Transcript SECTION 2

39: Advanced Airway Management
Cognitive Objectives (1 of 5)
8-1.1 Identify and describe the airway anatomy in the
infant, child, and the adult.
8-1.3 Explain the pathophysiology of airway
compromise.
8-1.4 Describe the proper use of airway adjuncts.
8-1.5 Review the use of oxygen therapy in airway
management.
Cognitive Objectives (2 of 5)
8-1.6 Describe the indications, contraindications, and
techniques for insertion of nasal gastric tubes.
8-1.7 Describe how to perform the Sellick maneuver
(cricoid pressure).
8-1.8 Describe the indications for advanced airway
management.
Cognitive Objectives (3 of 5)
8-1.9
List the equipment required for orotracheal
intubation.
8-1.10 Describe the proper use of the curved blade
for orotracheal intubation.
8-1.11 Describe the proper use of the straight blade
for orotracheal intubation.
8-1.12 State the reasons for and proper use of the
stylet for orotracheal intubation.
Cognitive Objectives (4 of 5)
8-1.13 Describe the methods of choosing the
appropriate size endotracheal tube in an adult
patient.
8-1.14 State the formula for sizing an infant or child
endotracheal tube.
8-1.15 List complications associated with advanced
airway management.
8-1.17 Describe the skill of orotracheal intubation in
the adult patient.
Cognitive Objectives (5 of 5)
8-1.18 Describe the skill of orotracheal intubation in
the infant and child patient.
8-1.19 Describe the skill of confirming endotracheal
tube placement in the adult, infant, and child
patient.
8-1.20 State the consequences of and the need to
recognize unintentional esophageal
intubation.
8-1.21 Describe the skill of securing the endotracheal
tube in the adult, infant, and child patient.
Affective Objectives (1 of 2)
8-1.22 Recognize and respect the feelings of the
patient and family during advanced airway
procedures.
8-1.23 Explain the value of performing advanced
airway procedures.
8-1.24 Defend the need for the EMT-B to perform
advanced airway procedures.
8-1.25 Explain the rationale for the use of a stylet.
Affective Objectives (2 of 2)
8-1.26 Explain the rationale for having a suction
unit immediately available during
intubation attempts.
8-1.27 Explain the rationale for confirming breath
sounds.
8-1.28 Explain the rationale for securing the
endotracheal tube.
Psychomotor Objectives
8-1.29 Demonstrate how to perform the Sellick
maneuver.
8-1.30 Demonstrate the skill of orotracheal intubation in
the adult patient.
8-1.31 Demonstrate the skill of orotracheal intubation in
the infant and child patient.
8-1.32 Demonstrate the skill of confirming endotracheal
tube placement in the adult patient.
8-1.33 Demonstrate the skill of confirming endotracheal
tube placement in the infant and child patient.
8-1.34 Demonstrate the skill of securing the
endotracheal tube in the adult patient.
Anatomy and Physiology
of the Airway
Basic Airway Management
• Airway is always assessed first.
• Advanced techniques are used after basic
management.
• The first step is opening the patient’s airway.
• Once the airway has been cleared, determine the
need for an airway adjunct.
Gastric Tubes
•
•
•
•
Provide channel into patient’s stomach
Nasogastric tubes: Inserted through the nose
Orogastric tubes: Inserted through the mouth
Nasogastric tubes: Contraindicated in a patient with
major facial, head, or spinal trauma
Equipment
• Proper-sized tubes
• Catheter-tipped 60-mL
syringe
• Water-soluble lubricant
• Emesis container
• Tape
• Stethoscope
• Suctioning unit and
catheters
Gastric Tube Insertion
•
•
•
•
•
•
Measure the tube.
Lubricate the distal end of the tube.
Place the patient in proper position.
Pass the tube until you reach the tape marker.
Confirm proper tube placement.
Aspirate air and stomach contents with the
syringe.
• Secure the tube in place with tape.
Sellick Maneuver
• Visualize the cricoid
cartilage.
• Palpate to confirm its
location.
• Apply firm pressure on the
cricoid ring.
• Maintain pressure until
intubated.
