Airway management in the prehospital setting

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Airway management in the prehospital setting
Dr X.Combes, SAMU du Val de Marne, Créteil, France
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Airway management in the prehospital setting

• Dr X.Combes, SAMU du Val de Marne, Créteil, France

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Why airway control is mandatory out of hospital?

• Airway protection
• Coma
• Sedation
• Respiratory assistance with positive pressure
  ventilation
• Respiratory distress
• Cardiopulmonary rescucitation
• Limitation or prevention of evolutive injury
• severe head traumatism

Winchell Rj et col Arch Surg 1997 Gentleman D et
col Lancet 1990
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How airway can be controlled?
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Indications for prehospital tracheal intubation
Jabre P, SFAR 2003 Adnet F,Ann Emerg
1998 Ricard-Hibon A, Eur J Anaesthesiology 2002
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Characteristics of extrahospital airway management

• Emergency context
• Hostile environnment
• Non cooperative patients
• Poor knowledge of medical patients history
• Not much time to upper airway evaluation
• Risk of pulmonary aspiration
• Interaction between patient and operator body
  position

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Potential adverse physical interaction between
patient and operator
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Medical conditions and anatomical abnormalities
may induce difficult laryngeal visualization.....
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Incidence of failed prehospital intubation
100
80
60
Intubations ()
40
20
0
a
b
c
d
e
f
g
h
i
j
k
l
g Cantineau 1997 (224) h Adnet 1998 (n
691) i Orliaguet 1997 (n 157) j Adnet 1997
(n 394) k Ricard-Hibon 1997 (n 147) l
Adnet 1997 (n 311)

• a Stewart 1994 (n 779)
• b Pointer 1988 (n 383)
• c Krisanda 1992 (n 278)
• d Sayre 1998 (n 103)
• e Hedges 1988 (n 310)
• f Thompson 1994 (n 862)

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Influence of the sedation technique on intubation
difficulties
Adnet F Eur J Emerg Med 1998
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Effect of a RSI protocol introduction in a
medical prehospital unit
Ricard-Hibon A et col Eur J Anaesthesiol. 2002
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RSI helps Paramedics too

• Extrahospital paramedic heliported unit
• Introduction of a RSI protocol in daily practice
• Assessment of successful tracheal intubation

Rose WD Air Med J. 1994
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Orotracheal or Nasotracheal intubation?
Dronen SC et colAnn. Emerg Med 1987 
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Influence of operator position when patient is
lying on the ground
Adnet F, Can J Anaesth 1998
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BURP backward, upward, rightward laryngeal
pressure
60 Cormack III gt II
BURP gt BACK
Knill R Can J Anaesth 1993
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Bougie and stylet

• First use in 1943 by Macintosh
• Successful blind tracheal intubation confirmed by
  tactile sensation
• Helpful for patient with cervical immobilisation

• Standard of practice in US emergency dpt
• Rigid with little flexibility
• Potentially traumatic for larynx and trachea

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Success rates of GEB and Stylet assisted
intubation in Cormack grade 3 patients


Gataure PS Anaesthesia 1996
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Use of Gum Elastic Bougie for Prehospital
Difficult Intubation

• Observationnal study during 30 months
• 1442 intubations
• 42 uses of GEB
• Success rate 80
• 60 of patients had associated factors for DI
• ENT neoplasy
• Morbid obesity
• Cervical reduced mobility
• Facial trauma

Jabre et al Am J Emerg med (in press)
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Pharyngeal artificial airways in extrahospital
setting

• Pharyngeal / oesopharyngeal
• Single / double cuff
• Single/double lumen
• Allowing or not blind intubation

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Combitube

• Often used as first airway device during CPR in
  paramedic system
• Several extrahospital cases of difficult airway
  in trauma patients resolved with Combitube
• Successful insertion by paramedics in 95 of
  patients with extrahospital difficult airway

Davis DP and al Ann Emerg Med. 2003 Blostein PA
and al J Trauma. 1998
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LMA

• Proposed as initial method of airway control
  during CPR
• Particulary interesting in the difficult
  intubation and difficult ventilation scenario
• Several case reports of prehospital difficult
  airway resolved with LMA have been reported

Greene MK and col, Anaesthesia 1992 Martin SE
and alThe journal of trauma 1999
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ILMA

• ILMA, first described in 1997 has become a
  cornerstone of the in operating room difficut
  airway
• Some case reports in prehospital settings have
  been reported
• Its use with high success rate needs probably a
  minimal initial training

Gibbs M and al Acad Emerg Med 2003 Combes and
al Ann Emerg Med 2004
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Training with ILMA on Manikin
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New airway devices

• CobraPLA
• (PerilaryngealAirway)
• PAxpress
• Laryngeal tube

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Cricothyroidotomy

• Ultimate Airway management strategy
• Frequently used in North American prehospital
  paramedical system
• Success rate 80-100
• Major complications 10

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What Is the Minimum Training Required for
Successful Cricothyroidotomy? A Study in
Mannequins

• 102 anesthesiologists
• Vidéo démonstration
• Performance of 10 cricothyroidotomies in manikins

Wong D et col Anesthesiology 2003
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Failure of intubation after 2 attempts under
direct laryngoscopy
New direct laryngoscopy with BURP
Success
Use of GEB ( 2 attempts)
Success
Use of the ILMA and call for help
Intubation through the ILMA
Success
Ventilation through the ILMA
Success
Failure
Transfer to the Hospital with ventilation through
the ILMA
Cricothyroidotomy
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Non invasive positive pressure ventilation

• CPAP or BiPAP
• Validated for COPD decompensation and severe
   cardiogenic pulmonary oedema 
• Majority of the studies are inhospital
• Potential large indications exist in the
  prehospital setting

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In practice
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Conclusion

• In the prehospital setting the gold standard of
  invasive airway management remains tracheal
  intubation under direct laryngoscopy
• Rapid sequence induction should be performed for
  all patients with spontaneaous cardiac activity
  in absence of contreindications
• Predefined strategy including simple and
  effective devices is the best mean to solve
  difficult airway management situations
• Non invasive airway control with face mask is
  feasible in prehospital setting. Further large
  studies are needed to precise the best
  indications of prehospital NPPV