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
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Sliding from First to Second Place: Airway Mike McEvoy, PhD, NRP, RN, CCRN EMS Coordinator – Saratoga County, NY EMS Editor – Fire Engineering magazine.
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Sliding from First toSecond 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: 20101. Immediate recognition and activation of
emergency response system2. Early CPR with emphasis on
chest compressions3. Rapid defibrillation4. Effective ALS5. Integrated post-cardiac arrest care
CPR SequenceChange 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
Berg et al, 2001
Blo
od P
ress
ure
= chest compressionB
lood
Pre
ssur
e
Time
Standard CPR
CCR
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 bettertools
• Video laryngoscopy is abetter 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® Kingsystems
• Price
• Most akin to conventional
• More compact and portable
• Larger screen
• CON: adult only
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
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. ETIOutcome Odds
Ratio95% 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 ComparisonSkill EMR EMT AEMT Medic
OPA X X X X
NPA X X X
Esophageal, SGA X X
ET X
Trach/Cricothyrotomy X
End-Tidal CO2 X
CPAP/BiPAP/PEEP X
Demand Valve/ATV X X X
Pulse Oximetry X X X
Oxygen: NC/NRBM X X X X
Oxygen: SFM/Venturi/PRBM X X X
Oxygen: Humidifiers X X X
Tracheostomy Tubes• Who has them?
• Why?
• Where would you encounter them?
• What are the typicalcomplications?
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
• When possible, lubricate the new tube before insertion
• If lubricant not available, use saline or water
Prepare the trach tube with lubricant
BLBLSS
RULES for Inserting a Tracheostomy Tube
Inserting a Tracheostomy Tube BLBL
SS • TWO providers• Head/neck
neutral to slightly flexed
Insertion of a Tracheostomy Tube
If you meet resistance : STOP !
BLBLSS
Syringe Full, No Air In Cuff
Cuff Inflated, Syringe Empty
Securing the Tracheostomy TubeBLBL
SS
Securing the Tracheostomy Tube
One Fingertip Fits Under the Adult Ties
Baby with One Fingertip
BLBLSS
If BLS Is Unable to Re-Insert the Tracheostomy Tube…
BVM, Dressing to Stoma for Adult Manikin
Same, with Baby Manikin
BLBLSS
Decannulation
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
ALS
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)
Obstruction:Suction the Tracheostomy Tube
Suction Catheter Inserted To Measured Depth – Adult
Suction Catheter Inserted To The Measured Depth –Baby
BLBLSS
Suction Available: Step 1
Instilling Saline into Adult Trach
Instilling Saline into Baby Trach
BLBLSS
Suction AvailableSupplemental Oxygen: Step 2
BV to trach
pre-suctionBV to trach
pre-suction
BLBLSS
Suction: Inserting Suction Catheter - Step 3
• Keep fingers at the measured depth to insert the catheter
• Insert suction catheter without applying suction
BLBLSS
Suction: Step 4
Apply suction:• Cover the opening on
catheter
• For NO MORE than 5-10 seconds (time you can hold your breath comfortably)
BLBLSS
Obstruction: Single Cannula• If unable to insert
suction catheter to a reasonable depth
• Obstruction is IN the tube itself
• Remove the tracheostomy tube
BLBLSS
Obstruction: Inner Cannula
• 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
BLBLSS
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
BLBLSS
Removing a Cuffed Tracheostomy Tube: Step 1
Empty Syringe Attached, Balloon Full
Syringe Full, Balloon Empty
BLBLSS
Removing a Cuffed Tracheostomy Tube: Step 2
Cut the Ties Remove the Trach
BLBLSS
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
• 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
• 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 CapnographyAttaches to ET tube, measures CO2
Oxygen Lungs alveoli blood
Muscles + Organs
Oxygen
Cells
Oxygen
Oxygen+
Glucose
ENERGY
CO2
Blood
Lungs
CO2
Breath
CO2
Physiology of Metabolism
SpO2 versus EtCO2
Oxygenation and VentilationOxygenation (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
45
0
45
0
Hypoventilation
Normal
Hyperventilation
45
0
98
Sp02
What about the Pulse Ox?
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 rescuerEvery 2 minutes
Guidelines 2010• Continuous quantitative waveform
capnography recommended for intubated patients throughout peri-arrest period. In adults:
1. Confirm ETT placement
2. Monitor CPR quality
3. Detect ROSC with EtCO2 values
Guidelines 2005EtCO2 recommended to confirm ET
tube placement
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.
• 13 survivors: rapid rise in exhaled CO2 was the earliest indicator of ROSC
• Before pulse or blood pressure were palpable
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
Mike73%
Godlisten84%
Pete41%
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;66:126-30Hoffman C, et al. Am J Physiol 1946;145:685-692
“Normal” Oxygen SaturationNormal 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 UKaudit of 320 stable adultsaged >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…
Passengers unconscious in <60 seconds if depressurized
Barthel Index 100 (95-100) 100 (95-100) 70 (32-90) 80 (47-95)
Ronning OM, Guldvog B. Should Stroke Victims Routinely Receive Supplemental Oxygen? A Quasi-Randomized Controlled Trial. Stroke. 1999;30:2033-2037.
No oxygen
Oxygen
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 withroom 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
Davis PG, Tan A, O’Donnell CP, et al: Resuscitation of newborn infants with 100% oxygen or air: a systematic review and meta-analysis. Lancet 364:1329-1333, 2004
Rabi Y, Rabi D, Yee W: Room air resuscitation of the depressed newborn: a systematic review and meta-analysis. Resuscitation 72:353-363, 2007
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 HypothermiaVanderbuilt 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 (1/19/30/2002):• 5,549 trauma patients by EMS
Mortality:
PENETRATING
BLUNT
OVERALL
Oxygen None
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%
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%
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)