Airway Management and Ventilation

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Airway Management and Ventilation
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What is the most commonly neglected prehospital
skill related to airway?

• Manual airway maneuvers
• Head-Tilt/Chin-Lift
• Jaw-Thrust Maneuver

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Gastric Distention

• Occurs when air becomes trapped in the stomach
• Very common with BVM usage
• Interferes with lung expansion
• Resistance to BVM ventilation
• felt by rescuer
• Vomiting/aspiration precautions
• necessary

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Gastric Distention

• Prevention technique
• Sellicks Maneuver - pressure applied to solid
  ring of cricoid cartilage to occlude esophagus
• Reduces risk of regurgitation and possible
• aspiration
• Minimizes gastric
• distention during BVM
• use

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Gastric Distention

• Noninvasive maneuvers for control
• Distention may be reduced by increasing BVM
  ventilation time (slower breaths)
• Prepare for large volume suction and suction as
  needed
• Position patient left lateral (side) as you
  slowly apply pressure to epigastric region to
  deflate distended stomach if you must

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Gastric Distention

• Invasive maneuver for control- Gastric tubes
• Tube placed in the stomach for gastric
  decompression and/or emesis control

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Nasogastric Tube
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Nasogastric Tube

• Indications
• Need to decompress stomach to reduce threat of
  aspiration
• Need for lavage to remove toxic material after
  accidental or intentional overdose
• Need to instill food, liquids, medicine

• Contraindications - (relative absolute)
• Extreme caution in esophageal disease or trauma
• Facial trauma (caution)
• Deviated septum (caution)
• Esophageal obstruction

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Contraindication to inserting a gastric tube...

• ...facial trauma

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Nasogastric Tube

• Advantages
• Tolerated by conscious patients
• Doesnt interfere with intubation
• Mitigates recurrent gastric distention
• Patient can still talk

• Disadvantages
• Uncomfortable for patient
• May cause vomiting during insertion
• Interferes with BVM seal

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Nasogastric Tube

• Complications
• Soft tissue trauma from poor technique
• Inappropriate tracheal placement and especially
  not recognizing that NG tube is in the lungs

• Supragastric placement (not in far enough)
• Tube obstruction
• Improper anchoring of the tube
• Overtime, potential necrosis of external nares

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Orogastric Tube

• Gastric tube placed through the mouth into the
  stomach
• Same parameter guidelines as nasogastric tube
  with indications, contraindications, insertion
  technique, and complications
• Additional advantages can use larger tube, can
  lavage more aggressively, safer to pass in facial
  trauma, avoids pharynx structures
• Additional disadvantages may interfere with
  visualization during intubation

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Nasogastric Tube

• Equipment
• ?BSI equipment
• ? Gastric tube
• ? Topical anesthetic (ie viscous lidocaine)
• ? Lubrication (ie KY jelly)
• ? 30-50 ml syringe
• ? Stethoscope
• ? Suction
• ? Skin prep material
• ? Tape

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Nasogastric Tube Insertion

• Prepare patient
• Head neutral
• Oxygenate
• Measure tube length - tip of nose to ear to
  stomach

• Lubricate tube
• Advance into stomach
• Confirm Placement
• Secure in place

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NG Tube Insertion

• Patient positioning extremely important
• Patient cooperation would be extremely helpful
• Remember your BSI guidelines and wear your PPEs
  (gloves, goggles, mask)

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Two Person BVM

• Advantages over 1 person BVM use
• Minimizes/limits problem of hypoventilation due
  to poor mask seal
• Better c-spine control with extra pair of hands
• Improved tidal volume delivery easier to obtain

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Automatic Transport Ventilators

• Indications
• Extended ventilation of intubated patients
• Long transport times
• Limited personnel resources
• During CPR

• Contraindications
• Awake patients
• Patient with spontaneous respirations
• Obstructed airway
• Increased airway resistance
• trauma to chest
• Pneumothorax
• Asthma
• Pulmonary edema

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Automatic Transport Ventilators

• Advantages
• Frees personnel
• Reduces rescuer fatigue
• Lightweight
• Portable durable
• Simple to use
• Adjustable settings
• Adapts to portable O2

• Disadvantages
• Cannot detect/indicate accuracy of tube
  placement
• Does not detect increasing airway resistance (ie
  developing pneumothorax)
• Difficult to secure
• Dependent on O2 tank pressure to function
• Requires training practice for proper use

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Automatic Transport Ventilators

