Sliding from First to
Second Place: Airway
Mike McEvoy, PhD, NRP, RN, CCRN
EMS Coordinator – Saratoga County, NY
EMS Editor – Fire Engineering magazine
Staff RN – Cardiothoracic Surgery and
Chair – Resuscitation Committee, Albany Medical Center
www.mikemcevoy.com
Disclosures
• I am on the Physio-Control and
Masimo Speakers Bureaus
• I don’t know how to play golf or ski
www.mikemcevoy.com
Mike McEvoy - Books:
Outline (not in order):
•
•
•
•
•
•
•
•
•
CPR 2010: that was then, this is now…
EMS Education: déjà vu all over again
Airway basics
Oxygen or not?
Airway advances
Alternative devices
Video intubation
Where we are
What’s coming
Adult Chain of Survival: 2010
1. Immediate recognition and activation of
emergency response system
2. Early CPR with emphasis on
chest compressions
3. Rapid defibrillation
4. Effective ALS
5. Integrated post-cardiac arrest care
CPR Sequence
Change
 A-B-C to C-A-B
 Initiate chest compressions
before ventilations
Why?
 Reduce delay to
compressions
 Can be started immediately
 Emphasizes importance of
chest compressions
What? You’re Killing Me…
Standard CPR (with breaths) vs. CC alone
Standard CPR
Blood Pressure
= chest compression
Blood Pressure
CCR
Time
Berg et al, 2001
So, What Matters in CPR?
High quality, continuous compressions
So, don’t intubate, you say?
Many, many studies…
Bottom line:
“Rescuer procedural experience is
associated with improved patient survival
after out-of-hospital tracheal intubation of
cardiac arrest and medical
non-arrest patients.”
Wang, Yealy, et al. Out of Hospital Endotracheal Intubation
Experience and Patient Outcomes. Ann Emer Med, June
2010
Experience: real or simulated?
• Initial competence: 80 intubations
• Ongoing competence: 2 per month
Graham CA. Advanced airway management in the
emergency department: what are the training and
skills maintenance needs for UK emergency
physicians? Emerg Med J 2004;21:14-19
Scope of Problem (Population):
• 5% cannot be ventilated with a BVM
• 1% cannot be intubated without hospital
equipment
• It makes sense then, to
give paramedics better
tools
• Video laryngoscopy is a
better tool
GlideScope®
PRO
• All size patients
• Disposable covers
CON
• Screen on side
• Cost $$$$
Others:
• Storz
C-MAC®
• McGrath®
Vitaid
Others:
• PENTAX Airway
Scope Ambu
®
• King Vision®
Kingsystems
Others:
• Airtraq®
Prodol
And the winner is….
King Vision®
• Price
• Most akin to
conventional
• More compact and
portable
• Larger screen
• CON: adult only
Kingsystems
While we’re on ET Tubes:
•
•
•
•
Holder mandatory
Cuffed tubes for kids
Asynchronous breaths
Sloooooooow
LYFETYMER®
For those not in practice…
Alternative Airways
• EOA, EGTA
• Combitube™
King™
SGA (Supra Glottic Airways)
• Combitube, King, LMA, i-gel…
Recent Evidence: ROC
•
•
•
•
Resuscitation Outcomes Consortium
264 US/Canadian EMS agencies
Study cardiac arrest and trauma
ROC PRIMED Study:
1. 3 min high quality CPR
vs. immediate defib
2. Use of ITD (blinded)
(found no difference
with either intervention)
Stiell IG, et al & the Resuscitation Outcomes Consortium Investigators. Early versus later rhythm
analysis in patients with out-of-hospital cardiac arrest. New England Journal of Medicine,
2011:365(9), 787-797.
Aufderheide TP, et al & the Resuscitation Outcomes Consortium (ROC) Investigators. A trial of an
impedance threshold device in out-of-hospital cardiac arrest. New England Journal of Medicine,
2011:365(9), 798-806.
ET versus SGA
• 10,455 adult OOHCA with advanced airway placed
• ETI vs. SGA for ROSC, survival 24h and to discharge
• Most patients ETI, most SGA patients were King-LT
Airways
SGA
17%
19%
81%
ETI
SGA
King-LT
20%
Combitube
63%
LMA
Rittenberger JC, et al. Association between Cerebral Performance Category,
Modified Rankin Scale, and discharge disposition after cardiac arrest. Resuscitation,
2011:82(8), 1036-40.
