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Airway Management: Part 2 Prof.M.H.MUMTAZ. Risks/Protective Measures zBe prepared for: yCoughing ySpitting yVomiting yBiting zBody Substance Isolation.

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Presentation on theme: "Airway Management: Part 2 Prof.M.H.MUMTAZ. Risks/Protective Measures zBe prepared for: yCoughing ySpitting yVomiting yBiting zBody Substance Isolation."— Presentation transcript:

1 Airway Management: Part 2 Prof.M.H.MUMTAZ

2 Risks/Protective Measures zBe prepared for: yCoughing ySpitting yVomiting yBiting zBody Substance Isolation yGloves yFace, eye shields yRespirator, if concern for airborne disease

3 ALS Airway/Ventilation Methods zGastric Tubes yNasogastric xCaution with esophageal disease or facial trauma xTolerated by awake patients, but uncomfortable xPatient can speak xInterferes with BVM seal yOrogastric xUsually used in unresponsive patients xLarger tube may be used xSafe in facial trauma

4 ALS Airway/Ventilation Methods zNasogastric Tube Insertion ySelect size (French) yMeasure length (nose to ear to xiphoid) yLubricate end of tube (water soluble) yMaintain aseptic technique yPosition patient sitting up if possible

5 ALS Airway/Ventilation Methods zNasogastric Tube Insertion yInsert into nare towards angle of jaw yAdvance gradually to measured length yHave patient swallow yAssess placement xInstill air, ausculate xaspirate gastric contents ySecure yMay connect to low vacuum (80-100 mm Hg)

6 ALS Airway/Ventilation Methods zOrogastric Tube Insertion ySelect size (French) yMeasure length yLubricate end of tube yPosition patient (usually supine) yInsert into mouth yAdvance gradually but steadily yAssess placement (instill air or aspirate) ySecure yEvacuate contents as needed

7 ET Introduction zEndotracheal Intubation yTube into trachea to provide ventilations using BVM or ventilator ySized based upon inside diameter (ID) in mm yLengths increase with increased ID (cm markings along length) yCuffed vs. Uncuffed

8 Endotracheal Intubation zAdvantages ySecures airway yRoute for a few medications (LANE) yOptimizes ventilation, oxygenation yAllows suctioning of lower airway

9 Endotracheal Intubation zIndications yPresent or impending respiratory failure yApnea yUnable to protect own airway

10 Endotracheal Intubation zThese are NOT Indications yBecause I can intubate yBecause they are unresponsive yBecause I can’t show up at the hospital without it

11 Endotracheal Intubation zComplications ySoft tissue trauma/bleeding yDental injury yLaryngeal edema yLaryngospasm yVocal cord injury yBarotrauma yHypoxia yAspiration yEsophageal intubation yMainstem bronchus intubation

12 Endotracheal Intubation zInsertion Techniques yOrotracheal Intubation (Direct Laryngoscopy) yBlind Nasotracheal Intubation yDigital Intubation yRetrograde Intubation yTransillumination

13 Orotracheal Intubation zTechnique yPosition, ventilate patient yMonitor patient xECG xPulse oximeter yAssess patient’s airway for difficulty yAssemble, check equipment (suction) yHyperventilate patient (30-120 sec)

14 ALS Airway/Ventilation Methods zOrotracheal Intubation yPosition patient yOpen mouth yInsert laryngoscope blade on right side ySweep tongue to left yIdentify anatomical landmarks yAdvance laryngoscope blade xVallecula for curved (Miller) blade xUnder epiglottis for straight (Miller) blade

15 ALS Airway/Ventilation Methods zOrotracheal Intubation yElevate epiglottis yDirectly with straight (Miller) blade yIndirectly with curved (Macintosh) blade yVisualize vocal cords, glottic opening yEnter mouth with tube from corner of mouth

16 ALS Airway/Ventilation Methods zOrotracheal Intubation yAdvance tube into glottic opening about 1/2 inch past vocal cords yContinue to hold tube, note location yVentilate, ausculate xEpigastrium xLeft and right chest yInflate cuff until air leak around cuff stops yReassess tube placement

17 ALS Airway/Ventilation Methods zOrotracheal Intubation ySecure tube yReassess tube placement, ventilation effectiveness