• Complications
• hypoventilation and hypo-oxygenation
• inadvertent extubation

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Nasotracheal Intubation

• Indications
• Spontaneously breathing patients requiring
  intubation

• Contraindications
• Caution with facial trauma
• Caution with deviated septum

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Nasotracheal Intubation

• Advantages
• Does not require laryngoscope use
• Does not require sniffing position
• More easily secured
• Patient cannot bite tube

• Disadvantages
• Blind technique
• Can only be performed on spontaneously breathing
  patients

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Nasotracheal Intubation

• Procedure
• Place patients head in neutral position
• Standard pre-intubation precautions
• Prepare tube
• Hyperoxygenate

• Insert lubricated tube
• Advance tube through vocal cords on inspiration
• Inflate cuff
• Confirm placement
• Secure tube

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Airway Skills

• Prehospital airway maneuver complications can be
  diminished through training and ability to
  control emotions
• Too often BLS measures are forgotten during
  difficult intubations - remember the basics
• Principles and steps to remember
• jaw thrust to protect c-spine in trauma
• sweep tongue out of way with intubation blade
• lift up and away and dont pry with blade
• re-oxygenate as well as pre-oxygenate
• watch your 30 second time limit

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Airway Access Through Cricothyroid Membrane

• Translaryngeal cannula ventilation
• also known as needle cricothyrotomy
• cannulation of trachea below glottis using 12-14
  gauge needle
• Cricothyrotomy
• also known as surgical cricothyrotomy
• entrance to airway through cricothyroid membrane
• ? FYI - Tracheostomy - surgical opening to
  trachea through the neck, performed lower than
  cric

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Translaryngeal Cannula Ventilation - Needle Cric

• Indications
• Apnea
• Delayed or inability to ventilate the patient by
  other means (ie airway obstruction to edema,
  trauma
• Temporary procedure

• Contraindications
• Total lower airway obstruction (but you may not
  know this while attempting the procedure)
• Equipment not available

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Translaryngeal Cannula Ventilation - Needle Cric

• Advantages
• Rapidly performed
• Provides adequate ventilation
• Does not manipulate the cervical spine
• Does not interfere with subsequent attempts to
  intubate

• Disadvantages
• Jet ventilator sometimes preferred over BVM
• Expends high volumes of O2
• May not protect against aspiration

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Translaryngeal Cannula Ventilation - Needle Cric

• Typical Equipment
• Large bore IV catheter
• Skin prep material (ie alcohol or other swab)
• 10 cc syringe
• Jet ventilator or BVM
• Tape
• If BVM used may need adaptor end of 3.0 mm ETT
  attached to proximal end of catheter (to be able
  to connect BVM)

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Translaryngeal Cannula Ventilation

• Stabilize larynx and identify cricothyroid
  membrane
• 
  
• 
  
  thyroid cartilage
• 
  
• 
  
  
• 
  
  cricothyroid
• 
  
  membrane
• 
  
  
• 
  
  cricoid ring

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Translaryngeal Cannula Ventilation

• Insert needle of syringe
• downward through
• midline of membrane
• toward carina
• Apply negative pressure
• to syringe (aspirate)
• Air in syringe indicates
• needle is in trachea
• Advance catheter to hub

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Translaryngeal Cannula Ventilation

• Remove stylet/syringe stabilize catheter while
  securing with tape
• Connect oxygen tubing to oxygen regulator
• or
• Connect 3.0 mm adaptor from ETT to proximal
  catheter and then attach BVM
• Provide for a release valve

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Translaryngeal Cannula Ventilation

• Complications
• Bleeding
• Subcutaneous emphysema
• Airway obstruction
• Barotrauma - subcutaneous emphysema
• Hypoventilation
• Placement in soft tissue

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Surgical Cricothyrotomy

• Indications
• Total upper airway obstruction
• Massive facial trauma
• Inability to intubate or ventilate by other means
• Posterior tongue laceration
• Inability to open mouth

• Contraindications
• Inability to identify anatomical landmarks (no
  true age restriction, anatomical restriction)
• Crush injury to the larynx
• Tracheal transection
• Underlying anatomical abnormality

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Surgical Cricothyrotomy

• Advantages
• Rapidly performed
• Does not manipulate the cervical spine

• Disadvantages
• Not used often so difficult to master
• Difficult to perform in children
• Difficult to perform on patients with short,
  muscular, or fat necks
• Biohazard chances increased
• Anatomical AP essential

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Cricothyroid Anatomy Membrane Landmarks

• thyroid
• cartilage
• cricothyroid
• membrane
• cricoid ring

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Palpating Cricothyroid Membrane Landmarks

