Advanced airway management EMS 352 Dr Aqeela Bano

Advanced airway management

EMS 352 Dr Aqeela Bano

Advanced Airway Management

• One of the most common mistakes with respiratory or cardiac arrest is to use advanced techniques too early.– Establish and maintain a patent airway with basic

techniques first.

Advanced Airway Management

• Primary reasons:– Failure to maintain a patent airway and/or – Failure to adequately oxygenate and ventilate

• Involves insertion of advanced airway devices

Predicting the Difficult Airway

• Anatomic findings:– Congenital abnormalities– Recent surgery– Trauma– Infection– Neoplastic diseases

• LEMON– Look externally– Evaluate 3-3-2– Mallampati– Obstruction– Neck mobility

LEMON

• Look externally.– The following can make intubation difficult:

• Short, thick necks• Morbid obesity• Dental conditions

LEMON

• Evaluate 3-3-2.– 3 — mouth width of more

than 3 fingers is best– 3 — mandible length of 3

fingers is best– 2 — distance from hyoid

bone to thyroid notch of 2 fingers wide is best

LEMON

• Mallampati– Note oropharyngeal structures visible in an

upright, seated patient.

LEMON

• Obstruction– Note anything that might interfere with

visualization or ET tube placement.• Foreign body• Obesity• Hematoma• Masses

LEMON

• Neck mobility– Sniffing position is ideal– Neck mobility problems most common with:

• Trauma patients • Elderly patients

Endotracheal Intubation

• ET tube passes through glottic opening and is sealed with a cuff inflated against the tracheal wall– Orotracheal intubation: through the mouth– Nasotracheal intubation: through the nose

Endotracheal Intubation

• Advantages– Secure airway– Protection against

aspiration– Alternative to IV or IO route

• Disadvantages– Special equipment – Physiologic functions

bypassed

• Complications– Bleeding– Hypoxia– Laryngeal swelling– Laryngospasm– Vocal cord damage– Mucosal necrosis– Barotrauma

Endotracheal Tubes

• Basic structure includes:– Proximal end– Tube– Cuff and pilot

balloon– Distal tip

Endotracheal Tubes

• Sizes range – 2.5 to 9.0 mm in inside

diameter– 12 to 32 cm in length

Endotracheal Tubes

• Pediatric patients– 2.5 to 4.5 mm tubes used – Funnel-shaped cricoid ring forms an anatomic seal

with ET tube• No need for distal cuff in most cases.

Endotracheal Tubes

• Anatomic clues can help determine tube size – Internal diameter of the nostril approximates

diameter of glottic opening– Diameter of the little finger or size of thumbnail

approximates airway size.• Always have three sizes ready!

Laryngoscopes and Blades

• A laryngoscope is required to perform orotracheal intubation by direct laryngoscopy.

• Consists of a handle and interchangeable blades


• Straight (Miller and Wisconsin) blades– Tip extends beneath

epiglottis and lifts it up

• Useful with infants and small children

• More likely to damage teeth in adults


• Curved (Macintosh) blades– Curve conforms to

tongue and pharynx– Tip is placed in the

vallecula• Indirectly lifts

epiglottis to expose vocal cords


• Blade sizes range from 0 to 4– 0, 1, and 2 appropriate for infants and children– 3 and 4 considered adult sizes– Pediatric patients: based on age or height– Adults: based on experience, size of patient


• Stylet: semirigid wire inserted into ET tube– Molds and maintains shape of tube– Should be lubricated for removal– End should be bent to form a gentle curve– End should rest at least 1/2″ from end of ET tube


• Magill forceps– Remove airway obstructions under direct

visualization.– Guide tip of ET tube through glottic opening if the

proper angle cannot be achieved by manipulating the tube

Orotracheal Intubation by Direct Laryngoscopy

• ET tube inserted through mouth and into trachea while visualizing the glottic opening with a laryngoscope


• Indications– Airway control needed due

to coma, respiratory arrest, and/or cardiac arrest

– Ventilatory support before impending respiratory failure

– Prolonged ventilatory support

– Absence of gag reflex– Traumatic brain injury– Unresponsiveness– Impending airway

compromise – Medication administration


• Contraindications– Intact gag reflex– Inability to open mouth because of trauma,

dislocation of the jaw, or a pathologic condition– Inability to see the glottic opening– Copious secretions, vomitus, or blood in airway

Standard Precautions

• Intubation can expose you to bodily fluids.– Take proper precautions.

