Airway Control and Ventilation - ACLS 2006 With Pics N0V09
Transcript of Airway Control and Ventilation - ACLS 2006 With Pics N0V09
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Airway Control and
Ventilation
HONESTA DE GALAHONESTA DE GALA--VILLALUNA, MD,VILLALUNA, MD,
FPCCPFPCCP
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Ventilation
The purpose of ventilation during CPR isto maintain adequate oxygenation and
sufficient elimination of CO2 During the first few minutes of ventricular
fibrillation sudden cardiac death (VFSCA), rescue breaths are probably not as
important as chest compressions O2 delivery to the tissues appears to be
more dependent on blood flow than onarterial O2 content
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Ventilation
Beyond the first few minutes of cardiacarrest, tissue hypoxia develops
CPR provides approximately 25% to 33%of normal cardiac output
This low-flow state maintains a small butcritical amount of blood flow to the heartand brain, but tissue hypoxia will persistuntil restoration of effective spontaneousperfusion
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Bag-Mask Ventilation
Effective bagEffective bag--maskmask
ventilation requires adequateventilation requires adequate
training & frequent practicetraining & frequent practice
Tidal volume deliveredTidal volume delivered
should be sufficient toshould be sufficient to
produce chest rise over 1produce chest rise over 1
second (6second (6--7mL/kg or 5007mL/kg or 500--600mL)600mL)
During CPR, give 2 breathsDuring CPR, give 2 breaths
during a brief pause afterduring a brief pause after
every 30 chest compressionsevery 30 chest compressions
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Bag-Mask Ventilation
When an advanced airway has replacedWhen an advanced airway has replaced
the face mask,the face mask, 88--10breaths per minute10breaths per minute
should be delivered during CPRshould be delivered during CPR
Deliver each breath over 1 second whileDeliver each breath over 1 second while
chest compressions are delivered at achest compressions are delivered at arate ofrate of100per minute100per minute
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Bag-Mask Ventilation
In patients with severe obstructive pulmonaryIn patients with severe obstructive pulmonary
disease & increased resistance to exhalation,disease & increased resistance to exhalation,
air trapping should be prevented to minimizeair trapping should be prevented to minimizegeneration of autogeneration of auto--PEEPPEEP
AutoAuto--PEEP may reduce cardiac output & bloodPEEP may reduce cardiac output & blood
pressurepressure
UseUse low respiratory rateslow respiratory rates, allowing more time, allowing more timefor complete exhalationfor complete exhalation
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Severe Airway Obstruction
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Dynamic Hyperinflation
Initial breathing cycle
End Expiratory Volume
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Initial breathing cycle Next breathing cycle
End Expiratory Volume
Dynamic Hyperinflation
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Airway Adjuncts
Oropharyngeal AirwaysOropharyngeal Airways
Nasopharyngeal AirwaysNasopharyngeal Airways
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Airway Adjuncts
Oropharyngeal AirwaysOropharyngeal Airways
Reserved for use in unconsciousReserved for use in unconscious
(unresponsive) patients with no(unresponsive) patients with nocough or gag reflexcough or gag reflex
Should be inserted ONLY byShould be inserted ONLY by
people trained in their usepeople trained in their use
Incorrect insertion can displaceIncorrect insertion can displace
the tongue into the hypopharynx,the tongue into the hypopharynx,
causing obstructioncausing obstruction
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Oropharyngeal Airway:
Steps in Insertion
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Airway Adjuncts Nasopharyngeal AirwaysNasopharyngeal Airways
Useful in conditions such asUseful in conditions such aspersons with clenched jaw,persons with clenched jaw,which prevent placement of anwhich prevent placement of an
oral airwayoral airway Should be used with caution inShould be used with caution in
patients with severepatients with severecraniofacial injurycraniofacial injury
Better tolerated than oralBetter tolerated than oralairways not deeplyairways not deeplyunconsciousunconscious
No studies onNo studies on the use inthe use in
cardiac arrest patientscardiac arrest patients
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Advanced Airways
Rescuers must be aware of the risks &Rescuers must be aware of the risks &
benefits of insertion of an advancedbenefits of insertion of an advanced
airway during a resuscitation attemptairway during a resuscitation attempt
Rescuers mayRescuers may defer insertiondefer insertion of anof an
advanced airway until the patient fails toadvanced airway until the patient fails to
respond to initial CPR & defibrillation orrespond to initial CPR & defibrillation ordemonstrates return of spontaneousdemonstrates return of spontaneous
circulationcirculation
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Advanced Airways
Providers must have aProviders must have a second (backup)second (backup)
strategystrategy for airway management &for airway management &
ventilation if unable to establish the firstventilation if unable to establish the first--choice airway adjunctchoice airway adjunct
BagBag--mask ventilation is a backupmask ventilation is a backupstrategystrategy
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Advanced Airways
Once an advanced airway is in place, 2Once an advanced airway is in place, 2rescuers no longer deliver cycles of CPRrescuers no longer deliver cycles of CPR
(old method)(old method) New methodNew method
The compressing rescuer should giveThe compressing rescuer should givecontinuous chest compressions at a ratecontinuous chest compressions at a rate
of 100 per minute,of 100 per minute, WITHOUT PAUSESWITHOUT PAUSESFOR VENTILATIONFOR VENTILATION
