1. Basic Emergent Airway Management

2. Learning Objectives: Review of important facts and concepts Airway Management equipment and Skills (primarily hands on simulation skills stations) Integration of Knowledge Skills and Judgment through Simulated Clinical (simulation based practice) Formal assessment of skills (simulation-based clinical skills and case management)

3. Basic Emergent Airway Management

4. Review of Important Facts and Concepts: Practical “Basic Emergent Airway Guidelines Avoiding airway emergencies through judicious patient selection Monitoring Oxygenation and Ventilation Signs and Symptoms of respiratory Distress

5. Practical “Basic Emergent Airway Guidelines: A, B, C, D A—Airway – LOOK & LISTEN – LOOK (overall patient & specifically in mouth) B---Breathing (ASK, LOOK, LISTEN) Circulation---check pulse, Get monitors on! IMMEDIATELY ASK YOURSELF ARE THEY SAFE or in IMMEDIATE TROUBLE! Do ACT----- Get HELP!!!

6. Initial introduction to guidelines:

7. Take home points to make this easy: 1.The best way to handle an airway emergency is to avoid getting into the situation in the first place through judicious patient selection based on pre-procedural patient airway examination and history. This coupled with attentive monitoring of oxygenation and ventilation can avoid many bad situations. 2.When managing an airway problem focus on oxygenation signs and symptoms (i.e. SpO2, Resp. rate, LOC, EtCO2) then decide to either to: a.“Supplement”NC O2, face mask, Non-rebreather b.“Assist”BMV + a nasal airway c.“Control” BMV + a nasal and or oral airway, LMA if OMV fails

8. Pre-procedural Evaluation of the Upper Airway: “ Concept—look for things that correlate with difficult mask ventilation” 1.Size of Tongue versus Pharynx – Mallampati classification 2.Facial features that can directly compromise mask seal – Beard, edentulous 3.Neck features associated with difficult mass ventilation – Thyromental distance, large neck, laryngeal tongue

9. Understanding Upper Airway Obstruction— ”cork in the bottle”

10. 1. Size of Tongue vs Pharynx “Mallampati Classification” Concept: Patient’s with a Class 3-4 airway have a relatively large tongue relative to the volume of their pharynx which can lead to difficulty performing positive pressure ventilation.

11. 2. Facial features: Concept: Be wary of facial features in sedation candidates that could make trying to obtain a mask seal very difficult (they all leak).

12. 3. ↓ Anterior Mandibular Space & Large Neck Concept: “neck features that in the presence of sedation, relaxed airway, recumbent position: a) place a patient at higher risk for obstruction and b) that if needed, could make positive pressure ventilation difficult”.

13. Monitoring Oxygenation and Ventilation Respiratory Distress Signs & Symptoms Monitors

14. SIGNS OF RESPIRATORY DISTRESS Anxiety/altered mental status Diaphoresis Tachypnea Bradypnea Pursed lip breathing Short sentences Abnormal phonation Prolonged expirations Nasal flaring Retractions Accessory muscle use Paradoxical movement Snoring Crackles Wheezing

15. RESPIRATORY DISTRESS --MONITORS Pulse Oximetry (OXYGENATION, ventilation) Capnography (VENTILATION, oxygenation) Common Sensometer (look/listen/feel)

16. Pulse Oximetry Simulated desaturation example on simulator “Listen to the tone” (insert video/audio of desat) Concept: The Pulse oximeter tone is a good monitor that allows you to work at the same time (this requires training yourself to listen to the tone).

17. Pulse Oximetry (SpO2)

18. Pulse Oximetry SpO2 ~ SaO2 SpO2 90%~PaO2 60 mmHg (30-60, 60-90) Factors that influence accuracy of Pulse Oximetry Low blood flow states Patient movement Dysfunctional hemoglobins Altered oxyhemoglobin dissociation curve Note: oxygenation is not necessarily ventilation

19. Hg-SaO2 Concepts:

20. Capnography

22. Causes of changes in the exhaled concentrations of CO2 Increase Hypoventilation Rebreathing Admin. NaHCO3 Metabolic Decrease Hyperventilation Hypothermia Low Cardiac output Pulmonary embolism Cardiac arrest

23. Common Sensometer: (look/listen/feel) “How you doing---”

24. Common Sensometer: (look/listen/feel) Simulated “respiratory distress” example on simulator

25. Basic Emergent Airway Management: A, B, C, D A—Airway – LOOK & LISTEN – LOOK (overall patient & specifically in mouth) B---Breathing (ASK, LOOK, LISTEN) Get monitors on! IMMEDIATELY ASK YOURSELF ARE THEY SAFE or in IMMEDIATE TROUBLE! ACT----- Get HELP!!!

