Airway Scenarios We Don’t Like to
Think About
Dan Batsie
dbatsie@apems.org
Wang et al. Interruptions in Cardiopulmonary Resuscitation
From Paramedic Endotracheal Intubation. Annals . 54; 5, P.
645-652.e1, Nov. 2009
“Intubation frequently is associated with interruption of
compressions for many seconds. Placement of a
supraglottic airway is a reasonable alternative to
endotracheal intubation and can be done successfully
without interrupting chest compressions.”
-2010 AHA Guidelines
Airway management may be accomplished utilizing
any combination of live patients, high fidelity
simulations, low fidelity simulations, or cadaver labs.
-2013 Airway Management Recommendation
ME
Burton et al. Endotracheal Intubation in a Rural EMS
State: Procedure Utilization and Impact of Skills
Maintenance Guidelines. Prehosp. Emer. Care.
63.247.60.249
5 year review (1997-2001)
• 957,836 total encounters
• Annual mean of 1,352 ETI eligible providers
• 556 providers (41%) attempted at least 1 ETI each year.
• Mean of 27 providers (2%) annually attempted pediatric
ETI.
600
5
6
6
5
4
3
500
400
300
200
5
3
8
3
6
1
100
0
1999
2000
14
2001
18
13
2012
13
At its 18 March 2010 meeting the New Hampshire
EMS Medical Control Board voted to remove
all forms of cricothyrotomy from the 2011-2012
Patient Care Protocols.
Doing less with less
Plan for Today
• Scenarios
• Critical decision making
• Discuss options
• Review key elements of those options
Disclaimers
•
•
•
•
Pushing scope of practice
Sometimes there is no absolute right answer
No financial compensation related to devices
Not endorsing any specific devices
“Kenny”
31 yo male
Asthma
580 lbs (263 kg)
Altered MS
Periods of apnea
Hypoxia/Hypercapnea
First responders state they have been
unsuccessful with PPV
Decision Making
• Respiratory failure?
• What does he need?
• Does he need an advanced
airway?
• How to proceed?
Options
•
•
•
•
Continue with basic airway/breathing?
CPAP?
RSI?
Intubation without RSI?
Decision Making
Basic Airway
Simple
Low risk
May solve
problem
Bariatric
challenge
General
challenge
Short term
Hasn’t
worked
BIAD
Simple
Low risk
May solve
problem
Bariatric
challenge
General
challenge
Short term
ETI
Protective
Higher
pressure
Long term
Bariatric
challenge
General
challenge
Langeron, O., Masso, E. et al. Prediction of Difficult Mask
Ventilation. Anesthesiology. 2000; 92:1229–36
Kheterpal, S, Han, R. Incidence and Predictors of Difficult and
Impossible Mask Ventilation. Anesthesiology 2006; 105:885–91
• A combination of poor chest wall compliance,
decreased diaphragmatic excursion, increased
upper airway resistance, and redundant supraglottic
tissues makes mask ventilation more difficult in
obese patients.
Soft tissue of face and
mandible can make
traditional methods of
face mask seal
challenging
Joffe, A, Hetzel, S. A Two-handed Jaw-thrust Technique Is Superior to
the One-handed “EC-clamp” Technique for Mask Ventilation
in the Apneic Unconscious Person. Anesthesiology 2010; 113:873–9
Dr R. Levitan . http://www.airwaycam.com/rescue-ventilation.html
H.E.L.P.
Traditional methods of airway manipulation can be
ineffective due to excess soft tissue
•
•
Higher pharyngeal critical closing pressure
Exacerbated in supine position
Gold, A. Schwartz, A. The Pharyngeal Critical Pressure The Whys and Hows of Using Nasal Continuous Positive Airway Pressure Diagnostically. Chest 1996; 110:1077-88
Flexion and Extension
Levitan, R. et al. Head-Elevated Laryngoscopy Position: Improving Laryngeal Exposure During Laryngoscopy by Increasing Head Elevation ANNALS. 41:3 MARCH 2003
Sniffing Position
Flexion of
cervical spine
Extension of
atlanto-occipital
joint
Collins JS, Lemmens HJ, Brodsky JB. Obesity and difficult
intubation: where is the evidence? Anesthesiology. 2006;104: 617.
• The “sniffing” position, which involves 8 to 10 cm of
head elevation, results in suboptimal positioning for
laryngoscopy in an obese patient, and this may also
confound results and falsely worsen graded views.
http://www.edexam.com.au/managing-the-obese-difficult-airway/
H.E.L.P.
