THE SPECTRUM OF CONTINUOUS AIRWAY ASSESSEMENT AND MANAGEMENT

1. THE SPECTRUM OF CONTINUOUS AIRWAY ASSESSEMENT AND MANAGEMENT

2. Learning Objectives: The following module covers: Review of airway anatomy including pediatric differences. Acquiring and maintaining AW patency including manual and adjunct techniques. AW assessment and introduction to LEMON. Risk/benefit considerations. Problems and Rescue Procedures.

3. Anterior View of the Larynx

4. Upper Airway Structures

5. The Spectrum of Airway Management

6. Objectives Appreciate the spectrum of airway management from simple maneuvers to complex interventions Appreciate proper monitoring and need for further management during and after airway intervention

7. Airway spectrum Alert/patent airway Simple manual maneuvers Head-tilt, chin-lift, suction, left lateral recumbent, cricoid pressure (Sellick’s), chest compressions (FBOA) Simple and advanced adjuncts OPA, NPA, Bougie Supraglottic airways King-LT, LMA

8. Airway Spectrum Advanced airway Direct laryngoscopy/intubation BURP (not Sellick’s) Failed airway , can’t oxygenate/can’t ventilate Needle cricothyrotomy McGill forceps

9. Difficult Mask Ventilation Presence of 2 or more conditions – Difficult Bag Mask Ventilation

10. Difficult Face Mask Ventilation Signs of inadequate face mask ventilation include absent or inadequate chest movement absent or inadequate breath sounds auscultatory signs of severe obstruction gastric air entry or dilatation decreasing or inadequate oxygen saturation (SpO2) absent or inadequate exhaled carbon dioxide hemodynamic changes associated with hypoxia, hypoxemia or hypercarbia (hypertension, tachycardia and arrhythmias, cyanosis) Compliance vs. resistance? The ease which lung and thorax expand vs. any mechanical factor that limits inspired air to reach the alveoli

11. Bag Mask Ventilation

12. Bag Mask Ventilation Key—ventilation volume: “enough to produce obvious chest rise” 1-Persondifficult, less effective 2-Personeasier, more effective

13. Cricoid Pressure (Sellick’s) Posterior pressure on Cricoid Cartilage to occlude esophagus Purpose: prevent passive regurgitation of gastric contents **Can make intubation more difficult!

14. BURP maneuver Backward, upward, rightward pressure Purpose: facilitate better laryngoscopic view

15. King LT

16. Supraglottic Airway King LT

17. Features of King SG Airways The KING LTD is supplied clean, but is a non-sterile device It consists of a curved tube with ventilation apertures located between two inflatable cuffs. The distal cuff is designed to seal the esophagus Proximal cuff is intended to seal the oropharynx (King System, 2009). Cardiac arrest (PCP and ACP) Respiratory distress/arrest with GCS 3 (ACP only)

18. King LT Sizing Chart

19. Advantages Emergency ventilation can take place within 15 seconds without a laryngoscope. Requires minimal movement of patient head. Requires minimal education to insert. The King laryngeal airway is designed to be inserted without direct visualization. Minimal risk of aspiration. The KING LTD provides a more secure, non-intubating emergency airway when direct laryngoscopy is not feasible (King System, 2009).

20. Disadvantages Only make limited sizes. The KING LTD can be used in routine procedures only up to 8 hours. Unable to place medication down the tube. Trauma related to balloon in trachea (King System, 2009). Only minimizes risk of aspiration (aspiration can still occur)

22. Monitoring Airway Interventions Ventilation: Chest wall excursion, ease of BVM vents, ETCO2 Oxygenation: SpO2, skin colour, heart rate

23. Management of the Difficult Airway

24. DEFINITION Difficult airway: ANYTHING that interferes with ventilation or intubation Anatomic Traumatic Infectious (airway edema) Allergic Behavioral

25. Normal Adult Vocal Cords Cords Abducted (open)

26. Laryngoscopic View What we hope not to see...

27. LEMON Law Look at anatomy Examine the airway Mallampati Scale Obstructions Neck Mobility

28. Look at Anatomy Obesity: rapid desaturation, short or thick neck-difficult intubation. Facial hair: hides small chin, can make BVM ventilation difficult. Teeth: hide airway, obscure tube passage, may lacerate balloon, dentures. Poor Neck Mobility: surgery, kyphosis Large Tongue:

29. Evaluate the 3-3-2 Rule The 3 – 3 – 2 rule: Mouth open: 3 fingers Allows insertion of tube, laryngoscope Mentum (chin) to hyoid: 3 fingers Predicts ability to lift tongue into mandible Floor of mouth to thyroid cartilage: 2 fingers If high larynx, airway tucked under base of tongue, hard to visualize

30. Mallampati Score The Mallampati Score is based on the structures visualized with maximal mouth opening and tongue protrusion in the sitting position. The amount of the posterior pharynx you can visualize is important and correlates with the difficulty of intubation.  Visualization of the pharynx is obscured by a large tongue (relative to the size of the mouth), which also interferes with visualization of the larynx on laryngoscopy.

