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Bringing It All IntoView

Airway Management Strategies For the Rest of Us

Bill Landon, FP-C, CCPOctober 25, 2018

Introductory Disclaimer

What this presentation is:

A brief review of the pathophysand anatomy of the respiratorysystem and prominent airwaystructures.

An introduction to concepts ofairway evaluation andmanagement

A discussion about airwaymanagement alternatives

What this presentation is not:

A replacement for your medicalprotocols or SOP’s.

An intubation tutorial

A “this is how it’s done”presentation

Boring (hopefully)

Objectives

At the completion of this presentation you will be able to:

Discuss adult airway pathology encountered in prehospitalcare.

List the three general indications for intubation in prehospitalcare.

Describe the the Difficult Airway Triangle and why it isimportant to prehospital airway managers.

Identify various airway adjuncts used in prehospital care.

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Life Can Be Difficult When You Are APrehospital Airway Manager!

Unexpectedchallenges

occurunexpectedly

Our “Friend” Murphy is AlwaysLurking About

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There are the patients we wouldprefer to see . . .

But reality prevails!

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Most times managing an airway does not haveto be difficult if you use your head,

Follow a few rules,

Stay calm and maintain your focus.

Hope for the best but prepare for theworst.

Have a plan (training & algorithms)

Make sure everyone is aware of yourplan.

Have an alternate plan.

Remember the basics.

And recall your training

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The 7 P’sof

Airway Management

Proper

Practice and

Planning

Prevents

Piss

Poor

Performance

WISDOM . . .

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Difficult Airway Factors

o Morbid obesity

o Beard

o Immobility

o Poor dentition

o Lung & CV disease

o Edematous

o Chronic oxygen use

THE “ACROSS THE ROOM”EVALUATION

Difficult Airway Management isa TEAM SPORT!

Upper Airway

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Larynx & Glottic Structures

Larynx Structures

Lungs

o The bellows- function is mechanical respiration

o Negative pressure system influenced by narrowing andinflammation.

o Each lung is separated by the mediastinum and contents

o Heart, trachea, great vessels

o Base of each lung rests on the diaphragm

o Apex extends 2.5 cm above each clavicle

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Respiratory System Physiology

Ventilation ~ gas exchange system

Oxygen is diffused into the bloodstream for cellularmetabolism

Waste products including carbon dioxide, are eliminatedfrom the body via respiratory system

Pathophysiology

Related to:

Ventilation

Air in and air out

Diffusion (cellular respiration)

Gas exchange between the alveoli and pulmonary capillaries

Gases move from areas of high concentration to areas of

low concentration to maintain homeostasis andequilibrium

Perfusion

Adequate circulating blood through the capillary bed

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Ventilation

Air movement

Depends on:

Neurological control

Intact nervous system between the brain stem and respiratorymuscles

Healthy diaphragm and intercostal muscles

Patent upper airway

Functional lower airway

Healthy and functional alveoli (surfactant, adequate expansion)

Diffusion

Gas exchange between alveoli and pulmonary capillaries

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Why is ThisImportant?

Positioning?

Suction?

Nasal airway? (NPA)

BVM ventilation?

Oral airway? (OPA)

Supra-Glottic airway? *

Intubation?

Oral vs nasal

Med-assisted ETI?

DSI? / RSI?

Mechanical ventilation?

Because we need toknow WHEN tomanage ventilation andthe goal we are trying toachieve with ourintervention, as well asif we have achieved thatgoal. Or are at least moving in the

right direction.

Employ the Basics

Stay calm and maintain your focus.

Hope for the best but prepare for the worst.

Have a plan (training & protocols)

Make sure everyone is aware of your plan.

Have an alternate plan.

The 7 P’s

Know the current evidence-based studies

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Pragmatic AirwayResuscitation Trial

(PART)

Compared Out of Hospital Cardiac Arrest (OHCA) airway managementusing supra-glottic airway device (SGA) or endotracheal intubation (ETI).

