Transcript Airway - Rural Health Association of Tennessee, Inc.

Advanced Airway
Management
Airway Management:

Airway management is the most important
skill for the Pre-hospital/Hospital Clinician.
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ABC’S
Timely, effective, and decisive management
of the airway can literally make the difference
between life and death or between ability
and disability.
Its important for crew to have the skill,
confidence, knowledge, and equipment to
effectively manage the airway.

TRAINING IS KEY!!
ANATOMY
WE GOT TO KNOW THIS:
WHAT MAKES UP THE UPPER
AIRWAY?
 Nose-cartilaginous,
bony structure in the midline
of face that warms and humidifies inspired air.
 Mouth-begins at the lips and ends with the
oropharynx. Contains the tongue which is
attached to the mandible and teeth.
 Pharynx- U-shaped tube that begins at the base of
the skull and extends to lower border of cricoid
cartilage near the esophagus.
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Nasopharynx
Oropharynx
Hypopharnyx
WHAT MAKES UP THE LOWER
AIRWAY
 Trachea-
beginning at the inferior border
to the cricoid ring and ending at the
carina.
 Lungs- when the trachea divides into the
right and left mainstem bronchi, these
bronchi lead into the right and left lobes
of the lung. Right has 3 lobes and Left has
2 lobes. This is the site of gas exchange.
PUTTING IT ALL TOGETHER
What’s in my mouth?
WHY IS KNOWING ANATOMY
SO IMPORTANT?
Why?
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Because…
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You can not manage what you do not
understand!
Airway management is not just being able to
identify who needs additional airway assistance
but knowing the landmarks and anatomical
aspects of an airway so the assistance can be
given.
Burns, Edema, Blood, Vomit, Foreign Bodies in the
Airway will distort view so knowing what things
should look like and where they should be is very
beneficial.
Ex. IV in the A/C
Patient and Airway
Assessment
Now since we know what an airway looks
like lets assess.
Breathing Process
Unfortunately we all realize there are many
factors that prevent many people from
breathing properly..
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COPD
Asthma
Cystic fibrosis
Asbestosis
Mesotheolioma
Pneumonia
Trauma, Head Injury
Drug Overdose
Foreign Body Obstruction
Airway edema
Congenital Abnormality
Patient Assessment
 But…
Just because a patient has one or
more of these issues does not mean the
patient has an acute problem needing
intervention.
 We
first must assess the patient and see if
advanced intervention is necessary or if
less invasive but helpful application will
work.
Patient Assessment
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Who needs an Airway?
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Pt with diminished level of consciousness with
loss or airway control.
Absent or diminished gag reflex??? How about
ability to swallow secretions!
Glasgow Coma Scale of 8 or less (Pt Hx
Dependent)
Potential for aspiration
Respiratory Failure (hypoxemia, hypercarbia)
Cardiac arrest, after adequate CPR or bag
mask ventilations have been provided.
Airway Assessment
Airway Assessment
There are many ways we can assess an
airway and some techniques have been
proven very successful such as the Visual
Inspection, Auscultation, Lemon Law,
Mallampati Classification, and 3-3-2 Rule.
Airway Assessment
Lemon Law
 L – Look externally
 E – Evaluate the 3-3-2 rule
 M – Mallampati
 O – Obstruction
 N – Neck Mobility
Look Externally
 Evaluate
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patients general apperance:
LOC
Skin Color
Skin Temperature
Skin texture
Patient Posture
 Tripod
Position
Look Externally
 Visibly
is the patient having difficulty
breathing?
 Goldilocks Logic is it Slow, Fast, Just Right
 Normal Ranges
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RR Adult/Child (6-12 years) = 12-20 bpm
RR Child 1-5 years = 20-30 bpm
RR Infant 6-12 months = 24-30 bpm
RR Infant Newborn to 6 months = 30-60 bpm
Airway Assessment:
Look Externally
Airway Assessment:
Look Externally
Airway Assessment:
Look Externally
 Look
for things that could make intubating
or ventilating a patient difficult.
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Beards
False Teeth
Secretions
Obesity
Trauma to Facial area
Airway Assessment:
3-3-2 Rule
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3-3-2 Rule
The mouth should be at least three patient
fingers wide or 5 cm when open. Less than 3
fingers indicates a possible difficult airway.
