- Jaw thrust - Head extension Provider: - Index finger guides mask - Other hand guides tube LMA Insertion

1. Backup AirwaysBackup Airways
New HampshireNew Hampshire
Division of Fire Standards & Training andDivision of Fire Standards & Training and
Emergency Medical ServicesEmergency Medical Services

2. Know Your Options!!!
& Don’t hesitate to use them!

3. Purpose
 It is vital that the prehospital crew be
confident and comfortable with the rescue
airways approved for their level of
licensure.
 During this module you will review and
practice the back up airways for your level
of licensure.

4. Purpose
 Review Backup Airway Devices (Rescue
Airways)
 BVM
 LMA
 King-LT-D
 Combitube
 Cricothyrotomy

6. The Basics
 Position
 OPA
 BVM
 Suction
Most difficult airways will still be
manageable using basic airway
maneuvers!

7. The Need for Oxygen
 0 – 1 minute: cardiac irritability
 0 – 4 minutes: brain damage not likely
 4 – 6 minutes: brain damage possible
 6 – 10 minutes: brain damage very likely
 > 10 minutes: irreversible brain damage

8. Oxygen and Carbon Dioxide Exchange
 Oxygen-rich air is inhaled
to alveoli
 O2 exchanged at
alveolocapillary level
 Perfusion to capillary beds
 O2/CO2 exchange at
cellular level
 Perfusion from capillary
beds
 CO2 exhanged at
alveolocapillary level
 CO2 exhaled

9. Assessment of Respiration
 Patients level of consciousness
 Respiration quality
 Pulse quality
 Respiratory rate
 Pulse rate
 SPO2
 EtCO2
 Blood pressure
 Glasgow coma score

10. Every TRUE life saving intervention performed by EMS
reverses one or more failing components of respiration

11. BVM is the most essential intervention in RSI

12. Inadequate Breathing
 Fast or slow rate
 Irregular rhythm
 Abnormal lung sounds
 Reduced tidal volume
 Use of accessory muscles
 Cool, pale, diaphoretic, cyanotic skin

13. Head Tilt-Chin Lift
 One hand on the forehead
 Apply backward pressure
 Tips of fingers under mandible
 Lift the chin

14. Jaw-Thrust Maneuver
 Place fingers behind the angle of the jaw
 Use thumbs to open mouth

15. Look, Listen, and Feel
 Assess that Airway!

16. Basic Airway Adjuncts
 Oropharyngeals
 Keeps tongue from blocking oropharynx
 Eases suctioning
 Used with BVM
 Patients without gag reflex
 Nasopharyngeals
 Maintains patency of oropharynx
 Patients with gag reflex
 Should not be used with head trauma

17. Oxygen
 Nonrebreathing mask
– Provides up to 90% oxygen
– Used at 10 to 15 L/min
 Nasal cannula
– Provides 24% to 44% oxygen
– Used at 1 to 6 L/min

18. Oxygen
 Nasal cannula
 24-40% at 1-6 liters
 Non-rebreather mask
 Up to 90% at 15 liters
 BVM
 21% atmosphere
 Up to 100% at 15 liters with reservoir

19. Artificial Ventilation
 Mouth to mask
 BVM – one person
 BVM – two person

20. Ventilation Rates
 Adults: 8 - 10 breaths per minute
 Approximately one breath every 6 – 8 seconds
 Pediatric: 12 – 20 breaths per minute
 Approximately one breath every 3 – 6 seconds

21. Bag Valve Mask
 Delivers > 90% oxygen
 Requires practice and proficiency
 Use with airway adjuncts and/or advanced
airways
O2 Reservoir
Bag
Valve
Mask

22. BVM-Problems encountered
 Inattentiveness
 Poor mask seal = poor ventilatory ability
 Varying ventilatory rates
 Varying expiration rates
 Varying tidal volumes
 Often excessive airway pressure
 Often hyper-ventilation
Mastering the BVM overcomes these obstacles!

23. BVM – One person
 Insert an oral/nasal airway
 Seal mask by placing the apex over the bridge of
the nose and lower portion of the mask over the
mouth and upper chin.
 Make a “C” with your index finger and thumb
around the mask.
 Maintain the airway with your middle, ring and
little finger, creating a “E”, under the jaw to
maintain the chin lift.
 Squeeze the bag with your other hand slowly at a
rate of one breath every 6–8 seconds.
 Monitoring SpO2

24. BVM – Two Person
 Insert oral/nasal airway
 First provider hold the bag portion of the BVM
with both hands.
 Second provider seals the mask with apex over
the bridge of the nose and base at the upper
chin.
 Using two hands the second provider places
his/her thumbs over the top half of the mask;
index and middle finger over bottom half; ring
and little finger under jaw.
 Second provider also maintains chin-lift
 First provider squeezes bag every 6–8 seconds
 Monitoring SpO2.

