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Airway Scenarios We Don’t Like to Think About

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Presentation on theme: "Airway Scenarios We Don’t Like to Think About"— Presentation transcript:

1 Airway Scenarios We Don’t Like to Think About
Dan Batsie

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3 Wang et al. Interruptions in Cardiopulmonary Resuscitation From Paramedic Endotracheal Intubation. Annals . 54; 5, P e1, Nov. 2009 “Intubation frequently is associated with interruption of compressions for many seconds. Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions.” -2010 AHA Guidelines

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6 Airway management may be accomplished utilizing any combination of live patients, high fidelity simulations, low fidelity simulations, or cadaver labs. -2013 Airway Management Recommendation

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8 Burton et al. Endotracheal Intubation in a Rural EMS State: Procedure Utilization and Impact of Skills Maintenance Guidelines. Prehosp. Emer. Care 5 year review ( ) 957,836 total encounters Annual mean of 1,352 ETI eligible providers 556 providers (41%) attempted at least 1 ETI each year. Mean of 27 providers (2%) annually attempted pediatric ETI.

9 566 543 538 361 14 18 13

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12 At its 18 March 2010 meeting the New Hampshire EMS Medical Control Board voted to remove
all forms of cricothyrotomy from the Patient Care Protocols.

13 Doing less with less

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15 Plan for Today Scenarios Critical decision making Discuss options Review key elements of those options

16 Disclaimers Pushing scope of practice
Sometimes there is no absolute right answer No financial compensation related to devices Not endorsing any specific devices

17 “Kenny” 31 yo male Asthma 580 lbs (263 kg) Altered MS Periods of apnea Hypoxia/Hypercapnea

18 First responders state they have been unsuccessful with PPV

19 Decision Making Respiratory failure? What does he need?
Does he need an advanced airway? How to proceed?

20 Options Continue with basic airway/breathing? CPAP? RSI?
Intubation without RSI?

21 Decision Making Basic Airway BIAD ETI Simple Low risk
May solve problem Bariatric challenge General challenge Short term Hasn’t worked Simple Low risk May solve problem Bariatric challenge General challenge Short term Protective Higher pressure Long term Bariatric challenge General challenge

22 Langeron, O., Masso, E. et al. Prediction of Difficult Mask Ventilation. Anesthesiology. 2000; 92:1229–36

23 Kheterpal, S, Han, R. Incidence and Predictors of Difficult and Impossible Mask Ventilation. Anesthesiology 2006; 105:885–91

24 A combination of poor chest wall compliance, decreased diaphragmatic excursion, increased upper airway resistance, and redundant supraglottic tissues makes mask ventilation more difficult in obese patients.

25 Soft tissue of face and mandible can make traditional methods of face mask seal challenging

26 Joffe, A, Hetzel, S. A Two-handed Jaw-thrust Technique Is Superior to the One-handed “EC-clamp” Technique for Mask Ventilation in the Apneic Unconscious Person. Anesthesiology 2010; 113:873–9

27 Dr R. Levitan . http://www.airwaycam.com/rescue-ventilation.html

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29 H.E.L.P. Traditional methods of airway manipulation can be ineffective due to excess soft tissue Higher pharyngeal critical closing pressure Exacerbated in supine position the applied pressure below which airflow ceases or the airway occludes Gold, A. Schwartz, A. The Pharyngeal Critical Pressure The Whys and Hows of Using Nasal Continuous Positive Airway Pressure Diagnostically. Chest 1996; 110:

30 Flexion and Extension Levitan, R. et al. Head-Elevated Laryngoscopy Position: Improving Laryngeal Exposure During Laryngoscopy by Increasing Head Elevation ANNALS. 41:3 MARCH 2003

31 Sniffing Position Flexion of cervical spine
Extension of atlanto-occipital joint

32 Collins JS, Lemmens HJ, Brodsky JB
Collins JS, Lemmens HJ, Brodsky JB. Obesity and difficult intubation: where is the evidence? Anesthesiology. 2006;104: 617. The “sniffing” position, which involves 8 to 10 cm of head elevation, results in suboptimal positioning for laryngoscopy in an obese patient, and this may also confound results and falsely worsen graded views.

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35 H.E.L.P.

