39: Advanced Airway Management

1
39 Advanced Airway Management
2
Cognitive Objectives (1 of 5)

• 8-1.1 Identify and describe the airway anatomy in
  the infant, child, and the adult.
• 8-1.3 Explain the pathophysiology of airway
  compromise.
• 8-1.4 Describe the proper use of airway adjuncts.
• 8-1.5 Review the use of oxygen therapy in airway
  management.

3
Cognitive Objectives (2 of 5)

• 8-1.6 Describe the indications,
  contraindications, and techniques for insertion
  of nasal gastric tubes.
• 8-1.7 Describe how to perform the Sellick
  maneuver (cricoid pressure).
• 8-1.8 Describe the indications for advanced
  airway management.

4
Cognitive Objectives (3 of 5)

• 8-1.9 List the equipment required for orotracheal
  intubation.
• 8-1.10 Describe the proper use of the curved
  blade for orotracheal intubation.
• 8-1.11 Describe the proper use of the straight
  blade for orotracheal intubation.
• 8-1.12 State the reasons for and proper use of
  the stylet for orotracheal intubation.

5
Cognitive Objectives (4 of 5)

• 8-1.13 Describe the methods of choosing the
  appropriate size endotracheal tube in an adult
  patient.
• 8-1.14 State the formula for sizing an infant or
  child endotracheal tube.
• 8-1.15 List complications associated with
  advanced airway management.
• 8-1.17 Describe the skill of orotracheal
  intubation in the adult patient.

6
Cognitive Objectives (5 of 5)

• 8-1.18 Describe the skill of orotracheal
  intubation in the infant and child patient.
• 8-1.19 Describe the skill of confirming
  endotracheal tube placement in the adult, infant,
  and child patient.
• 8-1.20 State the consequences of and the need to
  recognize unintentional esophageal intubation.
• 8-1.21 Describe the skill of securing the
  endotracheal tube in the adult, infant, and child
  patient.

7
Affective Objectives (1 of 2)

• 8-1.22 Recognize and respect the feelings of the
  patient and family during advanced airway
  procedures.
• 8-1.23 Explain the value of performing advanced
  airway procedures.
• 8-1.24 Defend the need for the EMT-B to perform
  advanced airway procedures.
• 8-1.25 Explain the rationale for the use of a
  stylet.

8
Affective Objectives (2 of 2)

• 8-1.26 Explain the rationale for having a suction
  unit immediately available during intubation
  attempts.
• 8-1.27 Explain the rationale for confirming
  breath sounds.
• 8-1.28 Explain the rationale for securing the
  endotracheal tube.

9
Psychomotor Objectives

• 8-1.29 Demonstrate how to perform the Sellick
  maneuver.
• 8-1.30 Demonstrate the skill of orotracheal
  intubation in the adult patient.
• 8-1.31 Demonstrate the skill of orotracheal
  intubation in the infant and child patient.
• 8-1.32 Demonstrate the skill of confirming
  endotracheal tube placement in the adult patient.
• 8-1.33 Demonstrate the skill of confirming
  endotracheal tube placement in the infant and
  child patient.
• 8-1.34 Demonstrate the skill of securing the
  endotracheal tube in the adult patient.

10
Anatomy and Physiology of the Airway
11
Basic Airway Management

• Airway is always assessed first.
• Advanced techniques are used after basic
  management.
• The first step is opening the patients airway.
• Once the airway has been cleared, determine the
  need for an airway adjunct.

12
Gastric Tubes

• Provide channel into patients stomach
• Nasogastric tubes Inserted through the nose
• Orogastric tubes Inserted through the mouth
• Nasogastric tubes Contraindicated in a patient
  with major facial, head, or spinal trauma

13
Equipment

• Proper-sized tubes
• Catheter-tipped 60-mL syringe
• Water-soluble lubricant
• Emesis container
• Tape
• Stethoscope
• Suctioning unit and catheters

14
Gastric Tube Insertion

• Measure the tube.
• Lubricate the distal end of the tube.
• Place the patient in proper position.
• Pass the tube until you reach the tape marker.
• Confirm proper tube placement.
• Aspirate air and stomach contents with the
  syringe.
• Secure the tube in place with tape.

