Sliding from First toSecond Place: Airway

Mike McEvoy, PhD, NRP, RN, CCRN

EMS Coordinator – Saratoga County, NY

EMS Editor – Fire Engineering magazine

Staff RN – Cardiothoracic Surgery and

Chair – Resuscitation Committee, Albany Medical Center

www.mikemcevoy.com

Disclosures• I am on the Physio-Control and Masimo

Speakers Bureaus

• I don’t know how to play golf or ski

www.mikemcevoy.com

Mike McEvoy - Books:

Outline (not in order):• CPR 2010: that was then, this is now…

• EMS Education: déjà vu all over again

• Airway basics

• Oxygen or not?

• Airway advances

• Alternative devices

• Video intubation

• Where we are

• What’s coming

Adult Chain of Survival: 20101. Immediate recognition and activation of

emergency response system2. Early CPR with emphasis on

chest compressions3. Rapid defibrillation4. Effective ALS5. Integrated post-cardiac arrest care

CPR SequenceChange A-B-C to C-A-B Initiate chest compressions

before ventilations

Why? Reduce delay to

compressions Can be started immediately Emphasizes importance of

chest compressions

What? You’re Killing Me…

Standard CPR (with breaths) vs. CC alone

Berg et al, 2001

Blo

od P

ress

ure

= chest compressionB

lood

Pre

ssur

e

Time

Standard CPR

CCR

So, What Matters in CPR?High quality, continuous compressions

So, don’t intubate, you say?

Many, many studies…

Bottom line:

“Rescuer procedural experience is associated with improved patient

survival after out-of-hospital tracheal intubation of cardiac arrest and medical

non-arrest patients.”

Wang, Yealy, et al. Out of Hospital Endotracheal Intubation Experience and Patient Outcomes. Ann Emer Med, June 2010

Experience: real or simulated?• Initial competence: 80 intubations

• Ongoing competence: 2 per month

Graham CA. Advanced airway management in the emergency department: what are the training and skills maintenance needs for UK emergency physicians? Emerg Med J 2004;21:14-19

Scope of Problem (Population):• 5% cannot be ventilated with a BVM• 1% cannot be intubated without hospital

equipment• It makes sense then, to

give paramedics bettertools

• Video laryngoscopy is abetter tool

GlideScope®

PRO

• All size patients

• Disposable covers

CON

• Screen on side

• Cost $$$$

Others:

• Storz C-MAC® • McGrath® Vitaid

Others:

• PENTAX Airway Scope Ambu®

• King Vision® Kingsystems

Others:

• Airtraq® Prodol

And the winner is….

King Vision® Kingsystems

• Price

• Most akin to conventional

• More compact and portable

• Larger screen

• CON: adult only

While we’re on ET Tubes:• Holder mandatory

• Cuffed tubes for kids

• Asynchronous breaths

• Sloooooooow

LYFETYMER®

For those not in practice…

Alternative Airways

• EOA, EGTA

• Combitube™ King™

SGA (Supra Glottic Airways)

• Combitube, King, LMA, i-gel…

Recent Evidence: ROC• Resuscitation Outcomes Consortium• 264 US/Canadian EMS agencies• Study cardiac arrest and trauma• ROC PRIMED Study:

1. 3 min high quality CPR vs. immediate defib

2. Use of ITD (blinded)

(found no difference with either intervention)

Stiell IG, et al & the Resuscitation Outcomes Consortium Investigators. Early versus later rhythm analysis in patients with out-of-hospital cardiac arrest. New England Journal of Medicine,

2011:365(9), 787-797.Aufderheide TP, et al & the Resuscitation Outcomes Consortium (ROC) Investigators. A trial of an impedance threshold device in out-of-hospital cardiac arrest. New England Journal of Medicine, 2011:365(9), 798-806.

ET versus SGA• 10,455 adult OOHCA with advanced airway placed• ETI vs. SGA for ROSC, survival 24h and to discharge• Most patients ETI, most SGA patients were King-LT

Rittenberger JC, et al. Association between Cerebral Performance Category, Modified Rankin Scale, and discharge disposition after cardiac arrest. Resuscitation, 2011:82(8), 1036-40.

