advanced airway management ems 352 dr aqeela bano
TRANSCRIPT
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Advanced airway management
EMS 352 Dr Aqeela Bano
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Advanced Airway Management
• One of the most common mistakes with respiratory or cardiac arrest is to use advanced techniques too early.– Establish and maintain a patent airway with basic
techniques first.
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Advanced Airway Management
• Primary reasons:– Failure to maintain a patent airway and/or – Failure to adequately oxygenate and ventilate
• Involves insertion of advanced airway devices
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Predicting the Difficult Airway
• Anatomic findings:– Congenital abnormalities– Recent surgery– Trauma– Infection– Neoplastic diseases
• LEMON– Look externally– Evaluate 3-3-2– Mallampati– Obstruction– Neck mobility
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LEMON
• Look externally.– The following can make intubation difficult:
• Short, thick necks• Morbid obesity• Dental conditions
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LEMON
• Evaluate 3-3-2.– 3 — mouth width of more
than 3 fingers is best– 3 — mandible length of 3
fingers is best– 2 — distance from hyoid
bone to thyroid notch of 2 fingers wide is best
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LEMON
• Mallampati– Note oropharyngeal structures visible in an
upright, seated patient.
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LEMON
• Obstruction– Note anything that might interfere with
visualization or ET tube placement.• Foreign body• Obesity• Hematoma• Masses
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LEMON
• Neck mobility– Sniffing position is ideal– Neck mobility problems most common with:
• Trauma patients • Elderly patients
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Endotracheal Intubation
• ET tube passes through glottic opening and is sealed with a cuff inflated against the tracheal wall– Orotracheal intubation: through the mouth– Nasotracheal intubation: through the nose
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Endotracheal Intubation
• Advantages– Secure airway– Protection against
aspiration– Alternative to IV or IO route
• Disadvantages– Special equipment – Physiologic functions
bypassed
• Complications– Bleeding– Hypoxia– Laryngeal swelling– Laryngospasm– Vocal cord damage– Mucosal necrosis– Barotrauma
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Endotracheal Tubes
• Basic structure includes:– Proximal end– Tube– Cuff and pilot
balloon– Distal tip
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Endotracheal Tubes
• Sizes range – 2.5 to 9.0 mm in inside
diameter– 12 to 32 cm in length
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Endotracheal Tubes
• Pediatric patients– 2.5 to 4.5 mm tubes used – Funnel-shaped cricoid ring forms an anatomic seal
with ET tube• No need for distal cuff in most cases.
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Endotracheal Tubes
• Anatomic clues can help determine tube size – Internal diameter of the nostril approximates
diameter of glottic opening– Diameter of the little finger or size of thumbnail
approximates airway size.• Always have three sizes ready!
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Laryngoscopes and Blades
• A laryngoscope is required to perform orotracheal intubation by direct laryngoscopy.
• Consists of a handle and interchangeable blades
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Laryngoscopes and Blades
• Straight (Miller and Wisconsin) blades– Tip extends beneath
epiglottis and lifts it up
• Useful with infants and small children
• More likely to damage teeth in adults
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Laryngoscopes and Blades
• Curved (Macintosh) blades– Curve conforms to
tongue and pharynx– Tip is placed in the
vallecula• Indirectly lifts
epiglottis to expose vocal cords
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Laryngoscopes and Blades
• Blade sizes range from 0 to 4– 0, 1, and 2 appropriate for infants and children– 3 and 4 considered adult sizes– Pediatric patients: based on age or height– Adults: based on experience, size of patient
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Laryngoscopes and Blades
• Stylet: semirigid wire inserted into ET tube– Molds and maintains shape of tube– Should be lubricated for removal– End should be bent to form a gentle curve– End should rest at least 1/2″ from end of ET tube
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Laryngoscopes and Blades
• Magill forceps– Remove airway obstructions under direct
visualization.– Guide tip of ET tube through glottic opening if the
proper angle cannot be achieved by manipulating the tube
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Orotracheal Intubation by Direct Laryngoscopy
• ET tube inserted through mouth and into trachea while visualizing the glottic opening with a laryngoscope
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Orotracheal Intubation by Direct Laryngoscopy
• Indications– Airway control needed due
to coma, respiratory arrest, and/or cardiac arrest
– Ventilatory support before impending respiratory failure
– Prolonged ventilatory support
– Absence of gag reflex– Traumatic brain injury– Unresponsiveness– Impending airway
compromise – Medication administration
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Orotracheal Intubation by Direct Laryngoscopy
• Contraindications– Intact gag reflex– Inability to open mouth because of trauma,
dislocation of the jaw, or a pathologic condition– Inability to see the glottic opening– Copious secretions, vomitus, or blood in airway
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Standard Precautions
• Intubation can expose you to bodily fluids.– Take proper precautions.
