AIRWAY MANAGEMENT CHRIS POULSEN, D.O. MEDICAL DIRECTOR, REACH AIR MEDICAL SERVICES

AIRWAY MANAGEMENT CHRIS POULSEN, D.O. MEDICAL DIRECTOR, REACH AIR MEDICAL SERVICES

OBJECTIVES At the conclusion the participant will 1.Understand airway anatomy applicable to airway management devices and techniques. 2.Verbalize an understanding of airway management devices and theory. 3.Verbalize indications and contraindications of airway pharmacology. 4.Understand the impact on scene time when Rapid Sequence Airway is performed at the scene. 5.Recognize the signs of a potentially difficult airway.

AIRWAY MANAGEMENT Introduction Anatomy / Physiology Positioning Basics - Adjuncts ALS - Intubation

ANATOMY Children are different than adults!!!

ANATOMY

PEDIATRIC AIRWAYS Epiglottis: Relatively large size in children Omega shaped Floppy not much cartilage

ANATOMY: ADULT vs PEDIATRIC

AIRWAY ANATOMY - SHAPE

ANATOMY

POSITIONING

AIRWAY POSITIONING FOR CHILDREN <2yrs

POSITIONING

SIGNS OF RESPIRATORY DISTRESS

PHYSIOLOGY: EFFECT OF EDEMA Poiseuille s law R = 8 n l r 4 pedi adult When radius is halved ---- Resistance increases 16 fold

BREATHING Breathing should always be divided in two! Oxygenation Ventilation In with the new (Inhalation) Out with the old (Exhalation) It s not a ventilator --- it s an oxygenator/ventilator Priority 1) Oxygen Delivery Priority 2) Not to hyperventilate Priority 3) Adequate ventilation

BREATHING: OXYGENATION Big tidal volumes and rates don t increase oxygenation For Hypoxemia: turn up the FiO2, or the pressure D - O - P - E (dislodged - obstructed - PTX - Equipment) Use a PEEP valve! If still dropping.. EPIC study (Dan Spaite - Arizona) Hypoxia is REALLY BAD for TBI: 500 cases of hypoxia/10,000 = 4 X mortality! A single sat <90 doubles mortality in severe TBI! Always utilize 100% O2 on TBI patients!

OXYGENATION: HENRY S LAW the quantity of a gas dissolved in liquid is proportional to the partial pressure of the gas in contact with the liquid - So higher FIO2 = higher po2 - Higher PEEP or PIP = higher po2 Oxygen (Hg) saturation is dependent on po2 (Note: Rate / TV have no effect here ---- minute ventilation )

AIRWAY MANAGEMENT Adjuncts: High Flow Nasal Canula Preoxygenation and Prevention of Desaturation During Emergency Airway Management Scott D. Weingart, MD Richard M. Levitan, MD

BREATHING: VENTILATION Remember tidal volume x rate = minute ventilation Minute Ventilation RAPIDLY affects pco2 Medical Providers all Hyperventilate! ** We want to feel the lungs inflate! Use a 1 liter BVM 1 breath every 5 seconds And flow control / counter

BREATHING: VENTILATION Remember tidal volume x rate = minute ventilation Follow ETCO2 in all critical patients ETCO2 is about 5mmhg less that PCO2 Waveform capnography is best! All that is ETCO2 is not ventilation It s only accurate if there is adequate Cardiac Output If blood is not pumped to the lungs, CO2 will not off-gas (CPR, Shock, etc) EMMA Colorimetric

BREATHING VENTILATION Do Not Hyperventilate TBI Patients! * We were taught to do this in the 80 s and 90 s We killed thousands based on expert opinion Goal ETCO2: 35-40 TBI patients begin to drop off at pco2 < 35* *Davis, et al and Dumont, et al

AIRWAY MANAGEMENT We manage airways so we can manage breathing Less is More! Utilize the least invasive method that solves the problem Positioning NPA (over OPA) BVM SGA (LMA type devices) ETT Cricothyrotomy

AIRWAY MANAGEMENT BASICS: BLS Positioning head tilt/chin lift or jaw thrust Effective BVM - most important skill Get a good seal (two person better) Don t over ventilate Adjuncts OPA - good choice if tolerated (no gag) NPA better tolerated new better materials SUCTION!!! BROSELOW!!!

