Emergency Airway and Ventilation—The Difficult

AirwayBy: Darryl Jamison

NREMT-P

Hey ya’ll watch this….

GoalsPredict a difficult airway based on clinical criteriaPlan for appropriate action in the difficult airwayInitiate appropriate plans of attack with confidence in the “Can’t Ventilate/Can't Intubate” (CVCI) situationBecome informed about some new (and not so new) airway options out there.

What this class assumesYou already understand the basic anatomy of the AirwayYou already have a basic understanding of both BLS airway maneuvers and Endotracheal Intubation by Oral and Nasal meansYou are familiar with needle and traditional surgical airway procedures. You are an experienced operator in the field of EMS.

Function of the Respiratory System

Pulmonary ventilation—movement of air into and out of lungs so that gases in the alveoli are continuously exchanged.External respiration—gas exchange between blood and alveoliTransport of respiratory gases—02 and CO2 between lungs and tissue

Internal respiration—gas exchange between systemic blood and tissue cells

Why do we Intubate?

Inability to protect and maintain patent airway.Failure of oxygenation or ventilation.Anticipated need based on clinical course

Ideal conditions for intubation

Ideal Lighting, positioning, etc.Plenty of assistanceTime to prepare, plan, discussOption to AbortEmpty StomachBack up available.

Ideal Pt. for intubationIntact, clear airwayWide open mouthPre-OxygenatedIntact respiratory driveNormal dentition/good oral hygieneClearly identifiable and intact Neck and FaceBig open NostrilsGood Neck MobilityGreater than 90 KG, Less than 110 kg.

Ped and Adult Normal Trachea0

In Reality Our patients are:

ImmobilizedTraumatizedCompromisedPrioritizedBeer-n-Pizza-ized

They Tend to look like This:

Or this…

Or this (after failed ETT)

Most of our Patients are already “difficult airways” by “OR” Standards. Why should EMS personnel try to further identify a difficult airway?

The American Society of Anesthesiology (AMA)has noted:

“… there is strong agreement among consultants that preparatory efforts enhance success and minimize risk.”And “…The literature provides strong evidence that specific strategies facilitate the management of the difficult airway “Thus Identifying a potentially difficult airway is essential to preparation and developing a strategy.

What does this mean to us?

Well, many Anesthesiologist have the option to “Abort” induction, or to work through a problem with as much assistance as needed.In the REAL WORLD of EMS that is seldom the case for Paramedics. However many of the BASIC principles are valid in the clinical evaluation of Patients, and thus valuable in our education as medics. Knowing these principles will improve our decision making process and Patient Care;.

How can we further identify a difficult airway?

PMHxBasic Physical ExamThyromental DistanceDr. Binnions “Lemon” LawMallampati Classification

Past Medical History

Rheumatoid Arthritis Ankylosing Spondylitis: Painful Stiffening of the Joint Cervical Fixation DevicesKlippel-Fiel Syndrome: Short wide neck, reduction in number of cervical vertebrae, and possible fusion of vertebrae. Thyroid or major neck surgeriesPierre Robin Syndrome: Small Jaw, cleft Pallet, No Gag reflex, downward displacement of tongueAcromegaly: Thickening of Jaw, Soft tissue structures of the face, associated with middle age

Past Medical History (Continued)Reduced Jaw MobilityEpiglottitisTumors, Known Abnormal StructuresPrevious Problems in surgery

Basic Physical Exam

Anything that would limit movement of the neckScars that indicate neck surgeriesKyphosisBurnsTrauma, especialy instability of the facial and neck structures.

ThyroMental Distance

Measure from upper edge of thyroid cartilage to chin with the head fully extended. A short thyromental distance equates with an anterior larynx that is at a more acute angle and also results in less space for the tongue to be compressed into by the laryngoscope blade. Greater than 7 cm is usually a sign of an easy intubationLess than 6 cm is an indicator of a difficult airwayRelatively unreliable test unless combined with other tests.

Dr. Binnions Lemon Law: An easy way to remember multiple tests…

Look externally.Evaluate the 3-3-2 rule.Mallampati.Obstruction?Neck mobility.

L: Look ExternallyObesity or very small.Short Muscular neckLarge breastsProminent Upper Incisors (Buck Teeth)Receding Jaw (Dentures)BurnsFacial TraumaS/S of AnaphylaxisStridorFBAO

E: Evaluate the 3-3-2 rule

Greater than three fingers from Jaw to NeckJaw is Greater than 3 fingers wideYou can open the mouth greater than two fingers

M: Mellampati classificationA Method used by Anesthesiologist, reliable to predict difficult direct Laryngoscopy (Cormack & Lehane grading)A Class I view is a Grade I Intubation 99% of the timeA Class IV view is a Grade III or IV intubation 99% of the time

Mellampati Classification

Cormack & Lehane Grading

O: Obstruction?BloodBloodVomitusVomitusTeeth (“chicklets”)Teeth (“chicklets”)EpiglotisEpiglotisDenturesDenturesTumorsTumorsImpaled ObjectsImpaled Objects

N: Neck Mobility

Spinal PrecautionsImpaled ObjectsLack of accessSee PMHx for others.

What do we do when we have a difficult airway?

So what do we do?

Before intubation

Is there another means of getting our desired results BEFORE we attempt Direct Oral ETT? (Especially if we RSI)CPAP ?PPV with BVM or Demand Valve?Nasal ETT?Do we have all the help we need, all Airway equipment with us? (Suction?)

In Pediatric Advanced Life Support (PALS), the LMA™ airway is classified as a Class Indeterminate device, defined as "Interventions can still be recommended for use, but reviewers must acknowledge that research quantity/quality fall short of supporting a final class

decision. Indeterminate is limited to promising interventions." Therefore, the LMA™ airway may be utilized depending on the

situation at the time of the arrest.

What are we going to do if we don’t get the Tube?

Plans “A”, “B” and “C”Know this answer before you tube.

Plan “A”: (ALTERNATE)

Different Length of bladeDifferent Type of BladeDifferent Position

Plan “B”: (BVM and BLIND INTUBATION Techniques )

Cam you Ventilate with a BVM? (Consider two NPA’s and a OPA, gentile Ventilation)Combi-Tube? PTLA (No Longer produced) EOA, EGTA? LMA an Option? Retrograde Intubation?

What do we do when faced with a Can’t Intubate Can’t Ventilate situation?

Plan “C”: (CRIC) Needle, Surgical,

Do YOU feel ready to enact Plans A, B, C at a drop of a hat?

Feel familiar with all those tools and techniques?As Paramedics we should, After all we will provide the only definitive care in these patients.ACEMS ED will be trying to increase training in these areas.

Questions or Comments