• Gloves• Mask that covers your entire face
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Preoxygenation
• Critical before intubating– 2–3 minutes for apneic or hypoventilating patient – Prevents hypoxia from occurring– Monitor SpO2 and achieve as close to 100%
saturation as possible.
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Positioning the Patient
• Airway has three axes: mouth, pharynx, and larynx– At acute angles in
neutral position– Place patient in
“sniffing” position to facilitate visualization of the airway.
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Positioning the Patient
• Sniffing position– 20° extension of the
atlanto-occipital joint– 30° flexion at C6 and
C7 with short neck and/or no chin
– Elevate head and/or neck until ear is at the level of the sternum
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Blade Insertion
• Position yourself at the patient’s head.
• Grasp laryngoscope. • If mouth is not open:
– Place thumb below bottom lip and push open.
– “Scissor” thumb and index finger between molars
– Open with tongue-jaw lift
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Blade Insertion
• Insert blade into right side of mouth
• Sweep tongue to the left while moving blade into midline
• Slowly advance the blade.
© Jones & Bartlett Learning. Courtesy of MIEMSS. Specimens provided by the Maryland State Anatomy Board, Department of Health and Mental Hygiene at the Anatomical Services Division, University of Maryland School of Medicine
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Blade Insertion
• Exert gentle traction at a 45° angle as you lift the patient’s jaw. – Keep your back and
arm straight as you pull upward.
© Jones & Bartlett Learning. Courtesy of MIEMSS. Specimens provided by the Maryland State Anatomy Board, Department of Health and Mental Hygiene at the Anatomical Services Division, University of Maryland School of Medicine
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Visualization of the Glottic Opening
• Continue lifting the laryngoscope as you look down the blade.
• Work the tip of the blade into position.– The glottic opening
should come into view.
• The vocal cords lie within.
Courtesy of James P. Thomas, M.D. www.voicedoctor.net
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Visualization of the Glottic Opening
• Gum elastic bougie – Flexible device– Approximately 1 cm in diameter, 60 cm long– Used in epiglottis-only views to facilitate
intubation
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Visualization of the Glottic Opening
• Gum elastic bougie (cont’d)– Insert through the
glottic opening under direct laryngoscopy.
– Once placed, it becomes a guide for the ET tube.
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Tube Insertion
• Pick up preselected ET tube.– Hold it near connector as you would a pencil.
• Insert tube from the right corner of mouth through the vocal cords.– Continue until the proximal end of the cuff is 1 to
2 cm past the vocal cords.
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Tube Insertion
• Do not pass the tube down the barrel of the laryngoscope blade. – Will obscure your
view of the glottic opening
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Ventilation
• After you have seen the ET tube cuff pass roughly 1/2″ beyond the vocal cords– Gently remove the blade.– Secure tube with right hand– Remove stylet from tube
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Ventilation
• Inflate the distal cuff with 5 to 10 mL of air, then detach the syringe from the inflation port.
• Have your assistant attach the bag-mask device to the ET tube; continue ventilation.– Ensure that the patient’s chest rises with each
ventilation.
