Transcript 2006_07_20-Storck-Airway_mgmt

Airway Management
Aric Storck PGY-5
Dr. Mike Betzner
July 20, 2005
Objectives

Crash course in ED airway management:

Indications
Who do you intubate
 Who do you not intubate


What type of airway is it

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

easy, difficult, failed, crash
RSI
Pediatric Airways
Hands on procedural skills station
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Practical skill stations
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Gum elastic bougie
LMA & I-LMA
Trachlight
Needle cricothyrotomy / surgical
cricothyrotomy
Case

78F
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Acutely SOB
Alert
Talking one word sentences
JVP up
Diffuse wheeze
Sats 84%
ABG 7.25 / 60 / 50 / 19
Does she need intubation?
Step 1
Who needs intubation?
Indications for Intubation

ABCDE

A - Airway protection


aspiration, obstruction
B – Breathing
Failure to oxygenate
 Failure to ventilate



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C – Circulation (Shock)
D – Disability / neuro (GCS <9 or drop by 2)
E - Expected clinical course
Does our patient have a reason to
intubate?


Airway – not a concern right now
Breathing

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


Failure to oxygenate
Failure to ventilate
Circulation – not a concern right now
Disability – not a concern right now
Expected Course – likely to get worse
Does our patient need to be
intubated immediately?
Crash Airway
APPROACH TO THE AIRWAY
Does the patient need to be intubated? ABCDEs
Quckly evaluate the situation and the patient?
What type of airway?
CRASH AIRWAY
EASY AIRWAY
DIFFICULT AIRWAY
Cardiac arrest
Apneic
Near death
Not a crash airway
No anticipated difficulty
Difficult anatomy
Difficult pathology
THE CRASH AIRWAY
JUST DO IT!
Direct laryngoscopy with no drugs
Unsuccessful
TIME
(can bag, sats ok)
NO TIME
(can't bag, sats dropping)
Repeat attempts (up to 3)
Add succinylcholine prn
Go to failed airway algorithm
Go to failed airway algorithm
You have decided to intubate.
How do you assess her airway?
Predicting a Difficult Airway
the LEMON law
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L = Look
E = Examine
M = Mallampatti
O = Obstruction
N = Neck mobility
LEMON - Look
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Obesity
Micrognathia
High arched palate
Narrow face
Short or thick neck
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Easy intubation
Neck trauma
Large tongue
Presence of facial hair
Dentures
Large teeth
Call anesthesia
LEMON –Evaluate 3-3-2

Evaluate 3-3-2
3
fingers of mouth opening
 3 fingers between front of chin and hyoid
 2 fingers from mandible to thyroid cartilage
LEMON – Mallampati score

Mallampati score

Grade 1: entire post.
Pharynx, visualized to
tonsillar pillars


Grade 2: hard palate,
soft palate and top of
uvula only


No difficulty
Grade 3: hard and soft
palate only


No difficulty
Moderate difficulty
Grade 4: no
visualization post
pharynx or uvula (hard
palate only

Severe difficulty
LEMON -Obstruction

Upper and lower airway obstruction

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Foreign body aspiration
Epiglottitis
Croup
Abscesses
Trauma
Others
LEMON –Neck Mobility



C-spine collar
Rheumatoid arthritis
Spinal surgery
Is this likely a difficult airway?
RSI
(Rapid Sequence Intubation)

What is it?


Why do we do it?


Preoxygentation + Induction agent + NMB + Sellicks
maneuver
To minimize risk of aspiration in unfasted pts i.e.
almost anybody in the ED
Whom do you do it in?

Pts w/ anticipated easy airways & no
contraindications to RSI (~80% of ED intubations)
Steps of RSISellicks maneuver =
key concept in RSI

7 P’s
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Preoxygenation
Preparation
Premedication
Paralysis & Induction
Protection & Positioning
Pass the tube w/ Proof
Post-intubation care
-10 to -5 min
-3 min
0 min
+20 sec
+ 45-60 sec
+60 – 80 sec
Preoxygenation

Why do we do it?


How do we do it?


Replace nitrogen portion of FRC w/ 100% O2, creating a O2
reservoir for delaying desaturation during apneic period
Ideally 5 min of 100% O2 via BVM or alternatively 8 VC breaths
Pearls



NRB delivers only 70% O2 – need to use BVM w/ good seal
Spontaneous breaths only -- DON’T BAG THE PT (unless
clinically indicated)
DON’T BREAK SEAL – single RA breath sets you back to step 1
Preparation

Even SIMPLE BOB can do it…


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S – Suction
I – IV
M – Meds & Monitors
P – Personnel
L – Laryngoscopes
E – ETT’s (3 sizes)
B – BVM
O – Oxygen
B – Backups / alternative devices
Pretreatment