27 EMS agencies from five metropolitan areas in U.S.

Randomized clinical trial

Compared King LT (1,505 pts) vs ETI (1,499 pts) in adult non-traumaOHCA patients over 23 months 2015-2017.

Providers were allowed to perform “rescue” airway management usingKing LT, BVM, ETI, or cricothyrotomy.

One specific airway was used for 3-6 months then the agency switched tothe other device as primary.

Outcomes

Primary outcome was survival to 72hours post arrest.

Secondary outcomes were:

ROSC at arrival to hospital;surviving till discharge.

Neurologically favorablesurvival to discharge.

Conclusion

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Indications For Intubation

The decision to intubate should be based on threefundamental clinical assessments:

1. Is there a failure of airway maintenance or protection?

2. Is there a failure of ventilation or oxygenation?

3. What is the anticipated clinical course?

Manual of Emergency Airway Management, 4th EditionWalls, RM, Ed. Philadelphia, Lippincott 2012

Is there a failure of airway maintenance orprotection?

Conscious and alert patients use upper airway musculatureand protective reflexes to protect from aspiration and maintainairway patency.

Clear, unobstructed phonation is strong evidence of intactprotective reflexes maintaining a patent airway.

As a rule, any patient who needs an adjunctive airway placedneeds his/her airway protected.

The gag reflex does not correlate well with airwayprotection and is of little clinical value when assessing theneed for intubation. ENT studies show swallowing to bemuch more predictive of ability to manage/maintainairway patency.

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Is there a failure of ventilation or oxygenation?

o Oxygenation of the vital organs (brain, heart, lungs) is theprimary function of the respiratory system.

o If your patient is unable to ventilate or oxygenate sufficientlydespite use of supplemental oxygen, then intubation is indicated.

o EXAMPLES:

o Status asthmaticus- why?

o COPD exacerbation with upward trending EtCO2 - why?

o Severe pulmonary edema after CPAP/BiPAP- why?

o Severe hypovolemic shock with inability to maintain perfusion- why?

Correcting Hypoxia

o Correct rate and tidal volume (BVM) rate x Vt = Min Vol

o Increase percentage of O2 delivery (FiO2)

o NPPV (increase PEEP/FRC via CPAP or BiPAP)

o Pharmacology- Beta agonists, Catecholamines, MgSO4

o PPV, intubation, mechanical ventilation

What is the anticipated clinical course?

Most patients that require intubation have one or multipleindications discussed above, however. . .

There is one group of patients that may not immediately exhibitinability to maintain airway patency, loss of protective reflexes, orinability to oxygenate or ventilate.

Those patients whose clinical course is expected to deteriorate,or showing downward trending appearance should be stronglyconsidered for “pre-emptive” and proactive intubation.

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Those patients who are expected to deteriorate due toworsening clinical condition or fail to oxygenate because ofcatastrophic illness or injury should be intubated early!

EXAMPLES:

Stab wound to the neck with a hematoma

Airway burns with signs of impending airwaycompromise.

Traumatic brain injuries with signs of herniation.

Sepsis with respiratory fatigue and ARDS.

Expected Clinical Deterioration

Now We Have Decided toIntubate, How Do We Do It?

Using the Airway Algorithms

Universal Airway Algorithm

Difficult Airway Algorithm

Crash airway Algorithm

Failed Airway Algorithm

RSI Algorithm

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Decision tointubate

Near death?Unresponsive?

DifficultAirway?

RapidSequenceIntubation

CrashAirway

DifficultAirway

Techniques

FailedAirway

Approach to theEmergency Airway

Adapted from: Walls, RM, Ed. Manual of Emergency Airway Management, 4th Ed, Philadelphia, Lippincott, 2012

Decision toIntubate

Airway maintenance

Oxygenation

Ventilation

Corrective intervention

Expected course

Decision to Intubate: Considerations

Operator experience (most experienced laryngoscopist)

Setting: prehospital vs in-clinic/hospital

Potential for a difficult airway

3-3-2 evaluation

L.E.M.O.N.

