ce oct 12 airway key

2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.

AirwayOxygenation & Ventilation

Continuing EducationOctober 2012

Diana Neubecker RN BSN PMEMS System In-Field Coordinator


Objective

Airway Management, Respiration, and Artificial Ventilation

Paramedic Education Standard

Integrate complex knowledge of anatomy,

physiology, and pathophysiology into assessment

to develop and implement a treatment plan

with the goal of assuring a patent airway,

adequate mechanical ventilation, and respiration

for pts of all ages.


Problem

King LTSD

• Does not protect airway, from

secretions, as well as ETT

• Pts should be preoxygenated

prior to advanced airway, which

often requires BVM use

• BVM ventilation often results in

gastric distention……

• 18 fr soft suction catheter is too

short to reach the stomach


SOLUTION: KLTSD has“gastric access lumen”


NEW: Salem-Sump NGT

Leave

Open

Connect

To Suction OpeningsOpenings

NGT = nasogastric tube

Salem-Sump dual lumen NGT

1. Secondary lumen (blue pigtail,

smaller) open to atmosphere

– Vents large lumen

– Keeps suction @ gastric openings

low to prevent mucosal irritation

2. Drainage lumen (larger)


Salem-Sump NGT & KLTSD

• Indications when KLTSD in place– Vomiting

– Gastric distention

– Prolonged BVM ventilation prior

• Contraindications

Same as KLTSD

• NOTE:Insert AFTER placement & verification of KLTSD


Salem-Sump NGT & KLTSDProcedure

1. Measure for insertion depth (Nose � Ear � Xyphoid)

2. Lubricate

3. Insert into proximal lumen & gently advance– If resistance felt – abort procedure

4. If concern about proper placement– Attach capnography (should have no persistent ETCO2)

– Inject 60mL air & auscultation over epigastrium– Insert end into cup of water & observe for bubbling

5. Connect to suction– continuous 30-40 mmHg

– Intermittent up to 120 mmHg PRN


How far to insert tube?

Measure from:

� tip of nose

� around ear

� down to xyphoid process

Salem-Sump & KLTSD


Review Question

Which is the correct order of steps for KLTSD insertion?

E

Inflate

Insert

Ventilate

Auscultate

Withdraw

D

Insert

Inflate

Auscultate

Ventilate

Withdraw

C

Insert

Withdraw

Inflate

Ventilate

Auscultate

B

Insert

Withdraw

Ventilate

Auscultate

Inflate

A

Insert

Ventilate

Auscultate

Inflate

Withdraw

Insert NGT after above steps completed


Airway, Oxygenation, & Ventilation

• Without an airway, nothing else matters……

• However, airway management requires careful risk – benefit analysis.

• Paramedics are expected to assess and manage pts, beyond using an inflexible algorithm, and use critical thinking skills, evidence based practice, and focus on outcomes-based management.


Research

1. Review assigned abstract.

2. Prepare 1-2 sentence summary (< 20 words), that you can verbally report in <1 minute.



Cardiac

Arrest�

�

Resp

Arrest�

�

Resp

Failure�

�

Resp

Distress�

�

No

Distress

Goals:

1. prevent from getting worse

2. improve status


EMS Treatment

Priority:

1. Obtain airway

2. Oxygenate

3. Ventilate


Assessment

Airway & breathing are assessed on all pts:

• UNconscious – after circulation (CAB)

• Conscious – before circulation (ABC)


When approaching an UNconscious pt, with a pulse, how should an EMS provider first determine the airway is patient?

Are they breathing?

Review Question


When approaching a conscious pt, how should an EMS provider determine the airway is patent?– Can they speak

What else can above assessment determine?– Respiratory distress

• Sound – is voice hoarse/raspy?• How many words can pt speak?

Review Question


Respiratory dysfunction/obstruction can be upper or lower airway


The “classic” upper airway dysfunction often thought of is – the person choking

Far more common….upper airway obstruction is the tongue, often due to altered mental status

Why does this happen?

Airway


Pt w/ AMS lying supine, � muscle tone of jaw allows heavy tongue to fall back & obstruct airway

Airway


Review Question

What are s/s of tongue obstructing airway?

Apnea

Snoring


Review Question

List other causes of upper airway disorders?

– Laryngeal edema due to allergic reaction

– Epiglottitis

– Tonsillar abscess


Noisy breathing

is

Obstructed breathing


Review Question

EMS crew arrives on scene of a pt who is not breathing, but has a radial pulse. In preparing to ventilate, which is the LEAST critical piece of equipment to use during the first few breaths?

