Management of the Airway

LTC John McManus Brooke Army Medical Center

Government Services Chapter American College of Emergency Physicians

Introduction to Airway Management

The first priority in patient care; the A of the ABCs Rapid airway intervention is critical to prevent CNS injury and death Knowledge and skill in airway management techniques are vital for successful outcome

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Airways in the Emergency Department

Uncontrolled Environment Patients Not Fasting Variable Transport Times to ED Limited Back-Up Airway Alternatives??

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Pathophysiology of Airway Compromise

Etiologies trauma infection edema tumor foreign body anatomic anomalies
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Pathophysiology (Cont)
Complete obstruction- physiologic response cyanosis patient distressed; unable to cough, speak, or breathe unconsciousness, apnea increased HR and BP bradycardia, asystole
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Basic Maneuvers
Supplemental oxygen
O2 never bad in emergency

Opening the airway

With C-spine protection

Airway adjuncts
Keep It Simple

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Supplemental Oxygen
Indicated for any seriously ill or injured patient May vary oxygen concentration delivered by using various devices Use 100% O2 for any critical patient Provides oxygen reserve prior to intubation

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Opening the Airway

Head and jaw positioning
Use of Adjuncts Suction

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Head and Jaw Positioning

Head tilt
do not use if possible c-spine injury combine with chin lift/jaw thrust to maximize airway patency

Chin lift / jaw thrust

methods of choice if suspect c-spine injury

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Beware of C-spine Injury

C1 subluxed forward on C2.

Forcep Extraction
Preferred method in unconscious patient Direct visualization of foreign object with laryngoscope Removal of foreign body with Kelly or Magill forceps

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Suction
Used to clear blood, secretions, and particulate matter from the airway Most effectively and safely used under direct visualization

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Airway Adjuncts
Oropharyngeal airway
prevents tongue from falling onto pharynx and occluding airway use only in the unconscious patient can obstruct airway if improperly placed

Nasopharyngeal airway
may use in semi-conscious or unconscious patient

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Endotracheal Intubation
Basic Orotracheal intubation Rapid sequence intubation

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Orotracheal Intubation
Indications
Apnea Upper airway obstruction Airway protection Respiratory insufficiency Controlled hyperventilation Drug administration
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Orotracheal Intubation (cont)

Contraindications
No absolute contraindications Use caution and immobilization in patients with potential cervical spine injury

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Orotracheal Intubation
Technique
Equipment preparation Pre-oxygenation Laryngoscopy Tube insertion Confirm tube placement Anchor tube
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Orotracheal Intubation
Preparation
Ensure all necessary equipment is ready and within easy reach Suction Oxygen/Bag Valve Mask Endotracheal tubes, one half size larger and smaller than anticipated

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Orotracheal Intubation
Preoxygenation
Denitrogenation of FRC 100% O2 for 5 minutes provides up to 5 minutes of complete apnea before desaturation < 90% 4 breaths at full vital capacity provide 60-80% of same effect Essential to eliminate bag valve mask ventilation of patient
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Orotracheal Intubation
Technique: Laryngoscopy
insert blade into right side of mouth, sweeping tongue to left

lift laryngoscope along line of handle, do not leverage teeth

cricoid pressure, suction as needed, visualize cords

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Orotracheal Intubation

Epiglottis
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Orotracheal Intubation

Epiglottis

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Orotracheal Intubation

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Orotracheal Intubation
If Done Correctly This Is The Reward

Epiglottis

The Vocal Cords

Trachea

The Vocal Cords

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Orotracheal Intubation
Technique: Tube Placement
tube insertion
insert tube into right side of mouth and watch it go through cords inflate balloon

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Orotracheal Intubation (cont)

Technique problems
Improper position of patients head/neck Not clearing tongue from line of sight Obscuring line of vision with ET tube Leveraging laryngoscope against teeth Using incorrect type and/or size of blade Equipment malfunction

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Orotracheal Intubation

This is what is referred to aligning the airway axis as to cause optimization of visualization of the larynx and vocal cords. Remember to not head tilt if c-spine injury is suspected.
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Orotracheal Intubation
Sub optimal airway axis Alignment. Intubation Almost Impossible!