Endotracheal Intubation
• Insertion of a tube into the trachea in order to
maintain the airway
• Orotracheal intubation: Through the mouth
• Nasotracheal intubation: Through the nose
• EMT-Bs only intubate patients who are:
– Unresponsive with no gag reflex
– In cardiac arrest
Equipment (1 of 2)
• BSI equipment
• Proper-equipment endotracheal tube
(ET tube)
• Laryngoscope handle and blade
(visualized technique)
• Stylet or light stylet
• 10-mL syringe
• Oxygen, with BVM device
Equipment (2 of 2)
• A suctioning unit with rigid and soft-tip catheters
• Magill forceps
• Towels for raising the patient’s head and/or
shoulders
• A stethoscope
• Water-soluble lubricant for tubes and scopes
• A commercial securing device or tape
Laryngoscope
• Sweeps the tongue out of the way and aligns the
airway
• Has a light powered by batteries in handle
• Has blades that connect to handle
– Blades are curved or straight.
– They range in size from 0 to 4.
Curved Blade
Straight Blade
Endotracheal Tubes
• Tubes come in many sizes, from adult to
infant.
• Normal tube-to-teeth mark is usually around
22 cm.
• Diameter for normal adult male ranges from
7.5 to 8.5 mm.
• Diameter for normal adult female ranges from
6.5 to 8.0 mm.
• Use tape or chart for pediatric sizes.
Stylet
• Plastic-coated wire may be inserted in the ET
tube to add rigidity and shape to the tube.
• Bend the tip of the stylet to form a gentle curve
in adults.
• Bend the tip of the stylet to form a hockey stick
shape for an infant and child.
• Confirm that the stylet is not sticking out past
the end of the ET tube.
Syringe
• Use the 10-mL syringe to
test for air leaks in the
ET tube before
intubation.
• After the ET tube has
been properly inserted,
inflate the cuff with 5 to
10 mL of air.
• Remove the syringe from
the pilot balloon to
prevent air from leaking.
Other Equipment
•
•
•
•
•
Oxygen
A suctioning unit
A BVM device
Magill forceps
Towels for raising the patient’s head or
shoulders
• Secondary confirmation device
• C-collar backboard
The Intubation Procedure
• First EMT-B applies AED.
• Second and third EMT-B
perform CPR.
• Fourth EMT-B prepares and
intubates patient.
Visualized (Oral)
Intubation (1 of 2)
• Open airway.
• Insert an oropharyngeal airway.
• Preoxygenate the patient.
• Assemble equipment.
• Position the head and neck.
Visualized (Oral)
Intubation (2 of 2)
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•
•
•
•
•
Grasp laryngoscope with left hand.
Visualize vocal cords.
Insert ET tube.
Inflate balloon.
Confirm placement.
Secure tube.
Blind (Nasal) Intubation (1 of 2)
• Many of the steps are the same as those for oral
intubations.
• Preoxygenate the patient.
• Check for gag reflex.
• Insert tube through nostril.
• Pass tube through vocal cords as patient is
inhaling.
Blind (Nasal) Intubation (2 of 2)
•
•
•
•
•
Release the jaw and hold tube against nostril.
Inflate cuff.
Attach the BVM device.
Confirm placement.
Secure the tube.
Intubation Complications
• Intubating the right
main stem bronchus
• Intubating the
esophagus
• Aggravating spinal
injuries
• Taking too long to
ventilate
• Patient vomiting
• Soft-tissue trauma
• Mechanical failure
• Patient intolerant of the
ET tube
• Decrease in heart rate
Multilumen Airways
• Inserted without direct
visualization
• Provide ventilation when
placed in either trachea or
esophagus
Esophageal Tracheal
Combitube (ETC)
Combitube Contraindications
• Conscious or semiconscious patients with gag
reflex
• Children younger than 16 years
• Adults shorter than 5'
• Patients who have ingested a caustic substance
• Patients with esophageal disease
Inserting the ETC (1 of 2)
• Assemble and check the
proper equipment.
• Apply water-soluble lubricant
to the ETC.
• Position the patient.
• Preoxygenate the patient.
• Lift the lower jaw and tongue.
Inserting the ETC (2 of 2)
• Guide the ETC along
the base of the tongue.
• Inflate the blue and
then the white pilot
balloon.
• Ventilate the patient.
• Confirm placement.
• Monitor the patient.
Removing the ETC
• Be prepared to suction patient.
• Deflate both balloon cuffs.
• Gently remove the tube.
Pharyngeotracheal Lumen Airway
(PtL)
PtL Contraindications
• Conscious or semiconscious patients with
gag reflex
• Children younger than 14 years
• Adults shorter than 5'
• Patients who have ingested a caustic
substance
• Patients with esophageal disease
Inserting the PtL (1 of 2)
• Assemble and check equipment.
