Advanced Airway Management

Chapter Advanced Airway Management Twenty-Nine

Chapter Purpose and procedure for nasogastric tubes and orotracheal intubation How to perform Sellick’s maneuver How to use the Combitube® airway and the LMA Usefulness of an ATV Twenty-Nine CORE CONCEPTS

Anatomy of the Respiratory System

Shallow chest expansion Depth: Outside normal range Rate: (fast or slow) Regular or irregular Rhythm: (Continued) Inadequate Breathing

Abnormal breath sounds Quality: (noisy, diminished, or absent) Unequal chest expansion Increased breathing effort (Continued) Inadequate Breathing

Just before death Agonal Respirations: Pale, cyanotic, cool, or clammy Skin: Above clavicles, between/below ribs Retractions: Inadequate Breathing

Nasal flaring “ See-saw” breathing Inadequate Breathing in Infants and Children

Airway Differences between Adults and Children

Mouth and nose Pharynx Trachea Cricoid cartilage Diaphragm Differences between the Airways of Children and Adults

Orotracheal Intubation Purpose Most effective way to control airway. Use in apneic patients: Minimizes risk of aspiration. Allows more oxygen delivery. Allows deeper suctioning.

Complications Stimulation of airway can cause bradycardia. Trauma can occur to lips, teeth, tongue, gums, airway structures. Orotracheal Intubation (Continued)

Hypoxia may result from prolonged attempts. No oxygen to left lung because tube is in right mainstem bronchus. Complications Orotracheal Intubation (Continued)

Esophageal intubation Vomiting Self-extubation Movement of tube out of trachea when patient moved Complications Orotracheal Intubation

Laryngoscope handle Laryngoscope blades Equipment Assorted sizes (0–4) Curved or straight (straight preferred for infants/children) Orotracheal Intubation (Continued)

Straight blade brings vocal cords into view by lifting epiglottis.

Curved blade brings vocal cords into view by lifting vallecula and indirectly lifting epiglottis.

Assembly of Laryngoscope Handle and Blade Align identification with bar, press-forward to lock Press To lock

Adult female: Adult male: 7.0–8.0 mm 8.0–8.5 mm Endotracheal Tubes: Average Sizes (Inner diameter) (Continued)

Endotracheal Tubes Emergency rule: Have available one size larger 7.5 fits most adults. and one size smaller.

Teeth to cords: Teeth to suprasternal notch: Teeth to carina: Teeth to tip: 15 cm 20 cm 25 cm 22 cm Endotracheal Intubation Useful Dimensions

Provides stiffness/shape. Lubricant may ease removal. Used to shape tube like Stylet hockey stick. Do not let stylet get closer than 1/4 inch to end of tube. Endotracheal Intubation

Water-soluble lubricant 10 cc syringe Securing devices Suction unit Towels Equipment Endotracheal Intubation

Endotracheal Intubation Inability to ventilate Indications apneic patient Unresponsiveness to painful stimuli No cough or gag reflex Inability of patient to protect airway

Use in unresponsive patient who lacks a cough or gag reflex to help prevent regurgitation and aspiration during endotracheal intubation. Sellick’s Maneuver

Cricoid Cartilage Surrounds entire trachea, inferior to cricothyroid membrane (depression below thyroid cartilage or Adam’s apple) K EY TERM

Perform Sellick’s maneuver by exerting posterior pressure on cricoid cartilage.

Sellick’s Maneuver Verify correct position to avoid damaging other structures. Cricoid is more difficult to find in infants/children. (Continued)

Have third rescuer perform maneuver. Maintain maneuver until patient is intubated. Sellick’s Maneuver

Ensure proper ventilation of patient.

Assemble, prepare, and test equipment.

If trauma is suspected, have rescuer hold head in neutral position. Position patient’s head.

Make sure airway structures are aligned.

Insert laryngoscope blade into mouth, avoiding contact with teeth.

Insert blade and lift mandible.

Have rescuer apply Sellick’s maneuver. (Bring vocal cords into view.)

Visualize glottic opening between vocal cords.

