1. 39: Advanced Airway Management

2. Cognitive Objectives (1 of 5)
8-1.1 Identify and describe the airway anatomy in the infant, child, and the adult.
8-1.3 Explain the pathophysiology of airway compromise.
8-1.4 Describe the proper use of airway adjuncts.
8-1.5 Review the use of oxygen therapy in airway management.

3. Cognitive Objectives (2 of 5)
8-1.6 Describe the indications, contraindications, and techniques for insertion of nasal gastric tubes.
8-1.7 Describe how to perform the Sellick maneuver (cricoid pressure).
8-1.8 Describe the indications for advanced airway management.

4. Cognitive Objectives (3 of 5)
8-1.9 List the equipment required for orotracheal intubation.
Describe the proper use of the curved blade for orotracheal intubation.
Describe the proper use of the straight blade for orotracheal intubation.
State the reasons for and proper use of the stylet for orotracheal intubation.

5. Cognitive Objectives (4 of 5)
Describe the methods of choosing the appropriate size endotracheal tube in an adult patient.
State the formula for sizing an infant or child endotracheal tube.
List complications associated with advanced airway management.
Describe the skill of orotracheal intubation in the adult patient.

6. Cognitive Objectives (5 of 5)
Describe the skill of orotracheal intubation in the infant and child patient.
Describe the skill of confirming endotracheal tube placement in the adult, infant, and child patient.
State the consequences of and the need to recognize unintentional esophageal intubation.
Describe the skill of securing the endotracheal tube in the adult, infant, and child patient.

7. Affective Objectives (1 of 2)
Recognize and respect the feelings of the patient and family during advanced airway procedures.
Explain the value of performing advanced airway procedures.
Defend the need for the EMT-B to perform advanced airway procedures.
Explain the rationale for the use of a stylet.

8. Affective Objectives (2 of 2)
Explain the rationale for having a suction unit immediately available during intubation attempts.
Explain the rationale for confirming breath sounds.
Explain the rationale for securing the endotracheal tube.

9. Psychomotor Objectives
Demonstrate how to perform the Sellick maneuver.
Demonstrate the skill of orotracheal intubation in the adult patient.
Demonstrate the skill of orotracheal intubation in the infant and child patient.
Demonstrate the skill of confirming endotracheal tube placement in the adult patient.
Demonstrate the skill of confirming endotracheal tube placement in the infant and child patient.
Demonstrate the skill of securing the endotracheal tube in the adult patient.

10. Anatomy and Physiology of the Airway

11. Basic Airway Management
Airway is always assessed first.
Advanced techniques are used after basic management.
The first step is opening the patient’s airway.
Once the airway has been cleared, determine the need for an airway adjunct.

12. Gastric Tubes Provide channel into patient’s stomach
Nasogastric tubes: Inserted through the nose
Orogastric tubes: Inserted through the mouth
Nasogastric tubes: Contraindicated in a patient with major facial, head, or spinal trauma

13. Equipment Proper-sized tubes Catheter-tipped 60-mL syringe
Water-soluble lubricant
Emesis container
Tape
Stethoscope
Suctioning unit and catheters

14. Gastric Tube Insertion
Measure the tube.
Lubricate the distal end of the tube.
Place the patient in proper position.
Pass the tube until you reach the tape marker.
Confirm proper tube placement.
Aspirate air and stomach contents with the syringe.
Secure the tube in place with tape.

15. Sellick Maneuver Visualize the cricoid cartilage.
Palpate to confirm its location.
Apply firm pressure on the cricoid ring.
Maintain pressure until intubated.

16. Endotracheal Intubation
Insertion of a tube into the trachea in order to maintain the airway
Orotracheal intubation: Through the mouth
Nasotracheal intubation: Through the nose
EMT-Bs only intubate patients who are:
Unresponsive with no gag reflex
In cardiac arrest

17. Equipment (1 of 2) BSI equipment
Proper-equipment endotracheal tube (ET tube)
Laryngoscope handle and blade (visualized technique)
Stylet or light stylet
10-mL syringe
Oxygen, with BVM device

18. Equipment (2 of 2) A suctioning unit with rigid and soft-tip catheters
Magill forceps
Towels for raising the patient’s head and/or shoulders
A stethoscope
Water-soluble lubricant for tubes and scopes
A commercial securing device or tape

19. Laryngoscope Sweeps the tongue out of the way and aligns the airway
Has a light powered by batteries in handle
Has blades that connect to handle
Blades are curved or straight.
They range in size from 0 to 4.

