10/5/2018
ADVANCED AIRWAY MANAGEMENT AND THE DON’T PRACTICE DIFFICULT AIRWAY UNTIL YOU GET IT RIGHT. PRACTICE UNTIL YOU CAN’T GET IT WRONG.
The Decision to Intubate Deciding to Intubate
n Can the patient protect their airway? n If you must establish an airway, you must protect that airway. n Can the patient adequately ventilate / oxygenate? n Do not rely on the gag reflex. n Swelling or progressive distortion only gets n What do you expect to happen? worse, intubate early. – Evaluate the patient n ABG’s are not helpful.
Airway Algorithm
n Is this a crash airway? n Is this a difficult airway? n Was intubation successful? n Oxygenation n Ventilation n 3 attempts ©MANTA2006
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©MANTA2006 ©MANTA2006
Difficult Airway
n Is there time? n Ability to ventilate or intubate n Can you proceed with RSI? *not a contraindication n Evaluate anatomic landmarks n Evaluate patient position ©MANTA2006
Can’t Intubate Can’t Ventilate Failed Airway CICV Airway
n Unable to Immediate rescue oxygenate airway n Oxygen saturations drop below 90% Cricothyroidotomy n 3 failed attempts n Attempt = entering larynx
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Rapid Sequence Intubation Rapid Sequence Intubation
n “The purpose of RSI is to render the RSI can be used over 80 percent of patient unconscious and paralyzed and the time. then to intubate the trachea without the 97 percent of all patients can be use of bag ventilation.” successfully intubated within 2 Ron Walls attempts. 1 percent require cricothyrotomy.
Rapid Sequence Intubation Rapid Sequence Intubation
n Assume they have a full stomach. n Preparation n Minimize bagging. n Preoxygenation n NO titration of medications or “slow n Pretreatment push.” n Paralysis with Induction n Protection and Positioning n Placement with Proof n Postintubation Management
Check Every Patient for a Preparation potentially Difficult Airway n Assess for difficult airway – L-look externally n Difficult Ventilation- inability of – E-evaluate landmarks/3-3-2 trained provider to maintain O2 – M-Mallampati saturation >90% using face mask – O-obstruction ventilation – N-neck mobility n Difficult Intubation- need for >3 – S-aturations intubation attempts or attempts at n Assemble equipment intubation lasting > 10 minutes n Fallback plan and equipment immediately available
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MALLAMPATI SCALE
n Mouth opening < 3 fingers n Hyoid-mentum distance <3 fingers n n Thyroid to floor of mouth Score 3 or 4 distance <2 fingers
HEAVEN vs LEMONS HEAVEN What is the difference? n Hypoxemia n HEAVEN is a prescreening tool that is used to determine difficult n Extremes of size resuscitation/intubation n Anatomic disruption/obstruction n LEMONS is a prescreening tool to n Vomit/blood/fluid in airway determine difficult direct laryngoscopy n Exsanguination n Anticipation vs reality n Neck mobility
Non-Invasive Airway Which option to use? Monitoring
BOTH n Capnography (ETCO2) Quantitative & Waveform Qualitative The combination of both LEMONS n Why is waveform better than and HEAVEN will help determine colormetric? the difficulty of intubation and n What is normal? resuscitation n Measurement of Ventilation, NOT Oxygenation
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Not Every Patient In Distress Don’t Forget there is a Patient Needs Intubation Attached to that Airway
n Is there failure to maintain or protect the airway? n It is easy to lose track of the rest of the patient while dealing with an n Is there failure of oxygenation and ventilation? airway emergency – Don’t skimp on Pre-oxygenation n Is there a need for intubation based on the anticipated clinical course?
