Amy Gutman MDprehospitalmd@gmail.com

Anatomy & Physiology

Ventilation & Oxygenation

Decision-Making Algorithms

Pediatric Airways

You are called to the scene of a morbidly obese male with complaint of “short of breath”. He is in obvious respiratory distress, then becomes apneic

You make one attempt to endotracheally intubate, but have significant difficulty due to his body habitus, large tongue, & short neck

The patient rapidly decompensates; attempts made to BVM ventilate & oxygenate are failing

What is your next step?

A: Tongue Edema Post Lye Injury B: Neck Injury With Epiglottis Swelling

Respiration involves entire gas exchange circuit

Inhaled O2

O2 & Co2 exchange at alveolar-capillary membrane

Capillary bed perfusion

CO2 exhaled

Subjective Respiration quality Pulse quality Mentation

Objective Respiration & Pulse rate BP O2 Sat ETCO2 GCS

The act of placing oxygen on a patient does not necessarily improve ventilation or respiration

Delivery Liters O2%

Nasal Cannula

1-6 24-40%

Simple Mask 8-10 40-60%

NRB 10 60%

Venturi 4-10 24-50%

BVM 12 + Reservoir >90%

General Concepts

“Basic” Advanced Airways

“Advanced” Advanced Airways

Biluminal Airways

Every airway is a difficult airway until that patient has a confirmed tracheal tube

Just because you have never missed an airway, do not assume that you never will

Limit problems by anticipating that everything is just a minute away from becoming a SNAFU

Weigh benefits vs risks of intubation

Rapid transport with efficient BVM often the better airway management technique

Properly position

Facilitate O2 deliveryOP/ NP airwaysCPAPBreathing treatments

if neededCalm patient down

Drive faster (& safer)

Maintaining & Protecting Airway?

Ventilating?Oxygenating?

Likely deterioration?

Reposition, O2

DextroseNarcan

BVMAdvanced Airway

Rapid TransportBVM

CPAPAdvanced Airway

No

NoYes

Yes

Unsuccessful

Successful

O2Transport

“Master BVM. There are few airway emergencies in the prehospital setting not managed adequately with proper bag & mask ventilation until the patient can be transported to the hospital”

~Ron Walls MD

4$ smartp

hone

app

Maintain airway: Jaw-thrust, head-tilt, chin-

lift OPA, NPA

Ventilation Assistance Synchronous & rhythmic

Maintain seal & low airway pressures

Don’t forget O2!

Hypercapnia Too fastHypotension secondary

to increased intrathoracic pressures

Hypocapnia Too slowBrain injury due to

cerebral vascular constriction

Can’t Intubate, Can Ventilate2 unsuccessful intubation attemptsBVM maintains O2 sat > 90%

Can’t Intubate, Can’t Ventilate2 unsuccessful intubation attemptsCannot maintain O2 sat > 90% with BVM

Post Airway Management

Alternatives:Biluminal

LMACombitube

Lighted StyletteUnsuccessful Successful

Successful

CricothyrotomyOr

Retrograde

ETI / NTI

A: “Alternate”Tube BladeApproach

B: “Blind, BVM, Bougie”Blind BVM Bougie-assisted

C: “Cric”Surgical Airways

AnatomyObesityShort/ muscular neckProtruding incisorsArched / high palate with long/ narrow

oropharynxEdematous mouth/ neck/ chest

Other Neck trauma Cannot jaw opening (i.e. c-collar) Cannot move neck (i.e. trauma)

3 Finger Mouth Opening 3 Finger Chin to Hyoid 2 Finger Mouth to Thyroid

LL Look ExternallyEE Evaluate 3-3-2 RuleMM Mallanpati ScoreOO Obstruction PresentNN Neck Mobility

Edentulous

Obesity

Facial Hair

Protruding/ buck teeth

Protruding tongue

Facial/ neck trauma

MMallampati Scoringallampati ScoringMM

Soft palate, uvula,

anterior & posterior

pillars

Soft palate, uvula

Soft palate, base of uvula

Soft palate not visible

Class 1 Class 2 Class 3 Class 4

Neck trauma Laryngeal crush injuries

Foreign body obstruction Food Tumor

Edema Burns Anaphylaxis

Cannot manipulate in trauma patients

Ability to flex, extend or manipulate head/ neck of non-trauma patient can increase likelihood of visualizing cords

Preoxygenate, BVM, Full O2 tank 2 large bore IV / IO & IVF Monitor 2 sizes ETT, checked cuffs,

back-up Blade, checked light, back-up Alternative airway checked Handle, checked batteries,

back-up Stylette, back-up Suction McGills ETCO2 detector, back-up Syringe x 2 Manpower & tape

You GUARANTEE Failure If You Do Not Prepare!