26. © 2007 John J. Schaefer III, MD

27. ROTATE TO NEXT STATION:

28. Basic Emergent Airway Management

29. Station A: Airway Management equipment and Skills – Supplemental O2 Setting up O2 tank Nasal Cannula Simple Face Mask Non-Rebreather Face Mask Take home points – Jaw thrust, Nasal & Oral Airways Jaw thrust Nasal Airway Oral Airway Take home points

30. Setting up an O2 Tank: --need to finish---

31. Supplemental Oxygen: Nasal Cannula Simple Face Mask Non-rebreather Face Mask

32. Nasal Cannula Increases in FiO2 varies with respiratory rate, depth, and mouth breathing Each ^ 2 LPM =^ FiO2 2-4% Intolerable > 8-10 LPM

33. Simple Facemask: FiO2 = 30-60% 6-10 LPM

34. Nonrebreathing Mask: FiO2 = 60-90% 15 LPM

35. Jaw Thrust Concept:

36. Nasopharyngeal Airway: Secure air passage from nose to posterior pharynx, bypassing tongue Tolerated in conscious patients Can lead to epistaxis

37. Nasopharyngeal Airway: How to-- 1.Observe nares for deviated septum 2.Lubricate nasal airway 3.Direct airway posterior approximately perpendicular, not in same direction as nasal bridge 4.Important concept is that it needs to be long enough to get pass base of tongue

38. Oropharyngeal Airway Secure air passage from mouth to pharynx, bypassing tongue Patient must be areflexic/unresponsive

39. Oropharyngeal Airway: How to--

40. Oral & Nasal Airway Practice: Do on each other! ----or simulator

41. Supplemental O2 Safety Reminder--- Be extremely careful and avoid if possible use of an ignition source in the presence of supplemental O 2 !

42. ROTATE TO NEXT STATION:

43. Basic Emergent Airway Management

44. Station: Bag-Mask ventilation Setting up equipment How to get a face mask seal & basic bag mask ventilation – Concept and demonstration – Simulation-based practice Two person bag mask ventilation – Concept and demonstration – Simulation-based practice Optimal Mask ventilation – Concept and demonstration – Simulation-based practice Assisted mask ventilation – Concept and demonstration – Simulation-based practice Take home points

45. Bag-Mask: Assist or control ventilation Combine with NPA/OPA if possible TV: 5-7 ml/kg Ventilation rate: 1 breath every 5-6 secs Avoid hyperventilation

46. Masking Concepts & Tips: Tip #1 USE AN AIRWAY! It is too hard to both seal and do a good jaw thrust. By using an airway, one can focus on mask seal which is hard enough and not worry about trying to do a good jaw thrust at the same time.

47. Masking Concept: “It is all about the seal” “Correct” “Classic -- mistake”

48. How to obtain a mask seal– the key is understanding and applying how to apply force to all parts of the mask! The most common mistake leading to leakage is positioning your hand such that mask seal is sacrificed for jaw thrust.

49. How to obtain a mask seal– the key is understanding and applying how to apply force to all parts of the mask! In theory the reason why jaw thrust is emphasized is to “open the airway” The reality is that unless one has a very large hand, this is extremely difficult to do at the same time one extends their fingers to the distal side of the mask

50. Solution! –how to both seal the mask and “open the airway” -4 step process- 1.Use either a nasal (reflexes present) and or oral airway (reflexes absent) “to open the airway” –same function as “jaw thrust”

51. Solution! –how to both seal the mask and “open the airway” 2.Place web of thumb-index finger as close as possible to center of mask (this allows your fingers to maximally spread around the entire mask) and through a combination of palm and finger pressure, apply pressure around the entire mask. 3.Hook 1-2 fingers anywhere comfortable along the mandible to facilitate applying leverage with your other fingers and palm (this should not be confused with trying to perform a “jaw thrust”).

52. Solution! –how to both seal the mask and “open the airway” 4.For mechanical advantage and comfort, the wrist should not be flexed. This means that instead of standing directly behind the patient, one should move a little to the same side of the patient you are masking with (usually left side).

53. Tricks that help-- Place the mask from the bridge of the nose first to affect a better seal. Position the patient supine and at about waist height (if chair can be adjusted). If necessary to achieve the equivalent position (chair doesn’t adjust enough) use a step stool. Use part of your weight by leaning into the mask to assist in obtaining a mask seal (note: only do this with an airway in place or one can cause obstruction). If the mask you are using has mask strap bracket on it, take it off so your hand can get closer to the center of the mask.

54. Optimal Mask Ventilation Bag-Mask Nasal Airway Oropharyngeal Airway Two-person mask ventilation

56. “Assist” BMV Time it with inhalation by either a) watching chest rise or b) watching abdominal rise (non- compliant chest) If you time it wrong you can make things worse

57. Training exercise: 1.Demonstrate competent mask ventilation on simulator 2.Demonstrate optimal mask ventilation 3.Demonstrate two person mask ventilation 4.Demonstrate “assisted” mask ventilation Facilitator Note: use “mask ventilation practice” scenario

58. ROTATE TO NEXT STATION:

59. Basic Emergent Airway Management

60. Station: Laryngeal Mask Ventilation—Rescue airway and Applied Guidelines practice -LMA Indications, contraindications, complications LMA placement – Concept and demonstration – Simulation-based practice -Integration of Knowledge Skills and Judgment through Simulated Clinical Practice – Review of guidelines – Simulation practice

61. Laryngeal Mask Airways (LMA), Indications and Use

62. Introduction The LMA was invented by Dr. Archie Brain at the London Hospital, Whitechapel in 1981 The LMA consists of two parts: – The mask – The tube The LMA has proven to be very effective in the management of bag mask ventilation

63. Introduction The LMA design: – Provides an “oval seal around the laryngeal inlet” once the LMA is inserted and the cuff inflated. – Once inserted, it lies at the crossroads of the digestive and respiratory tracts.

