Airway Management

Yohanes WH George,SpAn

Topics for Discussion

Airway Maintenance Objectives Airway A&P Review Causes of Respiratory Difficulty & Distress Assessing Respiratory Function Methods of Airway Management Methods of Ventilatory Management Common Out-of-Hospital Equipment Utilized Advanced Methods of Airway Mgmt & Ventilations Risks to the Paramedic

Objectives of Airway Management & Ventilation

Primary Objective:
Ensure optimal ventilation
Deliver oxygen to the blood Eliminate carbon dioxide (C02) from the body

Definitions
What is Airway Management? How does it differ from spontaneous, manual or assisted Ventilations?

Objectives of Airway Management & Ventilation

Why is this so important?
Brain death occurs rapidly; Other tissue follows EMS providers can reduce additional injury/disease EMS providers often neglect BLS airway & ventilation skills

Airway Anatomy Review

Anatomy of the Upper Airway Anatomy of the Lower Airway Lung Capacities/Volumes Pediatric Airway Differences

Anatomy of the Upper Airway

Functions: Warm, Filter, Humidify Nasopharynx
formed by union of facial bones nasal floor towards ear not eye lined with mucous membranes and cilia tissues are delicate and vascular

Anatomy of the Upper Airway

Oropharynx
Teeth Tongue
Lg muscle attached at mandible and hyoid bones Most common airway obstruction

Palate
Roof of mouth Separates oro- & nasopharynx Anterior=hard palate; Posterior=soft palate

Anatomy of the Upper Airway

Oropharynx
Adenoids
lymph tissue - filters bacteria commonly infected

Epiglottis
Prevents aspiration Directs air vs. other

Vallecula
pocket formed by the base of tongue & epiglottis

Anatomy of the Upper Airway

Anatomy of the Upper Airway

Sinuses
cavities formed by cranial bones act as tributaries for fluid to & from eustachian tubes & tear ducts trap bacteria, commonly infected

Anatomy of the Upper Airway

Larynx
attached to hyoid bone
hyoid: horseshoe shaped bone (cartilage) hyoid supports trachea

thyroid cartilage
first tracheal cartilage - shield shaped cartilage anterior but smooth muscle posterior Adams Apple Glottic opening directly behind

Anatomy of the Upper Airway

Larynx (cont)
Glottic opening
narrowest part of adult trachea dependent on muscle tone contains vocal bands
white bands of cartilage produce voice

Arytenoid cartilage
posterior attachment of vocal bands

Anatomy of the Upper Airway

Larynx (cont)
Cricoid ring
first tracheal ring completely cartilaginous compression occludes esophagus
Sellick maneuver

Cricothyroid membrane
membrane between cricoid & thyroid cartilage site for surgical and needle airway placement

Anatomy of the Upper Airway

Larynx (cont)
associated & adjacent structures
thyroid gland
below cricoid cartilage lies across trachea and up both sides

carotid arteries
branches across and lie closely alongside trachea

jugular veins
branch across and lie close to trachea

Anatomy of the Upper Airway

Anatomy of the Upper Airway

Pediatric vs Adult Upper Airway
Larger tongue in comparison to size of mouth Floppy epiglottis Delicate teeth and gums Larynx is more superior Funnel shaped larynx due to undeveloped cricoid cartilage Narrowest point at cricoid ring before 10 yoa

Anatomy of the Upper Airway

From: CPEM, TRIPP, 1998

Anatomy of the Upper Airway

Anatomy of the Lower Airway

Function
exchange O2 and CO2

Location
From the glottic opening to pulmonary capillary membrane

Anatomy of the Lower Airway

Trachea
Bifurcates at carina Right and Left mainstem bronchi Right mainstem bronchi has less angle Lined with mucous cells & Beta 2 receptors

Bronchi
Branch into secondary & tertiary bronchi that branch into bronchioles

Anatomy of the Lower Airway

Bronchioles
Branch into alveolar ducts that end at alveolar sacs

Alveoli
Balloon-like clusters Site of gas exchange Lined with surfactant
increases surface tension eases expansion surfactant or alveoli not inflated atelectasis

Anatomy of the Lower Airway

Lungs
Right lung = 3 lobes; Left lung = 2 lobes Parenchymal tissue Membranous outer lining called pleura
visceral and parietal pleural space

