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Case Evaluation • How do you think you did? • What do you think you did well? • What would you have done differently? • How do you think your colleagues did?
Diagnosis? • Status Asthmaticus with respiratory failure • Spontaneous iatrogenic pneumothorax developing of a tension pneumothorax
General Assessment of the Dyspneic Patient • Ability to speak • Mental status • Position – Lying back, upright and forward or slumped back • Cyanosis – Central or acrocyanosis • Pulmonary exam – Inspection, percussion auscultation • Cardiovascular • Extremities
Advanced Airway Management Techniques • Definitive • Oral awake • Nasotracheal • RSI • Rescue • LMA • Combitube • Cricothyrotomy • Others
Factors Predictive of a Difficult Airway • Mallampati class • Neck mobility • Jaw size • Laryngeal trauma • Tongue size • Prominent incisors • Combativeness
Mallampati Classes • I – The tonsillar pillars, fauces, soft pallet and uvula are visualized • II – The fauces, soft pallet and uvula are visualized • III – The soft pallet and the base of the uvula are visualized • IV – Only the hard pallet is visualized
Risks Associated with Intubation • Inability to intubate • Aspiration • Misplacement of the tube • C-spine injury • Increased ICP • Hemodynamic changes
Orotracheal Intubation Technique • Chose appropriate sized tube & blade • Check equipment • Sniffing position if no C-spine injury • Identify Cricoid cartilage for BURP maneuver • Laryngoscope in left hand, open mouth with right hand • Advance blade on dorsal surface of tongue to ID epiglottis and position blade • Pass tube through cords to 2 cm beyond cuff • Remove stylet, inflate cuff, confirm tracheal placement • Secure Tube (22-24 cm at teeth)
Contraindications to RSI • Clinical and/or anatomical considerations that predict difficulty intubating the patient
Nasotracheal Intubation Technique • Select and Prep both tube and nares • Place tube bevel flat against nasal septum • Gentle consistent pressure • When in the nasopharynx, position ear at end of tube, advance tube to loudest point • As patient inspires, advance tube 2-3 cm • Assess tube position and reposition if needed • If in trachea, inflate cuff, confirm placement, and secure tube
Contraindications to Nasotracheal Intubation • Absolute – Apnea • Relative • Midface/basilar skull fracture • Coagulation defects • Potential altered airway anatomy • Impaired airway reflexes • Closed head injury • Myocardial ischemia
Nonpulmonary Causes of Dyspnea • Is it true dyspnea? • Thoracic pain • Hyperventilation • CHF • ACS/MI • Decreased oxygen-carrying capacity • Acid-base disorders
Pulmonary Causes of Dyspnea • Asthma • Pneumonia • COPD • Emphysema • Chronic Bronchitis • Pulmonary Embolus • Pneumothorax
Asthma • Etiology – Bronchospasm, increased mucous production and inflammation • Hx – Prior episodes, precipitating factors • PE – Tachypnea, tachycardia, wheezing, prolonged expiratory phase • Tests – Spirometry, pulse ox (?CXR, ABG) • Rx – Oxygen, Inhaled bronchodilators, Steroids, rehydration, SC epinephrine, magnesium, active airway control in nonresponders
How do you treat a pneumothorax? • Chest tube • Pleuricath • Needle aspiration • When do you need to drain the air?
What is the major complication you have to be aware of? • Tension pneumothorax • When would this occur?