1.  A patient who needs intubation may be awake.  Need for airway control may necessitate intubation.  RSI paralyzes the patient to facilitate endotracheal intubation.

4.  Anatomical Differences  Smaller and more flexible than an adult  Tongue proportionately larger  Epiglottis floppy and round  Glottic opening higher and more anterior  Vocal cords slant upward, and are closer to the base of the tongue  Narrowest part is the cricoid cartilage

5.  A straight laryngoscope blade is preferred for most pediatric patients.  Selecting the appropriate tube diameter for children is critical.  ETT size (mm) = (Age in years + 16) ÷ 4  Matching it to the diameter of the child’s smallest finger  Use non-cuffed endotracheal tubes with infants and children under the age of 8 years.

7. © Scott Metcalfe

15.  Mask seal can be more difficult  Bag size depends on age of child  Ventilate according to current standards  Obtain chest rise and fall with each breath  Assess adequacy of ventilations by observing chest rise, listening to lung sounds, and assessing clinical improvement

17.  “Blind” procedure without direct visualization of the vocal cords  Indications include:  Possible spinal injury  Clenched teeth  Fractured jaw, oral injuries, or recent oral surgery  Facial or airway swelling  Obesity  Arthritis preventing sniffing position

18.  Contraindications  Suspected nasal fractures  Suspected basilar skull fractures  Significantly deviated nasal septum or other nasal obstruction  Cardiac or respiratory arrest

19.  Advantages  The head and neck can remain in neutral position  It does not produce as much gag response and is better tolerated by the awake patient  It can be secured more easily than an orotracheal tube  The patient cannot bite the ETT

20.  Disadvantages  More difficult and time consuming  Potentially more traumatic for patients  Tube may kink or clog more easily  Greater risk of infection  Improper placement more likely  Requires that patient be breathing

22.  Field extubation may be indicated when:  The patient is clearly able to maintain and protect his airway.  The patient is not under the influence of sedatives.  Reassessment indicates the problem that led to endotracheal intubation is resolved.  Consider the high risk of laryngospasm

23.  A dual-lumen airway  The longer, blue port (#1) is the proximal port  The shorter, clear port (#2) is the distal port, which opens at the distal end of the tube  Two inflatable cuffs  100-mL cuff just proximal to the distal port  15-mL cuff just distal to the proximal port

25. ETC Airway Tracheal Placement

26.  Advantages  Provides alternate airway control  Insertion is rapid and easy  Does not require visualization of the larynx  Pharyngeal balloon anchors the airway  Patient may be ventilated regardless of tube placement  Significantly diminishes gastric distention  Can be used on trauma patients  Gastric contents can be suctioned

27.  Disadvantages  Suctioning tracheal secretions is impossible when the airway is in the esophagus.  Placing an endotracheal tube is very difficult with the ETC in place.  It cannot be used in conscious patients or in those with a gag reflex.

28.  Disadvantages  The cuffs can cause esophageal, tracheal, and hypopharyngeal ischemia.  It does not isolate and completely protect the trachea.  It cannot be used in patients with esophageal disease or caustic ingestions.  It cannot be used with pediatric patients.

29. Click here to view a video on ETC.here

30.  Two-tube system:  Proximal cuff seals oropharynx  Distal cuff seals either the esophagus or the trachea  Advantages  Disadvantages

31.  Has an inflatable distal end that is placed in the hypopharynx and then inflated  Blind insertion  Disadvantage:  Does not isolate trachea

32.  It is designed to facilitate endotracheal intubation.  An epiglottic elevating bar in the mask aperture elevates the epiglottis.  Tube is directed centrally and anteriorly. © LMA North America

33.  Similar to the laryngeal mask  Supraglottic airway  “Cobra head” of the airway holds both the soft tissue and the epiglottis out of the way © Engineered Medical Systems, Inc. Indianapolis, IN

34.  Supraglottic, single- use, disposable airway  Features a special curve that replicates the natural human airway anatomy © Ambu Inc. Baltimore, MD

35.  Alternative airway  Large silicone cuff that disperses pressure over a large mucosal surface area  Stabilizes the airway at the base of the tongue ©Tracey Lemons/King Systems Corporation, Indianapolis, Indiana

36.  Removing an obstructing foreign body using Magill forceps or a suction device  You should carry out basic life support maneuvers first.  If these fail to alleviate the obstruction, direct visualization of the airway for foreign body removal is indicated.

38.  You should use surgical airway procedures only after you have exhausted your other airway skills:  Needle cricothyrotomy  Surgical cricothyrotomy

39.  Indications  Massive facial or neck trauma  Total upper airway obstruction  Contraindications  Inability to identify anatomical landmarks  Crush injury to the larynx  Tracheal transection  Underlying anatomical abnormalities

40.  Transtracheal jet insufflation is required  Complications:  Barotrauma from overinflation  Excessive bleeding due to improper catheter placement  Subcutaneous emphysema  Airway obstruction  Hypoventilation

47.  It is preferred to needle cricothyrotomy when a complete obstruction prevents a glottic route for expiration.  Its greater potential complications mandate even more training and skills monitoring.  Contraindications:  Includes children under 12

48.  Cricothyrotomy Complications:  Incorrect tube placement into a false passage  Cricoid and/or thyroid cartilage damage  Thyroid gland damage  Severe bleeding  Laryngeal nerve damage  Subcutaneous emphysema  Vocal cord damage  Infection

