3 wydro airway.pptsuccessful intubation subjective confirmation secure tube determine method oral /...

10/27/2009

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Gerald Wydro, MD

Clinical Associate Professor Emergency Medicine

Temple University School of Medicine

When I started….

When I started…. When I started….

When I started…. When I started….

How To Make A Fertile Polyploid Hybrid

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When I started….

In the beginning….EMS & Airway Management…..




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Look at us now….

So what have we really learned?

A lot of advancement… New Equipment…. New Medications…

But???

The goal has not changed in a century, Has EMS evolved?? Objectives

Brief Anatomy / Physiology Review

Intubation Indications and Techniques

Preintubation Airway Assessment

Alternative Airways

Confirmation of placement

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Anatomy

Upper airway

Larynx

Trachea

Cartilage ringsCartilage rings

Carina

Mainstem bronchi

Left and right

Bronchioloes

Alveoli

Mediastinal Structures

Tracheal Rings Alveolar Sacs

Physiology

Prepare the air

Warm

Humidify

Clean

Physiology

Prepare the air

Warm

Humidify

Clean

Exchange

Capillary exchange

CO2

O2.

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Indications for IntubationIndications for Intubation

Failure to maintain / protect the airway Value of intact gag

Never really studied May induce vomiting

More realistic handle secretions handle secretions swallowing mechanism

Remember reversible causes Hypoglycemia Opiate intoxication

Failure of Ventilation or Oxygenation

Clinical assessment Not reversible

Increased oxygen

CPAP / BiPAP

D50 / Narcan5

Overall status VS

Mental status Be careful not to manage the numbers

Clinical Situation Mandates“They are only getting sicker”

Potential for badness Status epilepticus

Penetrating torso / neck trauma

Closed head injury SDH SAH

Serious Overdoses TCA’s

Endotracheal Intubation

These are NOT Indications

Because I can

Because they are unresponsive

Because the ED staff will expect it

Endotracheal IntubationComplications

Soft tissue trauma/bleeding

Dental injury

L l d

Barotrauma

Hypoxia

Aspiration

Esophageal intubation Laryngeal edema

Laryngospasm

Vocal cord injury

Esophageal intubation

Mainstem bronchus intubation

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Pre‐Intubation Technique

Position, ventilate patient

Monitor patient / Safety Net Cardiac monitor

Pulse oximeter

Preintubation Airway Assessment

Assemble, check equipment (suction)

Hyperventilate patient (30‐120 sec)

It seems easy enough

Sobering statistics

Intubation success rate

Intubation Success???Author Misplaced / total Misplaced

%

Jenkins

Bozeman

2/39

1/100

5.1%

1.0%

Stewart

Sayre

Pointer

3/779

3/103

5/383

0.4%

2.9%

1.3%

verification of tube placement was performed in the field.

Does it make a difference??

Out-of-hospital endotracheal intubation: where are we?Wang HE - Ann Emerg Med - 01-JUN-2006; 47(6): 532-41

Frequency of Prehospital Intubation in PA

How would minimum experience standards affect the distribution of out-of-hospital endotracheal intubations?Wang HE - Ann Emerg Med - 01-SEP-2007; 50(3): 246-52

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Sobering Statistics


Undetected esophageal bintubations

Misplaced endotracheal tubes by paramedics in an urban emergency medical services system. Katz SH ‐ Ann Emerg Med ‐ 01‐Jan‐2001; 37(1): 32‐7

Purpose: The purpose of our study was to determine the incidence of unrecognized misplaced ETTs that had been inserted in the field, in an emergency

( )medical services (EMS) community in which ETCO2

monitoring was not consistently used.

Results: 108 intubated patients who were brought by paramedics to the ED d i th 8 th t d ED during the 8‐month study period. . The overall rate of improperly placed ETTs was 25%

Sobering Statistics


Undetected esophageal intubationsintubations

Frequency of performing the skill

Effect of out‐of‐hospital pediatric endotracheal intubation on survival and neurological outcome: a controlled clinical trial JAMA ‐ 2000 Feb 9; 283(6): 783‐90

OBJECTIVE: To compare the survival and neurological outcomes of pediatric patients treated with bag‐valve‐mask ventilation (BVM) with those of patients treated mask ventilation (BVM) with those of patients treated with BVM followed by ETI.

