Transcript Airway Algorithm Review

AIRWAY ALGORITHM REVIEW
By Maine EMS
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WHY AIRWAY REVIEW?
Most important aspect of patient care (?)
Failure = Gravest Consequence
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WHY AIRWAY REVIEW?
Many Quality Assurance
Concerns:
-Gausche et al study
-PALS update
-Burton et al study
-Kendall et al study
-Marcolini et al study
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MAINE’S PLAN
These Concerns led MDPB to do
a comprehensive review of the
current airway protocol and
create the new…
Airway Algorithm
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AIRWAY PROTOCOL
-Makes airway procedures a “step
by step” process
-Adds concept of “rescue airway”
-Adds new airway devices
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AIRWAY PROTOCOL
Protocol Initiated 5/23/05
The MDPB’s goal is to train all
intubating providers by a yet to be
determined date
*Providers may use new protocol if trained but not
until they are trained
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MANDATORY EQUIPMENT
Goal is for services to comply with
mandatory airway devices by a yet
to be determined roll out date.
MEMS will allow time for budgeting
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MANDATORY EQUIPMENT
Mandatory Equipment
*All intubating services must carry
Laryngeal Mask Airways (LMA)
(Note all LMA’s are now available in disposable form)
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OPTIONAL EQUIPMENT
Optional Equipment
*Dual Lumen Airways
*Intubation Adjuncts
-Gum elastic Bougees (Tube changers)
-Lighted Styllettes
*Commercial Tracheotomy Kits
-Pertrach, Quick Trach, etc.
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AIRWAY PROTOCOL
QA Component
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TRAINING OBJECTIVES
-Practical walk through airway
management from BLS to ALS
-Introduce the algorithm idea
-Review fundamental concepts
-Practice hands on skills
-Debunk myths
-Trade tips
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ANATOMY REVIEW
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OXYGENATION IS GOOD
Indicated in those
patients who are in
respiratory distress
and remain able to
exchange air on their
own.
*Beware of decompensating patients!
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WHY MANAGE AN AIRWAY
Anyone can be taught to
use a BVM or
intubate…the real
question is why manage
an airway?
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AIRWAY MANAGEMENT
Reasons To Manage an Airway:
-Obstruction
-None present, (trauma, medical)
-Decompensating (not maintaining)
-Breathing too fast or too slow?
What are your indicators?
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AIRWAY MANAGEMENT
Respiratory Distress vs. Respiratory Failure
Distress
Failure
-Increased work of
breathing
-Increased work of breathing
-Relative
hypoxia/hypercapnea
-Profound
hypoxia/hypercapnea
-Decompensating
-Compensating
It’s a constant reassessment process…
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AIRWAY ALGORITHM

A step by step approach at evaluating each
patients ability to maintain an open airway.

Immediate corrective actions based on this
assessment

A constant reassessment of current
procedures to determine the need to be
more or less aggressive in the best interest
to the patient.
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STEP 1. OPEN AND CLEAR
Clear and Suction
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STEP 2. KEEP IT OPEN
 Benefits and Limitations
 Indications and Contraindications
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STEP 2. KEEP IT OPEN
Sizing and Insertion
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STEP 3. VENTILATE (BLS)
Procedure:
-Attach high flow O2
-Select appropriate mask
(good seal imperative)
-Override pop-offs (?)
What are the limitations?
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STEP 3. VENTILATE (BLS)
-BVM Rate Re-Examined
-BVM Depth Re-Examined
Practical Exercise on Ventilation
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STEP 3. VENTILATE (BLS)
Approximate normal ventilation rates:



