airway algorithm review

11

AIRWAY ALGORITHM REVIEW

22

WHY AIRWAY REVIEW?WHY AIRWAY REVIEW?

Most important aspect of patient care (?)Most important aspect of patient care (?)

Failure = Gravest ConsequenceFailure = Gravest Consequence

33

WHY AIRWAY REVIEW?WHY AIRWAY REVIEW?

Many Quality Assurance Many Quality Assurance Concerns:Concerns:

--Gausche et al studyGausche et al study

-PALS update -PALS update

-Burton et al study-Burton et al study

-Kendall et al study-Kendall et al study

-Marcolini et al study-Marcolini et al study

44

MAINE’S PLANMAINE’S PLAN

These Concerns led MDPB to do These Concerns led MDPB to do a comprehensive review of the a comprehensive review of the

current airway protocol and current airway protocol and create the new…create the new…

Airway AlgorithmAirway Algorithm

55

AIRWAY PROTOCOLAIRWAY PROTOCOL

-Makes airway procedures a “step -Makes airway procedures a “step by step” processby step” process

-Adds concept of “rescue airway”-Adds concept of “rescue airway”

-Adds new airway devices-Adds new airway devices

66


Protocol Initiated 5/23/05Protocol Initiated 5/23/05

The MDPB’s goal is to train all The MDPB’s goal is to train all intubating providers by a yet to be intubating providers by a yet to be

determined datedetermined date

*Providers may use new protocol if trained but not *Providers may use new protocol if trained but not until they are traineduntil they are trained

77

MANDATORY EQUIPMENTMANDATORY EQUIPMENT

Goal is for services to comply Goal is for services to comply with mandatory airway devices with mandatory airway devices by a yet to be determined roll by a yet to be determined roll out date. MEMS will allow time out date. MEMS will allow time

for budgetingfor budgeting

88

Mandatory EquipmentMandatory Equipment

*All intubating services must carry *All intubating services must carry Laryngeal Mask Airways (LMA) Laryngeal Mask Airways (LMA)

(Note all LMA’s are now available in disposable form)(Note all LMA’s are now available in disposable form)

MANDATORY EQUIPMENTMANDATORY EQUIPMENT

99

OPTIONAL OPTIONAL EQUIPMENTEQUIPMENT

Optional EquipmentOptional Equipment

*Dual Lumen Airways*Dual Lumen Airways

*Intubation Adjuncts*Intubation Adjuncts

-Gum elastic Bougees (Tube changers)-Gum elastic Bougees (Tube changers)

-Lighted Styllettes-Lighted Styllettes

*Commercial Tracheotomy Kits*Commercial Tracheotomy Kits

-Pertrach, Quick Trach, etc.-Pertrach, Quick Trach, etc.

1010


QA ComponentQA Component

1111

TRAINING OBJECTIVESTRAINING OBJECTIVES

-Practical walk through airway -Practical walk through airway management from BLS to ALSmanagement from BLS to ALS

-Introduce the algorithm idea-Introduce the algorithm idea

-Review fundamental concepts -Review fundamental concepts

-Practice hands on skills-Practice hands on skills

-Debunk myths-Debunk myths

-Trade tips-Trade tips

1212

ANATOMY REVIEWANATOMY REVIEW

1313

OXYGENATION IS GOODOXYGENATION IS GOOD

Indicated in those Indicated in those patients who are in patients who are in respiratory distress respiratory distress and remain able to and remain able to exchange air on their exchange air on their own.own.

*Beware of decompensating patients!

1414

WHY MANAGE AN AIRWAYWHY MANAGE AN AIRWAY

Anyone can be taught to Anyone can be taught to use a BVM or intubate…use a BVM or intubate…the real question isthe real question is why why

manage an airway?manage an airway?

1515

AIRWAY MANAGEMENTAIRWAY MANAGEMENT

Reasons To Manage an Airway:Reasons To Manage an Airway:

-Obstruction-Obstruction

-None present, (trauma, medical)-None present, (trauma, medical)

-Decompensating (not maintaining)-Decompensating (not maintaining)

-Breathing too fast or too slow?-Breathing too fast or too slow?

What are your indicators?What are your indicators?

