Airway Management Back to the basics Why? Growing body of

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Airway Management

• Back to the basics

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Why?

• Growing body of literature that suggests that
  pre-hospital providers are not proficient at
  airway management
• Undiagnosed eso intubations
• Poor assessment skills
• Lack of practice
• Advanced directives
• Hospice
• Progressive protocols

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Primum non nocere

• An increase in mortality has been documented in
  association with paramedic rapid sequence
  intubation (RSI) of severely head-injured
  patients. This analysis explores the impact of
  hypoxia and hyperventilation on outcome.
• The impact of hypoxia and hyperventilation on
  outcome after paramedic rapid sequence intubation
  of severely head-injured patients.Davis DP,
  Dunford JV, Poste JC, Ochs M, Holbrook T,
  Fortlage D, Size MJ, Kennedy F, Hoyt DB.

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Primum non nocere

• During the six-month study period, 208
  out-of-hospital intubations by ground paramedics
  were enrolled, which included 160 (76.9) medical
  patients and 48 (23.1) trauma patients. A total
  of 12 (5.8) endotracheal tubes were incorrectly
  placed outside the trachea.
• Emergency physician-verified out-of-hospital
  intubation miss rates by paramedics.Jones JH,
  Murphy MP, Dickson RL, Somerville GG, Brizendine
  EJ.

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Primum non nocere

• However, ETI requires skills which are difficult
  to maintain especially if practised infrequently.
  The laryngeal tube (LT) has been successfully
  tested and used in anaesthesia and in simulated
  cardiac arrest in manikins. To compare the
  initiation and success of ventilation with the
  LT, ETI and bag-valve mask (BVM) in a cardiac
  arrest scenario, 60 fire-fighter emergency
  medical technician (EMT) students formed teams of
  two rescuers at random and were allocated to use
  these devices. We found that the teams using the
  LT were able to initiate ventilation more rapidly
  than those performing ETI (P lt 0.0001). The LT
  and ETI provided equal minute volumes of
  ventilation, which was significantly higher than
  that delivered with the BVM (P lt 0.0001). Our
  data suggest that the LT may enable airway
  control more rapidly and as effectively as ETI,
  and compared to BVM, may provide better minute
  ventilation when used by inexperienced personnel.

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Primum non nocere

• Adequate oxygenation at all times is of paramount
  importance to the critically injured patient to
  avoid secondary damage. The role of endotracheal
  intubation in out-of-hospital advanced trauma
  life support, however, remains controversial.
  Initiated by a recent observational study, this
  commentary discusses risks and benefits
  associated with prehospital intubation, the
  required personnel and training, and ethical
  implications. Recent evidence suggests that
  comprehensive ventilatory care already initiated
  in the field and maintained during transport may
  require the presence of a physician or another
  adequately skilled person at the scene. Benefits
  of such as service need to be balanced against
  increased costs

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http//www.ncbi.nlm.nih.gov/entrez/query.fcgi
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Why?
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Upper Airway Anatomy

• Nasopharynx
• Oropharynx
• Laryngopharynx
• Piriform fossa
• Vocal chords
• Thyroid cartilage
• Cricoid cartilage

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Anatomy of Neck

• Thyroid cartilage
• Thyroid gland
• Internal jugular veins
• Recurrent laryngeal nerve
• Cricothyroid ligament/membrane

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Anatomy of Neck

• Thyroid cartilage
• Thyroid gland
• Internal jugular veins
• Recurrent laryngeal nerve
• Cricothyroid ligament/membrane

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The Esophageal-Tracheal Combitube (ETC)

• Class IIa

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The Combitube (ETC)

• Indications
• Difficult face mask fit (beards, absence of
  teeth)
• Patient in whom intubation has been unsuccessful
  and ventilation is difficult
• Patient in whom airway management is necessary
  but healthcare provider is untrained in technique
  of visualized orotracheal intubation

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The Combitube (ETC)

• Contraindications
• Patient with an intact gag reflex
• Patient with known or suspected esophageal
  disease
• Patient known to have ingested a caustic
  substance
• Suspected upper airway obstruction due to
  laryngeal foreign body or pathology
• Patient less than 4 feet tall