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Orotracheal Intubation

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Optimal airway axis alignment. Note the build up of support between the patients shoulders with towels. Compare with the previous slide.

Orotracheal Intubation (cont)

Complications
Right main stem intubation Esophageal intubation Aspiration Dental trauma Vocal cord spasm/injury

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Rapid Sequence Intubation

Use of pharmacologic adjuncts to intubation to induce rapid sedation and paralysis Allows immediate control of the airway Minimizes the risk of aspiration Optimizes conditions for successful intubation

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Rapid Sequence Intubation

Indications
Facilitate emergent intubation Evidence of increased intracranial pressure

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Rapid Sequence Intubation

Contraindications
Inability to perform orotracheal intubation Not prepared to obtain surgical control of the airway Unresponsive patient/Cardiac arrest (unnecessary delay to intubation, if patient without any gag or signs of life no need for RSI)
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Rapid Sequence Intubation

Technique
Preparation and preoxygenation as per general orotracheal intubation Premedication Sedation Paralysis Intubation

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Premedication
Defasiculation
Pancuronium or vecuronium 0.01 mg/kg rapid IV push May prevent succinylcholine associated fasciculation's May prevent increased intragastric, intracranial, and intraocular pressure

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Premedication
Lidocaine
Used to suppress cough reflex and increased intracranial pressure response in patients with head injury Dose: 1.5 mg/kg IV over 30-60 seconds

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Premedication
Atropine
Prevent succinylcholine induced bradycardia Pre-treat children < 8; adults if given repeat dose of succinylcholine Dose: 0.01 mg/kg IV push (min 0.2 mg)

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Sedation
Etomidate
Ideal agent for ED RSI: few hemodynamic effects, positive cerebro-protective effects Non-barbiturate sedative Rapid onset and offset Dose of 0.3 mg/kg IVP

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Sedation
Thiopental
Barbiturate- rapid acting, brief sedation Alternative in adult patients with head trauma who are hemodynamically stable Adverse effects: hypotension, respiratory depression Dose: 3-5 mg/kg IV push

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Sedation
Fentanyl
Potent narcotic analgesic with rapid onset and short duration Adverse effects- respiratory depression, chest wall rigidity if >10 ug/kg given rapidly Dose: 2-3 ug/kg at rate 1-2 ug/min; titrating to effect

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Sedation
Midazolam
Rapidly acting benzodiazepine with short duration of action and an amnestic effect Adverse effects: respiratory depression, hypotension Dose: 0.02-0.04 mg/kg

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Paralysis
Succinylcholine
Drug of choice for ED RSI Depolarizing paralytic agent, onset of paralysis in 1 minute, offset < 5 mins Adverse effects: muscle fasciculation's, hyperkalemia, vagal stimulation, and malignant hyperthermia Dose: 1.5 mg/kg IV push
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Paralysis
Always administer cricoid pressure prior to paralysis and continue until cuffed ET tube is in place and confirmed!

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Intubation
Always confirm ETT placement Auscultate over all lung fields (apices and axilla) and epigastrium Confirm CO2 return by colorimetry Post-intubation CXR

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Nasotracheal Intubation
Indications
Difficult / impossible direct laryngoscopy Alternative to orotracheal intubation in: awake patients requiring intubation with spontaneous respirations

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Nasotracheal Intubation Indication

Patient with spontaneous respirations and orally is probably impossible.