Specific lung capacities

Anatomy of the Lower Airway

Anatomy of the Lower Airway

Occlusion of the bronchiole
Smooth muscle Foreign body (not shown) Inflammation

Lung Volumes & Capacities

Total lung capacity (TLC) in a typical adult male is 6 liters
Much of inspired air does not enter alveoli

Tidal Volume (VT)

volume of gas inhaled/exhaled during a single ventilatory cycle Usually 5-7 cc/kg (typically 500 cc)

Lung Volumes & Capacities

Dead Space Air (VD)
Air remaining in air passageways, unavailable for gas exchange (usually 150 cc) Anatomic dead space
trachea bronchi

Physiologic dead space

formed by factors like disease or obstruction Examples: COPD & atelectasis

Lung Volumes & Capacities

Minute Volume [Vmin](minute ventilation)
amount of gas moved in and out of respiratory tract per minute (tidal volume - dead space volume) X RR

Functional Reserve Capacity (FRC)

after optimal inspiration, the optimum amount of air that can be forced from the lungs in a single exhalation

Lung Volumes & Capacities

Alveolar Air (alveolar volume) [VA]
Air reaching alveoli for gas exchange Usually 350 cc

Inspiratory Reserve (IRV)

Amount of gas that can be inspired in addition to tidal volume

Expiratory Reserve (ERV)

Amount of gas that can be expired after a passive (relaxed) expiration

Lung Volumes & Capacities

Ventilation
Defined as movement of air into & out of lungs Inspiration
stimulus from respiratory center of brain (medulla) transmitted via phrenic nerve to diaphragm diaphragm flattens during contraction intercostal muscles contract ribs elevate and expand results in intrapulmonic pressure (pressure gradient) results in air being drawn into lungs & alveoli inflated

Ventilation
Expiration
Stretch receptors in lungs signal respiratory center via vagus nerve to inhibit inspiration Hering-Breuer Reflex Natural elasticity of lungs passively expires air (in non-diseased lung)

Control via Pons

Apneustic & Pneumotaxic centers

Ventilation
Chemoreceptors
Carotid bodies & Aortic arch Stimulated by PaO2, PaCO2 or pH PaCO2 considered normal neuroregulatory control of ventilations

Hypoxic Drive
default regulatory control Senses changes in Pa02

Ventilation
Other stimulations or depressants to ventilatory drive
body temp: w/ fever & w/hypothermia drugs/meds: increase or decrease pain: increases but occasionally decreases emotion: increases acidosis: increases sleep: decreases

Ventilation

Ventilation

Measurement of Gases
Total Pressure
combined pressure of all atmospheric gases 760 mm Hg or torr at sea level

Partial Pressure
Pressure exerted by each gas of a mixture Atmospheric
Nitrogen 597.0 torr (78.62%); Oxygen 159.0 torr (20.84%); Carbon Dioxide 0.3 torr (0.04%); Water 3.7 torr (0.5%)

Measurement of Gases
Partial Pressures
Alveolar
Nitrogen 569.0 torr (74.9%); Oxygen 104.0 torr (13.7%); CO2 40.0 torr (5.2%); Water 47.0 torr (6.2%)

Respiration
Ventilation vs. Respiration Exchange of gases between a living organism and its environment External Respiration
exchange between lungs & blood cells

Internal Respiration
exchange between blood cells & tissues

Respiration
How are O2 and CO2 transported?
Diffusion
definition gases dissolved in water and pass through alveolar membrane

FiO2
% of oxygen in inspired air (e.g. FiO2 = 0.95)

Respiration
Oxygen Content of Blood
dissolved O2 crosses pulm cap membrane and binds to Hgb of RBC Transport = O2 bound to hemoglobin (97%) or dissolved in plasma O2 Saturation: % of hemoglobin saturated with oxygen (usually carries >96% of total) O2 content divided by O2 carrying capacity

Respiration
Oxygen saturation affected by:
low Hgb (anemia, hemorrhage) inadequate oxygen availability at alveoli poor diffusion across pulm membrane (pneumonia, pulm edema, COPD) Ventilation/Perfusion (V/Q) mismatch
blood moves past collapsed alveoli (shunting) alveoli intact but blood flow impaired