20. Curved Blade

21. Straight Blade

22. Endotracheal Tubes Tubes come in many sizes, from adult to infant.
Normal tube-to-teeth mark is usually around 22 cm.
Diameter for normal adult male ranges from 7.5 to 8.5 mm.
Diameter for normal adult female ranges from 6.5 to 8.0 mm.
Use tape or chart for pediatric sizes.

23. Stylet
Plastic-coated wire may be inserted in the ET tube to add rigidity and shape to the tube.
Bend the tip of the stylet to form a gentle curve in adults.
Bend the tip of the stylet to form a hockey stick shape for an infant and child.
Confirm that the stylet is not sticking out past the end of the ET tube.

24. Syringe
Use the 10-mL syringe to test for air leaks in the ET tube before intubation.
After the ET tube has been properly inserted, inflate the cuff with 5 to 10 mL of air.
Remove the syringe from the pilot balloon to prevent air from leaking.

25. Other Equipment Oxygen A suctioning unit A BVM device Magill forceps
Towels for raising the patient’s head or shoulders
Secondary confirmation device
C-collar backboard

26. The Intubation Procedure
First EMT-B applies AED.
Second and third EMT-B perform CPR.
Fourth EMT-B prepares and intubates patient.

27. Visualized (Oral) Intubation (1 of 2)
Open airway.
Insert an oropharyngeal airway.
Preoxygenate the patient.
Assemble equipment.
Position the head and neck.

28. Visualized (Oral) Intubation (2 of 2)
Grasp laryngoscope with left hand.
Visualize vocal cords.
Insert ET tube.
Inflate balloon.
Confirm placement.
Secure tube.

29. Blind (Nasal) Intubation (1 of 2)
Many of the steps are the same as those for oral intubations.
Preoxygenate the patient.
Check for gag reflex.
Insert tube through nostril.
Pass tube through vocal cords as patient is inhaling.

30. Blind (Nasal) Intubation (2 of 2)
Release the jaw and hold tube against nostril.
Inflate cuff.
Attach the BVM device.
Confirm placement.
Secure the tube.

31. Intubation Complications
Intubating the right main stem bronchus
Intubating the esophagus
Aggravating spinal injuries
Taking too long to ventilate
Patient vomiting
Soft-tissue trauma
Mechanical failure
Patient intolerant of the ET tube
Decrease in heart rate

32. Multilumen Airways Inserted without direct visualization
Provide ventilation when placed in either trachea or esophagus

33. Esophageal Tracheal Combitube (ETC)

34. Combitube Contraindications
Conscious or semiconscious patients with gag reflex
Children younger than 16 years
Adults shorter than 5'
Patients who have ingested a caustic substance
Patients with esophageal disease

35. Inserting the ETC (1 of 2) Assemble and check the proper equipment.
Apply water-soluble lubricant to the ETC.
Position the patient.
Preoxygenate the patient.
Lift the lower jaw and tongue.

36. Inserting the ETC (2 of 2) Guide the ETC along the base of the tongue.
Inflate the blue and then the white pilot balloon.
Ventilate the patient.
Confirm placement.
Monitor the patient.

37. Removing the ETC Be prepared to suction patient.
Deflate both balloon cuffs.
Gently remove the tube.

38. Pharyngeotracheal Lumen Airway (PtL)

39. PtL Contraindications
Conscious or semiconscious patients with gag reflex
Children younger than 14 years
Adults shorter than 5'
Patients who have ingested a caustic substance
Patients with esophageal disease

40. Inserting the PtL (1 of 2) Assemble and check equipment.
Lubricate tube with water-soluble lubricant.
Position the patient.
Preoxygenate the patient.
Lift the lower jaw and tongue.
Hold the PtL so that it curves in the same direction as the pharynx.

41. Inserting the PtL (2 of 2) Inflate balloon cuffs.
Ventilate patient through the short, green tube.
Evaluate placement.
Verify that the patient is receiving adequate ventilations.
Monitor the patient.

