Airway Control and Ventilation - ACLS 2006 With Pics N0V09

8/8/2019 Airway Control and Ventilation - ACLS 2006 With Pics N0V09

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Airway Control and

Ventilation

HONESTA DE GALAHONESTA DE GALA--VILLALUNA, MD,VILLALUNA, MD,

FPCCPFPCCP


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Ventilation

The purpose of ventilation during CPR isto maintain adequate oxygenation and

sufficient elimination of CO2 During the first few minutes of ventricular

fibrillation sudden cardiac death (VFSCA), rescue breaths are probably not as

important as chest compressions O2 delivery to the tissues appears to be

more dependent on blood flow than onarterial O2 content


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Ventilation

Beyond the first few minutes of cardiacarrest, tissue hypoxia develops

CPR provides approximately 25% to 33%of normal cardiac output

This low-flow state maintains a small butcritical amount of blood flow to the heartand brain, but tissue hypoxia will persistuntil restoration of effective spontaneousperfusion


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Bag-Mask Ventilation

Effective bagEffective bag--maskmask

ventilation requires adequateventilation requires adequate

training & frequent practicetraining & frequent practice

Tidal volume deliveredTidal volume delivered

should be sufficient toshould be sufficient to

produce chest rise over 1produce chest rise over 1

second (6second (6--7mL/kg or 5007mL/kg or 500--600mL)600mL)

During CPR, give 2 breathsDuring CPR, give 2 breaths

during a brief pause afterduring a brief pause after

every 30 chest compressionsevery 30 chest compressions


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When an advanced airway has replacedWhen an advanced airway has replaced

the face mask,the face mask, 88--10breaths per minute10breaths per minute

should be delivered during CPRshould be delivered during CPR

Deliver each breath over 1 second whileDeliver each breath over 1 second while

chest compressions are delivered at achest compressions are delivered at arate ofrate of100per minute100per minute


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In patients with severe obstructive pulmonaryIn patients with severe obstructive pulmonary

disease & increased resistance to exhalation,disease & increased resistance to exhalation,

air trapping should be prevented to minimizeair trapping should be prevented to minimizegeneration of autogeneration of auto--PEEPPEEP

AutoAuto--PEEP may reduce cardiac output & bloodPEEP may reduce cardiac output & blood

pressurepressure

UseUse low respiratory rateslow respiratory rates, allowing more time, allowing more timefor complete exhalationfor complete exhalation


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Severe Airway Obstruction


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Dynamic Hyperinflation

Initial breathing cycle

End Expiratory Volume


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Initial breathing cycle Next breathing cycle

End Expiratory Volume

Dynamic Hyperinflation


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Airway Adjuncts

Oropharyngeal AirwaysOropharyngeal Airways

Nasopharyngeal AirwaysNasopharyngeal Airways


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Airway Adjuncts

Oropharyngeal AirwaysOropharyngeal Airways

Reserved for use in unconsciousReserved for use in unconscious

(unresponsive) patients with no(unresponsive) patients with nocough or gag reflexcough or gag reflex

Should be inserted ONLY byShould be inserted ONLY by

people trained in their usepeople trained in their use

Incorrect insertion can displaceIncorrect insertion can displace

the tongue into the hypopharynx,the tongue into the hypopharynx,

causing obstructioncausing obstruction


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Oropharyngeal Airway:

Steps in Insertion


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Airway Adjuncts Nasopharyngeal AirwaysNasopharyngeal Airways

Useful in conditions such asUseful in conditions such aspersons with clenched jaw,persons with clenched jaw,which prevent placement of anwhich prevent placement of an

oral airwayoral airway Should be used with caution inShould be used with caution in

patients with severepatients with severecraniofacial injurycraniofacial injury

Better tolerated than oralBetter tolerated than oralairways not deeplyairways not deeplyunconsciousunconscious

No studies onNo studies on the use inthe use in

cardiac arrest patientscardiac arrest patients


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Advanced Airways

Rescuers must be aware of the risks &Rescuers must be aware of the risks &

benefits of insertion of an advancedbenefits of insertion of an advanced

airway during a resuscitation attemptairway during a resuscitation attempt

Rescuers mayRescuers may defer insertiondefer insertion of anof an

advanced airway until the patient fails toadvanced airway until the patient fails to

respond to initial CPR & defibrillation orrespond to initial CPR & defibrillation ordemonstrates return of spontaneousdemonstrates return of spontaneous

circulationcirculation


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Advanced Airways

Providers must have aProviders must have a second (backup)second (backup)

strategystrategy for airway management &for airway management &

ventilation if unable to establish the firstventilation if unable to establish the first--choice airway adjunctchoice airway adjunct

BagBag--mask ventilation is a backupmask ventilation is a backupstrategystrategy


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Advanced Airways

Once an advanced airway is in place, 2Once an advanced airway is in place, 2rescuers no longer deliver cycles of CPRrescuers no longer deliver cycles of CPR

(old method)(old method) New methodNew method

The compressing rescuer should giveThe compressing rescuer should givecontinuous chest compressions at a ratecontinuous chest compressions at a rate

of 100 per minute,of 100 per minute, WITHOUT PAUSESWITHOUT PAUSESFOR VENTILATIONFOR VENTILATION