Gently insert endotracheal tube (with stylet in place) until cuff passes between vocal cords.

Remove laryngoscope and stylet without moving tube. Inflate cuff with 5–10 cc of air.

Attach bag-valve resuscitator and ventilate. Observe rise of chest.

Confirm placement by auscultating epigastrium and lungs.

Observe chest rise and fall. Auscultate epigastrium for absence of sounds. Auscultate apex and base of each lung. Confirm Correct Tube Placement (Continued)

Observe for signs such as cyanosis. As protocols direct, use end-tidal CO 2 detector and “tube-check.” (Continued) Confirm Correct Tube Placement

Colorimetric end-tidal CO 2 detector

Combined devices check pulse oximetry, ETCO 2 blood pressure, pulse, respiratory rate, and temperature.

Tube Placement If correct placement is confirmed, secure tube and continue to ventilate.

Tube Placement If breath sounds are present only on right, deflate cuff and withdraw tube slightly until breath sounds are equal. Secure tube with a commercial device and ventilate. (Continued)

If sounds are present only in epigastrium, deflate cuff, remove tube, and hyperventilate for at least 2 minutes before reattempting intubation. Tube Placement (Continued)

Tube Placement Reassess breath sounds after every major move: From scene to ambulance From ambulance to hospital

It cannot be overemphasized that inadvertent esophageal intubation will likely result in death. Because of the magnitude of this complication, tell new EMT-Bs that if at any time, despite the best efforts to properly assess tube placement, they are in doubt of proper tube placement, they should immediately withdraw the tube and manage the airway with basic airway adjuncts. P RECEPTOR P EARL

Mouth and nose (smaller) Pharynx (tongue proportionally larger) Epiglottis (floppier) Glottic opening (smaller) Anatomic and Physiologic Considerations (Continued)

Vocal cords (harder to see) Trachea (narrower) Cricoid cartilage (less rigid; part of child’s airway) Diaphragm (children rely more on diaphragm for breathing) narrowest Anatomic and Physiologic Considerations

Cricoid Cartilage Child and Adult Airways

Since cricoid ring is narrowest part of child’s airway, Pediatric tube has no cuff. Tube size depends on size of cricoid ring. Infant and Child Intubation Special Considerations

Most effective means of controlling airway. In apneic patients, also allows deeper suctioning. Infant and Child Intubation Purpose

Orotracheal Intubation Complications Stimulation of airway can cause bradycardia. Trauma can occur to lips, teeth, tongue, gums, airway structures. (Continued)

Hypoxia can result from prolonged attempts. No oxygen to left lung because tube is in right mainstem bronchus. Complications Orotracheal Intubation (Continued)

Prolonged artificial Indications Infant and Child Intubation ventilation required Inability to ventilate by other means (Continued)

Indications Apnea Unresponsiveness without cough or gag reflex Infant and Child Intubation (Continued)

Prevents gastric distention Minimizes risk of aspiration Permits suctioning of airway secretions Advantages Infant and Child Intubation

Bag-valve mask with mask of correct size Equipment Laryngoscope handle Infant and Child Intubation

Straight blade allows: Greater displacement of tongue Better visualization of glottis (preferred in infants) (Continued) Infant and Child Intubation Laryngoscope Blades

Curved blade inserted into vallecula allows: Visualization of glottis, cords (preferred in older children) Infant and Child Intubation Laryngoscope Blades

Consult chart or tape. In general, use: Endotracheal Tube Size 3.0–3.5 for newborns, small infants 4.0 for up to 1 year old (Continued) Infant and Child Intubation

Formula for Endotracheal Tube Size 16 + age (years) 4 = Tube size (mm) (Continued) Infant and Child Intubation

Alternative: Have tubes one size larger and Use tube same size as patient’s little finger or that will fit nostril. smaller available. Infant and Child Intubation

Use UNCUFFED tubes for children up to 8 years old. ET Tubes (Narrowing of cricoid acts as a cuff.) Infant and Child Intubation (Continued)

Use CUFFED tubes for children older than 8 years. ET Tubes (Tube should have marker for vocal cords, to ensure proper insertion depth.) Infant and Child Intubation

(Measured from teeth to midtrachea) Pediatric ET Tube Distances

Endotracheal Intubation Provides stiffness/shape. Lubricant may ease removal. Used to shape tube like Stylet hockey stick. Do not let stylet get closer than 1/4 inch to end of tube.

