advanced airway management. advanced airway management one of the most common mistakes with...

Advanced airway management

Advanced Airway Management One of the most common mistakes with respiratory or cardiac arrest is to use advanced techniques too early. Establish and maintain a patent airway with basic techniques first.

Advanced Airway Management Primary reasons: Failure to maintain a patent airway and/or Failure to adequately oxygenate and ventilate Involves insertion of advanced airway devices

Predicting the Difficult Airway Anatomic findings: Congenital abnormalities Recent surgery Trauma Infection Neoplastic diseases LEMON Look externally Evaluate 3-3-2 Mallampati Obstruction Neck mobility

LEMON Look externally. The following can make intubation difficult: Short, thick necks Morbid obesity Dental conditions

LEMON Evaluate 3-3-2. 3 mouth width of more than 3 fingers is best 3 mandible length of 3 fingers is best 2 distance from hyoid bone to thyroid notch of 2 fingers wide is best

LEMON Mallampati Note oropharyngeal structures visible in an upright, seated patient.

LEMON Obstruction Note anything that might interfere with visualization or ET tube placement. Foreign body Obesity Hematoma Masses

LEMON Neck mobility Sniffing position is ideal Neck mobility problems most common with: Trauma patients Elderly patients

Endotracheal Intubation ET tube passes through glottic opening and is sealed with a cuff inflated against the tracheal wall Orotracheal intubation: through the mouth Nasotracheal intubation: through the nose

Endotracheal Intubation Advantages Secure airway Protection against aspiration Alternative to IV or IO route Disadvantages Special equipment Physiologic functions bypassed Complications Bleeding Hypoxia Laryngeal swelling Laryngospasm Vocal cord damage Mucosal necrosis Barotrauma

Endotracheal Tubes Basic structure includes: Proximal end Tube Cuff and pilot balloon Distal tip

Endotracheal Tubes Sizes range 2.5 to 9.0 mm in inside diameter 12 to 32 cm in length

Endotracheal Tubes Pediatric patients 2.5 to 4.5 mm tubes used Funnel-shaped cricoid ring forms an anatomic seal with ET tube No need for distal cuff in most cases.

Endotracheal Tubes Anatomic clues can help determine tube size Internal diameter of the nostril approximates diameter of glottic opening Diameter of the little finger or size of thumbnail approximates airway size. Always have three sizes ready!

Laryngoscopes and Blades A laryngoscope is required to perform orotracheal intubation by direct laryngoscopy. Consists of a handle and interchangeable blades

Laryngoscopes and Blades Straight (Miller and Wisconsin) blades Tip extends beneath epiglottis and lifts it up Useful with infants and small children More likely to damage teeth in adults

Laryngoscopes and Blades Curved (Macintosh) blades Curve conforms to tongue and pharynx Tip is placed in the vallecula Indirectly lifts epiglottis to expose vocal cords

Laryngoscopes and Blades Blade sizes range from 0 to 4 0, 1, and 2 appropriate for infants and children 3 and 4 considered adult sizes Pediatric patients: based on age or height Adults: based on experience, size of patient

Laryngoscopes and Blades Stylet: semirigid wire inserted into ET tube Molds and maintains shape of tube Should be lubricated for removal End should be bent to form a gentle curve End should rest at least 1/2 from end of ET tube

Laryngoscopes and Blades Magill forceps Remove airway obstructions under direct visualization. Guide tip of ET tube through glottic opening if the proper angle cannot be achieved by manipulating the tube

Orotracheal Intubation by Direct Laryngoscopy ET tube inserted through mouth and into trachea while visualizing the glottic opening with a laryngoscope

Orotracheal Intubation by Direct Laryngoscopy Indications Airway control needed due to coma, respiratory arrest, and/or cardiac arrest Ventilatory support before impending respiratory failure Prolonged ventilatory support Absence of gag reflex Traumatic brain injury Unresponsiveness Impending airway compromise Medication administration

Orotracheal Intubation by Direct Laryngoscopy Contraindications Intact gag reflex Inability to open mouth because of trauma, dislocation of the jaw, or a pathologic condition Inability to see the glottic opening Copious secretions, vomitus, or blood in airway

Standard Precautions Intubation can expose you to bodily fluids. Take proper precautions. Gloves Mask that covers your entire face

Preoxygenation Critical before intubating 23 minutes for apneic or hypoventilating patient Prevents hypoxia from occurring Monitor SpO 2 and achieve as close to 100% saturation as possible.

