1. Airway Management GMVEMSC Education Committee

2. Objectives Review proper airway management Review assessment Review adjuncts and proper use

3. Airway Issues BLS intervention usually good Ensure patent airway Practice good BVM airway management with Oral or Nasal Airway Adjuncts Advanced Airway Devices Intubation Rescue Airways Confirmation Methods (Use and Documentation)

4. Orotracheal Intubation Why Securing patent airway Protects from aspiration Known Issues Right mainstem intubation Unrecognized esophageal intubations Dislodged tubes

5. Orotracheal Intubation Techniques Non Trauma Inline Trauma Tools to assist Fiberoptic scopes Bougies Viewmax blades Grandview blades Confirmation Probably done in most cases, lacks documentation

6. Nasotracheal Intubation Why Spontaneously breathing patient Clenched jaw Known Issues Use of too small an E.T. Tube Hypopharyngeal placement Trauma to airway

7. Confirmation Methods “Dave’s Five” End Tidal CO2 OR EDD Detection Waveform / Numerical Capnography Visualization Auscultation Measurement at the teeth (or gum line in peds) Chest Rise / Fall Fogging of the tube Skin color and change Pulse Oximetry Use Multiple Methods (at least five)

8. Confirmation Methods Other Apply Cervical Collar following intubation to maintain head / neck position Secure with commercial device or other methods Document Include all methods used in your narrative This should include at least five items Also document the results Especially capnography and / or colorimetric color change Recheck of tube placement post movement

9. Rescue Airways When are they appropriate As a Primary Airway; Due to suspected difficult airway capture based on assessment and anatomical features Pediatric patients as preferred by Children’s As a Rescue Airway; After failed attempts at intubation After failed attempt at intubation during the Sedate to Intubate procedure.

10. Types of Rescue Devices LMA Combitube PTL King

11. Laryngeal Mask Airway http://www.lmana.com/unique.php

12. Laryngeal Mask Airway Why As an alternative to the face mask for achieving and maintaining control of the airway. LMA™ airways are indicated for use in: Known or unexpected difficult airways Establishing an airway during resuscitation in the profoundly unconscious patient with absent gag reflex Known Issues Multiple sizes, based on weight, match correct syringe with device to inflate cuff Does not prevent aspiration Improper placement (cuff folded over) EDD is not recommended as a confirmation device with the LMA Is NOT a medication route for Endotracheal drugs

14. Combitube http://www.combitube.org/

15. Combitube Why Unconscious / unresponsive patients without gag reflex Blind insertion technique Alternative to E.T.T. Known Issues Two sizes, limited to patients over 4 foot. Obtaining proper seal / placement Ventilating through correct tube Is NOT a medication route for Endotracheal drugs unless placed in the trachea (i.e. ventilating tube 2) (consult mfg recommendations) Contraindications Patients with intact gag reflexes Patient's height below 4 feet Patients with known esophageal pathology Patients after ingestion of caustic substances Central-airway obstruction

16. PTL Gettig Pharmaceutical Instrument Company http://216.92.52.175/ptl.html

17. PTL Why Unconscious / unresponsive patients without gag reflex Blind insertion technique Alternative to E.T.T. Known Issues Obtaining proper seal / placement Ventilating through correct tube Is NOT a medication route for Endotracheal drugs unless it is placed in the trachea (consult manufacturer recommendations) CONTRAINDICATIONS: Children - under the age of 14 Conscious or semiconscious patients Known caustic poisoning cases Known esophageal disease

18. King Airway http://www.kingsystems.com/

19. King Airway Why Unconscious / unresponsive patients without gag reflex Blind insertion technique Alternative to E.T.T. Known Issues Obtaining proper seal / placement Is NOT a medication route for Endotracheal drugs Multiple sizes, based on height, also multiple cuff volumes Contraindications Responsive patients with an intact gag reflex. Patients with known esophageal disease. Patients who have ingested caustic substances.

20. Conclusion Many devices available to providers Be familiar with what you have available to your organization. Immobilize to maintain head / neck position. Recheck lung sounds and End Tidal CO2 frequently Document device use and at least five confirmation methods used with results.

21. Questions / Discussion