• Gloves• Mask that covers your entire face

Preoxygenation

• Critical before intubating– 2–3 minutes for apneic or hypoventilating patient – Prevents hypoxia from occurring– Monitor SpO2 and achieve as close to 100%

saturation as possible.

Positioning the Patient

• Airway has three axes: mouth, pharynx, and larynx– At acute angles in

neutral position– Place patient in

“sniffing” position to facilitate visualization of the airway.

Positioning the Patient

• Sniffing position– 20° extension of the

atlanto-occipital joint– 30° flexion at C6 and

C7 with short neck and/or no chin

– Elevate head and/or neck until ear is at the level of the sternum

Blade Insertion

• Position yourself at the patient’s head.

• Grasp laryngoscope. • If mouth is not open:

– Place thumb below bottom lip and push open.

– “Scissor” thumb and index finger between molars

– Open with tongue-jaw lift

Blade Insertion

• Insert blade into right side of mouth

• Sweep tongue to the left while moving blade into midline

• Slowly advance the blade.

© Jones & Bartlett Learning. Courtesy of MIEMSS. Specimens provided by the Maryland State Anatomy Board, Department of Health and Mental Hygiene at the Anatomical Services Division, University of Maryland School of Medicine

Blade Insertion

• Exert gentle traction at a 45° angle as you lift the patient’s jaw. – Keep your back and

arm straight as you pull upward.

© Jones & Bartlett Learning. Courtesy of MIEMSS. Specimens provided by the Maryland State Anatomy Board, Department of Health and Mental Hygiene at the Anatomical Services Division, University of Maryland School of Medicine

Visualization of the Glottic Opening

• Continue lifting the laryngoscope as you look down the blade.

• Work the tip of the blade into position.– The glottic opening

should come into view.

• The vocal cords lie within.

Courtesy of James P. Thomas, M.D. www.voicedoctor.net


• Gum elastic bougie – Flexible device– Approximately 1 cm in diameter, 60 cm long– Used in epiglottis-only views to facilitate

intubation


• Gum elastic bougie (cont’d)– Insert through the

glottic opening under direct laryngoscopy.

– Once placed, it becomes a guide for the ET tube.

Tube Insertion

• Pick up preselected ET tube.– Hold it near connector as you would a pencil.

• Insert tube from the right corner of mouth through the vocal cords.– Continue until the proximal end of the cuff is 1 to

2 cm past the vocal cords.

Tube Insertion

• Do not pass the tube down the barrel of the laryngoscope blade. – Will obscure your

view of the glottic opening

Ventilation

• After you have seen the ET tube cuff pass roughly 1/2″ beyond the vocal cords– Gently remove the blade.– Secure tube with right hand– Remove stylet from tube

Ventilation

• Inflate the distal cuff with 5 to 10 mL of air, then detach the syringe from the inflation port.

• Have your assistant attach the bag-mask device to the ET tube; continue ventilation.– Ensure that the patient’s chest rises with each

ventilation.

Ventilation

• Listen to both lungs and to the stomach.– You should hear equal breath sounds and a quiet

epigastrium.• Ventilation should be dictated by age.

– Adult with a pulse: 10 to 12 breaths/min – Infant/child with a pulse: 12 to 20 breaths/min – Patient in cardiac arrest: 8 to 10 breaths/min

Confirmation of Tube Placement

• Visualize the ET tube passing between the vocal cords.

• Auscultate.– Unequal or absent breath sounds suggest:

• Esophageal placement• Right mainstem bronchus placement• Pneumothorax• Bronchial obstruction


• Auscultate (cont’d).– Bilaterally absent breath sounds or gurgling over

the epigastrium: esophagus was intubated • Immediately remove ET tube.• Be prepared to suction the airway.


• Auscultate (cont’d).– Breath sounds only on right: tube has been

advanced too far. • Reposition the tube.


• With proper tube position:– Bag-mask device should be easy to compress.– You should see corresponding chest expansion.

• Increased resistance may indicate:– Gastric distention– Esophageal intubation– Tension pneumothorax


• Continuous waveform capnography plus clinical assessment– Most reliable method of confirming placement– Attach capnography T-piece when bag-mask

device is attached to the ET tube.