Positioning the Patient Airway has three axes: mouth, pharynx, and larynx At acute angles in neutral position Place patient in sniffing position to facilitate visualization of the airway.

Positioning the Patient Sniffing position 20 extension of the atlanto-occipital joint 30 flexion at C6 and C7 with short neck and/or no chin Elevate head and/or neck until ear is at the level of the sternum

Blade Insertion Position yourself at the patients head. Grasp laryngoscope. If mouth is not open: Place thumb below bottom lip and push open. Scissor thumb and index finger between molars Open with tongue-jaw lift

Blade Insertion Insert blade into right side of mouth Sweep tongue to the left while moving blade into midline Slowly advance the blade. Jones & Bartlett Learning. Courtesy of MIEMSS. Specimens provided by the Maryland State Anatomy Board, Department of Health and Mental Hygiene at the Anatomical Services Division, University of Maryland School of Medicine

Blade Insertion Exert gentle traction at a 45 angle as you lift the patients jaw. Keep your back and arm straight as you pull upward. Jones & Bartlett Learning. Courtesy of MIEMSS. Specimens provided by the Maryland State Anatomy Board, Department of Health and Mental Hygiene at the Anatomical Services Division, University of Maryland School of Medicine

Visualization of the Glottic Opening Continue lifting the laryngoscope as you look down the blade. Work the tip of the blade into position. The glottic opening should come into view. The vocal cords lie within. Courtesy of James P. Thomas, M.D. www.voicedoctor.net

Visualization of the Glottic Opening Gum elastic bougie Flexible device Approximately 1 cm in diameter, 60 cm long Used in epiglottis-only views to facilitate intubation

Visualization of the Glottic Opening Gum elastic bougie (contd) Insert through the glottic opening under direct laryngoscopy. Once placed, it becomes a guide for the ET tube.

Tube Insertion Pick up preselected ET tube. Hold it near connector as you would a pencil. Insert tube from the right corner of mouth through the vocal cords. Continue until the proximal end of the cuff is 1 to 2 cm past the vocal cords.

Tube Insertion Do not pass the tube down the barrel of the laryngoscope blade. Will obscure your view of the glottic opening

Ventilation After you have seen the ET tube cuff pass roughly 1/2 beyond the vocal cords Gently remove the blade. Secure tube with right hand Remove stylet from tube

Ventilation Inflate the distal cuff with 5 to 10 mL of air, then detach the syringe from the inflation port. Have your assistant attach the bag-mask device to the ET tube; continue ventilation. Ensure that the patients chest rises with each ventilation.

Ventilation Listen to both lungs and to the stomach. You should hear equal breath sounds and a quiet epigastrium. Ventilation should be dictated by age. Adult with a pulse: 10 to 12 breaths/min Infant/child with a pulse: 12 to 20 breaths/min Patient in cardiac arrest: 8 to 10 breaths/min

Confirmation of Tube Placement Visualize the ET tube passing between the vocal cords. Auscultate. Unequal or absent breath sounds suggest: Esophageal placement Right mainstem bronchus placement Pneumothorax Bronchial obstruction

Confirmation of Tube Placement Auscultate (contd). Bilaterally absent breath sounds or gurgling over the epigastrium: esophagus was intubated Immediately remove ET tube. Be prepared to suction the airway.

Confirmation of Tube Placement Auscultate (contd). Breath sounds only on right: tube has been advanced too far. Reposition the tube.

Confirmation of Tube Placement With proper tube position: Bag-mask device should be easy to compress. You should see corresponding chest expansion. Increased resistance may indicate: Gastric distention Esophageal intubation Tension pneumothorax

Confirmation of Tube Placement Continuous waveform capnography plus clinical assessment Most reliable method of confirming placement Attach capnography T-piece when bag-mask device is attached to the ET tube.

