1. 1 1 Case 1 Respiratory Emergencies © 2001 American Heart Association

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

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

4. 4 Learning and Skills Objectives t 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 CO 2 detection –Devices to detect esophageal placement Devices to prevent TT dislodgment

5. 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. 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 CO 2 detector or both (secondary tube confirmation) B = Breathing: use a commercial tube holder to prevent dislodgment B = Breathing: confirm effective oxygenation/ventilation by 0 2 sat, CO 2 levels, pH

7. 7 Anatomy of Airway

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

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

10. 10 The Oropharyngeal Airway

11. 11 Malposition of Oropharyngeal Airway Too short

12. 12 Nasopharyngeal Airway Insertion technique

13. 13 Barrier Devices Oral airway: inserts in patient

14. 14 Pocket-Mask Devices 1-way valve Port to attach O 2 source

15. 15 Mouth-to-Mask Ventilation t Advantages Eliminates direct contact Enables positive-pressure ventilation Oxygenates well if O 2 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. 16 Mouth-to-Mask Ventilation Fingers: jaw thrust upwardFingers: head tilt–chin lift

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

18. 18 Cricoid Pressure Thyroid Cartilage Cricoid

19. 19 Bag-Mask Ventilation t 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 t Potential complications Hypoventilation Gastric inflation

20. 20 Airway Adjunct Devices Nasal cannula 24%-44% O 2 concentration Face mask with O 2 reservoir, 60%-100% O 2 concentration

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

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

23. 23 Curved Blade Attaches to Laryngoscope Handle

24. 24 Curved Blade Attached to Laryngoscope Handle

25. 25 Curved Blade Laryngoscope Inserted Against Epiglottis

26. 26 Straight-Blade Laryngoscope

27. 27 Straight-Blade Laryngoscope Inserted Past Epiglottis

28. 28 Cricothyroid Membrane With Horizontal Cricothyrotomy Incision

29. 29 Aligning Axes of Upper Airway 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 C A B A B C Trachea Pharynx Mouth

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

31. 31 Tracheal Intubation t 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. 32 Tracheal Intubation t 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. 33 Tracheal Intubation t 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. 34 Tracheal Intubation t Complications Trauma—teeth, lips, tongue, mucosa, vocal cords, trachea Esophageal intubation Vomiting and aspiration Hypertension and arrhythmias

35. 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 Distal End Proximal End B C D E F G H A

36. 36 Esophageal-Tracheal Combitube Inserted in Esophagus 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 D A D B F H

37. 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. 38 LMA Introduced Through Mouth Into Pharynx

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

40. 40 Anatomic Detail

41. 41 Esophageal Detector Device (Bulb-Type)

42. 42 Confirmation: Tracheal Tube Placement End-tidal colorimetric CO 2 indicators

43. 43 Tracheal Tube Holders: Adult and Infant

44. 44 Qualitative End-Tidal CO 2 Detector What should the operator’s next action be?