Findings: SGA vs. ETIOutcome Odds

Ratio95% Confidence

Interval

ROSC 1.78 [1.54, 2.04]

24 hours survival 1.74 [1.49, 2.04]

Survival to discharge 1.40 [1.04, 1.89]

Secondary airway or pulmonary complications

0.84 [0.61, 1.16]

Uh Oh!

Why?• Vf induced in 9 pigs, CPR 3 min. intervals:

– ETT for first 3 minutes– Followed by 3 min each (random order):

• King LTS-D™• LMA Flexible™• Combitube™

• Primary endpoint = Carotid Blood Flow (CBF)• Findings: CBF significantly with SGA in

pigs during CPR

Segal N, et al. Impairment of carotid artery blood flow by supraglottic airway use in a swine model of cardiac arrest. 2012. Resuscitation, in press.

Prediction:

LMA Supreme™

EMS Education Standards• New cert levels:

– EMR– EMT– AEMT– Paramedic

• Defines skills and knowledge

• Curriculum from publishers

Skill ComparisonSkill EMR EMT AEMT Medic

OPA X X X X

NPA X X X

Esophageal, SGA X X

ET X

Trach/Cricothyrotomy X

End-Tidal CO2 X

CPAP/BiPAP/PEEP X

Demand Valve/ATV X X X

Pulse Oximetry X X X

Oxygen: NC/NRBM X X X X

Oxygen: SFM/Venturi/PRBM X X X

Oxygen: Humidifiers X X X

Tracheostomy Tubes• Who has them?

• Why?

• Where would you encounter them?

• What are the typicalcomplications?

Laryngectomy vs. Tracheostomy

Pre-Packaged Tracheostomy Tube

Common Problems with Trachs

Dislodged

Obstructed

Pneumothorax

Equipment

D is for Dislodged / Decannulation

RULES for Re-inserting a Tracheostomy Tube

Preparation:

• Proper positioning of the patient

• “Ready to go” trach set includes– Trach with obturator, ties, 10 cc syringe

• Suction equipment

• Water soluble lubricant (K-Y) or normal saline/sterile water

• When possible, lubricate the new tube before insertion

• If lubricant not available, use saline or water

Prepare the trach tube with lubricant

BLBLSS

RULES for Inserting a Tracheostomy Tube

Inserting a Tracheostomy Tube BLBL

SS • TWO providers• Head/neck

neutral to slightly flexed

Insertion of a Tracheostomy Tube

If you meet resistance : STOP !

BLBLSS

Syringe Full, No Air In Cuff

Cuff Inflated, Syringe Empty

Securing the Tracheostomy TubeBLBL

SS

Securing the Tracheostomy Tube

One Fingertip Fits Under the Adult Ties

Baby with One Fingertip

BLBLSS

If BLS Is Unable to Re-Insert the Tracheostomy Tube…

BVM, Dressing to Stoma for Adult Manikin

Same, with Baby Manikin

BLBLSS

Decannulation

ALS Interventions

BLS FIRST

Then consider:– Insert endotracheal tube into trach stoma

OR – As last resort - orally intubate (if appropriate)

while maintaining occlusive dressing over the stoma

ALS

O is for OBSTRUCTION

• Trachs may become obstructed:– Secretions– Improper positioning of the patient– Bleeding– Foreign body obstruction– Trach “nose” clogged– Tracheal edema (incredibly rare)

Obstruction:Suction the Tracheostomy Tube

Suction Catheter Inserted To Measured Depth – Adult

Suction Catheter Inserted To The Measured Depth –Baby

BLBLSS

Suction Available: Step 1

Instilling Saline into Adult Trach

Instilling Saline into Baby Trach

BLBLSS

Suction AvailableSupplemental Oxygen: Step 2

BV to trach

pre-suctionBV to trach

pre-suction

BLBLSS

Suction: Inserting Suction Catheter - Step 3

• Keep fingers at the measured depth to insert the catheter

• Insert suction catheter without applying suction

BLBLSS

Suction: Step 4

Apply suction:• Cover the opening on

catheter

• For NO MORE than 5-10 seconds (time you can hold your breath comfortably)