Tell new EMT-Bs that ideally a chart should be placed in the airway kit to help them determine what size tube is generally used for a certain age patient. As an alternative, there are commercially available measuring tapes that estimate tube size based on the length of the patient. P RECEPTOR P EARL

Ventilate appropriately. Assemble and test equipment. Take BSI precautions. (Continued) Infant and Child Intubation Techniques

Monitor heart rate throughout. (Mechanically stimulating airway may slow heart rate. If this happens, stop and ventilate.) Infant and Child Intubation Techniques

If trauma is suspected, have rescuer hold head in neutral position. Place head in “sniffing” position.

Using little force, insert laryngoscope blade into right corner of mouth. Sweep tongue out of way. Infant and Child Intubation Techniques (Continued)

Insert end of blade into position: Lift mandible: Straight lift–epiglottis Curved–vallecula Use care not to contact teeth. Infant and Child Intubation Techniques (Continued)

Have rescuer apply Sellick’s maneuver. Visualize glottic opening and vocal cords. Infant and Child Intubation Techniques (Continued)

Gently insert tube until glottic marker (if present) is at level of vocal cords. If using cuffed tube, insert cuff beyond vocal cords. Infant and Child Intubation Techniques (Continued)

Holding tube, remove laryngoscope blade and stylet. Have partner attach bag-valve and ventilate. Confirm correct placement. Infant and Child Intubation Techniques (Continued)

Observe chest rise and fall. Auscultate epigastrium for absence of sounds. Infant and Child Intubation Techniques (Continued)

Auscultate apex and base of each lung. Assess for improvement in heart rate and skin color. Infant and Child Intubation Techniques (Continued)

If correct placement is confirmed (no sounds over epigastrium and bilaterally equal breath sounds) , secure tube with commercial device and continue to ventilate. Infant and Child Intubation Techniques (Continued)

Ventilate patient at a rate appropriate for age. Note tube’s depth of insertion. May insert oral airway/bite block. Infant and Child Intubation Techniques (Continued)

If breath sounds are present only on right, withdraw tube slightly until breath sounds are equal. Secure tube and ventilate. Infant and Child Intubation Techniques (Continued)

Infant and Child Intubation Techniques (Continued) If sounds present only in epigastrium: Remove tube. Ventilate for at least 1 minute. Reattempt intubation.

Once tube is secured, secure head to prevent movement that can dislodge tube. Infant and Child Intubation Techniques (Continued)

Reassess breath sounds after every major move: Scene to ambulance Ambulance to hospital Infant and Child Intubation Techniques

If tube is in proper place, but lung expansion is inadequate: Tube too small/large air leak. Auscultate neck Replace with larger tube Consider cuffed tube if child > 8 years old Infant and Child Intubation Techniques

Pop-off valve on bag-valve device activated. Leak in bag-valve device. If tube is in proper place, but lung expansion is inadequate: Infant and Child Intubation Complications (Continued)

Inadequate compression of bag Tube blocked with secretions SUCTION ENDOTRACHEALLY; REPLACE TUBE. If tube is in proper place, but lung expansion is inadequate: Infant and Child Intubation Complications (Continued)

Stimulation of airway can cause bradycardia. Trauma can occur to lips, teeth, tongue, gums, airway structures. Infant and Child Intubation Complications (Continued)

Hypoxia may result from prolonged attempts. No oxygen to left lung because tube is in right mainstem. Infant and Child Intubation Complications (Continued)

Esophageal intubation Vomiting Self-extubation Tube dislodged by patient moving Collapse of lung Infant and Child Intubation Complications (Continued)

Reasons for Use Decompress stomach Gastric lavage Administration of medications/nutrition Nasogastric Tubes

Indications Inability to ventilate infant/child because of gastric distention Unresponsive infant/child Nasogastric Tubes

