1. Advanced Airway Management

2. Airway Management:
Airway management is the most important skill for the Pre-hospital/Hospital Clinician.
ABC’S
Timely, effective, and decisive management of the airway can literally make the difference between life and death or between ability and disability.
Its important for crew to have the skill, confidence, knowledge, and equipment to effectively manage the airway.
TRAINING IS KEY!!

3. ANATOMY WE GOT TO KNOW THIS:

4. WHAT MAKES UP THE UPPER AIRWAY?
Nose-cartilaginous, bony structure in the midline of face that warms and humidifies inspired air.
Mouth-begins at the lips and ends with the oropharynx. Contains the tongue which is attached to the mandible and teeth.
Pharynx- U-shaped tube that begins at the base of the skull and extends to lower border of cricoid cartilage near the esophagus.
Nasopharynx
Oropharynx
Hypopharnyx

5. WHAT MAKES UP THE LOWER AIRWAY
Trachea- beginning at the inferior border to the cricoid ring and ending at the carina.
Lungs- when the trachea divides into the right and left mainstem bronchi, these bronchi lead into the right and left lobes of the lung. Right has 3 lobes and Left has 2 lobes. This is the site of gas exchange.

6. PUTTING IT ALL TOGETHER

7. What’s in my mouth?

8. WHY IS KNOWING ANATOMY SO IMPORTANT?

9. Why? Because… You can not manage what you do not understand!
Airway management is not just being able to identify who needs additional airway assistance but knowing the landmarks and anatomical aspects of an airway so the assistance can be given.
Burns, Edema, Blood, Vomit, Foreign Bodies in the Airway will distort view so knowing what things should look like and where they should be is very beneficial.
Ex. IV in the A/C

10. Patient and Airway Assessment
Now since we know what an airway looks like lets assess.

11. Breathing Process
Unfortunately we all realize there are many factors that prevent many people from breathing properly..
COPD
Asthma
Cystic fibrosis
Asbestosis
Mesotheolioma
Pneumonia
Trauma, Head Injury
Drug Overdose
Foreign Body Obstruction
Airway edema
Congenital Abnormality

12. Patient Assessment
But… Just because a patient has one or more of these issues does not mean the patient has an acute problem needing intervention.
We first must assess the patient and see if advanced intervention is necessary or if less invasive but helpful application will work.

13. Patient Assessment Who needs an Airway?
Pt with diminished level of consciousness with loss or airway control.
Absent or diminished gag reflex??? How about ability to swallow secretions!
Glasgow Coma Scale of 8 or less (Pt Hx Dependent)
Potential for aspiration
Respiratory Failure (hypoxemia, hypercarbia)
Cardiac arrest, after adequate CPR or bag mask ventilations have been provided.

14. Airway Assessment

15. Airway Assessment
There are many ways we can assess an airway and some techniques have been proven very successful such as the Visual Inspection, Auscultation, Lemon Law, Mallampati Classification, and Rule.

16. Airway Assessment Lemon Law L – Look externally
E – Evaluate the rule
M – Mallampati
O – Obstruction
N – Neck Mobility

17. Look Externally Evaluate patients general apperance: LOC Skin Color
Skin Temperature
Skin texture
Patient Posture
Tripod Position

18. Look Externally Visibly is the patient having difficulty breathing?
Goldilocks Logic is it Slow, Fast, Just Right
Normal Ranges
RR Adult/Child (6-12 years) = bpm
RR Child 1-5 years = bpm
RR Infant 6-12 months = bpm
RR Infant Newborn to 6 months = bpm

19. Airway Assessment: Look Externally

20. Airway Assessment: Look Externally

21. Airway Assessment: Look Externally
Look for things that could make intubating or ventilating a patient difficult.
Beards
False Teeth
Secretions
Obesity
Trauma to Facial area

22. Airway Assessment: 3-3-2 Rule
The mouth should be at least three patient fingers wide or 5 cm when open. Less than 3 fingers indicates a possible difficult airway.
The space from the tip of chin to hyoid bone should be three fingers wide. Smaller mandibles have less room for displacement of tongue and epiglottis.
The distance from the hyoid bone to the thyroid notch should be at least two fingers wide.

