Airway management. Gabriel Blecher
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1 Airway management Gabriel Blecher
2 Richard Levitan 1: Weingart SD, Levitan RM. Preoxygenation and prevention of desaturation during emergency airway management. Ann Emerg Med Mar;59(3): e1. doi: /j.annemergmed Epub 2011 Nov 3. Review. PubMed PMID: ! 2: Levitan RM, Kelly JJ, Kinkle WC, Fasano C. Light intensity of curved laryngoscope blades in Philadelphia emergency departments. Ann Emerg Med Sep;50(3): Epub 2007 Jun 22. PubMed PMID: ! 3: Levitan RM, Chudnofsky C, Sapre N. Emergency airway management in a morbidly obese, noncooperative, rapidly deteriorating patient. Am J Emerg Med Nov;24(7): PubMed PMID: ! 4: Levitan RM, Pisaturo JT, Kinkle WC, Butler K, Everett WW. Stylet bend angles and tracheal tube passage using a straight-to-cuff shape. Acad Emerg Med Dec;13(12): Epub 2006 Nov 1. PubMed PMID: ! 5: Levitan RM, Kinkle WC, Levin WJ, Everett WW. Laryngeal view during laryngoscopy: a randomized trial comparing cricoid pressure, backward-upward-rightward pressure, and bimanual laryngoscopy. Ann Emerg Med Jun;47(6): Epub 2006 Mar 14. PubMed PMID:
3 Richard Levitan 6: Collins JS, Lemmens HJ, Brodsky JB, Brock-Utne JG, Levitan RM. Laryngoscopy and morbid obesity: a comparison of the "sniff" and "ramped" positions. Obes Surg Oct;14(9): PubMed PMID: ! 7: Levitan RM, Everett WW, Ochroch EA. Limitations of difficult airway prediction in patients intubated in the emergency department. Ann Emerg Med Oct;44(4): PubMed PMID: ! 8: Levitan RM, Mechem CC, Ochroch EA, Shofer FS, Hollander JE. Head-elevated laryngoscopy position: improving laryngeal exposure during laryngoscopy by increasing head elevation. Ann Emerg Med Mar;41(3): PubMed PMID: ! 9: Levitan RM, Mickler T, Hollander JE. Bimanual laryngoscopy: a videographic study of external laryngeal manipulation by novice intubators. Ann Emerg Med Jul;40(1):30-7. PubMed PMID:
4 PPPPPP Prior Preparation Prevents Piss Poor Performance
5 Pre-oxygenation: why?
6 Preoxygenation goals 1. Bring SpO2 close to 100% 2. Denitrogenate lungs 3. Denitrogenate + maximally oxygenate bloodstream
7 Preoxygenation How long? 3 minutes How? Reservoir facemask with max flow rate (beyond 15L/min) OR BVM with 1-way inhalation and exhalation ports with 2-hand technique (E-C grip)
8 Bad lungs? If SpO2 <93-95% after 3min preox: SHUNT eg consolidation, atelectasis, interstitial/alveolar fluid Rx? NIV or PEEP valve on BVM
9 Fighting NIV mask? Consider DSI - i.e. procedural sedation using! ketamine! See
10 Delayed Sequence Intubation (DSI) Weingart SD. J Emerg Med PMID: Weingart SD, Levitan RM. Ann Emerg Med PMID: EMCrit Podcast 40 Delayed Sequence Intubation (DSI) Sehdev RS, et al. Emerg Med Australas 2006 PMID: Bourgoin A, et al. Crit Care Med 2003 PMID: General Concepts DSI is procedural sedation/dissociation where the procedure is preoxygenation Breaks up the sequence of RSI to preoxygenate prior to paralysis prolongs safe apnea duration and decreases risk of gastric insufflation or aspiration Maintains patient s spontaneous respirations and reflexes Candidates for DSI Agitated due to EtOH, head injury, or psychosis, but with normal lungs Agitated, but with lungs capable of being oxygenated on non-rebreather (NRB) mask: hypoxic due to COPD, pneumonia, ARDS Agitated, but require NIV to preoxygenate Unobtainable or unacceptable vital signs due to any of the above Need to perform a procedure that the patient is not tolerating prior to intubation (e.g. NGT placement prior to intubation of GI bleeder) Ketamine Dose: 1 mg/kg IV push (may need to re-dose 0.5 mg/kg to maintain dissociation) Pros: 30 sec onset, achieves dissociative state, maintains spontaneous respirations and airway reflexes, maintains hemodynamic stability Cons: May increase intracranial pressure in patients with high MAP, may cause laryngospasm, use with caution in patients with CAD, HTN, or tachycardia Equipment & Troubleshooting Respiratory therapist Nasal cannula (NC) Non-rebreather (NRB) mask Bag valve mask (BVM) with PEEP valve 2 O 2 flow meters (NRB or BVM, NC) Ventilator with NIV settings Non-vented mask with straps for CPAP ETCO 2 monitor Pearls: DSI NIV Preoxygenation may be achieved with NC, NRB mask, OR NIV, depending on the patient s needs If your patient is not agitated, NIV may be sufficient without the need for sedation/dissociation Intubation may be avoided if adequate dissociation and oxygenation is attained
11 Positioning Preoxygenation: NOT FLAT!! Why? atelectasis regurgitation/aspiration risk
12 Apneic oxygenation Mechanism: 250mL/min of O2 moves from alveoli into bloodstream Only 8-29mL/min of CO2 moves into alveoli > subatmospheric pressure in alveoli mass flow of gas from pharynx to alveoli
13 Apneic oxygenation: how Nasal cannulae set to >15L/min Need clear path from nose > pharynx: Consider nasopharyngeal airways Head elevation Jaw thrust Chin lift Ear to sternal notch position