PREPERATION Apneic Oxygenation
n Pre intubation using NC at 15- 25lpm Completely washes out nitrogen from the lungs (replacing it with 100% oxygen) helping to recruit alveoli for maximum oxygen absorption
Preoxygenation Preoxygenation
n Essential to the “no bagging” principle n BVM only if necessary n Establish an oxygen reservoir SpO2 =/>94% no need to assist – 8 full deep breaths on 100% in 60 SpO2 < 90%, assist ventilations seconds –Alternative -8 vital capacity breaths with BVM SpO2 <93% limit intubations attempts to 20 seconds
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AIRWAY ASSESSMENT
The Lost Art n ROMAN- Difficult bag-valve-mask ventilation –Radiation/restriction n The Original Airway Resistance to ventilate, COPD, ARDS, Term Pregnant n Essential to airway management –Obesity/Obstruction n Basic principle is BMI over 26 oxygen –Mask seal, male sex, mallampati Bushy beards, male faces, Mallampati 3-4 –Aged face Greater than 55 less than 3 –No teeth
Bag Mask Ventilation Bag Mask Ventilation n Standard bag holds 1500 cc oxygen. n Adequate seal BVM on face with oral / nasal airways n Standard ventilation volumes of 500cc n Patent airway –jaw thrust – ventilation rate or 16-24 breaths per minute. – oral airway – nasal airway n Use Sellick’s maneuver while bagging?
Seated Ventilation Bag Mask Ventilation n Two thumbs up method with patient head turned to the side n Two hand mask n Second rescuer providing either small hold volume or large volume ventilations – most effective for BMV n Attach ETCO2 device with BVM – Two thumbs up n Minimizes aspiration based on gastric method bubble 12-18 inches lower than glottis n Easier with atelectasis and airway pressures required to maintain adequate tidal volumes
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PREOXYGENATION Normal 70 kg Adult n Patients in whom intubation was attempted with SpO2 values above 93%, desaturations occurred only 6% Sick 70 kg Adult after 7 minutes n Patients in whom intubation was attempted with SpO2 values below Child 10 kg 93%, desaturations were inevitable Obese 127 kg adult
From Benumof J, Dagg R, Benumof R. Critical desaturation will occur before return to an unparalyzed state following 1mg/kg IV succinylcholine. Anesthesiology 1997;87:979.
Communication and Communication and Teamwork are Essential Teamwork n The key factor that makes problem solving n Two-Challenge Rule and crisis management successful or not is – If first verbal observation of a problem is not communication and teamwork acknowledged or acted upon, challenge – Clear leadership again. –Stay calm – If the safety issue persists, become more n Is the patient being ventilated? assertive. C- I am Concerned about… n Do you have enough help? U- I am Unconfortable because... n Verbalize your thoughts S- This is a Safety issue....
Communication and Communication and Teamwork Teamwork
. It is difficult to challenge someone in n Leaders in a critical event need to be authority open to feedback and suggestions. . Airline Industry recognized and implemented n Foster clinical environment in which industry wide changes and training. all staff feels empowered to speak up. . If a co-pilot facing personal death in an airplane crash, can’t question the pilot, how is n See something, Say something. for a nurse to challenge a doctor?
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GOALS Things to Consider n Pretreatment n Drugs and side effects n Induction Agents n Co-morbid conditions n Paralytics n Pathophysiologic reflexes n Topical Agents n Increased intracranial pressure
Pretreatment Lidocaine n Administration of drugs to minimize n Blunts cough reflex the adverse effects of intubation n Prevents rise in –L-Lidocaine intracranial pressure –O-Opiates n ? Reactive airway –A-Atropine disease – D-Defasciculating dose
Lidocaine Fentanyl n Sodium channel blockade decreases n Decreases cerebral metabolism, stabilizes cell sympathetic membranes – neuroprotective. response n Decreases n Reduces cardiomyopathic myocardial oxygen dysrhythmias by up to 50% - consumption cardioprotective. n Provides analgesia n Decreases intraocular pressure. and sedation
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Atropine Non-Depolarizing Paralytic
n Indicated for every child under 1yr old. n Defasciculating dose n Indicated for every – 1/10 dose of competitive paralytic. child under 10 yr old – For use with succinylcholine. receiving – Suppresses ICP response of succinylcholine. succinylcholine. n Indicated for every adolescent or adult getting repeat doses of succinylcholine.