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Ventilation
• Listen to both lungs and to the stomach.– You should hear equal breath sounds and a quiet
epigastrium.• Ventilation should be dictated by age.
– Adult with a pulse: 10 to 12 breaths/min – Infant/child with a pulse: 12 to 20 breaths/min – Patient in cardiac arrest: 8 to 10 breaths/min
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Confirmation of Tube Placement
• Visualize the ET tube passing between the vocal cords.
• Auscultate.– Unequal or absent breath sounds suggest:
• Esophageal placement• Right mainstem bronchus placement• Pneumothorax• Bronchial obstruction
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Confirmation of Tube Placement
• Auscultate (cont’d).– Bilaterally absent breath sounds or gurgling over
the epigastrium: esophagus was intubated • Immediately remove ET tube.• Be prepared to suction the airway.
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Confirmation of Tube Placement
• Auscultate (cont’d).– Breath sounds only on right: tube has been
advanced too far. • Reposition the tube.
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Confirmation of Tube Placement
• With proper tube position:– Bag-mask device should be easy to compress.– You should see corresponding chest expansion.
• Increased resistance may indicate:– Gastric distention– Esophageal intubation– Tension pneumothorax
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Confirmation of Tube Placement
• Continuous waveform capnography plus clinical assessment– Most reliable method of confirming placement– Attach capnography T-piece when bag-mask
device is attached to the ET tube.
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Confirmation of Tube Placement
• Esophageal detector device– Syringe model:
plunger is withdrawn• Tube in the trachea:
plunger does not move
• Tube in the esophagus: plunger moves back
Courtesy of Marianne Gausche-Hill, MD, FACEP, FAAP
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Confirmation of Tube Placement
• Esophageal detector device (cont’d)– Bulb model: bulb is
squeezed • Tube in the
esophagus: bulb remains collapsed
• Tube in the trachea: bulb briskly expands
Courtesy of Marianne Gausche-Hill, MD, FACEP, FAAP
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Confirmation of Tube Placement
• After confirming proper placement, mark ET tube where it emerges from the mouth– Shows others whether tube has slipped in or out
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Securing the Tube
• Never take your hand off the ET tube before securing with an appropriate device.– Support the tube manually while you ventilate to
avoid a sudden jolt from the bag-mask device.
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Securing the Tube
• Steps:– Note the centimeter marking on the ET tube.– Remove the bag-mask device. – Position the tube in the center of the mouth. – Place the securing device over the tube. – Reattach the bag-mask device, auscultate, and
note the capnography reading and waveform.
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Securing the Tube
• Many devices feature a built-in bite block.– Alternative: Secure tube with tape and insert a
bite block or oral airway.• Minimize head movement in patient.
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• Nasotracheal Intubation
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Nasotracheal Intubation
• Advantages– Can be performed on
responsive patients – No need for laryngoscope– Mouth does not need to be
opened– Does not require sniffing
position– Patient cannot bite the
tube. – Can be secured more easily
• Disadvantage– Blind technique
• Complications– Bleeding
• Contraindicated:– Apnea – Head trauma and midface
fractures– Anatomic abnormalities;
frequent cocaine use
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Nasotracheal Intubation Equipment
• Same as for orotracheal intubation– Minus laryngoscope and stylet
• Some tubes are designed for blind method• Some devices allow confirmation of intubation
without placing face next to tube
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Technique for Nasotracheal Intubation
• Patient’s spontaneous respirations guide the tube and confirm proper placement.– Tube is advanced as patient inhales
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Technique for Nasotracheal Intubation
• Insert tube into nostril, bevel facing toward the nasal septum– Aim tip straight back
toward ear – Position just above
the glottic opening
© Jones & Bartlett Learning. Courtesy of MIEMSS.
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Technique for Nasotracheal Intubation
• Manipulate head to control tube tip position and to maximize air movement.
