39: advanced airway management

39: Advanced Airway Management

8-1.1 Identify and describe the airway anatomy in the infant, child, and the adult.

8-1.3 Explain the pathophysiology of airway compromise.

8-1.4 Describe the proper use of airway adjuncts.

8-1.5 Review the use of oxygen therapy in airway management.

Cognitive Objectives (1 of 5)

8-1.6 Describe the indications, contraindications, and techniques for insertion of nasal gastric tubes.

8-1.7 Describe how to perform the Sellick maneuver (cricoid pressure).

8-1.8 Describe the indications for advanced airway management.


8-1.9 List the equipment required for orotracheal intubation.

8-1.10 Describe the proper use of the curved blade for orotracheal intubation.

8-1.11 Describe the proper use of the straight blade for orotracheal intubation.

8-1.12 State the reasons for and proper use of the stylet for orotracheal intubation.


8-1.13 Describe the methods of choosing the appropriate size endotracheal tube in an adult patient.

8-1.14 State the formula for sizing an infant or child endotracheal tube.

8-1.15 List complications associated with advanced airway management.

8-1.17 Describe the skill of orotracheal intubation in the adult patient.


8-1.18 Describe the skill of orotracheal intubation in the infant and child patient.

8-1.19 Describe the skill of confirming endotracheal tube placement in the adult, infant, and child patient.

8-1.20 State the consequences of and the need to recognize unintentional esophageal intubation.

8-1.21 Describe the skill of securing the endotracheal tube in the adult, infant, and child patient.


8-1.22 Recognize and respect the feelings of the patient and family during advanced airway procedures.

8-1.23 Explain the value of performing advanced airway procedures.

8-1.24 Defend the need for the EMT-B to perform advanced airway procedures.

8-1.25 Explain the rationale for the use of a stylet.

Affective Objectives (1 of 2)

8-1.26 Explain the rationale for having a suction unit immediately available during intubation attempts.

8-1.27 Explain the rationale for confirming breath sounds.

8-1.28 Explain the rationale for securing the endotracheal tube.

Affective Objectives (2 of 2)

8-1.29 Demonstrate how to perform the Sellick maneuver.

8-1.30 Demonstrate the skill of orotracheal intubation in the adult patient.

8-1.31 Demonstrate the skill of orotracheal intubation in the infant and child patient.

8-1.32 Demonstrate the skill of confirming endotracheal tube placement in the adult patient.

8-1.33 Demonstrate the skill of confirming endotracheal tube placement in the infant and child patient.

8-1.34 Demonstrate the skill of securing the endotracheal tube in the adult patient.

Psychomotor Objectives

Anatomy and Physiology of the Airway

Basic Airway Management

• Airway is always assessed first.• Advanced techniques are used after basic

management.• The first step is opening the patient’s airway.• Once the airway has been cleared, determine the

need for an airway adjunct.

Gastric Tubes

• Provide channel into patient’s stomach• Nasogastric tubes: Inserted through the nose• Orogastric tubes: Inserted through the mouth• Nasogastric tubes: Contraindicated in a patient with

major facial, head, or spinal trauma

Equipment

• Proper-sized tubes• Catheter-tipped 60-mL

syringe• Water-soluble lubricant• Emesis container• Tape• Stethoscope• Suctioning unit and

catheters

Gastric Tube Insertion

• Measure the tube.• Lubricate the distal end of the tube.• Place the patient in proper position.• Pass the tube until you reach the tape marker.• Confirm proper tube placement.• Aspirate air and stomach contents with the

syringe.• Secure the tube in place with tape.

Sellick Maneuver

• Visualize the cricoid cartilage.

• Palpate to confirm its location.

• Apply firm pressure on the cricoid ring.

• Maintain pressure until intubated.