50. Stabilize larynx and make a 1–2 cm vertical skin incision over cricothyroid membrane

52. Using a curved hemostat, spread membrane incision open

58.  Terms  Difficult airway A conventionally trained paramedic experiences difficulty with mask ventilation, endotracheal intubation, or both  Difficult mask ventilation Inability of unassisted paramedic to maintain an SpO 2 > 90% using 100% oxygen and positive pressure mask ventilation Inability of the unassisted paramedic to prevent or reverse signs of inadequate ventilation during positive pressure mask ventilation

59.  Terms (cont.)  Difficult laryngoscopy Not being able to see any part of the vocal cords with conventional laryngoscopy  Difficult intubation Conventional laryngoscopy requires either (1) more than three attempts, or (2) more than ten minutes  Factors related to difficult airway are related to historical information, anatomical, and poor technique

60.  Historical Factors:  Patient has had a history of problems with airway management or anesthesia.  If time and patient condition allows, obtain a brief airway history.

61.  Anatomical Considerations  Anatomy of the upper airway varies significantly across the human species.  The most frequently used system of pre- intubation airway assessment is the Mallampati Classification system. The tonsillar pillars and the uvula are assessed.

62.  Class 1  Entire tonsil clearly visible  Class 2  Upper half of tonsil fossa visible  Class 3  Soft and hard palate clearly visible  Class 4  Only hard palate visible The Mallampati classification system is at top.

63.  Other rating systems  Revised Cormack and LeHane classifications Similar to Mallampati Assigns 4 classes  POGO The percentage of the glottis that can be visualized is scored From 0 to 100%

64.  Short neck  Thick neck  Restricted range of motion  Dentition  Small mouth  Short mandible  Anterior larynx  Obesity  Anatomical distortion

67.  Patients who have had a laryngectomy or tracheostomy breathe through a stoma.  There are often problems with excess secretions, and a stoma may become plugged.  Use extreme caution with any suctioning.

70.  Anticipating complications when managing an airway  Be prepared to suction all airways to remove blood or other secretions and for the patient to vomit. Tracheostomy cannulae

73.  Wear protective eyewear, gloves, and face mask.  Preoxygenate the patient.  Determine depth of catheter insertion.  With suction off, insert catheter.  Suction while removing catheter.  Ventilate patient.

74.  It is sometimes necessary to remove secretions or mucous plugs that can cause respiratory distress.  Hypoxia is a concern.  Use sterile technique.  It may be necessary to instill sterile water to thin secretions.

76.  A common problem with ventilating a nonintubated patient is gastric distention.  You should place a tube in the stomach for gastric decompression.  Nasogastric tube  Orogastric tube

77.  Indications:  The need for decompression because of the risk of aspiration or difficulty ventilating  Gastric lavage in hypothermia and some overdose emergencies  Complications:  Possibility of esophageal bleeding  Increased risk of esophageal perforation

78.  Procedure  Place head in neutral position  Measure tube  Use topical anesthetic  Lubricate and insert tube Encourage patient to swallow  Advance to pre-determined mark  Verify placement  Apply suction  Secure in place

80. DeviceOxygen Percentage Nasal cannula Simple face mask Nonrebreather mask Venturi mask 40% 24, 28, 35, or 40% 40 – 60% 80 – 95%

81.  Small Volume Nebulizer  Allows for delivery of medications in aerosol form (nebulization)  Oxygen Humidifier  Benefits patients with croup, epiglottitis, or bronchiolitis, as well as those patients receiving long-term oxygen therapy

83.  Effective ventilatory support requires a tidal volume of at least 800 mL of oxygen at 10 to 12 breaths per minute.  Effective artificial ventilation requires:  A patent airway  An effective seal between the mask and the patient’s face  Delivery of adequate volumes

84.  Mouth-to-mouth  Mouth-to-nose  Mouth-to-mask  Bag-valve device  Demand valve device  Automatic transport ventilator

85.  Indicated in the presence of apnea when no other ventilation devices are available  Limited by the capacity of the person delivering the ventilations  Potential for exposing either the rescuer or the patient to communicable diseases

86.  Prevents direct contact between you and your patient’s mouth  Devices usually have a one-way valve that prevents you from contacting the patient’s expired air.  May also provide an inlet for supplemental oxygen

87.  Prehospital and emergency department personnel most commonly use the bag-valve device.  One, two, or three rescuers may perform bag-valve- mask ventilation. © Scott Metcalfe

88.  Observe the patient for chest rise, gastric distention, and changes in compliance of the bag with ventilation.  Complications:  Inadequate volume delivery  Barotrauma  Gastric distention

90.  Flow-restricted, oxygen-powered ventilation device  Flow is restricted to 30 cm H 2 O or less to diminish gastric distention  Cannot measure delivered volumes or feel lung compliance

91.  Advantages:  Maintain minute volume  Mechanically simple and adapts to a portable oxygen supply  Typically comes with two or three controls  Rate  Volume  Contraindications

93.  A significant percentage of claims and lawsuits involve inadequate patient ventilation.  Detailed documentation shown could go a long way toward warding off such a claim.

94. It is crucial to document in medically correct and legally sufficient terms exactly what was done in managing the airway.

95.  Anatomy of the Respiratory System  Physiology of the Respiratory System  Respiratory Problems  Respiratory System Assessment  Basic Airway Management  Advanced Airway Management  Orotracheal Intubation  Pediatric Orotracheal Intubation  Nasotracheal Intubation  Managing Patients with Stoma Sites  Suctioning  Gastric Distention and Decompression  Oxygenation  Ventilation  Documentation