1. Respiratory Emergencies
Case 1
Respiratory Emergencies
© 2001 American Heart Association
No notes for this case. 1

2. Case Presentation Patient = 69-year-old man, smoker (4 packs/day)
PMHx = severe COPD
CC = severe shortness of breath; “hungry for air!”
VS = not obtained; patient suddenly becomes unresponsive

3. Learning and Skills Objectives
Describe ACLS Approach (Primary and Secondary ABCD Surveys) in CPR
Describe and demonstrate the “airway hierarchy”:
Supplemental oxygen:
Nasal cannulae
Face masks
Noninvasive airway devices:
Nasopharyngeal airway
Oropharyngeal airway

4. Learning and Skills Objectives
The airway hierarchy (cont’d)
Recommended invasive airway devices:
Laryngeal mask airway (LMA)
Esophageal-tracheal (Combitube) tube
Tracheal tube
Primary/secondary confirmation of tracheal tube placement:
Physical exam criteria
End-tidal CO2 detection
Devices to detect esophageal placement
Devices to prevent TT dislodgment

5. Primary ABCD Survey Focus: Basic CPR and Defibrillation
Check responsiveness
Activate emergency response system
Call for defibrillator
A = Airway: open the airway
B = Breathing: check breathing, provide positive-pressure ventilations
C = Circulation: check circulation, give chest compressions
D = Defibrillation: assess for and shock VF/pulseless VT

6. Secondary ABCD Survey
A = Airway: insert advanced airway device as soon as able (new: 3 types)
B = Breathing: confirm placement by PE (primary tube confirmation)
PLUS
B = Breathing: confirm placement with esophageal detector device or end-tidal CO2 detector or both (secondary tube confirmation)
B = Breathing: use a commercial tube holder to prevent dislodgment
B = Breathing: confirm effective oxygenation/ventilation by 02 sat, CO2 levels, pH

7. Anatomy of Airway

8. Airway Obstruction
Most common cause: tongue and/or epiglottis

9. Opening the Airway
Jaw thrust
Head tilt–chin lift

10. The Oropharyngeal Airway

11. Malposition of Oropharyngeal Airway
Too short

12. Nasopharyngeal Airway
Insertion technique

13. Oral airway: inserts in patient
Barrier Devices
Oral airway: inserts in patient

14. Pocket-Mask Devices
1-way valve
Port to attach O2 source

15. Mouth-to-Mask Ventilation
Advantages
Eliminates direct contact
Enables positive-pressure ventilation
Oxygenates well if O2 attached
Easier to perform than bag-mask ventilation
Best for small-handed rescuers
1-rescuer technique; performed from side
Rescuer slides over for chest compressions
Fingers: head tilt–chin lift

16. Mouth-to-Mask Ventilation
Fingers: jaw thrust upward
Fingers: head tilt–chin lift

17. Bag-Mask Ventilation
Key—ventilation volume: “enough to produce obvious chest rise”
1-Person: difficult, less effective
2-Person: easier, more effective

18. Cricoid Pressure
Thyroid Cartilage
Cricoid

19. Bag-Mask Ventilation Advantages
Provides immediate ventilation and oxygenation
Operator gets sense of compliance and airway resistance
May provide excellent short-term support of ventilation
High oxygen concentrations are possible
Can be used to assist spontaneous respirations
Potential complications
Hypoventilation
Gastric inflation

20. Airway Adjunct Devices
Nasal cannula 24%-44% O2 concentration
Face mask with O2 reservoir, 60%-100% O2 concentration

21. Types of Portable Suction
Courtesy of Laerdal Medical Corporation, Armonk, NY

22. Equipment for Intubation
Laryngoscope with several blades
Tracheal tubes
Malleable stylet
10-mL syringe
Magill forceps
Water-soluble lubricant
Suction unit, catheters, and tubing

23. Curved Blade Attaches to Laryngoscope Handle

24. Curved Blade Attached to Laryngoscope Handle

25. Curved Blade Laryngoscope Inserted Against Epiglottis

26. Straight-Blade Laryngoscope

27. Straight-Blade Laryngoscope Inserted Past Epiglottis

28. Cricothyroid Membrane With Horizontal Cricothyrotomy Incision

29. Aligning Axes of Upper Airway
Mouth A A B B C C
Pharynx
Trachea
Extend-the-head-on-neck (“look up”): aligns axis A relative to B
Flex-the-neck-on-shoulders (“look down”): aligns axis B relative to C

30. Visualization of Vocal Cords
Anatomy
Tongue
Vallecula
Epiglottis
Vocal cord
Glottic opening
Arytenoid cartilage

31. Tracheal Intubation Advantages
Protects airway from aspiration of foreign material
Facilitates ventilation and oxygenation
Facilitates suctioning of trachea and bronchi
Provides route for drug administration
Prevents gastric inflation if used with cuff
Allows faster chest compressions

32. Tracheal Intubation Indications
Inability to ventilate the unconscious patient
After insertion of pharyngeal airway
Inability of patient to protect own airway (coma, areflexia, or cardiac arrest)
Need for prolonged mechanical ventilation

33. Tracheal Intubation Recommendations
Intubate as soon as possible after ventilation and oxygenation in cardiac arrest
Intubation should be done by most experienced person
Do not take longer than 30 seconds per attempt
Auscultate the thorax and epigastrium after intubation

34. Tracheal Intubation Complications
Trauma—teeth, lips, tongue, mucosa, vocal cords, trachea
Esophageal intubation
Vomiting and aspiration
Hypertension and arrhythmias

35. Esophageal-Tracheal Combitube
A = esophageal obturator; ventilation into trachea through side openings = B
C = tracheal tube; ventilation through open end if proximal end inserted in trachea
D = pharyngeal cuff; inflated through catheter = E
F = esophageal cuff; inflated through catheter = G
H = teeth marker; blindly insert Combitube until marker is at level of teeth E
Distal End A C H
Proximal End B D F G

36. Esophageal-Tracheal Combitube Inserted in EsophagusF
A = esophageal obturator; ventilation into trachea through side openings = B
D = pharyngeal cuff (inflated)
F = inflated esophageal/tracheal cuff
H = teeth markers; insert until marker lines at level of teeth

37. Laryngeal Mask Airway (LMA)
The LMA is an adjunctive airway that consists of a tube with a cuffed mask-like projection at distal end.

38. LMA Introduced Through Mouth Into Pharynx

39. Once the LMA is in position, a clear, secure airway is present.
LMA in Position
Once the LMA is in position, a clear, secure airway is present.

40. Anatomic Detail

41. Esophageal Detector Device (Bulb-Type)

42. Confirmation: Tracheal Tube Placement
End-tidal colorimetric CO2 indicators

43. Tracheal Tube Holders: Adult and Infant1 4 2 3

44. Qualitative End-Tidal CO2 Detector
What should the operator’s next action be? 1