CONCLUSION: These results indicate that the addition of out‐of‐hospital ETI to a paramedic scope of practice that already includes p yBVM did not improve survival or neurological outcome of pediatric patients treated in an urban EMS system.

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So maybe it is time to change our thought

process!process!

Can we ever consider an Alternative Airway Algorithm as our initial Intervention?

Would you get this patient? Multitude of reasons to consider alternative airway from the initial assessment

Must be confident in your Must be confident in your skill level and more importantly know the limitations of laryngoscopy!

No teeth… No problem?? What challenges might this patient provide?

Mask Seal

Landmarks Landmarks

BLS Airways

Securing the tube

Open the MouthDon’t be surprised! External characteristics are key

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LEMON Rule L=Look externally (facial trauma, large incisors, beard or moustache,

and large tongue)

E=Evaluate the 3‐3‐2 rule (incisor distance <3 fingerbreadths, hyoid/mental distance <3 fingerbreadths, thyroid‐to‐mouth distance <2 fingerbreadths)<2 fingerbreadths)

M=Mallampati Score

O=Obstruction (presence of any condition that could cause an obstructed airway)

N=Neck mobility (limited neck mobility).

Pre‐Intubation Airway Assessment

Jaw opening

3 fingers


Jaw opening

3 fingers

Hyoid Mental distance Hyoid‐Mental distance

3 fingers


Jaw opening

3 fingers

Hyoid‐Mental distance

3 fingers3 g

Thyro‐Mental distance

2 fingers


Jaw opening

3 fingers

Hyoid Mental distance Hyoid‐Mental distance

3 fingers

Thyro‐Mental distance

2 fingers

Prominent Upper Incisors

Airway Assessment

Cormack / Lehane Grade

Mallampati’s classification

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Neck Mobility

Align axis to facilitate orotracheal intubation

Decreased mobility

C‐Spine immobilization

Extend Back – Flex Forward

Rheumatoid arthritis

Quick Test

Put chin on chest then move toward ceiling

Assumes no trauma

Is there an optimal position? Sniffing position

the neck must be flexed on the chest by elevating the head with a cushion under the occiput and the under the occiput and the head extended at the atlanto‐occipital joint.

Extension position The neck is placed into simple extension

What is the problem?

Ventilate and Visualize This is the perfect candidate


Ventilate and Visualize

This is the perfect candidate

Ventilate but cannot Ventilate but cannot Visualize

Consider alternative methods


Ventilate and Visualize

This is the perfect candidate

Ventilate cannot Visualize

C id l i h d Consider alternative methods

Cannot Ventilate or Visualize

Your worst nightmare

What we do now!Pre-hospital Intubation

Determine need for IntubationHypoventilationSecure Airway

Potential deterioration

Alternative AirwayBVM

LMA / CombitubeNeedle / Surgical Cric

Unsuccessful

Successful IntubationSubjective Confirmation

Secure Tube

Determine MethodOral / Nasal

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What we do now!Pre-hospital Intubation

Determine need for IntubationHypoventilationSecure Airway

Potential deterioration

Alternative AirwayBVM

LMA / CombitubeNeedle / Surgical Cric

Unsuccessful

Successful IntubationSubjective Confirmation

Secure Tube

Determine MethodOral / Nasal

Most prehospital intubations are: Dead / Nearly dead

There are others

Awake

Facilitated

Rapid Sequence

Awake Intubation Used in the awake patient with a full stomach.

Topical anesthesia with lidocaine, cetocaine or other agent.

Careful oral insertion of tube.

Generally used in the OR.

Facilitated IntubationMedication Assisted

Used for patients who need definitive airway, but require some sedative.

P i l d Patient not paralyzed.

Requires use of sedatives / induction agents.

Rapid Sequence Induction Take the patient from a state of conscious and breathing to complete unconsciousness with apnea.

Emergency intubation indicated

P i h f ll h Patient has a full stomach

Predicted to be successful

If fail, manual ventilation will be successful

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Sellick Maneuver Cricoid Pressure!

Lessens the chance of aspiration??