The space from the tip of chin to hyoid bone
should be three fingers wide. Smaller
mandibles have less room for displacement of
tongue and epiglottis.
The distance from the hyoid bone to the
thyroid notch should be at least two fingers
wide.
Airway Assessment:
Mallampati/Cormack and
Lehane
Airway Assessment:
Obstruction
 Obstruction
is anything that might
interfere with visualization or tracheal tube
placement.
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Foreign Body
Hematoma
Masses
Airway Assessment:
Obstruction
Airway Assessment:
Obstruction
That Airway Makes Me
Nervous
Airway Assessment:
Neck Mobility
 Ideally
we want our patients in a sniffing
position for better visualization with the
adult head slightly elevated and
extended.
 This may be impossible with the Elderly
and Trauma patients
 Does patient have a c-collar in place?
 Does patient have osteoporosis or
arthritis?
Airway Assessment
Our Goal:
Our assessments will ultimately determine
whether a patient has a open and patent
airway and wither a patients breathing is
sufficient on its own or if it needs some form
of intervention to assist.
Airway Management
 Lets
say our assessment has been
performed and we determine that
intervention is necessary?
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Basic Management
Advanced Management
Basic Airway Management
Although intubation is considered the
GOLD STANDARD for airway
management, basic airway skills are the
starting point in the initial patient assessment
and treatment and what we fall back on in
times of difficulty.
Basic Airway Management
Basic skills may be as simple as positioning
the non-trauma victim in the recovery
position or using the head tilt-chin lift or jaw
thrust maneuver to maintain airway
patency. Other basic skills may use other
adjuncts such as the OPA and NPA.
Basic Airway Management
So….. What is an Advanced
Airway
Advanced Airway
Management
 Advanced
Airway Management is
Definitive Airway Management.
 The
placement of a ET tube or
tracheostomy tube in the trachea is
definitive airway management because it
facilitates adequate oxygenation and
ventilation of the patient.
Types of Advanced Airway
Equipment and Procedures
 Combitube
(double lumen airway)
 LMA (supraglottic airway)
 King LT (supraglottic airway)
 Endotracheal Tube
 Needle Cricothyrotomy
 Surgical Cricothyrotomy
 Pertrach (Emergency Cric)
 Rapid Sequence Intubation
Rapid Sequence Intubation
 Originally
developed in 1946 to facilitate
airway management in ob patients
requiring intubation for c-section with full
stomach
 By definition involves the coadministration of both anesthetic agents
and neuromuscular blocking agents to
produce a state of unconsciousness and
paralysis to allow tracheal intubation.
Rapid Sequence Intubation
 Indications
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Actual/impending respiratory failure
Actual/impending inability to protect the
airway
Combative secondary to presumed head
injury
Hypoxemia despite supplemental oxygen
and medications
Rapid Sequence Intubation
 Contraindications
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Anticipated difficult intubation
Anticipated difficult BVM
Crash Airway Situation
Cardiac Arrest
 These
Patients should have no muscle tone
Rapid Sequence Intubation
Steps to RSI
1.
2.
3.
4.
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6.
Preparation
Pre-oxygenate
Pre-medicate
Paralyze
Intubate and Confirm
Maintain paralysis and sedation
Rapid Sequence Intubation
Preparation
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When preparing for RSI procedure we should
gather all medications used in procedure, get
them drawn up, labeled, and ready for
administration.
Gather all necessary equipment and make
sure it is in working order.
We should also prepare for worst case
scenario which means having different sized
laryngoscope blades and ET tubes available.
We also need our back up airways very close
by and ready for use if necessary.
Rapid Sequence Intubation
Preparation
Rapid Sequence Intubation
Preparation
Rapid Sequence Intubation
Pre-oxygenate
 Oxygen
21% and Nitrogen 78%
 100% Oxygen delivered for at least 3
minutes in an attempt to achieve
NITROGEN WASHOUT.
 We do this in hopes to increase the
amount of oxygen and develop a reserve
in order to help patient desaturate less
quickly while intubation attempt is being
made.
Rapid Sequence Intubation
Pre-medicate
 The
first medications given should help the
patient’s adverse physiologic responses to
the subsequent medications and
laryngoscopy.