Findings: SGA vs. ETI
Outcome
Odds
Ratio
95% Confidence
Interval
ROSC
1.78
[1.54, 2.04]
24 hours survival
1.74
[1.49, 2.04]
Survival to discharge
1.40
[1.04, 1.89]
Secondary airway or
pulmonary complications
0.84
[0.61, 1.16]
Uh Oh!
Why?
• Vf induced in 9 pigs, CPR 3 min. intervals:
– ETT for first 3 minutes
– Followed by 3 min each (random order):
• King LTS-D™
• LMA Flexible™
• Combitube™
• Primary endpoint = Carotid Blood Flow (CBF)
• Findings: CBF significantly  with SGA in
pigs during CPR
Segal N, et al. Impairment of carotid artery blood flow by
supraglottic airway use in a swine model of cardiac arrest.
2012. Resuscitation, in press.
Prediction:
LMA Supreme™
EMS Education Standards
• New cert levels:
– EMR
– EMT
– AEMT
– Paramedic
• Defines skills and
knowledge
• Curriculum from
publishers
Skill Comparison
Skill
OPA
EMR
X
NPA
EMT
AEMT Medic
X
X
X
X
X
X
X
X
Esophageal, SGA
ET
X
Trach/Cricothyrotomy
X
End-Tidal CO2
X
CPAP/BiPAP/PEEP
X
Demand Valve/ATV
X
X
X
Pulse Oximetry
X
X
X
X
X
X
Oxygen: SFM/Venturi/PRBM
X
X
X
Oxygen: Humidifiers
X
X
X
Oxygen: NC/NRBM
X
Tracheostomy Tubes
• Who has them?
• Why?
• Where would you encounter them?
• What are the typical
complications?
Laryngectomy vs.
Tracheostomy
Pre-Packaged Tracheostomy
Tube
Common Problems with Trachs
Dislodged
Obstructed
Pneumothorax
Equipment
D is for Dislodged /
Decannulation
RULES for Re-inserting a
Tracheostomy Tube
Preparation:
• Proper positioning of the patient
• “Ready to go” trach set includes
– Trach with obturator, ties, 10 cc syringe
• Suction equipment
• Water soluble lubricant (K-Y) or normal
saline/sterile water
BLS
RULES for Inserting a
Tracheostomy Tube
• When possible, lubricate
the new tube before
insertion
• If lubricant not available,
use saline or water
Prepare the trach tube with
lubricant
BLS
Inserting a Tracheostomy Tube
• TWO providers
• Head/neck
neutral to slightly
flexed
BLS
Insertion of a Tracheostomy Tube
If you meet resistance : STOP !
BLS
Securing the Tracheostomy Tube
Syringe Full,
No Air In Cuff
Cuff Inflated,
Syringe Empty
BLS
Securing the Tracheostomy Tube
One Fingertip Fits
Under the Adult Ties
Baby with
One Fingertip
BLS
If BLS Is Unable to Re-Insert
the Tracheostomy Tube…
BVM, Dressing to Stoma
for Adult Manikin
Same, with Baby Manikin
Decannulation
ALS
ALS Interventions
BLS FIRST
Then consider:
– Insert endotracheal tube into trach stoma
OR
– As last resort - orally intubate (if appropriate)
while maintaining occlusive dressing over the
stoma
O is for OBSTRUCTION
• Trachs may become obstructed:
– Secretions
– Improper positioning of the patient
– Bleeding
– Foreign body obstruction
– Trach “nose” clogged
– Tracheal edema (incredibly rare)
BLS
Obstruction:
Suction the Tracheostomy Tube
Suction Catheter Inserted To
Measured Depth – Adult
Suction Catheter Inserted To The
Measured Depth –Baby
BLS
Suction Available: Step 1
Instilling Saline into Adult
Trach
Instilling Saline into Baby
Trach
BLS
Suction Available
Supplemental Oxygen: Step 2
BV to trach
pre-suction
BV to trach
pre-suction
BLS
Suction: Inserting Suction
Catheter - Step 3
• Keep fingers at the
measured depth to
insert the catheter
• Insert suction catheter
without applying suction
BLS
Suction: Step 4
Apply suction:
• Cover the opening on
catheter
• For NO MORE than
5-10 seconds (time
you can hold your
breath comfortably)
BLS
Obstruction: Single Cannula
• If unable to insert
suction catheter to a
reasonable depth
