Airway Scenarios We Don’t Like to Think About Dan Batsie dbatsie@apems.org.

Airway Scenarios We Don’t Like to Think About

Dan Batsiedbatsie@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.

1999 2000 2001 2012

0

100

200

300

400

500

600

13

543

566

538

361

14 18 13

At its 18 March 2010 meeting the New Hampshire EMS Medical Control Board voted to removeall 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 maleAsthma580 lbs (263 kg)Altered MSPeriods of apneaHypoxia/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

SimpleLow riskMay solve problem

Bariatric challengeGeneral challengeShort termHasn’t worked

BIAD

SimpleLow riskMay solve problem

Bariatric challengeGeneral challengeShort term

ETI

Bariatric challengeGeneral challenge

ProtectiveHigher pressureLong term

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.

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

Traditional methods of airway manipulation can be ineffective due to excess soft tissue• Higher pharyngeal critical closing pressure • Exacerbated in supine position

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

Extension of atlanto-occipital joint

Flexion of cervical spine

Collins JS, Lemmens HJ, Brodsky JB. Obesity and difficultintubation: 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

Levitan, R. et al. Head-Elevated Laryngoscopy Position: Improving Laryngeal Exposure During Laryngoscopy by Increasing Head Elevation ANNALS. 41:3 MARCH 2003

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)

• Supine position exacerbates breathing challenges

• Obese abdomens prevent normal diaphragmatic excursion– Increased

pressure required to ventilate

– Decreased FRC• Esophageal sphincter opens at 20-

25 cm H2O • Once opened, lower pressures will

cause continued insufflation

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?

http://burnssurgery.blogspot.com/2012/04/scald-burns-face-accidental-cooker.html

Manuel30y maleDyspnea, Difficulty speaking

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

SimpleLow riskMay not require protection

Rapid changes thus farCould go from bad to really bad

ETI

Edema may be thereCan exacerbate short term problemCan exacerbate long term problem

Protection vs. edemaLong term

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 statisticsHuffer, 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

Basic Airway

SimpleLow riskMay buy time

No protectionLikely doesn’t solve the ongoing problem

Do nothing

SimpleLow riskPharm might work

Not good nowLikely getting worse

ETI

Edema may be thereCan exacerbate short term problemCan exacerbate long term problem

ProtectiveClinical courseLong term

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 Jul-Sep;7(3):316-21.

Marx JA, Hockberger RS, Walls RM. Airway. In: Rosen's Emergency Medicine: Concepts and Clinical Practice. Philadelphia: Mosby Elsevier; 2013

Roberts, Hedges. Surgical cricothyrotomy. In: Clinical Procedures in Emergency Medicine. 5th ed. Philadelphia: Saunders Elsevier; 2010:Chapter 6

12

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, OrderliesR: RAMP: Build a big ramp!A: APNOEIC OXYGENATION: use nasal prongs to maintain diffusion of O2M: MINIMAL DRUGS: local anaesthetic spray/neb, ketamine/ketofol +/- sux/rocP: PRE-OXYGENATE WITH NIVP: PARALYSIS – ONLY IF NEEDEDP: PLAN FOR FAILURE: Surgical airway kit by the bedsideP: POST INTUBATION CARE

http://www.edexam.com.au/managing-the-obese-difficult-airway/