BLBLSS

Obstruction: Single Cannula• If unable to insert

suction catheter to a reasonable depth

• Obstruction is IN the tube itself

• Remove the tracheostomy tube

BLBLSS

Obstruction: Inner Cannula

• If a double lumen trach, remove the inner cannula

• Replace with new inner cannula

• If new inner cannula not available, rinse original inner cannula with water and reinsert

• Reassess patient

BLBLSS

Obstruction: Remove Trach

• If you have not been able to:– ventilate the patient, or– insert a suction catheter to a reasonable

depth

• You need to REMOVE the trach as the obstruction is IN the tracheostomy tube

BLBLSS

Removing a Cuffed Tracheostomy Tube: Step 1

Empty Syringe Attached, Balloon Full

Syringe Full, Balloon Empty

BLBLSS

Removing a Cuffed Tracheostomy Tube: Step 2

Cut the Ties Remove the Trach

BLBLSS

P is for Pneumothorax• Pneumothorax can occur from:

– High Peak Inspiratory Pressures– High Positive-End-Expiratory Pressures– Vigorous BVM ventilations– Underlying disease process (COPD, blebs,

etc)

Equipment: Problems

• Equipment problems may include:– Oxygen issues (tank empty, disconnects, etc)– Tubing issues (disconnect, obstructed)– Trach kit not “ready to go”– Home vents:

• Power failure/unplugged from outlet• Home ventilator failure/dead battery• Home oxygen not connected properly

Equipment

• FOR ALL EQUIPMENT PROBLEMS:- Take the patient off the equipment- Attempt to ventilate the patient using BVM to trach- Assess for effectiveness of ventilations- Add supplemental oxygen if saturation < 94%- Take the equipment with the patient to the hospital

BLBLSSBLBLSS

New Stuff:• Oxygen humidifiers

• SFM, PRBM, Venturi

• Pulse Oximetry

• Demand Valve/ATV

SALT® Airway ECOLAB $19

• Supraglottic Airway Laryngopharyngeal Tube• Facilitates blind ETT placement• Mixed reviews

• However, in difficult to ventilate patients, this

may be a lifesaving tool

Mazurek P. Should You Use SALT? EMS1.com Air Medical Transport column July, 2010.

CPR is Complicated!

Probability of ROSC

Stiell et al. Crit Care Med 2012; 40:1192-1198

Survival to Discharge

Stiell et al. Crit Care Med 2012; 40:1192-1198

CPR Rate vs. ROSC

p < 0.0083

Abella et al. Circulation. 2005;111:428-434

Effective CPR?• How do you measure the effectiveness

of CPR?– End tidal carbon dioxide– Feedback devices

• Measurement of CPR effectiveness is a proposed TJC future standard

Waveform CapnographyAttaches to ET tube, measures CO2

Oxygen Lungs alveoli blood

Muscles + Organs

Oxygen

Cells

Oxygen

Oxygen+

Glucose

ENERGY

CO2

Blood

Lungs

CO2

Breath

CO2

Physiology of Metabolism

SpO2 versus EtCO2

Oxygenation and VentilationOxygenation (Pulse Ox)

– O2 for metabolism

– SpO2 measures % of O2 in RBCs

– Reflects changes in oxygenation within 5 minutes

Ventilation (Capnography)

– CO2 from metabolism

– EtCO2 measures exhaled CO2 at point of exit

– Reflects changes in ventilation within 10 seconds

Measuring Exhaled CO2

Colorimetric

Capnometry

Capnography

Measuring Exhaled CO2

Colorimetric

Capnometry

Capnography

Measuring Exhaled CO2

Colorimetric

Capnometry

Capnography

Capnography Waveforms

45

0

45

0

Hypoventilation

Normal

Hyperventilation

45

0

98

Sp02

What about the Pulse Ox?

