CHRIS POULSEN, D.O. MEDICAL DIRECTOR, REACH AIR MEDICAL SERVICES OBJECTIVES
At the conclusion the participant will • 1.Understand airway anatomy applicable to airway management devices and techniques. • 2.Verbalize an understanding of airway management devices and theory. • 3.Verbalize indications and contraindications of airway pharmacology. • 4.Understand the impact on scene time when Rapid Sequence Airway is performed at the scene. • 5.Recognize the signs of a potentially difficult airway. AIRWAY MANAGEMENT
. Introduction . Anatomy / Physiology . Positioning . Basics - Adjuncts . ALS - Intubation ANATOMY
Children are different than adults !!! ANATOMY PEDIATRIC AIRWAYS
Epiglottis: • Relatively large size in children • Omega shaped • Floppy – not much cartilage ANATOMY: ADULT vs PEDIATRIC AIRWAY ANATOMY - SHAPE ANATOMY POSITIONING AIRWAY POSITIONING FOR CHILDREN <2yrs POSITIONING SIGNS OF RESPIRATORY DISTRESS PHYSIOLOGY: EFFECT OF EDEMA
Poiseuille’s law
R = 8 n l r4 pedi adult
When radius is halved ---- Resistance increases 16 fold BREATHING
Breathing should always be divided in two! Oxygenation Ventilation In with the new Out with the old (Inhalation) (Exhalation)
• It’s not a ventilator --- it’s an oxygenator/ventilator
Priority 1) Oxygen Delivery Priority 2) Not to hyperventilate Priority 3) Adequate ventilation BREATHING: OXYGENATION
Big tidal volumes and rates don’t increase oxygenation . For Hypoxemia: turn up the FiO2, or the pressure • D - O - P - E (dislodged - obstructed - PTX - Equipment) • Use a PEEP valve! • If still dropping…….. . EPIC study (Dan Spaite - Arizona) . Hypoxia is REALLY BAD for TBI: • 500 cases of hypoxia/10,000 = 4 X mortality! • A single sat <90 doubles mortality in severe TBI! • Always utilize 100% O2 on TBI patients! OXYGENATION: HENRY’S LAW
“the quantity of a gas dissolved in liquid is proportional to the partial pressure of the gas in contact with the liquid…”
- So higher FIO2 = higher pO2 - Higher PEEP or PIP = higher pO2
Oxygen (Hg) saturation is dependent on pO2
(Note: Rate / TV have no effect here ---- “minute ventilation”) AIRWAY MANAGEMENT
. Adjuncts: High Flow Nasal Canula
Preoxygenation and Prevention of Desaturation During Emergency Airway Management
Scott D. Weingart, MD Richard M. Levitan, MD BREATHING: VENTILATION
Remember tidal volume x rate = minute ventilation Minute Ventilation RAPIDLY affects pCO2 . Medical Providers all Hyperventilate! ** • We want to feel the lungs inflate! • Use a 1 liter BVM • 1 breath every 5 seconds • And flow control / counter BREATHING: VENTILATION Remember tidal volume x rate = minute ventilation . Follow ETCO2 in all critical patients • ETCO2 is about 5mmhg less that PCO2 • Waveform capnography is best! • All that is ETCO2 is not ventilation It’s only “accurate” if there is adequate Cardiac Output . If blood is not pumped to the lungs, CO2 will not off-gas (CPR, Shock, etc)
EMMA Colorimetric BREATHING VENTILATION
Do Not Hyperventilate TBI Patients! *
. We were taught to do this in the 80’s and 90’s • We killed thousands based on “expert opinion” • Goal ETCO2: 35-40 • TBI patients begin to drop off at pCO2 < 35*
*Davis, et al and Dumont, et al AIRWAY MANAGEMENT