Confirmation of Tube Placement Esophageal detector device Syringe model: plunger is withdrawn Tube in the trachea: plunger does not move Tube in the esophagus: plunger moves back Courtesy of Marianne Gausche-Hill, MD, FACEP, FAAP

Confirmation of Tube Placement Esophageal detector device (contd) Bulb model: bulb is squeezed Tube in the esophagus: bulb remains collapsed Tube in the trachea: bulb briskly expands Courtesy of Marianne Gausche-Hill, MD, FACEP, FAAP

Confirmation of Tube Placement After confirming proper placement, mark ET tube where it emerges from the mouth Shows others whether tube has slipped in or out

Securing the Tube Never take your hand off the ET tube before securing with an appropriate device. Support the tube manually while you ventilate to avoid a sudden jolt from the bag-mask device.

Securing the Tube Steps: Note the centimeter marking on the ET tube. Remove the bag-mask device. Position the tube in the center of the mouth. Place the securing device over the tube. Reattach the bag-mask device, auscultate, and note the capnography reading and waveform.

Securing the Tube Many devices feature a built-in bite block. Alternative: Secure tube with tape and insert a bite block or oral airway. Minimize head movement in patient.

Nasotracheal Intubation Insertion of tube into trachea through nose Indicated: Breathing spontaneously but requires definitive airway management

Nasotracheal Intubation Advantages Can be performed on responsive patients No need for laryngoscope Mouth does not need to be opened Does not require sniffing position Patient cannot bite the tube. Can be secured more easily Disadvantage Blind technique Complications Bleeding Contraindicated: Apnea Head trauma and midface fractures Anatomic abnormalities; frequent cocaine use

Nasotracheal Intubation Equipment Same as for orotracheal intubation Minus laryngoscope and stylet Some tubes are designed for blind method Some devices allow confirmation of intubation without placing face next to tube

Technique for Nasotracheal Intubation Patients spontaneous respirations guide the tube and confirm proper placement. Tube is advanced as patient inhales

Technique for Nasotracheal Intubation Insert tube into nostril, bevel facing toward the nasal septum Aim tip straight back toward ear Position just above the glottic opening Jones & Bartlett Learning. Courtesy of MIEMSS.

Technique for Nasotracheal Intubation Manipulate head to control tube tip position and to maximize air movement. Instruct patient to take a deep breath, and gently advance tube. Placement will be evidenced by an increase in air movement through the tube.

Technique for Nasotracheal Intubation Soft-tissue bulge on either side of the airway Tube is probably in the piriform fossa Hold head still, slightly withdraw the tube Once maximum airflow is detected, advance tube No soft-tissue bulge Tube has entered the esophagus. Withdraw until you detect airflow; extend head.

Technique for Nasotracheal Intubation Once tube is in place, inflate the distal cuff Attach bag-mask device and ventilate. Clean up any secretions or excess lubricant. Secure the tube with tape. Document depth of insertion at the nostril.

Digital Intubation Directly palpate the glottic structures and elevate the epiglottis with your finger while guiding the ET tube into the trachea. Option in extreme circumstances

Digital Intubation Indications (exceptional circumstances) Laryngoscope, or other techniques, have failed Patient in confined space Patient is obese or has a short neck Copious secretions Head cannot be moved Cannot visualize intubation landmarks

Digital Intubation Can be performed in pediatric patients, but usually impossible due to finger size Absolutely contraindicated if patient is: Breathing Not deeply unresponsive Has intact gag reflex

Digital Intubation Advantages Does not require a laryngoscope Ideal if vocal cords are obscured by secretions Does not require sniffing position Disadvantages Risk of being bitten Risk of exposure to infectious disease

Digital Intubation Complications Misplacement of the ET tube Bite block can cause lip and tooth damage Vigorous or improper attempts can cause airway trauma or swelling. Can result in hypoxia

Digital Intubation Equipment Same as for orotracheal intubation (minus laryngoscope), plus fingers Stylet ETCO 2 detector or esophageal detector device Appropriate device to secure the tube

Technique for Digital Intubation Prepare equipment as assistant ventilates Select tube: one half to a full size smaller than with direct laryngoscopy Tip of the tube is guided into the trachea

Technique for Digital Intubation Two configurations are recommended. Open J configuration U-handle configuration Jones & Bartlett Learning. Courtesy of MIEMSS.

Technique for Digital Intubation Sniffing position is not required Insert bite block between molars. Insert index and middle fingers into right side of the mouth. Press against tongue. Pull epiglottis forward.

