Case Evaluation How do you think you did? What do you think you did well? What would you have done differently? How do you think your colleagues did?

Diagnosis? Status Asthmaticus with respiratory failure Spontaneous iatrogenic pneumothorax developing of a tension pneumothorax

General Assessment of the Dyspneic Patient Ability to speak Mental status Position – Lying back, upright and forward or slumped back Cyanosis – Central or acrocyanosis Pulmonary exam – Inspection, percussion auscultation Cardiovascular Extremities

Advanced Airway Management Techniques Definitive –Oral awake –Nasotracheal –RSI Rescue –LMA –Combitube –Cricothyrotomy –Others

Factors Predictive of a Difficult Airway Mallampati class Neck mobility Jaw size Laryngeal trauma Tongue size Prominent incisors Combativeness

Mallampati Classes I – The tonsillar pillars, fauces, soft pallet and uvula are visualized II – The fauces, soft pallet and uvula are visualized III – The soft pallet and the base of the uvula are visualized IV – Only the hard pallet is visualized

Risks Associated with Intubation Inability to intubate Aspiration Misplacement of the tube C-spine injury Increased ICP Hemodynamic changes

Orotracheal Intubation Technique Chose appropriate sized tube & blade Check equipment Sniffing position if no C-spine injury Identify Cricoid cartilage for BURP maneuver Laryngoscope in left hand, open mouth with right hand Advance blade on dorsal surface of tongue to ID epiglottis and position blade Pass tube through cords to 2 cm beyond cuff Remove stylet, inflate cuff, confirm tracheal placement Secure Tube (22-24 cm at teeth)

Six Ps of RSI ProcessTiming PreparationEarly Preoxygenation- 5 Min Pretreatment- 3 Min Paralysis (with induction, cricoid pressure) - 1 Min Placement of tube 0 Postintubation Management +…..

Contraindications to RSI Clinical and/or anatomical considerations that predict difficulty intubating the patient

Nasotracheal Intubation Technique Select and Prep both tube and nares Place tube bevel flat against nasal septum Gentle consistent pressure When in the nasopharynx, position ear at end of tube, advance tube to loudest point As patient inspires, advance tube 2-3 cm Assess tube position and reposition if needed If in trachea, inflate cuff, confirm placement, and secure tube

Contraindications to Nasotracheal Intubation Absolute – Apnea Relative –Midface/basilar skull fracture –Coagulation defects –Potential altered airway anatomy –Impaired airway reflexes –Closed head injury –Myocardial ischemia

Nonpulmonary Causes of Dyspnea Is it true dyspnea? –Thoracic pain –Hyperventilation CHF ACS/MI Decreased oxygen-carrying capacity Acid-base disorders

Pulmonary Causes of Dyspnea Asthma Pneumonia COPD –Emphysema –Chronic Bronchitis Pulmonary Embolus Pneumothorax

Asthma Etiology – Bronchospasm, increased mucous production and inflammation Hx – Prior episodes, precipitating factors PE – Tachypnea, tachycardia, wheezing, prolonged expiratory phase Tests – Spirometry, pulse ox (?CXR, ABG) Rx – Oxygen, Inhaled bronchodilators, Steroids, rehydration, SC epinephrine, magnesium, active airway control in nonresponders

Pneumothorax

How do you treat a pneumothorax? Chest tube Pleuricath Needle aspiration When do you need to drain the air?

What is the major complication you have to be aware of? Tension pneumothorax –When would this occur?

Time to Practice Chest Tubes