25. Adequate Ventilation
 Equal chest rise and fall
 Appropriate rate
 Heart rate returns to normal

26. Inadequate Ventilation
 Minimal or no chest rise
 Ventilating too fast or too slow
 Heart rate does not return to normal

27. Asthma and COPD
 These patients complicate the
traditional RSI approach due to the
difficulty encountered when mask
ventilating
 Alveolar hyperinflation secondary to
underlying pathophysiology must be
considered and adequate passive
ventilation time must be ensured
 Tidal volumes should be reduced,
initially, to reduce likelihood of
barotrauma and air trapping

28. Gastric Distention
 Air fills the stomach from too forceful or
too frequent ventilations
 Airway may be blocked and ventilations
are re-routed to stomach
 Decreases lung capacity
 May cause patient to vomit

29. Airway Obstructions
 Tongue
 Vomit
 Blood, clots, traumatized tissue
 Swelling
 Foreign objects

30. Recognizing an Obstruction
 Partial or complete?
 Can patient speak? Cough?
 If unconscious, deliver artificial ventilation
 Does air go in? Does the chest rise?

31. Removing an Obstruction
 Heimlich maneuver
 Suction
 Magills (paramedics)

32. Suctioning
 Turn on unit and ensure proper suctioning
pressure (300 mmHg)
 Select proper tip and measure
 Insert with suction off
 Suction on the way out
 Suction for no more than 15 seconds

33. Continuous Positive Airway Pressure (CPAP)
Is the patient a candidate for CPAP?

34. CPAP Indications
 Any patient in respiratory distress associated
with CHF with any of the below obvious signs
and symptoms or a history of CHF:
 Bibasilar or diffuse rales
 Respiratory rate greater than 25
 Pulse oximetry below 92%
 Retractions or accessory muscle use
 Abnormal capnography (rate, waveform, CO2 levels)

35. RSI Indication
 Immediate severe airway compromise in
the context of trauma, drug overdose,
status epilepticus, etc. where respiratory
arrest in imminent.

36. Always have a back-up plan.
 Plans “A”, “B”, and “C”
 Know the answers before you begin

37. Plan “A”: (ALTERNATIVES)
 Different:
 Size of blade
 Type of blade
 Miller
 Macintosh
 Specialty
 Position (patient & provider)
 Hockey stick bend in ETT or Directional tip ETT
 Remove the stylette as you pass through the cords
 “BURP” (aka “ELM”)
 Gum Elastic Bougie
 2-person technique
 “cowboy” or “skyhook”
 Have someone else try

38. Viewmax Scope
 Easy of use
 Can be used like a Mac or Miller
 Should improve your view by one grade

39. “BURP” – a.k.a. “External
Laryngeal Manipulation”
 Backward, Upward,
Rightward Pressure:
manipulation of the
trachea
 90% of the time the
best view will be
obtained by pressing
over the thyroid
cartilage
Differs from the Sellick ManeuverDiffers from the Sellick Maneuver

40. Plan “B”: (BVM and BACK UP
Airways)
 Can you ventilate with a BVM?
 (Consider two NPA’s and an OPA, +
Cricoid pressure w/ gentle ventilation)
 KING–LT-D
 Combitube
 LMA

41. King-LT-D

42. King LT-D

62. Combitube

63. CombiTube

64. Insertion Technique
• Tongue-Jaw Lift
• Anatomical
Insertion
• Black rings will lie
between teeth or
alveolar ridges
• Bending the tip
prior to use may
ease insertion

65. CombiTube
• Inflate Blue
Balloon
• Inflate White
Balloon
• The
CombiTube
may reposition
as the
oropharyngeal
is inflated.