36 H.E.L.P.

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39 Ear to sternal notch Head Elevation Ramping

40 RAMP also improves preoxygenation times in bariatric patients
Altermatt, F, Munoz, H. Pre-oxygenation in the obese patient: effects of position on tolerance to apnoea. British Journal of Anaesthesia 95 (5): 706–9 (2005) Levitan, R. et al. Head-Elevated Laryngoscopy Position: Improving Laryngeal Exposure During Laryngoscopy by Increasing Head Elevation ANNALS. 41:3 MARCH 2003

41 Supine position exacerbates breathing challenges

42 Obese abdomens prevent normal diaphragmatic excursion
Increased pressure required to ventilate Decreased FRC Esophageal sphincter opens at cm H2O  Once opened, lower pressures will cause continued insufflation Lawes EG, Campbell I, et al. INFLATION PRESSURE, GAST. INSUFFLATION AND RSI. Br. J. Anaesth. (1987) 59 (3): 

43 Mask Ventilation Performance Points
Good seal Adjuncts Open airway Ramp Increased pressure (beware) NG/OG tubes?

44 “We conclude that obesity alone is not predictive of tracheal intubation difficulties.”
Larger neck circumference was associated with a higher Mallampati score (P ) and Grade 3 views during laryngoscopy (P ) Anesth Analg 2002;94:732–6

45 Jense HG, Dubin SA, Silverstein PI, et al
Jense HG, Dubin SA, Silverstein PI, et al. Effect of obesity on safe duration of apnea in anesthetized humans. Anesth Analg. 1991;72:89-93 Obese patients may undergo oxygen desaturation to 90% within 3 minutes compared with 6 minutes in normal-weight patients

46 Pre-Intubation: Pre-oxygenate sitting up if possible. CPAP

47 Aligning axis of vision may be more challenging due to excess soft tissue
Obesity can also make “lifting up” on the laryngoscope handle harder, as there is more weight to lift.

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50 Additional Thoughts?

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52 Dyspnea, Difficulty speaking
Manuel 30y male Dyspnea, Difficulty speaking

53 First responders state that his difficulty breathing has gotten worse since their arrival.

54 Decision Making Is it open? Will it stay open? How long? How to proceed?

55 Options Do nothing Run Supplemental oxygen Plastic

56 Decision Making Basic Airway ETI Simple Low risk
May not require protection Rapid changes thus far Could go from bad to really bad Protection vs. edema Long term Edema may be there Can exacerbate short term problem Can exacerbate long term problem

57 Liquid Scald Burns 24% of all burns
2nd highest mortality among causes of burns Highest percentage <2 yrs Increases mortality rate among burns by 20% 50% if >20% TSA US CDC 2010 statistics Huffer, C. The Role of Bronchoscopy in Acute Burns. Indiana University Pulmonary and Critical Care Fellowship Fellows’ Case Archive Case #2

58 Protective keratin layer of skin not present in orotracheal pathway
Steam vs. Copper (both heated to 100°C) Transfer heat to body tissue Decreases by 60°C,, Copper transfers only 230 W xsec Water gives up 2530 W xsec Protective keratin layer of skin not present in orotracheal pathway

59 Inhalation Injury Commonly limited to the upper airway
Animal experiments have shown that if air at 142°C is inhaled it has cooled to 38°C by the time it reaches carina Steam, frequently injures lower airway Hathaway, P, Stern, E. Steam Inhalation Causing Delayed Airway Occlusion. AJR 1996;166:322

60 Mlcak, R, Suman O, et al. Respiratory Management of Inhalation Injury
Mlcak, R, Suman O, et al. Respiratory Management of Inhalation Injury. Burns. 33(2007) 2-13 Acute upper airway obstruction occurs in approximately one-fifth to one-third of hospitalized burn victims with inhalation injury

61 Most common 12-24 hour post insult
Can occur w/in 30 minutes

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67 Cook Airway Exchange Catheter

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71 Additional Thoughts?

