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ADVANCED AIRWAY MANAGEMENT AND THE

DIFFICULT AIRWAY

DON’T PRACTICE UNTIL YOU GET IT RIGHT. PRACTICE UNTIL YOU CAN’T GET IT WRONG.

The Decision to Intubate

n Can the patient protect their airway?n Can the patient adequately ventilate /

oxygenate?n What do you expect to happen?

– Evaluate the patient

Deciding to Intubate

n If you must establish an airway, you must protect that airway.

n Do not rely on the gag reflex.n Swelling or progressive distortion only gets

worse, intubate early.n ABG’s are not helpful.

Airway Algorithm

n Is this a crash airway?

n Is this a difficult airway?

n Was intubation successful?

n Oxygenationn Ventilationn 3 attempts

©MANTA2006

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©MANTA2006©MANTA2006

©MANTA2006

Difficult Airwayn Is there time?n Ability to ventilate or

intubaten Can you proceed

with RSI? *not a contraindication

n Evaluate anatomic landmarks

n Evaluate patient position

Failed Airway

n Unable to oxygenate

n Oxygen saturations drop below 90%

n 3 failed attemptsn Attempt = entering

larynx

Can’t Intubate Can’t VentilateCICV Airway

Immediate rescue airway

Cricothyroidotomy

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n “The purpose of RSI is to render the patient unconscious and paralyzed and then to intubate the trachea without the use of bag ventilation.”

Ron Walls

Rapid Sequence Intubation Rapid Sequence Intubation

RSI can be used over 80 percent of the time.

97 percent of all patients can be successfully intubated within 2 attempts.

1 percent require cricothyrotomy.

Rapid Sequence Intubation

n Assume they have a full stomach.n Minimize bagging.n NO titration of medications or “slow

push.”

Rapid Sequence Intubation

n Preparationn Preoxygenationn Pretreatmentn Paralysis with Inductionn Protection and Positioningn Placement with Proofn Postintubation Management

Check Every Patient for a potentially Difficult Airway

n Difficult Ventilation- inability of trained provider to maintain O2 saturation >90% using face mask ventilation

n Difficult Intubation- need for >3 intubation attempts or attempts at intubation lasting > 10 minutes

Preparation

n Assess for difficult airway– L-look externally

– E-evaluate landmarks/3-3-2

– M-Mallampati

– O-obstruction

– N-neck mobility

– S-aturations

n Assemble equipment

n Fallback plan and equipment immediately available

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n Mouth opening < 3 fingers

n Hyoid-mentum distance <3 fingers

n Thyroid to floor of mouth distance <2 fingers

MALLAMPATI SCALE

n Score 3 or 4

HEAVEN

n Hypoxemia

n Extremes of size

n Anatomic disruption/obstruction

n Vomit/blood/fluid in airway

n Exsanguination

n Neck mobility

HEAVEN vs LEMONSWhat is the difference?

n HEAVEN is a prescreening tool that is used to determine difficult resuscitation/intubation

n LEMONS is a prescreening tool to determine difficult direct laryngoscopy

n Anticipation vs reality

Which option to use?

BOTH

The combination of both LEMONS and HEAVEN will help determine the difficulty of intubation and resuscitation

Non-Invasive Airway Monitoring

n Capnography (ETCO2)Quantitative & WaveformQualitative

n Why is waveform better than colormetric?

n What is normal?n Measurement of Ventilation, NOT

Oxygenation

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Not Every Patient In Distress Needs Intubation

n Is there failure to maintain or protect the airway?

n Is there failure of oxygenation and ventilation?

n Is there a need for intubation based on the anticipated clinical course?

