Advanced airway

Advanced AirwayAdvanced Airway

Lynn K. Wittwer, MD, MPDLynn K. Wittwer, MD, MPD

Clark County EMSClark County EMS

Advanced AirwayAdvanced Airway

Anatomic ConsiderationsAnatomic Considerations

Rapid Sequence inductionRapid Sequence induction

Induction AgentsInduction Agents

Intubation tricksIntubation tricks

Indications for Definitive AirwayNeed for Airway ProtectionNeed for Airway Protection Need for VentilationNeed for Ventilation

UnconsciousUnconscious ApneaApnea

Neuromuscular ParalysisNeuromuscular Paralysis

UnconsciousUnconscious

Severe Maxillofacial fx’sSevere Maxillofacial fx’s Inadequate Respiratory Effort’Inadequate Respiratory Effort’

TachypnealTachypneal

HypoxiaHypoxia

HypercarbiaHypercarbia

CyanosisCyanosis

Risk for aspirationRisk for aspiration

BleedingBleeding

VomitingVomiting

Severe closed head injury with need Severe closed head injury with need for hyperventilationfor hyperventilation

Risk for obstructionRisk for obstruction

Neck hematomaNeck hematoma

Laryngeal, tracheal injury/burnLaryngeal, tracheal injury/burn

StridorStridor

Mouth:Mouth:– TongueTongue : :

variable in size (angioedema)variable in size (angioedema)

attached inferior to epiglottisattached inferior to epiglottis– MandibleMandible– UvulaUvula

PharynxPharynx– TonsilsTonsils– Merges with larynx anterior, esophagus Merges with larynx anterior, esophagus

posteriorposterior– Epiglottis high long flaccid and narrow in childEpiglottis high long flaccid and narrow in child

ANATOMIC CONSIDERATIONS ANATOMIC CONSIDERATIONS FOR INTUBATIONFOR INTUBATION

The LarynxThe Larynx– High relative to mandible in childHigh relative to mandible in child– Cricoid smaller in child, narrow part of airwayCricoid smaller in child, narrow part of airway– vocal cord narrow part of adult airwayvocal cord narrow part of adult airway– arytenoid cartilagesarytenoid cartilages

ANATOMIC CONSIDERATIONS ANATOMIC CONSIDERATIONS FOR INTUBATION (cont.)FOR INTUBATION (cont.)

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TracheaTrachea– 12-15 cm. Adult12-15 cm. Adult– 4 cm. Newborn4 cm. Newborn– right mainstem right mainstem

larger,shorter and larger,shorter and less angleless angle

ANATOMIC CONSIDERATIONS ANATOMIC CONSIDERATIONS FOR INTUBATION (cont.)FOR INTUBATION (cont.)

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ANATOMIC CONSIDERATIONS FOR INTUBATION ANATOMIC CONSIDERATIONS FOR INTUBATION (cont.)(cont.)

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– Tube Sizes (Kids)Tube Sizes (Kids) Fit through noseFit through nose

Age(years)/4 + 4Age(years)/4 + 4

Oral tube lengthOral tube length– Age(years)/2 + 12 cm.Age(years)/2 + 12 cm.– Nasal add 3 cm.Nasal add 3 cm.

No cuff under 6 to 8 yearsNo cuff under 6 to 8 years

OTHER CONSIDERATIONS FOR OTHER CONSIDERATIONS FOR INTUBATION (cont.)INTUBATION (cont.)

Difficult tubes Difficult tubes – Immobilized trauma patientImmobilized trauma patient– Combative patientCombative patient– Children, esp. InfantsChildren, esp. Infants– Short neckShort neck– Prominent upper incisorsProminent upper incisors– Receding mandibleReceding mandible– Limited jaw opening, limited Limited jaw opening, limited

cervical mobilitycervical mobility– Upper airway conditionsUpper airway conditions– Facial, laryngeal traumaFacial, laryngeal trauma

OTHER CONSIDERATIONS FOR OTHER CONSIDERATIONS FOR INTUBATION (cont.)INTUBATION (cont.)

Correct Placement for intubation (b)

Patient in correct position for intubation (sniffing position)

Incorrect airway position (hyperflexed)Incorrect airway position (hyperflexed)

Rapid Sequence InductionRapid Sequence Induction

IndicationsIndications– Ventilatory failureVentilatory failure– Airway maintenance/protectionAirway maintenance/protection– Treatment and evaluationTreatment and evaluation

neuro resuscitation(hyperventilate)neuro resuscitation(hyperventilate)

shockshock

drug overdosedrug overdose

ContraindicationsContraindications– Cardiac arrestCardiac arrest– Adequate ventilationAdequate ventilation– Deeply comatose patient, absent toneDeeply comatose patient, absent tone– Post-intubation sedationPost-intubation sedation


Contraindications Contraindications (cont.)(cont.)– Intubation likely Intubation likely

unsuccessfulunsuccessfulPartially Partially obstructed airwayobstructed airway

Severe facial Severe facial abnormality(trauabnormality(trauma, etc.)ma, etc.)


