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Topics 2013

The Difficult Airway� Anatomy

• Visualization• Difficult BVM / LMA ventilation

� Physiology• Unable to oxygenate• Unable to ventilate• Severe Acidosis• Hypotension

The Difficult Airway� Deciding which patient to intubate� Timing

• Stable – semi-elective• Crashing• Crashed

Drama BUT ‘REAL’

� May be the single most important topic in Emergency Medicine

Airway management

The area of EM with the greatest immediatebreadth of outcomes within minutes: life and death

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Sexy

HEROIC

Dramatic Life Saving

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� Forethought� Planning� Attention to detail� Knowledge

Plan Ahead� Equipment� Drugs� Positioning � Check lists…

An intervention to dec complications related to EI in the ICU…..Int Care Med 2010

Severe Mild to Moderate

Death Difficult tube

Cardiac Arrest Esophageal

Severe Hypoxemia Aspiration

Severe Cardiovascular Collapse Arrhythmia requiring RX

Dangerous agitation

� Presence of two operators� Fluid Loading� Pre-oxygenation� RSI drug prep� Sellick� Placement confirmation – capnography� Pressor support� Longer term sedation� Protective low volume vent

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Difficult / High Risk� Hypoxic� Hypotensive� Acidotic� Shock� Obstruction� Anatomic difficulty

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Oxygenation� Preoxygenation� Positioning� DSI� Apneic Oxygenation

Positioning� Head up 20 degrees /reverse

trendelenberg• Delay time to desat by about 100 seconds

� Jaw thrust

Apneic Oxygenation� Prolong time to desat:

• Normal BMI – by 2-3 minutes• BMI > 30 – by about 100 seconds

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Journal of Clinical Anesthesia 2010

Preoxygenation Strategies� NIV

• USE NIV mask or BVM• 5cm of PEEP / 100% O2 / High flow• Sat >95% for >3 min• Leave Mask in place while pushing drugs• Leave NC on at all times

strategies� Ventilator to drive the BVM

• Oral airway• Standard BVM vent• Ventilator on AC at 550ml• Flow at 30 L /min• 12 vent / min + 5-15 PEEP• Attach the vent to the mask

strategies� Ventilator Vs. Bagging� Peep� Atelectasis� Saturation

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Delayed Sequence Intubation

• Ketamine 1mg/kg slow push (glycopyrrolate)• NIV / non-rebreather / LMA…….• Sat >95% for >3 min• Paralytic – leave mask while inducing• Leave nasal cannula and intubate

Hydration before induction� Most critically ill are dry� Loss of sympathetic support� Loss of muscle tone� Peep / Pos Pressure vent� Drugs

� Hydration� Phenylephrine

PLAN AHEAD� What drugs do you have available

� What tools do you have

� What are you experienced and comfortable to perform

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Can you bag – valve –mask ventilate this patient?Will you be able to see cords?Oral endotracheal intubation fails – what next? This pt develops stridor and sat’s begin to fall??

This asthmatic becomes agitated –her PH is 6.8 PCO2 = 110

Difficult AirwayManagement Steps (7)

1. Always assume the intubation will be difficult! **

2. Familiarize yourself: **Where are your airway tools locatedWhat devices are at your disposal

3. Have backup plans A B & Cdeveloped before the scairway arrives **

** MAJOR TAKE HOME POINTS

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Airway Plans A B & COptimize Oral Endotracheal Intubation

conditions

LMA – Combitube – Stylet guided Intubation

Surgical: Needle, Seldinger, or Traditional

A

B

C

More Steps4. Consider the urgency of the case

Airway control is needed:NOW!!Within minutesSemi – elective

5.Can the patient be bag-valve-mask ventilated?

More Steps

4. Consider the urgency of the case5. Can the patient be bag-valve-mask ventilated?

6. Assess airway anatomy7. How great is the risk of aspiration?

1ST ATTEMPT HAS FAILED

� Start with back up plan A

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Preparing for the second attempt� Positioning can make a huge difference

• Raise the bed • Top of patients head at very end of gurney• Flex neck 30o - extend head / ramp up

� Change blades – or use the Mac like a Miller� BURP maneuver

• Back – UP - Right - Pressure

Things to Do in Every Airway

Alternative Airway Approaches / Devices� Nasal intubation� Fiberoptic intubation� Gum elastic bougie� Lighted Stylet� Laryngeal Mask Airway (LMA)� Combitube / King

Alternative Airway Approaches / Devices� Tactile digital intubation� Retrograde intubation� Percutaneous transtracheal intubation� Cricothyrotomy – traditional� Cricothyrotomy – needle guided� Video laryngoscopes

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Personal recommendations

Bougie

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Bougie 60 cm long – 15 French

� Use a laryngoscope� Advance with the concavity facing anterior� As the tip of the bougie enters the glottic opening

feel for ‘clicks’ as it passes over the tracheal rings� Rotate the ETT counter-clockwise

Percutaneous Transtracheal Ventilation (PTV)�Ventilation via a catheter placed through

the cricoid membrane• High frequency jet ventilation (small volumes

of oxygen at rates of 100-200/min)• High pressure standard ventilation (large

volumes at 50psi at a rate of 12-20.min)• Traditional bag valve ventilation (intermediate

volumes, low pressure std rate)

Percutaneous Transtracheal Ventilation� Indications:

• Rescue airway – especially in children

� Contraindications:• *Complete airway obstruction• Unable to identify landmarks

� Complications:• Barotrauma• Esophageal perforation• Hypercapnea

Percutaneous Transtracheal Ventilation

Google search Manual Jet Ventilator

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Percutaneous Transtracheal Ventilation

(The MacGuyver Approach)Ketamine

Ketamine� Can be used IM� Doesn’t require refrigeration� Wide safety index� No apnea� Rapid onset

Dexmedetomidine� Alpha 2 agonist� Dissociative state� Preserves airway reflexes� Hypotension, bradycardia, nausea

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Midazolam� No refrigeration� IM� Reversible� Rapid onset

Vomiting blood� 45 yr old male with hematemesis� + past hx of ETOH and GI bleed

� 92/64 134 26 94%� Actively vomiting blood� Awake but confused

Hematemesis� What are the immediate issues / questions

that need to be answered?

Can the pt be bag mask ventilated?

Is aspiration a real threat?

How difficult is traditional oral trachealintubation likely to be?

How much time do we have?

Hematemesis� BVM vent likely to be very difficult� A secure airway is needed NOW!!!� Aspiration is a major threat� Too crashed for nasal (+probable

coagulopathy)� +- one attempt at traditional oral

intubation ….

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Hematemesis� I recommend trying to pass a bougie if

you can see some anatomy but have the ILMA and a needle cric kit ready

� KETAMINE!

Needle Cricothyrotomy

I suggest using a # 10 blade to produce a larger skin ‘nick’

Needle Cricothyrotomy Needle Cricothyrotomy

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Airway Pearls� DSI and NIV as a preoxygenation tool

-Apneic Oxygenation should be standard

-The BVM – bag – holds about 2 L of air – one only needs to administer about 1/4 of the bag to ventilate

-Ketamine is invaluable

Summary� Expect the worst and be prepared� Consider the urgency� Don’t forget BVM ventilation� Balance the needs for ventilation & oxygenation vs.

the risk of aspiration� Become familiar with

• LMA or Combitube• Lightwand or Bougie• Traditional or Seldinger cric• PTV