Don’t Forget there is a Patient Attached to that Airway

n It is easy to lose track of the rest of the patient while dealing with an airway emergency– Don’t skimp on Pre-oxygenation

PREPERATIONApneic Oxygenation

n Pre intubation using NC at 15-25lpm

Completely washes out nitrogen from the lungs (replacing it with 100% oxygen) helping to recruit alveoli for maximum oxygen absorption

Preoxygenation

n Essential to the “no bagging” principlen Establish an oxygen reservoir

– 8 full deep breaths on 100% in 60 seconds

– Alternative - 8 vital capacity breaths with BVM

Preoxygenation

n BVM only if necessarySpO2 =/>94% no need to assistSpO2 < 90%, assist ventilations

SpO2 <93% limit intubations attempts to 20 seconds

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The Lost Art

n The Original Airwayn Essential to airway

managementn Basic principle is

oxygen

AIRWAY ASSESSMENTn ROMAN- Difficult bag-valve-mask ventilation

–Radiation/restrictionResistance to ventilate, COPD, ARDS, Term Pregnant

–Obesity/ObstructionBMI over 26

–Mask seal, male sex, mallampatiBushy beards, male faces, Mallampati 3-4

–Aged faceGreater than 55 less than 3

–No teeth

Bag Mask Ventilation

n Standard bag holds 1500 cc oxygen.n Standard ventilation volumes of 500cc

– ventilation rate or 16-24 breaths per minute.

n Use Sellick’s maneuver while bagging?

Bag Mask Ventilation

n Adequate sealn Patent airway

– jaw thrust– oral airway– nasal airway

BVM on face with oral / nasal airways

Bag Mask Ventilation

n Two hand mask hold– most effective for

BMV– Two thumbs up

method

Seated Ventilationn Two thumbs up method with patient

head turned to the siden Second rescuer providing either small

volume or large volume ventilationsn Attach ETCO2 device with BVMn Minimizes aspiration based on gastric

bubble 12-18 inches lower than glottisn Easier with atelectasis and airway

pressures required to maintain adequate tidal volumes

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PREOXYGENATION

n Patients in whom intubation was attempted with SpO2 values above 93%, desaturations occurred only 6% after 7 minutes

n Patients in whom intubation was attempted with SpO2 values below 93%, desaturations were inevitable

Normal 70 kg Adult

Sick 70 kg Adult

Child 10 kg

Obese 127 kg adult

From Benumof J, Dagg R, Benumof R. Critical desaturation will occur before return to an unparalyzed state following 1mg/kg IV succinylcholine. Anesthesiology 1997;87:979.

Communication and Teamwork are Essential

n The key factor that makes problem solving and crisis management successful or not is communication and teamwork– Clear leadership– Stay calm

n Is the patient being ventilated?n Do you have enough help?n Verbalize your thoughts

Communication and Teamwork

n Two-Challenge Rule– If first verbal observation of a problem is not

acknowledged or acted upon, challenge again.

– If the safety issue persists, become more assertive. C- I am Concerned about…

U- I am Unconfortable because...S- This is a Safety issue....

Communication and Teamwork

It is difficult to challenge someone in authority

Airline Industry recognized and implemented industry wide changes and training.

If a co-pilot facing personal death in an airplane crash, can’t question the pilot, how is for a nurse to challenge a doctor?

Communication and Teamwork

n Leaders in a critical event need to be open to feedback and suggestions.

n Foster clinical environment in which all staff feels empowered to speak up.

n See something, Say something.

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GOALS

n Pretreatmentn Induction Agentsn Paralyticsn Topical Agents

Things to Consider

n Drugs and side effectsn Co-morbid conditionsn Pathophysiologic reflexesn Increased intracranial pressure

Pretreatment

n Administration of drugs to minimize the adverse effects of intubation– L-Lidocaine– O-Opiates – A-Atropine– D-Defasciculating dose

Lidocaine

n Blunts cough reflexn Prevents rise in

intracranial pressure

n ? Reactive airway disease

Lidocaine

n Sodium channel blockade decreases cerebral metabolism, stabilizes cell membranes – neuroprotective.

n Reduces cardiomyopathic dysrhythmias by up to 50% -cardioprotective.

n Decreases intraocular pressure.

Fentanyl

n Decreases sympathetic response

n Decreases myocardial oxygen consumption

n Provides analgesia and sedation

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Atropinen Indicated for every

child under 1yr old.n Indicated for every

child under 10 yr old receiving succinylcholine.

n Indicated for every adolescent or adult getting repeat doses of succinylcholine.

Non-Depolarizing Paralytic

n Defasciculating dose– 1/10 dose of competitive paralytic.– For use with succinylcholine.– Suppresses ICP response of

succinylcholine.