LOAFD – given 3 min before Induction

L – Lidocaine


O – Opiates (Fentanyl)



2-3 ug/kg IV – blunts sympathetic response
A – Atropine 0.02 mg/kg IV


1.5 mg/kg IV (tight heads, tight lungs)
Kids ≤ 10 or 2nd dose Sux
F – Fluid bolus
D – Defasiculating agent

Rocuronium 0.1 mg/kg – blunts rise in ICP
Paralysis & Induction

Induction agent

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Etomidate 0.15-0.30 mg/kg IV push
Midazolam 0.1-0.2 mg/kg IV push
Ketamine 1-2 mg/kg IV push
Thiopental 1-5 mg/kg IV push
NMB


Succinylcholine 1.5 mg/kg IV push
Rocuronium 0.6 – 1.0 mg/kg IV push
Protection….

Sellicks Maneuver



Gentle (10 lb) pressure on cricoid ring –
compresses esophagus & prevents passive
regurgitation
Initiate 10-20 sec after NMB – don’t release
until cuff inflated & ETT position confirmed
Release if vomiting occurs (rare once NMB in)

Key part of RSI but frequently done wrongly,
poorly, or forgotten altogether
… & Positioning


Key to successful intubation – don’t
neglect
Age & Body habitus dependent – goal is
“sniffing” position




Neonates & infants – towel under shoulders
Children – towel under neck
Adolescents & Adults – towel under head
Obese – towels under head, neck, &
shoulders
Pass the tube w/ Proof

Confirmation of ETT position


Watch it go through cords
ETCO2 monitors – gold standard



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Esophageal detector devices

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Colorimetric – Yellow = Yes / Purple = Poor
Portable digital – gives reading
Quantitative – good waveform
Bulb or syringe aspiration
Clinical methods – least reliable

Auscultation, chest rise, misting
Post-intubation Management

Right insertion depth?


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Secure ETT
Ventilator settings

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Adults: TT = TT (tip-teeth = 22 cm)
Kids: ETT size x3 = cm mark at teeth
Confirm w/ portable CXR
different talk but hugely important!
Continued sedation +/- paralysis

Rule of 1/3’s – give 1/3 of intubation doses prn
Case

You have just intubated your patient

Suddenly they becomes difficult to bag

What is your approach to dealing with
post-intubation complications?
Approach to post-intubation
complications

G-DOPE
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G – gastric distention (peds)
D – Displacement of ETT
O – Obstruction of ETT
P – Pneumothorax
E – Equipment failure
Pearls


Bradycardia = esophageal intubation until proven
otherwise
When in doubt, take it out (change everything)
Case 4
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45M
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Morbidly obese, big beard
Sudden collapse and grand mal seizure
Vomiting as EMS rolls them in
What kind of airway is this?
Difficult Airway
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Anesthesia literarture:




ED airways likely more difficult

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1-3% of intubations will be difficult
0.1-0.4% of anticipated “easy” intubations
end up failing intubation
~1/10,000 will be “can’t intubate, can’t bag”
NEAR data indicates 1% cricothyrotomy rate
Important to try and anticipate but often
cannot
Approach to the Difficult Airway
1.
Anticipate

2.
Call for help

3.
4.
thorough evaluation when possible
2nd EP, anesthesia, ENT, surgery, etc.
Evaluate ability to bag the patient
Make an intubation strategy
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Triple set-up
Topical anesthesia / awake laryngoscopy
Adjuncts / Alternatives / Backups
Predictors of the Difficult Airway

COMATOSE
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C – C-Spine mobility limitations
O – Obstructed, OSA
M – Mallampati grade 3 or 4
A – Anatomy

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dysmorphic features, retrognathia, short or thick neck, large
incisors, facial hair
T – Trauma (head, neck)
O – Obesity
S – “Soon to be moms” (pregnant)
E – Evaluate 3-3-2 rule
Predictors of Difficult BMV
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Age > 55 yo
Obesity (BMI > 26 kg/m2)
Facial Hair
Lack of teeth
Hx of snoring

Identified as independent predictors of difficlut BMV
ventilation in prospective analysis of 1502 pts

Anesthesiology 2000; 92:1229–36
Difficult Airway Algorithm
Anticipated Difficult Airway
Time (sats OK)
BNTI
Anticipate
easy to Bag
Triple Set-up
Awake Look +/- RSI
Backups
Ready 2 Cric
Failed Airway
Anticipate
hard to bag
No Time (desats)
BMV works
BMV Fails
Topical Anesthesia
Mild Sedation
Awake Laryngoscopy
Consider:
I-LMA
Trachlight
Fiberoptic
Cricothyrotomy
Failed Airway
Triple Set-Up
Awake laryngoscopy
1.


