A patient who needs intubation may be awake.Need for airway control may necessitate

intubation. RSI paralyzes the patient to facilitate

endotracheal intubation.

Anatomical DifferencesSmaller and more flexible than an adultTongue proportionately largerEpiglottis floppy and roundGlottic opening higher and more anteriorVocal cords slant upward, and are

closer to the base of the tongueNarrowest part is the cricoid cartilage

A straight laryngoscope blade is preferred for most pediatric patients.

Selecting the appropriate tube diameter for children is critical. ETT size (mm) = (Age in years + 16) ÷ 4Matching it to the diameter of the child’s

smallest finger Use non-cuffed endotracheal tubes with

infants and children under the age of 8 years.

© Scott Metcalfe

© Scott Metcalfe

© Scott Metcalfe

© Scott Metcalfe

© Scott Metcalfe

© Scott Metcalfe

© Scott Metcalfe

© Scott Metcalfe

Mask seal can be more difficult Bag size depends on age of child Ventilate according to current

standards Obtain chest rise and fall with each

breath Assess adequacy of ventilations by

observing chest rise, listening to lung sounds, and assessing clinical improvement

“Blind” procedure without direct visualization of the vocal cords

Indications include:Possible spinal injuryClenched teethFractured jaw, oral injuries, or recent

oral surgeryFacial or airway swellingObesityArthritis preventing sniffing position

ContraindicationsSuspected nasal fracturesSuspected basilar skull fracturesSignificantly deviated nasal septum or other

nasal obstructionCardiac or respiratory arrest

AdvantagesThe head and neck can remain in neutral

position It does not produce as much gag response

and is better tolerated by the awake patient It can be secured more easily than an

orotracheal tubeThe patient cannot bite the ETT

DisadvantagesMore difficult and time consuming Potentially more traumatic for patientsTube may kink or clog more easily Greater risk of infection Improper placement more likelyRequires that patient be breathing

Field extubation may be indicated when:The patient is clearly able to maintain and

protect his airway.The patient is not under the influence of

sedatives.Reassessment indicates the problem that

led to endotracheal intubation is resolved. Consider the high risk of laryngospasm

A dual-lumen airwayThe longer, blue port (#1) is the proximal

port The shorter, clear port (#2) is the distal port,

which opens at the distal end of the tube Two inflatable cuffs

100-mL cuff just proximal to the distal port 15-mL cuff just distal to the proximal port

ETC Airway Tracheal Placement

AdvantagesProvides alternate airway control Insertion is rapid and easyDoes not require visualization of the larynxPharyngeal balloon anchors the airway Patient may be ventilated regardless of tube

placementSignificantly diminishes gastric distention Can be used on trauma patientsGastric contents can be suctioned

DisadvantagesSuctioning tracheal secretions is impossible

when the airway is in the esophagus.Placing an endotracheal tube is very difficult

with the ETC in place. It cannot be used in conscious patients or in

those with a gag reflex.

DisadvantagesThe cuffs can cause esophageal, tracheal,

and hypopharyngeal ischemia. It does not isolate and completely protect

the trachea. It cannot be used in patients with

esophageal disease or caustic ingestions. It cannot be used with pediatric patients.

Click here to view a video on ETC.

Two-tube system:Proximal cuff seals

oropharynxDistal cuff seals

either the esophagus or the trachea

Advantages Disadvantages

Has an inflatable distal end that is placed in the hypopharynx and then inflated

Blind insertion Disadvantage:

Does not isolate trachea

It is designed to facilitate endotracheal intubation.

An epiglottic elevating bar in the mask aperture elevates the epiglottis.

Tube is directed centrally and anteriorly. © LMA North America

Similar to the laryngeal mask Supraglottic airway

“Cobra head” of the airway holds both the soft tissue and the epiglottis out of the way

© Engineered Medical Systems, Inc. Indianapolis, IN

Supraglottic, single-use, disposable airway

Features a special curve that replicates the natural human airway anatomy

© Ambu Inc. Baltimore, MD

Alternative airwayLarge silicone cuff

that disperses pressure over a large mucosal surface area

Stabilizes the airway at the base of the tongue

©Tracey Lemons/King Systems Corporation, Indianapolis, Indiana

Removing an obstructing foreign body using Magill forceps or a suction device

You should carry out basic life support maneuvers first. If these fail to alleviate the obstruction,

direct visualization of the airway for foreign body removal is indicated.

You should use surgical airway procedures only after you have exhausted your other airway skills:Needle cricothyrotomySurgical cricothyrotomy

Indications Massive facial or neck trauma Total upper airway obstruction

Contraindications Inability to identify anatomical landmarks Crush injury to the larynx Tracheal transection Underlying anatomical abnormalities

Transtracheal jet insufflation is required Complications:

Barotrauma from overinflationExcessive bleeding due to improper catheter

placementSubcutaneous emphysemaAirway obstructionHypoventilation

It is preferred to needle cricothyrotomy when a complete obstruction prevents a glottic route for expiration.

Its greater potential complications mandate even more training and skills monitoring.

