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Case 1

Respiratory Emergencies© 2001 American Heart Association

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Case PresentationCase Presentation

Patient = 69-year-old man, smoker (4 packs/day) PMHx = severe COPD CC = severe shortness of breath;

“hungry for air!” VS = not obtained; patient suddenly

becomes unresponsive

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Learning and Skills ObjectivesLearning and Skills Objectives

Describe ACLS Approach (Primary and Secondary ABCD Surveys) in CPR

Describe and demonstrate the “airway hierarchy”:• Supplemental oxygen:

– Nasal cannulae– Face masks

• Noninvasive airway devices:– Nasopharyngeal airway– Oropharyngeal airway

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Learning and Skills ObjectivesLearning and Skills Objectives

The airway hierarchy (cont’d)• Recommended invasive airway devices:

– Laryngeal mask airway (LMA)– Esophageal-tracheal (Combitube) tube– Tracheal tube

• Primary/secondary confirmation of tracheal tube placement:– Physical exam criteria– End-tidal CO2 detection– Devices to detect esophageal placement

• Devices to prevent TT dislodgment

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Primary ABCD Survey Primary ABCD Survey

Focus: Basic CPR and Defibrillation• Check responsiveness• Activate emergency response system• Call for defibrillator

A = Airway: open the airwayB = Breathing: check breathing, provide positive-pressure ventilationsC = Circulation: check circulation, give chest compressionsD = Defibrillation: assess for and shock VF/pulseless VT

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Secondary ABCD Survey Secondary ABCD Survey

A = Airway: insert advanced airway device as soon as able(new: 3 types)

B = Breathing: confirm placement by PE (primary tube confirmation)

PLUS

B = Breathing: confirm placement with esophageal detector device or end-tidal CO2 detector or both (secondary tube confirmation)

B = Breathing: use a commercial tube holder to prevent dislodgment

B = Breathing: confirm effective oxygenation/ventilation by 02 sat, CO2 levels, pH

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Anatomy of AirwayAnatomy of Airway

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Airway ObstructionAirway Obstruction

Most common cause: tongue and/or epiglottis

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Opening the AirwayOpening the Airway

Jaw thrust Head tilt–chin lift

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The Oropharyngeal AirwayThe Oropharyngeal Airway

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Malposition of Oropharyngeal Airway

Malposition of Oropharyngeal Airway

Too short

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Nasopharyngeal Airway Nasopharyngeal Airway

Insertion technique

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Barrier DevicesBarrier Devices

Oral airway: inserts in patient

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Pocket-Mask DevicesPocket-Mask Devices

1-way valve

Port to attach O2 source

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Mouth-to-Mask VentilationMouth-to-Mask Ventilation

Advantages

• Eliminates direct contact

• Enables positive-pressure ventilation

• Oxygenates well if O2 attached

• Easier to perform than bag-mask ventilation

• Best for small-handed rescuers

• 1-rescuer technique; performed from side

• Rescuer slides over for chest compressions

• Fingers: head tilt–chin lift

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Mouth-to-Mask VentilationMouth-to-Mask Ventilation

Fingers: jaw thrust upward Fingers: head tilt–chin lift

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Bag-Mask VentilationBag-Mask Ventilation

Key—ventilation volume: “enough to produce obvious chest rise”

1-Person: difficult, less effective

2-Person:easier, more effective

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Cricoid PressureCricoid Pressure

ThyroidCartilage

Cricoid

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Bag-Mask VentilationBag-Mask Ventilation

Advantages

• Provides immediate ventilation and oxygenation

• Operator gets sense of compliance and airway resistance

• May provide excellent short-term support of ventilation

• High oxygen concentrations are possible

• Can be used to assist spontaneous respirations Potential complications

• Hypoventilation

• Gastric inflation

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Airway Adjunct DevicesAirway Adjunct Devices

Nasal cannula24%-44% O2 concentration

Face mask with O2 reservoir,60%-100% O2 concentration

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Types of Portable SuctionTypes of Portable Suction

Courtesy of Laerdal Medical Corporation, Armonk, NY

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Equipment for IntubationEquipment for Intubation

