AIRWAY MANAGEMENT

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.

Introduction

Anatomy / Physiology

Positioning

Basics - Adjuncts

ALS - Intubation

AIRWAY MANAGEMENT

Children are different than adults !!!

ANATOMY

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

Poiseuille’s law

pedi adult

When radius is halved ----

Resistance increases 16 fold

R =8 n l

r4

PHYSIOLOGY: EFFECT OF EDEMA

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

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!

BREATHING: OXYGENATION

“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”)

OXYGENATION: HENRY’S LAW

Adjuncts: High Flow Nasal Canula

Preoxygenation and Prevention of Desaturation

During Emergency Airway Management

Scott D. Weingart, MD Richard M. Levitan, MD

AIRWAY MANAGEMENT

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

BREATHING VENTILATION

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

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

Pediatric Resuscitation Palm Pedi

BROSELOW TAPE…there’s an app for that

• Nasal airway

• Oral airway

AIRWAY ADJUNCTS

BASIC AIRWAY MANAGEMENT TECHNIQUES

AIRWAY MANAGEMENT ADJUNCTS (NPA)

Wrong size: Too Long

ADJUNCTS: ORAL AIRWAY

Wrong size: Too Short

Adjuncts: Oral Airway

Correct size

Adjuncts: Oral Airway

BAG VALVE MASK (BVM)

BAG VALVE MASK VENTILATIONPro’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)

• The SGA was invented byDr. Archie Brain at theLondon Hospital inWhitechapel in 1981

• The SGA consists of twoparts:– The tube– The mask

SGA’s (LMA’s)

• The SGA design:

– Provides an “oval seal around thelaryngeal inlet” when cuff inflated.

– Lube only the outside – not insidethe cup area

– Direct it posteriorly and upwards –past the posterior tongue (jawthrust will help)

Then Bury It!(avoid a “flipped tip”)

– Don’t overinflate (or don’t inflate!)

SGA’s (supraglottic airways)

• Failed less invasive techniques

• Failed more invasive techniques

• May be used as a:

– Rescue Device

– Bridging Device

– Destination Device

SGA INDICATIONS

• 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

CONTRAINDICATIONS

• 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

PREPARATIONS

• 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

STEP 1: SIZE SELECTION

THE i-Gel SGA…… no inflation

Manage the airway – don’t secure it !

Should we be intubating at all?

PRE HOSPITAL INTUBATION

Studies showing WORSE outcomes with ETIStiell: CMAJ 2008;178:1141-52Davis: J Trauma 2003;54:444-53Davis: J Trauma 2005;58:933-9Davis: J Trauma 2005;59:486-90Denninghoff: West J Emerg Med 2008;9:184-9Murray: J Trauma 2000;49:1065-70Wang: Ann Emerg Med 2004;44:439-50Wang: Prehosp Emerg Care 2006;10:261-71Eckstein: Ann Emerg Med 2005;45:504-9Bochicchio: J Trauma 2003;54:307-11Arbabi: J Trauma 2004;56:1029-32

Studies showing BETTER outcomes with ETI

¡ Winchell: Arch Surg 1997;132:592-7¡ Klemen: Acta Anaesthesiol Scand 2006;50:1250-4¡ Warner: Trauma 2007;9:283-89¡ Davis: Resuscitation 2007;73:354-61¡ Davis: Ann Emerg Med 2005;46:115-22¡ Bulger: J Trauma 2005;58:718-23¡ Bernard: Ann Surg 2010;252:959-965

The Debate on Prehospital Intubation Continues…

• 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: INDICATIONS

INTUBATION: PREPARATION

• Preoxygenate

– Monitors - ECG, pulse ox

– BLM (Sellick’s)

– Good basics

• Equipment selection

– Miller (< 4) vs. Mac

– Cuffed vs. uncuffed

– ETT size

• Positioning

• 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!

PRE-OXYGENATION PRIOR TO RSA (RSI)

The Oxygen Dissociation Curve

PO2 up

to 400

On 100%

• 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

AIRWAY EQUIPMENT

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

Macintosh

Miller

LARYNGOSCOPE BLADES

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

• Same as adults

– Lidocaine

– Etomidate

– Succinylcholine

– Rocuronium

• Atropine not “required”

• Consider ketamine

RSI MEDICATIONS

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