9/20/18

Rescue Ventilation is Born

Archie Brain received the Benefactor of Mankind Award from the Airway

Airway Rescue with Supraglottic Education & Research Foundation – Devices September 16, 2000

Airway Rescue with Supraglottic Devices

James Rich, CRNA SLAM Airway Training Institute Thank You Archie Brain

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Rescue Ventilation Pathway

•Rescue Ventilation with any FDA Approved SGA.

EMERGENCY USE OF THE LMA PULMONARY ASPIRATION AND THE LMA MIGHT BE USED IN EMERGENCIES Ü The LMA does not afford complete protection against gastric regurgitation and pulmonary þ Cardiac arrest aspiration. However… Ü During CPR the LMA does provide significantly þ Near drowning greater protection against aspiration than occurs with mouth-to-mouth / pocket mask / þ Drug overdose automatic resuscitator / bag-valve-mask ventilation, with or without an O/P or N/P þ Smoke inhalation / toxic fumes airway Ü The level of protection is enhanced when the þ Cannot Ventilate – Cannot Intubate LMA is used as the sole airway adjunct from the outset of resuscitation þ Trauma - including in those with Ü The cuff of the LMA also helps to guard against the aspiration of blood arising from oral or nasal head/facial trauma unable to maintain cavities. airway or oxygenation.

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THE LARYNGEAL MASK AIRWAY THE LARYNGEAL MASK AIRWAY Advantages over the tracheal tube: Disadvantages compared with the tracheal tube: Ü Placement easier to learn Ü Airway less effectively secured - the cuffed tracheal tube Ü Higher levels of skill retention over time remains the ‘Gold Standard’ airway device Ü Higher first-time placement rates Ü Airway obstruction at glottic and subglottic level cannot Ü Shorter time to achieve an adequate airway be prevented Ü Plentiful supply of routine cases on which to gain experience Ü Oropharyngeal leakage and gastric insufflation are more Ü Laryngoscopy unnecessary likely to occur

Ü Neuromuscular blockade not required Ü Ventilation pressures over 20 (or 30) cmH2O not possible Ü Avoids risk of oesophageal & endobronchial placement Ü Fixation said to require greater spatial awareness with Ü Placement easily achieved with MILS of cervical spine applied possible higher risk of dislodgement Ü Less invasive of and traumatic to the respiratory tract Ü Cost

Ü Lower incidence of bacteraemia & laryngospasm Ü Increased risk of aspiration? Ü Avoidance of barotrauma to lungs.

THE LARYNGEAL MASK AIRWAY THE LARYNGEAL MASK AIRWAY Disadvantages compared with the tracheal tube: Disadvantages compared with the tracheal tube: Ü Airway less effectively secured - the cuffed tracheal tube Ü Airway less effectively secured - the cuffed tracheal tube remains the ‘Gold Standard’ airway device remains the ‘Gold Standard’ airway device Ü Airway obstruction at glottic and subglottic level cannot Ü Airway obstruction at glottic and subglottic level cannot be prevented be prevented

Ü Oropharyngeal leakage and gastric insufflation are more Ü Oropharyngeal leakage and gastric insufflation are more likely to occur likely to occur

Ü Ventilation pressures over 20 (or 30) cmH2O not possible Ü Ventilation pressures over 20 (or 30) cmH2O not possible Ü Fixation said to require greater spatial awareness with Ü Fixation said to require greater spatial awareness with possible higher risk of dislodgement possible higher risk of dislodgement Ü Cost Ü Cost Ü Increased risk of aspiration? Not according to Ü Increased risk of aspiration? Not according to meta-analysis study by Brimacombe.

PITFALLS ASSOCIATED with LARYNGOSCOPIC TRACHEAL INTUBATION DRUGS TO FACILITATE LMA INSERTION Ü Scarcity of specialist anaesthetists in this environment 1. Drugs are not required for Cardiac Arrest patients or Ü Need for non-specialists to undertake regular practice to for those who are deeply unconscious with absent maintain intubation skills (with shrinking opportunities) glossopharyngeal reflexes (Tip - patients who will tolerate an O/P airway will Ü Limited availability of anaesthetic agents/neuromuscular blockers amongst pre-hospital care providers often tolerate careful insertion of an LMA) Ü Equipment issues (dead batteries, blown bulb, etc.) 2. ‘Judicious Sedation’ can be employed to facilitate LMA insertion in those who are not fully obtunded, Ü Poor vision of larynx due to blood & secretions (using midazolam, etomidate, propofol, etc.)

Ü Hypoxaemia associated with repeated/prolonged attempts 3. Neuromuscular blocking agents are not necessary for the insertion of LMA devices Ü Risk of undetected oesophageal or endobronchial tube placement 4. The LMA is tolerated at lighter levels of sedation Ü Potential for aggravation of cervical spine trauma than the tracheal tube. Ü Restricted access to trapped casualties.

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WHEN THE LMA IS CORRECTLY INSERTED IT PROVIDES A CLEAR SUPRAGLOTTIC PATHWAY

EXHALATION

Inhalation/Exhalation

CORRECT ORIENTATION OF INSERTING HAND DURING STANDARD INSERTION TECHNIQUE

Keep wrist well flexed

Push index finger Allow the palato- towards palm pharyngeal curve of opposite hand to guide the mask into position

LARYNX

TRACHEA

OESOPHAGUS

LMA Inflation Volumes Problems with LMA Insertion

• LMA #3 - 20 mL • LMA #4 - 30 mL • LMA #5 - 40 mL • LMA #6 - 50 mL

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King LT

• Insert • Inflate • Pull Back • Ventilate

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