18 Intubation Total time between ventilations should not exceed 30 seconds!

19 Intubation Death occurs from failure to Ventilate, not failure to Intubate

20 ALS Equipment zEquipment yLaryngoscope Handle (lighted) & Blades yStylet ySyringe yMagills yLubricant ySuction yBVM yBAAM (Blind Nasal) z Selection yTypical Adult ET Tube Sizes xMale - 8.0, 8.5 xFemale - 7.0, 7.5, 8.0 yBlade xMac - 3 or 4 xMiller - 3 yTube Depth xUsually 20 - 22 cm at the teeth

21 ALS Equipment

22 From AHA PALS

23 ALS Equipment

24 Pediatric ET Intubation zPediatric Equipment Differences yUncuffed tube < 8 yoa yMiller blade preferred yTube Size xPremie: 2.0, 2.5 xNewborn: 3.0, 3.5 x1 year: 4 xThen: (age/4)+4 z Pediatric Differences yAnatomic Differences yDepth (cm) xTube ID x 3 x12 + (age/2) xeasily dislodged yIntubation vs BVM

25 Positioning zPatient Positioning yGoal xAlign 3 planes of view, so xVocal cords are most visible yT - trachea yP - Pharynx yO - Oropharynx


27 Airway Assessment zCervical Spine zTemporal Mandibular Joint zA/O Joint zNeck length, size and muscularity zMandibular size in relation to face zOver bite zTongue size

28 Assessment Acronym zM Mandible zO Opening zU Uvula zT Teeth zH Head zS Silhouette

29 The Lemon Law zLLook externally zEEvaluate the 3-3-2 rule zMMallampati score zOObstruction? zNNeck Mobility

30 Look zMorbidly obese zFacial hair zNarrow face zOverbite zTrauma

31 Evaluate 3- 3 - 2 zTemporal Mandibular Joint yShould allow 3 fingers between incisors y3-4 cm

32 Evaluate 3 -3- 2 zMandible y3 fingers between mentum & hyoid bone yLess than three fingers xProportionately large tongue xObstructs visualization of glottic opening yGreater than three fingers xElongates oral axis xMore difficult to align the three axis

33 Evaluate 3 - 3 -2 zLarynx yAdult located C5,6 yIf higher, obstructive view of glottic opening yTwo fingers from floor of mouth to thyroid cartilage

34 Mallampati Score zEvaluates ability to visualize glottic opening yPatient seated with neck extended yOpen mouth as wide as possible yProtrude tongue as far as possible yLook at posterior pharynx yGrade based on visual field xGrades 1,2 have low intubation failure rates xGrades 3,4 have higher intubation failure rates

35 Mallampati Score zNot useful in emergent situations zInformal version yUse tongue blade to visualize pharynx


37 Mallampati Grades  Difficulty  Class I Class II Class III Class IV

38 Obstruction zKnow or suspected yForeign bodies yTumors yAbscess yEpiglottitis yHematoma yTrauma

39 Neck Mobility zAlign axis to facilitate orotracheal intubation zDecreased mobility from yC-Spine immobilization yRheumatoid arthritis zQuick Test yPut chin on chest then move toward ceiling

40 Curved Blade (Macintosh) zInsert from right to left zVisualize anatomy zBlade in vallecula zLift up and away DO NOT PRY ON TEETH zLift epiglottis indirectly From AHA ACLS

41 Straight Blade (Miller) zInsert from right to left zVisualize anatomy zBlade past vallecula and over epiglottis zLift up and away DO NOT PRY ON TEETH zLift epiglottis directly From AHA ACLS

42 Glottic Opening n Cormack-Lehane laryngoscopy grading system n Grade 1 & 2 low failure rates n Grade 3 & 4 high failure rates

43 Tube Placement From TRIPP, CPEM

44 Confirmation of Placement

45 Placement of the ETT within the esophagus is an accepted complication. However, failure to recognize and correct is not!