Paralysis with Induction

n Use rapid acting agents – Quick onset– Duration of action– Side effects– DO NOT TITRATE

Drugs

� Induction Agents– Etomidate– Ketamine – Propofol– Barbiturates– Benzodiazepines

n Paralytics– Depolarizing Agents– Non-Depolarizing

Agents

Etomidate

n Induction agent of choice

n Rapid actionn Short durationn Lack of cardio-

depressant side effects

n Cerebroprotective

Ketamine

� Induction agent of choice for bronchospasm

� Quick onset� Short duration� High potency

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Propofol

n Onset: less than 1 minute

n Duration: Rapidly metabolized within 10 minutes

n MOA: highly lipophyllic sedative-hypnotic

n Decreases ICPn Anticonvulsant

Midazolam

n Unparalleled amnesia

n Onset of action 3-5 minutes

n Variable dosen No role for

inductionn Valuable for post

intubation sedation

Depolarizing Paralytics Succinylcholine

n Onset: 30-60 seconds

n Duration: 5- 12 minutes

n MOA: depolarizing paralytic, binds to ACH receptors

Succinylcholine Contraindications

Burns over ten percent BSA: 48 hours to 6 months

Paralysis: 3 days to 6 months Denervation syndrome: Until inactive for 6

months Crush Injury: 3 days to 6 months Abdominal Sepsis: Longer than 3 days Hereditary myopathies Renal Failure?(avoid with elevated

potassium)

Nondepolarizing Paralytics

– Longer onset / long acting– Newer agents have rapid onset– Do not require defasciculation

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Rocuronium

n Onset: 55-70 secn Duration: 30-60

minutesn Dose:0.6-0.9

mg/kgn Drug of choice in

kids, if succinylcholine is contraindicated

Cis-atracurium

Onset: 2 minutes Duration: 40-60

minutes Dose: 0.1-0.2

mg/kg

Vecuronium

n Onset 2-3 minutesn Duration: 30-60

minutesn Dose - 0.1 mg/kg

– High doses have quicker action-0.3 mg/kg

– Useful as defasciculating agent

NondepolarizingNeuromuscular blockade

Reversal

� Atropine PLUS– blunts muscarinic response

� Neostigmine / Edrophonium– duration of action 10-30 min

� Sugammadex-rapid reversal agent

Topical Agents

n Lidocainen Cocainen Neosynephrine

Position is Critical

Protection and Position

n ? Sellick’s maneuver

n ? Sniffing positionn Head Upn C-Spine precautions

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HEADS UP

n 50% lung volume is lost lying flatn Preoxygenation with 20 degree head-

up tilt provides longer duration of non-hypoxic apnea than conventional preoxygenation in non-obese healthy adult

Position

n “Ear at the sternal notch”

Flexion

Neutral Extension

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Jaw Thrust Tongue Traction

Head Elevated Position Sellick’s Maneuver

Flexion Neutral Extension

Protection and Position

n Sellick’sn BURP - Backward, Upward, Rightward

Pressuren ELM - External Laryngeal Manipulation

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ELM

n External manipulation by the laryngoscopist.

n Improves POGO scores 57%.

ENDOTRACHEAL INTUBATION

n Preferred method for airway management

n Protect against aspiration

INDICATIONS

n Failure to protect or maintain airwayn Failure to Oxygenate or Ventilaten Anticipated clinical course

Contraindicated when patient is managing a patent airway without clinical indication to provide advanced airway management

Equipment needed

n Oxygenn BVMn Suctionn BLS Airwaysn ET Tubes/styletsn Syringen Bougie

n Magil Forcepsn Laryngoscope/blad

esn Video

Laryngoscopen Back up airwaysn Monitoring devicesn Confirmation

devicesn Stabilization device

Blade choices

n Personal preferencen Use it as it was

designedn Bigger blades

control bigger tongues

n Millern Macintosh

Curved Blades

n Designed to be placed in the vallecula– can be used as a

straight blade

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Straight Blades

n Designed to pick up the epiglottis

n Thinner blade design

n Less tongue control

Technique

n Grip– avoid the “death

grip”– use fingers for

precision movements

– use shoulder for leverage

– lift toward the ceiling over patient’s feet

Tube Angle

Straight tube 90 degree hook 30 degree bend

BougieEndotracheal Tube

Exchanger/introducer

Landmarks

n Tongue is your enemy

n Epiglottis is your friend

n Cords are the goal

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Open Mouth Tongue Sweep

SALAD Suction –Assisted Laryngoscopy

Airway Decontamination

n Developed by Dr. James DuCanton Constant upper airway suctionn After clearing contaminant from the airway,