Paralysis with Induction Drugs n Use rapid acting agents Induction Agents n Paralytics –Quick onset – Etomidate – Depolarizing Agents – Ketamine – Non-Depolarizing – Duration of action –Propofol Agents – Side effects – Barbiturates – DO NOT TITRATE – Benzodiazepines
Etomidate Ketamine n Induction agent of Induction agent of choice choice for n Rapid action bronchospasm n Short duration Quick onset n Lack of cardio- Short duration depressant side High potency effects n Cerebroprotective
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Propofol
n Onset: less than 1 minute n Duration: Rapidly metabolized within 10 minutes n MOA: highly lipophyllic sedative- hypnotic n Decreases ICP n Anticonvulsant
Depolarizing Paralytics Midazolam Succinylcholine
n Unparalleled n Onset: 30-60 amnesia seconds n Onset of action 3-5 n Duration: 5- 12 minutes minutes n Variable dose n MOA: depolarizing n No role for paralytic, binds to induction ACH receptors n Valuable for post intubation sedation
Succinylcholine Contraindications Nondepolarizing Paralytics
Burns over ten percent BSA: 48 hours to 6 – Longer onset / long acting months – Newer agents have rapid onset Paralysis: 3 days to 6 months – Do not require defasciculation Denervation syndrome: Until inactive for 6 months Crush Injury: 3 days to 6 months Abdominal Sepsis: Longer than 3 days Hereditary myopathies Renal Failure?(avoid with elevated potassium)
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Rocuronium Cis-atracurium
n Onset: 55-70 sec Onset: 2 minutes n Duration: 30-60 Duration: 40-60 minutes minutes n Dose:0.6-0.9 Dose: 0.1-0.2 mg/kg mg/kg n Drug of choice in kids, if succinylcholine is contraindicated
Nondepolarizing Vecuronium Neuromuscular blockade Reversal n Onset 2-3 minutes
n Duration: 30-60 Atropine PLUS minutes – blunts muscarinic response n Dose - 0.1 mg/kg – High doses have Neostigmine / Edrophonium quicker action-0.3 – duration of action 10-30 min mg/kg Sugammadex-rapid reversal agent –Useful as defasciculating agent
Position is Critical Topical Agents Protection and Position n Lidocaine n Cocaine n ? Sellick’s n Neosynephrine maneuver n ? Sniffing position n Head Up n C-Spine precautions
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HEADS UP Position n 50% lung volume is lost lying flat n “Ear at the sternal notch” n Preoxygenation with 20 degree head- up tilt provides longer duration of non-hypoxic apnea than conventional preoxygenation in non-obese healthy adult
Flexion
Neutral Extension
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Jaw Thrust Tongue Traction
Head Elevated Position Sellick’s Maneuver
Protection and Position
n Sellick’s n BURP - Backward, Upward, Rightward Pressure n ELM - External Laryngeal Manipulation
Flexion Neutral Extension
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ELM ENDOTRACHEAL INTUBATION
n External n Preferred method for airway manipulation by the management laryngoscopist. n Protect against aspiration n Improves POGO scores 57%.
INDICATIONS Equipment needed n Failure to protect or maintain airway n Oxygen n Magil Forceps n BVM n Laryngoscope/blad n Failure to Oxygenate or Ventilate n Suction es n Anticipated clinical course n BLS Airways n Video Laryngoscope n ET Tubes/stylets n Back up airways Contraindicated when patient is n Syringe n Monitoring devices managing a patent airway without n Bougie clinical indication to provide advanced n Confirmation airway management devices n Stabilization device
Blade choices Curved Blades
n Personal preference n Miller n Designed to be n Use it as it was n Macintosh placed in the designed vallecula – can be used as a n Bigger blades straight blade control bigger tongues
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Straight Blades Technique n Designed to pick up n Grip the epiglottis –avoid the “death grip” n Thinner blade – use fingers for design precision n Less tongue control movements – use shoulder for leverage – lift toward the ceiling over patient’s feet
Bougie Tube Angle Endotracheal Tube Exchanger/introducer Straight tube 90 degree hook 30 degree bend
Landmarks
n Tongue is your enemy n Epiglottis is your friend n Cords are the goal
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Open Mouth Tongue Sweep
SALAD Video Laryngoscopy Suction –Assisted Laryngoscopy Airway Decontamination What have we learned? n SUCTION!! n Developed by Dr. James DuCanto n Walk the blade down n Constant upper airway suction the mouth n Insert midline or n After clearing contaminant from the airway, slightly left of center the catheter can be left in place, to the left of the laryngoscope blade continuously n When you see the uvula, lift to expose the removing blood, vomit and other materials. airway The practitioner can intubate, with the n Slide stylet out slightly catheter in place via either direct or video laryngoscopy.