– Mask– Oxygen tank– Bag-valve device– Oral/nasal airway


Review Question

Why is an OP/NPA so important?

• Failure to use an OP/NPA will require an

increased amount of force/pressure to

ventilate past obstruction of tongue

• Increased force/pressure opens esophageal

sphincter and allows gastric distention


Pressure <15 cm H2O rarely causes distention>25 cm H2O often causes gastric distention

Br J Anaesth 1987;59:315

ACTA Anaesth Scand 1961;5:107


Priority of Care

Airway before Breathing

ALWAYS*

insert an oral/nasal airway

prior to BVM ventilation

*unless contraindicated


When using an oral/nasal airway, how important is it to use the correct size?

– Critical– Too small is worse than no airway

Review Question


Review Question

How should an oral airway be sized?


Oral Airway Sizing


Review Question

Is this OPA• too large?

• too small?

• the right size?


Review Question

How should an oral airway be inserted?


Review Question

How should an nasal airway be sized?


Review Question

How should an nasal airway be inserted?


Review Question

How can the use ofOP/NPA’s be optimized?

“Ortinau Airway Method”

NPA - bilateral

with

OPA


Review Question

When assessing breathing what are theFIRST 2 things that should be determined?

A. Respiratory rate & lung sounds

B. Respiratory rate & depth

C. Breath sounds & O2 sat

D. O2 sat & ETCO2


Review Question

What can help an EMS provider determineif respiratory depth is adequate?

Breath sounds


Review Question

When doing a quick check of breath sounds(e.g., to determine they are present bilat)where is the first place you should listen?

A. Over trachea

B. Anteriorly above 1st ribs

C. Mid-axillary line (under armpits)

D. Upper lobes on posterior chest wall

Why?


Quick � Breath Sounds

Lateral chest

• Peripheral lung fields

• Less risk sound transmission


Auscultation Sites


Review Question

What are the 2 major goals of breathing?

1. Oxygenation2. Ventilation

How are they different?

– Oxygenation: taking in and using oxygen– Ventilation: elimination of carbon dioxide


Review Question

What are signs of inadequate oxygenation?

– Low O2 sat

What are signs of inadequate ventilation?

– High ETCO2


Assisted Ventilation


Why is head elevation recommended?

Bring oral (OA), pharyngeal (PA), laryngeal (LA)

axis in alignment


Alternate to

“E-C” Mask Hold


2 Hand – Mask Seal


What’s wrong with this picture?


Review Question

At what rate should adult pts be ventilated?

10-12/m prior to advanced airway

8-10/m after advanced airway

6-8/m if PMH asthma/COPD


Review Question

• How much volume should be delivered?~400 – 600 mL

• Why are bag-valve devices so large (hold 1200-1500 mL of air)?

Designed so only one hand is needed to

squeeze bag to deliver a sufficient tidal volume


Review Question

Why is hyperventilation harmful? (list 7 causes):

1. Gastric distention � diaphragm elevation &

impaired lung expansion

2. Gastric distention � vomiting & aspiration

3. Decreased venous return � � cardiac output

4. Alkalosis

5. Constriction of cerebral vessels

6. Constriction of coronary arteries

7. Barotrauma � tension pneumothorax


Review Question

What can help EMS providers avoid hyperventilating pts?

capnography


Review Question

What will happen to EtCO2 w/ hyperventilation?

Will decrease

Why?

Ventilating pt faster than making CO2


Review Question

What else can cause low ETCO2 levels?

– Perfusion �• Hypotension (shock, cardiac arrest)

• Pulmonary Embolus

– Metabolism �• Hypothermia


BVM Ventilation Pitfalls

1. Failure to use OP/NPA

2. Inadequate pt positioning

3. Improper mask holding

4. Occluding nostrils w/ mask

5. Poor positioning of ventilator

6. Hyperventilation


Review Question

What are examples of lower airway disorders?

– Asthma/COPD

– Pulmonary edema due to HF

– Pulmonary embolus

– Pneumonia



Cardiac

Arrest�

�

Resp

Arrest�

�

Resp

Failure�

�

Resp

Distress�

�

No

Distress

Goals:

1. prevent from getting worse

2. improve status


Review Question

What normally happens when a pt experiences respiratory distress?

– The body attempts to compensate

What signals the body to compensate?

– Increasing CO2

– Decreasing O2


Review Question

What are signs of compensation for respiratory distress?

– Increasing respiratory rate

– Accessory muscle use, tripod positioning

– Tachycardia, due to SNS stimulation


Review Question

What are accessory muscles?

– Neck

– Chest

– Abdomen


Review Question

How is respiratory failure different from

resp distress?

