Airway management in the prehospital setting

1. Airway management in the prehospital setting Dr X.Combes, SAMU du Val de Marne, Créteil, France

2. Airway management in the prehospital setting Dr X.Combes, SAMU du Val de Marne, Créteil, France

3. Why airway control is mandatory out of hospital? • Airway protection • Coma • Sedation • Respiratory assistance with positive pressure ventilation • Respiratory distress • Cardiopulmonary rescucitation • Limitation or prevention of evolutive injury : • severe head traumatism Winchell Rj et col; Arch Surg 1997 Gentleman D et col; Lancet 1990

4. Indications for prehospital tracheal intubation Jabre P, SFAR 2003 Adnet F,Ann Emerg 1998 Ricard-Hibon A, Eur J Anaesthesiology 2002

5. Characteristics of extrahospital airway management • Emergency context • Hostile environnment • Non cooperative patients • Poor knowledge of medical patients history • Not much time to upper airway evaluation • Risk of pulmonary aspiration • Interaction between patient and operator body position

6. Potential adverse physical interaction between patient and operator

7. Medical conditions and anatomical abnormalities may induce difficult laryngeal visualization.....

8. 100 80 60 failure 40 success 20 0 Incidence of failed prehospital intubation 100 80 60 Intubations (%) 40 20 0 a b c d e f g h i j k l a : Stewart 1994 (n = 779) b :Pointer 1988 (n = 383) c : Krisanda 1992 (n = 278) d : Sayre 1998 (n = 103) e : Hedges 1988 (n = 310) f : Thompson 1994 (n = 862) g : Cantineau 1997 (224) h : Adnet 1998 (n = 691) i : Orliaguet 1997 (n = 157) j : Adnet 1997 (n = 394) k : Ricard-Hibon 1997 (n = 147) l : Adnet 1997 (n = 311)

9. Influence of the sedation technique on intubation difficulties Adnet F; Eur J Emerg Med 1998

10. Effect of a RSI protocol introduction in a medical prehospital unit Ricard-Hibon A et col; Eur J Anaesthesiol. 2002

11. 100 * Without RSI 80 (n=100) 60 Successful intubations 40 With RSI 20 (n=100) 0 RSI helps Paramedics too… • Extrahospital paramedic heliported unit • Introduction of a RSI protocol in daily practice • Assessment of successful tracheal intubation Rose WD; Air Med J. 1994

12. Orotracheal or Nasotracheal intubation? Dronen SC et col;Ann. Emerg Med 1987 

13. Influence of operator position when patient is lying on the ground Adnet F, Can J Anaesth 1998

14. BURP backward, upward, rightward laryngeal pressure 60% Cormack III => II BURP > BACK Knill R; Can J Anaesth 1993

15. Bougie and stylet • First use in 1943 by Macintosh • Successful blind tracheal intubation confirmed by tactile sensation • Helpful for patient with cervical immobilisation • Standard of practice in US emergency dpt • Rigid with little flexibility • Potentially traumatic for larynx and trachea

16. Success rates of GEB and Stylet assisted intubation in Cormack grade 3 patients * * Gataure PS; Anaesthesia 1996

17. Use of Gum Elastic Bougie for Prehospital Difficult Intubation • Observationnal study during 30 months • 1442 intubations • 42 uses of GEB • Success rate : 80% • 60% of patients had associated factors for DI • ENT neoplasy • Morbid obesity • Cervical reduced mobility • Facial trauma Jabre et al; submitted

18. Pharyngeal artificial airways in extrahospital setting • Pharyngeal / oesopharyngeal • Single / double cuff • Single/double lumen • Allowing or not blind intubation

19. Combitube • Often used as first airway device during CPR in paramedic system • Several extrahospital cases of difficult airway in trauma patients resolved with Combitube • Successful insertion by paramedics in 95% of patients with extrahospital difficult airway Davis DP and al; Ann Emerg Med. 2003 Blostein PA and al; J Trauma. 1998

20. LMA • Proposed as initial method of airway control during CPR • Particulary interesting in the difficult intubation and difficult ventilation scenario • Several case reports of prehospital difficult airway resolved with LMA have been reported Greene MK and col, Anaesthesia 1992 Martin SE and al;The journal of trauma: 1999

21. ILMA • ILMA, first described in 1997 has become a cornerstone of the in operating room difficut airway • Some case reports in prehospital settings have been reported • Its use with high success rate needs probably a minimal initial training Gibbs M and al; Acad Emerg Med 2003 Combes and al; Ann Emerg Med 2004

22. Training with ILMA on Manikin

23. New airway devices • CobraPLA™ (PerilaryngealAirway) • PAxpress™ • Laryngeal tube™

24. Cricothyroidotomy • Ultimate Airway management strategy • Frequently used in North American prehospital paramedical system • Success rate : 80-100% • Major complications : 10%

25. What Is the Minimum Training Required for Successful Cricothyroidotomy?: A Study in Mannequins • 102 anesthesiologists • Vidéo démonstration • Performance of 10 cricothyroidotomies in manikins Wong D et col; Anesthesiology 2003

26. Failure of intubation after 2 attempts under direct laryngoscopy Success New direct laryngoscopy with BURP Success Use of GEB ( 2 attempts) Use of the ILMA and call for help Success Intubation through the ILMA Ventilation through the ILMA Success Failure Transfer to the Hospital with ventilation through the ILMA Cricothyroidotomy

27. Non invasive positive pressure ventilation • CPAP or BiPAP • Validated for COPD decompensation and severe « cardiogenic pulmonary oedema » • Majority of the studies are inhospital • Potential large indications exist in the prehospital setting

28. In practice

29. Conclusion • In the prehospital setting the gold standard of invasive airway management remains tracheal intubation under direct laryngoscopy • Rapid sequence induction should be performed for all patients with spontaneous cardiac activity in absence of contraindications • Predefined strategy including simple and effective devices is the best mean to solve difficult airway management situations • Non invasive airway control with face mask is feasible in prehospital setting. Further large studies are needed to precise the best indications of prehospital NPPV