42. Removing the PtL Be prepared to suction the patient.
Deflate balloon cuffs.
Gently remove the tube.

43. Laryngeal Mask Airway (LMA)

44. LMA Contraindications
Asthma
COPD
Leaking mask
Active vomiting
Esophageal diseases

45. Inserting the LMA (1 of 2) Assemble and check equipment.
Open the airway.
Preoxygenate the patient.
Select proper size.
Hold LMA down.
Remove oropharyngeal device and begin insertion.

46. Inserting the LMA (2 of 2) Insert until you feel resistance.
Stabilize the tube.
Inflate mask.
Confirm placement.
Insert bite block and secure the LMA.

47. Review
You are called for a male patient complaining of respiratory distress. When you arrive, you assess the patient and find that he is unconscious and apneic, but has a pulse. You should:
A. perform immediate endotracheal intubation.
B. attach an AED and analyze the patient's rhythm.
C. ensure a patent airway and effective ventilation.
D. administer 100% oxygen via nonrebreathing mask.

48. Review
Answer: C
Rationale: Before performing advanced airway procedures (eg, endotracheal intubation), you must first ensure that the patient’s airway is patent. Open the airway, ensure that it is clear of secretions, insert a basic airway adjunct, and ventilate with a bag-mask device. Ventilate the patient for at least 2 to 3 minutes before attempting intubation.

49. Review
You are called for a male patient complaining of respiratory distress. When you arrive, you assess the patient and find that he is unconscious and apneic, but has a pulse. You should:
perform immediate endotracheal intubation.
Rationale: Perform BLS airway management before performing any advanced airway management.
B. attach an AED and analyze the patient's rhythm.
Rationale: The patient has a pulse, so immediate airway intervention is necessary.
C. ensure a patent airway and effective ventilation.
Rationale: Correct answer
D. administer 100% oxygen via nonrebreathing mask.
Rationale: The patient is apneic. You must initiate rescue breathing via a bag-mask device.

50. Review
2. Immediately after placing an endotracheal tube (ETT) in an unconscious patient, you should:
A. attach the bag device and begin ventilating.
B. inflate the balloon cuff and detach the syringe.
C. secure the tube in place with the proper device.
D. remove the malleable stylet from the ET tube.

51. Review
Answer: B
Rationale: After the ETT has been placed, you should immediately inflate the balloon cuff with 5-10 mL of air and detach the syringe. This will seal the trachea and prevent aspiration if regurgitation occurs. Once the cuff is inflated, remove the stylet, attach the bag device, and begin ventilating.

52. Review
2. Immediately after placing an endotracheal tube (ETT) in an unconscious patient, you should:
attach the bag device and begin ventilating.
Rationale: Do this only after the balloon cuff is inflated and the stylet is removed.
B. inflate the balloon cuff and detach the syringe.
Rationale: Correct answer
C. secure the tube in place with the proper device.
Rationale: This is the last step. Note the centimeter marking at the lips and secure the tube.
D. remove the malleable stylet from the ET tube.
Rationale: This is performed after the balloon has been inflated.

53. Review
3. When intubating a patient with a curved blade, the blade will:
A. lift the tongue so that you can see the vocal cords.
B. lift the uvula and bring the vocal cords into clear view.
C. fit under the epiglottis and directly expose the vocal cords.
D. fit into the vallecula and indirectly expose the vocal cords.

54. Review
Answer: D
Rationale: The curved blade is inserted just in front of the epiglottis, into the vallecula (the space between the base of the tongue and the epiglottis), indirectly allowing you to view the vocal cords. The straight blade is inserted directly under the epiglottis, directly allowing you to view the vocal cords.

55. Review
3. When intubating a patient with a curved blade, the blade will:
lift the tongue so that you can see the vocal cords.
Rationale: The blade pushes the tongue to the side during intubation.
B. lift the uvula and bring the vocal cords into clear view.
Rationale: You should visualize the epiglottis, and not the uvula.
C. fit under the epiglottis and directly expose the vocal cords.
Rationale: The straight blade fits under the epiglottis and allows providers to visualize the trachea.
D. fit into the vallecula and indirectly expose the vocal cords.
Rationale: Correct answer

56. Review
4. In which of the following patients would you NOT use a multi-lumen airway device?
A. 40-year-old man in cardiac arrest who has esophageal cancer.
B. 17-year-old patient in cardiac arrest secondary to electrocution.
C. 23-year-old man who is unconscious, apneic, and has a weak pulse.
D. 5’ 6” female who is unconscious and apneic after overdosing on heroin.

