Advanced Airway Management
Chapter 37
Esophageal Tracheal Combi-tube
Indications
- Unresponsive patients with no gag reflex
Contraindications
- Conscious or semi-conscious patients with a gag reflex
- Younger than 16 years old
- Shorter than 5 feet tall
- Over 7 feet tall
- Ingestion of a caustic substance
- Known esophageal disease
Steps of use
Assemble and check equiptment
- 100ml syringe
- 15ml syringe
- lubricant
- suction
1. Apply lubricant
2. Position the patient
- clear the airway of any obstructions
- Hyperextend neck
3. Hyperventilate patient
4. Tongue/jaw lift
5. Insert combitube slowly until teeth rest between black lines
- Do not force
6. Inflate blue pilot balloon
- 100ml of air
7. Inflate white pilot balloon
- 15ml of air
8. Ventilate through the blue tube
9. Confirm placement of the tube
- Watch for chest rise/fall
- Listen to lung sounds over mid-axillary
10. If no chest rise/fall or no lung sounds are heard ventilate
through the clear tube
11. Confirm placement
12. Continuously monitor the patient
- Watch for balloon cuff leaks
- Reassess placement every time patient is moved
Removal
- Do not remove unless the patient will not tolerate the device
- Place patient on their side
- Deflate both cuffs and gently remove tube
- Be ready to suction
Laryngeal Mask Airway
A. Types
1. Unique
a. Disposable
b. Most common for field due to cost
2. Fastrach
3. Classic
a. Fastrach and classic used primarily in operating room
b. Expensive
c. May be reused for several times if sterilized
4. This course will focus on the LMA Unique
B.
C.
D.
E.
Description of LMA
1. Single use airway
2. Secures airway without laryngoscopy
3. Easier to use than BVM
4. Hands free
5. Latex free
LMA is indicated for use in the following circumstances:
1. As an alternative to the face mask for achieving and
maintaining control of the airway during routine anesthetic
procedures
2. In a known or unexpected difficult airway situation.
3. As a method of establishing a clear airway in the
resuscitation situation in the profoundly unconscious
patient with absent glossopharyngeal and laryngeal
reflexes who may need artificial ventilation when tracheal
intubation is precluded by the lack of available expertise
or equipment or attempts at tracheal intubation have
failed.
Contraindications of using a LMA or similar device.
1. This type of airway does not protect the airway from the
effects of regurgitation and aspiration
2. This type of airway device should not be used in the
resuscitation or emergency situation in patients who are
not profoundly unconscious and who may resist its
insertion.
3. In patients with severe oropharyngeal trauma, the risk of
exacerbating the condition must be weighed against the
potential benefit of establishing an airway
Cautions
1. When resuscitating a profoundly unconscious patient, be
prepared for possible vomiting/regurgitation
2. Patients at higher risk for regurgitation include:
a. Morbidly obese
b. Greater than 14 weeks pregnant
c.
d.
II.
III.
Acute abdominal or thoracic injury
Any condition associated with delayed gastric
emptying
F. Warnings
1. Lubricate only the posterior surface of the LMA mask to
avoid blockage of the aperture or aspiration of the
lubricant
2. Patients should be adequately monitored at all times
during use of these airway devices.
3. To avoid trauma, force should never be used during
insertion.
4. Never over inflate the cuff after insertion. Over inflation
may cause malposition, loss of seal, or trauma.
5. If airway problems persist or ventilation is inadequate, the
LMA
should be removed and reinserted or an airway
established by other means.
Equipment needed
A. Oxygen source
B. Laryngeal mask airway
C. Bag-valve-mask
D. Water-soluble lubricant
E. Syringe
F. Suction equipment
G. Stethoscope
H. End-tidal CO2 detector (if available)
Index Finger Insertion Technique.
A. Remove the sterile LMA from its protective package.
B.
Check the integrity of the LMA cuff by inflating with the
maximum volume of air listed on the package insert as related
to LMA size.
C. Never over inflate the cuff.
1. Mask Size 3: up to 20 mL
2. Mask Size 4: up to 30mL
3. Mask Size 5: up to 40 mL
D.
E.
If the maximum inflation volume of air is necessary to
maintain a seal, the use of a larger size mask should be
considered.
Clinical studies have shown that a better seal is obtained
using a larger size with less air.
1. Using too small a mask and over-inflating the cuff will
decrease cuff compliance, and may result in a poor fit
within the pharyngeal space
2. Increased leak, gastric insufflation, and malpositioning
are more likely when the maximum cuff volume is
exceeded
3.
4.
Start by choosing the largest size you think will fit and
inflate with the smallest volume required to obtain an
adequate seal. You will find that the larger the size
used, the lower the intracuff pressure needed to obtain
an adequate seal.
Always have a larger and smaller size airway
immediately available
F.
Tightly deflate the cuff of the LMA with a syringe so that it forms
a flat oval disk with the rim facing away from the aperture.
G.