Technique for Digital Intubation Hold ET tube in right hand; insert it into the left side of the mouth Advance tube toward the glottis Once you feel the cuff pass 2 beyond your fingertip, stabilize the tube and withdraw fingers Remove the stylet and inflate the cuff.

Technique for Digital Intubation Attach bag-mask device and ventilate. Confirm placement. Auscultate lungs and epigastrium. Monitor ETCO 2. Properly secure the tube in place.

Transillumination Techniques for Intubation

Bright light source placed inside the trachea emits a bright, well- circumscribed light Jones & Bartlett Learning. Courtesy of MIEMSS.

Transillumination Techniques for Intubation Indicated Other techniques have failed. Contraindicated Intact gag reflex Airway obstruction May be difficult in obese or short neck patients Pediatric patients: stylet must fit inside tube

Transillumination Techniques for Intubation Advantages No laryngoscope Visual parameter Does not require visualization of the glottic opening Safe with possible spinal injuries Disadvantages Special equipment Proficiency with equipment Can be difficult in brightly lit areas Complications Misplacement

Transillumination Equipment Device with a rigid stylet and a bright light source at the end Light should shine laterally and forward. Stylet must be long enough to accommodate a standard-length ET tube Stylet must be secured within the tube

Technique for Transillumination-Guided Intubation Preoxygenate for at least 2 to 3 minutes. Choose ET tube and check the cuff Lubricate and insert the lighted stylet. Ensure it is firmly seated into the tube.

Technique for Transillumination-Guided Intubation Bend tube into the proper shape Head in neutral or slightly extended position While holding the stylet, displace the jaw forwardly. Turn on the lighted stylet, and insert it in the midline of the mouth.

Technique for Transillumination-Guided Intubation Continue insertion; draw wrist toward you. Tightly circumscribed light slightly below the thyroid cartilage: tube has entered trachea Faintly glowing light and bulging of the soft tissue: tube is in the vallecular space. Dim, diffuse light at the anterior part of the neck: esophageal placement

Technique for Transillumination-Guided Intubation Once light is visible at the midline, hold the stylet in place and advance the tube. When the tube is in the trachea, stabilize it and withdraw the stylet. Inflate the distal cuff, detach the syringe, and attach the bag-mask device.

Technique for Transillumination-Guided Intubation Ventilate the patient while auscultating both lungs and the epigastrium. Secure the tube and continue ventilations.

Retrograde Intubation

Needle: placed percutaneously within the trachea via the cricothyroid membrane Wire: placed through the needle, through the trachea, into the mouth Wire is visualized, secured ET tube is placed over wire and guided into trachea

Retrograde Intubation Indications Upper airway obstruction Copious secretions in the airway Failure to intubate by less invasive methods Contraindications Lack of familiarity with the procedure Laryngeal trauma Unrecognizable or distorted landmarks Coagulopathy Severe hypoxia

Retrograde Intubation Complications Hypoxia Cardiac dysrhythmia Mechanical trauma Infection Increased intracranial pressure

Failed Intubation and Field Extubation

Failed Intubation Definition: Failure to maintain oxygen saturation during or after one or more failed intubation attempts Total of three failed intubation attempts

Failed Intubation Many rescue airway techniques Simple BLS airway maneuvers with oral airway and/or nasal airway and bag-mask device Rescue airway device

Tracheobronchial Suctioning Involves passing a suction catheter into the ET tube to remove pulmonary secretions Do not do it if you do not have to! If it must be performed: Use sterile technique. Monitor cardiac rhythm and oxygen saturation.

Tracheobronchial Suctioning Preoxygenate for at least 2 to 3 minutes. Insert suction catheter until resisted. Apply suction as the catheter is extracted Reattach bag-mask device, continue ventilations, and reassess.

Field Extubation Extubation: process of removing tube from an intubated patient Before performing, contact medical control or follow local protocols.

Field Extubation Risks Over-estimating patients ability to protect airway Laryngospasm Upper airway swelling Do not remove tube unless you can reintubate!

Field Extubation Contraindicated with any risk of recurrent respiratory failure or uncertainty about a patients ability to maintain airway If indicated, ensure adequate oxygenation.

Field Extubation Explain procedure to patient Have patient sit up or lean slightly forward. Assemble equipment to suction, ventilate, and reintubate.

