2 WHY AIRWAY REVIEW? Most important aspect of patient care (?) Failure = Gravest Consequence
3 WHY AIRWAY REVIEW? Many Quality Assurance Concerns: -Gausche et al study -PALS update -PALS update -Burton et al study -Kendall et al study -Marcolini et al study
4 MAINE’S PLAN These Concerns led MDPB to do a comprehensive review of the current airway protocol and create the new… Airway Algorithm
5 AIRWAY PROTOCOL -Makes airway procedures a “step by step” process -Adds concept of “rescue airway” -Adds new airway devices
6 AIRWAY PROTOCOL Protocol Initiated 5/23/05 The MDPB’s goal is to train all intubating providers by a yet to be determined date *Providers may use new protocol if trained but not until they are trained
7 MANDATORY EQUIPMENT Goal is for services to comply with mandatory airway devices by a yet to be determined roll out date. MEMS will allow time for budgeting
8 Mandatory Equipment *All intubating services must carry Laryngeal Mask Airways (LMA) (Note all LMA’s are now available in disposable form) MANDATORY EQUIPMENT
13 OXYGENATION IS GOOD Indicated in those patients who are in respiratory distress and remain able to exchange air on their own. *Beware of decompensating patients!
14 WHY MANAGE AN AIRWAY Anyone can be taught to use a BVM or intubate…the real question is why manage an airway?
15 AIRWAY MANAGEMENT AIRWAY MANAGEMENT Reasons To Manage an Airway: -Obstruction -None present, (trauma, medical) -Decompensating (not maintaining) -Breathing too fast or too slow? What are your indicators?
16 AIRWAY MANAGEMENT Respiratory Distress vs. Respiratory Failure Distress -Increased work of breathing -Relative hypoxia/hypercapnea -Compensating Failure -Increased work of breathing -Profound hypoxia/hypercapnea -Decompensating It’s a constant reassessment process…
17 AIRWAY ALGORITHM A step by step approach at evaluating each patients ability to maintain an open airway. A step by step approach at evaluating each patients ability to maintain an open airway. Immediate corrective actions based on this assessment Immediate corrective actions based on this assessment A constant reassessment of current procedures to determine the need to be more or less aggressive in the best interest to the patient. A constant reassessment of current procedures to determine the need to be more or less aggressive in the best interest to the patient.
25 STEP 3. VENTILATE (BLS) Why is this helpful in all manual ventilation?
26 STEP 4. CONTROL THE AIRWAY Intubation vs. vs.BVM Why and why not?
27 STEP 4. CONTROL THE AIRWAY Airway Management Decision Process (Judge how aggressive you need to be.) -Time/Distance-Personnel-Equipment -Other Considerations?
28 STEP 4. CONTROL THE AIRWAY “Evaluate for signs of difficult intubation” (this may help in your decision as well) -Obesity-Small body habitus -Small jaw-Large teeth -Burns-Trauma -Anaphylaxis-Stridor
29 STEP 4. CONTROL THE AIRWAY The BLS vs. ALS airway decision may not be based on one single factor, but rather based on an overall assessment of many factors.
30 STEP 4. CONTROL THE AIRWAY Pre-Intubation -Prepare Equipment -Hyper-oxygenate
31 STEP 4. CONTROL THE AIRWAY Orotracheal Intubation Procedure Sweep Left and Look
32 STEP 4. CONTROL THE AIRWAY Backward, Upward, Right Pressure (B.U.R.P.) Find Your Landmarks
33 STEP 4. CONTROL THE AIRWAY Find Your Landmarks
34 STEP 4. CONTROL THE AIRWAY It may not be perfect! Find Your Landmarks
35 STEP 4. CONTROL THE AIRWAY Find Your Landmarks
36 STEP 4. CONTROL THE AIRWAY Readjusting with Cricoid Pressure
37 STEP 4. CONTROL THE AIRWAY Common Provider Mistakes * Making a difficult intubation more difficult *Rushing *Poor equipment preparation *Suction (lack there of)
38 STEP 4. CONTROL THE AIRWAY What is your back-up plan today? prolonged BVM… another provider… a smaller tube… better lighting… additional suctioning…
39 STEP 4. CONTROL THE AIRWAY Helpful Adjuncts Gum Elastic Bougie
40 STEP 4. CONTROL THE AIRWAY Helpful Adjuncts Lighted Stylette
41 Nasotracheal Intubation Indications: “Patient still breathing but in respiratory failure and in whom oral intubation is impossible or difficult.” STEP 4. CONTROL THE AIRWAY -AAOS