46 Traditional Methods zObservation of ETT passing through vocal cords. zPresence of breath sounds zAbsence of epigastric sounds zSymmetric rise and fall of chest zCondensation in ETT zChest Radiograph

47 All of these methods have failed in the clinical setting

48 Additional Methods zPulse Oximetry zAspiration Techniques zEnd Tidal CO 2

49 Confirming ETT Location zFail Safe zNear Fail Safe zNon-Fail Safe

50 Fail Safe zImprovement in Clinical Signs zETT visualized between vocal cords zFiberoptic visualization of yCartilaginous rings yCarina

51 Near Failsafe zCO2 detection zRapid inflation of EDD

52 Non-Failsafe zPresence of breath sounds zAbsence of epigastric sounds zAbsence of gastric distention zChest Rise and Fall zLarge Spontaneous Exhaled Tidal Volumes

53 Non Failsafe zCondensation in tube disappearing and reappearing with respiration zAir exiting tube with chest compression zBag Valve Mask having the appropriate compliance zPressure on suprasternal notch associated with pilot balloon pressure

54 ALS Airway/Ventilation Methods zBlind Nasotracheal Intubation yPosition, oxygenate patient yMonitor patient xECG monitor xPulse oximeter

55 ALS Airway/Ventilation Methods zBlind Nasotracheal Intubation yAssess for difficulty or contraindication xMid-face fractures xPossible basilar skull fracture xEvidence of nasal obstruction, septal deviation yAssemble, check equipment xLubricate end of tube; do not warm xAttach BAAM (if available)

56 ALS Airway/Ventilation Methods zBlind Nasotracheal Intubation yPosition patient (preferably sitting upright) yInsert tube into largest nare yAdvance slowly, but steadily yListen for sound of air movement in tube or whistle via BAAM yAdvance tube yAssess placement yInflate cuff, reassess placement ySecure, reassess placement

57 ALS Airway/Ventilation Methods zDigital Intubation yBlind technique yVariable probability of success yUsing middle finger to locate epiglottis yLift epiglottis ySlide lubricated tube along index finger yAssess tube placement/depth as with orotracheal intubation

58 ALS Airway/Ventilation Methods Digital Intubation From AMLS, NAEMT

59 ALS Airway Ventilation Methods zSurgical Cricothyrotomy yIndications xAbsolute need for definitive airway, AND unable to perform ETT due for structural or anatomic reasons, AND risk of not securing airway is > than surgical airway risk xOR xAbsolute need for definitive airway AND unable to clear an upper airway obstruction, AND multiple unsuccessful attempts at ETT, AND other methods of ventilation do not allow for effective ventilation, respiration

60 ALS Airway/Ventilation Methods zSurgical Cricothyrotomy yContraindications (relative) xNo real demonstrated indication xRisks > Benefits xAge < 8 years (some say 10, some say 12) xEvidence of fractured larynx or cricoid cartilage xEvidence of tracheal transection

61 ALS Airway/Ventilation Methods zSurgical Cricothyrotomy yTips xKnow anatomy xShort incision, avoid inferior trachea xIncise, do not saw xWork quickly xNothing comes out until something else is in xHave a plan xBe prepared with backup plan

62 ALS Airway/Ventilation Methods zNeedle Cricothyrotomy/Transtracheal Jet Ventilation yIndications xSame as surgical cricothyrotomy with xContraindication for surgical cricothyrotomy yContraindications xNone when demonstrated need xCaution with tracheal transection

63 ALS Airway/Ventilation Methods z Jet Ventilation yUsually requires high- pressure equipment yVentilate 1 sec then allow 3-5 sec pause yHypercarbia likely yTemporary: 20-30 mins yHigh risk for barotrauma

64 ALS Airway/ Ventilation Methods zAlternative Airways yMulti-Lumen Devices (CombiTube, PTLA) yLaryngeal Mask Airway (LMA) yEsophageal Obturator Airways (EOA, EGTA) yLighted Stylets

65 ALS Airway/ Ventilation Methods Pharyngeal Tracheal Lumen Airway (PTLA) From AMLS, NAEMT

66 ALS Airway/ Ventilation Methods Combitube® From AMLS, NAEMT

67 ALS Airway/ Ventilation Methods zCombitube ® yIndications yContraindications xHeight xGag reflex xIngestion of corrosive or volatile substances xHx of esophageal disease

68 ALS Airway/ Ventilation Methods zLaryngeal Mask Airway (LMA) y  use in OR yGaining use out-of- hospital yNot useful with high airway pressure yNot replacement for endotracheal tube yMultiple models, sizes

69 LMA

70 ALS Airway/ Ventilation Methods

71 BLS & ALS Airway/ Ventilation Methods zEsophageal Obturator Airway, Esophageal Gastric Tube Airway yUsed less frequently today yIncreased complication rate ySignificant contraindications xPatient height xCaustic ingestion xEsophageal/liver disease yBetter alternative airways are now available