• Lubricate tube with water-soluble
lubricant.
• Position the patient.
• Preoxygenate the patient.
• Lift the lower jaw and tongue.
• Hold the PtL so that it curves in
the same direction as the
pharynx.
Inserting the PtL (2 of 2)
• Inflate balloon cuffs.
• Ventilate patient through
the short, green tube.
• Evaluate placement.
• Verify that the patient is
receiving adequate
ventilations.
• Monitor the patient.
Removing the PtL
• Be prepared to suction the patient.
• Deflate balloon cuffs.
• Gently remove the tube.
Laryngeal Mask Airway (LMA)
LMA Contraindications
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•
•
•
•
Asthma
COPD
Leaking mask
Active vomiting
Esophageal diseases
Inserting the LMA (1 of 2)
• Assemble and check
equipment.
• Open the airway.
• Preoxygenate the patient.
• Select proper size.
• Hold LMA down.
• Remove oropharyngeal device
and begin insertion.
Inserting the LMA (2 of 2)
• Insert until you feel
resistance.
• Stabilize the tube.
• Inflate mask.
• Confirm placement.
• Insert bite block and
secure the LMA.
Review
1. You are called for a male patient complaining of
respiratory distress. When you arrive, you assess
the patient and find that he is unconscious and
apneic, but has a pulse. You should:
A. perform immediate endotracheal intubation.
B. attach an AED and analyze the patient's rhythm.
C. ensure a patent airway and effective ventilation.
D. administer 100% oxygen via nonrebreathing mask.
Review
Answer: C
Rationale: Before performing advanced airway
procedures (eg, endotracheal intubation), you must
first ensure that the patient’s airway is patent. Open
the airway, ensure that it is clear of secretions,
insert a basic airway adjunct, and ventilate with a
bag-mask device. Ventilate the patient for at least 2
to 3 minutes before attempting intubation.
Review
1. You are called for a male patient complaining of respiratory
distress. When you arrive, you assess the patient and find that he
is unconscious and apneic, but has a pulse. You should:
A. perform immediate endotracheal intubation.
Rationale: Perform BLS airway management before performing any
advanced airway management.
B. attach an AED and analyze the patient's rhythm.
Rationale: The patient has a pulse, so immediate airway intervention
is necessary.
C. ensure a patent airway and effective ventilation.
Rationale: Correct answer
D. administer 100% oxygen via nonrebreathing mask.
Rationale: The patient is apneic. You must initiate rescue breathing
via a bag-mask device.
Review
2. Immediately after placing an endotracheal tube
(ETT) in an unconscious patient, you should:
A. attach the bag device and begin ventilating.
B. inflate the balloon cuff and detach the syringe.
C. secure the tube in place with the proper device.
D. remove the malleable stylet from the ET tube.
Review
Answer: B
Rationale: After the ETT has been placed, you should
immediately inflate the balloon cuff with 5-10 mL of
air and detach the syringe. This will seal the
trachea and prevent aspiration if regurgitation
occurs. Once the cuff is inflated, remove the stylet,
attach the bag device, and begin ventilating.
Review
2. Immediately after placing an endotracheal tube (ETT) in an
unconscious patient, you should:
A. attach the bag device and begin ventilating.
Rationale: Do this only after the balloon cuff is inflated and the
stylet is removed.
B. inflate the balloon cuff and detach the syringe.
Rationale: Correct answer
C. secure the tube in place with the proper device.
Rationale: This is the last step. Note the centimeter marking at
the lips and secure the tube.
D. remove the malleable stylet from the ET tube.
Rationale: This is performed after the balloon has been inflated.
Review
3. When intubating a patient with a curved blade, the
blade will:
A. lift the tongue so that you can see the vocal cords.
B. lift the uvula and bring the vocal cords into clear view.
C. fit under the epiglottis and directly expose the vocal
cords.
D. fit into the vallecula and indirectly expose the vocal
cords.
Review
Answer: D
Rationale: The curved blade is inserted just in front of
the epiglottis, into the vallecula (the space between
the base of the tongue and the epiglottis), indirectly
allowing you to view the vocal cords. The straight
blade is inserted directly under the epiglottis,
directly allowing you to view the vocal cords.
Review
3. When intubating a patient with a curved blade, the blade will:
A. lift the tongue so that you can see the vocal cords.
Rationale: The blade pushes the tongue to the side during
intubation.