• Instruct patient to take a deep breath, and gently advance tube. – Placement will be evidenced by an increase in air
movement through the tube.
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Technique for Nasotracheal Intubation
• Soft-tissue bulge on either side of the airway– Tube is probably in the piriform fossa
• Hold head still, slightly withdraw the tube• Once maximum airflow is detected, advance tube
• No soft-tissue bulge– Tube has entered the esophagus.
• Withdraw until you detect airflow; extend head.
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Technique for Nasotracheal Intubation
• Once tube is in place, inflate the distal cuff– Attach bag-mask device and ventilate.– Clean up any secretions or excess lubricant.– Secure the tube with tape. – Document depth of insertion at the nostril.
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Digital Intubation
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Digital Intubation
• Indications (exceptional circumstances)– Laryngoscope, or other techniques, have failed– Patient in confined space– Patient is obese or has a short neck– Copious secretions– Head cannot be moved – Cannot visualize intubation landmarks
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Digital Intubation
• Can be performed in pediatric patients, but usually impossible due to finger size
• Absolutely contraindicated if patient is:– Breathing– Not deeply unresponsive– Has intact gag reflex
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Digital Intubation
• Advantages– Does not require a
laryngoscope– Ideal if vocal cords are
obscured by secretions– Does not require sniffing
position
• Disadvantages– Risk of being bitten – Risk of exposure to
infectious disease
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Digital Intubation
• Complications– Misplacement of the ET tube – Bite block can cause lip and tooth damage – Vigorous or improper attempts can cause airway
trauma or swelling.– Can result in hypoxia
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Digital Intubation Equipment
• Same as for orotracheal intubation (minus laryngoscope), plus fingers– Stylet – ETCO2 detector or esophageal detector device– Appropriate device to secure the tube
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Technique for Digital Intubation
• Prepare equipment as assistant ventilates– Select tube: one half to a full size smaller than
with direct laryngoscopy• Tip of the tube is guided into the trachea
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Technique for Digital Intubation
• Two configurations are recommended.– “Open J” configuration– “U-handle” configuration
© Jones & Bartlett Learning. Courtesy of MIEMSS.
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Technique for Digital Intubation
• Sniffing position is not required
• Insert bite block between molars.– Insert index and middle
fingers into right side of the mouth.
– Press against tongue. – Pull epiglottis forward.
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Technique for Digital Intubation
• Hold ET tube in right hand; insert it into the left side of the mouth
• Advance tube toward the glottis – Once you feel the cuff pass 2″ beyond your
fingertip, stabilize the tube and withdraw fingers– Remove the stylet and inflate the cuff.
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Technique for Digital Intubation
• Attach bag-mask device and ventilate.• Confirm placement.
– Auscultate lungs and epigastrium.– Monitor ETCO2.– Properly secure the tube in place.
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Transillumination Techniques for Intubation
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Transillumination Techniques for Intubation
• Bright light source placed inside the trachea emits a bright, well-circumscribed light
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Transillumination Techniques for Intubation
• Indicated – Other techniques have failed.
• Contraindicated – Intact gag reflex– Airway obstruction– May be difficult in obese or short neck patients – Pediatric patients: stylet must fit inside tube
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Transillumination Techniques for Intubation
• Advantages– No laryngoscope– Visual parameter – Does not require
visualization of the glottic opening
– Safe with possible spinal injuries
• Disadvantages– Special equipment – Proficiency with equipment– Can be difficult in brightly
lit areas
• Complications– Misplacement
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Transillumination Equipment
• Device with a rigid stylet and a bright light source at the end– Light should shine laterally and forward.– Stylet must be long enough to accommodate a
standard-length ET tube– Stylet must be secured within the tube
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Technique for Transillumination-Guided Intubation
• Preoxygenate for at least 2 to 3 minutes.• Choose ET tube and check the cuff• Lubricate and insert the lighted stylet.
– Ensure it is firmly seated into the tube.
