Basic Emergency Airway Management Pat Melanson,MD

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Basic Emergency Airway ManagementPat Melanson,MD
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Objectives

• Differentiate the Emergency Airway from elective
  intubation in the OR
• Assessment of airway compromise
• Indications for airway intervention
• Recognition of the difficult airway
• Bag-Mask Techniques
• Laryngoscopy

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Emergency Airway Management Unique
Considerations

• Full stomach - high aspiration risk
• Altered level of consciousness
• Deteriorating cardiorespiratory physiology -
  (hypotension, hypoxia)
• Abnormal or distorted upper airway anatomy
• No time for pre-op assessment

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Airway Assessment

• Assessment for airway compromise or threats and
  need for interventions
• Examination for the potentially difficult airway

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The Three Pillars of Airway Management (
Assessment of Compromises or Threats )

• Patency of Upper Airway
• ( airflow integrity )
• Protection against aspiration
• Assurance of oxygenation and ventilation

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Indications for Active Airway Intervention
including intubation

• Failure to maintain patency
• Protection from aspiration
• Hypoxic/ hypercapnic respiratory failure
• Airway access for pulmonary toilet, drug
  delivery,therapeutic hyperventilation
• Intractable Shock
• Anticipated clinical deterioration

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Indications for Intubation

• Is there failure of airway maintenance ?
• Is there failure of airway protection ?
• Is there failure of oxygenation or ventilation?
• What is the anticipated clinical course ? (i.e.,
  expected deterioration, long transport, long time
  in radiology, etc.)

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Clinical Signs of Airway Compromise Threatened
Patency

• Inspiratory stridor
• Snoring ( pharyngeal obstruction )
• Gurgling ( blood/ secretions )
• Drooling ( epiglottitis )
• Hoarseness ( laryngeal edema/ vocal cord
  paralysis)
• Paradoxical chest wall movement
• Tracheal tug
• Mass - abscess, hematoma, angioedema

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Clinical Signs of Airway Compromise Inadequate
Protection

• Blood in upper airway
• Pus in upper airway
• Persistent vomiting
• Loss of protective airway reflexes
• swallowing reflex is superior to gag reflex

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Clinical Signs of Airway CompromiseOxygenation
and Ventilation

• Central cyanosis
• Obtundation and diaphoresis
• Rapid shallow respirations
• Accessory muscle use
• Retractions
• Abdominal paradox

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Clinical Signs of Airway CompromiseOxygenation
and Ventilation

• The assessment of oxygenation and ventilation is
  a clinical one.
• Arterial blood gases should not be relied upon to
  assess whether intubation is necessary.

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Techniques for the Compromised Airway

• Head Positioning
• Jaw Thrust, Chin lift
• Orophryngeal/ Nasopharyngeal airways
• Bag-Valve-Mask Ventilation
• Endotracheal Intubation
• Advanced techniques
• Cric, LMA, Combitube, Retrograde, Fibreoptic,
  Light wand, Bouge

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The Difficult Airway

• Difficult Laryngoscopy
• poor visualization of cords
• Difficult bag-mask ventilation
• unable to oxygenate or ventilate
• Lower airway difficulty
• severe bronchospasm

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Golden Rules of Bagging

• Anybody ( almost ) can be oxygenated and
  ventilated with a bag and a mask
• The art of bagging should be mastered before the
  art of intubation
• Manual ventilation skill with proper equipment is
  a fundamental premise of advanced airway Rx

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BVM Ventilation

• The most important airway skill
• Always the first response to inadequate
  oxygenation and ventilation
• The first bail-out maneuver to a failed
  intubation attempt
• Attenuates the urgency to intubate
• Do not abandon bagging unless it is impossible
  with two people and both an OP and NP airway

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BVM Ventilation

• Requires practice to master
• One hand to
• maintain face seal
• position head
• maintain patency
• Other hand ventilates

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BVM Ventilation Technique

• Insert oropharyngeal/nasopharyngeal
• Sniffingposition if C-spine OK
• Thumb index to maintain face seal
• Middle finger under mandibular symphysis
• Ring/little finger under angle of mandible
• Maintain jaw thrust/mouth open

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Predictors of a Difficult Airway BVM

• Upper airway obstruction
• Lack of dentures
• Beard
• Midfacial smash
• Facial burns, dressings, scarring
• Poor lung mechanics
• resistance or compliance

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Difficult Airway BVM

• degree of difficulty from zero to infinite
• Zero no external effort or internal device
  required
• one person jaw thrust/ face seal
• oropharyngeal or nasopharyngeal AW
• two person jaw thrust / face seal
• both internal airway devices
• Infinite no patency despite maximal external
  effort and full use of OP/NP

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Algorithm for Difficulty Bagging

• Remove Foreign Bodies - Magill forceps
• Triple maneuver if c-spine clear
  
• Head tilt, jaw lift, mouth opening
• Nasal or oropharyngeal airways
• Two-person, four-hand technique

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BVM Ventilation Mask Seal Tips and Pearls

• Easier to get seals with masks too large than too
  small
• Inflate mask collar correctly
• Apply lubricant to beards to mat down hair
• If edentulous insert gauze sponges into cheeks

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Prediction of the Difficult Airway Laryngoscopy

• History of past airway problems
• check previous OR anesthesia records if time
  permits
• cricothyroidotomy scar
• Careful physical assessment
• mouth opening
• tongue to pharyngeal size
• hyo-mental distance
• Neck flexion, Head extension

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Technique of Laryngoscopy

• Sniffing position to align oral-pharyngeal-laryn
  geal axis
• Flex neck by placing pillow beneath occiput (
  raise 10 cm )
• Extend head maximally
• With laryngoscope
• open mouth fully
• push tongue to left out of view
• pull upward at 45 degrees

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Adducted vocal cords
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Predictors of Difficult Laryngoscopy

• Short thick neck
• Receding mandible
• Buck teeth
• Poor mandibular mobility/ limited jaw opening
• Limited head and neck movement
• ( including trauma )

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Difficult Airway Laryngoscopy

• Tumor, abscess or hematoma
• Burns
• Angioneurotic edema
• Blunt or penetrating trauma
• Rheumatoid arthritis, ankylosing spondylitis
• Congenital syndromes
• Neck surgery or radiation

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Predictors of Difficult Laryngoscopy

• 3 fingerbreadths mentum to hyoid
• 3 fb chin to thyroid notch
• 3 fb upper to lower incisors
• Head extension and neck flexion
• Mallimpadi classification
• Previous history of difficult intubation

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Mallimpadi Classification (Tongue to
Pharyngeal Size)

• I - soft palate, uvula, tonsillar pillars visible
• 99 have grade I laryngoscopic view
• II - soft palate, uvula visible
• III - soft palate, base of uvula
• IV - soft palate not visible
• 100 grade III or grade IV views

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The 4 Ds of Difficult Intubation

• Distortion
• ( edema, blood, vomitus, tumor, infection)
• Dysmobility of joints
• ( TMJ, alanto-occipital, C-spine)
• Disproportion
• thyomental, Mallimpadi, etc
• Dentition
• prominent upper teeth

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Unsuccessful Intubation

• Bag the patient
• Maximize neck flex/ head ex
• Move tongue out of line of site
• Maximize mouth opening
• ID landmarks and adjust blade
• BURP maneuver (Backwards Upwards Rightwards
  Pressure on Thyroid Cart.)
• Increasing lifting force
• Consider Miller blade
• Bag the patient