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Maintain adequate oxygenationMaintain adequate oxygenation

Airway protection Airway protection – Prevent regurgitation, aspirationPrevent regurgitation, aspiration

Obtund adverse cardiovascular and Obtund adverse cardiovascular and ICP response to intubationICP response to intubation

Better early than lateBetter early than late

Hypoxemia and acidosis effectsHypoxemia and acidosis effects


Treatment AlgorithmTreatment Algorithm– Preparation Preparation – Pre-oxygenation( functional reserve capacity)Pre-oxygenation( functional reserve capacity)– Pre-medicationPre-medication– SedationSedation– Cricoid pressureCricoid pressure– ParalysisParalysis– IntubationIntubation


DO NO HARM!DO NO HARM!

TAKE AWAY NOTHING TAKE AWAY NOTHING FROM THE PATIENT YOU FROM THE PATIENT YOU

CANNOT REPLACECANNOT REPLACE

Anticipate the difficultiesAnticipate the difficulties– Identify Identify in advancein advance the patient who may the patient who may

require RSIrequire RSI– Identify the patient with anatomic Identify the patient with anatomic

difficultydifficulty– Have sufficient skill and trainingHave sufficient skill and training– Have aHave a preformulated preformulated planplan for potential for potential

disasterdisaster


Airway EvaluationAirway Evaluation

Problem Airway

epiglottis Vocal cords

Be prepared:Be prepared:– Competence with all Competence with all

equipmentequipment– Working equipmentWorking equipment– Be prepared for surgical Be prepared for surgical

managementmanagement– Master the art of baggingMaster the art of bagging– Have at least one, if not Have at least one, if not

two, working IV linestwo, working IV lines


Equipment:Equipment:– Suction, OxygenSuction, Oxygen– Laryngoscope, ET Tubes, StyletLaryngoscope, ET Tubes, Stylet– BVMBVM– Pharmacologic agents, mixed and Pharmacologic agents, mixed and

readyready– Monitoring equipmentMonitoring equipment

Continuous cardiac monitoringContinuous cardiac monitoring

Pulse oximeter (continuous)Pulse oximeter (continuous)

Auto BP (ideal)Auto BP (ideal)

CO2 device (ET confirmation device)CO2 device (ET confirmation device)


Pre-oxygenation:Pre-oxygenation:– Functional residual capacityFunctional residual capacity– Oxygen 6-10 l/min via snug maskOxygen 6-10 l/min via snug mask– Three minutes ideal if spontaneous Three minutes ideal if spontaneous

breathingbreathing– In “crash”, may use RSI agents and O2 In “crash”, may use RSI agents and O2

by BVM with mandatory Sellickby BVM with mandatory Sellick


Pre-medication:Pre-medication:– AtropineAtropine

All children under 12 yearsAll children under 12 years

Adults with heart rate 100 or less ***Adults with heart rate 100 or less ***

Second dose of SuccinylcholineSecond dose of Succinylcholine

Dosage: 0.5 to 1.0 mg adultDosage: 0.5 to 1.0 mg adult

Dosage 0.01 to 0.02 mg child (1 mg max)Dosage 0.01 to 0.02 mg child (1 mg max)

Give ideally 2-3 minutes prior to intubationGive ideally 2-3 minutes prior to intubation


Pre-medication (cont.)Pre-medication (cont.)– LidocaineLidocaine

Decrease adrenergic and physiologic Decrease adrenergic and physiologic response to laryngoscopy and intubationresponse to laryngoscopy and intubation

Decreases ICP responseDecreases ICP response

Mucosal anesthesiaMucosal anesthesia

Dosage: 1.0-1.5 mg/kg IV 2-5 minutes prior Dosage: 1.0-1.5 mg/kg IV 2-5 minutes prior to intubationto intubation


Sedation AgentsSedation Agents– Selection of agent(s)Selection of agent(s)

perfusion stateperfusion state

presence of head injurypresence of head injury

clinical diagnosisclinical diagnosis

Paramedic drug boxParamedic drug box


Paralytics Have No Sedative Quality

Selection of Sedative (cont.)Selection of Sedative (cont.)– BenzodiazepinesBenzodiazepines