Endotracheal Intubation

• Insertion of a tube into the trachea in order to maintain the airway

• Orotracheal intubation: Through the mouth• Nasotracheal intubation: Through the nose• EMT-Bs only intubate patients who are:

– Unresponsive with no gag reflex– In cardiac arrest

Equipment (1 of 2)

• BSI equipment• Proper-equipment endotracheal tube

(ET tube)• Laryngoscope handle and blade

(visualized technique)• Stylet or light stylet• 10-mL syringe• Oxygen, with BVM device

Equipment (2 of 2)

• A suctioning unit with rigid and soft-tip catheters• Magill forceps• Towels for raising the patient’s head and/or

shoulders• A stethoscope• Water-soluble lubricant for tubes and scopes• A commercial securing device or tape

Laryngoscope

• Sweeps the tongue out of the way and aligns the airway

• Has a light powered by batteries in handle• Has blades that connect to handle

– Blades are curved or straight.– They range in size from 0 to 4.

Curved Blade

Straight Blade

Endotracheal Tubes

• Tubes come in many sizes, from adult to infant.

• Normal tube-to-teeth mark is usually around 22 cm.

• Diameter for normal adult male ranges from 7.5 to 8.5 mm.

• Diameter for normal adult female ranges from 6.5 to 8.0 mm.

• Use tape or chart for pediatric sizes.

Stylet

• Plastic-coated wire may be inserted in the ET tube to add rigidity and shape to the tube.

• Bend the tip of the stylet to form a gentle curve in adults.

• Bend the tip of the stylet to form a hockey stick shape for an infant and child.

• Confirm that the stylet is not sticking out past the end of the ET tube.

Syringe

• Use the 10-mL syringe to test for air leaks in the ET tube before intubation.

• After the ET tube has been properly inserted, inflate the cuff with 5 to 10 mL of air.

• Remove the syringe from the pilot balloon to prevent air from leaking.

Other Equipment

• Oxygen• A suctioning unit• A BVM device• Magill forceps• Towels for raising the patient’s head or

shoulders• Secondary confirmation device• C-collar backboard

The Intubation Procedure

• First EMT-B applies AED.• Second and third EMT-B

perform CPR. • Fourth EMT-B prepares and

intubates patient.

Visualized (Oral) Intubation (1 of 2)

• Open airway.

• Insert an oropharyngeal airway.

• Preoxygenate the patient.

• Assemble equipment.

• Position the head and neck.

Visualized (Oral)Intubation (2 of 2)

• Grasp laryngoscope with left hand. • Visualize vocal cords. • Insert ET tube.• Inflate balloon. • Confirm placement. • Secure tube.

Blind (Nasal) Intubation (1 of 2)

• Many of the steps are the same as those for oral intubations.

• Preoxygenate the patient.• Check for gag reflex.• Insert tube through nostril. • Pass tube through vocal cords as patient is

inhaling.

Blind (Nasal) Intubation (2 of 2)

• Release the jaw and hold tube against nostril. • Inflate cuff. • Attach the BVM device. • Confirm placement. • Secure the tube.

Intubation Complications

• Intubating the right main stem bronchus

• Intubating the esophagus

• Aggravating spinal injuries

• Taking too long to ventilate

• Patient vomiting

• Soft-tissue trauma

• Mechanical failure

• Patient intolerant of the ET tube

• Decrease in heart rate

Multilumen Airways

• Inserted without direct visualization

• Provide ventilation when placed in either trachea or esophagus

Esophageal TrachealCombitube (ETC)

Combitube Contraindications

• Conscious or semiconscious patients with gag reflex

• Children younger than 16 years• Adults shorter than 5'• Patients who have ingested a caustic substance• Patients with esophageal disease

Inserting the ETC (1 of 2)

• Assemble and check the proper equipment.

• Apply water-soluble lubricant to the ETC.

• Position the patient.• Preoxygenate the patient.• Lift the lower jaw and tongue.

Inserting the ETC (2 of 2)

• Guide the ETC along the base of the tongue.

• Inflate the blue and then the white pilot balloon.

• Ventilate the patient.• Confirm placement.• Monitor the patient.

Removing the ETC

• Be prepared to suction patient.• Deflate both balloon cuffs.• Gently remove the tube.

Pharyngeotracheal Lumen Airway (PtL)

PtL Contraindications

• Conscious or semiconscious patients with gag reflex

• Children younger than 14 years• Adults shorter than 5' • Patients who have ingested a caustic

substance• Patients with esophageal disease

Inserting the PtL (1 of 2)

• Assemble and check equipment.• Lubricate tube with water-soluble

lubricant.• Position the patient.• Preoxygenate the patient.• Lift the lower jaw and tongue.• Hold the PtL so that it curves in

the same direction as the pharynx.