EndotrachealDigitalBougieNasotrachealLMASupraglotticAwakeFiberoptic Videoscope Surgical

Neutral to head-tilt / chin-lift (no trauma)

Scissor open mouth with right hand

Remove dentures or foreign bodies

Grasp laryngoscope in left hand

If using a Miller, pass to right of the tongue, advance into hypopharynx, pushing tongue to the left

Lift laryngoscope up & forward to expose vocal cords

Endotracheal Endotracheal IntubationIntubation

If using a Macintosh: advance blade into hypopharynx, lift epiglottis with blade tip expose vocal cords

The blade tip fits below epiglottis (not visible with blade in position)

Pass tube through cords into trachea so balloon just passes cords

Pressing posteriorly on anterior neck at larynx level helps bring an anterior larynx into view BURP: Backwards, Upwards, to

the Right, with Pressure

Withdraw stylette

Ventilate with 100% O2

Confirm tube positionListen over stomach & BL chestFog in tubeNo epigastric soundsETCO2 (waveform after capnogram)Note position of tube at teethInflate the cuff with 10cc syringe

Tape, tape, tape!

Unconscious, No gag, Unconventional

Lift tongue, pull mandible forward

Slide middle & index fingers down tongue

Palpate epiglottis with middle finger

Slide ETT between tongue & finger under epiglottis into trachea

Anterior, difficult cord visualization

Angled tip “clicks” when passing through glottal opening onto trachea rings allowing ETT to be passed over it into the trachea

Thread ETT over bougie and advance it to a depth of 20-24 cm

Confirm ETT placement

Anticipated difficult airway, difficult BVM

Patient must be semi-alert / conscious

Contraindicated in uncooperative patients, coagulopathic, or head trauma

High secondary infection rate, often significant bleeding

Generous lubrication

Insert along floor of nasal cavity into hypopharynx

As patient exhales, gently & rapidly advance tube into trachea

Confirm placement

Variable sizes of traditional & intubating LMAs

Seals around glottic inlet

Downsides: NOT a definitive airwayHigh risk of aspirationBest for the OR

UpsidesAdult & pediatric sizesFairly simple to place

Hyper oxygenateCheck cuff Lubricate posterior cuffHead neutral or slightly

flexedInsert following hard palate

(use index finger to guide)Stop when met with

resistanceInflate cuff until “rises” &

secureConfirm & secure

Difficult or failed intubation, full stomach, neck trauma

PPE (patients cough in your face)

Open airway with laryngoscope

Wait for patient to cough or exhale – observe for bubbles or “white flash” indicating cords

Insert ETT & confirm

Unconscious, difficult airway, failed airway, primary

Blind insertion with neck in neutral position

Contraindicated if gag reflex, esophageal disease, ingested caustic substances

Anatomically shaped distal tip assists passage behind larynx into normally collapsed esophagus

Allows PPV >30cm H2O ventilation regardless of placement in esophagus or trachea

Choose size & test cuff

Apply lubricant to beveled distal tip

Hold King with right hand; open mouth & lift chin with left hand

Rotate King so blue line touches corner of mouth; insert tip into mouth

As tip passes tongue, rotate tube back to midline so that blue line faces chin

Advance tube until base of connector aligned with gums

Inflate cuff & confirm placement

More an ED / OR than EMS skill

Orally or nasally

Apply 2% lidocaine to oropharynx

Use oral airway to protect equipment

Introduce lubricated ETT in midline following base of tongue, pass uvula, behind epiglottis & between vocal cords until carina visualized

Advance until cords in center of visual field: Rotate, flex, advance, rotate, flex, advance until ETT tip 3-5 cm above carina

Remove scope, confirm airway

Alternative to direct laryngoscopy

Restricted oropharyngeal views

Airway obstructions

Nasotracheal intubation adjunct

Tube exchange

Educational

Open patient’s mouth & insert glidescope exactly as you would a laryngoscope

Watch video screen, not patient

When cords visualized, slide lubricated ETT alongside glidescope until visualized on screen passing cords

Remove handle, inflate cuff, confirm placement

Seldinger Technique Wire through a

needle

Downsides: Difficult to perform Difficult to master Long procedure

Not really an EMS skill

Locate cricothyroid membrane

Insert 16g needle in membrane midline at a 45 degree angle towards feet

After “pop” through membrane, advance needle 1 cm

Aspirate needle + catheter

Secure catheter & ventilate via BVM, or continue to surgical cricothyrotomy

Does not provide adequate ability to ventilate in the adult

Place patient supine with neck slightly extended In-line stabilization if

cervical trauma suspected

Locate cricothyroid membrane midline between thyroid cartilage (Adam’s apple) & cricoid cartilage