. We manage airways so we can manage breathing . Less is More! • Utilize the least invasive method that solves the problem Positioning NPA (over OPA) BVM SGA (LMA type devices) ETT Cricothyrotomy AIRWAY MANAGEMENT BASICS: BLS
• Positioning – head tilt/chin lift or jaw thrust • Effective BVM - most important skill – Get a good seal (two person better) – Don’t over ventilate • Adjuncts – OPA - good choice if tolerated – (no gag) – NPA – better tolerated – new better materials • SUCTION!!! • BROSELOW!!! BROSELOW TAPE BROSELOW TAPE…there’s an app for that
Pediatric Resuscitation Palm Pedi AIRWAY ADJUNCTS
• Nasal airway
• Oral airway BASIC AIRWAY MANAGEMENT TECHNIQUES AIRWAY MANAGEMENT ADJUNCTS (NPA) ADJUNCTS: ORAL AIRWAY
Wrong size: Too Long Adjuncts: Oral Airway
Wrong size: Too Short Adjuncts: Oral Airway
Correct size BAG VALVE MASK (BVM) BAG VALVE MASK VENTILATION Pro’s • Effective adjunct • Non invasive • Feel compliance
Give Slow Small Breaths: 6-8 cc/kg (smallest aprop. bag) Rate: Adults: 12 Child: 16-20 Infant: 20-30 ADJUNCTIVE & RESCUE AIRWAYS
• King LT (Periglottic Airways) • Supraglottic Airways (SGAs = LMAs)
SGA’s (LMA’s)
• The SGA was invented by Dr. Archie Brain at the London Hospital in Whitechapel in 1981
• The SGA consists of two parts: – The tube – The mask SGA’s (supraglottic airways)
• The SGA design:
– Provides an “oval seal around the laryngeal inlet” when cuff inflated.
– Lube only the outside – not inside the cup area
– Direct it posteriorly and upwards – past the posterior tongue (jaw thrust will help) Then Bury It! (avoid a “flipped tip”)
– Don’t overinflate (or don’t inflate!) SGA INDICATIONS
• Failed less invasive techniques
• Failed more invasive techniques
• May be used as a:
– Rescue Device
– Bridging Device
– Destination Device CONTRAINDICATIONS
• Intact Gag Reflex
• Patients requiring definitive airway protection:
(Swollen cords, burn, anaphylaxis, vomiting, high pressures, etc)
• Massive maxillofacial trauma
• Patients at High risk of aspiration PREPARATIONS
• Step 1: Size selection • Step 2: Examination of the LMA • Step 3: Check the cuff • Step 4: Lubrication of the LMA • Step 5: Position the Airway STEP 1: SIZE SELECTION
• Verify that the size of the LMA is correct for the patient – (Broselow or pckg insert) • Recommended Size guidelines:
– Size 1: under 5 kg – Size 1.5: 5 to 10 kg – Size 2: 10 to 20 kg – Size 2.5: 20 to 30 kg – Size 3: 30 kg to small adult – Size 4: adult – Size 5: Large adult THE i-Gel SGA…… no inflation Manage the airway – don’t secure it !
Should we be intubating at all? PRE HOSPITAL INTUBATION The Debate on Prehospital Intubation Continues…
Studies showing WORSE outcomes with ETI Studies showing BETTER outcomes with ETI Stiell: CMAJ 2008;178:1141-52 Davis: J Trauma 2003;54:444-53 ¡ Winchell: Arch Surg 1997;132:592-7 Davis: J Trauma 2005;58:933-9 ¡ Klemen: Acta Anaesthesiol Scand 2006;50:1250-4 Davis: J Trauma 2005;59:486-90 ¡ Warner: Trauma 2007;9:283-89 Denninghoff: West J Emerg Med 2008;9:184-9 ¡ Davis: Resuscitation 2007;73:354-61 Murray: J Trauma 2000;49:1065-70 ¡ Davis: Ann Emerg Med 2005;46:115-22 Wang: Ann Emerg Med 2004;44:439-50 ¡ Bulger: J Trauma 2005;58:718-23 Wang: Prehosp Emerg Care 2006;10:261-71 ¡ Bernard: Ann Surg 2010;252:959-965 Eckstein: Ann Emerg Med 2005;45:504-9 Bochicchio: J Trauma 2003;54:307-11 Arbabi: J Trauma 2004;56:1029-32 INTUBATION: INDICATIONS
