1. UNC Emergency Medicine Medical Student Lecture Series
AIRWAY
UNC Emergency Medicine
Medical Student Lecture Series
Created: Benjamin Leacock 6/21/08

2. THIS IS INTERACTIVE SO SPEAK UP
Objectives
Brief anatomy review
Indications for airway support
Passive oxygen assistance
Non-invasive mechanical ventilation
Intubation
Difficult Airway
Mechanical ventilation
Pediatric considerations
THIS IS INTERACTIVE SO SPEAK UP
BWL /16/2017

3. Anatomy
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4. Anatomy
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5. What are the indications for intubation?
What are some of the situations when you have seen someone intubated?
BWL /16/2017

6. Airway Support Intubation Airway protection Ventilation Oxygenation
GCS < 8,
Can not handle secretions,
Airway edema (burns, angioedema)
Ventilation
Oxygenation
High metabolic demand from work of breathing
Sepsis
BWL /16/2017

7. What are the types of passive oxygenation support?
(Tubes on your face)
How much O2 do they deliver?
What are the limitations?
BWL /16/2017

8. Passive Oxygen SupportNC
   2 L 29%        
   4 L 37%        
   6 L 45%
Venti Mask
4-10L 24-50%
Non-Rebreather – Reservoir bag
15L 60%
LIMITATION: You are not ventilating the patient, or protecting their airway.
BWL /16/2017

9. What is non-invasive ventilation?
BWL /16/2017

10. Non-Invasive Ventilation
CPAP
Continuous pressure
Settings: Typically 5-10 cm H2O
BIPAP
Inspiratory and expiratory levels
Settings: IPAP set at 10, EPAP set at 3 cm H2O
With either setting remember that you are increasing intrathorasic pressure, thus decreasing cardiac output.
BWL /16/2017

11. What conditions qualify for non-invasive ventilation?
What are the contraindications?
BWL /16/2017

12. Non-Invasive Ventilation
Conditions
Pulmonary Edema
COPD
Asthma – (Questionable efficacy)
Pneumonia – (Questionable efficacy)
Contraindications
Uncooperative patient
Obtunded patient
BWL /16/2017

13. Bag-Mask-Ventilation
How should you hold the BMV?
(Note: BMV is not part RSI)
BWL /16/2017

14. BMV
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15. How do you size and position oral and nasal airways?
Airway Adjuncts
How do you size and position oral and nasal airways?
4/16/2017

16. Size by looking at angle of jaw
Airway Adjuncts
Size by looking at angle of jaw
4/16/2017

17. Intubation
BWL /16/2017

18. Intubation
What is RSI?
Why do we use RSI?
BWL /16/2017

19. Intubation - RSI
RSI is administration of a potent induction agent followed immediately by a rapidly acting neuromuscular blocking agent to induce unconsciousness and motor paralysis for tracheal intubation
RSI increases success rates of intubation
RSI decreases aspiration
Limits sympathetic discharge and limits ICP increase.
BWL /16/2017

20. What are the basic steps of RSI?
Intubation
What are the basic steps of RSI?
BWL /16/2017

21. Intubation - RSI Preparation Pre-oxygenation Positioning Pre-induction
Paralysis
Tube
Confirmation
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22. What equipment do you need to set up?
Intubation
What equipment do you need to set up?
BWL /16/2017

23. Intubation - RSI Preparation: Patient Ambu bag Suction
Blades – check lights
Tubes – check cuff
Stylette
Syringe – 10 cc
Capnography
Patient
Needs IV, O2, Monitor
BWL /16/2017

24. How do you position the adult patient?
Intubation
How do you position the adult patient?
BWL /16/2017

25. Intubation - RSI Position: For c-spine precautions:
Place the pt in the “sniff position”
In the adult this means ramping the head up
Align the ear with the sternal notch
Maintain cricoid pressure.
For c-spine precautions:
You can not move the head
An assistant holds the head in position while the front of the collar is removed.
BWL /16/2017

26. Intubation Why do we pre-oxygenate?
How do we do it? How do we not do it?
BWL /16/2017

27. Intubation – Pre-Oxygenation
We preoxygenate to prevent hypoxia during the apnea that will follow.
100% for 2 min of normal breathing will permit 8 minutes of apnea in the healthy adult.
This should be done passively if possible
The reason is that bagging the patient will always put air in the stomach – thus increasing the chance of aspiration.
BWL /16/2017