Respiration
Carbon Dioxide content of blood
Byproduct of work (cellular respiration) Transported as bicarbonate (HCO3- ion) 20-30% bound to hemoglobin Pressure gradient causes CO2 diffusion into alveoli from blood increased level - hypercarbia

Anatomy of the Lower Airway

Inspired Air: PO2 160 & PCO2 0.3

Alveoli PO2 100 & PCO2 40

PO2 40 & PCO2 46 - Pulmonary circulation - PO2 100 & PCO2 40

Deoxygenated

Heart

Oxygenated

PO2 40 & PCO2 46 - Systemic circulation - PO2 100 & PCO2 40 Tissue cell PO2 <40 & PCO2 >46

Diagnostic Testing
Pulse Oximetry Peak Expiratory Flow Testing Pulmonary Function Testing End-Tidal CO2 Monitoring Laboratory Testing of Blood
Arterial Venous

Causes of Hypoxemia
Environment
lower partial pressure of atmospheric O2

Transport
inadequate hemoglobin level in blood hemoglobin bound by other gas

Medical
pulm alveolar membrane distance
pneumonia, pulmonary edema, COPD

Causes of Hypoxemia
Traumatic
Reduced surface area for gas exchange
pneumothorax, hemothorax, atelectasis

Decreased mechanical effort

pain, traumatic asphyxiation, hypoventilation sucking chest wound, obstruction

Pathologic Causes of Airway and/or Ventilatory Compromise

Obstruction of the Airway
Tongue
most common snoring reposition airway

Foreign Body
partial or complete choking, gagging, stridor, aphonia, dysphonia

Pathologic Causes of Airway and/or Ventilatory Compromise

Laryngeal Spasm or Edema
Spasmotic closure of vocal cords stimulation with intact gag reflex edema results in narrowed airway epiglottitis, anaphylaxis Treatment
calming ventilation muscle relaxants

Pathologic Causes of Airway and/or Ventilatory Compromise

Fractured Larynx
decreased airway size laryngeal edema increased ventilatory effort

Aspiration
increased mortality destroys bronchiolar tissue increased risk of infection increases pulm alveolar membrane distance

Assessment & Recognition of Airway & Ventilatory Compromise

Respiratory Difficulty & Distress
Upper or lower obstruction Inadequate ventilation rate or depth Impaired ventilatory muscles Impaired ventilatory stimulation system

Assessment & Recognition of Airway & Ventilatory Compromise

Dyspnea (rate, regularity or effort)
May be result of or result in hypoxia hypoxia
lack of oxygen available lack of oxygen to tissues anoxia = total absence

Assessment & Recognition of Airway & Ventilatory Compromise

Visual Assessment
Position
tripod orthopnea

Visual Assessment
Skin color Flaring of nares Pursed lips Retractions Accessory Muscle Use Altered Mental Status Inadequate Rate or depth of ventilations

Rise & Fall of chest Audible gasping, stridor, or wheezes Obvious pulm edema (fulminant)

Assessment & Recognition of Airway & Ventilatory Compromise

Auscultation
Air movement at mouth and nose Tracheal sounds Vesicular lung sounds

Palpation
Air movement at mouth and nose chest wall
paradoxical motion retractions

Assessment & Recognition of Airway & Ventilatory Compromise

Mechanical Ventilation
increased resistance or changing compliance with ventilations

Pulsus Paradoxus
Systolic BP drops > 10 mm Hg w/inspiration
may detect change in pulse quality common in COPD, asthma, pericardial tamponade

Assessment & Recognition of Airway & Ventilatory Compromise

History
Onset
sudden vs gradual Known cause?

Duration
Constant Recurrent

Provocation/Palliation

Assessment & Recognition of Airway & Ventilatory Compromise

Exacerbation Associated Signs/Symptoms
Cough, chest pain, fever

Interventions
past evals/admits meds ever intubated before?