• Obstruction is IN the
tube itself
• Remove the
tracheostomy tube
Obstruction: Inner Cannula
BLS
• If a double lumen trach,
remove the inner cannula
• Replace with new inner
cannula
• If new inner cannula not
available, rinse original inner
cannula with water and
reinsert
• Reassess patient
BLS
Obstruction: Remove Trach
• If you have not been able to:
– ventilate the patient, or
– insert a suction catheter to a reasonable
depth
• You need to REMOVE the trach as the
obstruction is IN the tracheostomy tube
BLS
Removing a Cuffed
Tracheostomy Tube: Step 1
Empty Syringe Attached,
Balloon Full
Syringe Full, Balloon
Empty
BLS
Removing a Cuffed
Tracheostomy Tube: Step 2
Cut the Ties
Remove the Trach
P is for Pneumothorax
• Pneumothorax can occur from:
– High Peak Inspiratory Pressures
– High Positive-End-Expiratory Pressures
– Vigorous BVM ventilations
– Underlying disease process (COPD, blebs,
etc)
Equipment: Problems
• Equipment problems may include:
– Oxygen issues (tank empty, disconnects,
etc)
– Tubing issues (disconnect, obstructed)
– Trach kit not “ready to go”
– Home vents:
• Power failure/unplugged from outlet
• Home ventilator failure/dead battery
• Home oxygen not connected properly
Equipment
BLS
• FOR ALL EQUIPMENT PROBLEMS:
-
Take the patient off the equipment
Attempt to ventilate the patient using BVM to trach
Assess for effectiveness of ventilations
Add supplemental oxygen if saturation < 94%
Take the equipment with the patient to the hospital
New Stuff:
•
•
•
•
Oxygen humidifiers
SFM, PRBM, Venturi
Pulse Oximetry
Demand Valve/ATV
SALT® Airway
ECOLAB $19
•
•
•
•
Supraglottic Airway Laryngopharyngeal Tube
Facilitates blind ETT placement
Mixed reviews
However, in difficult to ventilate patients, this
may be a lifesaving
tool
Mazurek P. Should You Use SALT? EMS1.com
Air Medical Transport column July, 2010.
CPR is Complicated!
Probability of ROSC
Stiell et al. Crit Care Med 2012; 40:1192-1198
Survival to Discharge
Stiell et al. Crit Care Med 2012; 40:1192-1198
CPR Rate vs. ROSC
p < 0.0083
Abella et al. Circulation. 2005;111:428-434
Effective CPR?
• How do you measure the effectiveness
of CPR?
– End tidal carbon dioxide
– Feedback devices
• Measurement of CPR effectiveness is a
proposed TJC future standard
Waveform Capnography
Attaches to ET tube, measures CO2
Physiology of Metabolism
Oxygen  Lungs  alveoli  blood
Breath
CO2
Muscles + Organs
Lungs
Oxygen
CO2
Blood
Oxygen
ENERGY
CO2
Cells
Oxygen
+
Glucos
e
SpO2 versus EtCO2
Oxygenation and Ventilation
Oxygenation (Pulse Ox)
– O2 for metabolism
– SpO2 measures
% of O2 in RBCs
– Reflects changes in
oxygenation within
5 minutes
Ventilation (Capnography)
– CO2 from metabolism
– EtCO2 measures exhaled
CO2 at point of exit
– Reflects changes in
ventilation within
10 seconds
Measuring Exhaled CO2
Colorimetric
Capnometry
Capnography
Measuring Exhaled CO2
Colorimetric
Capnometry
Capnography
Measuring Exhaled CO2
Colorimetric
Capnometry
Capnography
Capnography Waveforms
Normal
45
0
Hyperventilation
45
0
Hypoventilation
45
0
What about the Pulse Ox?
Sp02
98
Carbon Dioxide (CO2)
Production
What If…
But, with High-Quality CPR…
Meet Howard Snitzer
• 54-years old, collapsed Jan 5,
2011 outside Don’s Foods in
Goodhue, MN (pop. 900)
• 2 dozen rescuers took turns
providing CPR for 96 minutes
• 6 shocks with first responder
AED, 6 more shocks by Mayo
Clinic Air Flight Medics
• Transported to Mayo Clinic
Cardiac Cath Lab
Why Not Quit?