64. Indications for the use of the LMA Situations involving a difficult mask (BVM) fit. May be used as a back-up device where optimal mask ventilationis not successful. Patient must be areflexic (pharynx)

65. Relative Contraindications of the LMA Greater than 14 to 16 weeks pregnant Patients at risk of aspiration NOTE: Not all contraindications are absolute

66. Complications of the LMA Throat soreness Dryness of the throat and/or mucosa Side effects due to improper placement vary based on the nature of the placement

67. Preparation of the LMA for Insertion Step 1: Size selection Step 2:Examination of the LMA Step 3: Check deflation and inflation of the cuff Step 4:Lubrication of the LMA Step 5:Position the Airway

68. Step 1: Size Selection Verify that the size of the LMA is correct for the patient Recommended Size guidelines: – Size 1: under 5 kg – Size 1.5: 5 to 10 kg – Size 2: 10 to 20 kg – Size 2.5: 20 to 30 kg – Size 3: 30 kg to small adult – Size 4: adult – Size 5: Large adult/poor seal with size 4

69. Step 2: Examination of the LMA Visually inspect the LMA cuff for tears or other abnormalities Inspect the tube to ensure that it is free of blockage or loose particles Deflate the cuff to ensure that it will maintain a vacuum Inflate the cuff to ensure that it does not leak

70. Step 3: Deflation and Inflation of the LMA Slowly deflate the cuff to form a smooth flat wedge shape which will pass easily around the back of the tongue and behind the epiglottis. During inflation the maximum air in cuff should not exceed: – Size 1: 4 ml – Size 1.5: 7 ml – Size 2: 10 ml – Size 2.5: 14 ml – Size 3: 20 ml – Size 4: 30 ml – Size 5: 40 ml

71. Step 4: Lubrication of the LMA Use a water soluble lubricant to lubricate the LMA Only lubricate the LMA just prior to insertion Lubricate the back of the mask thoroughly

72. LMA Insertion Technique

73. LMA Insertion Step 1 Grasp the LMA by the tube, holding it like a pen as near as possible to the mask end. Place the tip of the LMA against the inner surface of the patient’s upper teeth

74. LMA Insertion Step 2 Under direct vision: – Press the mask tip upwards against the hard palate to flatten it out. – Using the index finger, keep pressing along hard-soft palate as you advance the mask into the pharynx to ensure the tip remains flattened and avoids the tongue.

75. LMA Insertion Step 3 Continue pushing with your index finger. – Guide the mask downward into position.

76. LMA Insertion Step 4 Grasp the tube firmly with the other hand – then withdraw your index finger from the pharynx. – Press gently downward with your other hand to ensure the mask is fully inserted.

77. LMA Insertion Step 5 Inflate the mask with the recommended volume of air. Do not over-inflate the LMA. Do not touch the LMA tube while it is being inflated unless the position is obviously unstable. – Normally the mask should be allowed to rise up slightly out of the hypopharynx as it is inflated to find its correct position.

78. Confirmation of Tube Placement End-tidal PCO2 Symmetric bilateral chest movements – Bilateral breath sounds Feel of compliance while manually inflating the lungs – Presence of expiratory refilling of bag Condensation of water in the tube lumen Hemoglobin oxygen saturation

79. Securing the LMA Insert a bite-block or roll of gauze to prevent occlusion of the tube should the patient bite down. Now the LMA can be secured utilizing the same techniques as those employed in the securing of an endotracheal tube.

80. Problems with LMA Insertion Failure to press the deflated mask up against the hard palate or inadequate lubrication or deflation can cause the mask tip to fold back on itself.

81. Training Exercise: 1.Practice placement of LMA until advanced beginner on simulator. 2.Understand the basic problem solving when placement fails. 3.Demonstrate how to secure an LMA. Facilitator Note: use “LMA Training” scenario

82. Part B. Practice putting it all together “Basic Emergency Airway Guidelines” Mega-airway code

83. Basic Emergent Airway Management: A, B, C, D A—Airway – LOOK & LISTEN – LOOK (overall patient & specifically in mouth) B---Breathing (ASK, LOOK, LISTEN) Get monitors on! IMMEDIATELY ASK YOURSELF ARE THEY SAFE or in IMMEDIATE TROUBLE! ACT----- Get HELP!!!

84. © 2007 John J. Schaefer III, MD

85. Training exercise: 1.Demonstrate applying BAM guidelines in real time---group practice Facilitator Note: use “guidelines practice” scenario

86. ROTATE TO NEXT STATION: Each individual is tested (post-test)

87. Basic Emergent Airway Management

88. Individual Simulation Assessment: 1.BMV competency 2.LMA placement competency 3.“Basic Emergency Guidelines” competency

89. Final Step: post-course survey—help us make this better Certificate upon completion of survey—found in classroom--