Backup Airways

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Backup Airways
New Hampshire Division of Fire Standards
Training and Emergency Medical Services
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Know Your Options!!! Dont hesitate to use them!
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Purpose

• It is vital that the prehospital crew be
  confident and comfortable with the rescue airways
  approved for their level of licensure.
• During this module you will review and practice
  the back up airways for your level of licensure.

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Purpose

• Review Backup Airway Devices (Rescue Airways)
• BVM
• LMA
• King-LT-D
• Combitube
• Cricothyrotomy

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What do we do when we have a difficult airway?
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The Basics

• Position
• OPA
• BVM
• Suction
• Most difficult airways will still be manageable
  using basic airway maneuvers!

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The Need for Oxygen

• 0 1 minute cardiac irritability
• 0 4 minutes brain damage not likely
• 4 6 minutes brain damage possible
• 6 10 minutes brain damage very likely
• gt 10 minutes irreversible brain damage

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Oxygen and Carbon Dioxide Exchange

• Oxygen-rich air is inhaled to alveoli
• O2 exchanged at alveolocapillary level
• Perfusion to capillary beds
• O2/CO2 exchange at cellular level
• Perfusion from capillary beds
• CO2 exhanged at alveolocapillary level
• CO2 exhaled

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Assessment of Respiration

• Patients level of consciousness
• Respiration quality
• Pulse quality
• Respiratory rate
• Pulse rate
• SPO2
• EtCO2
• Blood pressure
• Glasgow coma score

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Every TRUE life saving intervention performed by
EMS reverses one or more failing components of
respiration
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BVM is the most essential intervention in RSI
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Inadequate Breathing

• Fast or slow rate
• Irregular rhythm
• Abnormal lung sounds
• Reduced tidal volume
• Use of accessory muscles
• Cool, pale, diaphoretic, cyanotic skin

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Head Tilt-Chin Lift

• One hand on the forehead
• Apply backward pressure
• Tips of fingers under mandible
• Lift the chin

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Jaw-Thrust Maneuver

• Place fingers behind the angle of the jaw
• Use thumbs to open mouth

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Look, Listen, and Feel

• Assess that Airway!

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Basic Airway Adjuncts

• Oropharyngeals
• Keeps tongue from blocking oropharynx
• Eases suctioning
• Used with BVM
• Patients without gag reflex
• Nasopharyngeals
• Maintains patency of oropharynx
• Patients with gag reflex
• Should not be used with head trauma

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Oxygen

• Nonrebreathing mask
• Provides up to 90 oxygen
• Used at 10 to 15 L/min
• Nasal cannula
• Provides 24 to 44 oxygen
• Used at 1 to 6 L/min

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Oxygen

• Nasal cannula
• 24-40 at 1-6 liters
• Non-rebreather mask
• Up to 90 at 15 liters
• BVM
• 21 atmosphere
• Up to 100 at 15 liters with reservoir

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Artificial Ventilation

• Mouth to mask
• BVM one person
• BVM two person

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Ventilation Rates

• Adults 8 - 10 breaths per minute
• Approximately one breath every 6 8 seconds
• Pediatric 12 20 breaths per minute
• Approximately one breath every 3 6 seconds

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Bag Valve Mask

• Delivers gt 90 oxygen
• Requires practice and proficiency
• Use with airway adjuncts and/or advanced airways

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BVM-Problems encountered

• Inattentiveness
• Poor mask seal poor ventilatory ability
• Varying ventilatory rates
• Varying expiration rates
• Varying tidal volumes
• Often excessive airway pressure
• Often hyper-ventilation

Mastering the BVM overcomes these obstacles!
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BVM One person

• Insert an oral/nasal airway
• Seal mask by placing the apex over the bridge of
  the nose and lower portion of the mask over the
  mouth and upper chin.
• Make a C with your index finger and thumb
  around the mask.
• Maintain the airway with your middle, ring and
  little finger, creating a E, under the jaw to
  maintain the chin lift.
• Squeeze the bag with your other hand slowly at a
  rate of one breath every 68 seconds.
• Monitoring SpO2

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BVM Two Person

• Insert oral/nasal airway
• First provider hold the bag portion of the BVM
  with both hands.
• Second provider seals the mask with apex over the
  bridge of the nose and base at the upper chin.
• Using two hands the second provider places
  his/her thumbs over the top half of the mask
  index and middle finger over bottom half ring
  and little finger under jaw.
• Second provider also maintains chin-lift
• First provider squeezes bag every 68 seconds
• Monitoring SpO2.