• Esophageal detector device– Syringe model:

plunger is withdrawn• Tube in the trachea:

plunger does not move

• Tube in the esophagus: plunger moves back

Courtesy of Marianne Gausche-Hill, MD, FACEP, FAAP


• Esophageal detector device (cont’d)– Bulb model: bulb is

squeezed • Tube in the

esophagus: bulb remains collapsed

• Tube in the trachea: bulb briskly expands



• After confirming proper placement, mark ET tube where it emerges from the mouth– Shows others whether tube has slipped in or out

Securing the Tube

• Never take your hand off the ET tube before securing with an appropriate device.– Support the tube manually while you ventilate to

avoid a sudden jolt from the bag-mask device.

Securing the Tube

• Steps:– Note the centimeter marking on the ET tube.– Remove the bag-mask device. – Position the tube in the center of the mouth. – Place the securing device over the tube. – Reattach the bag-mask device, auscultate, and

note the capnography reading and waveform.

Securing the Tube

• Many devices feature a built-in bite block.– Alternative: Secure tube with tape and insert a

bite block or oral airway.• Minimize head movement in patient.

• Nasotracheal Intubation

Nasotracheal Intubation

• Advantages– Can be performed on

responsive patients – No need for laryngoscope– Mouth does not need to be

opened– Does not require sniffing

position– Patient cannot bite the

tube. – Can be secured more easily

• Disadvantage– Blind technique

• Complications– Bleeding

• Contraindicated:– Apnea – Head trauma and midface

fractures– Anatomic abnormalities;

frequent cocaine use

Nasotracheal Intubation Equipment

• Same as for orotracheal intubation– Minus laryngoscope and stylet

• Some tubes are designed for blind method• Some devices allow confirmation of intubation

without placing face next to tube

Technique for Nasotracheal Intubation

• Patient’s spontaneous respirations guide the tube and confirm proper placement.– Tube is advanced as patient inhales


• Insert tube into nostril, bevel facing toward the nasal septum– Aim tip straight back

toward ear – Position just above

the glottic opening

© Jones & Bartlett Learning. Courtesy of MIEMSS.


• Manipulate head to control tube tip position and to maximize air movement.

• Instruct patient to take a deep breath, and gently advance tube. – Placement will be evidenced by an increase in air

movement through the tube.


• Soft-tissue bulge on either side of the airway– Tube is probably in the piriform fossa

• Hold head still, slightly withdraw the tube• Once maximum airflow is detected, advance tube

• No soft-tissue bulge– Tube has entered the esophagus.

• Withdraw until you detect airflow; extend head.


• Once tube is in place, inflate the distal cuff– Attach bag-mask device and ventilate.– Clean up any secretions or excess lubricant.– Secure the tube with tape. – Document depth of insertion at the nostril.

Digital Intubation

Digital Intubation

• Indications (exceptional circumstances)– Laryngoscope, or other techniques, have failed– Patient in confined space– Patient is obese or has a short neck– Copious secretions– Head cannot be moved – Cannot visualize intubation landmarks

Digital Intubation

• Can be performed in pediatric patients, but usually impossible due to finger size

• Absolutely contraindicated if patient is:– Breathing– Not deeply unresponsive– Has intact gag reflex

Digital Intubation

• Advantages– Does not require a

laryngoscope– Ideal if vocal cords are

obscured by secretions– Does not require sniffing

position

• Disadvantages– Risk of being bitten – Risk of exposure to

infectious disease

Digital Intubation

• Complications– Misplacement of the ET tube – Bite block can cause lip and tooth damage – Vigorous or improper attempts can cause airway

trauma or swelling.– Can result in hypoxia

Digital Intubation Equipment

• Same as for orotracheal intubation (minus laryngoscope), plus fingers– Stylet – ETCO2 detector or esophageal detector device– Appropriate device to secure the tube

Technique for Digital Intubation

• Prepare equipment as assistant ventilates– Select tube: one half to a full size smaller than

with direct laryngoscopy• Tip of the tube is guided into the trachea


• Two configurations are recommended.– “Open J” configuration– “U-handle” configuration



• Sniffing position is not required

• Insert bite block between molars.– Insert index and middle

fingers into right side of the mouth.