Prep overlying skin

Puncture cricothyroid membrane at 90° angle

Confirm needle entry into trachea by aspirating air

Change hand angle to 60°; slide catheter sheath forward to stopper hub level

Advance plastic cannula as you remove needle & syringe If cuffed, inflate with 2-3cc

Begin ventilation when needle & syringe removed

• Cut 1.5-cm longitudinal midline incision over cricoid & thyroid cartilages

• Separate skin edges to see cricothyroid membrane

• Make a transverse stab incision through membrane into trachea

• Push scalpel handle into membrane opening & rotate 90 degrees

• Use scissors to extend tracheal incision, tracheal hook to grab tracheal rings, & grasp skin edges with hemostats

• Introduce 5.0-6.0 ETT into trachea with bevel pointed caudally to 1cm above endotracheal balloon, which is then inflated

• Secure ETT

Ventilate patient, observing for chest rise & fall

Auscultate for BL breath soundsIf absent, ETT may be in

neck subcutaneous fascia or esophagus

Remove & attempt to re-insert

Secure device

Continuous evaluation & documentation of oxygen saturation, ETCO2, vitals

Notify ED of Priority 1 patient

• Direct Visualization

• Lung Sounds

• Tube Condensation

• Colormetric capnography followed by continuous waveform ETCO2 capnography

• Pulse Ox improvement

• Vital signs stabilization

• Serial examinations / re-assessments

Preoxygenate, BVM, Full O2 tank

2 large bore IV / IO & IVF Monitor 2 sizes ETT, checked cuffs,

back-up Blade, checked light, back-up Alternative airway checked Handle, checked batteries,

back-up Stylette, back-up Suction McGills ETCO2 detector, back-up

Syringe x 2 Manpower & tape

Relatively large head & tongue

Anterior pharynx

Cricoid cartilage narrowest part of airway

Long, floppy, omega-shaped epiglottic

Easily compressed tracheal rings

Compliant chest wall Retractions

Airway collapses at lower lung volumes Laryngomalacia, stridor

High O2 Consumption 6-10 cc O2/Kg/Minute Less reserve = quick deterioration

PMH Prematurity Hospitalizations/ Illnesses Previous intubations

When did child become ill? Choking/ coughing? How fast is child

deteriorating? Fever?

Allergies/ Medications?

What’s been done so far?

Comfortable vs distressed

Rate Too fast vs too slow

Noisy? Wheeze, stridor, silent?

Position Supine, sitting, tripod

Color Unreliable; pink, grey, cyanotic, ashen

Symmetric

Adult: 12 – 20 breaths/ minute

Child: 18 – 30 breaths/ minute

Infant: 30 – 60 breaths/ minute

WheezeLower airway

obstructionUsually expiratory

StridorUpper airway

obstructionUsually inspiratory

H. influenzae bacteria usually found in unimmunized or immunocompromised children (now in adults as well)

Rare but life-threatening

High fever, “toxic” child, sudden onset

Tripodding, drooling

Stridor

Do not look in airway!!!!!

Blow-by O2, & drive fast

Anticipated difficult airway or epiglottitis

Your own inexperience

Improper equipment

Short transport time with easy BVM

Newborn: 3.5 mm

4 - 12 Months: 4.0 mm

Older Child: 4 + Age in Years/ 4

Why & what intervention was necessary i.e. respiratory distress

Condition before & during treatmentVital signs including O2 satDocument CO2 level prior to application,

and during treatment – print out the summary

Pre-Intubation Vitals Respiratory effort + sat, HR, BP, GCS

Rationale for advanced airway

Laryngoscopy: Tube size Placement at lips Passed through cords No epigastric sounds + BL breath sounds + ETCO2 w/ waveform

Q 5 minute vitals + tube rechecks

Maine Department of EMS. “Advanced Airway Training”. 2010

S Hopkins RN. “Equipment Review”. Condell Medical Center EMS System. 2008

Proulx A, MPAS, PA-C. “Airway Management in the Combat Casualty”. 2011

Emergency Medicine: A Comprehensive Study Guide, Tintinalli, 6th ed, Mcgraw-Hill, 2004

www.myrusch.com Ron Walls “Textbook Emergency

Airway Management” (2011) Difficult Airway Site

(www.theairwaysite.com) Brady & Caroline Paramedic Texts NAEMSP position papers on RSI,

Prehospital intubation

Know your anatomy

Know your options

Practice those options

Good BLS often better than ALS with difficult patients

Know when to say when!

1 month later!

2nd & 3rd degree burns to face, OP, ear, scalp, nares, melted dental plate