Assessment & Recognition of Airway & Ventilatory Compromise

Respiratory Patterns
Cheyne-Stokes
brain stem

Respiratory Patterns
Central Neurogenic Hyperventilation
increased ICP

Kussmaul
acidosis

Agonal
brain anoxia

Biots
increased ICP

Assessment & Recognition of Airway & Ventilatory Compromise

Inadequate Ventilation
body cannot compensate for increased oxygen demand or maintain balance Causes
infection trauma brainstem injury toxic inhalation renal failure

Airway & Ventilation Methods: BLS

Supplemental Oxygen
increased FiO2 increases available oxygen objective is to maximize hemoglobin saturation

Airway & Ventilation Methods: BLS

Oxygen source
compressed gas liquid oxygen

Delivery Devices
nasal cannula partial rebreather mask non-rebreather mask venturi mask small volume nebulizer

Regulators Humidifier

Airway & Ventilation Methods: BLS

Airway Maneuvers
Head-tilt/Chin-lift Jaw thrust Sellicks maneuver

Airway Devices
Oropharyngeal airway Nasopharyngeal airway

Other Types
tracheostomy with tube tracheostomy with stoma

Airway & Ventilation Methods: BLS

Mouth to Mouth Mouth to Nose Mouth to Mask One person BVM Two person BVM Three person BVM Flow restricted powered ventilator Transport ventilator One Person BVM
difficult to master mask seal often inadequate may result in inadequate tidal vol gastric distention risk ventilate only until see chest rise

Airway & Ventilation Methods: BLS

Two person BVM
most efficient method Useful in C-spine inj improved mask seal and tidal volume

Three person BVM

less utilized used when difficulty with mask seal crowded

Airway & Ventilation Methods: BLS

Flow-restricted, powered ventilator
Cardiac sphincter opens at 30 cm H2O high volume/high conc not recommended for children, noncompliant or poor tidal volume oxygen delivered on inspiratory effort may cause barotrauma

Airway & Ventilation Methods: BLS

Automatic transport ventilators
Not like a real ventilator Usually only controls Volume and rate Useful during prolonged ventilation times Not useful in obstructed airway or increased airway resistance Frees personnel Can not detect changes

Airway & Ventilation Methods: BLS

Pediatric considerations
mask seal force may obstruct airway best if used with jaw thrust BVM sizes: neonate & infant=450 ml + Children > 8 yoa require adult BVM just enough volume to see chest rise
Squeeze - Release - Release

Airway & Ventilation Methods: BLS

Stoma patients
expose stoma pocket mask BVM
Seal around stoma site seal mouth and nose if air leak is evident

Airway & Ventilation Methods: BLS

Airway Obstruction Techniques
Positioning OPA/NPA Heimlich maneuver Finger sweep with caution Chest Thrusts Chest thrust and back blows for infants Suctioning Direct laryngoscopy

Airway & Ventilation Methods: BLS

Suctioning
Manual or Powered devices Suction catheters
rigid soft

Tracheobronchial suctioning
lubricate catheter 3-5 cc sterile water or saline insert catheter until resistance is felt

Airway & Ventilation Methods: BLS

Gastric Distention
Common when ventilating without intubation pressure on diaphragm resistance to BVM ventilation increase time of BVM ventilation

Airway Management: Part 2

EMS Professions Temple College

Airway & Ventilation Methods: ALS

Gastric Tubes
nasogastric
caution with esophageal disease or facial trauma tolerated by awake patients but is uncomfortable patient can speak interferes with BVM seal

orogastric
usually used in unresponsive patients larger tube may be used safe in facial trauma

Airway & Ventilation Methods: ALS

Nasogastric Tube Insertion
Select size (french) Measure length
nose to ear to xiphoid

Lubricate end of tube

water soluble

Maintain aseptic technique Position patient sitting up if possible

Airway & Ventilation Methods: ALS

Nasogastric Tube Insertion (cont)
Insert into nare towards base Advance gradually but steadily to measured length Have patient swallow Assess placement & secure
Instill air & ausculate aspirate gastric contents

May connect to low vacuum (80-100 mm Hg)

Airway & Ventilation Methods: ALS

Orogastric Tube Insertion
Select size (french) Measure length Lubricate end of tube Maintain aseptic technique Position patient (usually supine) Insert into mouth Advance gradually but steadily

Airway & Ventilation Methods: ALS

Orogastric Tube Insertion (cont)
Assess placement & secure
instill air or aspirate