72 Sherry 2 yo female New onset dyspnea Expiratory stridor Difficulty speaking Altered MS Cyanosis Hypercapnea Prefers upright position

73 No recent illness No fever Was “restless at bedtime” but settled No PMHx

74 Decision Making Is it open? Will it stay open? What is the etiology of the stridor? How to proceed?

75 Options Do nothing Run Supplemental oxygen Pharmacology Plastic

76 Decision Making Do nothing Basic Airway ETI Simple Low risk
Pharm might work Not good now Likely getting worse Simple Low risk May buy time No protection Likely doesn’t solve the ongoing problem Protective Clinical course Long term Edema may be there Can exacerbate short term problem Can exacerbate long term problem

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78 Epidemiology estimated 252,338 persons <14 years treated with non-fatal coin-related aspiration/ingestion deaths each year 80% of deaths are pediatric Coins are most common non-food foreign body Chena, X, Milkovich, S. Pediatric coin ingestion and aspiration. Int J of Ped Otorhinolaryngology (2006) 70, 325—329

79 Chena, X, Milkovich, S. Pediatric coin ingestion and aspiration
Chena, X, Milkovich, S. Pediatric coin ingestion and aspiration. Int J of Ped Otorhinolaryngology (2006) 70, 325—329

80 Signs and Symptoms >40% have no symptoms
Classic presentation (present in roughly 40% Stridor Wheezing Coughing Dyspnea Jim Holliman. Aspirated and Ingested Foreign Bodies. Uniformed Services U. of the Health Sciences. Bethesda, MD

81 Jim Holliman. Aspirated and Ingested Foreign Bodies
Jim Holliman. Aspirated and Ingested Foreign Bodies. Uniformed Services U. of the Health Sciences. Bethesda, MD

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83 Jim Holliman. Aspirated and Ingested Foreign Bodies
Jim Holliman. Aspirated and Ingested Foreign Bodies. Uniformed Services U. of the Health Sciences. Bethesda, MD

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85 Higgins G, Burton J. Comparison of extraction devices for the removal of supraglottic foreign bodies. Prehosp Emerg Care. 2003 Jul-Sep;7(3):

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87 12 Roberts, Hedges. Surgical cricothyrotomy. In: Clinical Procedures in Emergency Medicine. 5th ed. Philadelphia: Saunders Elsevier; 2010:Chapter 6 Marx JA, Hockberger RS, Walls RM. Airway. In: Rosen's Emergency Medicine: Concepts and Clinical Practice. Philadelphia: Mosby Elsevier; 2013

88 Heard, A, Green, J, Eakins, P. The formulation and introduction of a ‘can’t intubate,can’t ventilate’ algorithm into clinical practice. Anaesthesia, 2009, 64, pages 601–608

89 10mm X 22mm (adult) 2.6mm X 3mm (neonate)
May not be able to palpate with pad of your finger. May need to palpate with finger nail.

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91 Needle Cricothyroidotomy
Prepare equipment. 14 ga IV catheter or bigger Syringe (if possible) Transtracheal jet insufflation device (or BVM?) 6.0 ET hub

92 Oxygenation without Ventilation
Apneac oxygenation 4 seconds of 15 LPM O2 = roughly 800 mL of oxygen into the trachea May or may not be effective due to shunt physiology Heard, A, Green, J, Eakins, P. The formulation and introduction of a ‘can’t intubate,can’t ventilate’ algorithm into clinical practice. Anaesthesia, 2009, 64, pages 601–608

93 CAMS © EMRCI 2005

94 Performance Points Right needle Syringe 45 degree angle Aspirate
Allow for chest fall

95 Additional Thoughts?

96 Key Points Use your brain – Skills are no substitute for critical thinking. Use the right tool for the right job. Escalate when necessary.

97 Questions? Dan Batsie

98 BIG RAMPPPP B: BUY TIME: Increase FiO2, NIV, Optimise Medical Rx I:  INDICATION FOR INTUBATION: do you really need to do it & do it now? G: GET HELP: Anaesthetics, ICU, ENT, Nurses, Orderlies R: RAMP: Build a big ramp! A: APNOEIC OXYGENATION: use nasal prongs to maintain diffusion of O2 M: MINIMAL DRUGS: local anaesthetic spray/neb, ketamine/ketofol +/- sux/roc P: PRE-OXYGENATE WITH NIV P: PARALYSIS – ONLY IF NEEDED P: PLAN FOR FAILURE: Surgical airway kit by the bedside P: POST INTUBATION CARE


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