UNC Emergency Medicine Medical Student Lecture Series AIRWAY UNC Emergency Medicine Medical Student Lecture Series Created: Benjamin Leacock 6/21/08

THIS IS INTERACTIVE SO SPEAK UP Objectives Brief anatomy review Indications for airway support Passive oxygen assistance Non-invasive mechanical ventilation Intubation Difficult Airway Mechanical ventilation Pediatric considerations THIS IS INTERACTIVE SO SPEAK UP BWL 4/16/2017

Anatomy BWL 4/16/2017

Anatomy BWL 4/16/2017

What are the indications for intubation? What are some of the situations when you have seen someone intubated? BWL 4/16/2017

Airway Support Intubation Airway protection Ventilation Oxygenation GCS < 8, Can not handle secretions, Airway edema (burns, angioedema) Ventilation Oxygenation High metabolic demand from work of breathing Sepsis BWL 4/16/2017

What are the types of passive oxygenation support? (Tubes on your face) How much O2 do they deliver? What are the limitations? BWL 4/16/2017

Passive Oxygen Support NC    2 L 29%            4 L 37%            6 L 45% Venti Mask 4-10L 24-50% Non-Rebreather – Reservoir bag 15L 60% LIMITATION: You are not ventilating the patient, or protecting their airway. BWL 4/16/2017

What is non-invasive ventilation? BWL 4/16/2017

Non-Invasive Ventilation CPAP Continuous pressure Settings: Typically 5-10 cm H2O BIPAP Inspiratory and expiratory levels Settings: IPAP set at 10, EPAP set at 3 cm H2O With either setting remember that you are increasing intrathorasic pressure, thus decreasing cardiac output. BWL 4/16/2017

What conditions qualify for non-invasive ventilation? What are the contraindications? BWL 4/16/2017

Non-Invasive Ventilation Conditions Pulmonary Edema COPD Asthma – (Questionable efficacy) Pneumonia – (Questionable efficacy) Contraindications Uncooperative patient Obtunded patient BWL 4/16/2017

Bag-Mask-Ventilation How should you hold the BMV? (Note: BMV is not part RSI) BWL 4/16/2017

BMV BWL 4/16/2017

How do you size and position oral and nasal airways? Airway Adjuncts How do you size and position oral and nasal airways? 4/16/2017

Size by looking at angle of jaw Airway Adjuncts Size by looking at angle of jaw 4/16/2017

Intubation BWL 4/16/2017

Intubation What is RSI? Why do we use RSI? BWL 4/16/2017

Intubation - RSI RSI is administration of a potent induction agent followed immediately by a rapidly acting neuromuscular blocking agent to induce unconsciousness and motor paralysis for tracheal intubation RSI increases success rates of intubation RSI decreases aspiration Limits sympathetic discharge and limits ICP increase. BWL 4/16/2017

What are the basic steps of RSI? Intubation What are the basic steps of RSI? BWL 4/16/2017

Intubation - RSI Preparation Pre-oxygenation Positioning Pre-induction Paralysis Tube Confirmation BWL 4/16/2017

What equipment do you need to set up? Intubation What equipment do you need to set up? BWL 4/16/2017

Intubation - RSI Preparation: Patient Ambu bag Suction Blades – check lights Tubes – check cuff Stylette Syringe – 10 cc Capnography Patient Needs IV, O2, Monitor BWL 4/16/2017

How do you position the adult patient? Intubation How do you position the adult patient? BWL 4/16/2017

Intubation - RSI Position: For c-spine precautions: Place the pt in the “sniff position” In the adult this means ramping the head up Align the ear with the sternal notch Maintain cricoid pressure. For c-spine precautions: You can not move the head An assistant holds the head in position while the front of the collar is removed. BWL 4/16/2017

Intubation Why do we pre-oxygenate? How do we do it? How do we not do it? BWL 4/16/2017

Intubation – Pre-Oxygenation We preoxygenate to prevent hypoxia during the apnea that will follow. 100% for 2 min of normal breathing will permit 8 minutes of apnea in the healthy adult. This should be done passively if possible The reason is that bagging the patient will always put air in the stomach – thus increasing the chance of aspiration. BWL 4/16/2017