Carbon Dioxide (CO2) Production

What If…

But, with High-Quality CPR…

Meet Howard Snitzer• 54-years old, collapsed Jan 5,

2011 outside Don’s Foods in Goodhue, MN (pop. 900)

• 2 dozen rescuers took turns providing CPR for 96 minutes

• 6 shocks with first responder AED, 6 more shocks by Mayo Clinic Air Flight Medics

• Transported to Mayo Clinic Cardiac Cath Lab

Why Not Quit?• Thrombectomy, stent to LAD

• 10 days inpatient

• “The capnography told us not to give up”

• EtCO2 averaged 35 (range 32 – 37)

So What’s the Goal During CPR?

• Try to maintain a minimum EtCO2 of 10

• Push HARD (> 2”)FAST (at least 100)

• Change rescuerEvery 2 minutes

Guidelines 2010• Continuous quantitative waveform

capnography recommended for intubated patients throughout peri-arrest period. In adults:

1. Confirm ETT placement

2. Monitor CPR quality

3. Detect ROSC with EtCO2 values

Guidelines 2005EtCO2 recommended to confirm ET

tube placement

Wayne MA, Levine RL, Miller CC. “Use of End-tidal Carbon Dioxide to Predict Outcome in Prehospital Cardiac Arrest” . Annals of Emergency Medicine. 1995; 25(6):762-767.

Levine RL., Wayne MA., Miller CC. “End-tidal carbon dioxide and outcome of out-of-hospital cardiac arrest.” New England Journal of Medicine. 1997;337(5):301-306.

EtCO2 detects ROSC• 90 pre-hospital intubated arrest patients• 16 survivors

• 13 survivors: rapid rise in exhaled CO2 was the earliest indicator of ROSC

• Before pulse or blood pressure were palpable

Cat Pornography

Waveform: Bronchospasm

Mild Moderate

Interpretation of Waveforms• Algorithms are coming that will measure

– Slope of waveforms– Time– Other components associated with disease

• Breathing and/or non-breathing patients

Integrated Pulmonary Index™

IPI Values – fuzzy logic

IPI Patient Status

10 Normal

8-9 Within normal range

7 Close to normal range; requires attention

5-6 Requires attention

3-4 Requires attention or intervention

1-2 Requires intervention

Another Change:

2010• Tidal volume 600 ml

2005• Tidal volume 800 ml

Should we make BVMs smaller?

Smaller Tidal Volumes:

• Some systems are using pedi BVMs

• Little data, some conflicts, mostly fear:

Dorges V, et al. Smaller tidal volumes with room-air are not sufficient to ensure adequate oxygenation during bag-valve-mask ventilation. Resuscitation. 2000; March(44)1: 37-41.

Oxygen

• Oxygen therapy has always been a major component emergency care

• Health care providers believe oxygen alleviates breathlessness

Mike73%

Godlisten84%

Pete41%

Effects of sudden hypoxia(Removal of oxygen mask at altitude or in a pressure

chamber)• Impaired mental function; onset at mean

SaO2 64%• No evidence of impairment above 84% • Loss of consciousness at mean

saturation of 56%

Notes:– absence of breathlessness when healthy resting subjects

are exposed to sudden severe hypoxia – mean SpO2 of airline passengers in a pressurized cabin

falls from 97% to 93% (average nadir 88.6%) with no symptoms and no apparent ill effects

Akero A et al Eur Respir J. 2005;25:725-30 Cottrell JJ et al Aviat Space Environ Med.

1995;66:126-30Hoffman C, et al. Am J Physiol 1946;145:685-692

“Normal” Oxygen SaturationNormal range for healthy young adults is approximately 96-98% (Crapo AJRCCM, 1999;160:1525)

Previous literature suggested a gradual fall with advancing age…

However, a Salford/Southend UKaudit of 320 stable adultsaged >70 found:Mean SpO2 = 96.7% (2SD range 93.1-100%)

“Normal” nocturnal SpO2

• Healthy subjects in all age groups routinely desaturate to an average nadir of 90.4% during the night (SD 3.1%)*

(Gries RE et al Chest 1996; 110: 1489-92)

*Therefore, be cautious in interpreting a single oximetry measurement from a sleeping patient. Watch the oximeter for a few minutes if in any doubt (and the patient is otherwise stable) as normal overnight dips are of short duration.

What happens at 9,000 metres (approximately 29,000 feet)?

