Basic Airway ManagementThose who cannot do, teach.

Those who cannot teach, supervise

Murphy’s Laws for EMTS

Danine Jasumback BSc, RRT, EMT

Canada to Detroit to Montana via a short stay in CA

Don’t hold that against me

Paradigm shift: Less is more (except shoes)

• Prior to 2010 ACLS advocated halting compressions to allow line insertions and ETT

• 2015 guidelines recognize ETT is not necessary with good BMV technique or SGA insertion (two man, 6 bpm! Puny..slow adoption

• Early recognition of airway compromise may stop the progression to cardiac arrest

• If a patient accepts NPA best to use it.

• Positioning may be everything

2015 AHA guidelines change

• The use of a bag-valve-mask device to maintain, reestablish, or rescue the airway is clinically acceptable and vital to managing an airway emergency. CPR should not be stopped to facilitate ETT

• Current ACLS Guidelines discourage the use of bag-mask ventilation (BMV) by a single practitioner , and recommend bag-valve-mask ventilation be “performed by two trained and experienced providers”.

• Because BMV is a difficult skill to master, it is important staff be trained and provided ongoing education.

• In addition to the use of a bag-mask device, ACLS Guidelines promote the use of a blindly placed supraglottic airway as a means of achieving ventilation during the initial management of sudden cardiac arrest. The Guidelines suggest a laryngeal mask airway (LMA), Combitube(esophageal-tracheal tubes), or laryngeal tube can be used as an alternative to endotracheal tube intubation, if tracheal intubation will interrupt chest compressions.

• in addition to being trained at inserting supraglottic airways, it is essential we have the appropriate connectors to sample CO2 from the supraglottic airway device, as well.

So, intubation is good?

• Intubation during CPR was associated with worse survival and brain health. The patients who were intubated were less likely to survive (16% vs 19%) or have a good functional outcome (~11% vs ~14%). not associated

• Among adult patients with in-hospital cardiac arrest, initiation of tracheal intubation within any given minute during the first 15 minutes of resuscitation, compared with no intubation during that minute, was associated with decreased survival to hospital discharge. Although the study design does not eliminate the potential for confounding by indication, these findings do not support early tracheal intubation for adult in-hospital cardiac arrest.

• in any subgroup! JAMA 2/2017

Blind airways? SGA for the win?

• 300 pt study of King airway compared capnography vs run report and 20% of airways misplaced

• 14% of these went undetected

• Should we be placing these tubes without ETC02?

Changes in strategies: Less is more

• CPR was often interrupted for airway

• ETT by OHCP is under attack

• ETT is a difficult skill

• Esophageal intubation is a clean kill

• ETT is not without hazards

• OHCP in MT do not have RSI

• So what tools do you have?

BVM for the win?

Consistent mask seal with ETC02 and PEEP

Proper Vt (princess squeeze)

Controlled rate

2018 new guidelines 6bpm may be enough!

PEEP

• All BVMS should have PEEP valves

• Without PEEP airway pressure is lost between breaths (driving pressure)

• 5-20cmh20

• Small VT 400-600ml

• Pediatric bags for everyone?

Oxygenation and ventilation are not the same

• Oxygenation is simply adding oxygen to the human body through gas entering the lungs or recently ECMO

• Oxygenation is mostly achieved by increasing Fi02 and circulation

• Ventilation is the movement of gas into and out of the lungs so C02 may be expelled and 02 absorbed

• Oxygenation cannot occur without adequate ventilation! Wrong?

• Apneic oxygenation has been shown to be effective in the prearrest and pre intubation state to limit hypoxic events

Airway/oxygenate/ventilate

• High levels of blood oxygen have been associated with lower survival after cardiac arrest; worsened injury from myocardial infarction; and poorer outcomes from critical illness generally

• increased ventilations result in a lower partial pressure of CO2 (pCO2). This causes a slight cerebral vasoconstriction., if the patient is overventilated, the pCO2 can become so low that intense cerebral vasoconstriction ensues, worsening brain ischemia

• In our zeal to help we gravely injuring patients! Most likely from over ventilation than hyperoxia in the acute phase

Ventilation and oxygenation are

not the same

Failure to ventilate, not intubate kills

You can ventilate most patients with NPA/OPA and BVM or both

Serious complications arise from poorly performed intubations

95% of patient transports do

not involve cardiac arrest

• The airway is well addressed in ACLS and PALS guidelines

• The prearrest airway is not

• RRT have made huge difference in mortality in hospital patients

• Securing and maintaining the airway is most important

• Physiologically, spontaneous respirations are best for almost all patients

• Positive pressure ventilation can have disastrous results

Plan for failure

• Success has many Fathers, failure is an orphan

• Make plans for failure but enlist a lot of help for success

• When ego gets in the way people die

• Have many back up plans

• Be familiar with and know where your equipment is

• Don’t stuff 10lbs of equipment in a 5lb bag and except to find it

• Murphys EMT rules again

OHCA patients are few and far

between

Most transports are patients not in cardiac arrest

What is there was a way to treat respiratory dysfunction before it came to cardiac arrest?

PAT and ABCDE may be all I need to know

• PAT reveals a huge chunk of info in all patients

• WOB and RR are most important

• Appearance and positioning second

• Circulation first in cardiac arrest but airway is first in pre arrest

Predicting failure

• You must count a 60 sec RR. At the very least 30.

• 4 breaths on either side of normal can signal impending clinical badness

• Changes in RR are the first indication of deterioration before evidence of hypoxia, neuro and mental changes

• SP02 changes are late signs

• Cheat and use ETC02 if you have it.

30% of patients are morbidly obese

• 10% of these are morbidly obese or super obese (BMI>40%)

• M/M occur primarily from respiratory or ventilatory failure whether acute or chronic

• Decrease VT, Cwall compliance, increased airway pressure from abdomen leads to decreased ERV, VQ mismatch and poorly ventilated areas of lung

• FRC decreased leaving little 02 reserve

• 02 consumption and c02 production are high from inc WOB

Old friends

This Photo by Unknown Author is licensed under CC BY-SA

New ideas

Heads up for survival?

CPAP or NIV for the win!

Reality Check

• So many new skills being practiced basic skills are deteriorating

• Low man usually gets to bag but this may be the most important

• Oxygenate/ventilate/protect

• Position to decrease airway pressure

• Ask for help Jaw thrust/ head tilt

• CPAP can stent the airway and help avert decline

• Ramp almost everybody