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Combitube - Advantages

• Minimal training and retraining required
• Visualization of upper airway or use of special
  equipment not required for insertion
• Reasonable technique for use in suspected neck
  injury since head does not need to be
  hyperextended
• Because of oropharyngeal balloon, need for a face
  mask is eliminated
• Can provide a patent airway with either
  esophageal or tracheal placement
• If placed in esophagus, allows suctioning of
  gastric contents without interruption of patient
  ventilation
• Reduces risk of aspiration of gastric contents

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Combitube - Disadvantages

• Proximal port may be occluded with secretions
• Proper identification of tube location may be
  difficult, leading to ventilation through wrong
  lumen
• Impossible to suction trachea when the tube is in
  the esophagus
• Esophageal or tracheal trauma due to poor
  insertion technique or use of wrong size device
• Damage to cuffs by patients teeth during
  insertion
• Inability to insert due to limited mouth opening

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The Esophageal-Tracheal Combitube (ETC)

• Special considerations
• Good assessment skills are essential to confirm
  proper placement
• Misidentification of placement has been reported
  use multiple techniques to confirm proper
  placement

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Combitube - Technique
Insert 15 ml of air into white cuff
100 ml of air into blue cuff
Insert until teeth are between black lines
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Combitube - Technique
Begin with longer or port closer to you
If ventilation is inadequate change to the other
port
Its in the eso- think EOA
In the trachea- its an ETT
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Bag-Valve-Mask (BVM) Ventilation

• Oxygen delivery

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Bag-Valve-Mask (BVM) Ventilation

• Oxygen delivery

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Bag-Valve-Mask (BVM) Ventilation

• Oxygen delivery

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Bag-Valve-Mask (BVM) Ventilation

• Tidal volumes and inspiratory times (adult
  patient)
• Oxygen available
• Lower tidal volumes recommended
• 6 to 7 mL/kg (400 to 600 mL) given over 1 to 2
  seconds until chest rises
• No oxygen available
• 10 mL/kg (700 to 1000 mL) delivered over 2
  seconds sufficient to make chest rise

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Bag-Valve-Mask (BVM) Ventilation

• Eupnic adult
• 400-600ml of Vt (500 x 12 bpm) 6L Vol min
• Old school hyperventilation
• 800 ml of Vt (800 x 28 bpm) 22.4L Vol min
• Current Theory
• 500 ml of Vt (500 x 16bpm) 8L Vol min

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Bag-Valve-Mask (BVM) Ventilation

• Advantages
• Provides a means for delivery of an oxygen
  enriched mixture to the patient
• Conveys a sense of compliance of patients lungs
  to the BVM operator
• Provides a means for immediate ventilatory
  support
• Can be used with spontaneously breathing patient
  as well as apneic patient

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Bag-Valve-Mask (BVM) Ventilation

• Disadvantages
• Inability to provide adequate ventilatory volumes
• Should only be used by trained operators
• Difficult to use by inexperienced operators
• Gastric distention

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Bag-Valve-Mask Ventilation

• If the chest does not rise and fall with
  bag-valve-mask ventilation, reevaluate
• Reassess head position reposition the airway,
  and reattempt to ventilate
• Inadequate tidal volume delivery may be the
  result of an improper mask seal or incomplete bag
  compression
• If air is escaping from under the mask,
  reposition fingers and mask
• Reevaluate effectiveness of bag compression
• Check for obstruction
• Lift the jaw
• Suction the airway as needed

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Endotracheal Tube Sizing

• ETT are measured in millimeters by their internal
  diameter (ID) and external diameter (OD)
• Average ETT sizes
• Adult female 7.0 8.0 mm ID
• Adult male 8.0 8.5 mm ID

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ETT - Distance or Depth of Insertion

• After successful placement, observe and record cm
  markings on side of ETT
• Typically between 19 and 23-cm mark at front teeth

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Mallampati Classification

• Airway risk assessment
• Assess for intubation difficulty
• Establishes clear and patent airway
• Can prepare mentally (L-scope, ETT, etc.)
• Easy to assess in a conscious patient
• Graded Class I through IV depending on anatomy
  visualized through mouth (sitting position

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Mallampati Classification
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Stylet
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ET Intubation Technique

• If trauma is not suspected, place patients head
  in sniffing position
• Aligns axes of mouth, pharynx, and trachea

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ET Intubation Technique

• Advance the laryngoscope blade until the distal
  end reaches the base of the tongue

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ET Intubation Technique

• Lift the laryngoscope to elevate the mandible
  without putting pressure on the front teeth
• Visualize the epiglottis
• Suction the laryngopharynx as necessary
• Identify the vocal cords
• Place the blade in proper position

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• The straight blade is advanced under the
  epiglottis.
• The blade is then lifted anteriorly, directly
  exposing the vocal cords.

