OWN THE AIRWAY Airway Management Bruce Barry, RN, CEN, CPEN, TCRN, NRP
The largest detriment to airway management has nothing to do with the patient, but everything to do with you as a provider. PRACTICE..PRACTICE.PRACTICE.
Context Confidence / Competence Conscientiousness GOOD AIRWAY MANAGEMENT
STAY CALM!! Physiologic changes Effect your abilities
Performance White 75 Yellow 115 RED 145 Gray 175 Black Heart Rate
THE BASICS Almost every assessment we ve ever learned starts with Airway. Is the patient maintaining their own? Adequately? Do I need to provide intervention? Which should we choose? Do I have the skills and ability? The key to good ALS is good BLS.
GOOD BLS Simple positioning Suctioning Bag Valve Mask BLS Airway Adjuncts OPEN-ASSESS-SUCTION-SECURE
BLS TREATMENTS Positioning Ear-Sternal Notch Head elevated Sniffing position
ANTICIPATING DIFFICULTY Identifying patients that may be difficult to manage airway by BLS measures M- Mask seal O- Obesity/ Obstruction A- Age (over 55) N- No Teeth S- Stiffness (neck)
ROUTINES = OR +
THINK OUTSIDE THE BOX.
NEWER BLS ADJUNCTS NuMask Intra Oral Mask S.A.L.T. Airway (Supraglotic Airway Laryngopharyngeal Tube)
NUMASK INTRAORAL MASK
S.A.L.T.
J.A.W.S. Jaw Displacement Airway Adjuncts Work Together Slow Small Squeezes
HYPOXIC Difficulty Breathing / Short of Breath Airway or ventilation issue Airways NIV/PPV Medications Hypoxic Oxygenation issue Oxygen Medications OR BREATHLESS BOTH??
OXYGENATION Nasal Cannula (NC) Vs. Non-Rebreather (NRB) Over-oxygenate? YES- Hyperoxemia Vasoconstriction Oxidation free radicals
SOMETIMES YOU NEED MORE Recognition No Number Sounds BVM Tones Count Down
NON-INVASIVE VENTILATION CPAP BiPAP High Pressure Nasal Cannula
Increase alveolar distention Increasing the O2-CO2 exchange zone Increases Oxygen diffusion pressure Forces Interstitial Fluids out (CHF) Splints airways open (COPD/Asthma) Increases Intrathorasic pressure Decreases Preload & Afterload NON-INVASIVE VENTILATION
NON-INVASIVE VENTILATION CPAP Continuous Positive Airway Pressures Effective Cheap Reduces intubation BiPAP Bi-level Positive Airway Pressure More Effective Expensive Reduces intubation
High Flow Nasal Cannula Blender Up to 60Lpm Humidified NON-INVASIVE VENTILATION
SELL IT!!!
Boussignac DISPOSABLE CPAP O2- RESQ OxyPeep Flow Safe CPAP
MECHANICAL CPAP Whisperflow Ventilators w/ CPAP Vital Signs PortO2 CPAP
Blindly inserted 2 tubes in 1 Esophageal vs. Tracheal intubation DUAL LUMEN AIRWAYS
Combitube DLA s PtL Airway EasyTube
EXTRAGLOTTIC AIRWAYS King LT Blindly inserted Different sizes One valve blows up 2 cuffs Only one tube to ventilate thru
KING VS. EOA
Laryngeal Mask Airway (LMA) Blindly inserted Multiple sizes based on weight One valve to inflate One tube to ventilate thru
Improper device placement Pneumothorax Hypotension Gastric distention COMPLICATIONS OF AIRWAY MANAGEMENT
DEVICE OVERLOAD YET?
CLEARING DEVICE CONFUSION With Time Laryngoscopy Without Time Blind Insertion Airway Devices
1. Witness correct insertion placement 2. Watch chest rise and fall 3. Listen to epigastrum / lungs 4. Capnography CONFIRMATION OF AIRWAY
Measures Ventilations- rate and quality End-Tidal CO2 levels Cellular level perfusion Determinants of ETCO2: alveolar ventilation pulmonary perfusion (cardiac output) CO2 production (metabolism). CAPNOGRAPHY
WAVEFORMS A-B is post inspiration/dead space exhalation B is the start of alveolar exchange B-C is the exhalation upstroke where dead space gas mixes with lung gas C-D is the continuation of exhalation, or the plateau(all the gas is alveolar now, rich in C02) D is the end-tidal value the peak concentration D-E is the inspiration washout.
NORMAL Normal capnogram Gradual upslope and the alveolar plateau.
ABNORMAL WAVEFORMS Hyperventilation/ Tachypnea Causes- hyperventilation, anxiety, overzealous bagging
ABNORMAL WAVEFORMS Apnea- Loss of waveform= no CO2 Instantaneous recognition Cause- Dislodged ET tube, total obstruction of ETT, Respiratory arrest, equipment malfunction (treat the patient)
ABNORMAL WAVEFORMS Loss of Alveolar Plateau- incomplete or obstructed exhalation. Shark fin pattern. Causes- Asthma, COPD, Allergic reactions, Incomplete airway obstruction, ETT kinked or mucus obstruction
TROUBLESHOOTING What to do if you re not registering any CO2. Check your patient!!! Apnea Check your equipment. Improper tube placement Tube obstruction Tube dislodgement
Loss of circulatory function Massive Pulmonary Embolism Cardiac Arrest Exsanguination (extensive loss of blood) OTHER PROBLEMS WITH CAPNOGRAPHY
CAPNOGRAPHY Qualifies ventilation and perfusion. Shows immediate physiologic changes. Maintaining as close to normal values correlates to better patient outcome.
BACK TO AIRWAY
Performance Over-learning SKILL ATROPHY IS REAL! Time
AIRWAY KATA S Go thru the motions Fixed Action Patterns Muscle Memory
THANK YOU Bruce Barry, RN, BSN, CEN, CPEN, TCRN, NRP bbarry@ech.org peakparamedicine@gmail.com 518-873-3022 518-524-0050