57. Review
Answer: A
Rationale: Multi-lumen airway devices are contraindicated in conscious or semiconscious patients who have a gag reflex, patients younger than 16 years of age, adults shorter than 5’ tall, patients who have ingested a corrosive substance, and patients with an esophageal disease (ie, cancer, varices).

58. Review
4. In which of the following patients would you NOT use a multi-lumen airway device?
40-year-old man in cardiac arrest who has esophageal cancer.
Rationale: Correct answer
B. 17-year-old patient in cardiac arrest secondary to electrocution.
Rationale: This device is not used in patients less than 16 years of age.
C. 23-year-old man who is unconscious, apneic, and has a weak pulse.
Rationale: There is not a contraindication, unless the patient has a gag reflex.
D. 5’ 6” female who is unconscious and apneic after overdosing on heroin.
Rationale: The minimum height for using this device is 5’0”.

59. Review
5. You are assisting your paramedic partner while she intubates a 50-year-old man who is in cardiac arrest. You should anticipate that she will ask you for a ____ mm ET tube.
A. 6.0
B. 6.5
C. 7.5
D. 9.0

60. Review
Answer: C
Rationale: The proper-sized ET tube ranges from 7.5 to 8.5 mm for the adult male and 6.5 to 8.0 mm for the adult female. A good rule of thumb is to have a 7.5 mm ETT on hand; this size tube will fit most male and female adults. Of course, a variety of tube sizes should always be available.

61. Review
5. You are assisting your paramedic partner while she intubates a 50-year-old man who is in cardiac arrest. You should anticipate that she will ask you for a ____ mm ET tube.
6.0
Rationale: This sized tube would be used in a very small individual.
B. 6.5
Rationale: This sized tube would be in the range for an average female patient.
C. 7.5
Rationale: Correct answer
D. 9.0
Rationale: This sized tube would be used in large adults.

62. Review
6. Which of the following is clearly a lethal complication of endotracheal intubation?
A. Unrecognized esophageal intubation
B. Chipping two of the patient’s front teeth
C. Slightly extending the neck of a trauma patient
D. Ventilating the patient without supplemental oxygen

63. Review
Answer: A
Rationale: While all of the choices in this question will cause some degree of harm to the patient, unrecognized esophageal intubation is, without doubt, the most lethal. If you intubate the esophagus, and do not recognize and immediately correct it, the patient will die—period!

64. Review
6. Which of the following is clearly a lethal complication of endotracheal intubation?
Unrecognized esophageal intubation
Rationale: Correct answer
B. Chipping two of the patient’s front teeth
Rationale: This is a complication of intubation, but it is typically not lethal.
C. Slightly extending the neck of a trauma patient
Rationale: This is something that needs to be avoided. Paralysis — not death — is usually the end result of this mistake.
D. Ventilating the patient without supplemental oxygen
Rationale: 100% oxygen must be delivered to a patient using a bag-mask. It is not a lethal error to deliver less.

65. Review 7. A single intubation attempt in an adult should not exceed:
A. 10 seconds.
B. 20 seconds.
C. 30 seconds.
D. 40 seconds.

66. Review
Answer: C
Rationale: An intubation attempt should not exceed 30 seconds in the adult, and 20 seconds in infants and children. During the period of time that you are intubating, the patient is not breathing. Prolonged intubation attempts increase the risk of severe hypoxia and must be avoided.

67. Review 7. A single intubation attempt in an adult should not exceed:
10 seconds.
Rationale: The maximum time should not exceed 30 seconds in adult patients.
B. 20 seconds.
Rationale: This is the maximum time for infants and children.
C. 30 seconds.
Rationale: Correct answer
D. 40 seconds.