Contraindications Presence of major face, head, or spine trauma (use orogastric technique instead) Nasogastric Tubes

Complications Tracheal intubation Nasal trauma Emesis Passage into cranium through basilar skull fracture Nasogastric Tubes

Newborn/Infant 8.0 French Toddler/Preschool 10.0 French School age 12.0 French Adolescent 14-16 French Tube Sizes Nasogastric Tubes

Equipment 20 cc syringe Water-soluble lubricant Emesis basin Tape, stethoscope Suction unit and catheters Nasogastric Tubes

Nasogastric Intubation Infant/Child: Oxygenate patient; prepare and assemble equipment.

Measure tube from tip of nose, around ear, to below xiphoid process. Pass lubricated tube downward along nasal floor into stomach.

Confirm placement as you inject 10–20 cc air. Listen for bubbling.

Aspirate for stomach contents. Secure tube in place.

Indications Obvious secretions Poor compliance when using bag-valve mask Orotracheal Suctioning

Complications Orotracheal Suctioning Arrhythmias Hypoxia Coughing Damage to mucosa Bronchospasm

Take BSI precautions! Preoxygenate and ventilate patient.

Carefully check equipment. Insert catheter without suction. Use sterile technique.

Advance catheter no farther than carina.

Apply suction and withdraw catheter in twisting motion.

Resume ventilation. (Suctioning should not interrupt ventilation longer than 15 seconds.) Orotracheal Suctioning

Nothing is more embarrassing for the EMT-B, or harmful for the patient, than fumbling around to get a suction unit working when the airway is filled with vomit or blood. Remind new EMT-Bs that a working rigid-tip suction catheter is an essential piece of equipment for suctioning the mouth and pharynx, which must be done before orotracheal intubation. P RECEPTOR P EARL

Indication Combitubes ® Unconscious patient in need of airway management

Contraindications: Conscious patient Patient with gag reflex Under 5 feet tall Under 16 years old Ingestion of caustic substance Known esophageal disease Combitubes ®

Take BSI precautions. Ventilate with bag-valve mask. Prepare and check equipment. Have suction readily available. If patient becomes conscious, at any time, remove the tube! Combitubes ® Insertion Techniques

Insert device blindly along center of the mouth. Advance device until the teeth are centered between the black rings on the Combitube ® . Combitube ® Insertion Techniques

Inflate valve #1 cuff with 100 cc of air. Inflate valve #2 cuff with 15 cc of air. Combitubes ® Insertion Techniques

Combitube ® in place with cuffs inflated.

Ventilate through tube #1 (blue tube).

Auscultate for lung sounds and the absence of epigastric sounds. If lung sounds are present and no epigastric sounds are heard, continue ventilating through the blue tube (tube #1). Combitubes ® Insertion Techniques

If no lung sounds are present and epigastric sounds are heard, ventilate through the shorter tube (tube #2).

Take BSI precautions. Ventilate with bag-valve mask. Prepare and check equipment. Have suction readily available. Place patient in a sniffing position. Laryngeal Mask Airway Insertion Techniques

Lubricate the posterior side of cuff. Insert tube with open side facing anteriorly. Stop when resistance is felt. Laryngeal Mask Airway Insertion Techniques

Inflate cuff with air based on size of LMA. Ventilate through the tube. Auscultate for lung sounds and the absence of epigastric sounds. Insert an oral airway as a bite block. Laryngeal Mask Airway Insertion Techniques

Automatic Transport Ventilators (ATVs)

An Automatic Transport Ventilator

Protocols may allow use in place of bag-valve mask. Controls set rate of ventilations and weight-based tidal volume. Automatic Transport Ventilators

1. Explain the procedure of nasogastric tube insertion. 2. Discuss the indications for orotracheal intubation. 3. How and when should the Sellick maneuver be performed? 4. When is an ETC appropriate to use? R EVIEW QUESTIONS

Advanced Airway Management

In this document

More Related Content

What's hot

Viewers also liked

Similar to Advanced Airway Management

More from paramedicbob

Recently uploaded

Advanced Airway Management