Backup Airways

1. Backup Airways New Hampshire Division of Fire Standards & Training and Emergency Medical Services

2. Know Your Options!!!& Don’t hesitate to use them!

3. Purpose • It is vital that the prehospital crew be confident and comfortable with the rescue airways approved for their level of licensure. • During this module you will review and practice the back up airways for your level of licensure.

4. Purpose • Review Backup Airway Devices (Rescue Airways) • BVM • LMA • King-LT-D • Combitube • Cricothyrotomy

5. What do we do when we have a difficult airway?

6. The Basics • Position • OPA • BVM • Suction Most difficult airways will still be manageable using basic airway maneuvers!

7. The Need for Oxygen • 0 – 1 minute: cardiac irritability • 0 – 4 minutes: brain damage not likely • 4 – 6 minutes: brain damage possible • 6 – 10 minutes: brain damage very likely • > 10 minutes: irreversible brain damage

8. Oxygen and Carbon Dioxide Exchange • Oxygen-rich air is inhaled to alveoli • O2 exchanged at alveolocapillary level • Perfusion to capillary beds • O2/CO2 exchange at cellular level • Perfusion from capillary beds • CO2 exhanged at alveolocapillary level • CO2 exhaled

9. Assessment of Respiration • Patients level of consciousness • Respiration quality • Pulse quality • Respiratory rate • Pulse rate • SPO2 • EtCO2 • Blood pressure • Glasgow coma score

10. Every TRUE life saving intervention performed by EMS reverses one or more failing components of respiration

11. BVM is the most essential intervention in RSI

12. Inadequate Breathing • Fast or slow rate • Irregular rhythm • Abnormal lung sounds • Reduced tidal volume • Use of accessory muscles • Cool, pale, diaphoretic, cyanotic skin

13. Head Tilt-Chin Lift • One hand on the forehead • Apply backward pressure • Tips of fingers under mandible • Lift the chin

14. Jaw-Thrust Maneuver • Place fingers behind the angle of the jaw • Use thumbs to open mouth

15. Look, Listen, and Feel • Assess that Airway!

16. Basic Airway Adjuncts • Oropharyngeals • Keeps tongue from blocking oropharynx • Eases suctioning • Used with BVM • Patients without gag reflex • Nasopharyngeals • Maintains patency of oropharynx • Patients with gag reflex • Should not be used with head trauma

17. Oxygen • Nonrebreathing mask • Provides up to 90% oxygen • Used at 10 to 15 L/min • Nasal cannula • Provides 24% to 44% oxygen • Used at 1 to 6 L/min

18. Oxygen • Nasal cannula • 24-40% at 1-6 liters • Non-rebreather mask • Up to 90% at 15 liters • BVM • 21% atmosphere • Up to 100% at 15 liters with reservoir

19. Artificial Ventilation • Mouth to mask • BVM – one person • BVM – two person

20. Ventilation Rates • Adults: 8 - 10 breaths per minute • Approximately one breath every 6 – 8 seconds • Pediatric: 12 – 20 breaths per minute • Approximately one breath every 3 – 6 seconds

21. Bag O2 Reservoir Valve Mask Bag Valve Mask • Delivers > 90% oxygen • Requires practice and proficiency • Use with airway adjuncts and/or advanced airways

22. BVM-Problems encountered • Inattentiveness • Poor mask seal = poor ventilatory ability • Varying ventilatory rates • Varying expiration rates • Varying tidal volumes • Often excessive airway pressure • Often hyper-ventilation Mastering the BVM overcomes these obstacles!

23. BVM – One person • Insert an oral/nasal airway • Seal mask by placing the apex over the bridge of the nose and lower portion of the mask over the mouth and upper chin. • Make a “C” with your index finger and thumb around the mask. • Maintain the airway with your middle, ring and little finger, creating a “E”, under the jaw to maintain the chin lift. • Squeeze the bag with your other hand slowly at a rate of one breath every 6–8 seconds. • Monitoring SpO2

24. BVM – Two Person • Insert oral/nasal airway • First provider hold the bag portion of the BVM with both hands. • Second provider seals the mask with apex over the bridge of the nose and base at the upper chin. • Using two hands the second provider places his/her thumbs over the top half of the mask; index and middle finger over bottom half; ring and little finger under jaw. • Second provider also maintains chin-lift • First provider squeezes bag every 6–8 seconds • Monitoring SpO2.

25. Adequate Ventilation • Equal chest rise and fall • Appropriate rate • Heart rate returns to normal

26. Inadequate Ventilation • Minimal or no chest rise • Ventilating too fast or too slow • Heart rate does not return to normal

27. Asthma and COPD • These patients complicate the traditional RSI approach due to the difficulty encountered when mask ventilating • Alveolar hyperinflation secondary to underlying pathophysiology must be considered and adequate passive ventilation time must be ensured • Tidal volumes should be reduced, initially, to reduce likelihood of barotrauma and air trapping

28. Gastric Distention • Air fills the stomach from too forceful or too frequent ventilations • Airway may be blocked and ventilations are re-routed to stomach • Decreases lung capacity • May cause patient to vomit

29. Airway Obstructions • Tongue • Vomit • Blood, clots, traumatized tissue • Swelling • Foreign objects

30. Recognizing an Obstruction • Partial or complete? • Can patient speak? Cough? • If unconscious, deliver artificial ventilation • Does air go in? Does the chest rise?

31. Removing an Obstruction • Heimlich maneuver • Suction • Magills (paramedics)

32. Suctioning • Turn on unit and ensure proper suctioning pressure (300 mmHg) • Select proper tip and measure • Insert with suction off • Suction on the way out • Suction for no more than 15 seconds

33. Continuous Positive Airway Pressure (CPAP) Is the patient a candidate for CPAP?

34. CPAP Indications • Any patient in respiratory distress associated with CHF with any of the below obvious signs and symptoms or a history of CHF: • Bibasilar or diffuse rales • Respiratory rate greater than 25 • Pulse oximetry below 92% • Retractions or accessory muscle use • Abnormal capnography (rate, waveform, CO2 levels)

35. RSI Indication • Immediate severe airway compromise in the context of trauma, drug overdose, status epilepticus, etc. where respiratory arrest in imminent.

36. Always have a back-up plan. • Plans “A”, “B”, and “C” • Know the answers before you begin

37. Plan “A”: (ALTERNATIVES) • Different: • Size of blade • Type of blade • Miller • Macintosh • Specialty • Position (patient & provider) • Hockey stick bend in ETT or Directional tip ETT • Remove the stylette as you pass through the cords • “BURP” (aka “ELM”) • Gum Elastic Bougie • 2-person technique • “cowboy” or “skyhook” • Have someone else try

38. Viewmax Scope • Easy of use • Can be used like a Mac or Miller • Should improve your view by one grade

39. “BURP” – a.k.a. “External Laryngeal Manipulation” • Backward, Upward, Rightward Pressure: manipulation of the trachea • 90% of the time the best view will be obtained by pressing over the thyroid cartilage Differs from the Sellick Maneuver

40. Plan “B”: (BVM and BACK UP Airways) • Can you ventilate with a BVM? • (Consider two NPA’s and an OPA, + Cricoid pressure w/ gentle ventilation) • KING–LT-D • Combitube • LMA

41. King-LT-D

42. King LT-D