DON T PRACTICE UNTIL YOU GET IT RIGHT. PRACTICE UNTIL YOU CAN T GET IT WRONG.

Transcription

1 ADVANCED AIRWAY MANAGEMENT AND THE DIFFICULT AIRWAY DON T PRACTICE UNTIL YOU GET IT RIGHT. PRACTICE UNTIL YOU CAN T GET IT WRONG. The Decision to Intubate n Can the patient protect their airway? n Can the patient adequately ventilate / oxygenate? n What do you expect to happen? Evaluate the patient Deciding to Intubate n If you must establish an airway, you must protect that airway. n Do not rely on the gag reflex. n Swelling or progressive distortion only gets worse, intubate early. n ABG s are not helpful. Airway Algorithm n Is this a crash airway? n Is this a difficult airway? n Was intubation successful? n Oxygenation n Ventilation n 3 attempts MANTA2006 1

2 MANTA2006 MANTA2006 Difficult Airway MANTA2006 n Is there time? n Ability to ventilate or intubate n Can you proceed with RSI? *not a contraindication n Evaluate anatomic landmarks n Evaluate patient position Failed Airway Can t Intubate Can t Ventilate CICV Airway n Unable to oxygenate n Oxygen saturations drop below 90% n 3 failed attempts n Attempt = entering larynx Immediate rescue airway Cricothyroidotomy 2

3 Rapid Sequence Intubation n The purpose of RSI is to render the patient unconscious and paralyzed and then to intubate the trachea without the use of bag ventilation. Ron Walls Rapid Sequence Intubation RSI can be used over 80 percent of the time. 97 percent of all patients can be successfully intubated within 2 attempts. 1 percent require cricothyrotomy. Rapid Sequence Intubation n Assume they have a full stomach. n Minimize bagging. n NO titration of medications or slow push. Rapid Sequence Intubation n Preparation n Preoxygenation n Pretreatment n Paralysis with Induction n Protection and Positioning n Placement with Proof n Postintubation Management Check Every Patient for a potentially Difficult Airway n Difficult Ventilation- inability of trained provider to maintain O2 saturation >90% using face mask ventilation n Difficult Intubation- need for >3 intubation attempts or attempts at intubation lasting > 10 minutes Preparation n Assess for difficult airway L-look externally E-evaluate landmarks/3-3-2 M-Mallampati O-obstruction N-neck mobility S-aturations n Assemble equipment n Fallback plan and equipment immediately available 3

4 MALLAMPATI SCALE n Mouth opening < 3 fingers n Hyoid-mentum distance <3 fingers n Thyroid to floor of mouth distance <2 fingers n Score 3 or 4 HEAVEN n Hypoxemia n Extremes of size n Anatomic disruption/obstruction n Vomit/blood/fluid in airway n Exsanguination n Neck mobility HEAVEN vs LEMONS What is the difference? n HEAVEN is a prescreening tool that is used to determine difficult resuscitation/intubation n LEMONS is a prescreening tool to determine difficult direct laryngoscopy n Anticipation vs reality Which option to use? BOTH The combination of both LEMONS and HEAVEN will help determine the difficulty of intubation and resuscitation Non-Invasive Airway Monitoring n Capnography (ETCO2) Quantitative & Waveform Qualitative n Why is waveform better than colormetric? n What is normal? n Measurement of Ventilation, NOT Oxygenation 4

5 Not Every Patient In Distress Needs Intubation n Is there failure to maintain or protect the airway? n Is there failure of oxygenation and ventilation? n Is there a need for intubation based on the anticipated clinical course? Don t Forget there is a Patient Attached to that Airway n It is easy to lose track of the rest of the patient while dealing with an airway emergency Don t skimp on Pre-oxygenation PREPERATION Apneic Oxygenation n Pre intubation using NC at 15-25lpm Completely washes out nitrogen from the lungs (replacing it with 100% oxygen) helping to recruit alveoli for maximum oxygen absorption Preoxygenation n Essential to the no bagging principle n Establish an oxygen reservoir 8 full deep breaths on 100% in 60 seconds Alternative -8 vital capacity breaths with BVM Preoxygenation n BVM only if necessary SpO2 =/>94% no need to assist SpO2 < 90%, assist ventilations SpO2 <93% limit intubations attempts to 20 seconds 5