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Adequate Ventilation

• Equal chest rise and fall
• Appropriate rate
• Heart rate returns to normal

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Inadequate Ventilation

• Minimal or no chest rise
• Ventilating too fast or too slow
• Heart rate does not return to normal

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Asthma and COPD

• These patients complicate the traditional RSI
  approach due to the difficulty encountered when
  mask ventilating
• Alveolar hyperinflation secondary to underlying
  pathophysiology must be considered and adequate
  passive ventilation time must be ensured
• Tidal volumes should be reduced, initially, to
  reduce likelihood of barotrauma and air trapping

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Gastric Distention

• Air fills the stomach from too forceful or too
  frequent ventilations
• Airway may be blocked and ventilations are
  re-routed to stomach
• Decreases lung capacity
• May cause patient to vomit

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Airway Obstructions

• Tongue
• Vomit
• Blood, clots, traumatized tissue
• Swelling
• Foreign objects

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Recognizing an Obstruction

• Partial or complete?
• Can patient speak? Cough?
• If unconscious, deliver artificial ventilation
• Does air go in? Does the chest rise?

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Removing an Obstruction

• Heimlich maneuver
• Suction
• Magills (paramedics)

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Suctioning

• Turn on unit and ensure proper suctioning
  pressure (300 mmHg)
• Select proper tip and measure
• Insert with suction off
• Suction on the way out
• Suction for no more than 15 seconds

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Continuous Positive Airway Pressure (CPAP)

• Is the patient a candidate for CPAP?

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CPAP Indications

• Any patient in respiratory distress associated
  with CHF with any of the below obvious signs and
  symptoms or a history of CHF
• Bibasilar or diffuse rales
• Respiratory rate greater than 25
• Pulse oximetry below 92
• Retractions or accessory muscle use
• Abnormal capnography (rate, waveform, CO2 levels)

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RSI Indication

• Immediate severe airway compromise in the context
  of trauma, drug overdose, status epilepticus,
  etc. where respiratory arrest in imminent.

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Always have a back-up plan.

• Plans A, B, and C
• Know the answers before you begin

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Plan A (ALTERNATIVES)

• Different
• Size of blade
• Type of blade
• Miller
• Macintosh
• Specialty
• Position (patient provider)
• Hockey stick bend in ETT or Directional tip ETT
• Remove the stylette as you pass through the cords
• BURP (aka ELM)
• Gum Elastic Bougie
• 2-person technique
• cowboy or skyhook
• Have someone else try

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Viewmax Scope

• Easy of use
• Can be used like a Mac or Miller
• Should improve your view by one grade

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BURP a.k.a. External Laryngeal Manipulation

• Backward, Upward, Rightward Pressure
  manipulation of the trachea
• 90 of the time the best view will be obtained by
  pressing over the thyroid cartilage

Differs from the Sellick Maneuver
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Plan B (BVM and BACK UP Airways)

• Can you ventilate with a BVM?
• (Consider two NPAs and an OPA, Cricoid
  pressure w/ gentle ventilation)
• KINGLT-D
• Combitube
• LMA

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King-LT-D
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King LT-D
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Combitube
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CombiTube
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Insertion Technique

• Tongue-Jaw Lift
• Anatomical Insertion
• Black rings will lie between teeth or alveolar
  ridges
• Bending the tip prior to use may ease insertion

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CombiTube

• Inflate Blue Balloon
• Inflate White Balloon
• The CombiTube may reposition as the oropharyngeal
  is inflated.

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Esophageal Placement

• Ventilate Blue Tube
• Visualize
• Auscultate
• EtCO2

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Tracheal Placement

• Ventilate Clear Tube
• Visualize
• Auscultate
• EtCO2

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Laryngeal Mask AirLMA
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LMA

• The LMA was invented by Dr. Archie Brain at the
  London Hospital in Whitechapel in 1981
• The LMA consists of two parts
• The mask
• The tube
• The LMA has proven to be a very effective
  management tool for the airway

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Introduction continued

• The LMA design
• Provides an oval seal around the laryngeal
  inlet once the LMA is inserted and the cuff
  inflated.
• Once inserted, it lies at the crossroads of the
  digestive and respiratory tracts.