H.E.L.P.
http://anaesthesiatoday.blogspot.com/
Ear to sternal notch
Head Elevation
Ramping
RAMP also
improves
preoxygenation
times in bariatric
patients
Altermatt, F, Munoz, H. Pre-oxygenation in the obese patient: effects of position on tolerance to apnoea. British Journal of Anaesthesia 95 (5): 706–9 (2005)
Levitan, R. et al. Head-Elevated Laryngoscopy Position: Improving Laryngeal Exposure During Laryngoscopy by Increasing Head Elevation ANNALS. 41:3 MARCH 2003
• Supine position
exacerbates
breathing challenges
• Obese abdomens
prevent normal
diaphragmatic
excursion
• Esophageal sphincter opens at 2025 cm H2O
• Once opened, lower pressures will
cause continued insufflation
– Increased
pressure required
to ventilate
– Decreased FRC
Lawes EG, Campbell I, et al. INFLATION PRESSURE, GAST. INSUFFLATION AND RSI. Br. J. Anaesth. (1987) 59 (3): 315-318
Mask Ventilation Performance Points
•
•
•
•
•
Good seal
Adjuncts
Open airway
Ramp
Increased pressure (beware)
–NG/OG tubes?
http://www.das.uk.com/
• “We conclude that obesity alone is not predictive of
tracheal intubation difficulties.”
– Larger neck circumference was associated with a higher
Mallampati score (P 0.0029) and Grade 3 views during
laryngoscopy (P 0.0375)
Anesth Analg 2002;94:732–6
Jense HG, Dubin SA, Silverstein PI, et al. Effect of obesity on safe
duration of apnea in anesthetized humans. Anesth Analg. 1991;72:89-93
• Obese patients may undergo oxygen desaturation
to 90% within 3 minutes compared with 6 minutes in
normal-weight patients
Pre-Intubation:
• Pre-oxygenate
sitting up if possible.
• CPAP
Aligning axis of vision
may be more challenging
due to excess soft tissue
Obesity can also make
“lifting up” on the
laryngoscope handle
harder, as there is more
weight to lift.
Additional Thoughts?
Manuel
30y male
Dyspnea, Difficulty speaking
http://burnssurgery.blogspot.com/2012/04/scald-burns-face-accidental-cooker.html
First responders state
that his difficulty
breathing has gotten
worse since their
arrival.
Decision Making
• Is it open?
• Will it stay open?
• How long?
• How to proceed?
Options
•
•
•
•
Do nothing
Run
Supplemental oxygen
Plastic
Decision Making
Basic Airway
Simple
Low risk
May not require
protection
Rapid changes
thus far
Could go from
bad to really
bad
ETI
Protection Edema may be
vs. edema there
Long term Can exacerbate
short term
problem
Can exacerbate
long term problem
Liquid Scald Burns
• 24% of all burns
• 2nd highest mortality among causes of burns
– Highest percentage <2 yrs
– Increases mortality rate among burns by 20%
• 50% if >20% TSA
US CDC 2010 statistics
Huffer, C. The Role of Bronchoscopy in Acute Burns. Indiana University Pulmonary and Critical Care Fellowship Fellows’ Case Archive Case #2
• Steam vs. Copper (both heated to 100°C)
– Transfer heat to body tissue
– Decreases by 60°C,,
• Copper transfers only 230 W xsec
• Water gives up 2530 W xsec
Protective keratin layer of skin not present in
orotracheal pathway
Inhalation Injury
• Commonly limited to the upper airway
– Animal experiments have shown that if air at 142°C is
inhaled it has cooled to 38°C by the time it reaches
carina
• Steam, frequently injures lower airway
Hathaway, P, Stern, E. Steam Inhalation Causing Delayed Airway Occlusion. AJR 1996;166:322
Mlcak, R, Suman O, et al. Respiratory Management of
Inhalation Injury. Burns. 33(2007) 2-13
• Acute upper airway obstruction occurs in
approximately one-fifth to one-third of
hospitalized burn victims with inhalation injury
Most common 12-24
hour post insult
Can occur w/in 30
minutes
http://emcrit.org/wee/bougie-prepass-and-criccon/
http://www.hindawi.com/journals/arp/2012/820961/fig4/
Cook Airway
Exchange Catheter
http://www.hindawi.com/journals/arp/2012/820961/fig4/
Additional Thoughts?
Sherry
• 2 yo female
• New onset dyspnea
• Expiratory stridor
• Difficulty speaking
• Altered MS
• Cyanosis
• Hypercapnea
• Prefers upright position
• No recent illness
• No fever
• Was “restless at
bedtime” but settled
• No PMHx
Decision Making
• Is it open?