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Technique for Transillumination-Guided Intubation
• Bend tube into the proper shape– Head in neutral or slightly extended position
• While holding the stylet, displace the jaw forwardly.
• Turn on the lighted stylet, and insert it in the midline of the mouth.
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Technique for Transillumination-Guided Intubation
• Continue insertion; draw wrist toward you .– Tightly circumscribed light slightly below the
thyroid cartilage: tube has entered trachea– Faintly glowing light and bulging of the soft tissue:
tube is in the vallecular space.– Dim, diffuse light at the anterior part of the neck:
esophageal placement
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Technique for Transillumination-Guided Intubation
• Once light is visible at the midline, hold the stylet in place and advance the tube.
• When the tube is in the trachea, stabilize it and withdraw the stylet.
• Inflate the distal cuff, detach the syringe, and attach the bag-mask device.
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Technique for Transillumination-Guided Intubation
• Ventilate the patient while auscultating both lungs and the epigastrium.
• Secure the tube and continue ventilations.
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Retrograde Intubation
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Retrograde Intubation
• Needle: placed percutaneously within the trachea via the cricothyroid membrane
• Wire: placed through the needle, through the trachea, into the mouth– Wire is visualized, secured– ET tube is placed over wire and guided into
trachea
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Retrograde Intubation
• Indications– Upper airway obstruction– Copious secretions in the
airway– Failure to intubate by less
invasive methods
• Contraindications– Lack of familiarity with the
procedure– Laryngeal trauma– Unrecognizable or distorted
landmarks– Coagulopathy – Severe hypoxia
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Retrograde Intubation
• Complications– Hypoxia– Cardiac dysrhythmia– Mechanical trauma– Infection– Increased intracranial pressure
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Failed Intubation and Field Extubation
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Failed Intubation
• Definition: – Failure to maintain oxygen saturation during or
after one or more failed intubation attempts – Total of three failed intubation attempts
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Failed Intubation
• Many rescue airway techniques– Simple BLS airway maneuvers with oral airway
and/or nasal airway and bag-mask device– Rescue airway device
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Tracheobronchial Suctioning
• Involves passing a suction catheter into the ET tube to remove pulmonary secretions – Do not do it if you do not have to!– If it must be performed:
• Use sterile technique. • Monitor cardiac rhythm and oxygen saturation.
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Tracheobronchial Suctioning
• Preoxygenate for at least 2 to 3 minutes.• Insert suction catheter until resisted.
– Apply suction as the catheter is extracted• Reattach bag-mask device, continue
ventilations, and reassess.
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Field Extubation
• Extubation: process of removing tube from an intubated patient– Before performing, contact medical control or
follow local protocols.
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Field Extubation
• Risks– Over-estimating patient’s ability to protect airway– Laryngospasm– Upper airway swelling
• Do not remove tube unless you can reintubate!
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Field Extubation
• Contraindicated with any risk of recurrent respiratory failure or uncertainty about a patient’s ability to maintain airway
• If indicated, ensure adequate oxygenation.
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Field Extubation
• Explain procedure to patient• Have patient sit up or lean slightly forward.• Assemble equipment to suction, ventilate, and
reintubate.
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Field Extubation
• Confirm patient can protect airway• Suction oropharynx• Deflate distal cuff as patient exhales• On next exhalation, remove tube
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Pediatric Intubation Technique
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Pediatric Endotracheal Intubation
• If bag-mask is not producing adequate ventilation, patient should be intubated – Indications are the
same as those in adults
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Laryngoscope and Blades
• Thinner pediatric handles are preferred.• Straight blades facilitate lifting of epiglottis• Blade should extend from mouth to ear
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Laryngoscope and Blades
• Use length-based resuscitation tape measure or the following guidelines:– Premature newborn: size 0 straight blade– Newborn to 1 year: size 1 straight blade– 2 years to adolescent: size 2 straight blade– Adolescent and older: size 3 straight or curved
blade
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Endotracheal Tubes
• To estimate the appropriate size:– Length-based resuscitation
tape measure– Formulas
• [Age (in years) + 16] ÷ 4 • [Age (in years) ÷ 4] + 4
– Anatomic clues – General guidelines
Courtesy of Marianne Gausche-Hill, MD, FACEP, FAAP
© Jones & Bartlett Learning. Courtesy of MIEMSS.
