Is there a Middle Way?

Faculty of Pre-hospital Care

Thursday 8th July 2010Birmingham

SO YOU THINK YOU KNOW ALL ABOUT VENTILATION

Dr Andy Mason, Bury St Edmunds, Suffolk, UK

BASICS-Accredited Immediate Care PhysicianMember, Suffolk Accident Rescue Service (1974- ; Committee 1980-

2006 ; Chairman 1997-2000)Advisory Panel Member, SLAM Airway Training Institute, Dallas,

Texas Airway Training Course Adviser, Santa Casa Hospital CTVA, Sao

Paulo, BrazilFormer Lecturer, Paramedic Training Course, East Anglian Ambulance

Trust Former Prehospital Care Adviser, Intavent Orthofix Ltd, Maidenhead,

UKFormer Medical Adviser, Laryngeal Mask Company, Worldwide

PREHOSPITAL AIRWAY MANAGEMENTIS THERE A “MIDDLE WAY”?

SLAM AIRWAY MANAGEMENT TEXTBOOK

Dr. ANDY MASON

ASSISTANT EDITOR & CHAPTER CO-AUTHOR

THE “MIDDLE WAY”

The “Middle Way” is an ancient Buddhist concept representing a path mid-way between the extremes

of self-denial and self-indulgence.

Buddhists believe that this high middle path hasan intrinsic value which is greater than a mere compromise

The Middle Way

Self-denial Self-indulgence

Basic Airway Care Conventional RSI

THE “MIDDLE WAY” – THE CHALLENGE

Is there a similar “Middle Way” in pre-hospital carenot just a compromise between

Basic Airway Care and Conventional RSIbut an effective method of emergency care

with its own intrinsic value?

?

1. Selection of appropriate patients

2. Use of the most appropriate airway device

3. Use of appropriate drugs, when necessary, to help secure the airway

THE “MIDDLE WAY”

THE “MIDDLE WAY” OF PREHOSPITAL AIRWAY MANAGEMENT

IS BASED ON THREE PRINCIPLES:

1. Selection of appropriate patients

2. Use of the most appropriate airway device

3. Use of appropriate drugs, when necessary, to help secure the airway

THE “MIDDLE WAY”

THE “MIDDLE WAY” OF PREHOSPITAL AIRWAY MANAGEMENTIS BASED ON THREE PRINCIPLES:

1. Apnoea2. Airway injury3. Large flail segment or respiratory failure4. Unstable mid-face trauma5. GCS <9 (or sustained seizure activity)6. High aspiration risk7. Inability otherwise to maintain an airway or

oxygenation.Source: www.trauma.org/anaesthesia/airway.html

SELECTION OF APPROPRIATE PATIENTS

The trauma.org website identifies the following categories of patient “who require a definitively secured airway”

Condition-based guidelines all suffer from a lack of claritywhich can result in haphazard and inappropriate

selection of patients

1. Those who are ‘P’ or ‘U’ on AVPU scale

AND…

2. Also have an SpO2 reading of 92% (despite optimal efforts to improve oxygenation using ‘basic’ methods)or…Also have a respiratory rate 10 or 30 breaths-per-minute (when an SpO2 is unobtainable)

SELECTION OF APPROPRIATE PATIENTS

PATIENTS CAN BE SELECTED USING ‘PU-92 CONCEPT’

Hypoxemia occurs when SaO2 ≤90%

Most pulse oximeters have ± 2% error

Therefore, to avoid hypoxemia, the SpO2 should be maintained above 92%.

Why adopt an SpO2 threshold of 92%?

THE ‘PU-92 CONCEPT’

THE ‘PU-92 CONCEPT’ ALGORITHM

1. Selection of appropriate patients

2. Use of the most appropriate airway device

3. Use of appropriate drugs, when necessary, to help secure the airway

THE “MIDDLE WAY”

THE “MIDDLE WAY” OF PREHOSPITAL AIRWAY MANAGEMENTIS BASED ON THREE PRINCIPLES:

The Cuffed Endotracheal Tubeis the

in Emergency Airway ManagementGOLD STANDARD

(but only when it is placed into the trachea!)

THE GOLD STANDARD

OBJECTS INSERTED INTO THE AIRWAYDON’T ALWAYS FOLLOW THE INTENDED ROUTE!

Not from aFailure to Intubate!

A Failure to Ventilate

&A Failure to Oxygenate

Patients die from:

EMERGENCY VENTILATION

Bag-Valve-Mask Device Endotracheal Tube

Laryngeal Mask Airway1987

WHEN IT FIRST APPEARED THE LMA WAS DESCRIBED AS “THE MISSING LINK”

Slide courtesy of Dr Harald V Genzwürker, University Hospital Mannheim, Germany harald.genzwuerker@anaes.ma.uni-heidelberg.de

BUT WHICH SUPRAGLOTTIC AIRWAY DEVICE (SAD) TO CHOOSE?

LMA Classic™(Class IIa)

Combitube™(Class IIa)

BUT WHICH SUPRAGLOTTIC AIRWAY DEVICE (SAD) TO CHOOSE?