Inserting the PtL (2 of 2)

• Inflate balloon cuffs.• Ventilate patient through

the short, green tube.• Evaluate placement.• Verify that the patient is

receiving adequate ventilations.

• Monitor the patient.

Removing the PtL

• Be prepared to suction the patient.• Deflate balloon cuffs.• Gently remove the tube.

Laryngeal Mask Airway (LMA)

LMA Contraindications

• Asthma• COPD• Leaking mask• Active vomiting• Esophageal diseases

Inserting the LMA (1 of 2)

• Assemble and check equipment.

• Open the airway.• Preoxygenate the patient.• Select proper size.• Hold LMA down.• Remove oropharyngeal device

and begin insertion.

Inserting the LMA (2 of 2)

• Insert until you feel resistance.

• Stabilize the tube.• Inflate mask.• Confirm placement.• Insert bite block and

secure the LMA.

Review

1. You are called for a male patient complaining of respiratory distress. When you arrive, you assess the patient and find that he is unconscious and apneic, but has a pulse. You should:

A. perform immediate endotracheal intubation.

B. attach an AED and analyze the patient's rhythm.

C. ensure a patent airway and effective ventilation.

D. administer 100% oxygen via nonrebreathing mask.

Review

Answer: C

Rationale: Before performing advanced airway procedures (eg, endotracheal intubation), you must first ensure that the patient’s airway is patent. Open the airway, ensure that it is clear of secretions, insert a basic airway adjunct, and ventilate with a bag-mask device. Ventilate the patient for at least 2 to 3 minutes before attempting intubation.

Review1. You are called for a male patient complaining of respiratory

distress. When you arrive, you assess the patient and find that he is unconscious and apneic, but has a pulse. You should:

A. perform immediate endotracheal intubation.Rationale: Perform BLS airway management before performing any

advanced airway management.B. attach an AED and analyze the patient's rhythm.Rationale: The patient has a pulse, so immediate airway intervention

is necessary.C. ensure a patent airway and effective ventilation.Rationale: Correct answerD. administer 100% oxygen via nonrebreathing mask.Rationale: The patient is apneic. You must initiate rescue breathing

via a bag-mask device.

Review

2. Immediately after placing an endotracheal tube (ETT) in an unconscious patient, you should:

A. attach the bag device and begin ventilating.

B. inflate the balloon cuff and detach the syringe.

C. secure the tube in place with the proper device.

D. remove the malleable stylet from the ET tube.

Review

Answer: B

Rationale: After the ETT has been placed, you should immediately inflate the balloon cuff with 5-10 mL of air and detach the syringe. This will seal the trachea and prevent aspiration if regurgitation occurs. Once the cuff is inflated, remove the stylet, attach the bag device, and begin ventilating.

Review

2. Immediately after placing an endotracheal tube (ETT) in an unconscious patient, you should:

A. attach the bag device and begin ventilating.

Rationale: Do this only after the balloon cuff is inflated and the stylet is removed.

B. inflate the balloon cuff and detach the syringe.

Rationale: Correct answer

C. secure the tube in place with the proper device.

Rationale: This is the last step. Note the centimeter marking at the lips and secure the tube.

D. remove the malleable stylet from the ET tube.

Rationale: This is performed after the balloon has been inflated.

Review

3. When intubating a patient with a curved blade, the blade will:

A. lift the tongue so that you can see the vocal cords.

B. lift the uvula and bring the vocal cords into clear view.

C. fit under the epiglottis and directly expose the vocal cords.

D. fit into the vallecula and indirectly expose the vocal cords.

Review

Answer: D

Rationale: The curved blade is inserted just in front of the epiglottis, into the vallecula (the space between the base of the tongue and the epiglottis), indirectly allowing you to view the vocal cords. The straight blade is inserted directly under the epiglottis, directly allowing you to view the vocal cords.