• Palpate the Adams apple (laryngeal prominence)
  or thyroid cartilage on anterior surface of neck
• Palpate firm landmark (cricoid cartilage) below
  thyroid cartilage
• Cricothyroid membrane is soft area between these
  2 landmarks

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Equipment for Cook Cric Kit

• Radiopaque airway catheter
• Tapered curved dilator - fits inside airway
• catheter
• Extra stiff wire guide with single flexible tip

• 15 scalpel
• 6 cc syringe
• 18 gauge catheter introducer needle
• 18 gauge introducer needle (wont be used)

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Insertion Steps Cook Cric Kit

• Locate palpate cricothyroid membrane
• Prep site with aseptic solution (ie alcohol
  wipe)
• Stabilize thyroid cartilage with fingers
• Make vertical (up down) incision thru skin with
  scalpel long enough to insert airway device (max
  1" (2cm) may be needed)
• Use suction and 4x4s for bleeding control

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Cook Cric Kit Insertion Steps

• Attach 6 cc syringe to 18G catheter introducer
  needle insert thru incision made
• Advance needle at 45o angle aiming towards feet
  aspirate for free air while advancing
• Free air return confirms placement in trachea
• Remove syringe and needle, leave catheter in
  place

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Cook Cric Kit Insertion Steps

• Advance flexible tip wire guide thru catheter
  only a few inches (keep wire guide in protective
  shroud as it is advanced) majority of wire guide
  remains outside pt
• Remove catheter pulling it over wire guide leave
  wire guide in place
• Advance dilator catheter assembly, tapered end
  first, over wire guide until catheter completely
  in trachea and wire guide protrudes from proximal
  end of catheter

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Cook Cric Kit Insertion Steps

• Remove wire guide and dilator simultaneously
  airway catheter remains in patient
• Immediately connect a BVM to airway catheter end
  and begin ventilations at same rate as intubated
  patients
• Assess for breath sounds
• Secure airway catheter with cloth ties provided
• Cuff may be inflated to help control secretions,
  blood (helps prevent further aspiration)

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Cook Cric Kit Tips

• Lubrication can be used on surface of dilator
• Always, always, always be able to visualize
  proximal end of wire guide - do not want
  inadvertent loss of wire guide into trachea!!!
• Might consider attaching one end of cloth tie to
  airway catheter before inserting into patient -
  difficult enough to thread cloth tie with airway
  catheter in place
• BVM will quickly attach to standardized 15/22mm
  adapter on airway catheter

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Surgical Cricothyrotomy

• Complications
• Incorrect airway placement without recognition
• Once started, procedure must be carried out
• Thyroid gland damage
• Laceration of major vessels in neck
• Severe bleeding (can hamper visualization and
  placement)
• Subcutaneous emphysema
• Laryngeal nerve damage

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PEEP

• Positive End-Expiratory Pressure
• Maintains a degree of positive pressure at the
  END of exhalation to keep alveoli open
• If alveoli are allowed to collapse, much effort
  is required to reopen them on next inhalation
• Helpful in patients with ARDS (adult respiratory
  distress syndrome) and pulmonary edema
• PEEP pushes fluid from alveoli back into
  interstitial or capillary levels
• PEEP can be accomplished prehospital and
• in-hospital with specific equipment training

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CPAP

• Continuous Positive Airway Pressure
• Transmits positive pressure into airway of the
  breathing patient during inhalation AND
  exhalation
• Airway pressure increase allows for better
  diffusion of gases and reexpansion of collapsed
  alveoli
• Outcome is improvement of gas exchange and
  reduction in work of breathing

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CPAP Equipment
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CPAP

• Reduces inspiratory workload of breathing
• Lowers mean airway pressures
• Manages patients with pulmonary congestion,
• blunt/penetrating
• pulmonary injury,
• and COPD
• Pt needs a lot of
• coaching from
• crew during use

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BiPAP

• Biphasic Positive Airway Pressure
• Combines partial ventilatory pressure support and
  CPAP
• Applied by face mask/nose mask through
  noninvasive ventilator device with two settings
  to provide water pressure
• Water pressure difference is between inspiratory
  positive airway pressure and expiratory positive
  airway pressure

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BiPAP

• Leak-tolerant system (CPAP is not) that allows
  for titration of settings to reach a desired PEEP
  range
• Used in select group of patients with COPD,
  pulmonary edema, pneumonia, asthma
• May eliminate need for ETT intubation

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Airway Management
Questions ??