Evacuate contents as needed

Airway & Ventilation Methods: ALS

Endotracheal Intubation
Tube into the trachea to provide ventilations using BVM or ventilator Sized based upon inside diameter in mm Lengths increase with increased ID
cm markings along length

Cuffed vs Uncuffed

Airway & Ventilation Methods: ALS

Endotracheal Intubation
Indications
present or impending respiratory failure apnea unable to protect own airway

Advantages
secures airway route for a few medications optimizes ventilation and oxygenation

Airway & Ventilation Methods: ALS

These are NOT Indications
Because I can intubate Because they are unresponsive Because I cant show up at the hospital

without it

Airway & Ventilation Methods: ALS

Complications of endotracheal intubation
Bleeding or dental injury Laryngeal edema Laryngospasm Vocal cord injury Barotrauma Hypoxia Aspiration Dislodged tube or esophageal intubation Right or Left mainstem intubation

Airway & Ventilation Methods: ALS

Techniques of Insertion
Orotracheal Intubation by direct laryngoscopy Blind Nasotracheal Intubation Digital Intubation Retrograde Intubation Transillumination techniques

Airway & Ventilation Methods: ALS

Orotracheal Intubation by direct laryngoscopy
Position & Ventilate patient Monitor patient
ECG Pulse oximeter

Assess patients airway for difficulty Assemble & check equipment (suction) Hyperventilate patient (30-120 sec)

Airway & Ventilation Methods: ALS

Orotracheal Intubation by direct laryngoscopy (cont)
Position patient Open mouth & insert laryngoscope blade Attempt to sweep tongue (straight blade) Identify anatomical landmarks Advance laryngoscope blade
Vallecula for curved (Miller) blade Under epiglottis for straight (Miller) blade

Airway & Ventilation Methods: ALS

Orotracheal Intubation by direct laryngoscopy (cont)
Elevate epiglottis Directly with straight (miller) blade Indirectly with curved (macintosh) blade Visualize the vocal cords & glottic opening Enter the mouth with the tube from corner of mouth

Airway & Ventilation Methods: ALS

Orotracheal Intubation by direct laryngoscopy (cont)
Advance into glottic opening approx. 1/2 inch past vocal cords Continue to hold tube & note location Inflate cuff until firm (approx 10 cc) Ventilate & Auscultate
epigastrium left and right chest

Airway & Ventilation Methods: ALS

Orotracheal Intubation by direct laryngoscopy (cont)
Secure tube Reassess Ventilation Effectiveness
auscultation clinical signs end-tidal CO2 Esophageal detection device

Airway & Ventilation Methods: ALS

Equipment
Laryngoscope Handle (lighted) & Blades Stylet Syringe Magills Lubricant Suction BVM BAAM (BNI)

Selection
Typical Adult ET Tube Sizes
Male - 8.0, 8.5 Female - 7.0, 7.5, 8.0

Blade
Mac - 3 or 4 Miller - 3

Tube Depth
Usually 20 - 22 cm at the teeth

Equipment Review

From AHA PALS

Airway & Ventilation Methods: ALS

Airway & Ventilation Methods: ALS

Pediatric Equipment Differences
Uncuffed tube < 8 yoa Miller blade preferred Tube Size
Premie: 2.0, 2.5 Newborn: 3.0, 3.5 1 year: 4 Then: (age/4)+4

Pediatric Differences
Anatomic Differences Depth (cm)
Tube ID x 3 12 + (age/2) easily dislodged

Intubation vs BVM

Airway & Ventilation Methods: ALS

Patient Positioning
Goal
Align the 3 planes of view, so that The vocal cords are most visible

T - trachea P - Pharynx O - Oropharynx

From AHA PALS

Airway & Ventilation Methods: ALS

Assessing the Possibility of Difficulty in Intubation
Difficulty

Airway & Ventilation Methods: ALS

What effect would the angle of the mandible have on intubation difficulty?