6 The Lost Art n The Original Airway n Essential to airway management n Basic principle is oxygen AIRWAY ASSESSMENT n ROMAN- Difficult bag-valve-mask ventilation Radiation/restriction Resistance to ventilate, COPD, ARDS, Term Pregnant Obesity/Obstruction BMI over 26 Mask seal, male sex, mallampati Bushy beards, male faces, Mallampati 3-4 Aged face No teeth Greater than 55 less than 3 Bag Mask Ventilation Bag Mask Ventilation n Standard bag holds 1500 cc oxygen. n Standard ventilation volumes of 500cc ventilation rate or breaths per minute. n Use Sellick s maneuver while bagging? n Adequate seal n Patent airway jaw thrust oral airway nasal airway BVM on face with oral / nasal airways Bag Mask Ventilation n Two hand mask hold most effective for BMV Two thumbs up method Seated Ventilation n Two thumbs up method with patient head turned to the side n Second rescuer providing either small volume or large volume ventilations n Attach ETCO2 device with BVM n Minimizes aspiration based on gastric bubble inches lower than glottis n Easier with atelectasis and airway pressures required to maintain adequate tidal volumes 6

7 PREOXYGENATION n Patients in whom intubation was attempted with SpO2 values above 93%, desaturations occurred only 6% after 7 minutes n Patients in whom intubation was attempted with SpO2 values below 93%, desaturations were inevitable Normal 70 kg Adult Sick 70 kg Adult Child 10 kg Obese 127 kg adult From Benumof J, Dagg R, Benumof R. Critical desaturation will occur before return to an unparalyzed state following 1mg/kg IV succinylcholine. Anesthesiology 1997;87:979. Communication and Teamwork are Essential n The key factor that makes problem solving and crisis management successful or not is communication and teamwork Clear leadership Stay calm n Is the patient being ventilated? n Do you have enough help? n Verbalize your thoughts Communication and Teamwork n Two-Challenge Rule If first verbal observation of a problem is not acknowledged or acted upon, challenge again. If the safety issue persists, become more assertive. C- I am Concerned about U- I am Unconfortable because... S- This is a Safety issue... Communication and Teamwork It is difficult to challenge someone in authority Airline Industry recognized and implemented industry wide changes and training. If a co-pilot facing personal death in an airplane crash, can t question the pilot, how is for a nurse to challenge a doctor? Communication and Teamwork n Leaders in a critical event need to be open to feedback and suggestions. n Foster clinical environment in which all staff feels empowered to speak up. n See something, Say something. 7

8 GOALS n Pretreatment n Induction Agents n Paralytics n Topical Agents Things to Consider n Drugs and side effects n Co-morbid conditions n Pathophysiologic reflexes n Increased intracranial pressure Pretreatment n Administration of drugs to minimize the adverse effects of intubation L-Lidocaine O-Opiates A-Atropine D-Defasciculating dose Lidocaine n Blunts cough reflex n Prevents rise in intracranial pressure n? Reactive airway disease Lidocaine n Sodium channel blockade decreases cerebral metabolism, stabilizes cell membranes neuroprotective. n Reduces cardiomyopathic dysrhythmias by up to 50% - cardioprotective. n Decreases intraocular pressure. Fentanyl n Decreases sympathetic response n Decreases myocardial oxygen consumption n Provides analgesia and sedation 8

