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 1 10/5/2018 ©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 2 10/5/2018 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 3 10/5/2018 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 4 10/5/2018 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 5 10/5/2018 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 6 10/5/2018 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? 7 10/5/2018 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 8 10/5/2018 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 9 10/5/2018 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) 10 10/5/2018 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