31. Obstruction Evaluation for stridor, foreign bodies, and other forms of sub- and supraglottic obstruction should be performed in every patient prior to laryngoscopy

33. Foreign Bodies Food More common in children In adults there are typically co-factors

34. Causes of Obstruction Foreign Body (food, toys) Trauma Edema Neoplasm Blood

35. Neck Mobility Patients with degenerative or rheumatoid arthritis may have limited neck motion, and this should be assessed to assure the ability to adequately extend the neck during laryngoscopy and intubation.

36. Indications for Intubation Based on three fundamental clinical assessments: Is there a failure of airway maintenance or protection? Is there a failure of ventilation or oxygenation? What is the anticipated clinical course?

37. Failure of Airway Maintenance or Protection Upper airway muscles and protective reflexes normally protect the airway from aspiration. Patent airway helps with ensuring adequate oxygenation. What devices do we carry to help maintain a patent airway? Not all airway devices protect the airway. In absence of immediately reversible condition, intubation should be considered. What is the most reliable method to assess protective reflexes?

38. Failure of Oxygenation/Ventilation Oxygenation/Ventilation provide oxygen to vital organs, remove waste carbon dioxide and help regulate pH. If oxygenation still does not improve despite efforts to improve ventilation, intubation should be considered. Eg. Asthma/CHF-these patients have patent airways and can protect them, but ventilatory failure will ultimately lead to inadequate oxygenation and death.

39. What is Anticipated Clinical Course? Although airway and ventilation are adequate at this time, conditions may change in future require airway control or protection: stab wound to neck for example. Other examples?

40. Tracheal Tube Introducer (Bougie) GEB or “Bougie” is a device utilized to increase success when securing an airway. EMS and hospital trials have shown increased success rate, and decreased time to intubate with the use of the bougie. First used by Robert Macintosh in 1943 during a difficult intubation.

41. Gum Elastic Bougie The Bougie is a long (60 cm) introducer with a 38 degree bend at the tip. Became popular among hospital staff about 30 years ago. Crept its way into EMS approximately 10 years ago.

42. Logistics to Consider It can be a challenge to store the device. It’s shape has a lot to do with its advantage as an airway adjunct so it must be stored in a way to not compromise that. It is a single use, disposable device. Applicable to ACP scope of practice. Does not require a specific Medical Directive as it is considered an adjunct under the ETI Medical Directive.

43. Inserting the Bougie You may choose to lubricate the tip of the Bougie with a water based solution, however it is generally not required. Perform laryngoscopy as per your normal technique. At this point instead of the usual ET tube with stylet, grasp the Bougie. Pass the Bougie through the glottic opening to the point of the 40 cm marking on the device, or until slight resistance is met. The resistance indicates the device contacting the carina or entering the bronchial tree. At this point, ideally it becomes a two person procedure.

44. Bougie Insertion

45. Confirming the Tube As you advance the device, you get two additional indications of correct placement, both tactile in nature. i) Clicking sensation as the device passes over the tracheal rings. Studies indicate these are felt up to 90% of the time. ii) Slight resistance as the device advances to the carina or into the bronchi (generally around 40 cm in an adult). The device is marked at this point. Other methods of tube confirmation should still be utilized and remain unchanged i.e.) ETCO2, chest rise and fall, auscultation, misting etc.

46. SpO2 & ETCO2 SpO2 – Reflects the percentage of Oxyhemoglobin in the blood. SpO2 less than 90 = SpO2 less than 60 = Hypoxia SpO2 80 = PaO2= 45 !! Goal: To keep Saturation between 94-98%

47. SpO2 & ETCO2 ETCO2: The highest measurable point of CO2 concentration during patient exhalation cycle. Always reflects the current amount of exhaled CO2: Provides the most reliable sign of patients cardiopulmonary performance. Normal physiological range: 35-45 >45 Hypercarbia (R. Acidosis) <35 Hypocarbia (R. Alkalosis)

48. SpO2 & ETCO2 Points to remember: There is no correlation between SpO2 and ETCOs2 (Pt. can present high O2SAT and low ETCO2 and vise versa). SpO2 can’t be measured accurately in hemodynamicaly compromised pt’s (levels lower than 90 may not be accurate). ETCO2 will reflect the patients current cardiopulmonary physiological condition.

49. SpO2 & ETCO2 In case of sudden loss of ETCO2 waveform, check and correct: Displacement (tube, king LT) Obstruction(kink, blood) Pneumothorax (usually tension) Equipment malfunction (probe, cable, connections) Bronchconstriction Pulmonary embolism And remember… Its always a great idea to check Pt’s pulse

50. Needle Cricothyrotomy Replacing Portex as of May 4th Only 13 have been done in a 5 year period (PRPS and TEMS) 1 outright successful 1 was a tracheal tube replacement 50% were successfully intubated in the field post surgical airway attempt Extremely expensive for training / stocking (for the number of uses)