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Nasotracheal Intubation
Contraindications
Apnea Basilar skull fracture Anticoagulant use or coagulopathy Airway foreign body, abscess, or tumor Severe midface trauma

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Nasotracheal Intubation Contraindication

Abscess

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Nasotracheal Intubation Contraindication

Mid-face trauma

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Nasotracheal Intubation
Technique
Equipment preparation Patient positioning Tube insertion Confirm placement Anchor tube

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Nasotracheal Intubation
Helpful hints
Occlude opposite nostril Whistling cap for ET tube Cricoid pressure when passing tube If breath sounds decrease, pull back Direct visualization technique using Magill forceps

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Nasotracheal Intubation
Complications
Esophageal intubation Aspiration Nasal trauma / epistaxis Posterior pharyngeal wall perforation Vocal cord injury

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Surgical Airways
Cricothyrotomy Percutaneous Transtracheal Ventilation (needle cricothyrotomy)

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Cricothyrotomy
Indications
Failure of oral or nasal intubation Upper airway obstruction unrelieved with other measures Injuries making oral or nasal intubation difficult or dangerous, especially to the midface

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Cricothyrotomy
Contraindications
Patients without contraindications to oral or nasal intubation who can be successfully intubated Severe trauma to larynx, cricoid cartilage, or a transected trachea Children under 10-12 years old

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Cricothyrotomy
Technique4 step technique 1/3 time of standard Ann Emerg Med Oct 98
Identify cricothyroid membrane (vert incision PRN) Horizontal stab (skin and membrane) Stabilize Larynx tracheal hook inf aspect, caudal traction Place Shiley

Limitation: No bleeding (cadaver model)

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Cricothyrotomy
Complications
Bleeding Injury to adjacent structures Incorrect tube placement Infection Subglottic stenosis

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Transtracheal Ventilation
Indications
Same as surgical cricothyrotomy Surgical airway of choice for children under 12 years old Contraindications as for surgical cricothyrotomy

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Transtracheal Ventilation
Technique
Locate membrane Anesthesia and sterile skin prep Using 14 G catheter over needle, puncture skin and then membrane Advance catheter and withdraw needle Attach to oxygen/ventilation device

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Transtracheal Ventilation
Complications
Subcutaneous emphysema Kinking or blockage of catheter Bleeding Infection Incorrect placement Damage to surrounding structures
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Pediatric Airway Management

Anatomic differences Basic maneuvers Orotracheal intubation

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Pediatric Anatomic Differences

Head and occiput relatively larger Airway smaller Larger tongue / oropharynx ratio Larynx higher and more anterior Narrowest portion of airway is at cricoid

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Pediatric Basic Maneuvers

Opening the airway
Sniffing position ideal Avoid hyperextension-may occlude airway Avoid hyperflexion-may make visualizing the glottis difficult Chin lift / jaw thrust indications as in adult

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Pediatric Basic Maneuvers

Bag-valve-mask
Often can ventilate despite significant upper airway obstruction Tidal volume 10-15 cc/kg Use with 100% oxygen Use cricoid pressure to avoid gastric distention

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Pediatric Orotracheal Intubation

Technique similar to adult intubation Equipment different
straight blades in up to age 4-5 years uncuffed tubes in patients <8 years old estimate tube size by size of little finger, or age formula or tables

Be familiar with equipment and anatomy

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Other Adjuncts
Combitube Laryngeal Mask Airway (LMA) King LT

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Combitube
Blind insertion Success Rates 69%-100% Incorrect port ventilated 3.5% (must confirm placement) Esophageal or phyaryngeal trauma

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Laryngeal Mask Airway

Developed by 1980s Originally designed to permit ventilation and maintain patient airway that was intermediate in intensity and invasiveness between facemask and the endotracheal tube (ETT)

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LMA
In recent decade, LMA has received popularity in OR and ED as:
A tool for management of difficult airway A rescue ventilation device that provides a temporizing airway in the patient American Heart Association accepted airway (IIa) in cardiac arrest ILMA rescue airway and primary airway

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LMA

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LMA

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King LT
Blind insertion Both balloons filled at once Small balloon esophageal Aspiration protection Smaller & easier Than combitube ? Asai, Aug 2003 Acta Anaesthesiol Scand
97% success after 2 attempts (90/7)

Asai, Apr 2001 Anaesthesia

94% success after 1 attempt
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