Airway Review

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AIRWAY ALGORITHM REVIEW
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WHY AIRWAY REVIEW?
Most important aspect of patient care
(?) Failure Gravest Consequence
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WHY AIRWAY REVIEW?
Many Quality Assurance Concerns -Gausche et al
study -PALS update -Burton et al
study -Kendall et al study -Marcolini et al
study
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MAINES PLAN
These Concerns led MDPB to do a comprehensive
review of the current airway protocol and create
the new
Airway Algorithm
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AIRWAY PROTOCOL
-Makes airway procedures a step by step
process -Adds concept of rescue airway -Adds
new airway devices
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AIRWAY PROTOCOL
Protocol Initiated 5/23/05 The MDPBs goal is to
train all intubating providers by a yet to be
determined date Providers may use new protocol
if trained but not until they are trained
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MANDATORY EQUIPMENT
Goal is for services to comply with mandatory
airway devices by a yet to be determined roll out
date. MEMS will allow time for budgeting
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MANDATORY EQUIPMENT
Mandatory Equipment All intubating services must
carry Laryngeal Mask Airways (LMA) (Note all
LMAs are now available in disposable form)
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OPTIONAL EQUIPMENT
Optional Equipment Dual Lumen Airways Intubation
Adjuncts -Gum elastic Bougees (Tube
changers) -Lighted Styllettes Commercial
Tracheotomy Kits -Pertrach, Quick Trach, etc.
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AIRWAY PROTOCOL
QA Component
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TRAINING OBJECTIVES
-Practical walk through airway management from
BLS to ALS -Introduce the algorithm idea -Review
fundamental concepts -Practice hands on
skills -Debunk myths -Trade tips
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ANATOMY REVIEW
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OXYGENATION IS GOOD
Indicated in those patients who are in
respiratory distress and remain able to exchange
air on their own.
Beware of decompensating patients!
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WHY MANAGE AN AIRWAY
Anyone can be taught to use a BVM or intubatethe
real question is why manage an airway?
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AIRWAY MANAGEMENT
Reasons To Manage an Airway -Obstruction -None
present, (trauma, medical) -Decompensating (not
maintaining) -Breathing too fast or too slow?
What are your indicators?
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AIRWAY MANAGEMENT
Respiratory Distress vs. Respiratory Failure
Distress -Increased work of breathing -Relative
hypoxia/hypercapnea -Compensating
Failure -Increased work of breathing -Profound
hypoxia/hypercapnea -Decompensating
Its a constant reassessment process
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AIRWAY ALGORITHM

• A step by step approach at evaluating each
  patients ability to maintain an open airway.
• Immediate corrective actions based on this
  assessment
• A constant reassessment of current procedures to
  determine the need to be more or less aggressive
  in the best interest to the patient.

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STEP 1. OPEN AND CLEAR
Clear and Suction
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STEP 2. KEEP IT OPEN
? Benefits and Limitations ? Indications and
Contraindications
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STEP 2. KEEP IT OPEN
Sizing and Insertion
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STEP 3. VENTILATE (BLS)
Procedure -Attach high flow O2 -Select
appropriate mask (good seal imperative) -Override
pop-offs (?)
What are the limitations?
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STEP 3. VENTILATE (BLS)
-BVM Rate Re-Examined -BVM Depth Re-Examined
Practical Exercise on Ventilation
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STEP 3. VENTILATE (BLS)

• Approximate normal ventilation rates
• 10 bpm Adult
• 20 bpm Child
• 25 bpm Infant

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STEP 3. VENTILATE (BLS)
Cricoid Pressure
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STEP 3. VENTILATE (BLS)
Why is this helpful in all manual ventilation?
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STEP 4. CONTROL THE AIRWAY
Intubation vs. BVM Why and why not?
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STEP 4. CONTROL THE AIRWAY
Airway Management Decision Process (Judge how
aggressive you need to be.)
-Time/Distance -Personnel -Equipment -Other
Considerations?
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STEP 4. CONTROL THE AIRWAY
Evaluate for signs of difficult intubation
(this may help in your decision as
well) -Obesity -Small body habitus -Small
jaw -Large teeth -Burns -Trauma -Anaphylaxis -
Stridor
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STEP 4. CONTROL THE AIRWAY
The BLS vs. ALS airway decision may not be based
on one single factor, but rather based on an
overall assessment of many factors.
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STEP 4. CONTROL THE AIRWAY
Pre-Intubation
-Prepare Equipment -Hyper-oxygenate
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STEP 4. CONTROL THE AIRWAY
Orotracheal Intubation Procedure
Sweep Left and Look
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STEP 4. CONTROL THE AIRWAY
Find Your Landmarks
Backward, Upward, Right Pressure (B.U.R.P.)
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STEP 4. CONTROL THE AIRWAY
Find Your Landmarks
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STEP 4. CONTROL THE AIRWAY
Find Your Landmarks
It may not be perfect!
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STEP 4. CONTROL THE AIRWAY
Find Your Landmarks
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STEP 4. CONTROL THE AIRWAY
Readjusting with Cricoid Pressure
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STEP 4. CONTROL THE AIRWAY
Common Provider Mistakes Making a difficult
intubation more difficult Rushing Poor
equipment preparation Suction (lack there of)
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STEP 4. CONTROL THE AIRWAY
What is your back-up plan today? prolonged
BVM another provider a smaller tube better
lighting additional suctioning
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STEP 4. CONTROL THE AIRWAY
Helpful Adjuncts
Gum Elastic Bougie


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STEP 4. CONTROL THE AIRWAY
Helpful Adjuncts
Lighted Stylette