68. Review
8. After your partner has intubated a patient in respiratory arrest, you auscultate to confirm proper ET tube placement. You hear gurgling over the epigastrium and faint breath sounds over all four lung fields. Your partner should:
A. attach an end-tidal C02 detector to the end of the ET tube.
B. withdraw the ET tube 1 to 2 cm and ask you to reauscultate.
C. inflate the distal balloon cuff and attach the bag device to the tube.
D. remove the ET tube at once and ventilate with a bag-mask device.

69. Review
Answer: D
Rationale: If the ET tube is properly placed in the trachea, you should hear lungs sounds that are equal on both sides of the chest and NO epigastric sounds. If you hear gurgling over the epigastrium—even if you think you hear breath sounds—the ET tube should be removed immediately and ventilations with a bag-mask device should be resumed.

70. Review (1 of 2)
8. After your partner has intubated a patient in respiratory arrest, you auscultate to confirm proper ET tube placement. You hear gurgling over the epigastrium and faint breath sounds over all four lung fields. Your partner should:
attach an end-tidal C02 detector to the end of the ET tube.
Rationale: The detector is only attached after placement is confirmed through auscultation and chest rise.
B. withdraw the ET tube 1 to 2 cm and ask you to reauscultate.
Rationale: The tube is drawn back only if the provider hears lung sounds on one side, which means that the tube is advanced too far.

71. Review (2 of 2)
8. After your partner has intubated a patient in respiratory arrest, you auscultate to confirm proper ET tube placement. You hear gurgling over the epigastrium and faint breath sounds over all four lung fields. Your partner should:
C. inflate the distal balloon cuff and attach the bag device to the tube.
Rationale: The balloon is inflated before providers listen to lung sounds.
D. remove the ET tube at once and ventilate with a bag-mask device.
Rationale: Correct answer

72. Review
9. After inserting an endotracheal tube, you auscultate the patient’s lungs and do not hear breath sounds on the left side of the chest. You should suspect:
A. a tension pneumothorax.
B. intubation of the right mainstem bronchus.
C. intubation of the left mainstem bronchus.
D. that the ET tube has entered the esophagus.

73. Review
Answer: B
Rationale: The right mainstem bronchus is shorter and straighter than the left; therefore, if the ET tube is inserted too far, it will come to rest in the right mainstem bronchus. You will hear breath sounds over the right side of the chest, absent sounds over the left side of the chest, and absent sounds over the epigastrium. To correct this, simply withdraw the tube 1 to 2 cm until breath sounds are equal on both sides of the chest. If breath sounds are present on the left side of the chest and absent on the right, suspect a pneumothorax.

74. Review
9. After inserting an endotracheal tube, you auscultate the patient’s lungs and do not hear breath sounds on the left side of the chest. You should suspect:
a tension pneumothorax.
Rationale: This is suspected if you hear breath sounds on the left and not on the right side of the chest.
B. intubation of the right mainstem bronchus.
Rationale: Correct answer
C. intubation of the left mainstem bronchus.
Rationale: If the left mainstem bronchus was intubated, then providers would hear sounds on the left.
D. that the ET tube has entered the esophagus.
Rationale: The provider would not hear breath sounds if the esophagus was intubated.

75. Review
10. Which of the following devices provides the MOST effective delivery of oxygen into the lungs?
A. Combitube
B. Bag-mask device
C. Endotracheal tube
D. Laryngeal mask airway

76. Review
Answer: C
Rationale: The endotracheal tube is considered to be the superior airway device for delivering oxygen into the lungs. It enters the trachea, has a cuff that provides a seal against vomitus, and allows the delivery of 100% oxygen directly into the lungs. The Combitube and laryngeal mask airway (LMA), while effective airway devices, do not enter the trachea. They have been shown to provide better ventilation than a bag-mask device, but are not superior to the ET tube.

77. Review
10. Which of the following devices provides the MOST effective delivery of oxygen into the lungs?
Combitube
Rationale: The combitube works well, but does not enter the trachea.
B. Bag-mask device
Rationale: The bag-mask device works well as a BLS procedure, but is not the most effective device.
C. Endotracheal tube
Rationale: Correct answer
D. Laryngeal mask airway
Rationale: The laryngeal mask airway works well, but does not enter the trachea.