66. Esophageal Placement
• Ventilate Blue
Tube
• Visualize
• Auscultate
• EtCO2

67. Tracheal Placement
• Ventilate Clear
Tube
• Visualize
• Auscultate
• EtCO2

68. Laryngeal Mask Air
LMA

69. LMA
 The LMA was invented by Dr. Archie Brain at
the London Hospital in Whitechapel in 1981
 The LMA consists of two parts:
 The mask
 The tube
 The LMA has proven to be a very effective
management tool for the airway

70. Introduction continued
 The LMA design:
 Provides an “oval seal around
the laryngeal inlet” once the
LMA is inserted and the cuff
inflated.
 Once inserted, it lies at the
crossroads of the digestive
and respiratory tracts.

71. Indications
 Situations involving a difficult mask (BVM) fit.
 May be used as a back-up device where endotracheal
intubation is not successful.
 May be used as a “second-last-ditch” airway where a
surgical airway is the only remaining option.

72. Contraindications
 Greater than 14 to 16 weeks pregnant
 Patients with multiple or massive injury
 Massive thoracic injury
 Massive maxillofacial trauma
 Patients at risk of aspiration
 NOTE: Not all contraindications are absolute

73. Complications
 Throat soreness
 Dryness of the throat and/or mucosa
 Complications due to improper placement vary
based on the nature of the placement

74. Equipment for LMA Insertion
 Body Substance Isolation equipment
 Appropriate size LMA
 Syringe with appropriate volume for LMA cuff
inflation
 Water soluble lubricant
 Ventilation equipment
 Stethoscope
 Tape or other device(s) to secure LMA

75. Preparation
 Step 1: Size selection
 Step 2: Examination of the LMA
 Step 3: Check deflation and inflation
of the cuff
 Step 4: Lubrication of the LMA
 Step 5: Position the Airway

76. Step 1: Size Selection
 Verify that the size of the LMA is correct for the
patient
 Recommended Size guidelines:
 Size 1: under 5 kg
 Size 1.5: 5 to 10 kg
 Size 2: 10 to 20 kg
 Size 2.5: 20 to 30 kg
 Size 3: 30 kg to small adult
 Size 4: adult
 Size 5: Large adult/poor seal with size 4

77. Step 2: Examine the LMA
 Visually inspect the LMA cuff for tears or other
abnormalities
 Inspect the tube to ensure that it is free of
blockage or loose particles
 Deflate the cuff to ensure that it will maintain a
vacuum
 Inflate the cuff to ensure that it does not leak

78. Step 3: Deflation & Inflation
 Slowly deflate the cuff to form a smooth flat
wedge shape which will pass easily around
the back of the tongue and behind the
epiglottis.
 During inflation the maximum air in cuff
should not exceed:
 Size 1: 4 ml
 Size 1.5: 7 ml
 Size 2: 10 ml
 Size 2.5: 14 ml
 Size 3: 20 ml
 Size 4: 30 ml
 Size 5: 40 ml

79. Step 4: Lubrication
 Use a water soluble lubricant to lubricate the LMA
 Only lubricate the LMA just prior to insertion
 Lubricate the back of the mask thoroughly
Important Notice:
 Avoid excessive amounts of lubricant
 on the anterior surface of the cuff or
 in the bowl of the mask.
 Inhalation of the lubricant following placement may
result in coughing or obstruction.

80. Step 5: Positioning of the Airway
 Extend the head and flex the
neck
 Avoid LMA fold over:
 Assistant pulls the lower
jaw downwards.
 Visualize the posterior oral
airway.
 Ensure that the LMA is not
folding over in the oral
cavity as it is inserted.

81. LMALMA
InsertionInsertion
TechniqueTechnique
Step 1
Step 5
Step 4
Step 2
Step 3

82. LMA Insertion Step 1
 Grasp the LMA by the
tube, holding it like a pen
as near as possible to the
mask end
 Place the tip of the LMA
against the inner surface
of the patient’s upper
teeth

83. LMA Insertion Step 2
 Under direct vision:
 Press the mask tip upwards
against the hard palate to
flatten it out.
 Using the index finger, keep
pressing upwards as you
advance the mask into the
pharynx to ensure the tip
remains flattened and avoids
the tongue.

84. LMA Insertion Step 3
 Keep the neck flexed
and head extended:
 Press the mask into
the posterior
pharyngeal wall
using the index
finger.

85. LMA Insertion Step 4
 Continue pushing with your
index finger.
 Guide the mask downward
into position.

86. LMA Insertion Step 5
 Grasp the tube firmly with the
other hand
 Then withdraw your index
finger from the pharynx.
 Press gently downward with
your other hand to ensure the
mask is fully inserted.