It Depends…

Passengers unconscious in <60 seconds if depressurized

Everest has been climbedwithout oxygen

SUDDEN ACCLIMATIZATION

OxygenWe began giving oxygen because it

seemed like the right thing to do…

Documented benefits:HypoxiaNausea/vomitingMotion sickness

Oxygen

• Today, there are numerous textbooks on the reactive oxygen species.

Oxygen

• We are learning that oxygen is a two-edged sword

• It can be beneficial

• It can be harmful

The Chemistry of Oxygen• Oxygen is highly

reactive; it has 2 unpaired electrons

• Molecules/atoms with unpaired electrons are extremely unstable and highly-reactive

• Referred to as “free radicals”

The Chemistry of Oxygen• An excess of free-radicals damages cells

and is called oxidative stress.

The Chemistry of Oxygen

00.20.40.60.8

11.21.41.61.8

Rat

Parakeet

Canary

H2O2 Leakage from Cardiomyocytes

Lifespan = 3.5 years

Lifespan = 21 years

Lifespan = 24 years

Not a new concept

ACLS Guidelines 2000:

• Supplemental oxygen only for saturations < 90%

• 2005: ditto

• 2010: < 94%

StrokeMinor or Moderate

StrokesSevere Strokes

Variable Oxygen Control Oxygen Control

Survival 81.8% 90.7% 53.4% 47.7%

SSS Score 54 (54-58) 57 (52-58) 47 (28-54) 47 (40-52)

Barthel Index 100 (95-100) 100 (95-100) 70 (32-90) 80 (47-95)

Ronning OM, Guldvog B. Should Stroke Victims Routinely Receive Supplemental Oxygen? A Quasi-Randomized Controlled Trial. Stroke. 1999;30:2033-2037.

No oxygen

Oxygen

Stroke• “Supplemental oxygen should not

routinely be given to non-hypoxic stroke victims with minor to moderate strokes.” - AHA 1994

• “Further evidence is needed to give conclusive advice concerning oxygen supplementation for patients with severe strokes.”

Ronning OM, Guldvog B. Should Stroke Victims Routinely Receive Supplemental Oxygen? A Quasi-Randomized Controlled Trial. Stroke. 1999;30:2033-2037.

Neonates• 1,737 depressed neonates:

– 881 resuscitated withroom air

– 856 resuscitated with 100% oxygen

• Mortality:– Room air resuscitation: 8.0%– 100% oxygen resuscitation: 13.0%

• Room air superior to 100% oxygen for initial resuscitation

Davis PG, Tan A, O’Donnell CP, et al: Resuscitation of newborn infants with 100% oxygen or air: a systematic review and meta-analysis. Lancet 364:1329-1333, 2004

Rabi Y, Rabi D, Yee W: Room air resuscitation of the depressed newborn: a systematic review and meta-analysis. Resuscitation 72:353-363, 2007

Therapeutic Hypothermia

Post ROSC Survival:

• Post cardiac arrest hypothermia

• 58 patients, all ROSC in OOH CPA

• Cooling protocol: keep sat 92-96%– Survival by 50% when sats < 92%– Survival by 83% when sats > 96%

Unpublished data. Albany Medical Center, Albany, New York, USA. Division of Cardiothoracic Surgery 2009.

Therapeutic HypothermiaVanderbuilt Univ – TH post ROSC

•170 patients - highest PaO2 during 24° TH (32-34°C):

– Survivors had significantly lower PaO2 (198) vs non-suriviors (254)

– Higher PaO2 risk death (OR 1.439)

– Favorable neuro outcomes (CPC 1-2) also linked to lower PaO2

– Higher PaO2 neuro outcomes (OR 1.485)

Janz et al. Hyperoxia is associated with increased mortality in patients treated with mild therapeutic hypothermia after sudden cardiac arrest. Crit Care Med 2012; 40(12): 3135-3139.

Trauma• Charity Hospital (1/19/30/2002):• 5,549 trauma patients by EMS

Mortality:

PENETRATING

BLUNT

OVERALL

Oxygen None

Trauma• “Our analysis suggest that there is no

survival benefit to the use of supplemental oxygen in the prehospital setting in traumatized patients who do not require mechanical ventilation or airway protection.”