1616

AIRWAY MANAGEMENTAIRWAY MANAGEMENT

Respiratory Distress vs. Respiratory FailureRespiratory Distress vs. Respiratory Failure

DistressDistress

-Increased work of -Increased work of breathingbreathing

--RelativeRelative hypoxia/hypercapneahypoxia/hypercapnea

--CompensatingCompensating

FailureFailure

-Increased work of breathing-Increased work of breathing

--ProfoundProfound hypoxia/hypercapneahypoxia/hypercapnea

--DecompensatingDecompensating

It’s a constant reassessment process…

1717

AIRWAY ALGORITHMAIRWAY ALGORITHM

A step by step approach at evaluating A step by step approach at evaluating each patients ability to maintain an each patients ability to maintain an open airway.open airway.

Immediate corrective actions based on Immediate corrective actions based on this assessmentthis assessment

A constant reassessment of current A constant reassessment of current procedures to determine the need to procedures to determine the need to be more or less aggressive in the best be more or less aggressive in the best interest to the patient.interest to the patient.

1818

STEP 1. OPEN AND CLEARSTEP 1. OPEN AND CLEAR

Clear and SuctionClear and Suction

1919

STEP 2. KEEP IT OPENSTEP 2. KEEP IT OPEN

Benefits and LimitationsBenefits and Limitations

Indications and ContraindicationsIndications and Contraindications

2020

STEP 2. KEEP IT OPENSTEP 2. KEEP IT OPEN

Sizing and InsertionSizing and Insertion

2121

STEP 3. VENTILATE STEP 3. VENTILATE (BLS)(BLS)

Procedure:Procedure:

-Attach high flow O2-Attach high flow O2

-Select appropriate mask -Select appropriate mask (good seal imperative)(good seal imperative)

-Override pop-offs (?)-Override pop-offs (?)

What are the limitations?What are the limitations?

2222

-BVM Rate Re-Examined-BVM Rate Re-Examined

-BVM Depth Re-Examined-BVM Depth Re-Examined


Practical Exercise on Ventilation

2323

Approximate normal ventilation Approximate normal ventilation rates:rates:

10 bpm Adult10 bpm Adult 20 bpm Child20 bpm Child 25 bpm Infant25 bpm Infant


2424


Cricoid PressureCricoid Pressure

2525

STEP 3. VENTILATE (BLS)STEP 3. VENTILATE (BLS)

Why is this helpful in all Why is this helpful in all manual ventilation?manual ventilation?

2626

STEP 4. CONTROL THE STEP 4. CONTROL THE AIRWAYAIRWAY

IntubationIntubation

vs. vs.

BVMBVM

Why and why not?Why and why not?

2727


Airway Management Decision ProcessAirway Management Decision Process

(Judge how aggressive you need to be.)(Judge how aggressive you need to be.)

-Time/Distance-Time/Distance

-Personnel-Personnel

-Equipment-Equipment

-Other Considerations?-Other Considerations?

2828


““Evaluate for signs of difficult intubation”Evaluate for signs of difficult intubation”

(this may help in your decision as well)(this may help in your decision as well)

-Obesity-Obesity -Small body habitus-Small body habitus

-Small jaw-Small jaw -Large teeth-Large teeth

-Burns-Burns -Trauma-Trauma

-Anaphylaxis-Anaphylaxis -Stridor-Stridor

2929


The BLS vs. ALS airway The BLS vs. ALS airway decision may not be based on decision may not be based on one single factor, but rather one single factor, but rather

based on an overall based on an overall assessment of many factors.assessment of many factors.

3030


Pre-IntubationPre-Intubation

-Prepare Equipment-Prepare Equipment

-Hyper-oxygenate-Hyper-oxygenate

3131


Orotracheal Intubation ProcedureOrotracheal Intubation Procedure

Sweep Sweep Left and Left and

LookLook

3232


Backward, Upward, Right Pressure (B.U.R.P.)Backward, Upward, Right Pressure (B.U.R.P.)

Find Your LandmarksFind Your Landmarks

3333



3434


It may not be perfect!It may not be perfect!


3535



3636


Readjusting with Cricoid PressureReadjusting with Cricoid Pressure

3737


Common Provider MistakesCommon Provider Mistakes

**Making a difficult intubation more difficultMaking a difficult intubation more difficult

*Rushing*Rushing

*Poor equipment preparation*Poor equipment preparation

*Suction (lack there of)*Suction (lack there of)

3838


What is your back-up plan today?

prolonged BVM…

another provider…

a smaller tube…

better lighting…

additional suctioning…

3939


Helpful AdjunctsHelpful Adjuncts

Gum Gum Elastic Elastic BougieBougie

4040


Helpful AdjunctsHelpful Adjuncts

Lighted StyletteLighted Stylette

4141

Nasotracheal IntubationNasotracheal Intubation

IndicationsIndications::

““Patient still breathing but Patient still breathing but in respiratory failure and in respiratory failure and

in whom oral intubation is in whom oral intubation is impossible or difficult.”impossible or difficult.”