28. Intubation What are the common pre-induction agents?
When should you consider them?
BWL /16/2017

29. Intubation – Pre-Induction
LOAD
Lidocaine: 1.5 mg/kg – limits bronchospasm in reactive airways and limits ICP response.
Opioid: Fentanyl 3ug/kg – limits sympathetic response, used in CAD, ICH, ICP or aortic dissection.
Atropine: mg/kg in kids under 10 to prevent bradycardia.
Defasciculation: 10% of the planed defasiculationg dose to mitigate succ induced elevated ICP.
BWL /16/2017

30. Common inductions agents?
Intubation
Common inductions agents?
BWL /16/2017

31. Intubation - Induction
Etomidate – Most often used.
Hemodynamically stable,
No ICP increase
Myoclonus is common
Propofol – Quick on, quick off
Can cause hypotension
Ketamine –
Sympathometic – may be useful in asthma.
May increase ICP.
Many additional agents: Benzos, barbiturates
BWL /16/2017

32. Intubation The two basic classes of paralytics?
What are the contraindications?
BWL /16/2017

33. Intubation - Paralytics
Depolarizing - Succinylcholine
Basically two Ach molecules (so it can cause bradycardia)
Works within 60 sec, lasts 6-10 min (resp may occur within 7 min)
Contrainducations many related to K.
Hyperkalemia
Burns, Crush, Stroke, cord injury, intra abdominal sepsis. For all of these must have condition > 5 days
Non-Depolarizing – Rocuronium and vecuronium
Rocuronium is agent of choice when succinylcholine is contraindicated. Give 1mg/kg which works within 60 sec and lasts 50 minutes
BWL /16/2017

34. Intubation What is the difference between a Mac and Miller blades?
Typical tube sizes in adults?
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35. Intubation – Tubes + Blades
BWL /16/2017

36. What are the basic steps once you are ready to intubate?
Intubation
What are the basic steps once you are ready to intubate?
BWL /16/2017

37. Intubation - Steps Scope in left hand.
Scissor teeth open with right hand.
Place blade in right of mouth and sweep tongue to left.
Insert blade deeper
Lift up and away
With R hand manipulate head and/or cricoid for the best view
Pass tube
DO NOT PASS THE TUBE IF YOU CAN NOT VISUALIZE
DO NOT LET GO OF THE TUBE UNTIL SECURE
BWL /16/2017

38. Intubation - Steps
BWL /16/2017

39. How do we confirm the tube?
Intubation
How do we confirm the tube?
BWL /16/2017

40. Intubation - Confirmation
Visualization!
Capnography – most sensitive
Listen – stomach, then lungs
X-ray
Esophageal Detector
DO NOT LET GO OF TUBE UNTIL IT IS SECURED
BWL /16/2017

41. Options for the difficult airway?
Intubation
Options for the difficult airway?
BWL /16/2017

42. Intubation – Difficult Airway
Boggie
Glide-Scope – Camera on blade
LMA/ILMA - useful out of hospital but should only be used in ED in failed airway. Does not protect airway.
Lighted Stylet – Primary or rescue
Combitube – difficult to use if C-spine immobilized, should be temporary only. Same indications as LMA.
Retrograde Intubation – The cricothyroid membrane is punctured, wire sent through and retrieved through mouth.
Fiberoptic Intubation – View while you intubate
Transtracheal Jet Ventilation – larger 10g needle inserted through the cricothyroid. Inferior to cricothyrotomy, only use is in children <10 where a cric is difficult.
Surgical Airway
BWL /16/2017

43. How do you perform a surgical airway?
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44. Surgical Airway
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45. Anatomical differences of kids?
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46. Intubation – Kid Anatomy
Don’t forget that kids have big heads
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47. Kids How do you determine tube size in a kid?
How is positioning of the child different?
Blades?
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48. Intubation – Kids Tubes Blades Positioning
(Age + 4)/4Width of the nail of the little (5th) finger
The narrowest part of the child’s airway is subglottic so use a tube without a cuff or a low pressure cuff.
Blades
In younger kids the epiglottis is large and floppy so use a Miller blade.
Positioning
Kids have large heads so they typically do not need to be “ramped up.”
BWL /16/2017