The LMA Fastrach and LMA CTrach are the only two SADs that act both as rescue ventilation devices AND offer seamless progression to tracheal

intubation without any interruption in ventilation and oxygenation

LMA Fastrach

“The current structure of prehospital management is insufficient to meet the needs of the severely injured patient. There is a high incidence of failed intubation and a high incidence of patients arriving at hospital with a partially or completely obstructed airway. Change is urgently required to provide a system that reliably provides a clear airway with good oxygenation and control of ventilation. This may be through the provision of personnel with the ability to provide anaesthesia and intubation in the prehospital phase or the use of alternative airway devices.”

NCEPOD Report , Chapter 6 (Airway & Breathing), 2007

NATIONAL CONFIDENTIAL ENQUIRY INTOPATIENT OUTCOME AND DEATH - 2007

We are Family!

LMA Flexible

LMA ProSealLMA Classic

LMA Fastrach

Single-useLMA Flexible

Single-useLMA Unique

Single-useLMA Fastrach

LMA™ RANGE OF SADs

LMA CTrach™

Re-usable intubating LMA with twin fibreoptic channels and detachable full-colour viewer

LMA SUPREME™

LMA Supreme™

Single-use LMA with gastric port anatomically-curved airway tube

and redesigned cuff

Cuff inflation valve (with pilot balloon)

Anatomically-curvedstainless steel airway tube

Handle

Cuff inflation line

Silicone coating on airway tube

Silicone cuff

Epiglottic elevating bar

RE-USABLE LMA FASTRACH™ (iLMA)

RE-USABLE LMA FASTRACH™

SINGLE-USE LMA FASTRACH™

1. No need for laryngoscopy

2. Head & neck must be kept in neutral alignment for insertion

3. Neuromuscular blockade not necessary

4. At least as easy to insert as the standard LMA

5. Requires an inter-dental gap of only 20mm

6. Can be introduced blindly with one hand from any position

7. No need to insert a finger into patient’s mouth

8. Rigid airway tube resists occlusion by biting

9. Suitable as a rescue ventilation device in its own right

10. Facilitates seamless progression to tracheal intubation

11. Permits ventilation between/during intubation attempts

12. Available as disposable single-use device.

12 REASONS WHY THE LMA FASTRACH™

IS SUITABLE FOR PREHOSPITAL USE

1. Selection of appropriate patients

2. Use of the most appropriate airway device

3. Use of appropriate drugs, when necessary, to help secure the airway

THE “MIDDLE WAY”

THE “MIDDLE WAY” OF PREHOSPITAL AIRWAY MANAGEMENTIS BASED ON THREE PRINCIPLES:

All drugs require careful titration

and all can worsen the physiological parameters especially hypotension

Drug Management

Midazolam has become the drug used to facilitate the insertion of the LMA

A sliding scale based upon the patient’s GCS score has been developed

0.5 mg of midazolam given IV for every point on the GCS score above 3, repeated after 3 minutes if conditions are still unsuitable for

LMA insertion

Drug Management

Thus a patient with a GCS of 8 would receive 0.5 x 5 mgGiving a starting dose of 2.5mg

This may be repeated after 3 minutes To give a maximum of 5mg

A paper from USA - Swanson ER, Fosnocht DE, Jensen SC. Comparison of etomidate and midazolam for prehospital rapid-sequence intubation. Prehosp Emerg Care 2004 Jul-Sep;8(3):273-9) – supports such doses

Drug Management

Having gained airway security

For the journey to hospital

A mixture of midazolam and fentanyl

may be used

Drug Management

Trapped Trauma Case Serieswith LMA Fastrach™

LMA FASTRACH™

ACKNOWLEDGEMENTGRATEFUL THANKS TO THOSE PATIENTS AND RELATIVES WHO GAVE PERMISSION

FOR PHOTOGRAPHS TO BE USEDIN THIS PRESENTATION

ACKNOWLEDGEMENT

LMA FASTRACH™

Picture courtesy Life-Assist Inc., Rancho Cordova, CA, USA

The Beck Airway Airflow Monitor (BAAM)

Can take up to a size 8 ET tube

Chandy Manoeuvre

The ILMAcan be removed;

best done in hospital

LMA FASTRACH™

FINAL REFERENCE (6)(Timmermann A, Russo SG, Rosenblatt WH, Eich C, Barwing J, Roessler M, Graf BM. Intubating laryngeal mask airway for difficult

out-of-hospital airway management: a prospective evaluation. Br J Anaesth. 2007 Aug;99(2):286-91.)

21 anaesthesia-trained emergency physicians used the ILMA in out-of-hospital patients with difficult-to-manage airways over a period of 1 year

Difficult-to-manage airways included patients with difficult laryngoscopy, multiple intubation attempts, limited access to the patient's head, presence of pharyngo-laryngeal trauma, and gastric fluids or bleeding obscuring the view of the vocal cords

146 (5.8%) of 2513 patients treated underwent tracheal intubation or insertion of an alternate rescue airway device. Eleven (7.5%) of the 146 had difficult-to-manage airways and were treated using the ILMA

Ventilation and intubation via the ILMA were achieved in all 11 patients, 10 at the first attempt and 1 at the second.

CONCLUSIONS: Our data support the use of the ILMA as a rescue device for out-of-hospital airway management by staff who have appropriate airway skills and have received appropriate training.

Br J Anaesth. August 2007

FINAL REFERENCE

The LMA Fastrach™ offers trauma patients the opportunity of dying of

something other than a compromised airway in the prehospital setting

LMA FASTRACH™ IN PREHOSPITAL CARE

Mason A.M.

Recognise that appropriate airway skills and training are both required

to correctly use the iLMA