1 AIRWAY ALGORITHM REVIEW

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

9 OPTIONAL EQUIPMENT Optional Equipment *Dual Lumen Airways *Intubation Adjuncts -Gum elastic Bougees (Tube changers) -Lighted Styllettes *Commercial Tracheotomy Kits -Pertrach, Quick Trach, etc.

10 AIRWAY PROTOCOL QA Component

11 TRAINING OBJECTIVES -Practical walk through airway management from BLS to ALS -Introduce the algorithm idea -Review fundamental concepts -Practice hands on skills -Debunk myths -Trade tips

12 ANATOMY REVIEW

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.

18 STEP 1. OPEN AND CLEAR Clear and Suction

19 STEP 2. KEEP IT OPEN Benefits and Limitations Benefits and Limitations Indications and Contraindications Indications and Contraindications

20 STEP 2. KEEP IT OPEN Sizing and Insertion

21 STEP 3. VENTILATE (BLS) Procedure: -Attach high flow O2 -Select appropriate mask (good seal imperative) -Override pop-offs (?) What are the limitations?

22 -BVM Rate Re-Examined -BVM Depth Re-Examined STEP 3. VENTILATE (BLS) Practical Exercise on Ventilation

23 Approximate normal ventilation rates: 10 bpm Adult 10 bpm Adult 20 bpm Child 20 bpm Child 25 bpm Infant 25 bpm Infant STEP 3. VENTILATE (BLS)

24 Cricoid Pressure

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 kg = Size 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 cc 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

65 Commercial Needle Cricothyrotomy Devices Quick TrachPertrach STEP 8. SURGICAL AIRWAYS Needle Cricothyrotomy

66 WHY AN ALGORITHM? 1.Step by step process in order 2.Start simple and work up 3.Alternatives 4.Be sure 5.Get it done

67 Questions?

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) ext. 550 Tri-Anim- Cobra PLA, Per-Trach Jaclyn Emanuelson (877) ext 6306 Rüsch- Quick Trach Dave Henry (800) ext. 1707