15
Sellick Maneuver

• Visualize the cricoid cartilage.
• Palpate to confirm its location.
• Apply firm pressure on the cricoid ring.
• Maintain pressure until intubated.

16
Endotracheal Intubation

• Insertion of a tube into the trachea in order to
  maintain the airway
• Orotracheal intubation Through the mouth
• Nasotracheal intubation Through the nose
• EMT-Bs only intubate patients who are
• Unresponsive with no gag reflex
• In cardiac arrest

17
Equipment (1 of 2)

• BSI equipment
• Proper-equipment endotracheal tube (ET tube)
• Laryngoscope handle and blade (visualized
  technique)
• Stylet or light stylet
• 10-mL syringe
• Oxygen, with BVM device

18
Equipment (2 of 2)

• A suctioning unit with rigid and soft-tip
  catheters
• Magill forceps
• Towels for raising the patients head and/or
  shoulders
• A stethoscope
• Water-soluble lubricant for tubes and scopes
• A commercial securing device or tape

19
Laryngoscope

• Sweeps the tongue out of the way and aligns the
  airway
• Has a light powered by batteries in handle
• Has blades that connect to handle
• Blades are curved or straight.
• They range in size from 0 to 4.

20
Curved Blade
21
Straight Blade
22
Endotracheal Tubes

• Tubes come in many sizes, from adult to infant.
• Normal tube-to-teeth mark is usually around 22
  cm.
• Diameter for normal adult male ranges from 7.5 to
  8.5 mm.
• Diameter for normal adult female ranges from 6.5
  to 8.0 mm.
• Use tape or chart for pediatric sizes.

23
Stylet

• Plastic-coated wire may be inserted in the ET
  tube to add rigidity and shape to the tube.
• Bend the tip of the stylet to form a gentle curve
  in adults.
• Bend the tip of the stylet to form a hockey stick
  shape for an infant and child.
• Confirm that the stylet is not sticking out past
  the end of the ET tube.

24
Syringe

• Use the 10-mL syringe to test for air leaks in
  the ET tube before intubation.
• After the ET tube has been properly inserted,
  inflate the cuff with 5 to 10 mL of air.
• Remove the syringe from the pilot balloon to
  prevent air from leaking.

25
Other Equipment

• Oxygen
• A suctioning unit
• A BVM device
• Magill forceps
• Towels for raising the patients head or
  shoulders
• Secondary confirmation device
• C-collar backboard

26
The Intubation Procedure

• First EMT-B applies AED.
• Second and third EMT-B perform CPR.
• Fourth EMT-B prepares and intubates patient.

27
Visualized (Oral) Intubation (1 of 2)

• Open airway.
• Insert an oropharyngeal airway.
• Preoxygenate the patient.
• Assemble equipment.
• Position the head and neck.

28
Visualized (Oral)Intubation (2 of 2)

• Grasp laryngoscope with left hand.
• Visualize vocal cords.
• Insert ET tube.
• Inflate balloon.
• Confirm placement.
• Secure tube.

29
Blind (Nasal) Intubation (1 of 2)

• Many of the steps are the same as those for oral
  intubations.
• Preoxygenate the patient.
• Check for gag reflex.
• Insert tube through nostril.
• Pass tube through vocal cords as patient is
  inhaling.

30
Blind (Nasal) Intubation (2 of 2)

• Release the jaw and hold tube against nostril.
• Inflate cuff.
• Attach the BVM device.
• Confirm placement.
• Secure the tube.