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ET Intubation - Complications

• Bleeding
• Laryngospasm
• Vocal cord damage
• Mucosal necrosis
• Barotrauma
• Aspiration
• Cuff leak
• Esophageal intubation
• Right mainstem intubation

• Occlusion caused by patient biting tube or
  secretions
• Laryngeal or tracheal edema
• Tube occlusion
• Inability to talk
• Hypoxia due to prolonged or unsuccessful
  intubation
• Dysrhythmias
• Trauma to lips, teeth, tongue, or soft tissues of
  oropharynx
• Increased intracranial pressure

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ET Intubation - Technique

• Secure ET tube with commercial tube-holder
  (preferred) or tape
• Provide ventilatory support with supplemental
  oxygen
• After securing the tube, observe and record tube
  depth at the patients teeth

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Confirming ET Tube Placement

• Primary methods
• Visualizing passage of ET tube between the vocal
  cords
• Auscultating presence of bilateral breath sounds
• Confirming absence of sounds over epigastrium
  during ventilation
• Adequate chest rise with each ventilation
• Absence of vocal sounds after placement of ET
  tube
• Secondary methods
• Monitoring for changes in the color (colorimetric
  device) or number (digital device) on an
  end-tidal CO2 detector
• Verification by an esophageal detector device
• Chest x-ray

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What About?

• Condensation within the tube as an indicator
• In this model, condensation on the inner surface
  of the endotracheal tube was common after
  placement within the esophagus. If these results
  are confirmed in human studies, the presence of a
  vapor trial should not be used as a clinical
  indicator of correct endotracheal tube placement
• Ann Emerg Med. 1998 May31(5)575-8.Related
  Articles, Links
•   Use of tube condensation as an indicator of
  endotracheal tube placement.

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• Tube migration?
• How to secure the tube?

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CO2 Sampling Technologies
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End-Tidal Carbon Dioxide (ETCO2) Detectors

• ETCO2 monitoring is used for
• Assessment of conscious sedation safety
• Evaluation of mechanical ventilation
• Verification of ETT placement

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Colormetric/Easy Cap

• Change in color when exposed to CO2
• ET tube placement patients not in cardiac
  arrest(tube in esophagus or circulation not
  bringing enough CO2 to lungs
• Can change when contaminated with gastric acid,
  Lidocaine, Epinephrine
• No reading if clogged with secretions

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• Colormetric method
• Disposable detector fits between ET tube and
  breathing circuit
• No power involved
• Color changes indicate amount of CO2 detected
• Similar to checking a pulse

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Capnometer

• A Capnometer provides only a numerical
  measurement of carbon dioxide

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• Capnometer
• Numerical reading of the amount of CO2 detected
• Sample of exhaled air through a sensor
• Device may also provide SpO2
• Similar to a heart rate reading

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Capnogram

• A Capnogram is a waveform display of carbon
  dioxide over time

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• Capnograph
• Sensor typically uses an infrared light to
  detect the concentration of CO 2 in exhaled gases
• Waveform graph
• Similar to an ECG monitor

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Esophageal Detector Devices (EDD)

• Simple, inexpensive, easy to use
• Two types
• Syringe
• Bulb
• Principle
• Esophagus is a collapsible tube
• Trachea is a rigid tube

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Esophageal Detector Device - Syringe

• Connect the syringe to the ETT with the plunger
  fully inserted into the barrel of the syringe
• If the ETT is in the trachea, the plunger can be
  easily withdrawn from the syringe barrel
• If the ETT is in the esophagus, the walls of the
  esophagus will collapse when negative pressure is
  applied to the syringe
• Prevents air from being drawn out of the syringe

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Esophageal Detector Device Bulb

• Compress the bulb before connecting to the ETT
• A vacuum is created as pressure on the bulb is
  released
• If the ETT is in the trachea, the bulb refills
  easily on release of pressure
• If the ETT is in the esophagus, the bulb remains
  collapsed

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Esophageal Detector Device

• Results may be misleading in patients with
• Morbid obesity
• Late pregnancy
• Status asthmaticus
• Copious tracheal secretions