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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
AIRWAY PROTOCOLAIRWAY PROTOCOL
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
AIRWAY PROTOCOLAIRWAY PROTOCOL
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
STEP 3. VENTILATE STEP 3. VENTILATE (BLS)(BLS)
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
STEP 3. VENTILATE STEP 3. VENTILATE (BLS)(BLS)
2424
STEP 3. VENTILATE STEP 3. VENTILATE (BLS)(BLS)
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
STEP 4. CONTROL THE STEP 4. CONTROL THE AIRWAYAIRWAY
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
STEP 4. CONTROL THE STEP 4. CONTROL THE AIRWAYAIRWAY
““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
STEP 4. CONTROL THE STEP 4. CONTROL THE AIRWAYAIRWAY
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
STEP 4. CONTROL THE STEP 4. CONTROL THE AIRWAYAIRWAY
Pre-IntubationPre-Intubation
-Prepare Equipment-Prepare Equipment
-Hyper-oxygenate-Hyper-oxygenate
3131
STEP 4. CONTROL THE STEP 4. CONTROL THE AIRWAYAIRWAY
Orotracheal Intubation ProcedureOrotracheal Intubation Procedure
Sweep Sweep Left and Left and
LookLook
3232
STEP 4. CONTROL THE STEP 4. CONTROL THE AIRWAYAIRWAY
Backward, Upward, Right Pressure (B.U.R.P.)Backward, Upward, Right Pressure (B.U.R.P.)
Find Your LandmarksFind Your Landmarks
3333
STEP 4. CONTROL THE STEP 4. CONTROL THE AIRWAYAIRWAY
Find Your LandmarksFind Your Landmarks
3434
STEP 4. CONTROL THE STEP 4. CONTROL THE AIRWAYAIRWAY
It may not be perfect!It may not be perfect!
Find Your LandmarksFind Your Landmarks
3535
STEP 4. CONTROL THE STEP 4. CONTROL THE AIRWAYAIRWAY
Find Your LandmarksFind Your Landmarks
3636
STEP 4. CONTROL THE STEP 4. CONTROL THE AIRWAYAIRWAY
Readjusting with Cricoid PressureReadjusting with Cricoid Pressure
3737
STEP 4. CONTROL THE STEP 4. CONTROL THE AIRWAYAIRWAY
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
STEP 4. CONTROL THE STEP 4. CONTROL THE AIRWAYAIRWAY
What is your back-up plan today?
prolonged BVM…
another provider…
a smaller tube…
better lighting…
additional suctioning…
3939
STEP 4. CONTROL THE STEP 4. CONTROL THE AIRWAYAIRWAY
Helpful AdjunctsHelpful Adjuncts
Gum Gum Elastic Elastic BougieBougie
4040
STEP 4. CONTROL THE STEP 4. CONTROL THE AIRWAYAIRWAY
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.”
STEP 4. CONTROL THE STEP 4. CONTROL THE AIRWAYAIRWAY
-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 (?)
STEP 4. CONTROL THE STEP 4. CONTROL THE AIRWAYAIRWAY
Nasotracheal IntubationNasotracheal Intubation
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
STEP 4. CONTROL THE STEP 4. CONTROL THE AIRWAYAIRWAY
Nasotracheal IntubationNasotracheal Intubation
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
Laryngeal Mask AirwayLaryngeal Mask Airway
STEP 7. ALTERNATIVES TO STEP 7. ALTERNATIVES TO ETIETI
4848
Contraindication/Limitations:Contraindication/Limitations:
-Obesity-Obesity
-Non-secure-Non-secure
-Size based-Size based
-Not a med route-Not a med route
Laryngeal Mask AirwayLaryngeal Mask Airway
STEP 7. ALTERNATIVES TO STEP 7. ALTERNATIVES TO ETIETI
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
Laryngeal Mask AirwayLaryngeal Mask Airway
STEP 7. ALTERNATIVES TO STEP 7. ALTERNATIVES TO ETIETI
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
Laryngeal Mask AirwayLaryngeal Mask Airway
STEP 7. ALTERNATIVES TO STEP 7. ALTERNATIVES TO ETIETI
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
Laryngeal Mask AirwayLaryngeal Mask Airway
STEP 7. ALTERNATIVES TO STEP 7. ALTERNATIVES TO ETIETI
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
Laryngeal Mask AirwayLaryngeal Mask Airway
STEP 7. ALTERNATIVES TO STEP 7. ALTERNATIVES TO ETIETI
5353
Common Provider Problems:Common Provider Problems:
-Failure to seat properly-Failure to seat properly
-Sizing difficulties -Sizing difficulties
-Aspiration-Aspiration
Laryngeal Mask AirwayLaryngeal Mask Airway
STEP 7. ALTERNATIVES TO STEP 7. ALTERNATIVES TO ETIETI
5454
Laryngeal Mask AirwayLaryngeal Mask Airway
STEP 7. ALTERNATIVES TO STEP 7. ALTERNATIVES TO ETIETI
5555
MDPB has approved allMDPB has approved all ““non-intubatingnon-intubating” ” LMA LMA
type devicestype devices
Laryngeal Mask AirwayLaryngeal Mask Airway
STEP 7. ALTERNATIVES TO STEP 7. ALTERNATIVES TO ETIETI
5656
(Combitube(Combitube®®))
STEP 7. ALTERNATIVES TO STEP 7. ALTERNATIVES TO ETIETI
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
Dual Lumen AirwayDual Lumen Airway
STEP 7. ALTERNATIVES TO STEP 7. ALTERNATIVES TO ETIETI
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
STEP 7. ALTERNATIVES TO STEP 7. ALTERNATIVES TO ETIETI
Dual Lumen AirwayDual Lumen Airway
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
STEP 7. ALTERNATIVES TO STEP 7. ALTERNATIVES TO ETIETI
Dual Lumen AirwayDual Lumen Airway
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
STEP 7. ALTERNATIVES TO STEP 7. ALTERNATIVES TO ETIETI
Dual Lumen AirwayDual Lumen Airway
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
STEP 7. ALTERNATIVES TO STEP 7. ALTERNATIVES TO ETIETI
Dual Lumen AirwayDual Lumen Airway
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