airway management - bryan - 05-09-2017 - final · 5/5/2017 2 head tilt –chin lift jaw thrust •...

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Spokane County EMS

Airway Management

Jim Bryan, MD, PhDMedical Director, Life Flight NetworkAssistant Professor, Emergency Medicine, OHSU

Objectives

• Review basic Airway Skills – These will save your patient

• Review the use of CPAP

• Discuss intubation and some tips to improve your chances of success

• Challenge some dogma

Airway Opening Techniques

• To alleviate upper airway obstruction

– Head tilt, chin lift method

– Jaw thrust • consider if suspect neck trauma

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Head Tilt – Chin LiftJaw Thrust

• Note position of thumbs

Suctioning

Yankauer tip suction catheter

Suctioning - Indications

• Audible secretions

• Visible secretions

• Vomiting or suspected aspiration

• Decreased oxygen saturations

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Suctioning - Complications

• Oxygen de-saturation from prolonged suctioning

• Trauma to the oropharynx

• Hypertension or hypotension

Nasopharyngeal Airway

• Indications– Awake or semi-conscious patients

– Intact gag reflex

– Airway obstruction or snoring

• Contraindications– Facial trauma

Do not ignore facial trauma

Nasopharyngeal Airways

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Nasopharyngeal Airways

• Select the proper size– Measure distance from nostril to tragus of the ipsilateral

ear– Consider diameter of airway in the nostril

• Lubricate the nasopharyngeal airway with a water-soluble lubricant

• Insert posteriorly (bevel should be toward the base of the nostril or toward the septum)

• If the airway cannot be inserted into one nostril, try the other side

Sizing NPA

• Measure distance from nostril to tragus of the ipsilateral ear

Oropharyngeal Airway

• Indications– Airway obstruction or impending obstruction

– Unconscious patients

• Contraindications– Intact gag reflex

– Conscious or semi-conscious patients

– Relative contraindication in patients who will likely awaken quickly (e.g., post-ictal patients)

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Oropharyngeal Airways Inserting the OP Airway

• Principle is to bring the tongue anteriorly• Insert upside down, with flange facing the top of

the head, rotate 180 degrees into place after flange contacts posterior oropharynx

• If available, a tongue depressor is useful in drawing the tongue anteriorly before inserting the OPA

• Complication – if inserted incorrectly, the OPA may displace the tongue posteriorly and obstruct the airway

Sizing the Oropharyngeal

Airway

Measure from corner of mouth to angle of jaw

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Delivering Oxygen

• Nasal cannula

Nasal Cannula

• Maximum flow?

– 6 lpm?

– 15 lpm?

Nasal Cannula

• Maximum flow?

– 6 lpm?

– 15 lpm

Nasal Cannula

• A Randomized Trial on Subject Tolerance and the Adverse Effects Associated With Higher- versus Lower-Flow Oxygen Through a Standard Nasal Cannula. Ann Emerg Med. 2015;65:356-361.

• Conclusion: Participants were able to tolerate higher-flow nasal cannula oxygen for 10 minutes without difficulty. Higher-flow nasal cannula oxygen at 15 L/minute was associated with some discomfort, but the discomfort quickly dissipated and caused no adverse events.

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Non-rebreather mask

• Regulator set on how many liters per minute?

Administering Oxygen

• How much oxygen will this regulator deliver?

• Trick question?

Administering Oxygen

• Actually: 40 – 60 liters per minute when valve is opened fully

Administering Oxygen

Non-rebreather mask

• Typically delivers an oxygen concentration between 60–80% FiO2

• Open the regulator all the way open to get 100% FiO2

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Bag-Mask Ventilation

• Get good at it

• It will save your patient’s life

Bag-Mask Ventilation

• Bag-mask devices require an oxygen reservoir to supply 100% oxygen when the deflated bag is re-inflated

• Reservoir attached bag or may be via attached corrugated tubing

• Collapsed corrugated tubing must be extended prior to using the bag-mask device

• Some bags do not deliver oxygen without actively squeezing the bag to open the valve

Bag-Mask Ventilation Technique• Open patient’s airway with head-tilt, chin-lift

technique (jaw thrust if suspect cervical trauma)

• Squeeze bag to deliver each breath over one second– Rapid insufflation may cause gastric distention

• Tidal volume: 6-7 mL per kg ideal body weight

• Ventilate at a rate of 10 to 12 breaths per minute—one breath every 5 to 6 seconds