31
Intubation Complications

• Intubating the right main stem bronchus
• Intubating the esophagus
• Aggravating spinal injuries
• Taking too long to ventilate

• Patient vomiting
• Soft-tissue trauma
• Mechanical failure
• Patient intolerant of the ET tube
• Decrease in heart rate

32
Multilumen Airways

• Inserted without direct visualization
• Provide ventilation when placed in either trachea
  or esophagus

33
Esophageal TrachealCombitube (ETC)
34
Combitube Contraindications

• Conscious or semiconscious patients with gag
  reflex
• Children younger than 16 years
• Adults shorter than 5'
• Patients who have ingested a caustic substance
• Patients with esophageal disease

35
Inserting the ETC (1 of 2)

• Assemble and check the proper equipment.
• Apply water-soluble lubricant to the ETC.
• Position the patient.
• Preoxygenate the patient.
• Lift the lower jaw and tongue.

36
Inserting the ETC (2 of 2)

• Guide the ETC along the base of the tongue.
• Inflate the blue and then the white pilot
  balloon.
• Ventilate the patient.
• Confirm placement.
• Monitor the patient.

37
Removing the ETC

• Be prepared to suction patient.
• Deflate both balloon cuffs.
• Gently remove the tube.

38
Pharyngeotracheal Lumen Airway (PtL)
39
PtL Contraindications

• Conscious or semiconscious patients with gag
  reflex
• Children younger than 14 years
• Adults shorter than 5'
• Patients who have ingested a caustic substance
• Patients with esophageal disease

40
Inserting the PtL (1 of 2)

• Assemble and check equipment.
• Lubricate tube with water-soluble lubricant.
• Position the patient.
• Preoxygenate the patient.
• Lift the lower jaw and tongue.
• Hold the PtL so that it curves in the same
  direction as the pharynx.

41
Inserting the PtL (2 of 2)

• Inflate balloon cuffs.
• Ventilate patient through the short, green tube.
• Evaluate placement.
• Verify that the patient is receiving adequate
  ventilations.
• Monitor the patient.

42
Removing the PtL

• Be prepared to suction the patient.
• Deflate balloon cuffs.
• Gently remove the tube.

43
Laryngeal Mask Airway (LMA)
44
LMA Contraindications

• Asthma
• COPD
• Leaking mask
• Active vomiting
• Esophageal diseases

45
Inserting the LMA (1 of 2)

• Assemble and check equipment.
• Open the airway.
• Preoxygenate the patient.
• Select proper size.
• Hold LMA down.
• Remove oropharyngeal device and begin insertion.

46
Inserting the LMA (2 of 2)

• Insert until you feel resistance.
• Stabilize the tube.
• Inflate mask.
• Confirm placement.
• Insert bite block and secure the LMA.

47
Review

• You are called for a male patient complaining of
  respiratory distress. When you arrive, you assess
  the patient and find that he is unconscious and
  apneic, but has a pulse. You should
• A. perform immediate endotracheal intubation.
• B. attach an AED and analyze the patient's
  rhythm.
• C. ensure a patent airway and effective
  ventilation.
• D. administer 100 oxygen via nonrebreathing mask.

48
Review

• Answer C
• Rationale Before performing advanced airway
  procedures (eg, endotracheal intubation), you
  must first ensure that the patients airway is
  patent. Open the airway, ensure that it is clear
  of secretions, insert a basic airway adjunct, and
  ventilate with a bag-mask device. Ventilate the
  patient for at least 2 to 3 minutes before
  attempting intubation.

49
Review

• You are called for a male patient complaining of
  respiratory distress. When you arrive, you assess
  the patient and find that he is unconscious and
  apneic, but has a pulse. You should
• perform immediate endotracheal intubation.
• Rationale Perform BLS airway management before
  performing any advanced airway management.
• B. attach an AED and analyze the patient's
  rhythm.
• Rationale The patient has a pulse, so immediate
  airway intervention is necessary.
• C. ensure a patent airway and effective
  ventilation.
• Rationale Correct answer
• D. administer 100 oxygen via nonrebreathing
  mask.
• Rationale The patient is apneic. You must
  initiate rescue breathing via a bag-mask device.

