10/5/2018

ADVANCED 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 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 /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 (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 (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- 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 : 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% 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

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 (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 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 .

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 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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