BROSELOW TAPE

BROSELOW TAPE there s an app for that Pediatric Resuscitation Palm Pedi

AIRWAY ADJUNCTS Nasal airway Oral airway

BASIC AIRWAY MANAGEMENT TECHNIQUES

AIRWAY MANAGEMENT ADJUNCTS (NPA)

ADJUNCTS: ORAL AIRWAY Wrong size: Too Long

Adjuncts: Oral Airway Wrong size: Too Short

Adjuncts: Oral Airway Correct size

BAG VALVE MASK (BVM)

BAG VALVE MASK VENTILATION Pro s Effective adjunct Non invasive Feel compliance Give Slow Small Breaths: 6-8 cc/kg (smallest aprop. bag) Rate: Adults: 12 Child: 16-20 Infant: 20-30

ADJUNCTIVE & RESCUE AIRWAYS King LT (Periglottic Airways) Supraglottic Airways (SGAs = LMAs)

SGA s (LMA s) The SGA was invented by Dr. Archie Brain at the London Hospital in Whitechapel in 1981 The SGA consists of two parts: The tube The mask

SGA s (supraglottic airways) The SGA design: Provides an oval seal around the laryngeal inlet when cuff inflated. Lube only the outside not inside the cup area Direct it posteriorly and upwards past the posterior tongue (jaw thrust will help) Then Bury It! (avoid a flipped tip ) Don t overinflate (or don t inflate!)

SGA INDICATIONS Failed less invasive techniques Failed more invasive techniques May be used as a: Rescue Device Bridging Device Destination Device

CONTRAINDICATIONS Intact Gag Reflex Patients requiring definitive airway protection: (Swollen cords, burn, anaphylaxis, vomiting, high pressures, etc) Massive maxillofacial trauma Patients at High risk of aspiration

PREPARATIONS Step 1: Size selection Step 2: Examination of the LMA Step 3: Check the cuff Step 4: Lubrication of the LMA Step 5: Position the Airway

STEP 1: SIZE SELECTION Verify that the size of the LMA is correct for the patient (Broselow or pckg insert) Recommended Size guidelines: Size 1: under 5 kg Size 1.5: 5 to 10 kg Size 2: 10 to 20 kg Size 2.5: 20 to 30 kg Size 3: 30 kg to small adult Size 4: adult Size 5: Large adult

THE i-gel SGA no inflation

Manage the airway don t secure it! Should we be intubating at all?

PRE HOSPITAL INTUBATION The Debate on Prehospital Intubation Continues Studies showing WORSE outcomes with ETI Stiell: CMAJ 2008;178:1141-52 Davis: J Trauma 2003;54:444-53 Davis: J Trauma 2005;58:933-9 Davis: J Trauma 2005;59:486-90 Denninghoff: West J Emerg Med 2008;9:184-9 Murray: J Trauma 2000;49:1065-70 Wang: Ann Emerg Med 2004;44:439-50 Wang: Prehosp Emerg Care 2006;10:261-71 Eckstein: Ann Emerg Med 2005;45:504-9 Bochicchio: J Trauma 2003;54:307-11 Arbabi: J Trauma 2004;56:1029-32 Studies showing BETTER outcomes with ETI Winchell: Arch Surg 1997;132:592-7 Klemen: Acta Anaesthesiol Scand 2006;50:1250-4 Warner: Trauma 2007;9:283-89 Davis: Resuscitation 2007;73:354-61 Davis: Ann Emerg Med 2005;46:115-22 Bulger: J Trauma 2005;58:718-23 Bernard: Ann Surg 2010;252:959-965

