base of uvula IV - soft palate not visible 100% grade III or grade IV views

The 4 D’s of Difficult Intubation Distortion ( edema, blood, vomitus, tumor, infection) Dysmobility of joints ( TMJ, alanto-occipital, C-spine) Disproportion thyomental, Mallimpadi, etc Dentition prominent upper teeth

Unsuccessful Intubation Bag the patient Maximize neck flex/ head ex Move tongue out of line of site Maximize mouth opening ID landmarks and adjust blade BURP maneuver (Backwards Upwards Rightwards Pressure on Thyroid Cart.) Increasing lifting force Consider Miller blade