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Endotracheal Tubes
• Cuffed ET tubes are generally not used in the field until the child is 8 to 10 years old.– Can cause ischemia and damage the tracheal
mucosa • Have tubes one size smaller and one size
larger than expected
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Endotracheal Tubes
• Appropriate depth of insertion is 2 to 3 cm beyond the vocal cords– Record depth at corner of mouth– Uncuffed tubes: stop when black band is at the
vocal cords.– Cuffed tubes: stop when cuff is just below the
vocal cords.
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Pediatric Stylet
• Insert into tube, stop at least 1 cm from end• Fit tube sizes 3.0 to 6.0 mm• After inserting into tube, bend tube into a
gentle upward curve
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Preoxygenation
• Preoxygenate for at least 2 to 3 minutes.• Ensure that the child’s head is in the sniffing
position or the neutral position. • If needed, insert an airway adjunct.
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Additional Preparation
• Monitor cardiac rhythm. • Monitor pulse rate and oxygen saturation.• Have suction available. • Atropine sulfate may be administered.
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Pediatric Intubation Technique
• With head in sniffing position, apply thumb pressure on chin to open mouth.
• If an oral airway was inserted, remove it.• Suction if needed.• Hold the laryngoscope in “trigger finger”
position.
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Pediatric Intubation Technique
• Insert the blade in the right side of the mouth.– Sweep tongue to the left, keep under blade.
• Advance the blade; apply traction upward. – Never use teeth/gums as a fulcrum for the blade
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Pediatric Intubation Technique
• Straight blade: When the blade passes the epiglottis, gently lift the epiglottis.
• Curved blade: place blade tip in vallecula; lift jaw, tongue, and blade at a 45° angle.
• Identify vocal cords and other landmarks.
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Pediatric Intubation Technique
• Hold tube in right hand; insert from the right-side corner of the mouth.
• Guide tube through the vocal cords, advancing until black band is just beyond– Record the depth, and remove the blade.
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Pediatric Intubation Technique
• Remove stylet; hold tube in place. • Recheck tube depth. • Cuffed tube: inflate to form seal • Attach tube to bag-mask device.
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Pediatric Intubation Technique
• Confirm tube placement.– Bilateral chest rise during ventilation– Auscultate lungs bilaterally. – If sounds are decreased on left, tube may be too
deep.• To correct, withdraw tube until sounds are equal.
– Rerecord tube depth.
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Pediatric Intubation Technique
• Auscultate over epigastrium. – Bubbling sounds indicate esophageal intubation.
• Additional methods to confirm placement:– Improvement in skin color, pulse rate, and oxygen
saturation– Waveform capnography
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Pediatric Intubation Technique
• Colorimetric ETCO2 detector or EDD– Cannot be used in children weighing < 15 kg– Esophageal bulb or syringe cannot be used in
children weighing < 20 kg• After placement, secure tube
– Reconfirm placement following any movement.
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Pediatric Intubation Technique
• If tube is too large or you cannot identify the vocal cords and glottic landmarks:– Abort intubation and ventilate. – Modify equipment and start from the beginning.– If intubation cannot be accomplished after two
attempts, discontinue.
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Pediatric Intubation Technique
• If child’s condition deteriorates, use DOPE for common causes.– Displacement– Obstruction– Pneumothorax– Equipment failure
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Complications of Endotracheal Intubation
• Essentially the same as for adults– Unrecognized esophageal intubation– Induction of emesis and aspiration– Hypoxia– Damage to teeth, soft tissues, and intraoral
structures