B. lift the uvula and bring the vocal cords into clear view.
Rationale: You should visualize the epiglottis, and not the uvula.
C. fit under the epiglottis and directly expose the vocal cords.
Rationale: The straight blade fits under the epiglottis and allows
providers to visualize the trachea.
D. fit into the vallecula and indirectly expose the vocal cords.
Rationale: Correct answer
Review
4. In which of the following patients would you NOT use
a multi-lumen airway device?
A. 40-year-old man in cardiac arrest who has esophageal
cancer.
B. 17-year-old patient in cardiac arrest secondary to
electrocution.
C. 23-year-old man who is unconscious, apneic, and has
a weak pulse.
D. 5’ 6” female who is unconscious and apneic after
overdosing on heroin.
Review
Answer: A
Rationale: Multi-lumen airway devices are
contraindicated in conscious or semiconscious
patients who have a gag reflex, patients younger
than 16 years of age, adults shorter than 5’ tall,
patients who have ingested a corrosive substance,
and patients with an esophageal disease (ie,
cancer, varices).
Review
4. In which of the following patients would you NOT use a multilumen airway device?
A. 40-year-old man in cardiac arrest who has esophageal cancer.
Rationale: Correct answer
B. 17-year-old patient in cardiac arrest secondary to electrocution.
Rationale: This device is not used in patients less than 16 years of
age.
C. 23-year-old man who is unconscious, apneic, and has a weak
pulse.
Rationale: There is not a contraindication, unless the patient has a
gag reflex.
D. 5’ 6” female who is unconscious and apneic after overdosing on
heroin.
Rationale: The minimum height for using this device is 5’0”.
Review
5. You are assisting your paramedic partner while she
intubates a 50-year-old man who is in cardiac
arrest. You should anticipate that she will ask you
for a ____ mm ET tube.
A. 6.0
B. 6.5
C. 7.5
D. 9.0
Review
Answer: C
Rationale: The proper-sized ET tube ranges from 7.5
to 8.5 mm for the adult male and 6.5 to 8.0 mm for
the adult female. A good rule of thumb is to have a
7.5 mm ETT on hand; this size tube will fit most
male and female adults. Of course, a variety of
tube sizes should always be available.
Review
5. You are assisting your paramedic partner while she intubates
a 50-year-old man who is in cardiac arrest. You should
anticipate that she will ask you for a ____ mm ET tube.
A. 6.0
Rationale: This sized tube would be used in a very small
individual.
B. 6.5
Rationale: This sized tube would be in the range for an average
female patient.
C. 7.5
Rationale: Correct answer
D. 9.0
Rationale: This sized tube would be used in large adults.
Review
6. Which of the following is clearly a lethal
complication of endotracheal intubation?
A. Unrecognized esophageal intubation
B. Chipping two of the patient’s front teeth
C. Slightly extending the neck of a trauma patient
D. Ventilating the patient without supplemental
oxygen
Review
Answer: A
Rationale: While all of the choices in this question will
cause some degree of harm to the patient,
unrecognized esophageal intubation is, without
doubt, the most lethal. If you intubate the
esophagus, and do not recognize and immediately
correct it, the patient will die—period!
Review
6. Which of the following is clearly a lethal complication of
endotracheal intubation?
A. Unrecognized esophageal intubation
Rationale: Correct answer
B. Chipping two of the patient’s front teeth
Rationale: This is a complication of intubation, but it is typically not
lethal.
C. Slightly extending the neck of a trauma patient
Rationale: This is something that needs to be avoided. Paralysis —
not death — is usually the end result of this mistake.
D. Ventilating the patient without supplemental oxygen
Rationale: 100% oxygen must be delivered to a patient using a bagmask. It is not a lethal error to deliver less.
Review
7. A single intubation attempt in an adult should not
exceed:
A. 10 seconds.
B. 20 seconds.
C. 30 seconds.
D. 40 seconds.
Review
Answer: C
Rationale: An intubation attempt should not exceed
30 seconds in the adult, and 20 seconds in infants
and children. During the period of time that you are
intubating, the patient is not breathing. Prolonged
intubation attempts increase the risk of severe
hypoxia and must be avoided.
Review
7. A single intubation attempt in an adult should not exceed:
A. 10 seconds.
Rationale: The maximum time should not exceed 30 seconds in
adult patients.
B. 20 seconds.
Rationale: This is the maximum time for infants and children.
C. 30 seconds.
Rationale: Correct answer
D. 40 seconds.
Rationale: The maximum time should not exceed 30 seconds in
adult patients.