10 bpm Adult
20 bpm Child
25 bpm Infant
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STEP 3. VENTILATE (BLS)
Cricoid Pressure
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STEP 3. VENTILATE (BLS)
Why is this helpful in all
manual ventilation?
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STEP 4. CONTROL THE AIRWAY
Intubation
vs.
BVM
Why and why not?
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STEP 4. CONTROL THE AIRWAY
Airway Management Decision Process
(Judge how aggressive you need to be.)
-Time/Distance
-Personnel
-Equipment
-Other Considerations?
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STEP 4. CONTROL THE AIRWAY
“Evaluate for signs of difficult intubation”
(this may help in your decision as well)
-Obesity
-Small body habitus
-Small jaw
-Large teeth
-Burns
-Trauma
-Anaphylaxis
-Stridor
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STEP 4. CONTROL THE AIRWAY
The BLS vs. ALS airway
decision may not be based on
one single factor, but rather
based on an overall
assessment of many factors.
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STEP 4. CONTROL THE AIRWAY
Pre-Intubation
-Prepare Equipment
-Hyper-oxygenate
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STEP 4. CONTROL THE AIRWAY
Orotracheal Intubation Procedure
Sweep
Left and
Look
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STEP 4. CONTROL THE AIRWAY
Find Your Landmarks
Backward, Upward, Right Pressure (B.U.R.P.)
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STEP 4. CONTROL THE AIRWAY
Find Your Landmarks
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STEP 4. CONTROL THE AIRWAY
Find Your Landmarks
It may not be perfect!
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STEP 4. CONTROL THE AIRWAY
Find Your Landmarks
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STEP 4. CONTROL THE AIRWAY
Readjusting with Cricoid Pressure
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STEP 4. CONTROL THE AIRWAY
Common Provider Mistakes
*Making a difficult intubation more difficult
*Rushing
*Poor equipment preparation
*Suction (lack there of)
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STEP 4. CONTROL THE AIRWAY
What is your back-up plan today?
prolonged BVM…
another provider…
a smaller tube…
better lighting…
additional suctioning…
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STEP 4. CONTROL THE AIRWAY
Helpful Adjuncts
Gum
Elastic
Bougie
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STEP 4. CONTROL THE AIRWAY
Helpful Adjuncts
Lighted Stylette
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STEP 4. CONTROL THE AIRWAY
Nasotracheal Intubation
Indications:
“Patient still breathing but
in respiratory failure and
in whom oral intubation is
impossible or difficult.”
-AAOS
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STEP 4. CONTROL THE AIRWAY
Nasotracheal Intubation
Contraindications:
-Apnea
-Resistance in the nares
-Blood clotting or
anticoagulation
problems
-Basilar Skull Fx (?)
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STEP 4. CONTROL THE AIRWAY
Nasotracheal Intubation
Technique:
-Prepare patient and nostril
-Prepare tube
-Insert on inspiration
-Take your time
Complications:
-Bleeding
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STEP 5. CONFIRM THE AIRWAY
Intubation Confirmation
Good, Better, Best
Traditional
Technology Based
•
Direct
Visualization
•
ETCO2 (monitor)
•
EDD (bulb)
•
Lung Sounds
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Colormetric (cap)
•
Tube
Condensation
•
Pulse Ox change
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STEP 6. SECURE THE AIRWAY
Secure Your Tube
Good, Better, Best
Tape
Improvised devices
Commercial devices
Immobilization (?)
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STEP 7. ALTERNATIVES TO ETI
Laryngeal Mask Airway
Developed in 1981 at the Royal London
Hospital By Dr Archie Brain
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STEP 7. ALTERNATIVES TO ETI
Laryngeal Mask Airway
Indications:
-When definitive airway management
cannot be obtained. (ETT)
Not a substitute for definitive airway
management
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STEP 7. ALTERNATIVES TO ETI
Laryngeal Mask Airway
Contraindication/Limitations:
-Obesity
-Non-secure
-Size based
-Not a med route