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Don’t rely on Video Patient characteristics associated Laryngoscopy to save the day with first-pass failure using VL include:
n First pass success rate with GlideScope n Morbid obesity reported 80-90% and ultimate success n Blood/ emesis in the airway rate of 98%. n Airway edema n BUT, VL can fail…. and if difficult-to- n Mass ventilate patient, first pass success is critical. n Restricted neck motion n Limited mouth opening n Surgery/radiation
Failure of VL can be related ETT Tip in Correct Plane of to technique Larynx
n Look at the Patient Until the ETT Tip ETT too deep Optimal Positioning Appears on the Monitor n A More Neutral Head Position Helps n Don’t Insert the Blade Too Deep n Don’t Insert the ETT Too Posteriorly n Don’t Forget to Lift the Blade and Jaw Upward n May Need Cricoid Pressure
If the ETT can’t make the turn into the There Is No Situation So Bad larynx, too deep/posterior of pharnyx That You Can’t Make Worse ETT bottom of monitor ETT middle/upper right n When do you stop if something’s not working? – Change technique – Change equipment – Change people – Two-Challenge Rule
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Supraglottic Devices Supraglottic Devices n Do not provide a “definitive airway.” n Laryngeal Mask Airway (LMA) n Rescue devices. n Intubating LMA n Can be as effective as intubation. n King LT n Can be used in failed airways provided n Combitube cricothyrotomy is being set up.
Laryngeal Mask Airway Intubating LMA
n Single lumen mask n Laryngeal Mask airway device. Airway with n Covers glottic intubation port. opening and allows n Allows placement ventilation. of cuffed tracheal tube.
Combitube King LT n Dual Lumen rescue n Single lumen airway device. airway device. n Two inflation ports. n Double balloon has n Ventilation aperture one inflation port. between balloons n Ventilation and distal tip. apertures between n Distal cuff does not the balloons. block esophagus. n Distal cuffs blocks esophagus.
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King LT
PLAN FOR THE END IN THE IGEL BEGINNING
n Preparation – Have everything ready for the worst. n Dentures – Leave them in while bagging, take them out to intubate. n Lubrication n External laryngeal manipulation – Master it and use it.
Postintubation Management Placement with Proof
n USE A STYLET n Bradycardia is due to esophageal n Take your time intubation and hypoxemia until proven n Visualization otherwise n Utilize detection n Confirm with methods ETCO2/SpO2/Auscultation/PCXR – ETT detector n Secure ETT – O2 saturation –Waveform n Sedation Capnography n Paralysis –Physical exam -not reliable n NGT/OGT
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Postintubation Management Summary
n Monitor tube depth n Consider specific measures to improve – Pediatric airway - use collar oxygenation and first time success n Reassess tube after moving patient or n Predict the updated pneumonic on any clinical change difficult airway assessment HEAVEN n Ventilator management / Bagging n Implement two thumbs up method, HOB elevated, High Flow NC, PEEP, and ETCO2 to airway management
SUMMARY
n Videoscopic intubation requires finesse than muscle n When in doubt, go back to the basics n Proper assessment and suctioning of airway will help prevent failure n First pass success vs desaturation are both equally important
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