Basic Emergency Airway Management Pat Melanson,MD

1. Basic Emergency Airway ManagementPat Melanson,MD

2. Objectives • Differentiate the Emergency Airway from elective intubation in the OR • Assessment of airway compromise • Indications for airway intervention • Recognition of the difficult airway • Bag-Mask Techniques • Laryngoscopy

3. Emergency Airway Management : Unique Considerations • Full stomach - high aspiration risk • Altered level of consciousness • Deteriorating cardiorespiratory physiology - (hypotension, hypoxia) • Abnormal or distorted upper airway anatomy • No time for “pre-op” assessment

4. Airway Assessment • Assessment for airway compromise or threats and need for interventions • Examination for the potentially difficult airway

5. The Three Pillars of Airway Management: ( Assessment of Compromises or Threats ) • Patency of Upper Airway • ( airflow integrity ) • Protection against aspiration • Assurance of oxygenation and ventilation

6. Indications for Active Airway Intervention: including intubation • Failure to maintain patency • Protection from aspiration • Hypoxic/ hypercapnic respiratory failure • Airway access for pulmonary toilet, drug delivery,therapeutic hyperventilation • Intractable Shock • Anticipated clinical deterioration

7. Indications for Intubation • Is there failure of airway maintenance ? • Is there failure of airway protection ? • Is there failure of oxygenation or ventilation? • What is the anticipated clinical course ? (i.e., expected deterioration, long transport, long time in radiology, etc.)

8. Clinical Signs of Airway Compromise : Threatened Patency • Inspiratory stridor • Snoring ( pharyngeal obstruction ) • Gurgling ( blood/ secretions ) • Drooling ( epiglottitis ) • Hoarseness ( laryngeal edema/ vocal cord paralysis) • Paradoxical chest wall movement • Tracheal tug • Mass - abscess, hematoma, angioedema

9. Clinical Signs of Airway Compromise: Inadequate Protection • Blood in upper airway • Pus in upper airway • Persistent vomiting • Loss of protective airway reflexes • swallowing reflex is superior to gag reflex

10. Clinical Signs of Airway Compromise:Oxygenation and Ventilation • Central cyanosis • Obtundation and diaphoresis • Rapid shallow respirations • Accessory muscle use • Retractions • Abdominal paradox

11. Clinical Signs of Airway Compromise:Oxygenation and Ventilation • The assessment of oxygenation and ventilation is a clinical one. • Arterial blood gases should not be relied upon to assess whether intubation is necessary.

12. Techniques for the Compromised Airway • Head Positioning • Jaw Thrust, Chin lift • Orophryngeal/ Nasopharyngeal airways • Bag-Valve-Mask Ventilation • Endotracheal Intubation • Advanced techniques • Cric, LMA, Combitube, Retrograde, Fibreoptic, Light wand, Bouge

13. The Difficult Airway • Difficult Laryngoscopy • poor visualization of cords • Difficult bag-mask ventilation • unable to oxygenate or ventilate • Lower airway difficulty • severe bronchospasm

14. Golden Rules of Bagging • “ Anybody ( almost ) can be oxygenated and ventilated with a bag and a mask “ • The art of bagging should be mastered before the art of intubation • Manual ventilation skill with proper equipment is a fundamental premise of advanced airway Rx

15. BVM Ventilation • The most important airway skill • Always the first response to inadequate oxygenation and ventilation • The first “bail-out” maneuver to a failed intubation attempt • Attenuates the urgency to intubate • Do not abandon bagging unless it is impossible with two people and both an OP and NP airway

16. BVM Ventilation • Requires practice to master • One hand to • maintain face seal • position head • maintain patency • Other hand ventilates

17. BVM Ventilation: Technique • Insert oropharyngeal/nasopharyngeal • “Sniffing”position if C-spine OK • Thumb + index to maintain face seal • Middle finger under mandibular symphysis • Ring/little finger under angle of mandible • Maintain jaw thrust/mouth open

18. Predictors of a Difficult Airway : BVM • Upper airway obstruction • Lack of dentures • Beard • Midfacial smash • Facial burns, dressings, scarring • Poor lung mechanics • resistance or compliance

19. Difficult Airway : BVM • degree of difficulty from zero to infinite • Zero = no external effort or internal device required • one person jaw thrust/ face seal • oropharyngeal or nasopharyngeal AW • two person jaw thrust / face seal • both internal airway devices • Infinite = no patency despite maximal external effort and full use of OP/NP

20. Algorithm for Difficulty “Bagging” • Remove Foreign Bodies - Magill forceps • Triple maneuver if c-spine clear • Head tilt, jaw lift, mouth opening • Nasal or oropharyngeal airways • Two-person, four-hand technique

21. BVM Ventilation: Mask Seal Tips and Pearls • Easier to get seals with masks too large than too small • Inflate mask collar correctly • Apply lubricant to beards to “mat down” hair • If edentulous insert gauze sponges into cheeks

22. Prediction of the Difficult Airway: Laryngoscopy • History of past airway problems • check previous OR anesthesia records if time permits • cricothyroidotomy scar • Careful physical assessment • mouth opening • tongue to pharyngeal size • hyo-mental distance • Neck flexion, Head extension

23. Technique of Laryngoscopy • “Sniffing” position to align oral-pharyngeal-laryngeal axis • Flex neck by placing pillow beneath occiput ( raise 10 cm ) • Extend head maximally • With laryngoscope • open mouth fully • push tongue to left out of view • pull upward at 45 degrees

24. Adducted vocal cords

26. Predictors of Difficult Laryngoscopy • Short thick neck • Receding mandible • Buck teeth • Poor mandibular mobility/ limited jaw opening • Limited head and neck movement • ( including trauma )

27. Difficult Airway : Laryngoscopy • Tumor, abscess or hematoma • Burns • Angioneurotic edema • Blunt or penetrating trauma • Rheumatoid arthritis, ankylosing spondylitis • Congenital syndromes • Neck surgery or radiation

28. Predictors of Difficult Laryngoscopy • 3 fingerbreadths mentum to hyoid • 3 fb chin to thyroid notch • 3 fb upper to lower incisors • Head extension and neck flexion • Mallimpadi classification • Previous history of difficult intubation

29. Mallimpadi Classification (Tongue to Pharyngeal Size) • I - soft palate, uvula, tonsillar pillars visible • 99 % have grade I laryngoscopic view • II - soft palate, uvula visible • III - soft palate, base of uvula • IV - soft palate not visible • 100% grade III or grade IV views

30. The 4 D’s of Difficult Intubation • Distortion • ( edema, blood, vomitus, tumor, infection) • Dysmobility of joints • ( TMJ, alanto-occipital, C-spine) • Disproportion • thyomental, Mallimpadi, etc • Dentition • prominent upper teeth

31. Unsuccessful Intubation • Bag the patient • Maximize neck flex/ head ex • Move tongue out of line of site • Maximize mouth opening • ID landmarks and adjust blade • BURP maneuver (Backwards Upwards Rightwards Pressure on Thyroid Cart.) • Increasing lifting force • Consider Miller blade • Bag the patient