9 Atropine n Indicated for every child under 1yr old. n Indicated for every child under 10 yr old receiving succinylcholine. n Indicated for every adolescent or adult getting repeat doses of succinylcholine. Non-Depolarizing Paralytic n Defasciculating dose 1/10 dose of competitive paralytic. For use with succinylcholine. Suppresses ICP response of succinylcholine. Paralysis with Induction Drugs n Use rapid acting agents Quick onset Duration of action Side effects DO NOT TITRATE Induction Agents Etomidate Ketamine Propofol Barbiturates Benzodiazepines n Paralytics Depolarizing Agents Non-Depolarizing Agents Etomidate Ketamine n Induction agent of choice n Rapid action n Short duration n Lack of cardiodepressant side effects n Cerebroprotective Induction agent of choice for bronchospasm Quick onset Short duration High potency 9

10 Propofol n Onset: less than 1 minute n Duration: Rapidly metabolized within 10 minutes n MOA: highly lipophyllic sedativehypnotic n Decreases ICP n Anticonvulsant Midazolam Depolarizing Paralytics Succinylcholine n Unparalleled amnesia n Onset of action 3-5 minutes n Variable dose n No role for induction n Valuable for post intubation sedation n Onset: seconds n Duration: 5-12 minutes n MOA: depolarizing paralytic, binds to ACH receptors Succinylcholine Contraindications Nondepolarizing Paralytics Burns over ten percent BSA: 48 hours to 6 months Paralysis: 3 days to 6 months Denervation syndrome: Until inactive for 6 months Crush Injury: 3 days to 6 months Abdominal Sepsis: Longer than 3 days Hereditary myopathies Renal Failure?(avoid with elevated potassium) Longer onset / long acting Newer agents have rapid onset Do not require defasciculation 10

11 Rocuronium Cis-atracurium n Onset: sec n Duration: minutes n Dose: mg/kg n Drug of choice in kids, if succinylcholine is contraindicated Onset: 2 minutes Duration: minutes Dose: mg/kg Vecuronium n Onset 2-3 minutes n Duration: minutes n Dose mg/kg High doses have quicker action-0.3 mg/kg Useful as defasciculating agent Nondepolarizing Neuromuscular blockade Reversal Atropine PLUS blunts muscarinic response Neostigmine / Edrophonium duration of action min Sugammadex-rapid reversal agent Topical Agents n Lidocaine n Cocaine n Neosynephrine Position is Critical Protection and Position n? Sellick s maneuver n? Sniffing position n Head Up n C-Spine precautions 11

12 HEADS UP n 50% lung volume is lost lying flat n Preoxygenation with 20 degree headup tilt provides longer duration of non-hypoxic apnea than conventional preoxygenation in non-obese healthy adult Position n Ear at the sternal notch Flexion Neutral Extension 12

13 Jaw Thrust Tongue Traction Head Elevated Position Sellick s Maneuver Protection and Position n Sellick s n BURP - Backward, Upward, Rightward Pressure n ELM - External Laryngeal Manipulation Flexion Neutral Extension 13

14 ELM ENDOTRACHEAL INTUBATION n External manipulation by the laryngoscopist. n Improves POGO scores 57%. n Preferred method for airway management n Protect against aspiration INDICATIONS Equipment needed n Failure to protect or maintain airway n Failure to Oxygenate or Ventilate n Anticipated clinical course Contraindicated when patient is managing a patent airway without clinical indication to provide advanced airway management n Oxygen n BVM n Suction n BLS Airways n ET Tubes/stylets n Syringe n Bougie n Magil Forceps n Laryngoscope/blad es n Video Laryngoscope n Back up airways n Monitoring devices n Confirmation devices n Stabilization device Blade choices Curved Blades n Personal preference n Use it as it was designed n Bigger blades control bigger tongues n Miller n Macintosh n Designed to be placed in the vallecula can be used as a straight blade 14