• Thrombectomy, stent to LAD
• 10 days inpatient
• “The capnography told us not to
give up”
• EtCO2 averaged 35 (range 32 – 37)
So What’s the Goal
During CPR?
• Try to maintain a
minimum EtCO2 of 10
• Push
HARD (> 2”)
FAST (at least 100)
• Change rescuer
Every 2 minutes
Guidelines 2010
• Continuous quantitative waveform
capnography recommended for
intubated patients throughout periarrest period. In adults:
1. Confirm ETT placement
2. Monitor CPR quality
3. Detect ROSC with EtCO2 values
Guidelines 2005
EtCO2 recommended to confirm ET
tube placement
EtCO2 detects ROSC
• 90 pre-hospital intubated arrest patients
• 16 survivors
• 13 survivors: rapid rise in exhaled CO2
was the earliest indicator of ROSC
• Before pulse or blood pressure were
palpable
Wayne MA, Levine RL, Miller CC. “Use of End-tidal Carbon
Dioxide to Predict Outcome in Prehospital Cardiac Arrest” .
Annals of Emergency Medicine. 1995; 25(6):762-767.
Levine RL., Wayne MA., Miller CC. “End-tidal carbon
dioxide and outcome of out-of-hospital cardiac arrest.” New
England Journal of Medicine. 1997;337(5):301-306.
Cat Pornography
Waveform: Bronchospasm
Mild
Moderate
Interpretation of Waveforms
• Algorithms are coming that will measure
– Slope of waveforms
– Time
– Other components associated with disease
• Breathing and/or non-breathing patients
Integrated Pulmonary
Index™
IPI Values – fuzzy logic
IPI
Patient Status
10
Normal
8-9
Within normal range
7
Close to normal range; requires attention
5-6
Requires attention
3-4
Requires attention or intervention
1-2
Requires intervention
Another Change:
2010
• Tidal volume 600 ml
2005
• Tidal volume 800 ml
Should we make BVMs smaller?
Smaller Tidal Volumes:
• Some systems are using pedi BVMs
• Little data, some conflicts, mostly fear:
Dorges V, et al. Smaller tidal volumes with room-air are not sufficient to ensure adequate
oxygenation during bag-valve-mask ventilation. Resuscitation. 2000; March(44)1: 37-41.
Oxygen
• Oxygen therapy
has always been a
major component
emergency care
• Health care
providers believe
oxygen alleviates
breathlessness
Pete
41%
Mike
73%
Godlisten
84%
Effects of sudden hypoxia
(Removal of oxygen mask at altitude or in a pressure
chamber)
• Impaired mental function; onset at mean
SaO2 64%
• No evidence of impairment above 84%
• Loss of consciousness at mean
saturation of 56%
Notes:
– absence of breathlessness when healthy resting subjects
are exposed to sudden severe hypoxia
– mean SpO2 of airline passengers in a pressurized cabin falls
from 97% to 93% (average nadir 88.6%) with no symptoms
and no apparent ill effects
Akero A et al Eur Respir J. 2005;25:725-30
Cottrell JJ et al Aviat Space Environ Med.
1995;66:126-30
Hoffman C, et al. Am J Physiol 1946;145:685-692
“Normal” Oxygen Saturation
Normal range for healthy young adults is
approximately 96-98% (Crapo AJRCCM, 1999;160:1525)
Previous literature suggested a gradual fall with
advancing age…
However, a Salford/Southend UK
audit of 320 stable adults
aged >70 found:
Mean SpO2 = 96.7%
(2SD range 93.1-100%)
“Normal” nocturnal SpO2
• Healthy subjects in all age groups
routinely desaturate to an average nadir
of 90.4% during the night (SD 3.1%)*
(Gries RE et al Chest 1996; 110: 1489-92)
*Therefore, be cautious in interpreting a single oximetry
measurement from a sleeping patient. Watch the oximeter for a
few minutes if in any doubt (and the patient is otherwise stable)
as normal overnight dips are of short duration.
What happens at 9,000 metres
(approximately 29,000 feet)?
