Airway Dr Albert Buchel MD CCFP EM CAC EM. Assistant Professor, Department of emergency medicine Program Director CCFP EM residency University of Manitoba
CONFLICT OF INTEREST NONE
AIRWAY TIPS PASSING THE TUBE IS NOT THE ONLY HARD PART!!
I CAN NOT Teach you to intubate Teach you to identify a difficult airway* Teach you to perform a tracheostomy Teach you about alternative devices such as supra-glottic and rescue devices
ASSUMPTIONS 1. you have basic knowledge of airway assessment and control 2. you have and will likely encounter an emergent or crash intubation 3. intubation will be done via RSI technique or crash intubation
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goals 1 Review intubating success rates 2 Define intubation success and difficult airways** 3 Discuss the basics in improving first pass success** 4 Plug for video laryngoscopy** 5 Discuss physiologically difficult airway** Radical evolution: the 2015 Difficult Airway Society guidelines for managing unanticipated difficult or failed tracheal intubation. Marshall SD 1,2, Pandit JJ 3, 4 Anaesthesia. 2016 Feb;71(2):131-7. doi: 10.1111/anae.13354. Epub 2015 Dec 16
Take-Home Points two of them optimize first pass success do not kill a patient by obtaining an airway- address their physiologic state
Intubation Success 20% defined as difficult airway 3% required a second method 3% to 5% required a second operator 1% failed DEFINED AS: excessive force required poor view multiple attempts multiple operators multiple devices UTD 1/5000-1/10000 can t intubate can t Ventilate
POINT #1 ALL AIRWAYS SHOULD BE CONSIDERED DIFFICULT IN ORDER TO MAXIMIXE FIRST PASS SUCCESS ****. all practitioners consider the possibility of a difficult airway in every encounter, and plan actively
Preoxygenation Positioning Video laryngoscopy+-
Pre-oygenation Apneic Diffusion Oxygenation Transnasal Humidied Rapid Insufation Ventilatory Exchange (THRIVE )
Tip 1- improved first pass Apneic Diffusion Oxygenation nasal cannula or an O2 catheter with Up to 15 L o2 in the oropharynx/nasal ( as well as the facemask) significant reduction in incidence of desaturation (SpO2 <93 95%) Significant reduction in incidence of critical desaturation (SpO2 <80%) Can provide up to 10 min of apneic oxygenation! Significant improvement in first pass intubation success rate
Positioning the need to reposition a patient in whom there has been a failed or difficult intubation is an admission of poor planning from the outset
Position number 1 Patients Position SNIFFING
From Benumof JL: Conventional (laryngoscopic) orotracheal and nasotracheal intubation (single lumen type). In Benumof JL (ed): Clinical Procedures in Anesthesia and Intensive Care. Philadelphia JB Lippincott Co, 1992, p 123
Tip 2-improved first pass Dynamic Positioning Do not anchor on a static position
Position number 2 Tip 3 improved first pass Tracheal position CRICOID PRESSURE BURP(backward-upward-rightward pressure) BIMANUAL/ EXTERNAL LARYNGEAL MANIPULATION LARYNGEAL VIEW DURING LARYNGOSCOPY: A RANDOMIZED TRIAL COMPARING CRICOID PRESSURE, BACKWARD-UPWARD- RIGHTWARD PRESSURE, AND BIMANUAL LARYNGOSCOPY Levitan, R.M., et al, Ann Emerg Med 27(6):548, June 2006
Tip 4 --maybe Video larnyngoscopy CMAC GLIDESCOPE 90 % first pass 97% beyond pgy1 1 st operator Direct Laryngoscopy 80 % First pass 97% beyond PYY1 1 st operator 83% First Pass 97% 1 st operator
Intubation Success Part Two PHYSIOLOGICALLY DIFFICULT AIRWAY 25% become hypotensive 3% of hypotensive patients have full cardiac arrest NEAR III (national emergency airway registry)
The Physiologically Difficult 1 2 Hypoxia pre intubation Hypotension: Airway intravascularly depleted, shock index >.8 1 Right ventricular failure: Right MI 1 Severe metabolic acidosis Mosier, J.M., et al, West J Emerg 2015 THE PHYSIOLOGICALLY DIFFICULT AIRWAY Med 16(7):1109, December
medications cause hypotension/hypoxia positive pressure ventilation decreases venous return PEEP increases right heart out flow pressures
What To Do?
STATE 1 ---------Hypoxia
Hypoxia STATE 2 AND 3 Hypotension / Right ventricular failure Assess volume status using IVC ultra sound(controversial) Volume reponders: IV fluid bolus Tip 5 Volume NON responders / pre arrest : Push dose pressors: epinephrine 5-20 mcg iv Take a 10 ml syringe with 9 ml of normal saline Into this syringe, draw up 1 ml of epinephrine from the car-diac amp (Cardiac amp contains Epinephrine 100 mcg/ml) 10 mls of Epinephrine 10 mcg/ml Onset-1 minute Duration-5-10 minutes Dose-0.5-2 ml every 2-5 minutes (5-20 mcg) Weingart August 2017 Emcrit podcast (#205), for information,dosing to be checked with local pharmacy
Hypoxia Hypotension / Right ventricular failure Assess volume status using IVC ultra sound (controversial) Volume reponders: IV fluid bolus Volume NON responders / pre arrest : Push dose pressors: epinephrine 5-20 mcg lowest dose of induction agent STATE 4. Metabolic acidosis: delayed sequence intubation(just ventilate)
Summary Make sure the patient needs to be intubated Assume all airways are difficult and optimize 1 st pass success Optimize positioning of both physician and patient Sniff position Active head manipulation External larangeal manipulation Consider video laryngoscopy Optimize intubation outcome by optimizing difficult physiological states prior to or during incubation: Passive apneic diffusion oxygenation Fluids Push dose pressors
THE PHYSIOLOGICALLY DIFFICULT AIRWAY Mosier, J.M., et al, West J Emerg Med 16(7):1109, December 2015 Radical evolution: the 2015 Difficult Airway Society guidelines for managing unanticipated difficult or failed tracheal intubation.marshall SD 1,2, Pandit JJ 3 4 Anaesthesia. 2016 Feb;71(2):131-7. doi: 10.1111/anae.13354. Epub 2015 Dec 16 Pavlov I et al. Apneic Oxygenation Reduces the Incidence of Hypoxemia During Emergency Intubation: A systematic Review and Meta-Analysis. Am J Emerg Med 2017; [Epub Ahead of Print] PMID: 28647137 Binks MJ et al. Apneic Oxygenation During Intubation in the Emergency Department and During Retrieval: A Systematic Review and Meta-Analysis. Am J Emerg Med 2017; S0735 6757 (17): 30497. PMID: 28684195 Oliveira L et al. Effectiveness of Apneic Oxygenation During Intubation: A systematic Review and Meta-Analysis. Ann Emerg Med 2017 [epub ahead of print www.uptodate.com Approach to the difficult airway in adults outside the operating room www.uptodate.com Devices for difficult airway management outside the or]