50
Review

• 2. Immediately after placing an endotracheal tube
  (ETT) in an unconscious patient, you should
• A. attach the bag device and begin ventilating.
• B. inflate the balloon cuff and detach the
  syringe.
• C. secure the tube in place with the proper
  device.
• D. remove the malleable stylet from the ET tube.

51
Review

• Answer B
• Rationale After the ETT has been placed, you
  should immediately inflate the balloon cuff with
  5-10 mL of air and detach the syringe. This will
  seal the trachea and prevent aspiration if
  regurgitation occurs. Once the cuff is inflated,
  remove the stylet, attach the bag device, and
  begin ventilating.

52
Review

• 2. Immediately after placing an endotracheal tube
  (ETT) in an unconscious patient, you should
• attach the bag device and begin ventilating.
• Rationale Do this only after the balloon cuff is
  inflated and the stylet is removed.
• B. inflate the balloon cuff and detach the
  syringe.
• Rationale Correct answer
• C. secure the tube in place with the proper
  device.
• Rationale This is the last step. Note the
  centimeter marking at the lips and secure the
  tube.
• D. remove the malleable stylet from the ET tube.
• Rationale This is performed after the balloon
  has been inflated.

53
Review

• 3. When intubating a patient with a curved blade,
  the blade will
• A. lift the tongue so that you can see the vocal
  cords.
• B. lift the uvula and bring the vocal cords into
  clear view.
• C. fit under the epiglottis and directly expose
  the vocal cords.
• D. fit into the vallecula and indirectly expose
  the vocal cords.

54
Review

• Answer D
• Rationale The curved blade is inserted just in
  front of the epiglottis, into the vallecula (the
  space between the base of the tongue and the
  epiglottis), indirectly allowing you to view the
  vocal cords. The straight blade is inserted
  directly under the epiglottis, directly allowing
  you to view the vocal cords.

55
Review

• 3. When intubating a patient with a curved blade,
  the blade will
• lift the tongue so that you can see the vocal
  cords.
• Rationale The blade pushes the tongue to the
  side during intubation.
• B. lift the uvula and bring the vocal cords into
  clear view.
• Rationale You should visualize the epiglottis,
  and not the uvula.
• C. fit under the epiglottis and directly expose
  the vocal cords.
• Rationale The straight blade fits under the
  epiglottis and allows providers to visualize the
  trachea.
• D. fit into the vallecula and indirectly expose
  the vocal cords.
• Rationale Correct answer

56
Review

• 4. In which of the following patients would you
  NOT use a multi-lumen airway device?
• A. 40-year-old man in cardiac arrest who has
  esophageal cancer.
• B. 17-year-old patient in cardiac arrest
  secondary to electrocution.
• C. 23-year-old man who is unconscious, apneic,
  and has a weak pulse.
• D. 5 6 female who is unconscious and apneic
  after overdosing on heroin.

57
Review

• Answer A
• Rationale Multi-lumen airway devices are
  contraindicated in conscious or semiconscious
  patients who have a gag reflex, patients younger
  than 16 years of age, adults shorter than 5
  tall, patients who have ingested a corrosive
  substance, and patients with an esophageal
  disease (ie, cancer, varices).

58
Review

• 4. In which of the following patients would you
  NOT use a multi-lumen airway device?
• 40-year-old man in cardiac arrest who has
  esophageal cancer.
• Rationale Correct answer
• B. 17-year-old patient in cardiac arrest
  secondary to electrocution.
• Rationale This device is not used in patients
  less than 16 years of age.
• C. 23-year-old man who is unconscious, apneic,
  and has a weak pulse.
• Rationale There is not a contraindication,
  unless the patient has a gag reflex.
• D. 5 6 female who is unconscious and apneic
  after overdosing on heroin.
• Rationale The minimum height for using this
  device is 50.