Direct pressure over i id h cricoid to compress the

esophagus against the anterior vertebral bodies. BURP Maneuver

Alternatives

Any patient that mayrequire intubation must undergo a Pre‐intubation Ai AAirway Assessment

Think of Alternative Airway maneuvers in a parallel fashion.

Positive Pressure VentilationWidely available

High flow oxygen

Requires precise airway control

No protection from aspiration

Can be used with other airway adjuncts

SupraglotticLaryngeal Mask Airway

Tube with a large ring at distal end

Low pressure to fill around glottis

Allows trachea to be ventilated

Limited Aspiration Protection

Not approved on PA for EMS use!

SupraglotticCombitube

Double lumen / Port

Place in esophagus or trachea

Blind placementBlind placement

Ventilate with BVM


Combitube

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Supraglottic King LT

Single Lumen / Port

Distal Esophageal placement

Blind PlacementBlind Placement

Ventilate with BVM


Bougie Semi‐rigid stylette‐like device

Advanced into the larynx and through the cords until the tip rubs cartilage irings

Thread an ETT over the end of the bougie, into the larynx. Once the ETT is in place, the bougie is removed.

Lighted Stylet

ETT placed on stylet

When in the trachea, the light will shine though the skin.

Area of thyroid cartilage

adjunct to blind intubation

Transtracheal Jet Ventilation Needle inserted through the cricothyroid membrane allows for

doxygenation and minimal ventilation of a patient

Rescue Technique!!!

Cricothyroidotomy Surgical airway !!!!!

Utilized when unable to secure airway with other means.

Can’t ventilate, Can’t visualize

Opening made in the cricothyroid membrane.

Tube placed into opening.

Expensive ToysShikani

GlideScope

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Confirmation of Tube Placement Subjective

Visualization

Breath Sounds

Misting in tube

Objective ETCO2

Waveform preferred – breath to breath

Esophageal devices EDD

Confirmation of Tube Placement

Document

Misting

Equal excursion

Equal BS

Absent Gastric

EDD

ETCO2

Continous Pulse‐ox

Confirmation of Tube Placement

Need confirmation Initial placement

Every patient move.

C bi Combine Subjective and Objective

ETCO2 limited value in arrest NAEMSP

Use ETCO2 and EDD for cardiac arrest.

Before intubation

Is there another means of getting our desired results BEFORE we attempt intubation? (Especially if we RSI) CPAP

PPV with BVM or Demand Valve?

Nasal ETT?

Do we have all the help we need, all Airway equipment with us? (Suction?)

Do not forget non‐invasive ventilation

Intrinsic positive end expiratory pressure is the concept that in patients with severe lung disease, the lung does not fully empty due to the obstruction in the airway resulting in a positive pressure in the airways at end expiration.

The patient must first overcome this positive airway pressure before generating a negative pressure to inhale more air

CPAPContinuous Positive Airway Pressure

Support spont. Resp Provide continuous

pressure throughout respiratory cycle

usually 10 cm H2Oy Counteract intrinsic

PEEP

decrease preload and afterload

improve lung compliance

decrease the work of breathing

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Contraindications

Patients unable to tolerate the increased work of breathing

Increased ICP

Hemodynamic instability Hemodynamic instability

Recent facial, oral, or skull surgery or trauma

Active epistaxis

Recent Esophageal surgery

Active hemoptysis

Untreated pneumothorax

Does it help! Less intubation

Down 16%*

Decreased Mortality

Down 18%*

Reduce

ICU admit

Patient discomfort

Cost

*Hubble MW, Richards ME and Wilfong DA: "Estimates of cost*Hubble MW, Richards ME and Wilfong DA: "Estimates of cost--effectiveness of prehospital continuous effectiveness of prehospital continuous positive airway pressure in the management of acute pulmonary edema." Prehospital Emergency Care. positive airway pressure in the management of acute pulmonary edema." Prehospital Emergency Care.

12(3):27712(3):277--85, 2008. 85, 2008.

Remember The Pre‐intubation Airway Assessment is Critical

Sometimes Less is More

Noninvasive ventilation when possible

Confirmation of placement always

Waveform capnography is gold standard!

3 wydro airway.pptsuccessful intubation subjective confirmation secure tube determine method oral /...

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