It Depends…
SUDDEN
ACCLIMATIZATION
Passengers unconscious in <60
seconds if depressurized
Everest has been climbed
without oxygen
Oxygen
We began giving oxygen because it
seemed like the right thing to do…
Documented benefits:
Hypoxia
Nausea/vomiting
Motion sickness
Oxygen
• Today, there are
numerous
textbooks on the
reactive oxygen
species.
Oxygen
• We are learning
that oxygen is a
two-edged sword
• It can be beneficial
• It can be harmful
The Chemistry of Oxygen
• Oxygen is highly
reactive; it has 2
unpaired electrons
• Molecules/atoms with
unpaired electrons are
extremely unstable and
highly-reactive
• Referred to as “free
radicals”
The Chemistry of Oxygen
• An excess of free-radicals damages cells
and is called oxidative stress.
The Chemistry of Oxygen
1.8
1.6
1.4
1.2
1
0.8
0.6
0.4
0.2
0
H2O2 Leakage from
Cardiomyocytes
Lifespan =
3.5 years
Rat
Parakeet
Canary
Lifespan =
21 years
Lifespan =
24 years
Not a new concept
ACLS Guidelines 2000:
• Supplemental oxygen only for
saturations < 90%
• 2005: ditto
• 2010: < 94%
Stroke
Minor or Moderate
Strokes
Severe Strokes
Variable
Oxygen
Control
Oxygen
Control
Survival
81.8%
90.7%
53.4%
47.7%
54 (54-58)
57 (52-58)
47 (28-54)
47 (40-52)
70 (32-90)
80 (47-95)
SSS Score
Barthel Index
100 (95-100) 100 (95-100)
No oxygen
Oxygen
Ronning OM, Guldvog B. Should Stroke Victims Routinely
Receive Supplemental Oxygen? A Quasi-Randomized Controlled
Trial. Stroke. 1999;30:2033-2037.
Stroke
• “Supplemental oxygen should not
routinely be given to non-hypoxic stroke
victims with minor to moderate strokes.”
- AHA 1994
• “Further evidence is needed to give
conclusive advice concerning oxygen
supplementation for patients with
severe strokes.”
Ronning OM, Guldvog B. Should Stroke Victims Routinely Receive Supplemental Oxygen? A
Quasi-Randomized Controlled Trial. Stroke. 1999;30:2033-2037.
Neonates
• 1,737 depressed neonates:
– 881 resuscitated with
room air
– 856 resuscitated with 100% oxygen
• Mortality:
– Room air resuscitation: 8.0%
– 100% oxygen resuscitation: 13.0%
• Room air superior to 100% oxygen for
initial resuscitation
Rabi Y, Rabi D, Yee W: Room air resuscitation of the depressed
newborn: a systematic review and meta-analysis. Resuscitation
72:353-363, 2007
Davis PG, Tan A, O’Donnell CP, et al: Resuscitation of newborn
infants with 100% oxygen or air: a systematic review and metaanalysis. Lancet 364:1329-1333, 2004
Therapeutic Hypothermia
Post ROSC Survival:
• Post cardiac arrest hypothermia
• 58 patients, all ROSC in OOH
CPA
• Cooling protocol: keep sat 92-96%
– Survival  by 50% when sats < 92%
– Survival  by 83% when sats > 96%
Unpublished data. Albany Medical Center, Albany, New York, USA. Division of
Cardiothoracic Surgery 2009.
Therapeutic Hypothermia
Vanderbuilt Univ – TH post ROSC
• 170 patients - highest PaO2 during 24°
TH (32-34°C):
– Survivors had significantly lower PaO2 (198)
vs non-suriviors (254)
– Higher PaO2  risk death (OR 1.439)
– Favorable neuro outcomes (CPC 1-2) also
linked to lower PaO2
– Higher PaO2  neuro outcomes (OR 1.485)
Janz et al. Hyperoxia is associated with increased mortality in patients treated with mild
therapeutic hypothermia after sudden cardiac arrest. Crit Care Med 2012; 40(12): 3135-3139.
Trauma
• Charity Hospital (1/19/30/2002):
• 5,549 trauma patients by EMS
Mortality:
Oxygen
None
PENETRATING
OVERALL
BLUNT
Trauma
• “Our analysis suggest that there is no
survival benefit to the use of
supplemental oxygen in the prehospital
setting in traumatized patients who do
not require mechanical ventilation or
airway protection.”
