Airway management in ED - Basics and advanced

Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09

Airway management in ER settings “Basic & Advanced”

Updated with recent advances

Dr.Venugopalan. P.P DA,DNB,MNAMS,MEM-GWU Director , Emergency Medicine

Aster DM Healthcare

Why airway management in Emergency Room ?

» Airway management is the cornerstone of resuscitation

» A defining skill for the specialty of emergency medicine

» The emergency physician has primary responsibility for management of the airway

» All airway management techniques lie within the domain of emergency medicine

When to intubate ?

» 1.Failure to maintain or protect the airway » 2.Failure of ventilation or oxygenation » 3.Anticipated clinical course and likelihood

of deterioration.

Clinical Decision

How do you know airway is patent?

» 1.Level of consciousness » 2.Ability to phonate in response to voice

command or query (Integrity of the upper airway and the level of consciousness)

» 3. Ability to manage his or her own secretions ( pooling of secretions in the oropharynx, absence of swallowing spontaneously or on command)

Intubation?

A patient who requires a maneuver to establish a patent airway or who easily tolerates an oral airway

probably requires intubation for protection of that airway, unless temporary or readily reversible

condition, such as opioid overdose, is present.

Ventilatory failure or Oxygenation failure?

» Clinical assessment » Pulse oximetry with or without

capnography » Observation of improvement or

deterioration in the patient’s clinical condition

The decision to intubate

intubate, and intubate early

especially in dynamic airways

Bullets - neck traumaBites- anaphylaxis / angioedema thermal and Burns -caustic airway injuries

• 3 Bs Bullets Bites Burns

ABCDEF

Airway - mouth and neck infections, tumors, foreign bodies, bleeds ]exam: stridor, phonation, swallowing, secretions, dyspnea

Breathing failure of oxygenation or ventilation often amenable to medical and non-invasive therapies – think NIV

Circulation supporting tissue oxygen delivery by unloading the muscles of respiration sepsis

ABCDEFDisability : CNS catastrophes and CNS depression, ongoing seizures, weakness exam: avoid gag – assess ability to swallow and handle secretions (pooling, drooling, gurgling) for neuromuscular weakness: FVC < 12 ml/kg and NIF < 20 cm H20

vomiting in the obtunded patient is a particular concern

Expected course :anticipated decline, transfer to radiology or another institution

» Feral -need for prompt, aggressive sedation to protect patient/others

especially with potential or undiagnosed medical instability

Arterial blood gases (ABGs) generally are not required to determine the patient’s need for intubation

Anticipated clinical deterioration

» Certain overdoses » Significant multiple trauma, with or without head

injury » Multiple trauma with hypotension, an open femur

fracture, and diffuse abdominal tenderness » Aggressive resuscitation, pain control,invasive

procedures and imaging outside of the emergency department ,inevitable operative management

» Evidence of vascular or direct airway injury in the neck

Obstructed airway ?

• Tongue and Epiglottis • Any Foreign materials ?

Clear it

Noisy breathing ?

Tongue obstructing Airway

Head tilt &Chin lift

Jaw thrust

Trauma ?

Airway

Not – Maintainable ?

Adjuncts

• Airway Reflexes ? …..No !

Choice –OPA !

Sizing - oropharyngeal airway

Oropharyngeal airway Insertion

OPA InsertionBest method

• OPA is not tolerating ? • Airway reflexes retained ? • Inability to open mouth ?

Airway

Still not – Maintainable ?

Advanced Airway

No Breathing ?

• Give Breaths • Cricoid Pressure ?

E – C Clamp

Place and hold mask properly

Non-maintainable Airway

Conscious patient? Semiconscious with retained reflexes?

RSI Defined

“Virtually simultaneous administration of a potent sedative agent and a neuromuscular blocking agent to induce unconsciousness and motor paralysis for tracheal intubation”

What are The Problems Inherent to Intubation?

• Laryngoscopy and Intubation – Increased bronchospasm – Increased ICP – Increased catecholamine release

Beneficial Effects of RSI• “Tight Heads”

– Intracranial pathology • “Tight Hearts” or “Tight Vessels”

– Cardiovascular disease • “Tight Lungs”

– Reactive airway disease

Conventional With LMA

RSI: TimelineT – 10 minutes Prepare T – 5 minutes Preoxygenate T – 3 minutes Pretreat T = 0 Paralysis with

induction T + 30 seconds Protection T + 45 seconds Placement T + 90 seconds Post-Intubation

management

Airway Evaluation

Problem Airway

epiglottis Vocal cords

Difficult airway ?

» Difficult intubation, » Difficult BMV, » Difficult ventilation with an extra glottic

device » Difficult circo thyrotomy.

Double set up » Neuromuscular paralysis

generally should be avoided in patients for whom a high degree of intubation difficulty is predicted, unless the administration of the neuromuscular blocking agent (NMBA) is part of a planned approach to the difficult airway

Look Externally

» Severely bruised » Bloodied face of a combative trauma patient » Immobilized in a cervical collar on a spine

board » Anatomical deformities » Subjective clinical judgment can be highly

specific (90%) but insensitive and so should be augmented by other evaluations.