Press the mask with its hollow side down on a sterile flat
surface
1.
2.
H.
I.
A completely flat and smooth leading edge helps the
insertion, avoids contact with the epiglottis, and is
important to assure success when positioning the device
Attempting to insert the airway with the cuff partially
inflated increases the chance of a down-folded epiglottis
Lubricate the posterior surface of the LMA just before insertion.
Pre-oxygenate the patient with 100% oxygen for approximately
3-5
minutes.
J. Position the patient with the neck flexed and the head extended
as in the classic sniffing position.
K. Pull the jaw and tongue forward, using your non-dominant
hand.
L. Hold the LMA like a pen, with the index finger placed at the
junction of the cuff and the tube.
M. Under direct vision, press the tip of the cuff upward against the
hard palate and flatten the cuff against it. The black line on the
airway tube should be oriented anteriorly toward the upper lip.
N. Use the index finger to guide the LMA, pressing upwards and
backwards toward the ears in one smooth movement.
O. Advance the LMA into the hypopharynx until a definite
resistance is felt. When properly inserted, the LMA lies just
above the glottic opening.
P. Before removing the index finger, gently press down on the
tube with the other hand to prevent the LMA for being pulled
out of place.
Q. Without holding the tube, inflate the cuff with just enough air to
obtain a seal. The maximum volumes are shown below:
Mask Size
Patient Size
Maximum Cuff
Volume (air)
3
Children 30-50 kg
up to 20 mL
4
Adults 50-70 kg
up to 30 mL
5
Adults 70-100 kg
up to 40 mL
These volumes and sizes are the recommendations for the LMA-Unique
product. Other products will have different sizes and volumes as listed on
the product instructions.
R.
IV.
V.
VI.
Connect the LMA to the bag-valve device. Check for adequate
air exchange with auscultation, rise and fall of the chest, and
end-tidal CO2 detector (if used by your agency).
S. Insert a bite block and secure the LMA and bite block with tape
to the patient’s face. Ensure that the airway tube is taped
downwards against the chin.
Thumb Insertion Technique
A. Deflate the cuff of the mask and apply a water-soluble lubricant
to the posterior surface. Hold the LMA ProSeal™ with the
thumb in the strap.
B. Insertion is similar to that using the index finger; however, the
thumb should be used to extend the head just prior to
completing insertion.
C. Fingers should be extended over head allowing the thumb to
pass further inward.
D. Hold the outer end of the airway tube while removing the
thumb.
E. Secure the tube by gently pressing it upwards and tape in
place. May also press the LMA downwards against the chin
and tape in place.
Indicators of Placement
A. Slight outward movement of the tube with inflation.
B. Smooth swelling in neck.
C. Chest movement and bilateral chest sounds.
D. If your agency has either, good end-tidal CO2 and O2 (pulse
oximetry) readings.
Removal
A. If the patient regains consciousness or develop a gag reflex.
B. Suction equipment should be readily available since vomiting is
common after removal.
C. Deflate the cuff and withdraw the airway rapidly.
Endotracheal Intubation
- Endotracheal Intubation is considered the preferred method of advanced
airway management in the prehospital setting.
- Preparation:
1. Hyperventilate patient with high flow oxygen
2. Select equipment including laryngoscope blade and ETT
3. Check to make sure light is bright and tight
4. Select proper ETT, syringe and stylette as desired
5. Check ETT cuff for leaks
- Indications
• Respiratory or cardiac arrest
• Unconsciousness
• Risk of aspiration
• Obstruction due to foreign bodies, trauma,
burns, or anaphylaxis
• Respiratory extremis due to disease
• Pneumothorax, hemothorax,
hemopneumothorax with respiratory difficulty
- Advantages of Endotracheal Intubation
• Isolates trachea and permits
complete control of airway
• Impedes gastric distention
• Eliminates need to maintain a mask seal
• Offers direct route for suctioning
• Permits administration of some medications
- Disadvantages of Endotracheal Intubation
• Requires considerable training and experience
• Requires specialized equipment
• Requires direct visualization of vocal cords
• Bypasses upper airway’s functions
of warming, filtering, and humidifying the inhaled air
- Complications of Endotracheal Intubation
• Equipment malfunction
• Teeth breakage and soft tissue lacerations
• Hypoxia
• Esophageal intubation
• Endobronchial intubation
• Tension pneumothorax
Procedure:
1.
2.
3.
4.
5.
Prepare Equipment
Apply Sellick’s Maneuver and insert laryngoscope
Visualize larynx and insert endotracheal tube
Infalte cuff and ventilate
Listen to sounds over the epigastrum and then lungs sounds
bilaterally
6. Confirm placement with end-tidal CO2 detector or esophageal bulb
detector.
i. Squeeze bulb, then place on ETT
ii. If bulb doesn’t refill, tube is in esophagus
iii. If bulb refills, tube is in trachea
7. Secure ETT
Advanced Airway Management can ONLY be accomplished after basic
airway management is complete!!!