Airway & Ventilation Methods: ALS

Curved (Macintosh) Blade
Visualize anatomy Insert from right to left Lift upward and away Blade in vallecula Lift epiglottis indirectly
From AHA ACLS

Airway & Ventilation Methods: ALS

Straight (Miller) Blade
Visualize anatomy Insert from right to left moving tongue away Lift upward and away Blade past vallecula and over epiglottis Lift epiglottis directly
From AHA ACLS

Tube Positioning

From TRIPP, CPEM

Airway & Ventilation Methods: ALS

Blind Nasotracheal Intubation
Position & Oxygenate patient Monitor patient
ECG Monitor Pulse oximeter

Assess for BNI difficulty or contraindication Assemble & check equipment

Lubricate end of tube; Do not warm Attach BAAM (if available)

Airway & Ventilation Methods: ALS

Blind Nasotracheal Intubation (cont)
Position patient (preferably sitting upright) Insert tube into largest nare Advance slowly but steadily Listen for sound of whistle via BAAM Advance tube Inflate cuff & Assess placement Secure & Reassess

Airway & Ventilation Methods: ALS

Digital Intubation
Blind technique Variable probability of success Using middle fingers to locate epiglottis Lift epiglottis Slide lubricated tube along side fingers Assess tube placement & depth as with orotracheal intubation

Airway & Ventilation Methods: ALS

Digital Intubation

From AMLS, NAEMT

Airway & Ventilation Methods: ALS

Surgical Cricothyrotomy
Indications
absolute need for a definitive airway AND
unable to perform ETT due for structural or anatomic reasons, AND risk of not intubating is > than surgical airway risk OR

absolute need for a definitive airway AND

unable to clear an upper airway obstruction, AND multiple unsuccessful attempts at ETT, AND other methods of ventilation do not allow for effective ventilation and respiration

Airway & Ventilation Methods: ALS

Surgical Cricothyrotomy
Contraindications (relative)
No real demonstrated indication Risks > benefits Age < 8 years (some say 10) evidence of fx larynx or cricoid cartilage evidence of tracheal transection

Airway & Ventilation Methods: ALS

Surgical Cricothyrotomy
Tips
Know your anatomy Short incision, avoid inferior trachea Incise, Do not saw Work quickly. Have a plan Be prepared with a backup plan

Airway & Ventilation Methods: ALS

Needle Cricothyrotomy & Transtracheal Jet Ventilation
Indications
Same as surgical cricothyrotomy along with Contraindication for surgical cricothyrotomy

Contraindications
None when demonstrated need caution with tracheal transection

Airway & Ventilation Methods: ALS

Jet Ventilation
Usually requires highpressure equipment Ventilate 1 sec then allow 3-5 sec pause Hypercarbia likely Temporary: 20-30 mins High risk for barotrauma

Airway & Ventilation Methods: BLS & ALS

Alternative Airways
Multi-Lumen Devices (CombiTube, PTLA) Laryngeal Mask Airway (LMA) Esophageal Obturator Airways (EOA, EGTA) Lighted Stylets

Airway & Ventilation Methods: BLS & ALS

Pharyngeal Tracheal Lumen Airway (PTLA)

From AMLS, NAEMT

Airway & Ventilation Methods: BLS & ALS

Combitube
2 . No
. No 2
No. 1

From AMLS, NAEMT

No . 2 15 ml

No. 1 100 ml

No. 1

No .2 15 ml

No. 1 100 ml

Airway & Ventilation Methods: BLS & ALS

Combitube
Indications Contraindications
Height Gag reflex Ingestion of corrosive or volatile substances Hx of esophageal disease

Airway & Ventilation Methods: BLS & ALS

Laryngeal Mask Airway (LMA)
Use in OR Gaining use in outof-hospital Not useful with high airway pressure Not a replacement for ETT Multiple models & sizes

LMA

Airway & Ventilation Methods: BLS & ALS

Airway & Ventilation Methods: BLS & ALS

Esophageal Obturator Airway & Esophageal Gastric Tube Airway
Used less frequently today Increased complication rate Significant contraindications Better alternative airways are now available

Esophageal Gastric Tube Airway (EGTA)

From AHA ACLS

Airway & Ventilation Methods: BLS & ALS

Lighted Stylette
Not yet widespread use expensive Another method of visual feedback re. placement in trachea

Airway & Ventilation Methods: ALS

Airway & Ventilation Methods: ALS

Pharmacologic Assisted Intubation (RSI)
Sedation
Reduce anxiety Induce amnesia Depress gag reflex & spontaneous breathing Used for
induction anxious or agitated patient