Stockinger ZT, McSwain NE. Prehospital Supplemental Oxygen in Trauma Patients: Its
Efficacy and Implications for Military Medical Care. Mil Med. 2004;169:609-612.
BMJ 18 Oct 2010
BMJ 18 Oct 2010
405 diff breathers randomized:
• NRBM (n=226)
• NC to SpO2 88-92% (n=179)
Titrated O2 reduced mortality:
• all patients 58%
• COPD patients 78%
ACS (Acute Coronary Syndrome)
•
•
•
•
O2 shows little benefit, may harm
No analgesic effect
Harm study needed since 1976
Dangers:
– Increases myocardial ischemia (Nicholson, 2004)
– Triples mortality (Rawles, 1976)
– Increases infarct size (Ukholkina, 2005)
• No benefit when sats >90%
Cabello JB, Burls A, Emparanza JI, Bayliss S, Quinn T. Oxygen therapy for acute
myocardial infarction (Review). The Cochrane Collection, 2010, Issue 6.
ACS: Why, why, why?
Within 5 minutes of 100% O2 (vs. RA):
•  coronary resistance ~ 40%
•  coronary blood flow (CBF) ~ 30%
• Blunted CBF response to Ach, marked  NO
McNulty PH, et al. Effects of supplemental oxygen administration on coronary blood
flow in patients undergoing cardiac catheterization. Am J Physiol Heart Circ Physiol.
2005; 288: H1057-H1062.
CBF (Coronary Blood Flow)
Right Heart Cath:
McNulty PH, et al. Effects of supplemental oxygen administration on coronary
blood flow in patients undergoing cardiac catheterization. Am J Physiol Heart
Circ Physiol. 2005; 288: H1057-H1062.
Where to from here?
British Thoracic Society
O2 therapy guideline (everywhere):
• Keep normal/near-normal O2 sats
– All patients except hypercapnic resp.
failure and terminal palliative care
– Keep sat 92-96%, tx only if hypoxic
– Use pulse oximetry to guide tx – max 98%
www.brit-thoracic.org.uk
What is the current standard?
Guidelines 2010:
• Oxygen for saturations < 94%
• Target range 94 – 96%
Got oxygen?
Oxygen?
Implications: Oximetry mandatory
Implications: Venturi Comeback
Prehospital Implications
Prehospital Implications
Prehospital Implications
• Pulse oximetry guided
supplemental oxygen
• Protocols needed!
Prehospital Implication$
• Rationalizing the O2 administration
using pulse-oximetry reduces O2 usage.
• Oxygen cost-saving justifies oximeter
purchase:
– Where patient volume > 1,750 per year.
– Less frequently for lower call volumes, or
– Mean transport time is < 23 minutes.
Macnab AJ, SusakL, Gagnon FA, Sun C. The cost-benefit of pulse oximeter
use in the prehospital environment. Prehosp Emerg Care. 1999:14:245-250.
Can We Attenuate Oxidative Stress?
• Perhaps
• Clues lie with Carbon Monoxide
– Known in vitro and in vivo
antioxidant and anti-inflammatory
properties
– Critically ill patients  CO production
• Survivors produce more CO
• Non-survivors produce less or no CO
– Multiple human studies now using CO to
attenuate oxidative pulmonary stress
Endogenous Sources of CO
• Normal heme catabolism (breakdown):
• Only biochemical reaction in the body
known to produce CO
• Hemolytic anemia
• Sepsis, critical
illness…
Future Predictions
• Continued de-emphasis on airway and
ventilation
• Oxygen = danger:
– Pulse oximeters for everyone
– Venturi mask revival
– CPAP with titrated FiO2
• ET will remain
– High volume, good oversight, skilled
– Video tools will cost less & sell more
– SGA for everyone else (including EMT?)
• Capnography technology will evolve
HFNC:
(High Flow
Nasal Cannula)
Vapotherm® (prototype)
• Humidifier (moisture)
• Oxygen blender (%)
– Air (50 PSI)
– Oygen (50 PSI)
• Flowmeter
• Up to 40 LPM, 100%
HFNC
Questions?
www.mikemcevoy.com