In respiratory failure, compensatory mechanisms have failed


Review Question

How can respiratory failure be differentiated from respiratory distress?

In addition to resp distress s/s may have:

– Altered mental status

(anxiety, combative, somnolence, unconscious)

– Hypoxia (despite O2 administration)

– Hypercarbia (increased ETCO2)

– Resp rate slowing, irregular, or gasping


Prompt Tx to STOP the Progression

• QI finding: Treatment not begun where pt found (or on-scene) and pt deteriorating while moving to amb (or while transporting to hospital).

• Respiratory DISTRESS should be treated to prevent respiratory FAILURE

• Respiratory FAILURE should be treated to prevent respiratory ARREST

• Respiratory ARREST should be treated to prevent CARDIAC arrest


Advanced Airways & Intubation

CombiTube

LMA

iGel


What are complications of intubation?

1. Vagal stimulation � bradycardia & hypotension

2. SNS stimulation � tachycardia

3. Hypoxia from inadequate preoxygention

4. Hypoxia from prolonged/multiple attempts

5. Infection from contamination of ET tube

6. Trauma to airway

7. Unrecognized esophageal intubation

8. Hyperventilation induced – Hypotension

– Vasoconstriction of cerebral & coronary arteries

– Gastric distention, vomiting & aspiration

– Alkalosis

– Barotrauma (tension pneumo)


ETI procedure

If not in cardiac arrest, what should assistant to intubator be doing? (list 4)

1. Watch monitor – HR (for changes)

2. Watch monitor – O2 sat (for desat)

3. Watch clock – elapsed time

4. Provide assistance as needed


Pre-Oxygenation Critical

How long should pts be preoxygenated?

3 minutes

ETI procedure


How long is allowed for an attempt?

30 seconds

In severe hypovolemic

shock, pts may desaturate

as quickly as 30 seconds

Anes Analgesia 2009;109:303-305

ETI procedure


ETI procedure

• Infection in intubated pt can be life-threatening

• Contaminated ET tube

– Can lead to pneumonia,

sepsis, & death

– Keep in pkg until scope in

hand & ready to visualize

– Treat ET tube w/ same

sterile technique as IV cath


ETI procedure

Unrecognized esophageal intubation

• Multiple confirmation techniques

• Redundancy to prevent deadly complication


Hypo/Hyperoxia

• Know hypoxia kills

• Learning just how harmful hyperoxia is

• Oxygen (~21%) is present in the environment

– However, in higher concentrations it becomes a “drug”

• Like all drugs, dose should be considered

• Prehospital, because ABG (arterial blood gas) is not

available, we rely on other methods to assess

oxygenation

• Pulse oximetry is one method


Hyperoxia

• When a pt has an O2 sat of 100%, it is unknown if arterial oxygen level is 100 or 600

– While 100 may be fine, 600 could be harmful

• Thus, oxygen administration should be titrated based on specific SOP


Breathing

• Under normal breathing, what type of pressure do we use used to bring air into our lungs?

– Negative pressure

• When ventilating w/ BVM, what type of pressure is used?

– Positive pressure ventilation (PPV)


Breathing

• PPV disrupts normal function, esp. filling of heart

• Leads to � venous return & � cardiac output/BP

• In hypotensive pts, � cardiac output can be lethal

• How can the risks of PPV be minimized?

– Ventilate at prescribed rate, avoid ventilating too fast

– Avoid too much tidal volume or ventilating too deeply


Which pt is at greatest risk of developing a tension pneumothorax, requiring a pleural decompression?

A. Breathing pt with an open pneumothorax

B. Any pt receiving assisted ventilation

C. Spontaneous pneumothorax in breathing pt

D. Simple/closed pneumothorax in breathing pt

Critical Thinking & Outcomes-Based Management


Negative vs Positive Pressure Breathing

• Intrapulmonary (inside lung) pressure = atmospheric pressure

– Lung open to outside, so same pressure

• Positive pressure breathing: pressure greater than atmospheric - increases risk of pneumothorax leading to tension pneumo


Tension Pneumothorax


Called to restaurant for a choking pt. Upon arrival, unresponsive adult male, not breathing, slow, weak radial pulse. • What should be done?

Attempt to ventilate• What if that is not successful?

Reposition head, attempt to ventilate• What if that is not successful?

Begin CPRAttempt to visualize w/ laryngoscope & remove w/ forceps/suction



Choking man continued

• What if that is not successful?

– Attempt to intubate

• What if that is unsuccessful?

– If unable to intubate or ventilate – perform

cricothyrotomy

• What if during surgical cric, PM is unable to pass ET tube?