Laryngoscope with several blades

Tracheal tubes Malleable stylet 10-mL syringe Magill forceps Water-soluble lubricant Suction unit, catheters, and tubing

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Curved Blade Attaches to Laryngoscope Handle

Curved Blade Attaches to Laryngoscope Handle

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Curved Blade Attached to Laryngoscope Handle

Curved Blade Attached to Laryngoscope Handle

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Curved Blade Laryngoscope Inserted Against Epiglottis

Curved Blade Laryngoscope Inserted Against Epiglottis

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Straight-Blade LaryngoscopeStraight-Blade Laryngoscope

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Straight-Blade Laryngoscope Inserted Past Epiglottis

Straight-Blade Laryngoscope Inserted Past Epiglottis

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Cricothyroid Membrane With Horizontal Cricothyrotomy Incision

Cricothyroid Membrane With Horizontal Cricothyrotomy Incision

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Aligning Axes of Upper AirwayAligning Axes of Upper Airway

Extend-the-head-on-neck (“look up”): aligns axis A relative to B

Flex-the-neck-on-shoulders (“look down”): aligns axis B relative to C

C

ABA

B

C

TracheaPharynx

Mouth

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Visualization of Vocal CordsVisualization of Vocal Cords

Glotticopening

Arytenoidcartilage

Tongue

EpiglottisVallecula

Vocalcord

AnatomyAnatomy

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Tracheal IntubationTracheal Intubation

Advantages• Protects airway from aspiration of foreign material • Facilitates ventilation and oxygenation• Facilitates suctioning of trachea and bronchi• Provides route for drug administration• Prevents gastric inflation if used with cuff• Allows faster chest compressions

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Tracheal IntubationTracheal Intubation

Indications• Inability to ventilate the unconscious patient• After insertion of pharyngeal airway• Inability of patient to protect own airway (coma,

areflexia, or cardiac arrest)• Need for prolonged mechanical ventilation

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Tracheal IntubationTracheal Intubation

Recommendations• Intubate as soon as possible after ventilation

and oxygenation in cardiac arrest• Intubation should be done by most

experienced person• Do not take longer than 30 seconds per attempt• Auscultate the thorax and epigastrium

after intubation

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Tracheal IntubationTracheal Intubation

Complications• Trauma—teeth, lips, tongue, mucosa,

vocal cords, trachea• Esophageal intubation• Vomiting and aspiration• Hypertension and arrhythmias

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Esophageal-Tracheal CombitubeEsophageal-Tracheal Combitube

A = esophageal obturator; ventilation into trachea through side openings = B

C = tracheal tube; ventilation through open end if proximal end inserted in trachea

D = pharyngeal cuff; inflated through catheter = E

F = esophageal cuff; inflated through catheter = G

H = teeth marker; blindly insert Combitube until marker is at level of teeth

Distal End

Proximal End

B

C

D

E

F

G

H

A

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Esophageal-Tracheal Combitube Inserted in Esophagus

Esophageal-Tracheal Combitube Inserted in Esophagus

A = esophageal obturator; ventilation into trachea through side openings = B

D = pharyngeal cuff (inflated)

F = inflated esophageal/tracheal cuff

H = teeth markers; insert until marker lines at level of teeth

D

A

DB F

H

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Laryngeal Mask Airway (LMA)

Laryngeal Mask Airway (LMA)

The LMA is an adjunctive airway that consists of a tube with a cuffed mask-like projection at distal end.

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LMA Introduced Through Mouth Into Pharynx

LMA Introduced Through Mouth Into Pharynx

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LMA in PositionLMA in Position

Once the LMA is in position, a clear, secure airway is present.

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Anatomic DetailAnatomic Detail

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Esophageal Detector Device (Bulb-Type)

Esophageal Detector Device (Bulb-Type)

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Confirmation: Tracheal Tube Placement

Confirmation: Tracheal Tube Placement

End-tidal colorimetric CO2 indicators

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Tracheal Tube Holders:Adult and Infant

Tracheal Tube Holders:Adult and Infant

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Qualitative End-Tidal CO2 Detector

Qualitative End-Tidal CO2 Detector

What should the operator’s next action be?