Evaluate 3-3-2.

Obstruction or obesity

» Visualization of the glottis, or intubation itself, mechanically impossible

» Epiglottitis, head and neck cancer, Ludwig’s angina, neck hematoma, or glottic polyps

» Examine the patient for airway obstruction and assess the patient’s voice to satisfy this evaluation step

Neck mobility

» Neck mobility is desirable for any intubation technique and is essential for positioning the patient for optimal direct laryngoscopy. Neck mobility is assessed with the patient’s flexion and extension of the head and neck through a full range of motion

Lemon in ER setting

» Unresponsive patient - Mallampatti is not practical - LEON

» Unresponsive plus Trauma - Mallampatti and Neck mobility are not practical - LEO

Cormack and Lehane[CL]

» The most widely used system for grading laryngoscopic view of the glottis is that of Cormack and Lehane (CL)

» Grades laryngoscopy according to the extent to which laryngeal and glottic structures can be seen.

CL grading

» Grade 1 laryngoscopy, all or nearly all of the glottic aperture is seen.

» Grade 2 laryngoscopy visualizes only a portion of the glottis (arytenoid cartilages alone or arytenoid cartilages plus part of the vocal cords).

» Grade 3 laryngoscopy visualizes only the epiglottis.

» Grade 4 laryngoscopy, not even the epiglottis is visible.

Percentage Of Glottic Opening (POGO) score

Confirmation of Endotracheal Tube Placement

» Direct visualisation » Chest auscultation » Gastric auscultation » Bag resistance » Exhaled volume » Visualization of condensation within the ETT » Chest radiography » All are prone to failure as means of confirming

tracheal intubation.

» End-tidal carbon dioxide (ETCO2) detection device to the ETT and assess it through six manual ventilations

» Disposable, colorimetric ETCO2 detectors are highly reliable, convenient, and easy to interpret, indicating adequate CO2 detection by color change

End tidal CO2 detection

USG- EDD» When ETCO2 detection is not possible,

tracheal tube position can be confirmed with other techniques.

» One novel approach Bedside ultrasound.

Esophageal Detector Devices (EDD)

Recognize Adequacy of Ventilations

Pulse oximeter

Chest X ray

» Although chest radiography is universally recommended after ETT placement, its primary purpose is to ensure that the tube is well positioned below the cords and above the carina.

Other methods Gold standard

• Fiberoptic confirmation

Difficult Airway Assessment• 4 D’s

– Distortion, Disproportion, Dysmobility, Dentition • BONES

– Beard, Obese, No teeth, Elderly, Snores (sleep apnea)

• SHORT – Surgery (head/neck/jaw), Hematoma, Obese,

Radiation, Tumor • LEMON • MALLAMPATI • Always have a “Rescue Airway” technique

Rescue Airways

• Gum Elastic Bougie (GEB) • Laryngeal Mask Airway (LMA/ILMA) • Combitube • Surgical Cricothyrotomy

Advanced airway –Best choice Intubation

Equipments Needed

❑ Laryngoscope with different types of blade.

❑ ET tube with proper size and type. Average adult male: 8.5 mm Average adult female: 7.5 mm Low pressure cuff tubes above 8 years Uncuffed tubes below 8 years

< 4 Age + 3.5

> 4 Age + 4.5

Laryngoscope

Align the airway axis by proper positions

• Align the 3 axes – critical for success • Sellick’s maneuver

ET Tube insertion

Laryngeal Mask Airway

❑A silicone rubber device that combines. Tracheal intubation and the use of a face mask.

❑Used for situations when intubation attempts have failed, bag-valve mask ventilation is unsuccessful, and the patient needs immediate airway management.

LMA- SizesSize Description Weight

1 Neonates Upto 5 Kg

1 ½ Pediatric 5 - 10 Kg

2 Infant 10 – 20 Kg

2 ½ Child 20-30 Kg

3 Large child/ Small Adult 30 – 50 Kg

4 Adult 50 – 70 Kg

5 Adult > 70 Kg

Combitube Insertion

Surgical Airway

Blind Nasotracheal Intubation

• BNTI remains a valid method of intubation in the out-of-hospital setting, where it occasionally is used. In the ED, BNTI rarely, if ever, should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives

Awake Oral Intubation» Awake oral intubation is a technique in which

sedative and topical anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade.

» Topical anesthesia may be achieved by spray, nebulization, or local anesthetic nerve block. After the patient is sedated and topical anesthesia has been achieved, gentle direct, video, or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible

Awake intubation

What is the Disaster in Airway management?

Can’t Intubate !

Can’t Ventilate !!

• Rescue Airway

LMA ,Combitube , Bougie assisted intubation

Surgical Airway

New Airway Devices

Video Assisted Laryngoscope

Airway management made easy

Algorithms

Approximate Blood oxygen level !

➢SpO2 100% = PaO2 100mm of Hg ➢SpO2 90%= PaO2 60mm of Hg ➢SpO2 60%= PaO2 30mm of Hg ➢SpO2 50%= PaO2 27mm of Hg

THANK YOU

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