INTUBATION: INDICATIONS Failure to oxygenate Failure to ventilate (Failure to remove CO2 = hypercarbic respiratory failure) Failure to protect the airway - (or expected failure to protect the airway (GCS <8, etc) Expected Course Demands ETT (prior to TOC)

INTUBATION: PREPARATION Preoxygenate Monitors - ECG, pulse ox BLM (Sellick s) Good basics Equipment selection Miller (< 4) vs. Mac Cuffed vs. uncuffed ETT size Positioning

PRE-OXYGENATION PRIOR TO RSA (RSI) 3-5 minutes of 100% oxygen - non-rebreather mask Hi Flow Nasal Cannula 15 L adults, 1 L/kg peds Avoid positive pressure ventilation if possible 6 full volume ventilations via BVM if needed Establishes O2 reserve via nitrogen washing Permits prolonged apnea w/o desaturation Healthy 70kg adult >90% for over 10 minutes Healthy10kg child >90% for over 4 minutes But! The Airway must be open!

The Oxygen Dissociation Curve PO2 up to 400 On 100%

AIRWAY EQUIPMENT Suction, Suction, Suction Zofran Pedi Bougie (4-6) Adult Bougie (6-8.5) Stylet ETT +/- one size Tube check and securing devices Magill forceps (Parker flex tip ETT)

ENDOTRACHEAL TUBE INTRODUCER (GUM ELASTIC BOUGIE) Bougie Replaces the stylet Able to use with poor view Feel tracheal rings If it goes in all the way = esophagus Fold it in ½ - in line with coudet tip Don t preload it

ENDOTRACHEAL TUBE INTRODUCER (GUM ELASTIC BOUGIE) Large study June 2018: Effect of Use of a Bougie vs Endotracheal Tube and Stylet on FirsAttempt Intubation Success Among Patients With Difficult AirwayUndergoing Emergency Intubation: A Randomized Clinical Trial. 757 patients: 1 st pass success went from 82% to 96%

ENDOTRACHEAL TUBE (ETT) Age kg ETT Length Newborn 3.5 3.5 9 3 mos 6.0 3.5 10 1 yr 10 4.0 11 2 yrs 12 4.5 12

TUBE SIZE ETT size (Age + 16) / 4 Diameter of nare Diameter of pinky Broselow tape Have one size smaller and larger

TUBE PLACEMENT TIP TO LIP ETT depth use the black line ETT size x 3 Infants: wt (kg) + 6

BACK-UP PLAN Can t ventilate or basics not working Consider adjuncts (OPA/NPA/positioning) Intubation? Can t intubate Rescue devices Can t rescue Surgical procedure Okay to stick with basics if working

LARYNGOSCOPE BLADES Macintosh Miller

LARYNGOSCOPE BLADES Better in younger children with a floppy epiglottis (<2-4)

LARYNGOSCOPE BLADES Better in adults and older children (stiffer epiglottis)

INTUBATION - CONFIRMATION Visualize tube passing through cords (video?) Breath sounds and no epigastric sounds End Tidal CO 2 (ETCO 2 ) Waveform better than colorimetric (not reliable in CPR) Masimo EMMA Device (mainstream ETCO2)

AIRWAY MANAGEMENT CHALLENGES

AIRWAY MANAGEMENT CHALLENGES

DETERIORATION OF INTUBATION: DOPE Displaced Obstructed PTX Equipment

RSI MEDICATIONS Same as adults Lidocaine Etomidate Succinylcholine Rocuronium Atropine not required Consider ketamine

IN CLOSING There is airway management and there is everything else Know your equipment and supporting policies Manage the airway don t stabilize A failed airway should never be unanticipated consider all airways potentially difficult! Have plan B before proceding with plan A Practice! Practice! Practice!

It s Not Okay to Continue with Failed Techniques HOPE is not an airway strategy

QUESTIONS