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Indications

• Situations involving a difficult mask (BVM) fit.
• May be used as a back-up device where
  endotracheal intubation is not successful.
• May be used as a second-last-ditch airway where
  a surgical airway is the only remaining option.

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Contraindications

• Greater than 14 to 16 weeks pregnant
• Patients with multiple or massive injury
• Massive thoracic injury
• Massive maxillofacial trauma
• Patients at risk of aspiration
• NOTE Not all contraindications are absolute

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Complications

• Throat soreness
• Dryness of the throat and/or mucosa
• Complications due to improper placement vary
  based on the nature of the placement

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Equipment for LMA Insertion

• Body Substance Isolation equipment
• Appropriate size LMA
• Syringe with appropriate volume for LMA cuff
  inflation
• Water soluble lubricant
• Ventilation equipment
• Stethoscope
• Tape or other device(s) to secure LMA

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Preparation

• Step 1 Size selection
• Step 2 Examination of the LMA
• Step 3 Check deflation and inflation of the
  cuff
• Step 4 Lubrication of the LMA
• Step 5 Position the Airway

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Step 1 Size Selection

• Verify that the size of the LMA is correct for
  the patient
• Recommended Size guidelines
• Size 1 under 5 kg
• Size 1.5 5 to 10 kg
• Size 2 10 to 20 kg
• Size 2.5 20 to 30 kg
• Size 3 30 kg to small adult
• Size 4 adult
• Size 5 Large adult/poor seal with size 4

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Step 2 Examine the LMA

• Visually inspect the LMA cuff for tears or other
  abnormalities
• Inspect the tube to ensure that it is free of
  blockage or loose particles
• Deflate the cuff to ensure that it will maintain
  a vacuum
• Inflate the cuff to ensure that it does not leak

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Step 3 Deflation Inflation

• Slowly deflate the cuff to form a smooth flat
  wedge shape which will pass easily around the
  back of the tongue and behind the epiglottis.
• During inflation the maximum air in cuff should
  not exceed
• Size 1 4 ml
• Size 1.5 7 ml
• Size 2 10 ml
• Size 2.5 14 ml
• Size 3 20 ml
• Size 4 30 ml
• Size 5 40 ml

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Step 4 Lubrication

• Use a water soluble lubricant to lubricate the
  LMA
• Only lubricate the LMA just prior to insertion
• Lubricate the back of the mask thoroughly
• Important Notice
• Avoid excessive amounts of lubricant
• on the anterior surface of the cuff or
• in the bowl of the mask.
• Inhalation of the lubricant following placement
  may result in coughing or obstruction.

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Step 5 Positioning of the Airway

• Extend the head and flex the neck
• Avoid LMA fold over
• Assistant pulls the lower jaw downwards.
• Visualize the posterior oral airway.
• Ensure that the LMA is not folding over in the
  oral cavity as it is inserted.

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LMAInsertionTechnique
Step 1
Step 2
Step 3
Step 4
Step 5
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LMA Insertion Step 1

• Grasp the LMA by the tube, holding it like a pen
  as near as possible to the mask end
• Place the tip of the LMA against the inner
  surface of the patients upper teeth

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LMA Insertion Step 2

• Under direct vision
• Press the mask tip upwards against the hard
  palate to flatten it out.
• Using the index finger, keep pressing upwards as
  you advance the mask into the pharynx to ensure
  the tip remains flattened and avoids the tongue.

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LMA Insertion Step 3

• Keep the neck flexed and head extended
• Press the mask into the posterior pharyngeal wall
  using the index finger.

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LMA Insertion Step 4

• Continue pushing with your index finger.
• Guide the mask downward into position.

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LMA Insertion Step 5

• Grasp the tube firmly with the other hand
• Then withdraw your index finger from the pharynx.
• Press gently downward with your other hand to
  ensure the mask is fully inserted.