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STEP 7. ALTERNATIVES TO ETI
Laryngeal Mask Airway
Weight Based Sizing
<5kg = Size 1
5-10 kg = Size 2
20-30 kg = Size 2.5
Small Adult= Size 3
Average Adult = Size 4
Large Adult = Size 5
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STEP 7. ALTERNATIVES TO ETI
Laryngeal Mask Airway
Average Adult Woman = 4
Average Adult Male = 5
*If in doubt, check the LMA
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STEP 7. ALTERNATIVES TO ETI
Laryngeal Mask Airway
Procedure:
-Hyper oxygenate
-Check cuff
-Lubricate posterior cuff
-Head in neutral or slightly flexed position
-Insert following hard palate (use index finger to guide)
-Stop when met with resistance
-Let go and inflate cuff (visualize “pop”)
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-Confirm and secure
STEP 7. ALTERNATIVES TO ETI
Laryngeal Mask Airway
Air volume is variable depending on cuff size
and individual patient anatomy
General Guideline:
Size 1 = 4 ml
Size 2 = 10 ml
Size 2.5 = 14 ml
Size 3 = 20 ml
Size 4 = 30 ml
Size 5 = 40 ml
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STEP 7. ALTERNATIVES TO ETI
Laryngeal Mask Airway
Common Provider Problems:
-Failure to seat properly
-Sizing difficulties
-Aspiration
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STEP 7. ALTERNATIVES TO ETI
Laryngeal Mask Airway
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STEP 7. ALTERNATIVES TO ETI
Laryngeal Mask Airway
MDPB has approved all
“non-intubating” LMA
type devices
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STEP 7. ALTERNATIVES TO ETI
Dual Lumen Airway
(Combitube®)
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STEP 7. ALTERNATIVES TO ETI
Dual Lumen Airway
Indications:
-When definitive airway management
cannot be obtained. (ETT)
Not a substitute for definitive airway
management
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STEP 7. ALTERNATIVES TO ETI
Dual Lumen Airway
Contraindications/Limitations:
-No pediatrics
-5’7-7’ tall (SA 4’-5’6)
-Pathological esophageal disease
-Non-secure airway
-Latex sensitivity
-Toxic or Caustic Ingestions
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STEP 7. ALTERNATIVES TO ETI
Dual Lumen Airway
Procedure:
-Hyper oxygenate
-Check equip.
-Head in neutral position
-Insert until to guide lines
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STEP 7. ALTERNATIVES TO ETI
Dual Lumen Airway
Procedure:
-Inflate Pharyngeal cuff
(blue) with 85-100cc of
air
-Inflate tracheal cuff
(white) with 10-15cc of
air
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STEP 7. ALTERNATIVES TO ETI
Dual Lumen Airway
-Ventilate port 1 (longer, blue tube, #1).
If no lung sounds, switch ports
-Ventilate port 2 (shorter, white tube, #2)
*You will be either in the esophagus or the trachea
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STEP 8. SURGICAL AIRWAYS
Indications
-Obstruction
-Facial Trauma
-Intubation or other
alternatives impossible
-Trismus (clenching)
->8 years old (for open
procedures)
LAST RESORT!
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STEP 8. SURGICAL AIRWAYS
Open Cricothyrotomy
-Vertical Incision over membrane
-Pierce membrane in horizontal plane
-Open and spread to insert 4.0 or 5.0 tube
-Secure tube in place and ventilate
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STEP 8. SURGICAL AIRWAYS
Needle Cricothyrotomy
Needle Procedure:
-Identify Cricothyroid
membrane
-Pierce at 45° angle
-Place catheter or styllette
-Advance dilator per
manufacturer’s
recommendation
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STEP 8. SURGICAL AIRWAYS
Needle Cricothyrotomy
Commercial Needle
Cricothyrotomy Devices
Quick Trach
Pertrach
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WHY AN ALGORITHM?
1. Step by step process in order
2. Start simple and work up
3. Alternatives
4. Be sure
5. Get it done
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Questions?
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MAINE EMS WISHES TO THANK THE FOLLOWING
MANUFACTURERS FOR THEIR CONTRIBUTIONS OF
TRAINING MATERIALS.
Boundtree Medical - LMA Products, Lighted Stylletes
Mike Evers-Jenkins
(800) 533-0523 ext. 550
Tri-Anim- Cobra PLA, Per-Trach
Jaclyn Emanuelson
(877) 207-4329 ext 6306
Rüsch- Quick Trach
Dave Henry
(800) 848-3766 ext. 1707
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