Review

3. When intubating a patient with a curved blade, the blade will:

A. lift the tongue so that you can see the vocal cords.

Rationale: The blade pushes the tongue to the side during intubation.

B. lift the uvula and bring the vocal cords into clear view.

Rationale: You should visualize the epiglottis, and not the uvula.

C. fit under the epiglottis and directly expose the vocal cords.

Rationale: The straight blade fits under the epiglottis and allows providers to visualize the trachea.

D. fit into the vallecula and indirectly expose the vocal cords.


Review

4. In which of the following patients would you NOT use a multi-lumen airway device?

A. 40-year-old man in cardiac arrest who has esophageal cancer.

B. 17-year-old patient in cardiac arrest secondary to electrocution.

C. 23-year-old man who is unconscious, apneic, and has a weak pulse.

D. 5’ 6” female who is unconscious and apneic after overdosing on heroin.

Review

Answer: A

Rationale: Multi-lumen airway devices are contraindicated in conscious or semiconscious patients who have a gag reflex, patients younger than 16 years of age, adults shorter than 5’ tall, patients who have ingested a corrosive substance, and patients with an esophageal disease (ie, cancer, varices).

Review4. In which of the following patients would you NOT use a multi-

lumen airway device?

A. 40-year-old man in cardiac arrest who has esophageal cancer.Rationale: Correct answerB. 17-year-old patient in cardiac arrest secondary to electrocution. Rationale: This device is not used in patients less than 16 years of

age.C. 23-year-old man who is unconscious, apneic, and has a weak

pulse. Rationale: There is not a contraindication, unless the patient has a

gag reflex.D. 5’ 6” female who is unconscious and apneic after overdosing on

heroin.Rationale: The minimum height for using this device is 5’0”.

Review

5. You are assisting your paramedic partner while she intubates a 50-year-old man who is in cardiac arrest. You should anticipate that she will ask you for a ____ mm ET tube.

A. 6.0

B. 6.5

C. 7.5

D. 9.0

Review

Answer: C

Rationale: The proper-sized ET tube ranges from 7.5 to 8.5 mm for the adult male and 6.5 to 8.0 mm for the adult female. A good rule of thumb is to have a 7.5 mm ETT on hand; this size tube will fit most male and female adults. Of course, a variety of tube sizes should always be available.

Review5. You are assisting your paramedic partner while she intubates

a 50-year-old man who is in cardiac arrest. You should anticipate that she will ask you for a ____ mm ET tube.

A. 6.0Rationale: This sized tube would be used in a very small

individual.B. 6.5Rationale: This sized tube would be in the range for an average

female patient.C. 7.5Rationale: Correct answerD. 9.0Rationale: This sized tube would be used in large adults.

Review

6. Which of the following is clearly a lethal complication of endotracheal intubation?

A. Unrecognized esophageal intubation

B. Chipping two of the patient’s front teeth

C. Slightly extending the neck of a trauma patient

D. Ventilating the patient without supplemental oxygen

Review

Answer: A

Rationale: While all of the choices in this question will cause some degree of harm to the patient, unrecognized esophageal intubation is, without doubt, the most lethal. If you intubate the esophagus, and do not recognize and immediately correct it, the patient will die—period!

Review6. Which of the following is clearly a lethal complication of

endotracheal intubation?

A. Unrecognized esophageal intubationRationale: Correct answerB. Chipping two of the patient’s front teethRationale: This is a complication of intubation, but it is typically not

lethal.C. Slightly extending the neck of a trauma patientRationale: This is something that needs to be avoided. Paralysis —

not death — is usually the end result of this mistake.D. Ventilating the patient without supplemental oxygenRationale: 100% oxygen must be delivered to a patient using a bag-

mask. It is not a lethal error to deliver less.

Review

7. A single intubation attempt in an adult should not exceed:

A. 10 seconds.

B. 20 seconds.

C. 30 seconds.

D. 40 seconds.

Review

Answer: C

Rationale: An intubation attempt should not exceed 30 seconds in the adult, and 20 seconds in infants and children. During the period of time that you are intubating, the patient is not breathing. Prolonged intubation attempts increase the risk of severe hypoxia and must be avoided.