 All
pre-medications require at least 3
minutes to work before laryngoscopy.
Rapid Sequence Intubation
Pre-medicate
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Anesthetize the
airway reflexes that
lead to elevate ICP.
Dose: 1-1.5 mg/kg
Peak : 3 mins
Duration: 20 mins
Adverse:
Hypotension, Allergy,
Seizures,
Bradydysrhythmias
Rapid Sequence Intubation
Induction
 Used
to render the patient unconscious
and unresponsive:
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1.
2.
3.
4.
Isn’t that what you would want?
Have a Rapid Onset/Short duration
Induce unconsciousness and
unresponsiveness
Provide amnesia
Typically have minimal hemodynamic and
adverse effects
Rapid Sequence Intubation
Induction
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Dose: 0.2-.04 mg/kg
Peak: 30 seconds
Duration: 10 minutes
Adverse: Adrenal
Suppression –
reduces the glands
ability to secrete
stress hormones,
Rapid Sequence Intubation
Induction
 Benzodiazepine
 Dose:
0.2-0.4
mg/kg but be
careful with
hypotensive
patients
 Peak: 3 mins
 Duration:Varies
Rapid Sequence Intubation
Defasciculating Agent
 Non-Depolarizing
 1/10
th of
paralyzing dose
 Used to help
prevent
fasciculations
caused by
succinylcholine
Rapid Sequence Intubation
Paralytics
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Non-competitive
Depolarizing Agent
Neuromuscular Blocking
Agent
Dose: 1-2 mg/kg
Peak: 45 seconds
Duration: 8 minutes
Adverse: Hyperkalemia,
Neuromuscular Diseases,
Burns greater than 24-48
hrs old, Malignant
Hyperthermia, increased
intraocular pressure,
Rhabdomyolysis
Long term Paralytic
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Non-Depolaring
Neuromuscular
Blocking Agent
Regular Dose: 0.1-0.3
mg/kg
Peak: 90 seconds
Duration: 30-90
minutes depending
on dose
Adverse: Minimal
Pass the Tube
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Now once you have
sedated and
paralyzed the
patient, you are
ready to pass the
tube.
Don’t forget to wait
until patient is full
paralyzed… we do
not want to cause
patient to vomit and
aspirate
Rapid Sequence Intubation
Intubate and Confirm
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3.
Once patient is paralyzed and intubation has
taken place it’s very important to confirm
your ET tube is in the correct position.
Objective ways to confirm:
Pulse Oximetry
ETCO2
EDD
Chest X-Ray
Subjective ways to confirm:
Direct visualization
Tube misting
Breath sounds
Pertrach
 If
your at this
point… it’s not a
good day Tater!!
 Indicated
for a
can’t
intubate/can’t
ventilate situation.
Pertrach
 Contraindication:
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Inability to identify
landmarks for
procedure.
 Complications:
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Hemorrhage
Subcutaneous
Emphysema
Infection
Accidental
removal
Tracheal and
esophageal
laceration
Pertrach
 Most
important
step is to identify
need for Pertrach
device.
 Equally as
important is making
sure you find the
correct landmark
for procedure.
Pertrach
 If
you can not find
landmarks… you
have no business
attempting to
perform the
procedure.
Pertrach
 If
appropriate to
continue
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Open kit and
assemble
equipment
Position patient as
appropriate and
find landmarks
Cleanse site of
insertion
Pertrach
We got the Airway.. I think?
 Remember
before we celebrate we first
have to confirm that our intervention is in
the right place and working.
 Also
note with sudden movements or
transferring of patient, airway should
always be reassessed for patency.
 Airways can be gained and Airways can
be lost.
Failed Airway
Advancements in Equipment
Ranger Glide Scope
 Used
during
difficult intubation
so better
visualization is
needed.
Gum Elastic Bougie
 Of
great use when
patient has a
anterior larynx that
cannot be
visualized despite
optimal positioning
and external
manipulation.
ETCO2 Monitoring
The New Standard
Conclusion:
 Airway
management is a very important
skill for all clinicians to have.
 Assess, Reassess, and Reassess again!
 TRAIN! Because your next airway may be
difficult.