ACC – A Week Aaqid Akram MBChB (2013) Clinical Education Fellow

Objectives Understand basic anatomy of airway Recognise an obstructed airway Simple management techniques to improve + maintain airway Recognise need for definitive airway Understand how to insert a definitive airway Be able to follow the choking algorithm Recognise and manage anaphylaxis Recognise different O2 giving devices, including concentration of O2 provided

Larynx

Case 1 5 year old boy Came to UK 2 years ago, from Nigeria Recent flu symptoms, including sore throat Losing voice since yesterday (hot potato) Finding it difficult to swallow since yesterday Now unable to eat or drink – now drooling No cough

Case 1 continued On examination: Tachypnoeic Tachycardic Funny inspiratory sounds Temp 39C Inspiratory sounds throughout auscultation Drooling Not allowing examination in the mouth

Case 2 70 year old Female Fell asleep with blanket on in front of open fire Woke up with blanket on fire Fire spread throughout room Fire brigade required to rescue patient Complaining of headache and burns on arms and legs only

Case 2 continued On examination: Covered in soot Hoarse voice + coughing sooty sputum Minor burns to forearms and legs Tachycardic Tachypnoeic BP 130/70 SpO2 97% RA Cherry red cheeks

Obstructive Airway Snoring Choking Gurgling Stridor Hoarseness Silent Paradoxical ‘see-saw’ chest movement Cyanosis / hypoxia

Case 3 45 year old male In a posh restaurant (on a date – not relevant) Starts to cough weakly and splutter while eating prawn starter Quickly becomes blue in the face Unable to speak or breathe

Choking Algorithm Assess Severity Severe (Ineffective Cough) Unconscious CPR Conscious 5 Back Blows 5 Abdominal Thrusts Mild (Effective Cough) Encourage Coughing

Case 4 FY1 working in BRI – On Call Crash 2 am!!! Female appx 20 years old Due for elective tonsillectomy in the morning PMH - Diabetes Found unresponsive by nurses

Case 4 continued Other members busy with another crash call that has just gone off on the other side of the hospital Patient snoring RR - 8 Has a pulse Not responding to pain

ETT (Definitive Airway) LMA / iGel Simple Airway Adjunct OropharyngealNasopharyngeal Head Tilt + Chin Lift / Jaw Thrust Clear visible airway obstruction

When is a definitive airway required? Airway Protection GCS<8 Severe maxillofacial / Multiple Trauma Aspiration Risk Airway obstruction risk Head Injury with abnormal mental status Ventilation and Oxygenation Respiratory arrest Respiratory failure Need for prolonged ventilatory support Class III or IV Haemorrhage with poor perfusion Severe Chest Injury Severe Closed Head Injury (GCS<8)

LEMON Assessment L = Look externally (facial trauma, large incisors, beard or moustache, large tongue) E = Evaluate the rule (incisor distance-3 finger breadths, hyoid-mental distance-3 finger breadths, thyroid-to-mouth distance-2 finger breadths) M = Mallampati (Mallampati score > 3). O = Obstruction (presence of any condition like epiglottitis, peritonsillar abscess, trauma). N = Neck mobility (limited neck mobility)

Case 5 30 year old female Admitted to hospital for acute pyelonephritis Seen on morning ward round Had been started on gentamicin, but consultant would like tazocin to be used instead FY1 prescribes it, rushing behind the consultant who has already moved on to the next patient

Case 5 continued Nurse immediately commences tazocin PMH: asthma only She has checked for allergy status – NKDA Within 20 mins: RR 30 Wheezy + tight chest HR 120 BP 80/50 Itchy all over

Case 6 18 year old female Attends emergency department Severely tachypnoeic and tachycardic Shallow panting and crying, but able to speak full sentences if prompted BP 110/80 No wheeze SpO2 99% PMH: mild asthma

Case 7 50 year old male Transferred back to ward following PCI Simple face mask with 5L O2 flow SpO2 100 RR 16 BP 120/80 Awake and talking Theatre notes advise 24% O2 therapy (they never really write that) escalate concentration if required to maintain saturations above 94%

Nasal Cannula Variable Performance Range: 0.5-6litres/min Delivers: 1-2litres/min = 24% Add 4% for each litre added after this Be careful at higher flow rates as can cause mucosal drying.

Simple Face Mask Variable Performance Range: 5-10L/min Delivers: 35-60% Do not run at less than 5L/min –to prevent CO2 rebreathing

Case 7 continued Continues to feel well within self Complaining of soreness in nostrils Developed small amounts of epistaxis with origin likely where the the nasal prong is irritating the nostril SpO2 now 90% without nasal cannula Not feeling breathless

Venturi Mask Fixed Performance Delivers: 24%/28%/35%/40% Flow rate should be that marked on the valve With RR>30 increase flow by 50% Helps maintain minute ventilation Increases flow but not oxygen delivered

Case 7 continued Later that night – Develops sudden onset severe central chest pain Radiating into left arm Become breathless + sweaty 9/10 pain SpO2 85% on 28% venturi RR 40 HR 140 regular BP 100/90 Temp 27.3C

Non-Rebreathe Mask Variable Performance Range: 10-15L/min Delivers: 60-(80%)100% Always ensure reservoir bag is filled before putting on patient Consider humidification of oxygen due to high flow

Theramist Fixed performance device Cold water nebulised humidification Suitable for 28-60% O 2 delivery

Essential Points… Always remember to connect tubing to O 2 supply and turn Oxygen on Oxygen flow metre Set middle of ball to flow rate required If your patient is not tolerating the device: Review and alter delivery method, if possible Hypoxia kills quicker than hypercapnoea!

Case 8 74 year old female COPD Two day history of increasing productive cough – green sputum Mild pyrexia since last night Short of breath (RR 33) and getting tired Inhalers have not helped Some chest tightness HR 120 regular SpO2 84 on RA BP 90/58 Temp 38C

VariableValueRange pH pCO pO cHCO BE+2-2 / +2 SaO 2 89%>95% Lactate2.1<2

Non-Invasive Ventilation CPAP versus BiPAP

Non Invasive Ventilation Bi-Level Ventilatory support Potentially reversible exacerbation Type 2 RF Respiratory acidosis (pH 5.9) Despite Max medical Rx for 1 hour Able to co-operate with mask IPAP – 10 EPAP – 4

NIV – Exclusion Criteria/CI Pneumothorax End stage malignancy Acute myocardial infarction Multi-organ failure Cranio-facial abnormalities/Trauma Normo-capnoeic metabolic acidosis Impaired consciousness (GCS <8) Patient declines use – refused consent Haemodynamically Unstable Irreversible condition Abdominal/upper GI surgery Unable to Co-operate with mask/no improvement Consider ICU Input

Long Term O2 Therapy LTOT – 15 to 20 hours per day Stable + PaO2 < 7.3 kPa Stable + PaO2< 8 kPa + one of: Secondary polycythaemia Nocturnal hypoxaemia Peripheral oedema Pulmonary hypertension

Have a read of this…

Objectives were: Understand basic anatomy of airway Recognise an obstructed airway Simple management techniques to improve + maintain airway Recognise need for definitive airway Understand how to insert a definitive airway Be able to follow the choking algorithm Recognise and manage anaphylaxis Recognise different O2 giving devices, including concentration of O2 provided