Contraindications
hypersensitivity hypotension

Airway & Ventilation Methods: ALS

Pharmacologic Assisted Intubation (RSI)
Common Medications for Sedation/Induction
Benzodiazepines (diazepam, midazolam) Narcotics (fentanyl) Anesthesia Induction Agents
etomidate ketamine propofol (Diprivan)

Airway & Ventilation Methods: ALS

Pharmacologic Assisted Intubation (RSI)
Neuromuscular Blockade
Induces temporary skeletal muscle paralysis Indications
When Intubation is required in a patient who is awake, has a gag reflex, or is agitated or combative

Airway & Ventilation Methods: ALS

Pharmacologic Assisted Intubation (RSI)
Neuromuscular Blockade
Contraindications
Most are Specific to the medication inability to ventilate patient once paralysis is induced

Advantages
enables to provider to intubate patients who otherwise would be difficult or impossible to intubate minimizes patient resistance to intubation reduces risk of laryngospasm

Airway & Ventilation Methods: ALS

Pharmacologic Assisted Intubation (RSI)
Mechanism of Action for NMB agent
acts at the neuromuscular junction where ACh normally allows nerve impulse transmission binds to nicotinic receptor sites at skeletal muscle depolarizes or does not depolarize specific to med blocks further action by ACh at receptor sites therefore, blocks further depolarization resulting in muscular paralysis

Airway & Ventilation Methods: ALS

Pharmacologic Assisted Intubation (RSI)
Disadvantages & Potential Complications
Does not provide sedation or amnesia Provider unable to intubate or ventilate after NMB Aspiration during procedure Difficult to detect motor seizure activity Side effects and adverse effects of specific meds

Airway & Ventilation Methods: ALS

Pharmacologic Assisted Intubation (RSI)
Common Used NMB Agents
Depolarizing NMB agents
succinylcholine (Anectine)

Non-depolarizing NMB agents

vecuronium (Norcuron) rocuronium (Zemuron) pancuronium (Pavulon)

Airway & Ventilation Methods: ALS

Pharmacologic Assisted Intubation (RSI)
Summarized Procedure
Prep all equipment and medications while ventilating patient Hyperventilate Administer induction/sedation agents & pretreatment meds (e.g. lidocaine or atropine) Administer NMB agent Sellick maneuver Intubate per usual Continue NMB and sedation/analgesia prn

Airway & Ventilation Methods: ALS

Examples of Secondary Tube Placement Confirmation Devices
(From AMLS, NAEMT)

From AMLS, NAEMT

Airway & Ventilation Methods: ALS

Needle Thoracostomy (chest decompression)
Indications
Positive sx/sx of tension pneumothorax Cardiac arrest with PEA or Asystole when the possibility of trauma and/or tension pneumo exist

Contraindications
Absence of indications

Airway & Ventilation Methods: ALS

Tension Pneumothorax
Sx/Sx
severe respiratory distress or absent lung sounds (unilateral usually) resistance to manual ventilation Cardiovascular collapse (shock) asymmetric chest expansion anxiety, restlessness or cyanosis (late) JVD or tracheal deviation (late)

Airway & Ventilation Methods: ALS

Needle Thoracostomy
Prep equipment Locate landmarks: 2nd intercostal space at midclavicular line one-way valve

Airway & Ventilation Methods: ALS

Chest Escharotomy
Indications
In the presence of severe edema to the soft tissue of the thorax as with circumferential burns:
inability to maintain adequate tidal volume even with PPV inability to obtain adequate chest expansion with PPV

Rarely needed

Airway & Ventilation Methods: ALS

Chest Escharotomy
Considerations
must rule out the possibility of upper airway obstruction

Procedure
Intubate if not already done Prep site and equipment Vertical incision to anterior axillary line Horizontal incision only if necessary Cover and protect

Airway & Ventilation: Risks & Protective Measures

BSI
Gloves Face & eye shields Respirator if concern for airborne disease Be prepared for
coughing spitting vomiting biting

Airway & Ventilation Methods

Saturdays class
Practice using the equipment
orotracheal intubation nasotracheal intubation gastric tube insertion surgical airways needle thoracostomy combitube retrograde intubation