– Press against tongue. – Pull epiglottis forward.


• Hold ET tube in right hand; insert it into the left side of the mouth

• Advance tube toward the glottis – Once you feel the cuff pass 2″ beyond your

fingertip, stabilize the tube and withdraw fingers– Remove the stylet and inflate the cuff.


• Attach bag-mask device and ventilate.• Confirm placement.

– Auscultate lungs and epigastrium.– Monitor ETCO2.– Properly secure the tube in place.

Transillumination Techniques for Intubation


• Bright light source placed inside the trachea emits a bright, well-circumscribed light



• Indicated – Other techniques have failed.

• Contraindicated – Intact gag reflex– Airway obstruction– May be difficult in obese or short neck patients – Pediatric patients: stylet must fit inside tube


• Advantages– No laryngoscope– Visual parameter – Does not require

visualization of the glottic opening

– Safe with possible spinal injuries

• Disadvantages– Special equipment – Proficiency with equipment– Can be difficult in brightly

lit areas

• Complications– Misplacement

Transillumination Equipment

• Device with a rigid stylet and a bright light source at the end– Light should shine laterally and forward.– Stylet must be long enough to accommodate a

standard-length ET tube– Stylet must be secured within the tube

Technique for Transillumination-Guided Intubation

• Preoxygenate for at least 2 to 3 minutes.• Choose ET tube and check the cuff• Lubricate and insert the lighted stylet.

– Ensure it is firmly seated into the tube.


• Bend tube into the proper shape– Head in neutral or slightly extended position

• While holding the stylet, displace the jaw forwardly.

• Turn on the lighted stylet, and insert it in the midline of the mouth.


• Continue insertion; draw wrist toward you .– Tightly circumscribed light slightly below the

thyroid cartilage: tube has entered trachea– Faintly glowing light and bulging of the soft tissue:

tube is in the vallecular space.– Dim, diffuse light at the anterior part of the neck:

esophageal placement


• Once light is visible at the midline, hold the stylet in place and advance the tube.

• When the tube is in the trachea, stabilize it and withdraw the stylet.

• Inflate the distal cuff, detach the syringe, and attach the bag-mask device.


• Ventilate the patient while auscultating both lungs and the epigastrium.

• Secure the tube and continue ventilations.

Retrograde Intubation


• Needle: placed percutaneously within the trachea via the cricothyroid membrane

• Wire: placed through the needle, through the trachea, into the mouth– Wire is visualized, secured– ET tube is placed over wire and guided into

trachea


• Indications– Upper airway obstruction– Copious secretions in the

airway– Failure to intubate by less

invasive methods

• Contraindications– Lack of familiarity with the

procedure– Laryngeal trauma– Unrecognizable or distorted

landmarks– Coagulopathy – Severe hypoxia


• Complications– Hypoxia– Cardiac dysrhythmia– Mechanical trauma– Infection– Increased intracranial pressure

Failed Intubation and Field Extubation

Failed Intubation

• Definition: – Failure to maintain oxygen saturation during or

after one or more failed intubation attempts – Total of three failed intubation attempts

Failed Intubation

• Many rescue airway techniques– Simple BLS airway maneuvers with oral airway

and/or nasal airway and bag-mask device– Rescue airway device

Tracheobronchial Suctioning

• Involves passing a suction catheter into the ET tube to remove pulmonary secretions – Do not do it if you do not have to!– If it must be performed:

• Use sterile technique. • Monitor cardiac rhythm and oxygen saturation.

Tracheobronchial Suctioning

• Preoxygenate for at least 2 to 3 minutes.• Insert suction catheter until resisted.

– Apply suction as the catheter is extracted• Reattach bag-mask device, continue

ventilations, and reassess.

Field Extubation

• Extubation: process of removing tube from an intubated patient– Before performing, contact medical control or

follow local protocols.

Field Extubation

• Risks– Over-estimating patient’s ability to protect airway– Laryngospasm– Upper airway swelling

• Do not remove tube unless you can reintubate!

Field Extubation

• Contraindicated with any risk of recurrent respiratory failure or uncertainty about a patient’s ability to maintain airway

• If indicated, ensure adequate oxygenation.

Field Extubation

• Explain procedure to patient• Have patient sit up or lean slightly forward.• Assemble equipment to suction, ventilate, and

reintubate.