• Will it stay open?
• What is the
etiology of the
stridor?
• How to proceed?
Options
•
•
•
•
•
Do nothing
Run
Supplemental oxygen
Pharmacology
Plastic
Decision Making
Do nothing
Simple
Low risk
Pharm
might work
Not good
now
Likely
getting
worse
Basic Airway
Simple
Low risk
May buy
time
No protection
Likely doesn’t
solve the
ongoing
problem
ETI
Protective
Clinical
course
Long term
Edema may
be there
Can
exacerbate
short term
problem
Can
exacerbate
long term
problem
Epidemiology
• 1994-2003 estimated 252,338 persons <14 years
treated with non-fatal coin-related
aspiration/ingestion
• 1500-3000 deaths each year
• 80% of deaths are pediatric
• Coins are most common non-food foreign body
Chena, X, Milkovich, S. Pediatric coin ingestion and aspiration. Int J of Ped Otorhinolaryngology (2006) 70, 325—329
Chena, X, Milkovich, S. Pediatric coin ingestion and aspiration. Int J of Ped Otorhinolaryngology (2006) 70, 325—329
Signs and Symptoms
• >40% have no symptoms
• Classic presentation (present in roughly 40%
– Stridor
– Wheezing
– Coughing
– Dyspnea
Jim Holliman. Aspirated and Ingested Foreign Bodies. Uniformed Services U. of the Health
Sciences. Bethesda, MD
Jim Holliman. Aspirated and Ingested Foreign Bodies. Uniformed Services U. of the Health
Sciences. Bethesda, MD
Jim Holliman. Aspirated and Ingested Foreign Bodies. Uniformed Services U. of the Health
Sciences. Bethesda, MD
Higgins G, Burton J. Comparison of extraction devices for the removal of supraglottic foreign bodies. Prehosp Emerg Care. 2003 JulSep;7(3):316-21.
12
Roberts, Hedges. Surgical cricothyrotomy. In: Clinical Procedures in Emergency Medicine. 5th ed.
Philadelphia: Saunders Elsevier; 2010:Chapter 6
Marx JA, Hockberger RS, Walls RM. Airway. In: Rosen's Emergency Medicine: Concepts and Clinical
Practice. Philadelphia: Mosby Elsevier; 2013
Heard, A, Green, J, Eakins, P. The formulation and introduction of a ‘can’t intubate,can’t ventilate’ algorithm
into clinical practice. Anaesthesia, 2009, 64, pages 601–608
10mm X 22mm (adult)
2.6mm X 3mm (neonate)
May not be able to palpate
with pad of your finger.
May need to palpate with
finger nail.
Needle Cricothyroidotomy
1. Prepare equipment.
–
–
–
–
14 ga IV catheter or bigger
Syringe (if possible)
Transtracheal jet insufflation device (or BVM?)
6.0 ET hub
Oxygenation without Ventilation
• Apneac oxygenation
• 4 seconds of 15 LPM O2 = roughly 800 mL of
oxygen into the trachea
• May or may not be effective due to shunt physiology
Heard, A, Green, J, Eakins, P. The formulation and introduction of a ‘can’t intubate,can’t ventilate’ algorithm
into clinical practice. Anaesthesia, 2009, 64, pages 601–608
CAMS
© EMRCI 2005
Performance Points
•
•
•
•
•
Right needle
Syringe
45 degree angle
Aspirate
Allow for chest fall
Additional Thoughts?
Key Points
• Use your brain – Skills are no substitute for
critical thinking.
• Use the right tool for the right job.
• Escalate when necessary.
Questions?
Dan Batsie
dbatsie@apems.org
BIG RAMPPPP
• B: BUY TIME: Increase FiO2, NIV, Optimise Medical Rx
I: INDICATION FOR INTUBATION: do you really need to do it &
do it now?
G: GET HELP: Anaesthetics, ICU, ENT, Nurses, Orderlies
R: RAMP: Build a big ramp!
A: APNOEIC OXYGENATION: use nasal prongs to maintain
diffusion of O2
M: MINIMAL DRUGS: local anaesthetic spray/neb,
ketamine/ketofol +/- sux/roc
P: PRE-OXYGENATE WITH NIV
P: PARALYSIS – ONLY IF NEEDED
P: PLAN FOR FAILURE: Surgical airway kit by the bedside
P: POST INTUBATION CARE
http://www.edexam.com.au/managing-the-obese-difficult-airway/