M.O.A.N.S.

Never remove someone’s ability to breathe if you cannotventilate them, or think you can’t!

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The Difficult Airway Triangle

RSI

Sakles’s triangle

Difficult Bag & Mask VentilationAssessment of Difficult BVM

Assessment of Difficult BVM

Consider the difficulty of BVM ventilation beforeadministering medications!

Everyone has a full stomach in our world.

Have all equipment out and ready before you start.

Five predictors of difficult BVM: facial hair, obesity, poordentition or edentulous, elderly (> 55 yrs), snoring or sleepapnea history.

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Difficult BVM: MOANS

M ask seal

O besity / obstruction

A ge > 55

N o teeth

S tiff lungs (COPD, asthma, ARDS)

Positioning the Obese Patient

In the Ambulance

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Difficult Laryngoscopy & Intubation

Difficult Laryngoscopy &Intubation

Difficult Intubation Assessment

Cormack-Lehane eval is cumbersome and does not oftenwork in our chaotic situations. Requires look withlaryngoscope.

Too little, too late

We are pre-hospital providers and need an evaluationsystem that is simpler, faster, and easier.

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DifficultAirwayPossibly?

Let’s Talk LEMONS!

“LEMON” LAW of Evaluating Difficult Airway

L ook externally

E xamine (3-3-2)

M allampati grade

O bstruction

N eck mobility

LEMON:Look

Simple visual inspectionoften reveals obviouspotential difficulties.

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LEMON:Examine 3-3-2

Open mouth should beable to accommodatethree fingers

Mouth opening forvisualization of glottis

LEMONExamine 3-3-2

Measure the mandible.You should be able to fit3 fingers between thementum and the hyoidbone.

Tongue displacement

LEMONExamine 3-3-2

Assess the position of thelarynx. You should get 2fingers between thethyroid cartilage and themandible

Larynx in relation to thebase of the tongue.

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MicrognathiaWhat’s wrong with this picture?

LEMON: Mallampati

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Mallampati I - IV

I II

Probable difficult airway IV

Uvula clearlyvisible

III

LEMON: Obstruction?

Location of obstruction

Fixed or mobile?

Speed of progression?

LEMON: Obstruction

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LEMON: Neck Mobility

How well can the patient extend and flex their neck?

Spinal immobilization / C-collar?Remove anterior portion of c-collarfor intubation

Arthritis / cervical fusions

What is Your Assessment?

Assessment Now?

Top ofUvula visible

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Failedairway

Post-intubationManagement

Or RSI

No

No

No

Difficult Airway Algorithm

Always have equipment ready prior to intubation attempt,especially with anticipated difficult airways.

Have rescue supraglottic airways ready (King, LMA,iGel)

Be prepared with BVM and ready to assist ventilations.

If unable to oxygenate, ventilate, or successfully intubatewithin 3 attempts (by most experienced intubator), thenyou have moved to the FAILED AIRWAY algorithm.

Failed Airway Algorithm

ALL AIRWAYS END IN ONE OF TWO WAYS:

Successful intubation

Failed airway algorithm

This is the EXPERIENCED bad airway

It is important to understand that to experience a failedairway does not mean you have failed the patient!

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Failed Airway Causes

Unable to intubate patient within 3 attempts by mostexperienced laryngoscopist.

Three attempts total. Not 3 each! What does your protocolsay?

An attempt is considered from the time the laryngoscope tipenters the mouth and is withdrawn for any reason.

Unable to maintain SpO2 > 90%

Desaturation Curve

yes

no

yes

If contraindicated

EGD may be attempted

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Key Point of Failed Airway

Cricothyrotomy is the end result.

A second practitioner MAY ATTEMPT a supraglottic airwaywhile the primary person is setting up to surgically cric thepatient, but the cricothyrotomy should not be delayed for ANYREASON!