59
Review

• 5. You are assisting your paramedic partner while
  she intubates a 50-year-old man who is in cardiac
  arrest. You should anticipate that she will ask
  you for a ____ mm ET tube.
• A. 6.0
• B. 6.5
• C. 7.5
• D. 9.0

60
Review

• Answer C
• Rationale The proper-sized ET tube ranges from
  7.5 to 8.5 mm for the adult male and 6.5 to 8.0
  mm for the adult female. A good rule of thumb is
  to have a 7.5 mm ETT on hand this size tube will
  fit most male and female adults. Of course, a
  variety of tube sizes should always be available.

61
Review

• 5. You are assisting your paramedic partner while
  she intubates a 50-year-old man who is in cardiac
  arrest. You should anticipate that she will ask
  you for a ____ mm ET tube.
• 6.0
• Rationale This sized tube would be used in a
  very small individual.
• B. 6.5
• Rationale This sized tube would be in the range
  for an average female patient.
• C. 7.5
• Rationale Correct answer
• D. 9.0
• Rationale This sized tube would be used in large
  adults.

62
Review

• 6. Which of the following is clearly a lethal
  complication of endotracheal intubation?
• A. Unrecognized esophageal intubation
• B. Chipping two of the patients front teeth
• C. Slightly extending the neck of a trauma
  patient
• D. Ventilating the patient without supplemental
  oxygen

63
Review

• Answer A
• Rationale While all of the choices in this
  question will cause some degree of harm to the
  patient, unrecognized esophageal intubation is,
  without doubt, the most lethal. If you intubate
  the esophagus, and do not recognize and
  immediately correct it, the patient will
  dieperiod!

64
Review

• 6. Which of the following is clearly a lethal
  complication of endotracheal intubation?
• Unrecognized esophageal intubation
• Rationale Correct answer
• B. Chipping two of the patients front teeth
• Rationale This is a complication of intubation,
  but it is typically not lethal.
• C. Slightly extending the neck of a trauma
  patient
• Rationale This is something that needs to be
  avoided. Paralysis not death is usually the
  end result of this mistake.
• D. Ventilating the patient without supplemental
  oxygen
• Rationale 100 oxygen must be delivered to a
  patient using a bag-mask. It is not a lethal
  error to deliver less.

65
Review

• 7. A single intubation attempt in an adult should
  not exceed
• A. 10 seconds.
• B. 20 seconds.
• C. 30 seconds.
• D. 40 seconds.

66
Review

• Answer C
• Rationale An intubation attempt should not
  exceed 30 seconds in the adult, and 20 seconds in
  infants and children. During the period of time
  that you are intubating, the patient is not
  breathing. Prolonged intubation attempts increase
  the risk of severe hypoxia and must be avoided.

67
Review

• 7. A single intubation attempt in an adult should
  not exceed
• 10 seconds.
• Rationale The maximum time should not exceed 30
  seconds in adult patients.
• B. 20 seconds.
• Rationale This is the maximum time for infants
  and children.
• C. 30 seconds.
• Rationale Correct answer
• D. 40 seconds.
• Rationale The maximum time should not exceed 30
  seconds in adult patients.

68
Review

• 8. After your partner has intubated a patient in
  respiratory arrest, you auscultate to confirm
  proper ET tube placement. You hear gurgling over
  the epigastrium and faint breath sounds over all
  four lung fields. Your partner should
• A. attach an end-tidal C02 detector to the end of
  the ET tube.
• B. withdraw the ET tube 1 to 2 cm and ask you to
  reauscultate.
• C. inflate the distal balloon cuff and attach the
  bag device to the tube.
• D. remove the ET tube at once and ventilate with
  a bag-mask device.

69
Review

• Answer D
• Rationale If the ET tube is properly placed in
  the trachea, you should hear lungs sounds that
  are equal on both sides of the chest and NO
  epigastric sounds. If you hear gurgling over the
  epigastriumeven if you think you hear breath
  soundsthe ET tube should be removed immediately
  and ventilations with a bag-mask device should be
  resumed.