Review

7. A single intubation attempt in an adult should not exceed:

A. 10 seconds.

Rationale: The maximum time should not exceed 30 seconds in adult patients.

B. 20 seconds.

Rationale: This is the maximum time for infants and children.

C. 30 seconds.


D. 40 seconds.

Rationale: The maximum time should not exceed 30 seconds in adult patients.

Review

8. After your partner has intubated a patient in respiratory arrest, you auscultate to confirm proper ET tube placement. You hear gurgling over the epigastrium and faint breath sounds over all four lung fields. Your partner should:

A. attach an end-tidal C02 detector to the end of the ET tube.

B. withdraw the ET tube 1 to 2 cm and ask you to reauscultate.

C. inflate the distal balloon cuff and attach the bag device to the tube.

D. remove the ET tube at once and ventilate with a bag-mask device.

Review

Answer: D

Rationale: If the ET tube is properly placed in the trachea, you should hear lungs sounds that are equal on both sides of the chest and NO epigastric sounds. If you hear gurgling over the epigastrium—even if you think you hear breath sounds—the ET tube should be removed immediately and ventilations with a bag-mask device should be resumed.

Review (1 of 2)


A. attach an end-tidal C02 detector to the end of the ET tube.

Rationale: The detector is only attached after placement is confirmed through auscultation and chest rise.

B. withdraw the ET tube 1 to 2 cm and ask you to reauscultate.

Rationale: The tube is drawn back only if the provider hears lung sounds on one side, which means that the tube is advanced too far.

Review (2 of 2)


C. inflate the distal balloon cuff and attach the bag device to the tube.

Rationale: The balloon is inflated before providers listen to lung sounds.

D. remove the ET tube at once and ventilate with a bag-mask device.


Review

9. After inserting an endotracheal tube, you auscultate the patient’s lungs and do not hear breath sounds on the left side of the chest. You should suspect:

A. a tension pneumothorax.

B. intubation of the right mainstem bronchus.

C. intubation of the left mainstem bronchus.

D. that the ET tube has entered the esophagus.

Review

Answer: B

Rationale: The right mainstem bronchus is shorter and straighter than the left; therefore, if the ET tube is inserted too far, it will come to rest in the right mainstem bronchus. You will hear breath sounds over the right side of the chest, absent sounds over the left side of the chest, and absent sounds over the epigastrium. To correct this, simply withdraw the tube 1 to 2 cm until breath sounds are equal on both sides of the chest. If breath sounds are present on the left side of the chest and absent on the right, suspect a pneumothorax.

Review9. After inserting an endotracheal tube, you auscultate the patient’s

lungs and do not hear breath sounds on the left side of the chest. You should suspect:

A. a tension pneumothorax.Rationale: This is suspected if you hear breath sounds on the left and

not on the right side of the chest.B. intubation of the right mainstem bronchus.Rationale: Correct answerC. intubation of the left mainstem bronchus. Rationale: If the left mainstem bronchus was intubated, then

providers would hear sounds on the left.D. that the ET tube has entered the esophagus. Rationale: The provider would not hear breath sounds if the

esophagus was intubated.

Review

10. Which of the following devices provides the MOST effective delivery of oxygen into the lungs?

A. Combitube

B. Bag-mask device

C. Endotracheal tube

D. Laryngeal mask airway

Review

Answer: C

Rationale: The endotracheal tube is considered to be the superior airway device for delivering oxygen into the lungs. It enters the trachea, has a cuff that provides a seal against vomitus, and allows the delivery of 100% oxygen directly into the lungs. The Combitube and laryngeal mask airway (LMA), while effective airway devices, do not enter the trachea. They have been shown to provide better ventilation than a bag-mask device, but are not superior to the ET tube.

Review10. Which of the following devices provides the MOST effective

delivery of oxygen into the lungs?

A. CombitubeRationale: The combitube works well, but does not enter the

trachea.B. Bag-mask deviceRationale: The bag-mask device works well as a BLS

procedure, but is not the most effective device.C. Endotracheal tubeRationale: Correct answerD. Laryngeal mask airwayRationale: The laryngeal mask airway works well, but does not

enter the trachea.