Review
8. After your partner has intubated a patient in
respiratory arrest, you auscultate to confirm proper ET
tube placement. You hear gurgling over the
epigastrium and faint breath sounds over all four lung
fields. Your partner should:
A. attach an end-tidal C02 detector to the end of the ET
tube.
B. withdraw the ET tube 1 to 2 cm and ask you to
reauscultate.
C. inflate the distal balloon cuff and attach the bag
device to the tube.
D. remove the ET tube at once and ventilate with a bagmask device.
Review
Answer: D
Rationale: If the ET tube is properly placed in the
trachea, you should hear lungs sounds that are
equal on both sides of the chest and NO epigastric
sounds. If you hear gurgling over the epigastrium—
even if you think you hear breath sounds—the ET
tube should be removed immediately and
ventilations with a bag-mask device should be
resumed.
Review (1 of 2)
8. After your partner has intubated a patient in respiratory arrest,
you auscultate to confirm proper ET tube placement. You hear
gurgling over the epigastrium and faint breath sounds over all
four lung fields. Your partner should:
A. attach an end-tidal C02 detector to the end of the ET tube.
Rationale: The detector is only attached after placement is
confirmed through auscultation and chest rise.
B. withdraw the ET tube 1 to 2 cm and ask you to reauscultate.
Rationale: The tube is drawn back only if the provider hears lung
sounds on one side, which means that the tube is advanced
too far.
Review (2 of 2)
8. After your partner has intubated a patient in respiratory arrest,
you auscultate to confirm proper ET tube placement. You hear
gurgling over the epigastrium and faint breath sounds over all
four lung fields. Your partner should:
C. inflate the distal balloon cuff and attach the bag device to the
tube.
Rationale: The balloon is inflated before providers listen to lung
sounds.
D. remove the ET tube at once and ventilate with a bag-mask
device.
Rationale: Correct answer
Review
9. After inserting an endotracheal tube, you
auscultate the patient’s lungs and do not hear
breath sounds on the left side of the chest. You
should suspect:
A. a tension pneumothorax.
B. intubation of the right mainstem bronchus.
C. intubation of the left mainstem bronchus.
D. that the ET tube has entered the esophagus.
Review
Answer: B
Rationale: The right mainstem bronchus is shorter and
straighter than the left; therefore, if the ET tube is
inserted too far, it will come to rest in the right
mainstem bronchus. You will hear breath sounds over
the right side of the chest, absent sounds over the left
side of the chest, and absent sounds over the
epigastrium. To correct this, simply withdraw the tube 1
to 2 cm until breath sounds are equal on both sides of
the chest. If breath sounds are present on the left side
of the chest and absent on the right, suspect a
pneumothorax.
Review
9. After inserting an endotracheal tube, you auscultate the patient’s
lungs and do not hear breath sounds on the left side of the chest.
You should suspect:
A. a tension pneumothorax.
Rationale: This is suspected if you hear breath sounds on the left and
not on the right side of the chest.
B. intubation of the right mainstem bronchus.
Rationale: Correct answer
C. intubation of the left mainstem bronchus.
Rationale: If the left mainstem bronchus was intubated, then
providers would hear sounds on the left.
D. that the ET tube has entered the esophagus.
Rationale: The provider would not hear breath sounds if the
esophagus was intubated.
Review
10. Which of the following devices provides the
MOST effective delivery of oxygen into the lungs?
A. Combitube
B. Bag-mask device
C. Endotracheal tube
D. Laryngeal mask airway
Review
Answer: C
Rationale: The endotracheal tube is considered to be
the superior airway device for delivering oxygen
into the lungs. It enters the trachea, has a cuff that
provides a seal against vomitus, and allows the
delivery of 100% oxygen directly into the lungs.
The Combitube and laryngeal mask airway (LMA),
while effective airway devices, do not enter the
trachea. They have been shown to provide better
ventilation than a bag-mask device, but are not
superior to the ET tube.
Review
10. Which of the following devices provides the MOST effective
delivery of oxygen into the lungs?
A. Combitube
Rationale: The combitube works well, but does not enter the
trachea.
B. Bag-mask device
Rationale: The bag-mask device works well as a BLS
procedure, but is not the most effective device.
C. Endotracheal tube
Rationale: Correct answer
D. Laryngeal mask airway
Rationale: The laryngeal mask airway works well, but does not
enter the trachea.