42 Contraindications: -Apnea -Resistance in the nares -Blood clotting or anticoagulation problems -Basilar Skull Fx (?) STEP 4. CONTROL THE AIRWAY Nasotracheal Intubation
43 Technique: -Prepare patient and nostril -Prepare tube -Insert on inspiration -Take your time Complications: -Bleeding STEP 4. CONTROL THE AIRWAY Nasotracheal Intubation
44 STEP 5. CONFIRM THE AIRWAY Technology Based ETCO2 (monitor)ETCO2 (monitor) EDD (bulb)EDD (bulb) Colormetric (cap)Colormetric (cap) Pulse Ox changePulse Ox change Intubation Confirmation Good, Better, Best Traditional Direct VisualizationDirect Visualization Lung SoundsLung Sounds Tube CondensationTube Condensation
45 STEP 6. SECURE THE AIRWAY Tape Improvised devices Commercial devices Immobilization (?) Secure Your Tube Good, Better, Best
46 Laryngeal Mask Airway Developed in 1981 at the Royal London Hospital By Dr Archie Brain STEP 7. ALTERNATIVES TO ETI
47 Indications: -When definitive airway management cannot be obtained. (ETT) Not a substitute for definitive airway management Laryngeal Mask Airway STEP 7. ALTERNATIVES TO ETI
48 Contraindication/Limitations:-Obesity-Non-secure -Size based -Not a med route Laryngeal Mask Airway STEP 7. ALTERNATIVES TO ETI
49 Weight Based Sizing <5kg = Size 1 5-10 kg = Size 2 20-30 kg = Size 2.5 Small Adult= Size 3 Average Adult = Size 4 Large Adult = Size 5 Laryngeal Mask Airway STEP 7. ALTERNATIVES TO ETI
50 Average Adult Woman = 4 Average Adult Male = 5 Average Adult Male = 5 *If in doubt, check the LMA Laryngeal Mask Airway STEP 7. ALTERNATIVES TO ETI
51 Procedure: -Hyper oxygenate -Check cuff -Lubricate posterior cuff -Head in neutral or slightly flexed position -Insert following hard palate (use index finger to guide) -Stop when met with resistance -Let go and inflate cuff (visualize “pop”) -Confirm and secure Laryngeal Mask Airway STEP 7. ALTERNATIVES TO ETI
52 Air volume is variable depending on cuff size and individual patient anatomy General Guideline: Size 1 = 4 ml Size 2 = 10 ml Size 2.5 = 14 ml Size 3 = 20 ml Size 4 = 30 ml Size 5 = 40 ml Laryngeal Mask Airway STEP 7. ALTERNATIVES TO ETI
53 Common Provider Problems: -Failure to seat properly -Sizing difficulties -Aspiration Laryngeal Mask Airway STEP 7. ALTERNATIVES TO ETI
54 Laryngeal Mask Airway STEP 7. ALTERNATIVES TO ETI
55 MDPB has approved all “non-intubating” LMA type devices Laryngeal Mask Airway STEP 7. ALTERNATIVES TO ETI
56 (Combitube®) STEP 7. ALTERNATIVES TO ETI Dual Lumen Airway
57 Indications: -When definitive airway management cannot be obtained. (ETT) Not a substitute for definitive airway management Dual Lumen Airway STEP 7. ALTERNATIVES TO ETI
58 Contraindications/Limitations: -No pediatrics -5’7-7’ tall (SA 4’-5’6) -Pathological esophageal disease -Non-secure airway -Latex sensitivity -Toxic or Caustic Ingestions STEP 7. ALTERNATIVES TO ETI Dual Lumen Airway
59 Procedure: -Hyper oxygenate -Check equip. -Head in neutral position -Insert until to guide lines STEP 7. ALTERNATIVES TO ETI Dual Lumen Airway
60 Procedure: -Inflate Pharyngeal cuff (blue) with 85-100cc of air -Inflate tracheal cuff (white) with 10-15cc of air STEP 7. ALTERNATIVES TO ETI Dual Lumen Airway
61 -Ventilate port 1 (longer, blue tube, #1). If no lung sounds, switch ports -Ventilate port 2 (shorter, white tube, #2) *You will be either in the esophagus or the trachea STEP 7. ALTERNATIVES TO ETI Dual Lumen Airway
62 Indications-Obstruction -Facial Trauma -Intubation or other alternatives impossible -Trismus (clenching) ->8 years old (for open procedures) STEP 8. SURGICAL AIRWAYS LAST RESORT!
63 STEP 8. SURGICAL AIRWAYS Open Cricothyrotomy -Vertical Incision over membrane -Pierce membrane in horizontal plane -Open and spread to insert 4.0 or 5.0 tube -Secure tube in place and ventilate
64 Needle Procedure: -Identify Cricothyroid membrane -Pierce at 45° angle -Place catheter or styllette -Advance dilator per manufacturer’s recommendation STEP 8. SURGICAL AIRWAYS Needle Cricothyrotomy
68 MAINE EMS WISHES TO THANK THE FOLLOWING MANUFACTURERS FOR THEIR CONTRIBUTIONS OF TRAINING MATERIALS. Boundtree Medical - LMA Products, Lighted Stylletes Mike Evers-Jenkins (800) 533-0523 ext. 550 Tri-Anim- Cobra PLA, Per-Trach Jaclyn Emanuelson (877) 207-4329 ext 6306 Rüsch- Quick Trach Dave Henry (800) 848-3766 ext. 1707