87. LMA Insertion Step 6
 Inflate the mask with the
recommended volume of air.
 Do not over-inflate the LMA.
 Do not touch the LMA tube while it
is being inflated unless the position
is obviously unstable.
 Normally the mask should be
allowed to rise up slightly out of the
hypopharynx as it is inflated to find
its correct position.

88. Verify Placement of the LMA
 Connect the LMA to a Bag-Valve Mask device or
low pressure ventilator
 Ventilate the patient while confirming equal
breath sounds over both lungs in all fields and the
absence of ventilatory sounds over the
epigastrium

89. Securing the LMA
 Insert a bite-block or roll of gauze to prevent
occlusion of the tube should the patient bite
down.
 Now the LMA can be secured utilizing the same
techniques as those employed in the securing of
an endotracheal tube.

90. Verify
 During ventilation
observe end-tidal
CO2 monitor or
pulseoximetry to
confirm
oxygenation

91. Waveform Capnometry
 Prerequisite
Requirement
 Becoming a
standard of care
 Easy to Use
 Good measure of
Pulmonary
Perfusion
 Relates well to
PaCO2
 Does have
limitations

92. Problems with LMA Insertion
 Failure to press the
deflated mask up against
the hard palate or
inadequate lubrication or
deflation can cause the
mask tip to fold back on
itself.

93. Problems with LMA Insertion
 Once the mask tip has
started to fold over, this
may progress, pushing the
epiglottis into its down-
folded position causing
mechanical obstruction

94. Problems with LMA Insertion
 If the mask tip is deflated
forward it can push down the
epiglottis causing obstruction
 If the mask is inadequately
deflated it may either
 push down the epiglottis
 penetrate the glottis

95. Plan C: Cricothyrotomy
Last resort!

96. Equipment
 Endotracheal or tracheostomy tube (or
commercial device)
 Scalpel
 Curved hemostats
 Suction apparatus
 Oxygen Supply
 BVM
 Securing device

97. Procedure
Have all supplies (including suction)
available and ready.
A commercially available device may be
desirable.

98. Commercial Cricothyrotomy Kits
 Must perform to recommendation of
manufacturer and Medical Director’s
satisfaction for proficiency.

99.
Find the persons Adam's apple (thyroid
cartilage)

100. Move your fingers about one inch down the
neck until you find another bulge.
This is the cricoid cartilage. The indentation between
the two is the cricothyroid membrane, where the
incision will be made.

101. Procedure
Locate the
cricothyroid
membrane utilizing
correct anatomical
landmarks. Thyroid Cartilage
Cricothyroid
Membrane
Cricoid Cartilage
Thyroid Gland
Tracheal Rings

102. Procedure
Prep the area with
an antiseptic swap
(e.g. Betadine).

103. Procedure
Using your non-
dominant hand,
stabilize the thyroid
cartilage and secure
the cricothyroid
membrane.

104. Procedure
Make a 1-inch vertical
incision through the
skin and subcutaneous
tissue using a scalpel.

105. Procedure
Using blunt dissection
technique, expose the
cricothyroid
membrane.
This is a bloody procedure.

106. Procedure
Some protocols
recommend stabilizing
the cricothyroid
membrane with a skin
or trach hook.

107. Procedure
Make a horizontal,
transverse incision
approximately ½ inch
long through the
membrane.

108. Procedure
Using a dilator,
hemostat, or gloved
finger to maintain
surgical opening,
insert the cuffed tube
into the trachea.
Cric tube from the kit
of a 6.0 ETT is usually
sufficient.

109. Procedure
Using a dilator,
hemostat, or gloved
finger to maintain
surgical opening,
insert the cuffed tube
into the trachea.
Cric tube from the kit
of a 6.0 ETT is usually
sufficient.

110. Procedure
Inflate the cuff with 5-
10cc of air and
ventilate the patient
while manually
stabilizing the tube.

111. Procedure
All of the standard assessment techniques
for ensuring tube placement should be
performed (auscultation, chest rise and
fall, end-tidal CO2 detector, etc..
Secure the tube.

112. Complications
 Incorrect tube placement/ false passage
 Thyroid gland damage
 Severe bleeding
 Subcutaneous emphysema
 Laryngeal nerve damage

113. Always expect the unexpected!

114. RSI Procedure: The Seven P’s
1. Preparation
2. Preoxygenate the patient
3. Premedicate the patient
4. Paralyze the patient
5. Pass the tube
6. Proof of placement
7. Post intubation care