15 Straight Blades n Designed to pick up the epiglottis n Thinner blade design n Less tongue control Technique n Grip avoid the death grip use fingers for precision movements use shoulder for leverage lift toward the ceiling over patient s feet Straight tube 90 degree hook 30 degree bend Tube Angle Bougie Endotracheal Tube Exchanger/introducer Landmarks n Tongue is your enemy n Epiglottis is your friend n Cords are the goal 15

16 Open Mouth Tongue Sweep SALAD Suction Assisted Laryngoscopy Airway Decontamination n Developed by Dr. James DuCanto n Constant upper airway suction n After clearing contaminant from the airway, the catheter can be left in place, to the left of the laryngoscope blade continuously removing blood, vomit and other materials. The practitioner can intubate, with the catheter in place via either direct or video laryngoscopy. Video Laryngoscopy What have we learned? n SUCTION!! n Walk the blade down the mouth n Insert midline or slightly left of center n When you see the uvula, lift to expose the airway n Slide stylet out slightly 16

17 Don t rely on Video Laryngoscopy to save the day n First pass success rate with GlideScope reported 80-90% and ultimate success rate of 98%. n BUT, VL can fail. and if difficult-toventilate patient, first pass success is critical. Patient characteristics associated with first-pass failure using VL include: n Morbid obesity n Blood/ emesis in the airway n Airway edema n Mass n Restricted neck motion n Limited mouth opening n Surgery/radiation Failure of VL can be related to technique ETT Tip in Correct Plane of Larynx n Look at the Patient Until the ETT Tip Appears on the Monitor n A More Neutral Head Position Helps n Don t Insert the Blade Too Deep n Don t Insert the ETT Too Posteriorly n Don t Forget to Lift the Blade and Jaw Upward n May Need Cricoid Pressure ETT too deep Optimal Positioning If the ETT can t make the turn into the larynx, too deep/posterior of pharnyx ETT bottom of monitor ETT middle/upper right There Is No Situation So Bad That You Can t Make Worse n When do you stop if something s not working? Change technique Change equipment Change people Two-Challenge Rule 17

18 Supraglottic Devices n Do not provide a definitive airway. n Rescue devices. n Can be as effective as intubation. n Can be used in failed airways provided cricothyrotomy is being set up. Supraglottic Devices n Laryngeal Mask Airway (LMA) n Intubating LMA n King LT n Combitube Laryngeal Mask Airway Intubating LMA n Single lumen mask airway device. n Covers glottic opening and allows ventilation. n Laryngeal Mask Airway with intubation port. n Allows placement of cuffed tracheal tube. Combitube King LT n Dual Lumen rescue airway device. n Two inflation ports. n Ventilation aperture between balloons and distal tip. n Distal cuff does not block esophagus. n Single lumen airway device. n Double balloon has one inflation port. n Ventilation apertures between the balloons. n Distal cuffs blocks esophagus. 18

19 King LT IGEL PLAN FOR THE END IN THE BEGINNING n Preparation Have everything ready for the worst. n Dentures Leave them in while bagging, take them out to intubate. n Lubrication n External laryngeal manipulation Master it and use it. Postintubation Management n Bradycardia is due to esophageal intubation and hypoxemia until proven otherwise n Confirm with ETCO2/SpO2/Auscultation/PCXR n Secure ETT n Sedation n Paralysis n NGT/OGT Placement with Proof n USE A STYLET n Take your time n Visualization n Utilize detection methods ETT detector O2 saturation Waveform Capnography Physical exam -not reliable 19

20 Postintubation Management n Monitor tube depth Pediatric airway - use collar n Reassess tube after moving patient or any clinical change n Ventilator management / Bagging Summary n Consider specific measures to improve oxygenation and first time success n Predict the updated pneumonic on difficult airway assessment HEAVEN n Implement two thumbs up method, HOB elevated, High Flow NC, PEEP, and ETCO2 to airway management SUMMARY n Videoscopic intubation requires finesse than muscle n When in doubt, go back to the basics n Proper assessment and suctioning of airway will help prevent failure n First pass success vs desaturation are both equally important 20