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STEP 4. CONTROL THE AIRWAY
Nasotracheal Intubation
Indications Patient still breathing but in
respiratory failure and in whom oral intubation
is impossible or difficult.
-AAOS
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STEP 4. CONTROL THE AIRWAY
Nasotracheal Intubation
Contraindications -Apnea -Resistance in the
nares -Blood clotting or anticoagulation
problems -Basilar Skull Fx (?)
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STEP 4. CONTROL THE AIRWAY
Nasotracheal Intubation
Technique -Prepare patient and nostril -Prepare
tube -Insert on inspiration -Take your
time Complications -Bleeding
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STEP 5. CONFIRM THE AIRWAY
Intubation Confirmation
Good, Better, Best

• Technology Based
• ETCO2 (monitor)
• EDD (bulb)
• Colormetric (cap)
• Pulse Ox change

• Traditional
• Direct Visualization
• Lung Sounds
• Tube Condensation

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STEP 6. SECURE THE AIRWAY
Secure Your Tube
Good, Better, Best
Tape Improvised devices Commercial
devices Immobilization (?)
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STEP 7. ALTERNATIVES TO ETI
Laryngeal Mask Airway
Developed in 1981 at the Royal London Hospital By
Dr Archie Brain
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STEP 7. ALTERNATIVES TO ETI
Laryngeal Mask Airway
Indications -When definitive airway management
cannot be obtained. (ETT) Not a substitute for
definitive airway management
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STEP 7. ALTERNATIVES TO ETI
Laryngeal Mask Airway
Contraindication/Limitations -Obesity -Non-secu
re -Size based -Not a med route
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STEP 7. ALTERNATIVES TO ETI
Laryngeal Mask Airway
Weight Based Sizing lt5kg Size 1 5-10 kg
Size 2 20-30 kg Size 2.5 Small Adult Size
3 Average Adult Size 4 Large Adult Size 5
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STEP 7. ALTERNATIVES TO ETI
Laryngeal Mask Airway
Average Adult Woman 4 Average Adult Male
5 If in doubt, check the LMA
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STEP 7. ALTERNATIVES TO ETI
Laryngeal Mask Airway
Procedure -Hyper oxygenate -Check cuff
-Lubricate posterior cuff -Head in neutral or
slightly flexed position -Insert following hard
palate (use index finger to guide) -Stop when met
with resistance -Let go and inflate cuff
(visualize pop) -Confirm and secure
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STEP 7. ALTERNATIVES TO ETI
Laryngeal Mask Airway
Air volume is variable depending on cuff size and
individual patient anatomy General
Guideline Size 1 4 ml Size 2 10
ml Size 2.5 14 ml Size 3 20 ml Size
4 30 ml Size 5 40 ml
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STEP 7. ALTERNATIVES TO ETI
Laryngeal Mask Airway
Common Provider Problems -Failure to seat
properly -Sizing difficulties -Aspiration
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STEP 7. ALTERNATIVES TO ETI
Laryngeal Mask Airway
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STEP 7. ALTERNATIVES TO ETI
Laryngeal Mask Airway
MDPB has approved all non-intubating LMA type
devices
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STEP 7. ALTERNATIVES TO ETI
Dual Lumen Airway
(Combitube)
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STEP 7. ALTERNATIVES TO ETI
Dual Lumen Airway
Indications -When definitive airway management
cannot be obtained. (ETT) Not a substitute for
definitive airway management
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STEP 7. ALTERNATIVES TO ETI
Dual Lumen Airway
Contraindications/Limitations -No
pediatrics -57-7 tall (SA 4-56) -Pathologica
l esophageal disease -Non-secure airway -Latex
sensitivity -Toxic or Caustic Ingestions
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STEP 7. ALTERNATIVES TO ETI
Dual Lumen Airway
Procedure -Hyper oxygenate -Check equip. -Head
in neutral position -Insert until to guide lines
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STEP 7. ALTERNATIVES TO ETI
Dual Lumen Airway
Procedure -Inflate Pharyngeal cuff (blue) with
85-100cc of air -Inflate tracheal cuff (white)
with 10-15cc of air
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STEP 7. ALTERNATIVES TO ETI
Dual Lumen Airway
-Ventilate port 1 (longer, blue tube, 1). If
no lung sounds, switch ports -Ventilate port 2
(shorter, white tube, 2) You will be either in
the esophagus or the trachea
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STEP 8. SURGICAL AIRWAYS
Indications -Obstruction -Facial
Trauma -Intubation or other alternatives
impossible -Trismus (clenching) -gt8 years old
(for open procedures)
LAST RESORT!
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STEP 8. SURGICAL AIRWAYS
Open Cricothyrotomy
-Vertical Incision over membrane -Pierce membrane
in horizontal plane -Open and spread to insert
4.0 or 5.0 tube -Secure tube in place and
ventilate
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STEP 8. SURGICAL AIRWAYS
Needle Cricothyrotomy
Needle Procedure -Identify Cricothyroid
membrane -Pierce at 45 angle -Place catheter or
styllette -Advance dilator per manufacturers
recommendation
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STEP 8. SURGICAL AIRWAYS
Needle Cricothyrotomy
Commercial Needle Cricothyrotomy Devices
Quick Trach
Pertrach
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WHY AN ALGORITHM?

• Step by step process in order
• Start simple and work up
• Alternatives
• Be sure
• Get it done

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Questions?
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MAINE EMS WISHES TO THANK THE FOLLOWING
MANUFACTURERS FOR THEIR CONTRIBUTIONS OF TRAINING
MATERIALS. Boundtree Medical - LMA Products,
Lighted Stylletes Mike Evers-Jenkins (800)
533-0523 ext. 550 Tri-Anim- Cobra PLA,
Per-Trach Jaclyn Emanuelson [phone] ext
6306 Rüsch- Quick Trach Dave Henry (800)
848-3766 ext. 1707