topical anaesthesia
may go to RSI if looks easy
Rapid Sequence Induction
2.
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2-3 backups immediately at hand:
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Bougie
Trachlight
I-LMA
Fiberoptic
McCoy blade
Cricothyroidotomy preparation
3.
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Neck prepped & draped, Cric kit open, 2nd person
gloved & gowned w/ scalpel in hand
Awake Laryngoscopy
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Mild sedation
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Small doses of midazolam (1-2 mg) +/- fentanyl (25-50 mcg)
Titrate q3-5 min to effect
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Topical anesthesia
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4% viscous lidocaine on gauze to pharynx, or
Lidocaine spray (10-20 sprays), or
Lidocaine neb

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Want pt able to follow instructions, w/ spont resps
5 cc 2% lido + 5 cc 2% lido w/ epi in nebulizer
Laryngoscopy or Fiberoptic

2 options if can see cords:


Dynamic airway (e.g. anaphylaxis)  tube right there
Stable airway (e.g. Pierre Robin)  do RSI
Airway Pharmacology
Drugs you need to know

Pre-medications
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L-O-A-D
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Lidocaine
Fentanyl
Atropine
Defasiculation
Neuromuscular Blockers
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Succinylcholine
Rocuronium
Induction Agents
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Etomidate
Midazolam
Ketamine
Thiopental
Succinylcholine
Pharmacology

Depolarizing NMB
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Dose:
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Binds to Ach-R, depolarizes it (fasiculations), and
stays bound preventing further depolarization
Adults: 1.5 mg/kg IV, 3.0 mg/kg IM
Kids <1 yo: 3.0 mg/kg IV
Kids >1 yo: 2.0 mg/kg
Onset: 45-60 sec
Duration of Action: ~10 min
Succinylcholine
Side Effects
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Bradycardia – vagotonic effect
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Fasiculations
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↑ IOP – questionable clinical significance
↑ ICP – prevent w/ defasiculating dose of Roc
Hyperkalemic arrest in at risk pts
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Kids <8 -- prevent w/ atropine
2nd dose – Tx w/ atropine
Pre-existing hyperK e.g. CRF
Burns: 24 hrs post – 1-2 yrs after healing
Crush injuries: 7d post – 2-3 months
Denervation injuries (CVA, spinal cord): 7d – 6 mo
Neuromuscular Dz (MS, Muscular dystrophies, ALS etc):
indefinite
Malignant Hyperthermia – rare but 60% mortality
Trismus / masseter spasm – usually transient
Succinylcholine
Contraindications

Absolute
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Personal or FHx of Malignant Hyperthermia
Burns >24 hrs old
Crush or denervation injuries >7d old
Neuromuscular Dz
Relative
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Lack of experience w/ drug
Anticipated difficult airway
Rocuronium
Pharmacology
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Non-depolarizing NMB
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Dose:


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Competes with ACh & binds to ACh-R
Doesn’t cause depolarization (no
fasciculations)
Intubation dose: 0.6-1.0 mg/kg
Defasiculation dose: 10% of intubation dose
Onset: 60 sec
Duration of Action: 40-60 min
Can you reverse it?

Sort of…

Neostigmine
Blocks Ach breakdown – thus increases [ACh] at
receptor to compete with rocuronium
 Won’t work until [Roc] ↓’s to ~40% therefore slow
onset (~30 min) making it clinically useless as
such in the ED
 Cholinergic side effects

Induction Agents


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ALL induction agents can potentially cause
myocardial depression & hypotension
Individualize agent & dose to clinical
situation
Inadequate induction (i.e. light pt)
increases risk of laryngospasm
Etomidate
Pharmacology

Imidazole derivative w/ hypnotic effects


Trauma drug of choice



Blunts ↑ in ICP, ↓’s cerebral O2 demand
Dose


Most hemodynamically stable agent we have
Cerebroprotective


Appears to work at GABA receptor
0.15 – 0.3 mg/kg (use lower dose if unstable)
Onset: 20-30 secs
Duration of Action: 7-14 mins
Etomidate
Side Effects

Vomiting SPAM

N&V

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S – Seizures


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Conflicting data, but appears to lower Sz threshold in pts w/ focal
seizures
P – Pain on injection
A – Adrenal surppression


occurs in 30-40%
Reversible & not associated w/ worse outcomes after single dose
M – Myoclonus

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Not associated w/ Sz activity on EEG
Occurs in 30-65% -- can ↓ incidence w/ fentanyl pre-Tx
Etomidate
Contraindications

4 p’s
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Prior Seizures
Pregnancy


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Category C: animal evidence of harm
Poor Adrenal function
Pediatrics
Likely to change; several studies documenting use
for RSI & PSA in kids
 Used by 70% of US ED’s