• Failure to oxygenate • Failure to ventilate – (Failure to remove CO2 = hypercarbic respiratory failure) • Failure to protect the airway - (or expected failure to protect the airway (GCS <8, etc) • Expected Course Demands ETT (prior to TOC) INTUBATION: PREPARATION
• Preoxygenate – Monitors - ECG, pulse ox – BLM (Sellick’s) – Good basics • Equipment selection – Miller (< 4) vs. Mac – Cuffed vs. uncuffed – ETT size • Positioning PRE-OXYGENATION PRIOR TO RSA (RSI)
• 3-5 minutes of 100% oxygen - non-rebreather mask • Hi Flow Nasal Cannula 15 L adults, 1 L/kg peds • Avoid positive pressure ventilation if possible 6 full volume ventilations via BVM if needed • Establishes O2 reserve via nitrogen washing • Permits prolonged apnea w/o desaturation Healthy 70kg adult >90% for over 10 minutes Healthy10kg child >90% for over 4 minutes
But! The Airway must be open! The Oxygen Dissociation Curve
PO2 up to 400 On 100% AIRWAY EQUIPMENT
• Suction, Suction, Suction • Zofran • Pedi Bougie (4-6) • Adult Bougie (6-8.5) • Stylet • ETT +/- one size (Parker flex tip ETT) • Tube check and securing devices • Magill forceps ENDOTRACHEAL TUBE INTRODUCER (GUM ELASTIC BOUGIE)
• Bougie Replaces the stylet • Able to use with poor view • Feel tracheal rings • If it goes in all the way = esophagus • Fold it in ½ - in line with coudet tip • Don’t preload it ENDOTRACHEAL TUBE INTRODUCER (GUM ELASTIC BOUGIE) Large study June 2018: Effect of Use of a Bougie vs Endotracheal Tube and Stylet on FirsAttempt Intubation Success Among Patients With Difficult AirwayUndergoing Emergency Intubation: A Randomized Clinical Trial.
757 patients: 1st pass success went from 82% to 96% ENDOTRACHEAL TUBE (ETT)
Age kg ETT Length
Newborn 3.5 3.5 9 3 mos 6.0 3.5 10 1 yr 10 4.0 11 2 yrs 12 4.5 12 TUBE SIZE
• ETT size – (Age + 16) / 4 – Diameter of nare – Diameter of pinky – Broselow tape – Have one size smaller and larger TUBE PLACEMENT – TIP TO LIP
• ETT depth – use the black line • ETT size x 3 • Infants: wt (kg) + 6 BACK-UP PLAN
• Can’t ventilate or basics not working – Consider adjuncts (OPA/NPA/positioning) – Intubation? • Can’t intubate – Rescue devices • Can’t rescue – Surgical procedure
• Okay to stick with basics if working LARYNGOSCOPE BLADES
Macintosh
Miller LARYNGOSCOPE BLADES
Better in younger children with a floppy epiglottis (<2-4) LARYNGOSCOPE BLADES
Better in adults and older children (stiffer epiglottis) INTUBATION - CONFIRMATION
• Visualize tube passing through cords (video?) • Breath sounds and no epigastric sounds
• End Tidal CO2 (ETCO2) – Waveform better than colorimetric (not reliable in CPR)
Masimo EMMA Device (mainstream ETCO2) AIRWAY MANAGEMENT CHALLENGES AIRWAY MANAGEMENT CHALLENGES DETERIORATION OF INTUBATION: “DOPE”
• Displaced • Obstructed • PTX • Equipment RSI MEDICATIONS
• Same as adults – Lidocaine – Etomidate – Succinylcholine – Rocuronium • Atropine not “required” • Consider ketamine IN CLOSING • There is airway management……and there is everything else
• Know your equipment and supporting policies
• Manage the airway – don’t “stabilize”
• A failed airway should never be unanticipated – consider all airways potentially difficult!
• Have plan B before proceding with plan A
• Practice! Practice! Practice! It’s Not Okay to Continue with Failed Techniques
“HOPE is not an airway strategy” QUESTIONS