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LMA Insertion Step 6

• Inflate the mask with the recommended volume of
  air.
• Do not over-inflate the LMA.
• Do not touch the LMA tube while it is being
  inflated unless the position is obviously
  unstable.
• Normally the mask should be allowed to rise up
  slightly out of the hypopharynx as it is inflated
  to find its correct position.

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Verify Placement of the LMA

• Connect the LMA to a Bag-Valve Mask device or low
  pressure ventilator
• Ventilate the patient while confirming equal
  breath sounds over both lungs in all fields and
  the absence of ventilatory sounds over the
  epigastrium

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Securing the LMA

• Insert a bite-block or roll of gauze to prevent
  occlusion of the tube should the patient bite
  down.
• Now the LMA can be secured utilizing the same
  techniques as those employed in the securing of
  an endotracheal tube.

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Verify

• During ventilation observe end-tidal CO2 monitor
  or pulseoximetry to confirm oxygenation

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Waveform Capnometry

• Prerequisite Requirement
• Becoming a standard of care
• Easy to Use
• Good measure of Pulmonary Perfusion
• Relates well to PaCO2
• Does have limitations

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Problems with LMA Insertion

• Failure to press the deflated mask up against the
  hard palate or inadequate lubrication or
  deflation can cause the mask tip to fold back on
  itself.

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Problems with LMA Insertion

• Once the mask tip has started to fold over, this
  may progress, pushing the epiglottis into its
  down-folded position causing mechanical
  obstruction

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Problems with LMA Insertion

• If the mask tip is deflated forward it can push
  down the epiglottis causing obstruction
• If the mask is inadequately deflated it may
  either
• push down the epiglottis
• penetrate the glottis

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Plan C Cricothyrotomy

• Last resort!

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Equipment

• Endotracheal or tracheostomy tube (or commercial
  device)
• Scalpel
• Curved hemostats
• Suction apparatus
• Oxygen Supply
• BVM
• Securing device
• Bandaging materials

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Procedure

• Have all supplies (including suction) available
  and ready.
• A commercially available device may be desirable.

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Commercial Cricothyrotomy Kits

• Must perform to recommendation of manufacturer
  and Medical Directors satisfaction for
  proficiency.

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Find the persons Adam's apple (thyroid cartilage)
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Procedure

• Locate the cricothyroid membrane utilizing
  correct anatomical landmarks.

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Procedure

• Prep the area with an antiseptic swap (e.g.
  Betadine).

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Procedure

• Using your non-dominant hand, stabilize the
  thyroid cartilage and secure the cricothyroid
  membrane.

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Procedure

• Make a 1-inch vertical incision through the skin
  and subcutaneous tissue using a scalpel.

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Procedure

• Using blunt dissection technique, expose the
  cricothyroid membrane.

This is a bloody procedure.
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Procedure

• Some protocols recommend stabilizing the
  cricothyroid membrane with a skin or trach hook.

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Procedure

• Make a horizontal, transverse incision
  approximately ½ inch long through the membrane.

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Procedure

• Using a dilator, hemostat, or gloved finger to
  maintain surgical opening, insert the cuffed tube
  into the trachea.
• Cric tube from the kit of a 6.0 ETT is usually
  sufficient.

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Procedure

• Using a dilator, hemostat, or gloved finger to
  maintain surgical opening, insert the cuffed tube
  into the trachea.
• Cric tube from the kit of a 6.0 ETT is usually
  sufficient.

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Procedure

• Inflate the cuff with 5-10cc of air and ventilate
  the patient while manually stabilizing the tube.

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Procedure

• All of the standard assessment techniques for
  ensuring tube placement should be performed
  (auscultation, chest rise and fall, end-tidal CO2
  detector, etc..
• Secure the tube.

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Complications

• Incorrect tube placement/ false passage
• Thyroid gland damage
• Severe bleeding
• Subcutaneous emphysema
• Laryngeal nerve damage

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Always expect the unexpected!
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RSI Procedure The Seven Ps

• 1. Preparation
• 2. Preoxygenate the patient
• 3. Premedicate the patient
• 4. Paralyze the patient
• 5. Pass the tube
• 6. Proof of placement
• 7. Post intubation care