Ketamine
Pharmacology

PCP deriviative

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Bronchodilator

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Drug of choice in Asthma / COPD
Catecholamine release  ↑ HR & BP


Analgesic, amnestic, anesthetic
Good in hypovolemic, hypotensive pts
Does not supress respiratory drive
Dose: 1-2 mg/kg IV or 4-6 mg/kg IM
Onset: 15-30 Sec
Duration: 10-15 min
Ketamine
Side Effects

Makes you SMILE


↑ ’s Secretions – prevent w/ atropine
Myocardial depression


Increases ICP


Avoid in head trauma
Laryngospasm


Avoid in kids w/ CHD
Gently bag them; NMB if sats drop/unable to bag
Emergence rxns

Midaz does not appear to prevent this
Midazolam
Pharmacology

Benzodiazepine





Acts at GABA receptor
Amnestic, anxiolytic, sedative, anticonvulsant
properties
Dose: 0.1 – 0.2 mg/kg IV
Onset: 30-60 sec
Duration of Action 30-60 min
Midazolam
Side Effects

Hypotension


Dose-related ↓ in SVR
Direct myocardial depression


Opiates potentiate effect
Respiratory depression
Case 6

4 yo boy



Found unresponsive in pool
Brought by EMS unintubated
What makes the pediatric intubation
different?
Pediatric Airways
Large head & occiput
Causes neck flexion – towel under
shoulders to obtain sniffing position
Large tongue, tonsils and adenoids
Obstructs airway, obstructs
laryngoscopy view view
High anterior larynx
Can be more difficult to see – may
need straight blade to lift epiglottis
Funnel-shaped larynx – narrowest
portion below cords
Use uncuffed tubes in kids <8 yo
Tiny cricithyroid membrane
Needle cric is difficult; surgical cric
impossible in age <8 yo
High basal metabolic rate &
relatively smaller FRC
Desat quickly (2x as fast as adults)
Relatively higher H2O content
Need larger doses of Sux
Monosynaptic airway reflexes
Vagal response to laryngoscopy 
bradycardia; need atropine
Pediatric Airway
Estimating Weight

(Age in yrs x 2) + 8

Broselow tape

Length-based method
Estimating ETT size

(Age / 4) + 4

Size of patient’s small finger = size of ETT

Broselow tape

Length-based method
ETT Insertion Depth

Size of of ETT x 3 = cm from tip-teeth

Broselow tape

Length-based method
Bottom Line

In pediatric resuscitation, the
Broselow tape is your friend!


Cuffed vs uncuffed airways in kids
Does it matter?
What kind of blade should you use?

Textbooks


Pediatric anesthetists:



Straight (Miller) blade
Many use curved (MacIntosh) blade in age>1yo
Many use curved blade in all kids
Bottomline

Use what works for you
the end
Basic Airway Skills

Pearls

BVM is cornerstone of airway management

Saves lives, especially in kids






Read up on it & practice at every opportunity
C-grip technique


Gauche 2000: kids did better w/ BVM pre-hospital than w/
intubation
SMALL adjustments (especially in kids)
Use OPA’s / NPA’s
KY jelly onto beards to improve seal
Stuff 4x4’s into cheeks
Keep dentures in place
Case 1




65 yo M presents w/ massive LGIB
PMHx: HTN, MIx2, A. fib
GCS 15, P120, BP 85/65, RR 28, SpO2
98% on NRB
What (if any) indications does he have to
be intubated?
Case 2


22 yo F brought in after taking GHB
overdose.
How would you specifically assess her
airway?
Assessing an Airway

Taking their last GASPS?





G – GCS impairment
A – Artificial airway (OPA) tolerated
S – Swallowing impaired / inability to handle
secretions
P – Pathological process involving airway e.g.
stab wound, anaphylaxis
S – Speech (quality, quantity)
Case 3




55 yo M brought in by EMS for chest pain
– suddenly becomes unresponsive
Apneic, pulseless on quick exam
Does he need intubation?
What kind of airway is he?
Approach to Airway Mangement


1) Are indications for intubation present?
Contraindications?
2) Define the type of airway:






Easy
Difficult
Failed
Crash
3) Choose strategieS best suited to airway & clinical
situation
4) Anticipate & plan for post-intubation complications
Step 2: Type of Airway
Requires Intubation
Easy Airway
Crash Airway
Difficult Airway
Failed Airway
No anticipated difficulty
w/ ETI or BVM
Unresponsive
Apneic / Arrested
Near-death
Anatomy
Pathology
Can’t intubate
Can’t bag
RSI
No Drugs or
SCh alone
Difficult Airway
Algorithm
Failed Airway
Algorithm
Do Kids really need Atropine?
Retrospective review of
163 pediatric ED pts
Fastle & Roback. Ped Emerg Care 2004; 10:651-655