The rescuer delivering ventilationThe rescuer delivering ventilationprovides 8 to 10 breaths per minuteprovides 8 to 10 breaths per minute
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Advanced Airways
The 2 rescuers should changeThe 2 rescuers should change
compressor & ventilator rolescompressor & ventilator roles
approximatelyapproximately every 2 minutesevery 2 minutes to preventto preventfatigue and deterioration and quality offatigue and deterioration and quality of
chest compressionschest compressions
For multiple rescuers, they should rotateFor multiple rescuers, they should rotatethe compressor role everythe compressor role every 2 minutes2 minutes
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Esophageal-Tracheal
Combitube The advantage ofThe advantage of
Combitube overCombitube over
endotracheal (ET) tube isendotracheal (ET) tube isrelated to ease of trainingrelated to ease of training
Advantages over bagAdvantages over bag--
mask ventilationmask ventilation Isolation of the airwayIsolation of the airway
Reduced risk of aspirationReduced risk of aspiration
More reliable ventilationMore reliable ventilation
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Esophageal-Tracheal
Combitube ComplicationsComplications
EsophagealEsophageal
traumatrauma
LacerationsLacerations
BruisingBruising
SubcutaneousSubcutaneousemphysemaemphysema
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Laryngeal Mask Airway (LMA)
Advantages over ET tube:Advantages over ET tube: Limited access to patientLimited access to patient
Unstable neck injuryUnstable neck injury
Appropriate positioning of patient notAppropriate positioning of patient notpossiblepossible
After successful insertion, a smallAfter successful insertion, a small
proportion of patients cannot beproportion of patients cannot beventilated with LMAventilated with LMA
An alternative strategy is importantAn alternative strategy is important
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Endotracheal Tube
Providers who perform ETProviders who perform ET
intubation require adequate initialintubation require adequate initial
training and either frequenttraining and either frequent
experience or frequent retrainingexperience or frequent retraining
Complications:Complications:
Trauma to the oropharynxTrauma to the oropharynx
Prolonged interruption ofProlonged interruption ofcompressions and ventilationcompressions and ventilation
HypoxemiaHypoxemia
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Endotracheal Tube
During CPR, the rescuersDuring CPR, the rescuers minimize theminimize the
number and duration of interruptions innumber and duration of interruptions in
chest compressionschest compressions, with a goal to limit, with a goal to limitinterruptions to no more that 10 secondsinterruptions to no more that 10 seconds
The compressions should be interruptedThe compressions should be interrupted
only as long as the intubating rescueronly as long as the intubating rescuerneeds to visualize the vocal cords &needs to visualize the vocal cords &
insert the tubeinsert the tube
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Endotracheal Tube
Thorough assessment of endotrachealThorough assessment of endotracheal
tube position should not requiretube position should not require
interruption of chest compressionsinterruption of chest compressions Visualization of bilateral chest expansionVisualization of bilateral chest expansion
Auscultation of the lung fields & epigastriumAuscultation of the lung fields & epigastrium
Confirmation of placementConfirmation of placement End tidal CO2End tidal CO2
Esophageal detection deviceEsophageal detection device
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Exhaled CO2 Detectors
One of several independent methodsOne of several independent methodsfor confirmation of tube placementfor confirmation of tube placement
When exhaled CO2 is detectedWhen exhaled CO2 is detected
(positive reading for CO2) in cardiac(positive reading for CO2) in cardiacarrest, it is usually a reliable indicatorarrest, it is usually a reliable indicatorfor tube positionfor tube position
FalseFalse--negative readings during CPR isnegative readings during CPR is
due to the blood flow & delivery of CO2due to the blood flow & delivery of CO2to the lungs is lowto the lungs is low
FalseFalse--negative readings may also benegative readings may also bedue to pulmonary embolusdue to pulmonary embolus
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Esophageal Detector
Device (EDD) Positive result for EDDPositive result for EDD thethe
tube is in the esophagustube is in the esophagus
Highly sensitive for detection ofHighly sensitive for detection ofET tubes that were misplaced inET tubes that were misplaced in
the esophagusthe esophagus
Considered as just one ofConsidered as just one ofseveral independent methodsseveral independent methods
for confirmationfor confirmation
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Esophageal DetectorDevice
(EDD) EDD may yield misleading results in theEDD may yield misleading results in the
ff:ff:
Morbid obesityMorbid obesity
Late pregnancyLate pregnancy
Status asthmaticusStatus asthmaticus
Presence of copious ET secretionsPresence of copious ET secretions
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Post-intubation Care
Caveats for rescuers:Caveats for rescuers:
Be sure the advanced airway isBe sure the advanced airway is
correctly placed (verify)correctly placed (verify) The compressing rescuer shouldThe compressing rescuer should
give continuous chest compressionsgive continuous chest compressionsat a rate of 100 per minute withoutat a rate of 100 per minute withoutpauses for ventilation. The rescuerpauses for ventilation. The rescuerdelivering ventilation provides 8delivering ventilation provides 8--1010breaths per minutebreaths per minute
Rescuers should avoid delivering anRescuers should avoid delivering anexcessive ventilation rateexcessive ventilation rate
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THANK YOU!