-AAOS

4242

ContraindicationsContraindications::

-Apnea-Apnea

-Resistance in the nares-Resistance in the nares

-Blood clotting or -Blood clotting or anticoagulation anticoagulation problemsproblems

-Basilar Skull Fx (?)-Basilar Skull Fx (?)



4343

TechniqueTechnique::

-Prepare patient and nostril-Prepare patient and nostril

-Prepare tube-Prepare tube

-Insert on inspiration-Insert on inspiration

-Take your time-Take your time

ComplicationsComplications::

-Bleeding-Bleeding



4444

STEP 5. CONFIRM THE STEP 5. CONFIRM THE AIRWAYAIRWAY

Technology BasedTechnology Based

• ETCO2 (monitor)ETCO2 (monitor)

• EDD (bulb)EDD (bulb)

• Colormetric (cap)Colormetric (cap)

• Pulse Ox changePulse Ox change

Intubation ConfirmationIntubation Confirmation

Good, Better, BestGood, Better, BestTraditionalTraditional

• Direct Direct VisualizationVisualization

• Lung SoundsLung Sounds

• Tube Tube Condensation Condensation

4545

STEP 6. SECURE THE STEP 6. SECURE THE AIRWAYAIRWAY

TapeTape

Improvised devicesImprovised devices

Commercial devicesCommercial devices

Immobilization (?)Immobilization (?)

Secure Your TubeSecure Your Tube

Good, Better, BestGood, Better, Best

4646

Laryngeal Mask AirwayLaryngeal Mask Airway

Developed in 1981 at the Royal London Hospital Developed in 1981 at the Royal London Hospital

By Dr Archie BrainBy Dr Archie Brain

STEP 7. ALTERNATIVES TO STEP 7. ALTERNATIVES TO ETIETI

4747

Indications:Indications:

-When definitive airway management -When definitive airway management cannot be obtained. (ETT)cannot be obtained. (ETT)

Not a substitute for definitive airway Not a substitute for definitive airway managementmanagement



4848

Contraindication/Limitations:Contraindication/Limitations:

-Obesity-Obesity

-Non-secure-Non-secure

-Size based-Size based

-Not a med route-Not a med route



4949

Weight Based SizingWeight Based Sizing<5kg = <5kg = Size 1Size 15-10 kg = 5-10 kg = Size 2Size 220-30 kg = 20-30 kg = Size 2.5Size 2.5Small Adult= Small Adult= Size 3Size 3Average Adult = Average Adult =

Size 4Size 4 Large Adult = Large Adult = Size 5Size 5



5050

Average Adult Woman = 4Average Adult Woman = 4 Average Adult Male = 5Average Adult Male = 5

*If in doubt, check the LMA*If in doubt, check the LMA



5151

Procedure:Procedure:

-Hyper oxygenate-Hyper oxygenate

-Check cuff -Check cuff

-Lubricate -Lubricate posteriorposterior cuff cuff

-Head in neutral or slightly flexed position-Head in neutral or slightly flexed position

-Insert following hard palate (use index finger to guide)-Insert following hard palate (use index finger to guide)

-Stop when met with resistance-Stop when met with resistance

-Let go and inflate cuff (visualize “pop”)-Let go and inflate cuff (visualize “pop”)

-Confirm and secure-Confirm and secure



5252

Air volume is variable depending on cuff size Air volume is variable depending on cuff size and individual patient anatomyand individual patient anatomy

General Guideline:General Guideline:

Size 1 = 4 mlSize 1 = 4 mlSize 2 = 10 mlSize 2 = 10 mlSize 2.5 = 14 mlSize 2.5 = 14 mlSize 3 = 20 mlSize 3 = 20 mlSize 4 = 30 mlSize 4 = 30 mlSize 5 = 40 mlSize 5 = 40 ml



5353

Common Provider Problems:Common Provider Problems:

-Failure to seat properly-Failure to seat properly

-Sizing difficulties -Sizing difficulties

-Aspiration-Aspiration



5454



5555

MDPB has approved allMDPB has approved all ““non-intubatingnon-intubating” ” LMA LMA

type devicestype devices



5656

(Combitube(Combitube®®))


Dual Lumen AirwayDual Lumen Airway

5757

Indications:Indications:

-When definitive airway management -When definitive airway management cannot be obtained. (ETT)cannot be obtained. (ETT)

Not a substitute for definitive airway Not a substitute for definitive airway managementmanagement



5858

Contraindications/LimitationsContraindications/Limitations::

-No pediatrics-No pediatrics

-5’7-7’ tall (SA 4’-5’6)-5’7-7’ tall (SA 4’-5’6)

-Pathological esophageal disease-Pathological esophageal disease

-Non-secure airway-Non-secure airway

-Latex sensitivity-Latex sensitivity

-Toxic or Caustic Ingestions-Toxic or Caustic Ingestions



5959

ProcedureProcedure::

-Hyper oxygenate-Hyper oxygenate

-Check equip. -Check equip.

-Head in neutral position-Head in neutral position

-Insert until to guide lines-Insert until to guide lines



6060

ProcedureProcedure::

-Inflate Pharyngeal cuff -Inflate Pharyngeal cuff (blue) with 85-100cc of (blue) with 85-100cc of airair

-Inflate tracheal cuff -Inflate tracheal cuff (white) with 10-15cc of (white) with 10-15cc of airair



6161

-Ventilate -Ventilate port 1port 1 (longer, blue tube, #1). (longer, blue tube, #1).

If no lung sounds, switch portsIf no lung sounds, switch ports

-Ventilate -Ventilate port 2port 2 (shorter, white tube, #2) (shorter, white tube, #2)

*You will be either in the esophagus or the trachea*You will be either in the esophagus or the trachea



6262

IndicationsIndications

-Obstruction-Obstruction

-Facial Trauma-Facial Trauma

-Intubation or other -Intubation or other alternatives impossiblealternatives impossible

-Trismus (clenching)-Trismus (clenching)

->8 years old (for open ->8 years old (for open procedures)procedures)

STEP 8. SURGICAL AIRWAYSSTEP 8. SURGICAL AIRWAYS

LAST RESORT!

6363

STEP 8. SURGICAL AIRWAYSSTEP 8. SURGICAL AIRWAYSOpen CricothyrotomyOpen Cricothyrotomy

-Vertical Incision over membrane-Vertical Incision over membrane-Pierce membrane in horizontal plane-Pierce membrane in horizontal plane-Open and spread to insert 4.0 or 5.0 -Open and spread to insert 4.0 or 5.0

tubetube-Secure tube in place and ventilate-Secure tube in place and ventilate

6464

Needle Procedure:Needle Procedure:

-Identify Cricothyroid -Identify Cricothyroid membranemembrane

-Pierce at 45-Pierce at 45° angle ° angle

-Place catheter or styllette-Place catheter or styllette

-Advance dilator per -Advance dilator per manufacturer’s manufacturer’s recommendationrecommendation

STEP 8. SURGICAL AIRWAYSSTEP 8. SURGICAL AIRWAYSNeedle CricothyrotomyNeedle Cricothyrotomy

6565

Commercial Needle Cricothyrotomy Devices

Quick Trach Pertrach

STEP 8. SURGICAL AIRWAYSSTEP 8. SURGICAL AIRWAYSNeedle CricothyrotomyNeedle Cricothyrotomy

6666

WHY AN ALGORITHM?WHY AN ALGORITHM?

1.1. Step by step process in orderStep by step process in order

2.2. Start simple and work upStart simple and work up

3.3. AlternativesAlternatives

4.4. Be sureBe sure

5.5. Get it doneGet it done

6767

Questions?Questions?

6868

MAINE EMS WISHES TO THANK THE FOLLOWING MAINE EMS WISHES TO THANK THE FOLLOWING MANUFACTURERS FOR THEIR CONTRIBUTIONS OF MANUFACTURERS FOR THEIR CONTRIBUTIONS OF

TRAINING MATERIALS.TRAINING MATERIALS.

Boundtree MedicalBoundtree Medical - - LMA Products, Lighted StylletesLMA Products, Lighted Stylletes

Mike Evers-JenkinsMike Evers-Jenkins

(800) 533-0523 ext. 550(800) 533-0523 ext. 550

Tri-AnimTri-Anim- - Cobra PLA, Per-TrachCobra PLA, Per-Trach

Jaclyn EmanuelsonJaclyn Emanuelson

(877) 207-4329 ext 6306(877) 207-4329 ext 6306

RüschRüsch- - Quick TrachQuick TrachDave HenryDave Henry(800) 848-3766 ext. 1707(800) 848-3766 ext. 1707

airway algorithm review

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