70
Review (1 of 2)

• 8. After your partner has intubated a patient in
  respiratory arrest, you auscultate to confirm
  proper ET tube placement. You hear gurgling over
  the epigastrium and faint breath sounds over all
  four lung fields. Your partner should
• attach an end-tidal C02 detector to the end of
  the ET tube.
• Rationale The detector is only attached after
  placement is confirmed through auscultation and
  chest rise.
• B. withdraw the ET tube 1 to 2 cm and ask you to
  reauscultate.
• Rationale The tube is drawn back only if the
  provider hears lung sounds on one side, which
  means that the tube is advanced too far.

71
Review (2 of 2)

• 8. After your partner has intubated a patient in
  respiratory arrest, you auscultate to confirm
  proper ET tube placement. You hear gurgling over
  the epigastrium and faint breath sounds over all
  four lung fields. Your partner should
• C. inflate the distal balloon cuff and attach the
  bag device to the tube.
• Rationale The balloon is inflated before
  providers listen to lung sounds.
• D. remove the ET tube at once and ventilate with
  a bag-mask device.
• Rationale Correct answer

72
Review

• 9. After inserting an endotracheal tube, you
  auscultate the patients lungs and do not hear
  breath sounds on the left side of the chest. You
  should suspect
• A. a tension pneumothorax.
• B. intubation of the right mainstem bronchus.
• C. intubation of the left mainstem bronchus.
• D. that the ET tube has entered the esophagus.

73
Review

• Answer B
• Rationale The right mainstem bronchus is shorter
  and straighter than the left therefore, if the
  ET tube is inserted too far, it will come to rest
  in the right mainstem bronchus. You will hear
  breath sounds over the right side of the chest,
  absent sounds over the left side of the chest,
  and absent sounds over the epigastrium. To
  correct this, simply withdraw the tube 1 to 2 cm
  until breath sounds are equal on both sides of
  the chest. If breath sounds are present on the
  left side of the chest and absent on the right,
  suspect a pneumothorax.

74
Review

• 9. After inserting an endotracheal tube, you
  auscultate the patients lungs and do not hear
  breath sounds on the left side of the chest. You
  should suspect
• a tension pneumothorax.
• Rationale This is suspected if you hear breath
  sounds on the left and not on the right side of
  the chest.
• B. intubation of the right mainstem bronchus.
• Rationale Correct answer
• C. intubation of the left mainstem bronchus.
• Rationale If the left mainstem bronchus was
  intubated, then providers would hear sounds on
  the left.
• D. that the ET tube has entered the esophagus.
• Rationale The provider would not hear breath
  sounds if the esophagus was intubated.

75
Review

• 10. Which of the following devices provides the
  MOST effective delivery of oxygen into the lungs?
• A. Combitube
• B. Bag-mask device
• C. Endotracheal tube
• D. Laryngeal mask airway

76
Review

• Answer C
• Rationale The endotracheal tube is considered to
  be the superior airway device for delivering
  oxygen into the lungs. It enters the trachea, has
  a cuff that provides a seal against vomitus, and
  allows the delivery of 100 oxygen directly into
  the lungs. The Combitube and laryngeal mask
  airway (LMA), while effective airway devices, do
  not enter the trachea. They have been shown to
  provide better ventilation than a bag-mask
  device, but are not superior to the ET tube.

77
Review

• 10. Which of the following devices provides the
  MOST effective delivery of oxygen into the lungs?
• Combitube
• Rationale The combitube works well, but does not
  enter the trachea.
• B. Bag-mask device
• Rationale The bag-mask device works well as a
  BLS procedure, but is not the most effective
  device.
• C. Endotracheal tube
• Rationale Correct answer
• D. Laryngeal mask airway
• Rationale The laryngeal mask airway works well,
  but does not enter the trachea.