Field Extubation Confirm patient can protect airway Suction oropharynx Deflate distal cuff as patient exhales On next exhalation, remove tube

Pediatric Intubation Technique

Pediatric Endotracheal Intubation If bag-mask is not producing adequate ventilation, patient should be intubated Indications are the same as those in adults

Laryngoscope and Blades Thinner pediatric handles are preferred. Straight blades facilitate lifting of epiglottis Blade should extend from mouth to ear

Laryngoscope and Blades Use length-based resuscitation tape measure or the following guidelines: Premature newborn: size 0 straight blade Newborn to 1 year: size 1 straight blade 2 years to adolescent: size 2 straight blade Adolescent and older: size 3 straight or curved blade

Endotracheal Tubes To estimate the appropriate size: Length-based resuscitation tape measure Formulas [Age (in years) + 16] 4 [Age (in years) 4] + 4 Anatomic clues General guidelines Courtesy of Marianne Gausche-Hill, MD, FACEP, FAAP Jones & Bartlett Learning. Courtesy of MIEMSS.

Endotracheal Tubes Cuffed ET tubes are generally not used in the field until the child is 8 to 10 years old. Can cause ischemia and damage the tracheal mucosa Have tubes one size smaller and one size larger than expected

Endotracheal Tubes Appropriate depth of insertion is 2 to 3 cm beyond the vocal cords Record depth at corner of mouth Uncuffed tubes: stop when black band is at the vocal cords. Cuffed tubes: stop when cuff is just below the vocal cords.

Pediatric Stylet Insert into tube, stop at least 1 cm from end Fit tube sizes 3.0 to 6.0 mm After inserting into tube, bend tube into a gentle upward curve

Preoxygenation Preoxygenate for at least 2 to 3 minutes. Ensure that the childs head is in the sniffing position or the neutral position. If needed, insert an airway adjunct.

Additional Preparation Monitor cardiac rhythm. Monitor pulse rate and oxygen saturation. Have suction available. Atropine sulfate may be administered.

Pediatric Intubation Technique With head in sniffing position, apply thumb pressure on chin to open mouth. If an oral airway was inserted, remove it. Suction if needed. Hold the laryngoscope in trigger finger position.

Pediatric Intubation Technique Insert the blade in the right side of the mouth. Sweep tongue to the left, keep under blade. Advance the blade; apply traction upward. Never use teeth/gums as a fulcrum for the blade

Pediatric Intubation Technique Straight blade: When the blade passes the epiglottis, gently lift the epiglottis. Curved blade: place blade tip in vallecula; lift jaw, tongue, and blade at a 45 angle. Identify vocal cords and other landmarks.

Pediatric Intubation Technique Hold tube in right hand; insert from the right- side corner of the mouth. Guide tube through the vocal cords, advancing until black band is just beyond Record the depth, and remove the blade.

Pediatric Intubation Technique Remove stylet; hold tube in place. Recheck tube depth. Cuffed tube: inflate to form seal Attach tube to bag-mask device.

Pediatric Intubation Technique Confirm tube placement. Bilateral chest rise during ventilation Auscultate lungs bilaterally. If sounds are decreased on left, tube may be too deep. To correct, withdraw tube until sounds are equal. Rerecord tube depth.

Pediatric Intubation Technique Auscultate over epigastrium. Bubbling sounds indicate esophageal intubation. Additional methods to confirm placement: Improvement in skin color, pulse rate, and oxygen saturation Waveform capnography

Pediatric Intubation Technique Colorimetric ETCO 2 detector or EDD Cannot be used in children weighing < 15 kg Esophageal bulb or syringe cannot be used in children weighing < 20 kg After placement, secure tube Reconfirm placement following any movement.

Pediatric Intubation Technique If tube is too large or you cannot identify the vocal cords and glottic landmarks: Abort intubation and ventilate. Modify equipment and start from the beginning. If intubation cannot be accomplished after two attempts, discontinue.

Pediatric Intubation Technique If childs condition deteriorates, use DOPE for common causes. Displacement Obstruction Pneumothorax Equipment failure

Complications of Endotracheal Intubation Essentially the same as for adults Unrecognized esophageal intubation Induction of emesis and aspiration Hypoxia Damage to teeth, soft tissues, and intraoral structures

advanced airway management. advanced airway management one of the most common mistakes with...

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