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
• Kussmaul’s
– Deep, gasping regular respirations
– Diabetic coma
• Biot’s
– 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