72 Esophageal Gastric Tube Airway (EGTA) From AHA ACLS

73 ALS Airway/ Ventilation Methods zLighted Stylette yNot yet widely used yExpensive yAnother method of visual feedback about placement in trachea

74 Lighted Slyest

75 ALS Airway/Ventilation Methods

76 Pharmacologic Assisted Intubation “RSI” zSedation yReduce anxiety yInduce amnesia yDepress gag reflex, spontaneous breathing yUsed for xinduction xanxious, agitated patient yContraindications xhypersensitivity xhypotension

77 Pharmacologic Assisted Intubation “RSI” zCommon Medications for Sedation yBenzodiazepines (diazepam, midazolam) yNarcotics (fentanyl) yAnesthesia Induction Agents xEtomidate xKetamine xPropofol (Diprivan®)

78 Pharmacologic Assisted Intubation zNeuromuscular Blockade yTemporary skeletal muscle paralysis yIndications xWhen intubation required in patient who: is awake, has gag reflex, or is agitated, combative

79 Pharmacologic Assisted Intubation zNeuromuscular Blockade yContraindications xMost are specific to medication xInability to ventilate once paralysis induced yAdvantages xEnables provider to intubate patients who otherwise would be difficult, impossible to intubate xMinimizes patient resistance to intubation xReduces risk of laryngospasm

80 Pharmacologic Assisted Intubation zNMB Agent Mechanism of Action yActs at neuromuscular junction where ACh normally allows nerve impulse transmission yBinds to nicotinic receptor sites on skeletal muscle yDepolarizing or non-depolarizing yBlocks further action by ACh at receptor sites yBlocks further depolarization resulting in muscular paralysis

81 Pharmacologic Assisted Intubation zDisadvantages/Potential Complications yDoes not provide sedation, amnesia yProvider unable to intubate, ventilate after NMB yAspiration during procedure yDifficult to detect motor seizure activity ySide effects, adverse effects of specific drugs

82 Pharmacologic Assisted Intubation zCommon Used NMB Agents yDepolarizing NMB agents xsuccinylcholine (Anectine®) yNon-depolarizing NMB agents xvecuronium (Norcuron®) xrocuronium (Zemuron®) xpancuronium (Pavulon®)

83 Pharmacologic Assisted Intubation ySummarized Procedure xPrepare all equipment, medications while ventilating patient xHyperventilate x Administer induction/sedation agents and pretreatment meds (e.g. lidocaine or atropine) xAdminister NMB agent xSellick maneuver xIntubate per usual xContinue NMB and sedation/analgesia prn

84 Pharmacologic Assisted Intubation Failure is not an option!

85 ALS Airway/Ventilation Methods zNeedle Thoracostomy yIndications xPositive signs/symptoms of tension pneumothorax xCardiac arrest with PEA or asystole with possible tension pneumothorax yContraindications xAbsence of indications

86 ALS Airway/Ventilation Methods zTension Pneumothorax Signs/Symptoms ySevere respiratory distress y  or absent lung sounds (usually unilateral) y  resistance to manual ventilation yCardiovascular collapse (shock) yAsymmetric chest expansion yAnxiety, restlessness or cyanosis (late) yJVD or tracheal deviation (late)

87 ALS Airway/Ventilation Methods zNeedle Thoracostomy yPrepare equipment xLarge bore angiocath yLocate landmarks: 2nd intercostal space at midclavicular line yInsert catheter through chest wall into pleural space over top of 3rd rib (blood vessels, nerves follow inferior rib margin) yWithdraw needle, secure catheter like impaled object

88 ALS Airway/Ventilation Methods zChest Escharotomy yIndications xPresence of severe edema to soft tissue of thorax as with circumferential burns xinability to maintain adequate tidal volume, chest expansion even with assisted ventilation yConsiderations xMust rule out upper airway obstruction xRarely needed

89 ALS Airway/Ventilation Methods zChest Escharotomy yProcedure xIntubate if not already done xPrepare site, equipment xVertical incision to anterior axillary line xHorizontal incision only if necessary xCover, protect

90 Airway & Ventilation Methods zSaturday’s class yPractice using equipment xorotracheal intubation xnasotracheal intubation xgastric tube insertion xsurgical airways xneedle thoracostomy xcombitube xretrograde intubation

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