AIRWAY

1. AIRWAY UNC Emergency Medicine Medical Student Lecture Series Created: Benjamin Leacock 6/21/08

2. Objectives • Brief anatomy review • Indications for airway support • Passive oxygen assistance • Non-invasive mechanical ventilation • Intubation • Difficult Airway • Mechanical ventilation • Pediatric considerations THIS IS INTERACTIVE SO SPEAK UP

3. Anatomy

4. Anatomy

5. What are the indications for intubation? What are some of the situations when you have seen someone intubated?

6. Airway Support • Intubation • Airway protection • GCS < 8, • Can not handle secretions, • Airway edema (burns, angioedema) • Ventilation • Oxygenation • High metabolic demand from work of breathing • Sepsis

7. What are the types of passive oxygenation support? (Tubes on your face) How much O2 do they deliver? What are the limitations?

8. Passive Oxygen Support • NC •    2 L 29%         •    4 L 37%         •    6 L 45% • Venti Mask • 4-10L 24-50% • Non-Rebreather – Reservoir bag • 15L 60% LIMITATION: You are not ventilating the patient, or protecting their airway.

9. What is non-invasive ventilation?

10. Non-Invasive Ventilation • CPAP • Continuous pressure • Settings: Typically 5-10 cm H2O • BIPAP • Inspiratory and expiratory levels • Settings: IPAP set at 10, EPAP set at 3 cm H2O With either setting remember that you are increasing intrathorasic pressure, thus decreasing cardiac output.

11. What conditions qualify for non-invasive ventilation? What are the contraindications?

12. Non-Invasive Ventilation • Conditions • Pulmonary Edema • COPD • Asthma – (Questionable efficacy) • Pneumonia – (Questionable efficacy) • Contraindications • Uncooperative patient • Obtunded patient

13. Bag-Mask-Ventilation How should you hold the BMV? (Note: BMV is not part RSI)

14. BMV

15. Airway Adjuncts How do you size and position oral and nasal airways?

16. Airway Adjuncts Size by looking at angle of jaw

17. Intubation

18. Intubation What is RSI? Why do we use RSI?

19. Intubation - RSI • RSI is administration of a potent induction agent followed immediately by a rapidly acting neuromuscular blocking agent to induce unconsciousness and motor paralysis for tracheal intubation • RSI increases success rates of intubation • RSI decreases aspiration • Limits sympathetic discharge and limits ICP increase.

20. Intubation What are the basic steps of RSI?

21. Intubation - RSI • Preparation • Pre-oxygenation • Positioning • Pre-induction • Induction • Paralysis • Tube • Confirmation

22. Intubation What equipment do you need to set up?

23. Intubation - RSI • Preparation: • Ambu bag • Suction • Blades – check lights • Tubes – check cuff • Stylette • Syringe – 10 cc • Capnography • Patient • Needs IV, O2, Monitor

24. Intubation How do you position the adult patient?

25. Intubation - RSI • Position: • Place the pt in the “sniff position” • In the adult this means ramping the head up • Align the ear with the sternal notch • Maintain cricoid pressure. • For c-spine precautions: • You can not move the head • An assistant holds the head in position while the front of the collar is removed.

26. Intubation Why do we pre-oxygenate? How do we do it? How do we not do it?

27. Intubation – Pre-Oxygenation • We preoxygenate to prevent hypoxia during the apnea that will follow. • 100% for 2 min of normal breathing will permit 8 minutes of apnea in the healthy adult. • This should be done passively if possible • The reason is that bagging the patient will always put air in the stomach – thus increasing the chance of aspiration.

28. Intubation What are the common pre-induction agents? When should you consider them?

29. Intubation – Pre-Induction LOAD • Lidocaine: 1.5 mg/kg – limits bronchospasm in reactive airways and limits ICP response. • Opioid: Fentanyl 3ug/kg – limits sympathetic response, used in CAD, ICH, ICP or aortic dissection. • Atropine: 0.02 mg/kg in kids under 10 to prevent bradycardia. • Defasciculation: 10% of the planed defasiculationg dose to mitigate succ induced elevated ICP.

30. Intubation Common inductions agents?

31. Intubation - Induction • Etomidate – Most often used. • Hemodynamically stable, • No ICP increase • Myoclonus is common • Propofol – Quick on, quick off • No ICP increase • Can cause hypotension • Ketamine – • Sympathometic – may be useful in asthma. • May increase ICP. • Many additional agents: Benzos, barbiturates

32. Intubation The two basic classes of paralytics? What are the contraindications?

33. Intubation - Paralytics • Depolarizing - Succinylcholine • Basically two Ach molecules (so it can cause bradycardia) • Works within 60 sec, lasts 6-10 min (resp may occur within 7 min) • Contrainducations many related to K. • Hyperkalemia • Burns, Crush, Stroke, cord injury, intra abdominal sepsis. For all of these must have condition > 5 days • Non-Depolarizing – Rocuronium and vecuronium • Rocuronium is agent of choice when succinylcholine is contraindicated. Give 1mg/kg which works within 60 sec and lasts 50 minutes

34. Intubation What is the difference between a Mac and Miller blades? Typical tube sizes in adults?

35. Intubation – Tubes + Blades

36. Intubation What are the basic steps once you are ready to intubate?

37. Intubation - Steps • Scope in left hand. • Scissor teeth open with right hand. • Place blade in right of mouth and sweep tongue to left. • Insert blade deeper • Lift up and away • With R hand manipulate head and/or cricoid for the best view • Pass tube DO NOT PASS THE TUBE IF YOU CAN NOT VISUALIZE DO NOT LET GO OF THE TUBE UNTIL SECURE

38. Intubation - Steps

39. Intubation How do we confirm the tube?

40. Intubation - Confirmation • Confirm • Visualization! • Capnography – most sensitive • Listen – stomach, then lungs • X-ray • Esophageal Detector DO NOT LET GO OF TUBE UNTIL IT IS SECURED

41. Intubation Options for the difficult airway?

42. Intubation – Difficult Airway • Boggie • Glide-Scope – Camera on blade • LMA/ILMA - useful out of hospital but should only be used in ED in failed airway. Does not protect airway. • Lighted Stylet – Primary or rescue • Combitube – difficultto use if C-spine immobilized, should be temporary only. Same indications as LMA. • Retrograde Intubation – The cricothyroid membrane is punctured, wire sent through and retrieved through mouth. • Fiberoptic Intubation – View while you intubate • Transtracheal Jet Ventilation – larger 10g needle inserted through the cricothyroid. Inferior to cricothyrotomy, only use is in children <10 where a cric is difficult. • Surgical Airway

43. Airway How do you perform a surgical airway?

44. Surgical Airway

45. Kids Anatomical differences of kids?

46. Intubation – Kid Anatomy Don’t forget that kids have big heads

47. Kids How do you determine tube size in a kid? How is positioning of the child different? Blades?

48. Intubation – Kids • Tubes • (Age + 4)/4Width of the nail of the little (5th) finger • The narrowest part of the child’s airway is subglottic so use a tube without a cuff or a low pressure cuff. • Blades • In younger kids the epiglottis is large and floppy so use a Miller blade. • Positioning • Kids have large heads so they typically do not need to be “ramped up.”