– Attempt smaller size ETT



What’s the best method to secure airway, oxygenate, & ventilate pts in cardiac arrest?



1. Does an OP/NPA provide a long-term airway that the pt in cardiac arrest may need?

2. Do these pts often require ETI?

3. Should compressions be interrupted for ETI?

4. What is more important than ETI?

5. What are alternatives to ETI?

6. Can ETI be performed without interrupting quality compressions?


Called for infant in cardiac arrest.

Should PM’s intubate?

• In peds, ETI should be attempted when BVM oxygenation/ventilation is not effective

• Peds pts often easier to BVM vent, due to small head, neck mobility, small tidal volumes

• Critical to use OP/NPA, due to lg tongue



Called for pt w/ blunt chest trauma, RR 40, lung sounds decreased on (R). Despite O2/NRBM, O2 sat is 75%

• What should be done? Assist ventilation

• At what rate should pt be ventilated (40 or 10)? 10

• How can this be done? Ventilate every 4th breath

• What is the risk of doing this? Gastric distention

• How can that risk be minimized?– Don’t over-ventilate or use too much TV, attempt cricoid

pressure, consider benefit/risk ETI




What’s the best method to secure airway, oxygenate, & ventilate pt with head injury?


Called for MVC, adult male w/ obvious head injury,

actively vomiting. Breathing (RR ~10) w/ strong radial

pulse, responds to pain by withdrawing (GCS 6).

– What should be the first priority?

– How long should suction attempts be limited to?

– What should be done between suctioning attempts?

Despite suctioning, pt continues to vomit

– How should oxygen be delivered to this pt?

– Should this pt be BVM ventilated?

– Should this pt be intubated?



Called for MVC, adult male w/ obvious head injury.

P 70, BP 160/80, RR 10, O2 sat 86% RA, ETCO2 45,

(+) gag reflex, withdraws to pain (GCS 6).

– How should oxygen be delivered to this pt?

– Should this pt be BVM ventilated?

– Should this pt be intubated?



70/F w/ difficulty breathing. Sitting upright, looking scared, not speaking. Family states PMH of COPD, problems breathing x 3 days, worse today. P = 98, Skin pale, cool, moist, BP = 164/92, RR = 48, lungs sounds diminished w/ wheezing, O2 sat = 64%, ETCO2 = 58 sharkfin, GCS 14 confused (not normal), Gluc = 104.

• Is she is respiratory distress or failure?– Failure

• What treatment would you initiate?– CPAP w/ albuterol-ipratropium neb

– Be prepared to intubate if no improvement

Family then tells you she has a history of heart failure.

• Will this change your treatment?– Add NTG



Called for very anxious 35/F sitting upright in sniffing position, c/o difficulty breathing, fever, difficulty speaking & swallowing. States if tries to lie down or lean back it becomes more difficult to breathe. Skin pale, hot, moist, RR 42, drooling, lungs clear, O2 sat 90% RA, ETCO2 48, HR 142, BP 162/92.

• What immediate treatment should she receive?

– Oxygen and suction w/ rigid tip for oral secretions

• What should be considered?

– Ideally pt may need intubation, but may be a difficult and best left to more experienced personnel w/ more resources

• If ETI unsuccessful, may require surgical cric



35/F continued

• What should be done if enroute to the hospital the pt stops breathing?

– Attempt ventilation w/ BVM

• Should intubation be immediately attempted? Why?

– No, may be able to ventilate w/ BVM pressure

• Under what circumstances should ETI be attempted?

– Only if unable to ventilate w/ BVM

• Sometimes, the most difficult intervention of all:

– Doing nothing


What you know; Not what you can do

• For providers with advanced skills the risk of the

“technological imperative” exists.

• Just because you can, does not mean you should,

perform a skill.

• In many cases, the least invasive skill may be the

most appropriate to use.

• Advanced invasive skills have the highest risk for

serious complications; thus, good judgment (critical

thinking) is essential.


FD rescued pt from house fire who not breathing.

PM’s unable to effectively ventilate pt w/ BVM.

Intubation attempted but unsuccessful.

• What is the next step?

– King LTSD was inserted and pt successfully

oxygenated/ventilated (Good work AHFD)

• Start basic and advance as needed

• What should PM’s have done if pt was unable to be

oxygenated/ventilated using King LTSD?

– Cricothyrotomy



What is the most important thing

you learned?

ce oct 12 airway key

Health & Medicine

northwest community

permission of nwcemss

kltsd insertion

kltsd note

salemsump ngt leavengt

advanced airway

patent airway

salemsump kltsdhow