23. Airway Assessment: Mallampati/Cormack and Lehane

24. Airway Assessment: Obstruction
Obstruction is anything that might interfere with visualization or tracheal tube placement.
Foreign Body
Hematoma
Masses

25. Airway Assessment: Obstruction

26. Airway Assessment: Obstruction

27. That Airway Makes Me Nervous

28. Airway Assessment: Neck Mobility
Ideally we want our patients in a sniffing position for better visualization with the adult head slightly elevated and extended.
This may be impossible with the Elderly and Trauma patients
Does patient have a c-collar in place?
Does patient have osteoporosis or arthritis?

29. Airway Assessment
Our Goal: Our assessments will ultimately determine whether a patient has a open and patent airway and wither a patients breathing is sufficient on its own or if it needs some form of intervention to assist.

30. Airway Management
Lets say our assessment has been performed and we determine that intervention is necessary?
Basic Management
Advanced Management

31. Basic Airway Management
Although intubation is considered the GOLD STANDARD for airway management, basic airway skills are the starting point in the initial patient assessment and treatment and what we fall back on in times of difficulty.

32. Basic Airway Management
Basic skills may be as simple as positioning the non-trauma victim in the recovery position or using the head tilt-chin lift or jaw thrust maneuver to maintain airway patency. Other basic skills may use other adjuncts such as the OPA and NPA.

33. Basic Airway Management

34. So….. What is an Advanced Airway

35. Advanced Airway Management
Advanced Airway Management is Definitive Airway Management.
The placement of a ET tube or tracheostomy tube in the trachea is definitive airway management because it facilitates adequate oxygenation and ventilation of the patient.

36. Types of Advanced Airway Equipment and Procedures
Combitube (double lumen airway)
LMA (supraglottic airway)
King LT (supraglottic airway)
Endotracheal Tube
Needle Cricothyrotomy
Surgical Cricothyrotomy
Pertrach (Emergency Cric)
Rapid Sequence Intubation

37. Rapid Sequence Intubation
Originally developed in 1946 to facilitate airway management in ob patients requiring intubation for c-section with full stomach
By definition involves the co-administration of both anesthetic agents and neuromuscular blocking agents to produce a state of unconsciousness and paralysis to allow tracheal intubation.

38. Rapid Sequence Intubation
Indications
Actual/impending respiratory failure
Actual/impending inability to protect the airway
Combative secondary to presumed head injury
Hypoxemia despite supplemental oxygen and medications

39. Rapid Sequence Intubation
Contraindications
Anticipated difficult intubation
Anticipated difficult BVM
Crash Airway Situation
Cardiac Arrest
These Patients should have no muscle tone

40. Rapid Sequence Intubation
Steps to RSI
Preparation
Pre-oxygenate
Pre-medicate
Paralyze
Intubate and Confirm
Maintain paralysis and sedation

41. Rapid Sequence Intubation Preparation
When preparing for RSI procedure we should gather all medications used in procedure, get them drawn up, labeled, and ready for administration.
Gather all necessary equipment and make sure it is in working order.
We should also prepare for worst case scenario which means having different sized laryngoscope blades and ET tubes available.
We also need our back up airways very close by and ready for use if necessary.

42. Rapid Sequence Intubation Preparation

43. Rapid Sequence Intubation Preparation

44. Rapid Sequence Intubation Pre-oxygenate
Oxygen 21% and Nitrogen 78%
100% Oxygen delivered for at least 3 minutes in an attempt to achieve NITROGEN WASHOUT.
We do this in hopes to increase the amount of oxygen and develop a reserve in order to help patient desaturate less quickly while intubation attempt is being made.