14 Digression: procedural sedation Do you use supplemental O2 or no?
15 Effect of supplemental O2
16 Procedural sedation Nasal cannulae on but not flowing Monitor SpO2 and ETCO2
17 Hypoventilation due to oversedation? O.O.P.S: Oxygen on: NC + NRB Pull mandible forward Sit patient up
18 Back to the programme.
19 Ventilation before laryngoscopy? Severe metabolic acidosis Raised ICP PaCO2 increases by 8-16 mmhg in first min of apnea then 3 mmhg/min How? Slow: 1-2 sec/breath Low volume: one hand squeezing bag (6-7mL/ kg) Low rate: 6-8/min
20 Laryngoscopy
21 Epiglottoscopy Finding the epiglottis is key Proceed slowly down tongue Fluids, blood, saliva pool in hypopharynx: use suction!
22 Bimanual laryngoscopy Manipulation of thyroid cartilage to improve view NOT B.U.R.P or cricoid pressure Once view optimized, assistant can maintain pressure
23 Positioning: EAM to sternal notch
24 Tube shape Too much tube curvature: tip catches on anterior tracheal rings limited maneuverability within hypopharynx obstructs view of target Solution: straight-to-cuff shape; angle <35
25 Tube shape
26 Tube delivery issues
27 1. Can t get tube to glottis
28 Tips Use right corner of mouth Insert tube behind maxilla Come from below: avoid line of sight Use bougie for epiglottis-only view
29 2. Tube won t pass
30
31 2. Tube won t thread off bougie
32
33 Video laryngoscopes 2 blade styles: hyperangulated shape: Glidescope Macintosh shape: eg C-MAC, Glidescope direct blade
34 Glidescope: common issues Great view - can t intubate! Poor view with blood/secretions
35 Solutions Use GlideRite stylet (70 ) Must have glottis in top half of screen: often need to back up scope Insert tube in midline, direct vision until can t see tip Hold tube at end, not as a pencil After passing through cords, pop stylet up Any resistance: turn tube clockwise Remove stylet (towards feet) before passing tube
36
37 Questions?
38 References Gerstein NS, Carey MC, Braude DA, Tawil I, Petersen TR, Deriy L, et al. Efficacy of facemask ventilation techniques in novice providers. Journal of Clinical Anesthesia May;25(3):193 7 Collins JS, Lemmens HJM, Brodsky JB, Brock-Utne JG, Levitan RM. Laryngoscopy and morbid obesity: a comparison of the "sniff" and ramped positions. Obes Surg Oct;14(9): Weingart SD, Levitan RM. Preoxygenation and prevention of desaturation during emergency airway management. Ann Emerg Med Mar;59(3): e1 Ramachandran SK, Cosnowski A, Shanks A, Turner CR. Apneic oxygenation during prolonged laryngoscopy in obese patients: a randomized, controlled trial of nasal oxygen administration. Journal of Clinical Anesthesia. Elsevier; 2010 May; 22(3): Fu ES, M.D., Downs, John B,M.D., F.C.C.P., Schweiger, John W,M.D., F.C.C.P., Miguel RV, M.D., Smith, Robert A,PhD., R.R.T. Supplemental Oxygen Impairs Detection of Hypoventilation by Pulse Oximetry*. Chest ;126(5):
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