• Do not hyperventilate

Bag-Mask Ventilation

• Corrugated tubing

• Bag reservoir

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Predicting Difficult Bag-Mask VentilationMOANS

• Mask Seal – facial hair, small chin

• Obese

• Age > 55

• No Teeth

• Stiff Lungs (RAD, COPD, ARDS, pregnancy)

• Add some pictures

What Do We Do About This Guy?• Lubricating gel

• Occlusive dressing

Lubricating Gel Method

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Occlusive Dressing Method

• Moderately effective; not particularly elegant

• Size matters - chose the biggest dressing available

• Cut a hole in the center of the dressing to accommodate the patient's nose

• During BVM, gas will flow through the nasal passage rather than the mouth, which should be occluded by basic airway maneuvers (unless they have an OPA in which case there needs to be an opening in the dressing for the mouth as well)

Pediatric Facemask Method

• Goal is to create a mask seal just around the nose (hence a smaller/ pediatric-size facemask is needed).

• Occlude the mouth with basic airway maneuvers, i.e. chin-lift and head-tilt.

• Won’t work with an oral airway as air will escape through the mouth.

• An NPA might increase the success rate.

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Depending on Scope of Practice

An 'early' supraglottic airway/ laryngeal mask

• A way of bypassing a potentially difficult BVM by moving early to inserting a supraglottic airway (King or I-gel) to oxygenate the patient with a beard.

• Requires a patient without a gag (unconscious or paralyzed) patient

Bag-Mask Ventilation

• Single person

• “E-C” hand position

Bag-Mask VentilationTwo Person

– One operator holds mask with two hands

– Second operator squeezes bag

Options if Bag Mask Ventilation Fails

• CPAP

• Supraglottic airways

• Intubation

• Choice depends on the situation

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Supraglottic airways

• I-gel

• King

Supraglottic airways

• Indications– Elective ventilation

– Difficult airway

– Cardiac arrest

– Rescue airway

Supraglottic airways• Contraindications

– Inability to open mouth

– Complete upper airway obstruction

• Relative contraindications

– Increased risk of aspiration: Prolonged bag-valve-mask ventilation, morbid obesity, second or third trimester pregnancy, upper gastrointestinal bleed

– Abnormalities of supraglottic anatomy

CPAP

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CPAP

• Continuous Positive Airway Pressure– Ideal option for many situations

• CHF

• COPD

• Asthma

• Has eliminated the need to intubate the majority of my patients.

How Does CPAP Work?

• Provides continuous airway pressure throughout inspiration and expiration as set by the provider (per protocols) 5 – 7.5 – 10 cm H2O

How Does CPAP Work? How Does CPAP Work?

• Reduces respiratory effort and eases work of breathing

• Keeps alveoli and airways open, improving gas exchange (oxygen and carbon dioxide)

• Increases intrathoracic pressure, which improves left ventricular output

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CPAP risks

• Hypotension – increased intrathoracic pressure causes decreased preload

• Increased size of PTX

• Barotrauma

• Skin breakdown from mask

Contraindications

• Respiratory arrest

• Known or suspected pneumothorax

• Patient with a tracheostomy

• Vomiting

Relative Contraindications• Altered mental status; not able to cooperate with the

procedure

• Failed at past attempts at non-invasive ventilation

• Upper gastrointestinal bleeding or history of recent gastric surgery

• Nausea

• Poor or inadequate respiratory effort

• Excessive secretions

• Facial deformity that prevents the use of CPAP

• Morbid obesity

• Claustrophobia

Endotracheal Intubation: Indications

• Inability to maintain airway patency.

• Inability to protect the airway against aspiration.

• Failure to ventilate (hypercarbia)

• Failure to oxygenate (hypoxia)

• Anticipation of a deteriorating course that will eventually lead to respiratory failure.

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That is the questionHamlet

(kind of)

Difficult Intubation

Each failed attempt at intubation causes further degeneration of the mask airway and progressive compromise of the airway - take a proactive approach

Ways to Improve Your Success at Intubation

Number one rule of intubation

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Slow Down

• Difficult to do when your patient is crashing

• Properly performed RSI takes 10 minutes

• Remember the first thing to do is to take your own pulse

Bigger isn’t always better

• If you can see the cords but you can’t pass the tube, it may be laryngospasm or it may be the tube is too big

• A 7.0 – 7.5 tube will work for most adults– The airway doesn’t get bigger just because

you are morbidly obese.

