Advanced Airway Management

Leaugeay Webre, BS, CCEMT-P, NREMT-P

Modified Forms of Respiration

• Reflexes which act to protect the respiratory system:– Cough- forceful, spasmodic exhalation of a large

volume of air– Sneeze- sudden forceful exhalation from the nose– Hiccough- sudden inspiration caused by spasmodic

contraction of the diaphragm & glottic closure– Gag reflex- spastic pharyngeal & esophageal reflex

caused by stimulation of posterior pharynx– Sighing- hyperinflation of lungs, opens atelectic

alveoli

The ability to breathe and the ability to protect the airway are not always the same.

ASSESSMENT

• BSI/ scene safety• General impression• Identify and correct any life threatening

conditions:• Responsiveness/ c-spine• Airway• Breathing • Circulation

GENERAL IMPRESSION

• POSITION– Tripod

– Bolt upright• COPD• CHF

• Able to speak in sentences

AIRWAY

• Is it patent?– Snoring, gurgling or stridor may indicate

potential problems– Secretions, objects, blood, vomitus present

• Neck– JVD (jugular vein distention)– TD (tracheal deviation, tugging)

BREATHING• Adequacy?

– Rate and quality?• Spontaneous & regular

• effortless

• Chest rise – Equal and present: excursion

• Deformity/ crepitus

• Ecchymosis

• Subcutaneous emphysema

• Paradoxical (asymmetric)– Flail chest

BREATHING EFFORT

• Normal• Labored/ dyspnic• Tachypnic/ bradypnea• Accessory muscle use

– Intercostal retractions– Suprasternal– Abdominal muscle use

• Pediatrics– Grunting– Nostril flaring

BREATH SOUNDS

• CTA bilat

• Diminished

• Rhonci

• Rales

• Wheezing

RESPIRATORY PATTERNS

• Cheyne –Stokes– Regular pattern of increasing rate & volume

followed by gradual decrease and a short period of apnea

– Brain stem insult

• Kussmaul’s– Deep, gasping regular respirations– Diabetic coma

• Biot’s– Irregular rate & volume with intermittent periods of

apnea– Increased ICP

• Central Neurogenic Hyperventilation– Regular, deep and rapid– Increased ICP

• Agonal– Slow, shallow, irregular– Brain hypoxia

PULSUS PARADOXUS

• Decrease in systolic BP > 10 mm HG during inspiration

• Caused by increase in intrathoracic pressure– COPD

• Interference with ventricular filling

• Results in decreased BP

DEFINITIONS

• Hypoxemia– Reduction of O2 in arterial blood

• Hypoxia– Insufficient O2 available to meet O2 requirements

• Hypercarbia– Increased level of CO@ in blood

Monitoring• Pulse oximetry

• End tidal CO2– Quantitative

• capnography

– Qualitative• Colormetric

– Purple to yellow

CAPNOGRAPHY- EtCO2

• Standard of care in hospital

• Immediate response to extubation

• Stand up in court to prove intubation

• Waveform indicative:– Normal– Obstructed airway- do you NEED a B-2

agonist?

WAVEFORM

• Normal– Acute upstroke- exhalation– Acute down stroke- inhalation– Straight across

– Shark fin- lower airway obstruction

Advanced Airway Management

• Manual airway control

• Ventilation

• Oxygenation

• …Proceed to advanced management

• Allows for correction of:– Profound hypoxia– hypercarbia

• Followed by advanced adjunct placement ASAP– Prevent gastric inflation

– Prevent aspiration

• Endotracheal tube

• Combitube

• PtL

• LMA

Endotracheal Intubation

• When ventilating an unresponsive patient through conventional methods cannot be achieved

• Protect the airway

• Prolonged artificial respiration required

• Patients with or likely to experience upper airway compromise

• Decreased tidal volume- bradypnea

• Airway obstruction

Advantages

• Controls the airway

• Facilitates ventilation/ O2

• Prevents gastric inflation

• Allows for direct suctioning

• Medication administration

Disadvantages

• Requires extensive and ongoing training for proficiency

• Requires specialized equipment• Bypasses physiological function of upper

airway– Warm– Filter– Humidify

Complications with Intubated Patients

• Displacement

• Obstruction

• Pneumothorax

• Equipment failure

• Contraindicated in epiglottitis

Possible Occurring Complications

• Bleeding• Laryngeal swelling• Laryngospasm• Vocal cord damage• Mucosal necrosis• Barotrauma• Dental trauma• Laryngeal trauma• Esophageal placement

Laryngoscope• Move tongue and epiglottis

• Allows visualization of cords and glottis

• Miller- straight– Lift epiglottis– pediatrics

• Macintosh- curved– Fits in valeculla– More room for visualization– Reduced trauma/ gag reflex

ETT• 15mm universal adapter

• 2.5-9.0mm diameter

• 12-32cm length– Male- 23cm 8.0-8.5mm– Female- 21cm 7.5-8.0mm

• Balloon cuff– Occludes tracheal lumen– Pilot balloon

• magill forceps

• Direct observation

• Breathing & apneic

• BSI- goggles & gloves

• Position- sniffing

• Preoxygenate– Replace nitrogen stores with O2

• Assemble & check equipment

Verify Placement

• Esophageal intubation detector

• CO2 detector

• Auscultation

• EtCO2 Capnography– 35-45mm Hg– Hyperventilation in head injury with herniation 30-

35mm HG

ASPIRATION

• Partially dissolved food

• Protein dissolving enzymes

• Hydrochloric acid

Pathophysiology

• Increased interstitial fluid due to injury

• Pulmonary edema

• Destruction of alveoli

• ARDS– Impaired gas exchange– Hypoxemia– Hypercarbia– Increased mortality

Prevention

• Cricoid pressure

• Suctioning– Tonsil tip– Whistle tip

• Positioning

Hazards of Suctioning

• Cardiac dysrhythmias

• Increased BP/ HR

• Decreased BP/ HR

• Gag reflex– Cough– Increased ICP– Decreased CBF

Multilumen Airways

• Combitube

• Pharyngotracheal Lumen Airway

Advantages

• Blind insertion

• Facial seal is not necessary

• Can be placed in esophagus or trachea

Contraindications

• < 16 years old

• < 5 feet tall or > 6 ft 7 in tall (4 ft combi)

• Ingestion of caustic substances

• Esophageal disease

• Presence of gag reflex