Intubation What are the common pre-induction agents? When should you consider them? BWL 4/16/2017

Intubation – Pre-Induction LOAD Lidocaine: 1.5 mg/kg – limits bronchospasm in reactive airways and limits ICP response. Opioid: Fentanyl 3ug/kg – limits sympathetic response, used in CAD, ICH, ICP or aortic dissection. Atropine: 0.02 mg/kg in kids under 10 to prevent bradycardia. Defasciculation: 10% of the planed defasiculationg dose to mitigate succ induced elevated ICP. BWL 4/16/2017

Common inductions agents? Intubation Common inductions agents? BWL 4/16/2017

Intubation - Induction Etomidate – Most often used. Hemodynamically stable, No ICP increase Myoclonus is common Propofol – Quick on, quick off Can cause hypotension Ketamine – Sympathometic – may be useful in asthma. May increase ICP. Many additional agents: Benzos, barbiturates BWL 4/16/2017

Intubation The two basic classes of paralytics? What are the contraindications? BWL 4/16/2017

Intubation - Paralytics Depolarizing - Succinylcholine Basically two Ach molecules (so it can cause bradycardia) Works within 60 sec, lasts 6-10 min (resp may occur within 7 min) Contrainducations many related to K. Hyperkalemia Burns, Crush, Stroke, cord injury, intra abdominal sepsis. For all of these must have condition > 5 days Non-Depolarizing – Rocuronium and vecuronium Rocuronium is agent of choice when succinylcholine is contraindicated. Give 1mg/kg which works within 60 sec and lasts 50 minutes BWL 4/16/2017

Intubation What is the difference between a Mac and Miller blades? Typical tube sizes in adults? BWL 4/16/2017

Intubation – Tubes + Blades BWL 4/16/2017

What are the basic steps once you are ready to intubate? Intubation What are the basic steps once you are ready to intubate? BWL 4/16/2017

Intubation - Steps Scope in left hand. Scissor teeth open with right hand. Place blade in right of mouth and sweep tongue to left. Insert blade deeper Lift up and away With R hand manipulate head and/or cricoid for the best view Pass tube DO NOT PASS THE TUBE IF YOU CAN NOT VISUALIZE DO NOT LET GO OF THE TUBE UNTIL SECURE BWL 4/16/2017

Intubation - Steps BWL 4/16/2017

How do we confirm the tube? Intubation How do we confirm the tube? BWL 4/16/2017

Intubation - Confirmation Visualization! Capnography – most sensitive Listen – stomach, then lungs X-ray Esophageal Detector DO NOT LET GO OF TUBE UNTIL IT IS SECURED BWL 4/16/2017

Options for the difficult airway? Intubation Options for the difficult airway? BWL 4/16/2017

Intubation – Difficult Airway Boggie Glide-Scope – Camera on blade LMA/ILMA - useful out of hospital but should only be used in ED in failed airway. Does not protect airway. Lighted Stylet – Primary or rescue Combitube – difficult to use if C-spine immobilized, should be temporary only. Same indications as LMA. Retrograde Intubation – The cricothyroid membrane is punctured, wire sent through and retrieved through mouth. Fiberoptic Intubation – View while you intubate Transtracheal Jet Ventilation – larger 10g needle inserted through the cricothyroid. Inferior to cricothyrotomy, only use is in children <10 where a cric is difficult. Surgical Airway BWL 4/16/2017

How do you perform a surgical airway? BWL 4/16/2017

Surgical Airway BWL 4/16/2017

Anatomical differences of kids? BWL 4/16/2017

Intubation – Kid Anatomy Don’t forget that kids have big heads BWL 4/16/2017

Kids How do you determine tube size in a kid? How is positioning of the child different? Blades? BWL 4/16/2017

Intubation – Kids Tubes Blades Positioning (Age + 4)/4Width of the nail of the little (5th) finger The narrowest part of the child’s airway is subglottic so use a tube without a cuff or a low pressure cuff. Blades In younger kids the epiglottis is large and floppy so use a Miller blade. Positioning Kids have large heads so they typically do not need to be “ramped up.” BWL 4/16/2017