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#3Intro to EM Airway Management-

Assessment and SupraGlottic Airways (SGA)

Andrew Brainard

#3 SupraGlottic Airway

• Learning Objectives: – Briefly describe plan, assign roles

• Declare “Crash Airway” • Skip checklist • Continue Chest Compressions

• Place SupraGlottic Airway – Proper sized LMA/AirQ – Proper insertion (<30sec) – Troubleshoot cuff leak – Tube confirmation

• Discuss– Crash vs Emergent vs Semi-elective– Advantages/Disadvantages of SGAs – Indications for SGA, RSI, ETT

• Safe removal of SGA – Formal Airway Assessment – MOANS/LEMON/RODS – Specific briefing for Plan A, B, C, & D– Suction– Leave Cuff Up– Remove under direct visualization

• Bell in Short Stay: – 60y/o M, chest compressions in progress on

patient admitted with chest pain – On floor unresponsive – GCS 3, No pulse, CPR in progress, – Unobtainable SaO2 – Difficulty with BVM seal (beard, small jaw, no

neck, emesis, high resistance)

• Crash SGA during compressions – Insert SGA – Oxygenate and Ventilate through SGA – Get ROSC – Transfer to resus – Intubate through SGA – Discuss removing SGA

• Formal Airway Assessment – MOANS – LEMON – RODS– SHORT

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Using SuperGlottic Airways (SGA)

Air Q

Fastrack I-LMA

• Indications• Predicting difficult (RODS)

• Sizing• Insertion Procedure• Troubleshooting• Intubating through an SGA

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• Indication(s)– Rescue Airway– Rescue Oxygenation– Anywhere on the

Algorithm– Replacing Inadequate

BVM– During

CPR/compressions– For Pre-Oxygenation

before Laryngoscopy(Rapid Sequence Airway)

– After unsuccessful Laryngoscopy– Before/during cric

SGA/LMA

SGA/LMASGA/LMA

SGA/LMA

SGA/LMA

SGA/LMA

SGA/LMA

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Intubating LMA (Fastrack)#3- Small Adults 30-50kgs#4- Most Adults 50-70 kgs#5- Large Adults 70-100 kgs

AirQ#1.0- Infant <7 kgs

#1.5- Toddler 7-17 kgs

#2.0- Child 17-30 kgs

#2.5- Small Adult 30-50kgs#3.5- Most Adults 50-70 kgs#4.5- Large Adult 70-100 kgs

Ideal Body Weight (height)

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Predictors of Difficult SGA

• RODS–R: restricted mouth–O: obstruction–D: disrupted or

distorted airway– S: stiff lungs or c-spine

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AirQ• Insertion

– Lubricate– Leave red tag on pilot balloon – Lift tongue

• Finger/Laryngoscope/Tongue depressor

– Can use finger to assist around the corner

– Jaw lift – Position incisors between 2 insertion

marks • Add ~5 cc’s of air.

• Minimizing Leaks – Neutral head position – Use jaw lift – Don’t over-inflate – Check position

• While inflated, pull back 1-3cm – Change size – Check ETCO2 waveform How to use a AirQ

http://www.youtube.com/watch?v=E0a1KYwfDk0 (9 minutes)

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Supraglottic Airway (SGA)• Prepare/position airway• Lubricate and deflate cuff• Pull the jaw and tongue

forward– Finger– Laryngoscope– Tongue depressor

• Insert the LMA – Press against hard palate– Advance until resistance

• Inflate the cuff– Poor seal may indicate over

inflation.• Ventilate the patient with PEEP• Confirm placement

– ETCO2– Chest Rise– Listen for Leak

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Troubleshooting SGAs

• Get best possible seal– Over-inflation is

frequently the cause of leaks

– Usually Too deep– Test airway pressures– Watch ETCO2 trace

• Chandy maneuver, – Rotate

• Sagittal• Coronal

– Lifting • Toward ceiling

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Intubating through the LMA

• Place LMA

• Ventilate– Relax

• Insert ETT• Reattach BVM to

ETT– Ventilate w/ETCO2

• Size ETT/I-LMA– Lubricate tube– Test ETT fit

• Confirm placement– Ventilate w/ ETCO2– Confirm tube placement – Inflate ETT cuff

• Advance ETT– Applying upward

pressure on the LMA

– Ventilate w/ ETCO2– Advance ETT

through cords

• Removing the LMA is optional

• Verify placement– ETCO2– Listen

for leak

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Airway briefing and checklist• CPR with chest compressions and BMV are in

progress.

•We are having difficulty assuring oxygenation with a BVM

• This is a crash airway

• Continue Chest Compressions

• Place the I-LMA #5

• Continue Chest Compressions

• Our plan is:•A- Continue to attempt to BVM•B- Place I-LMA #4 (now)•C- Direct/bougie/7.5 tube once we have ROSC or some more time•D- Cric if we get ROSC but can not get an airway

• Questions?

• Oxygenate the patient

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SuperGlottic Airways (SGA)

• Indications• Predicting

difficult (RODS)

• Sizing• Insertion

Procedure• Troubleshooting• Intubating

through an SGA

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Brief SGA References:• Thomas C. Mort The Supraglottic Airway Device in the Emergent Setting: Its

Changing Role Outside the Operating Room. Anesthesiology News, 2011- http://www.anesthesiologynews.com/download/sga_angam11.pdf (accessed on 15/6/2014)

• Daniel J Cook, AirQ Tips and Techniques Youtube- Mercury Medical https://www.youtube.com/watch?v=E0a1KYwfDk0 (accessed on 15/6/2014)

• Dr. Gallagher’s Neighborhood- Laryngeal Mask Airway: MICU Fellows Airway Course- https://www.youtube.com/watch?v=-oXa-f5qkGY&index=5&list=PLDvE6n0oI4ehBbTL_OAMeFQvJmJFz6tGU (accessed on 15/6/2014)

• Nichole Bosson- Laryngeal Mask Airway, Emedicine: http://emedicine.medscape.com/article/82527-overview#a15 (accessed on 15/6/2014)