Amnestic and at high dose, anestheticAmnestic and at high dose, anesthetic

Little cardiovascular depressionLittle cardiovascular depression– DiazepamDiazepam

Slow onset/longer lastingSlow onset/longer lasting

3-5 mg IV (adult)3-5 mg IV (adult)

0.2 to 0.4 mg/kg (kids) titrate0.2 to 0.4 mg/kg (kids) titrate


Benzodiazepines (cont.)Benzodiazepines (cont.)MidazolamMidazolam

– Rapid onsetRapid onset– Potent amnesticPotent amnestic– Moderate decrease in ICPModerate decrease in ICP– 1-3 mg IV (adult)1-3 mg IV (adult)– 0.1 mg.Kg titrated in kids0.1 mg.Kg titrated in kids


Selection of Sedative (cont.)Selection of Sedative (cont.)– NarcoticsNarcotics

Potent analgesics/sedativesPotent analgesics/sedatives

Rapid onset w/ brief durationRapid onset w/ brief duration

Effect can be reversed!Effect can be reversed!– MorphineMorphine

2-20 mg IV2-20 mg IV

May cause refractory May cause refractory bradycardia/hypotensionbradycardia/hypotension


Selection of Sedative (cont.)Selection of Sedative (cont.)– Butyrophenones:Butyrophenones:

Useful as anxiolyticsUseful as anxiolytics

May cause EPSMay cause EPS

Minimal cardiac effectMinimal cardiac effect– HaloperidolHaloperidol

Potentiates effect of narcoticsPotentiates effect of narcotics

EPS more commonEPS more common

2.5-5.0 mg IV/IM2.5-5.0 mg IV/IM



Selection of Sedative (cont.)Selection of Sedative (cont.)– EtomidateEtomidate

Non-barbiturate hypnoticNon-barbiturate hypnotic

Rapid onset of action, short durationRapid onset of action, short duration

Does not blunt sympathetic response to Does not blunt sympathetic response to intubationintubation

Dose:Dose:– 0.3 mg/kg IV0.3 mg/kg IV

20 mg maximum dose20 mg maximum dose

Not indicated for peds <10 yearsNot indicated for peds <10 years


ACh binds to post ACh binds to post synaptic receptors synaptic receptors causing depolarization causing depolarization … … Contraction of Contraction of musclemuscle

ACh removed by ACh removed by acetylcholinesterase acetylcholinesterase and by diffusion …. and by diffusion …. Relaxation of Relaxation of musclemuscle

Neuromuscular Junction

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Mechanism of action:Mechanism of action:– NondepolarizersNondepolarizers

CompetitiveCompetitive

Block ACh receptors … paralysisBlock ACh receptors … paralysis

– DepolarizersDepolarizersNoncompetitiveNoncompetitive

Persistent stimulation …fasciculationsPersistent stimulation …fasciculations

Unresponsiveness to ACh….ParalysisUnresponsiveness to ACh….Paralysis


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DepolarizingDepolarizing– SuccinylcholineSuccinylcholine

Vagal effectsVagal effects– Excessive bronchial secretionsExcessive bronchial secretions

Negative inotropic and chronotropic, esp. Negative inotropic and chronotropic, esp. with repeated dose and in childrenwith repeated dose and in children

Fasciculations (amelioration)Fasciculations (amelioration)

Malignant hyperthermia?Malignant hyperthermia?

Complete paralysis w/in 30-45 sec. Complete paralysis w/in 30-45 sec. Lasting 4-6 minLasting 4-6 min

– 1.5 mg/kg IV1.5 mg/kg IV


– Succinylcholine (cont.)Succinylcholine (cont.)Metabolized via CholinesteraseMetabolized via Cholinesterase

– 0.3% defective enzyme0.3% defective enzyme

ContraindicationsContraindications– Absolute - noneAbsolute - none– HyperkalemiaHyperkalemia

Renal failureRenal failure

Crush injury Crush injury

Burns Burns

MyotoniaMyotonia

ParaplegiaParaplegia


•Non-depolarizing

–Vecuronium•Minimal cardiovascular effect•Long duration of action (may exceed 90 mins)•Shorter onset than Pancuronium•0.1 mg/kg


RAPID SEQUENCE INTUBATIONINDICATIONS: Need for immediate intubation assumed with failed intubation attempt

PROCEDURE: Protect C-Spine prn O2 100% w/ BVM assist (hyperventilate pt. if possible)

Suction prn IV w/ balanced salt solution; EKG*** Cricothyroidotomy equipment available *** Lidocaine 1 mg/kg IV Atropine 05 mg IV adults w/ HR <80 (001 mg/kg IV All kids <12 )

