Advanced Airway Management

Leaugeay Webre, BS, CCEMT-P,

NREMT-P
Modified Forms of Respiration
Reflexes which act to protect the respiratory
system:
Cough- forceful, spasmodic exhalation of a large
volume of air
Sneeze- sudden forceful exhalation from the nose
Hiccough- sudden inspiration caused by spasmodic
contraction of the diaphragm & glottic closure
Gag reflex- spastic pharyngeal & esophageal reflex
caused by stimulation of posterior pharynx
Sighing- hyperinflation of lungs, opens atelectic
alveoli
The ability to breathe and
the ability to protect the
airway are not always the
same.
ASSESSMENT
BSI/ scene safety
General impression
Identify and correct any life threatening
conditions:
Responsiveness/ c-spine
Airway
Breathing
Circulation
GENERAL IMPRESSION
POSITION
Tripod
Bolt upright
COPD
CHF
Able to speak in sentences
AIRWAY
Is it patent?
Snoring, gurgling or stridor may indicate
potential problems
Secretions, objects, blood, vomitus present

Neck
JVD (jugular vein distention)
TD (tracheal deviation, tugging)
BREATHING
Adequacy?
Rate and quality?
Spontaneous & regular
effortless
Chest rise
Equal and present: excursion
Deformity/ crepitus
Ecchymosis
Subcutaneous emphysema
Paradoxical (asymmetric)
Flail chest

BREATHING EFFORT
Normal
Labored/ dyspnic
Tachypnic/ bradypnea
Accessory muscle use
Intercostal retractions
Suprasternal
Abdominal muscle use
Pediatrics
Grunting
Nostril flaring
BREATH SOUNDS
CTA bilat
Diminished
Rhonci
Rales
Wheezing
RESPIRATORY PATTERNS
Cheyne Stokes
Regular pattern of increasing rate & volume
followed by gradual decrease and a short period
of apnea
Brain stem insult
Kussmauls
Deep, gasping regular respirations
Diabetic coma
Biots
Irregular rate & volume with intermittent periods of
apnea
Increased ICP
Central Neurogenic Hyperventilation
Regular, deep and rapid
Increased ICP
Agonal
Slow, shallow, irregular
Brain hypoxia

PULSUS PARADOXUS
Decrease in systolic BP > 10 mm HG during
inspiration
Caused by increase in intrathoracic pressure
COPD
Interference with ventricular filling
Results in decreased BP
DEFINITIONS
Hypoxemia
Reduction of O2 in arterial blood
Hypoxia
Insufficient O2 available to meet O2 requirements
Hypercarbia
Increased level of CO@ in blood
Monitoring
Pulse oximetry
End tidal CO2
Quantitative
capnography
Qualitative
Colormetric
Purple to yellow
CAPNOGRAPHY- EtCO2
Standard of care in hospital
Immediate response to extubation
Stand up in court to prove intubation
Waveform indicative:
Normal
Obstructed airway- do you NEED a B-2
agonist?

WAVEFORM
Normal
Acute upstroke- exhalation
Acute down stroke- inhalation
Straight across

Shark fin- lower airway obstruction
Advanced Airway Management
Manual airway control
Ventilation
Oxygenation
Proceed to advanced management
Allows for correction of:
Profound hypoxia
hypercarbia


Followed by advanced adjunct
placement ASAP
Prevent gastric inflation
Prevent aspiration
Endotracheal tube
Combitube
PtL
LMA
Endotracheal Intubation
When ventilating an unresponsive patient
through conventional methods cannot be
achieved
Protect the airway
Prolonged artificial respiration required
Patients with or likely to experience upper
airway compromise
Decreased tidal volume- bradypnea
Airway obstruction
Advantages
Controls the airway
Facilitates ventilation/ O2
Prevents gastric inflation
Allows for direct suctioning
Medication administration
Disadvantages
Requires extensive and ongoing training for
proficiency
Requires specialized equipment
Bypasses physiological function of upper
airway
Warm
Filter
Humidify
Complications with Intubated
Patients
Displacement
Obstruction
Pneumothorax
Equipment failure

Contraindicated in epiglottitis
Possible Occurring
Complications
Bleeding
Laryngeal swelling
Laryngospasm
Vocal cord damage
Mucosal necrosis
Barotrauma
Dental trauma
Laryngeal trauma
Esophageal placement
Laryngoscope
Move tongue and epiglottis
Allows visualization of cords and glottis
Miller- straight
Lift epiglottis
pediatrics
Macintosh- curved
Fits in valeculla
More room for visualization
Reduced trauma/ gag reflex
ETT
15mm universal adapter
2.5-9.0mm diameter
12-32cm length
Male- 23cm 8.0-8.5mm
Female- 21cm 7.5-8.0mm
Balloon cuff
Occludes tracheal lumen
Pilot balloon
magill forceps
Direct observation
Breathing & apneic
BSI- goggles & gloves
Position- sniffing
Preoxygenate
Replace nitrogen stores with O2
Assemble & check equipment
Verify Placement
Esophageal intubation detector
CO2 detector
Auscultation
EtCO2 Capnography
35-45mm Hg
Hyperventilation in head injury with herniation 30-
35mm HG
ASPIRATION
Partially dissolved food
Protein dissolving enzymes
Hydrochloric acid

Pathophysiology
Increased interstitial fluid due to injury
Pulmonary edema
Destruction of alveoli
ARDS
Impaired gas exchange
Hypoxemia
Hypercarbia
Increased mortality
Prevention
Cricoid pressure
Suctioning
Tonsil tip
Whistle tip
Positioning
Hazards of Suctioning
Cardiac dysrhythmias
Increased BP/ HR
Decreased BP/ HR
Gag reflex
Cough
Increased ICP
Decreased CBF
Multilumen Airways
Combitube
Pharyngotracheal Lumen Airway
Advantages
Blind insertion
Facial seal is not necessary
Can be placed in esophagus or trachea
Contraindications
< 16 years old
< 5 feet tall or > 6 ft 7 in tall (4 ft combi)
Ingestion of caustic substances
Esophageal disease
Presence of gag reflex