The rescuer delivering ventilationThe rescuer delivering ventilationprovides 8 to 10 breaths per minuteprovides 8 to 10 breaths per minute


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Advanced Airways

The 2 rescuers should changeThe 2 rescuers should change

compressor & ventilator rolescompressor & ventilator roles

approximatelyapproximately every 2 minutesevery 2 minutes to preventto preventfatigue and deterioration and quality offatigue and deterioration and quality of

chest compressionschest compressions

For multiple rescuers, they should rotateFor multiple rescuers, they should rotatethe compressor role everythe compressor role every 2 minutes2 minutes


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Esophageal-Tracheal

Combitube The advantage ofThe advantage of

Combitube overCombitube over

endotracheal (ET) tube isendotracheal (ET) tube isrelated to ease of trainingrelated to ease of training

Advantages over bagAdvantages over bag--

mask ventilationmask ventilation Isolation of the airwayIsolation of the airway

Reduced risk of aspirationReduced risk of aspiration

More reliable ventilationMore reliable ventilation


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Esophageal-Tracheal

Combitube ComplicationsComplications

EsophagealEsophageal

traumatrauma

LacerationsLacerations

BruisingBruising

SubcutaneousSubcutaneousemphysemaemphysema


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Laryngeal Mask Airway (LMA)

Advantages over ET tube:Advantages over ET tube: Limited access to patientLimited access to patient

Unstable neck injuryUnstable neck injury

Appropriate positioning of patient notAppropriate positioning of patient notpossiblepossible

After successful insertion, a smallAfter successful insertion, a small

proportion of patients cannot beproportion of patients cannot beventilated with LMAventilated with LMA

An alternative strategy is importantAn alternative strategy is important


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Endotracheal Tube

Providers who perform ETProviders who perform ET

intubation require adequate initialintubation require adequate initial

training and either frequenttraining and either frequent

experience or frequent retrainingexperience or frequent retraining

Complications:Complications:

Trauma to the oropharynxTrauma to the oropharynx

Prolonged interruption ofProlonged interruption ofcompressions and ventilationcompressions and ventilation

HypoxemiaHypoxemia


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Endotracheal Tube

During CPR, the rescuersDuring CPR, the rescuers minimize theminimize the

number and duration of interruptions innumber and duration of interruptions in

chest compressionschest compressions, with a goal to limit, with a goal to limitinterruptions to no more that 10 secondsinterruptions to no more that 10 seconds

The compressions should be interruptedThe compressions should be interrupted

only as long as the intubating rescueronly as long as the intubating rescuerneeds to visualize the vocal cords &needs to visualize the vocal cords &

insert the tubeinsert the tube


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Endotracheal Tube

Thorough assessment of endotrachealThorough assessment of endotracheal

tube position should not requiretube position should not require

interruption of chest compressionsinterruption of chest compressions Visualization of bilateral chest expansionVisualization of bilateral chest expansion

Auscultation of the lung fields & epigastriumAuscultation of the lung fields & epigastrium

Confirmation of placementConfirmation of placement End tidal CO2End tidal CO2

Esophageal detection deviceEsophageal detection device


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Exhaled CO2 Detectors

One of several independent methodsOne of several independent methodsfor confirmation of tube placementfor confirmation of tube placement

When exhaled CO2 is detectedWhen exhaled CO2 is detected

(positive reading for CO2) in cardiac(positive reading for CO2) in cardiacarrest, it is usually a reliable indicatorarrest, it is usually a reliable indicatorfor tube positionfor tube position

FalseFalse--negative readings during CPR isnegative readings during CPR is

due to the blood flow & delivery of CO2due to the blood flow & delivery of CO2to the lungs is lowto the lungs is low

FalseFalse--negative readings may also benegative readings may also bedue to pulmonary embolusdue to pulmonary embolus


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Esophageal Detector

Device (EDD) Positive result for EDDPositive result for EDD thethe

tube is in the esophagustube is in the esophagus

Highly sensitive for detection ofHighly sensitive for detection ofET tubes that were misplaced inET tubes that were misplaced in

the esophagusthe esophagus

Considered as just one ofConsidered as just one ofseveral independent methodsseveral independent methods

for confirmationfor confirmation


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Esophageal DetectorDevice

(EDD) EDD may yield misleading results in theEDD may yield misleading results in the

ff:ff:

Morbid obesityMorbid obesity

Late pregnancyLate pregnancy

Status asthmaticusStatus asthmaticus

Presence of copious ET secretionsPresence of copious ET secretions


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Post-intubation Care

Caveats for rescuers:Caveats for rescuers:

Be sure the advanced airway isBe sure the advanced airway is

correctly placed (verify)correctly placed (verify) The compressing rescuer shouldThe compressing rescuer should

give continuous chest compressionsgive continuous chest compressionsat a rate of 100 per minute withoutat a rate of 100 per minute withoutpauses for ventilation. The rescuerpauses for ventilation. The rescuerdelivering ventilation provides 8delivering ventilation provides 8--1010breaths per minutebreaths per minute

Rescuers should avoid delivering anRescuers should avoid delivering anexcessive ventilation rateexcessive ventilation rate


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Airway Control and Ventilation - ACLS 2006 With Pics N0V09

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Transcript of Airway Control and Ventilation - ACLS 2006 With Pics N0V09