AIRWAY MANAGEMENT

Dave Duncan MDMedical Director CALSTAR / CAL FIRE

2019

Airway Management

Introduction

Anatomy / Physiology

Positioning

Basics - Adjuncts

ALS - Intubation

Anatomy

Anatomy

Children are different than adults !!!

Pediatric Airways

Epiglottis:

• Relatively large size in

children

• Omega shaped

• Floppy – not much

cartilage

Anatomy: Adult vs Pediatric

Airway Anatomy -- Shape

Column

Cone

Physiology: Effect of Edema

Poiseuille’s law

pedi adult

When radius is halved ----

Resistance increases 16 fold

R =8 n l

r4

Anatomy

Positioning

Airway positioning for children <2yrs

Positioning: Airway Vectors

Airway Management: General Approach

Airway Management

We manage airways so we can manage breathing

• Utilize the least invasive method that solves the problem ----- LESS IS MORE

Positioning

NPA (over OPA)

BVM

SGA (LMA type devices)

ETT

Cricothyrotomy

Airway Management

We manage airways so we can manage breathing

Priorities:

1) Oxygenate2) Don’t Hyperventilate3) Ventilate

Manage Airways = Manage Breathing

Breathing should always be divided in two!

Oxygenation Ventilation

In with the new Out with the old

(Inhalation) (Exhalation)

• It’s not a ventilator --- it’s an oxygenator/ventilator

Priority 1) Oxygen Delivery

Priority 2) Not to hyperventilate

Priority 3) Adequate ventilation

2 Very Different Processes! O2 = Active CO2 = Passive

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”)

Breathing: Oxygenate – that’s what we do

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:

• A single sat <90 doubles mortality in severe TBI!

• Always utilize 100% O2 on TBI patients!

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! DON’T!

• 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

Broselow Tape

Broselow Tape …there’s an app for that

Pediatric Pedi Stat Palm Pedi

Resuscitation

Bag Valve Mask Ventilation: THE SKILL!

Pro’s

• Defininitive Backup!

• Non invasive

• Feel compliance

Give Slow Small Breaths: 6-8 cc/kg (smallest aprop. bag)

Rate: Adults: 12 Child: 20 Infant: 30

Con’s

• Difficult to master

• Difficult to maintain seal

Bag Valve Mask Ventilation: 2 Thumbs Down

Use the 2 thumbs down technique:

- provides the best seal (hard part)

- provides the best jaw thrust (hard part)

Bag Valve Mask Ventilation: 2 Thumbs Down

Anyone can bag the patient……….

Airway Adjuncts

• Nasal airway

• Oral airway

Basic Airway Adjuncts:

OPA NPA

Airway Management: Adjuncts (NPA)

Adjuncts: Oral Airway

Wrong size: Too Long

Adjuncts: Oral Airway

Wrong size: Too Short

Adjuncts: Oral Airway

Correct size

Airway Management Basics: BLS

• Positioning – head tilt/chin lift or jaw thrust

• Effective BVM - most important skill

– Get a good seal = two persons

– Don’t over ventilate

• Adjuncts

– OPA - fair choice if tolerated – (no gag)

– NPA – better tolerated – new better materials

• SUCTION!!!

• BROSELOW!!!

Adjunctive & Rescue Airways

• King LT (Periglottic Airways)

• Supraglottic Airways (SGAs = LMAs)

SGA’s (LMA’s)

• The SGA was invented 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

Preparation

• Step 1: Size selection

• Step 2: Examination of the LMA

• Step 3: Check the cuff

• Step 4: Lubrication of the LMA (not inner mask)

• 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

The Debate on Prehospital

Intubation Continues…

Prehospital Intubation

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 protect the airway

-or expected failure to protect the airway (GCS <8, etc)

• Expected Course Demands ETT

(prior to TOC)

Intubation - Preparation

• Preoxygenate – Hi Flow O2

– Monitors - ECG, pulse ox, ETCO2

– 2 person BVM

• Equipment selection

– Miller (< 4) vs. Mac

– Cuffed vs. uncuffed

– ETT size

• Positioning

• Suction!!!

Pre-oxygenation Prior to RSA (RSI)

• 3 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

• 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

• Drugs: Zofran, Rocuronium

• Pedi Bougie (4-6)

• Adult Bougie (6-8.5)

• Stylet

• ETT +/- one size (Parker flex tip ETT)

• Tube securing devices

• Magill forceps

• ETCO2

Endotracheal Tube Introducer

(gum elastic bougie)

Large study June 2018:

Effect of Use of a Bougie vs Endotracheal

Tube and Stylet on First Attempt

Intubation: A Randomized Clinical Trial.

757 patients:

1st pass success went from 82% to 96%

Endotracheal Tube Introducer

(gum elastic bougie)

• Bougie Replaces the

stylet

• Feel tracheal rings

• If it goes in all the way

= esophagus

• Fold it in ½ - in line with

coudet tip

• Don’t preload it

Tube Size

• ETT size

– (Age + 16) / 4

– Diameter of nare

– Diameter of pinky

– Broselow tape

– Have one size smaller and larger

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

• Stick with basics if working

Laryngoscope Blades

Macintosh

Miller

VL (videolaryngoscope)

Better in younger

children with a

floppy epiglottis

(<2-4)

Straight

Laryngoscope Blades

Laryngoscope Blades

Better in adults

and older

children (stiffer

epiglottis)

Curved

Laryngoscope Blades: VL

Better in anteriorly

positioned airways

Videolaryngoscopy

Be Careful with the Anterior Trachea in VL

Intubation -Confirmation

• Visualize tube passing through

cords (video?)

• Breath sounds and no

epigastric sounds

• End Tidal CO2 (ETCO2)

– Waveform better than

colorimetric (not reliable in CPR)

Masimo EMMA Device

(mainstream ETCO2)

Cricothyroid Membrane

QuickTrach® Cricothyrotomy

QuickTrach® Cricothyrotomy

Airway Management Challenges

Airway Management Challenges

Deterioration of Intubation: “DOPE”

• Displaced

• Obstructed

• PTX

• Equipment

In closing

• There is airway management…… ……and there is everything else

• Know your equipment and policies

• Manage – don’t “secure” or “control”

• Load and Go!!!

• A “missed” airway should never be unanticipated

• Have plan B before proceeding with plan A

• Practice! Practice! Practice!

REMINDER:

It’s Not Okay to Continue with

Failed Techniques

“HOPE” is not an airway strategy

Questions ??? daveduncanmd@gmail.com