RSI ALGORITHM

YES

YES

YES

NO

NO

NO

NO

NO

YES

Adapted from: Walls, RM, Ed. Manual of Emergency Airway Management, 4th Ed, Philadelphia, Lippincott, 2012

So now we have moved to the appropriateairway algorithm . . .

HOW DO WE INTUBATE THIS PATIENT?

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The Rules

Stay calm and maintain your focus.

Prepare for the worst.

Have a plan.

Make sure everyone knows the plan.

Have an alternate plan.

Remember the 7 P’s.

Inability to intubate is not a failure! Inability to ventilate andoxygenate is!

The Bottom Line

Ventilation and oxygenation arethe TOP priorities.

Patients do not die or suffer braindamage because you do not orcannot intubate them . .

Patients die or suffer braindamage because you cannot, or donot ventilate and oxygenate them.

AirwayManagement DoesNOT NecessarilyMean Intubation

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Be an Expert at BVM Ventilation

Sizing, adult vs pediatric technique, proper rate, volume, and tempo

Remember PEEP

Use Alternate Airways

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Know Your Tools

WARNING! Objects in the mirrorare closer that they appear!

Useful Strategies

Passive oxygenation

Placing a NRB at 15 LPM on your patient a few minutes priorto your intubation attempt.

Then place a nasal cannula at 15-25 LPM while you areintubating and until the ETT is placed, verified withcapnography, and secured.

Minimal amounts of PEEP /Functional Residual Capacity(FRC) are established, and studies validate the lengthening ofdesaturation times by up to two minutes.

Passive Oxygenation

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Considerations

Delayed Sequence Intubation (DSI)

Many patients may require some sort of resuscitation and/orprior oxygenation prior to any sort of intubation or RSI/med-assisted attempt.

This may be due to chronic lung disease, trauma, or combativebehavior where they will not tolerate oxygenation with a NRBor NC immediately prior to intubation.

RSI or med-assisted intubation is then performed as usual.

DelayedSequenceIntubation

Push Dose Pressors

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Epinephrine 0.1 mg/ml

Epinephrine 0.1 mg/ml

Alpha Effects

Peripheral arterial vasoconstriction

++ preload

++ cardiac perfusion

Beta ½ Effects

Beta1

++ inotropic & dromotropic

Beta2

Smooth muscle relaxation

Bronchial dilation

Uterine relaxation

Insulin release

Push Dose Pressors

Used in peri-intubationhypotension and extremis

Not used for standard bloodpressure management

Assists in maintainingcompensatory physiologicalmechanisms

A strategy for use in med-assistedand rapid sequence intubation

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Video LaryngoscopyWhich device do you use and are you proficient

with it?

Thanks foryour attention.

Discussion?

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Not So Rapid SequenceIntubation

It’s All in the Wrist!

Definition:

“Rapid sequence intubation (RSI) is the administration,after preoxygenation, of a potent induction agent followedimmediately by a rapidly acting neuromuscular blockingagent to induce unconsciousness and motor paralysis fortracheal intubation.”

Ron M. Walls, MD, Michael F. Murphy, MDManual of Emergency Airway Management, Fourth Ed, Lippincott Williams &Wilkins, 2012

In other words, the purpose of RSI is to render the patientunconscious and paralyzed and then to intubate the tracheawithout the use of bag-mask ventilation (whenever possible*),which may cause gastric distention and increase the risk ofaspiration.

Ron M. Walls, MD, Michael F. Murphy, MDManual of Emergency Airway Management, Fourth Ed, Lippincott Williams &Wilkins, 2012

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If Only It Was That Simple!

When to Consider RSILet’s compare these next few slides to “Medication-

assisted” intubation

When an emergency intubation is indicated and the patientdoes not have difficult airway features that contraindicateuse of NMBA’s.

