Airway management in ED - Basics and advanced

Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Airway management in ER settings  
“Basic & Advanced”
Updated with recent advances
Dr.Venugopalan. P.P
DA,DNB,MNAMS,MEM-GWU
Director , Emergency Medicine
Aster DM Healthcare

Why airway management in
Emergency Room ?
» Airway management is the cornerstone of
resuscitation
» A defining skill for the specialty of
emergency medicine
» The emergency physician has primary
responsibility for management of the airway
» All airway management techniques lie
within the domain of emergency medicine

When to intubate ?
» 1.Failure to maintain or protect the airway
» 2.Failure of ventilation or oxygenation
» 3.Anticipated clinical course and likelihood
of deterioration.
Clinical Decision

How do you know airway is patent?
» 1.Level of consciousness
» 2.Ability to phonate in response to voice
command or query (Integrity of the upper
airway and the level of consciousness)
» 3. Ability to manage his or her own
secretions ( pooling of secretions in the
oropharynx, absence of swallowing
spontaneously or on command)

Intubation?
A patient who requires a maneuver to
establish a patent airway or who
easily tolerates an oral airway
probably requires intubation for
protection of that airway, unless
temporary or readily reversible
condition, such as opioid overdose, is
present.

Ventilatory failure or Oxygenation
failure?
» Clinical assessment
» Pulse oximetry with or without
capnography
» Observation of improvement or
deterioration in the patient’s clinical
condition

The decision to intubate
intubate, and intubate early
especially in dynamic airways
Bullets - neck trauma 
Bites- anaphylaxis /
angioedema thermal and
Burns -caustic airway
injuries
• 3 Bs
Bullets
Bites
Burns
#

ABCDEF
Airway - mouth and neck infections, tumors,
foreign bodies, bleeds
]exam: stridor, phonation, swallowing, secretions, dyspnea
Breathing failure of oxygenation or ventilation
often amenable to medical and non-invasive therapies – think NIV
Circulation supporting tissue oxygen delivery by
unloading the muscles of respiration
sepsis

ABCDEF
Disability : CNS catastrophes and CNS depression, ongoing
seizures, weakness
exam: avoid gag – assess ability to swallow and handle secretions (pooling, drooling,
gurgling) for neuromuscular weakness: FVC < 12 ml/kg and NIF < 20 cm H20
vomiting in the obtunded patient is a particular concern
Expected course :anticipated decline, transfer to radiology
or another institution
» Feral -need for prompt, aggressive sedation to protect
patient/others
especially with potential or undiagnosed medical instability

Arterial blood gases (ABGs) generally are not
required to determine the patient’s need for intubation

Anticipated clinical deterioration
» Certain overdoses
» Significant multiple trauma, with or without head
injury
» Multiple trauma with hypotension, an open femur
fracture, and diffuse abdominal tenderness
» Aggressive resuscitation, pain control,invasive
procedures and imaging outside of the emergency
department ,inevitable operative management
» Evidence of vascular or direct airway injury in the
neck

Obstructed airway ?
• Tongue and Epiglottis
• Any Foreign materials ?
Clear it
Noisy breathing ?

Tongue obstructing
Airway

Head tilt &Chin lift

Jaw thrust

Trauma ?

Airway
Not – Maintainable ?
Adjuncts

• Airway Reflexes ? …..No !
Choice –OPA !

O P A

Sizing - oropharyngeal airway

Oropharyngeal airway Insertion

• OPA is not tolerating ?
• Airway reflexes retained ?
• Inability to open mouth ?
N P A

N
P
A

Airway
Still not – Maintainable ?
Advanced Airway

No Breathing ?
• Give Breaths
• Cricoid Pressure ?
E – C Clamp
Place and hold mask
properly

Non-maintainable Airway
Conscious patient?
Semiconscious with retained reflexes?
R
S
I

RSI Defined
“Virtually simultaneous administration of a
potent sedative agent and a
neuromuscular blocking agent to induce
unconsciousness and motor paralysis
for tracheal intubation”

What are The Problems Inherent to
Intubation?
• Laryngoscopy and Intubation
– Increased bronchospasm
– Increased ICP
– Increased catecholamine release

Beneficial Effects of RSI
• “Tight Heads”
– Intracranial pathology
• “Tight Hearts” or “Tight Vessels”
– Cardiovascular disease
• “Tight Lungs”
– Reactive airway disease

Conventional
With LMA

RSI: Timeline
T – 10 minutes Prepare
T – 5 minutes Preoxygenate
T – 3 minutes Pretreat
T = 0 Paralysis with
induction
T + 30 seconds Protection
T + 45 seconds Placement
T + 90 seconds Post-Intubation
management

Airway Evaluation
Problem Airway
epiglottis Vocal cords

Difficult airway ?
» Difficult intubation,
» Difficult BMV,
» Difficult ventilation with an extra glottic
device
» Difficult circo thyrotomy.

Double set up
» Neuromuscular paralysis
generally should be
avoided in patients for
whom a high degree of
intubation difficulty is
predicted, unless the
administration of the
neuromuscular blocking
agent (NMBA) is part of
a planned approach to
the difficult airway

Look Externally
» Severely bruised
» Bloodied face of a combative trauma patient
» Immobilized in a cervical collar on a spine
board
» Anatomical deformities
» Subjective clinical judgment can be highly
specific (90%) but insensitive and so should
be augmented by other evaluations.

Evaluate 3-3-2.