the catheter can be left in place, to the left of the laryngoscope blade continuously removing blood, vomit and other materials. The practitioner can intubate, with the catheter in place via either direct or video laryngoscopy.

Video LaryngoscopyWhat have we learned?n SUCTION!!n Walk the blade down

the mouthn Insert midline or

slightly left of centern When you see the

uvula, lift to expose the airway

n Slide stylet out slightly

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Don’t rely on Video Laryngoscopy to save the day

n First pass success rate with GlideScopereported 80-90% and ultimate success rate of 98%.

n BUT, VL can fail…. and if difficult-to-ventilate patient, first pass success is critical.

Patient characteristics associated with first-pass failure using VL

include:

n Morbid obesityn Blood/ emesis in the airwayn Airway edeman Massn Restricted neck motionn Limited mouth openingn Surgery/radiation

Failure of VL can be related to technique

n Look at the Patient Until the ETT Tip Appears on the Monitor

n A More Neutral Head Position Helpsn Don’t Insert the Blade Too Deepn Don’t Insert the ETT Too Posteriorlyn Don’t Forget to Lift the Blade and Jaw

Upwardn May Need Cricoid Pressure

ETT Tip in Correct Plane of Larynx

ETT too deep Optimal Positioning

If the ETT can’t make the turn into the larynx, too deep/posterior of pharnyx

ETT bottom of monitor ETT middle/upper right

There Is No Situation So Bad That You Can’t Make Worse

n When do you stop if something’s not working?– Change technique– Change equipment– Change people– Two-Challenge Rule

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Supraglottic Devices

n Do not provide a “definitive airway.”n Rescue devices.n Can be as effective as intubation.n Can be used in failed airways provided

cricothyrotomy is being set up.

Supraglottic Devices

n Laryngeal Mask Airway (LMA)n Intubating LMAn King LT n Combitube

Laryngeal Mask Airway

n Single lumen mask airway device.

n Covers glottic opening and allows ventilation.

Intubating LMA

n Laryngeal Mask Airway with intubation port.

n Allows placement of cuffed tracheal tube.

Combitube

n Dual Lumen rescue airway device.

n Two inflation ports.n Ventilation aperture

between balloons and distal tip.

n Distal cuff does not block esophagus.

King LT

n Single lumen airway device.

n Double balloon has one inflation port.

n Ventilation apertures between the balloons.

n Distal cuffs blocks esophagus.

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King LT

IGELPLAN FOR THE END IN THE

BEGINNING

n Preparation– Have everything ready for the worst.

n Dentures– Leave them in while bagging, take them

out to intubate.

n Lubricationn External laryngeal manipulation

– Master it and use it.

Postintubation Management

n Bradycardia is due to esophageal intubation and hypoxemia until proven otherwise

n Confirm with ETCO2/SpO2/Auscultation/PCXR

n Secure ETTn Sedationn Paralysisn NGT/OGT

Placement with Proofn USE A STYLETn Take your timen Visualizationn Utilize detection

methods– ETT detector– O2 saturation– Waveform

Capnography– Physical exam - not

reliable

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Postintubation Management

n Monitor tube depth– Pediatric airway - use collar

n Reassess tube after moving patient or any clinical change

n Ventilator management / Bagging

Summary

n Consider specific measures to improve oxygenation and first time success

n Predict the updated pneumonic on difficult airway assessment HEAVEN

n Implement two thumbs up method, HOB elevated, High Flow NC, PEEP, and ETCO2 to airway management

SUMMARY

n Videoscopic intubation requires finesse than muscle

n When in doubt, go back to the basicsn Proper assessment and suctioning of

airway will help prevent failuren First pass success vs desaturation are

both equally important