Field Extubation

• Confirm patient can protect airway• Suction oropharynx• Deflate distal cuff as patient exhales• On next exhalation, remove tube

Pediatric Intubation Technique

Pediatric Endotracheal Intubation

• If bag-mask is not producing adequate ventilation, patient should be intubated – Indications are the

same as those in adults

Laryngoscope and Blades

• Thinner pediatric handles are preferred.• Straight blades facilitate lifting of epiglottis• Blade should extend from mouth to ear

Laryngoscope and Blades

• Use length-based resuscitation tape measure or the following guidelines:– Premature newborn: size 0 straight blade– Newborn to 1 year: size 1 straight blade– 2 years to adolescent: size 2 straight blade– Adolescent and older: size 3 straight or curved

blade

Endotracheal Tubes

• To estimate the appropriate size:– Length-based resuscitation

tape measure– Formulas

• [Age (in years) + 16] ÷ 4 • [Age (in years) ÷ 4] + 4

– Anatomic clues – General guidelines



Endotracheal Tubes

• Cuffed ET tubes are generally not used in the field until the child is 8 to 10 years old.– Can cause ischemia and damage the tracheal

mucosa • Have tubes one size smaller and one size

larger than expected

Endotracheal Tubes

• Appropriate depth of insertion is 2 to 3 cm beyond the vocal cords– Record depth at corner of mouth– Uncuffed tubes: stop when black band is at the

vocal cords.– Cuffed tubes: stop when cuff is just below the

vocal cords.

Pediatric Stylet

• Insert into tube, stop at least 1 cm from end• Fit tube sizes 3.0 to 6.0 mm• After inserting into tube, bend tube into a

gentle upward curve

Preoxygenation

• Preoxygenate for at least 2 to 3 minutes.• Ensure that the child’s head is in the sniffing

position or the neutral position. • If needed, insert an airway adjunct.

Additional Preparation

• Monitor cardiac rhythm. • Monitor pulse rate and oxygen saturation.• Have suction available. • Atropine sulfate may be administered.


• With head in sniffing position, apply thumb pressure on chin to open mouth.

• If an oral airway was inserted, remove it.• Suction if needed.• Hold the laryngoscope in “trigger finger”

position.


• Insert the blade in the right side of the mouth.– Sweep tongue to the left, keep under blade.

• Advance the blade; apply traction upward. – Never use teeth/gums as a fulcrum for the blade


• Straight blade: When the blade passes the epiglottis, gently lift the epiglottis.

• Curved blade: place blade tip in vallecula; lift jaw, tongue, and blade at a 45° angle.

• Identify vocal cords and other landmarks.


• Hold tube in right hand; insert from the right-side corner of the mouth.

• Guide tube through the vocal cords, advancing until black band is just beyond– Record the depth, and remove the blade.


• Remove stylet; hold tube in place. • Recheck tube depth. • Cuffed tube: inflate to form seal • Attach tube to bag-mask device.


• Confirm tube placement.– Bilateral chest rise during ventilation– Auscultate lungs bilaterally. – If sounds are decreased on left, tube may be too

deep.• To correct, withdraw tube until sounds are equal.

– Rerecord tube depth.


• Auscultate over epigastrium. – Bubbling sounds indicate esophageal intubation.

• Additional methods to confirm placement:– Improvement in skin color, pulse rate, and oxygen

saturation– Waveform capnography


• Colorimetric ETCO2 detector or EDD– Cannot be used in children weighing < 15 kg– Esophageal bulb or syringe cannot be used in

children weighing < 20 kg• After placement, secure tube

– Reconfirm placement following any movement.


• If tube is too large or you cannot identify the vocal cords and glottic landmarks:– Abort intubation and ventilate. – Modify equipment and start from the beginning.– If intubation cannot be accomplished after two

attempts, discontinue.


• If child’s condition deteriorates, use DOPE for common causes.– Displacement– Obstruction– Pneumothorax– Equipment failure

Complications of Endotracheal Intubation

• Essentially the same as for adults– Unrecognized esophageal intubation– Induction of emesis and aspiration– Hypoxia– Damage to teeth, soft tissues, and intraoral

structures

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Advanced airway management EMS 352 Dr Aqeela Bano