Contraindications: Includes children under 12

Cricothyrotomy Complications: Incorrect tube placement into a false

passageCricoid and/or thyroid cartilage damageThyroid gland damageSevere bleedingLaryngeal nerve damageSubcutaneous emphysemaVocal cord damage Infection

Stabilize larynx and make a 1–2 cm vertical skin incision over

cricothyroid membrane

Using a curved hemostat, spread membrane incision open

TermsDifficult airway

A conventionally trained paramedic experiences difficulty with mask ventilation, endotracheal intubation, or both

Difficult mask ventilation Inability of unassisted paramedic to maintain an

SpO2 > 90% using 100% oxygen and positive pressure mask ventilation

Inability of the unassisted paramedic to prevent or reverse signs of inadequate ventilation during positive pressure mask ventilation

Terms (cont.)Difficult laryngoscopy

Not being able to see any part of the vocal cords with conventional laryngoscopy

Difficult intubation Conventional laryngoscopy requires either (1) more

than three attempts, or (2) more than ten minutes Factors related to difficult airway are

related to historical information, anatomical, and poor technique

Historical Factors:Patient has had a history of problems with

airway management or anesthesia. If time and patient condition allows, obtain a

brief airway history.

Anatomical ConsiderationsAnatomy of the upper airway varies

significantly across the human species.The most frequently used system of pre-

intubation airway assessment is the Mallampati Classification system. The tonsillar pillars and the uvula are assessed.

Class 1 Entire tonsil clearly

visible Class 2

Upper half of tonsil fossa visible

Class 3 Soft and hard palate

clearly visible Class 4

Only hard palate visible

The Mallampati classification system is at top.

Other rating systemsRevised Cormack and LeHane classifications

Similar to Mallampati Assigns 4 classes

POGO The percentage of the glottis that can be visualized

is scored From 0 to 100%

Short neck Thick neck Restricted range

of motion Dentition Small mouth

Short mandible Anterior larynx Obesity Anatomical

distortion

Patients who have had a laryngectomy or tracheostomy breathe through a stoma.

There are often problems with excess secretions, and a stoma may become plugged.Use extreme caution with any suctioning.

Anticipating complications when managing an airway Be prepared to

suction all airways to remove blood or other secretions and forthe patient to vomit.

Tracheostomy cannulae

Wear protective eyewear, gloves, and face mask.

Preoxygenate the patient. Determine depth of catheter insertion. With suction off, insert catheter. Suction while removing catheter . Ventilate patient.

It is sometimes necessary to remove secretions or mucous plugs that can cause respiratory distress.

Hypoxia is a concern. Use sterile technique. It may be necessary to instill sterile

water to thin secretions.

A common problem with ventilating a nonintubated patient is gastric distention.

You should place a tube in the stomach for gastric decompression.Nasogastric tubeOrogastric tube

Indications:The need for decompression because of the

risk of aspiration or difficulty ventilating Gastric lavage in hypothermia and some

overdose emergencies Complications:

Possibility of esophageal bleeding Increased risk of esophageal perforation

ProcedurePlace head in neutral positionMeasure tubeUse topical anesthetic Lubricate and insert tube

Encourage patient to swallowAdvance to pre-determined markVerify placementApply suctionSecure in place

Device Oxygen Percentage

Nasal cannula

Simple face mask

Nonrebreather mask

Venturi mask

40%

24, 28, 35, or 40%

40 – 60%

80 – 95%

Small Volume NebulizerAllows for delivery of medications in aerosol

form (nebulization) Oxygen Humidifier

Benefits patients with croup, epiglottitis, or bronchiolitis, as well as those patients receiving long-term oxygen therapy

Effective ventilatory support requires a tidal volume of at least 800 mL of oxygen at 10 to 12 breaths per minute.

Effective artificial ventilation requires: A patent airwayAn effective seal between the mask and the

patient’s faceDelivery of adequate volumes

Mouth-to-mouth Mouth-to-nose Mouth-to-mask Bag-valve device Demand valve device Automatic transport ventilator

Indicated in the presence of apnea when no other ventilation devices are availableLimited by the capacity of the person

delivering the ventilations Potential for exposing either the rescuer or

the patient to communicable diseases

Prevents direct contact between you and your patient’s mouth

Devices usually have a one-way valve that prevents you from contacting the patient’s expired air.

May also provide an inlet for supplemental oxygen

Prehospital and emergency department personnel most commonly use the bag-valve device.

One, two, or three rescuers may perform bag-valve-mask ventilation.

© Scott Metcalfe

Observe the patient for chest rise, gastric distention, and changes in compliance of the bag with ventilation.

Complications: Inadequate volume deliveryBarotraumaGastric distention

Flow-restricted, oxygen-powered ventilation device

Flow is restricted to 30 cm H2O or less to diminish gastric distention

Cannot measure delivered volumes or feel lung compliance

Advantages: Maintain minute volume Mechanically simple and

adapts to a portable oxygen supply

Typically comes with two or three controls Rate Volume

Contraindications

A significant percentage of claims and lawsuits involve inadequate patient ventilation.

Detailed documentation shown could go a long way toward warding off such a claim.

It is crucial to document in medically correct and legally sufficient terms exactly what was done in managing the airway.

Anatomy of the Respiratory System Physiology of the Respiratory System Respiratory Problems Respiratory System Assessment Basic Airway Management Advanced Airway Management Orotracheal Intubation Pediatric Orotracheal Intubation Nasotracheal Intubation Managing Patients with Stoma Sites Suctioning Gastric Distention and Decompression Oxygenation Ventilation Documentation