L.E.M.O.N. assessment

Large tongue, small mandible, large teeth, short neck

Obesity (BMI does not correlate to predict difficulty)***

Small mouth opening***

Poor 3-3-2 assessment***

Obstruction: muffled voice, difficulty swallowing secretions,stridor, sensation of dyspnea

DifficultyPredictors

• C-spine immobilization

• Short, thick neck

• Facial hair (beard)

• Prominent upper incisors

• Face, neck, oral trauma

• Airway edema

• Laryngeal trauma

• High palate

• Dentures

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The Seven P’s of RSITimed Sequence of Events for a Healthy 80-kg Patient

1. Preparation Zero minus 10 minutes

2. Preoxygenation Zero minus 5 minutes

3. Pretreatment Zero minus 3 minutes

4. Paralysis with induction Zero

5. Positioning Zero plus 20-30 seconds

6. Placement with proof Zero plus 45 seconds

7. Postintubation management Zero plus 1 minute

It is important to mention the often lowsuccess rates of prehospital RSI,

sometimes 50% of first pass success, especially with acompressed timeline

Preparation

Thorough assessment fordifficulty of intubation

Monitoring equipment

Checklist, checklist, checklist

IV access x 2

Equipment checked and prepped

You and your partner synched

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Preoxygenation

• No bag-mask ventilationwhenever possible

• Nitrogen washout, increasingfunctional residual capacity(FRC) 30 ml/kg

• NC at 10+ lpm + NRB

• 3 minutes or greater

• 8 vital capacity breaths if pt. able

Pretreatment

Asthma (reactive airway disease)

Brain (elevated ICP)

Cardiovascular (ischemia,

vascular disease, aorta, ICH)

Meds administered 3 minutesprior to induction/paralysis.

Paralysis with Induction

Rapid IVP of induction agent

Etomidate

Ketamine*

Followed immediately by rapidIVP of NMBA

Succinylcholine

Rocuronium

• Be prepared for untoward effectsfrom rapid administration ofinduction agents* with criticaland hypotensive patients.

• Sepsis, extremely dyspneic, andhypotensive patients may likelydeteriorate!

• Consider preparation and useof push-dose pressors in thesesituations

• Consider Delayed SequenceIntubation (DSI) to achieveMAP > 80 mmHg

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Positioning

Spinal immobilizationprecautions- open the collar

Obesity

Peds- sniff position

Placement with Proof

20-40 seconds after Ketamine

Check jaw flaccidity. Massetermuscle is last to relax.

Intubate

If adequate preoxygenation wasachieved, you should haveseveral minutes of safe apneatime.

Post-intubation Management

Confirm proper depth and securethe ETT with a commercialdevice. Check after every move.

Secure head in neutral midlineposition. Elevate 15-30 degrees asnecessary, especially w CHI

Initiate mechanical ventilation

Administer sedation q 10minutes or prn

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Post-intubation Management

• Hypotension following intubation and ventilation mayoccur due to combined effects of induction meds andincreased intrathoracic pressure.

• While it may be temporary or respond to fluids, alwaysconsider a more significant cause.

• More than 10 seconds of hypotension with MAP < 90mmHg or hypoxia doubles mortality in brain traumapatients!

• Remember restraints, analgesia, and continuous sedation.

Desaturation Considerations

Be prepared, use most experience intubator andPREOXYGENATE!

Term pregnant women desaturate < 95% in less than 3minutes compared to non-pregnant. Positioning does notfavorably affect the duration of apneic oxygenation in termpregnancy.

Obese patients are similar, and desaturate quickly! Why?

Preoxygenating MorbidlyObese Patients

25%+ elevation head upposition for the entireprocedure

Oxygenation with a highflow nasal cannula 10+LPM maintained till ETTposition is confirmed withcapnography may increasedesaturation time < 92% to3.5 minutes.

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Causes of Post-RSIHypotension

Pneumothorax

Decreased venous return

Induction and sedation agents - iatrogenic

Cardiogenic causes: AMI, ischemia, poor baselinecondition, synergistic effect of induction meds withcardiac meds.

Discussion?