– Always have one tube bigger and smaller readily available

Preoxygenate

• 5 minutes of 100% oxygen or 8 deep breaths for 60 seconds– Time before sats < 90%

• 70 kg pt -- 8 minutes

• 120 kg pt -- 3 minutes

• 10 kg child -- 4 minutes

– Time for sats 90% 0%• 70 kg pt -- 120 seconds

• 10 kg child -- 45 seconds

Apneic Oxygenation

• Alveoli will continue to take up oxygen even without diaphragm movement or lung expansion.

• First described in 1905

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Apneic Oxygenation

• Pre-oxygenate with 100% oxygen via NRB

• Add a nasal cannula at 6 lpm (or 15 lpm) under the NRB mask to improve oxygenation

• After sedation, the nasal cannula flow rate needs to be 15 lpm

Position the Patient

• External auditory canal to sternal notch– Sniffing position

– Elevate shoulders (pediatrics and obese)

Sniffing Position Ramp Patient

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Adjuncts and Rescue Devices

• Eschmann/Flexguide/Bougie– Particularly useful for anterior airways

Bougie stylet• Increased intubation

success rate 15-30%

• Proper use– Leave laryngoscope

blade in place

– Watch the tube slide down the bougie

– Rotate 90 degrees counterclockwise

Bougie Stylet

• Simulated patient (Sim-Man)

• Paramedics, Flight Nurses and EM residents

• Without bougie: 77% success

• With bougie: 94% success

PREHOSPITAL EMERGENCY CARE 2011;15:30–33

Laryngoscope use

• Spend an extra 3-5 seconds sweeping the tongue completely out of the way.

• If you don’t do this, the laryngoscope displaces the tongue posteriorly, and it occludes the view

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External Laryngeal Manipulation (ELM)

• Also called bimanual laryngoscopy

• The laryngoscopist uses their right hand to manipulate the thyroid cartilage in order to facilitate viewing the cords

Modified Bimanual Laryngoscopy

• Assistant (A) places hand on patient's thyroid cartilage.

• Laryngoscopist uses right hand to guide the assistant's hand to obtain the best view.

• Assistant maintains this position while tube is passed; no phase where the optimal view is lost.

A

If You Predict a Difficult Mask Ventilation

• Can’t intubate = can’t ventilate

• You don’t have time to figure out a back-up plan once you are in trouble

• Think DOUBLE SET UP if you RSI– Standard intubation equipment

– Rescue equipment (supraglottic airways, surgical airways)

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RSI

• Remember that RSI is more than giving drugs to facilitate intubation

• Includes preoxygenation and optimal preparation

• RSI ≠ Crash Airway

RSI

• Why do we utilize Rapid Sequence Intubation?

• Reduce risk of aspiration of gastric contents

• We intubate with the assumption all of our patients have full stomach

RSI

• Paramount with this procedure:

– Once the drugs are administered, do not ventilate until patient is intubated or until forced to do so due to hypoxia and a failed intubation.

Conclusion

• Know your basic skills – especially good BVM technique

• Prepare - for everything

• Positioning - patient and provider

• CPAP will reduce your need to intubate

• Know how to rescue the airway– Supraglottic airways

– Surgical airways

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Thank You

Post Test

1. Contraindications to placing a nasopharyngeal airway include:a) Awake or semi-conscious patient

b) Facial trauma

c) Hypoxia

d) Intact gag reflex

2. The maximum flow on a standard nasal cannula without causing severe discomfort is 6 liters per minute.

a) True

b) False

3. Methods used to obtain a mask seal on a patient with a large beard include:

a) Apply gel to mask

b) Put an occlusive dressing over the face leaving a hole for the nose

c) Use a pediatric mask and ventilate through the nose

d) All of the above

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4. Supraglottic airways (King or I-gel) are useful in all of the following, EXCEPT:

a) Anaphylaxis

b) Cardiac Arrest

c) Difficult Airways

d) Rescue Airways

5. Continuous Positive Airway Pressure (CPAP) is contraindicated in patients with:

a) Asthma

b) CHF

c) COPD

d) Pneumothorax

Special thanks to

Sheila Crow

Stitchin’ Dreams Embroidery

wcsocrow@yahoo.com

For providing our Secret Question prize

Questions?

Contact: Samantha Roberts509-242-4264

1-866-630-4033robertss@inhs.orgFax: 509-232-8344

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