45. Rapid Sequence Intubation Pre-medicate
The first medications given should help the patient’s adverse physiologic responses to the subsequent medications and laryngoscopy.
All pre-medications require at least 3 minutes to work before laryngoscopy.

46. Rapid Sequence Intubation Pre-medicate
Anesthetize the airway reflexes that lead to elevate ICP.
Dose: mg/kg
Peak : 3 mins
Duration: 20 mins
Adverse: Hypotension, Allergy, Seizures, Bradydysrhythmias

47. Rapid Sequence Intubation Induction
Used to render the patient unconscious and unresponsive:
Isn’t that what you would want?
Have a Rapid Onset/Short duration
Induce unconsciousness and unresponsiveness
Provide amnesia
Typically have minimal hemodynamic and adverse effects

48. Rapid Sequence Intubation Induction
Dose: mg/kg
Peak: 30 seconds
Duration: 10 minutes
Adverse: Adrenal Suppression – reduces the glands ability to secrete stress hormones,

49. Rapid Sequence Intubation Induction
Benzodiazepine
Dose: mg/kg but be careful with hypotensive patients
Peak: 3 mins
Duration:Varies

50. Rapid Sequence Intubation Defasciculating Agent
Non-Depolarizing
1/10 th of paralyzing dose
Used to help prevent fasciculations caused by succinylcholine

51. Rapid Sequence Intubation Paralytics
Non-competitive
Depolarizing Agent Neuromuscular Blocking Agent
Dose: 1-2 mg/kg
Peak: 45 seconds
Duration: 8 minutes
Adverse: Hyperkalemia, Neuromuscular Diseases, Burns greater than hrs old, Malignant Hyperthermia, increased intraocular pressure, Rhabdomyolysis

52. Long term Paralytic Non-Depolaring Neuromuscular Blocking Agent
Regular Dose: mg/kg
Peak: 90 seconds
Duration: minutes depending on dose
Adverse: Minimal

53. Pass the Tube
Now once you have sedated and paralyzed the patient, you are ready to pass the tube.
Don’t forget to wait until patient is full paralyzed… we do not want to cause patient to vomit and aspirate

54. Rapid Sequence Intubation Intubate and Confirm
Once patient is paralyzed and intubation has taken place it’s very important to confirm your ET tube is in the correct position.
Objective ways to confirm:
Pulse Oximetry
ETCO2
EDD
Chest X-Ray
Subjective ways to confirm:
Direct visualization
Tube misting
Breath sounds

55. Pertrach If your at this point… it’s not a good day Tater!!
Indicated for a can’t intubate/can’t ventilate situation.

56. Pertrach Contraindication: Complications:
Inability to identify landmarks for procedure.
Complications:
Hemorrhage
Subcutaneous Emphysema
Infection
Accidental removal
Tracheal and esophageal laceration

57. Pertrach Most important step is to identify need for Pertrach device.
Equally as important is making sure you find the correct landmark for procedure.

58. Pertrach
If you can not find landmarks… you have no business attempting to perform the procedure.

59. Pertrach If appropriate to continue Open kit and assemble equipment
Position patient as appropriate and find landmarks
Cleanse site of insertion

60. Pertrach

61. We got the Airway.. I think?
Remember before we celebrate we first have to confirm that our intervention is in the right place and working.
Also note with sudden movements or transferring of patient, airway should always be reassessed for patency.
Airways can be gained and Airways can be lost.

63. Failed Airway

64. Advancements in Equipment

65. Ranger Glide Scope
Used during difficult intubation so better visualization is needed.

66. Gum Elastic Bougie
Of great use when patient has a anterior larynx that cannot be visualized despite optimal positioning and external manipulation.

67. ETCO2 Monitoring The New Standard

68. Conclusion:
Airway management is a very important skill for all clinicians to have.
Assess, Reassess, and Reassess again!
TRAIN! Because your next airway may be difficult.