Etomidate 03 mg/kg max 20 mg-5 mg IV Adults and peds >10 yr for sedation. Succinylcholine 15 mg/kg IV bolus*** Sellick until intubation successful and ETT cuff inflated ***

Perform intubation (once fasciculations stop)

If relaxation inadequate in 60-120 secs, repeat Succinylcholine 15 mg/kg IV reattempt intubation

Confirm placement by auscultation, capnography Secure ETT Ventilate w/ BVM & 100% O2

Maintain EtCO2 35-40 mm/Hg If further paralysis required: Vecuronium 01 mg/kg Versed 25-5 mg IV for sedation (peds 01mg/kg)

Airway ManagementAirway Management

Digital Digital Tactile Tactile IntubationIntubationEschmannEschmann

Lighted Lighted stylettestylette

FiberscopeFiberscope

BURPBURP

Intubation TricksIntubation Tricks

SURGICAL AIRWAYSSURGICAL AIRWAYS•Cricothyrotomy

–Indications (Identified need for intubation)•Maxillofacial trauma•Oropharyngeal obstruction

–Edema–FBAO–Mass Lesion–Cancer

•Unsuccessful oral/nasal tracheal•Difficult anatomy•Massive hemorrhage/regurgitation

SURGICAL AIRWAYSSURGICAL AIRWAYS•Cricothyrotomy (cont..)

–Contraindications:–Age <10-12–Laryngeal crush injury–Laryngeal tumor/stricture–Tracheal transsection–subglottic stenosis–Expanding hematoma–Coagulopathy–Unfamiliar w/ procedure

SURGICAL AIRWAYSSURGICAL AIRWAYS

Anatomy:Anatomy:– Thyroid cartilageThyroid cartilage– Cricoid ringCricoid ring– Cricoid cartilageCricoid cartilage– Thyroid glandThyroid gland– TracheaTrachea– Major vesselsMajor vessels


Netter; Atlas of Human Anatomy


Procedure:Procedure:– Identify thyroid cartilageIdentify thyroid cartilage

Cricothyroid membraneCricothyroid membrane

– Vertical incision through skinVertical incision through skinPrep priorPrep prior

Incise membraneIncise membrane

– Open incisionOpen incisionDilator/tracheal hookDilator/tracheal hook

– Insert ETT/Trach tubeInsert ETT/Trach tubeVentilate patientVentilate patient


Complications:Complications:– Incorrect placementIncorrect placement– Long execution timeLong execution time– HemorrhageHemorrhage– Passage sub QPassage sub Q– Plugging Plugging – PneumomediastinumPneumomediastinum– AspirationAspiration– etc.etc.

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Retrograde Tracheal Intubation Retrograde Tracheal Intubation (RTI):(RTI):– IndicationsIndications

Abnormal anatomyAbnormal anatomy– Pt. W/ epiglottitisPt. W/ epiglottitis– Severe kyphosisSevere kyphosis– Cervical spondylosisCervical spondylosis

TraumaTrauma

Reasonable alternative to Surg and Reasonable alternative to Surg and Needle CrikeNeedle Crike


RTI (cont...):RTI (cont...):– ContraindicationsContraindications

Trismus (w/o paralytic)Trismus (w/o paralytic)

CoagulopathyCoagulopathy

Enlarged thyroidEnlarged thyroid

– Procedure:Procedure:Supplemental OSupplemental O22

Catheter over needle into CTMCatheter over needle into CTM

Insert guidewire through catheterInsert guidewire through catheter

Visualize guidewire and pass tubeVisualize guidewire and pass tube

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SURGICAL AIRWAYSSURGICAL AIRWAYSNeedle CricothyrotomyNeedle Cricothyrotomy– IndicationsIndications

Same as for any surgical airwaySame as for any surgical airway

Considered safer and quicker than Considered safer and quicker than surgical crikesurgical crike

Will not compromise c-spine in trauma pt.Will not compromise c-spine in trauma pt.

– ContraindicationsContraindicationsTotal obstruction at or near the cords Total obstruction at or near the cords

– ComplicationsComplicationsMisdirectionMisdirection

Puncture tracheal wallPuncture tracheal wall

Local cord damageLocal cord damage

Does not prevent aspiration!Does not prevent aspiration!


Needle CricothyrotomyNeedle Cricothyrotomy– ProcedureProcedure

Supplemental OSupplemental O22

Catheter over needle into CTM (at least 14 Catheter over needle into CTM (at least 14 ga)ga)

Attach to high pressure OAttach to high pressure O22 source (50psi) source (50psi)

Ventilate using valve or “interrupter type Ventilate using valve or “interrupter type devicedevice

Advanced airway

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