Obstruction or obesity
» Visualization of the glottis, or intubation
itself, mechanically impossible
» Epiglottitis, head and neck cancer,
Ludwig’s angina, neck hematoma, or glottic
polyps
» Examine the patient for airway obstruction
and assess the patient’s voice to satisfy
this evaluation step

Neck mobility
» Neck mobility is desirable for any
intubation technique and is essential for
positioning the patient for optimal direct
laryngoscopy. Neck mobility is assessed
with the patient’s flexion and extension of
the head and neck through a full range of
motion

Lemon in ER setting
» Unresponsive patient - Mallampatti is not
practical - LEON
» Unresponsive plus Trauma - Mallampatti
and Neck mobility are not practical - LEO

Cormack and Lehane[CL]
» The most widely used system for grading
laryngoscopic view of the glottis is that of
Cormack and Lehane (CL)
» Grades laryngoscopy according to the
extent to which laryngeal and glottic
structures can be seen.

CL grading
» Grade 1 laryngoscopy, all or nearly all of the
glottic aperture is seen.
» Grade 2 laryngoscopy visualizes only a portion
of the glottis (arytenoid cartilages alone or
arytenoid cartilages plus part of the vocal cords).
» Grade 3 laryngoscopy visualizes only the
epiglottis.
» Grade 4 laryngoscopy, not even the epiglottis is
visible.

Percentage
Of Glottic Opening (POGO) score

Confirmation of Endotracheal Tube
Placement
» Direct visualisation
» Chest auscultation
» Gastric auscultation
» Bag resistance
» Exhaled volume
» Visualization of condensation within the ETT
» Chest radiography
» All are prone to failure as means of confirming
tracheal intubation.

ETCO2
» End-tidal carbon dioxide (ETCO2)
detection device to the ETT and assess it
through six manual ventilations
» Disposable, colorimetric ETCO2 detectors
are highly reliable, convenient, and easy to
interpret, indicating adequate CO2
detection by color change

End tidal CO2 detection

USG- EDD
» When ETCO2 detection is not possible,
tracheal tube position can be confirmed
with other techniques.
» One novel approach Bedside ultrasound.

Esophageal Detector Devices  
(EDD)

Recognize Adequacy of Ventilations
Pulse oximeter

Chest X ray
» Although chest radiography is universally
recommended after ETT placement, its
primary purpose is to ensure that the tube
is well positioned below the cords and
above the carina.

Other methods  
Gold standard
• Fiberoptic confirmation

Difficult Airway Assessment
• 4 D’s
– Distortion, Disproportion, Dysmobility, Dentition
• BONES
– Beard, Obese, No teeth, Elderly, Snores (sleep
apnea)
• SHORT
– Surgery (head/neck/jaw), Hematoma, Obese,
Radiation, Tumor
• LEMON
• MALLAMPATI
• Always have a “Rescue Airway” technique
ready

McIntyre;Thedifficulttrachealintubation

Rescue Airways
• Gum Elastic Bougie (GEB)
• Laryngeal Mask Airway (LMA/ILMA)
• Combitube
• Surgical Cricothyrotomy

Advanced airway –Best choice
Intubation

Equipments Needed
❑ Laryngoscope with different types of
blade.
❑ ET tube with proper size and type.
Average adult male: 8.5 mm
Average adult female: 7.5 mm
Low pressure cuff tubes above 8 years
Uncuffed tubes below 8 years
< 4 Age + 3.5
3
> 4 Age + 4.5
4

Laryngoscope

Align the airway axis by proper
positions

• Align the 3 axes – critical for success
• Sellick’s maneuver

ET Tube insertion

Laryngeal Mask Airway
❑A silicone rubber device that combines.
Tracheal intubation and the use of a face
mask.
❑Used for situations when intubation
attempts have failed, bag-valve mask
ventilation is unsuccessful, and the patient
needs immediate airway management.

LMA- Sizes
Size Description Weight
1 Neonates Upto 5 Kg
1 ½ Pediatric 5 - 10 Kg
2 Infant 10 – 20 Kg
2 ½ Child 20-30 Kg
3 Large child/ Small Adult 30 – 50 Kg
4 Adult 50 – 70 Kg
5 Adult > 70 Kg

Combitube Insertion

Surgical Airway

Blind Nasotracheal
Intubation
• BNTI remains a valid method of intubation in the
out-of-hospital setting, where it occasionally is
used. In the ED, BNTI rarely, if ever, should be
used and is reserved for patients in whom the
presence of a narrowly deﬁned type of difﬁcult
airway makes RSI undesirable or contraindicated
and alternatives

Awake Oral Intubation
» Awake oral intubation is a technique in which
sedative and topical anesthetic agents are
administered to permit management of a difficult
airway without neuromuscular blockade.
» Topical anesthesia may be achieved by spray,
nebulization, or local anesthetic nerve block. After
the patient is sedated and topical anesthesia has
been achieved, gentle direct, video, or flexible
endoscopic laryngoscopy is performed to determine
whether the glottis is visible and intubation possible

Awake intubation

What is the Disaster in Airway
management?
Can’t
Intubate !
Can’t
Ventilate !!

• Rescue Airway
LMA ,Combitube , Bougie assisted intubation
Surgical Airway

New Airway Devices

Video Assisted Laryngoscope

Airway management made
easy
Algorithms

Approximate Blood oxygen level !
➢SpO2 100% = PaO2 100mm of Hg
➢SpO2 90%= PaO2 60mm of Hg

THANK YOU

Airway management in ED - Basics and advanced

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