Stockinger ZT, McSwain NE. Prehospital Supplemental Oxygen in Trauma Patients: Its Efficacy and Implications for Military Medical Care. Mil Med. 2004;169:609-612.

BMJ 18 Oct 2010

BMJ 18 Oct 2010

405 diff breathers randomized:• NRBM (n=226)• NC to SpO2 88-92% (n=179)Titrated O2 reduced mortality:• all patients 58%• COPD patients 78%

ACS (Acute Coronary Syndrome)

• O2 shows little benefit, may harm

• No analgesic effect

• Harm study needed since 1976

• Dangers:– Increases myocardial ischemia (Nicholson, 2004)

– Triples mortality (Rawles, 1976)

– Increases infarct size (Ukholkina, 2005)

• No benefit when sats >90%

Cabello JB, Burls A, Emparanza JI, Bayliss S, Quinn T. Oxygen therapy for acute myocardial infarction (Review). The Cochrane Collection, 2010, Issue 6.

ACS: Why, why, why?

Within 5 minutes of 100% O2 (vs. RA):

coronary resistance ~ 40% coronary blood flow (CBF) ~ 30%• Blunted CBF response to Ach, marked NO

McNulty PH, et al. Effects of supplemental oxygen administration on coronary blood flow in patients undergoing cardiac catheterization. Am J Physiol Heart Circ Physiol. 2005; 288: H1057-H1062.

CBF (Coronary Blood Flow)

Right Heart Cath:

McNulty PH, et al. Effects of supplemental oxygen administration on coronary blood flow in patients undergoing cardiac catheterization. Am J Physiol Heart Circ Physiol. 2005; 288: H1057-H1062.

Where to from here?

British Thoracic Society

O2 therapy guideline (everywhere):

• Keep normal/near-normal O2 sats

– All patients except hypercapnic resp. failure and terminal palliative care

– Keep sat 92-96%, tx only if hypoxic– Use pulse oximetry to guide tx – max 98%

www.brit-thoracic.org.uk

What is the current standard?Guidelines 2010:

• Oxygen for saturations < 94%

• Target range 94 – 96%

Got oxygen?

Oxygen?

Implications: Oximetry mandatory

Implications: Venturi ComebackImplications: Venturi Comeback

Prehospital Implications

Prehospital Implications

Prehospital Implications

• Pulse oximetry guided supplemental oxygen

• Protocols needed!

Prehospital Implication$• Rationalizing the O2 administration

using pulse-oximetry reduces O2 usage.

• Oxygen cost-saving justifies oximeter purchase:– Where patient volume > 1,750 per year.– Less frequently for lower call volumes, or – Mean transport time is < 23 minutes.

Macnab AJ, SusakL, Gagnon FA, Sun C. The cost-benefit of pulse oximeter use in the prehospital environment. Prehosp Emerg Care. 1999:14:245-250.

Can We Attenuate Oxidative Stress?

• Perhaps

• Clues lie with Carbon Monoxide– Known in vitro and in vivo

antioxidant and anti-inflammatory properties

– Critically ill patients CO production• Survivors produce more CO• Non-survivors produce less or no CO

– Multiple human studies now using CO to attenuate oxidative pulmonary stress

Endogenous Sources of CO• Normal heme catabolism (breakdown):

• Only biochemical reaction in the body known to produce CO

• Hemolytic anemia• Sepsis, critical

illness…

Future Predictions • Continued de-emphasis on airway and

ventilation • Oxygen = danger:

– Pulse oximeters for everyone– Venturi mask revival– CPAP with titrated FiO2

• ET will remain– High volume, good oversight, skilled– Video tools will cost less & sell more– SGA for everyone else (including EMT?)

• Capnography technology will evolve

HFNC:(High Flow

Nasal Cannula)

Vapotherm® (prototype)

• Humidifier (moisture)

• Oxygen blender (%)– Air (50 PSI)– Oygen (50 PSI)

• Flowmeter

• Up to 40 LPM, 100%

HFNC

Questions?

www.mikemcevoy.com