Airway Management For Nurses

1
Airway Management For Nurses

• Todd Lang, MD
• VVMC ED
• 8/31/2005

2
Basic Airway ManagementBag-Mask Ventilation

• Slides adapted from Pat Melanson, MD

3
Airway Assessment

• Assessment for airway compromise or threats and
  need for interventions
• Understand recent medical conditions, medicines
  (blood thinners?), chest/neck problems
• Examination for the potentially difficult airway

4
Consider each patients airway in terms of
possible threats and difficulties in management.
5
Indications for Active Airway Intervention
including intubation

• Failure to maintain patency
• Protection from aspiration
• Hypoxic/ hypercapnic respiratory failure
• Airway access for pulmonary toilet, drug
  delivery,therapeutic hyperventilation
• Intractable Shock
• Anticipated clinical deterioration

6
Clinical Signs of Airway Compromise Threatened
Patency

• Inspiratory stridor
• Snoring ( pharyngeal obstruction )
• Gurgling ( blood/ secretions )
• Drooling ( epiglottitis )
• Hoarseness ( laryngeal edema/ vocal cord
  paralysis)
• Paradoxical chest wall movement
• Mass - abscess, hematoma, angioedema

7
Clinical Signs of Airway Compromise Inadequate
Protection

• Blood in upper airway
• Pus in upper airway
• Persistent vomiting
• Loss of protective airway reflexes
• swallowing reflex is superior to gag reflex

8
Clinical Signs of Airway CompromiseOxygenation
and Ventilation

• The assessment of oxygenation and ventilation is
  a clinical one.
• Arterial blood gases should not be relied upon to
  assess whether intubation is necessary.

9
Anticipated Course An elective airway is better
than an emergency or crash airway.

• Better training and more equipment in the ER
• In prep for transport (even to CT)
• Leaves time for failure and retry

10
Techniques for the Compromised Airway

• Head Positioning
• Jaw Thrust, Chin lift
• Orophryngeal/ Nasopharyngeal airways
• Bag-Valve-Mask Ventilation
• Endotracheal Intubation
• Advanced techniques
• Cric, LMA, Combitube, Retrograde, Fibreoptic,
  Light wand, Bouge

11
BVM Ventilation

• The most important airway skill
• Always the first response to inadequate
  oxygenation and ventilation
• The first bail-out maneuver to a failed
  intubation attempt
• Attenuates the urgency to intubate

12
Golden Rules of Bagging

• Anybody ( almost ) can be oxygenated and
  ventilated with a bag and a mask
• Manual ventilation skill with proper equipment is
  a fundamental premise of advanced airway Rx

13
BVM Ventilation

• Requires practice to master
• One hand to
• maintain face seal
• position head
• maintain patency
• Other hand ventilates

14
Emergent Airway Management
15
BVM Ventilation Technique

• insert oropharyngeal/nasopharyngeal
• Sniffingposition if C-spine OK
• Thumb index to maintain face seal
• Stem of mask in thenar webspace
• Middle finger under mandibular symphysis
• Ring/little finger under angle of mandible
• Maintain jaw thrust/mouth open

16
BVM Ventilation Assessment of Efficacy

• Observe the chest rise and fall
• Good bilateral air entry
• Lack of air entering the stomach
• Feeling the bag
• Pulse oximetry

17
BVM Ventilation Mask Seal Tips and Pearls

• Easier to get seals with masks too large than too
  small
• Inflate mask collar correctly
• Apply lubricant to beards to mat down hair
• It is easier to bag with dentures in place
• If edentulous insert gauze sponges into cheeks

18
Predictors of a Difficult Airway Bag-Valve-Mask
Ventilation

• Upper airway obstruction
• Lack of dentures
• Beard
• Midfacial smash
• facial burns, dressings, scarring
• poor lung mechanics( resistance or compliance )

19
Difficult Airway BVM

• degree of difficulty from zero to infinite
• zero no external effort or internal device
  required
• one person jaw thrust/ face seal
• oropharyngeal or nasopharyngeal AW
• two person jaw thrust / face seal
• both internal airway devices
• infinite no patency despite maximal external
  effort and full use of OP/NP

20
Algorithm for Difficulty Bagging

• Remove FB - Magill forceps
• Triple maneuver if c-spine clear
  
• Head tilt, jaw lift, mouth opening
• Nasal or oropharyngeal airways
• two-person, four-hand technique
• Do not abandon bagging unless it is impossible
  with two people and both an OP and NP airway

21
Difficult Ventilation Obese Patients

• excess soft tissue causes obstruction
• Use both OP and NP airways
• Two hands for mask seal and jaw thrust
• Avoid pushing in on soft tissue under jaw
• may force into airway, worsen obstruction
• Place patient in reverse Trendelenburg
• decreases abdo pressure on diaphragm
• lowers amount of pressure needed to bag

22
Difficult Ventilation Edentulous Patients

• Cheeks fall inward difficult seal
• Inflate mask cuff to maximum
• Allow weight of bag to fall down over side of
  leak
• Place gauze at site of leak or inside mouth to
  puff out cheek
• Two-handed technique using 3rd and 4th fingers to
  bunch up cheek

23
Difficult Airway Maxims

• The first response to failure of bag-mask
  ventilation is always better bag-mask ventilation
• optimize airway position
• place OP and NP airways
• two-handed technique
• try lifting head off pillow to open airway
• Generate as much positive pressure as possible
  without inflating the stomach

24
Technique of Laryngoscopy

• Sniffing position to align oral-pharyngeal-laryn
  geal axis
• Flex neck by placing pillow beneath occiput (
  raise 10 cm )
• Extend head maximally
• With laryngoscope
• open mouth fully
• push tongue to left out of view
• pull upward at 45 degrees

25
Adducted vocal cords
26
Open Cords
27
Predictors of Difficult Laryngoscopy

• Short thick neck
• Receding mandible
• Buck teeth
• Poor mandibular mobility/ limited jaw opening
• Limited head and neck movement
• ( including trauma )

28
Unsuccessful Intubation

• Bag the patient
• Maximize neck flex/ head ex
• Move tongue out of line of site
• Maximize mouth opening
• ID landmarks and adjust blade
• BURP maneuver (Backwards Upwards Rightwards
  Pressure on Thyroid Cart.)
• Increasing lifting force
• Consider Miller blade
• Bag the patient

29
A Nurse Can

• BURP the patient
• Extend neck
• Bag Patient
• Watch the SaO2
• Suggest another devicetell doc to move on!!!
• Put towel under head
• Make sure the ETCO2 is measured

30
Difficult Airway Ideas

• Awake looksedate dont paralyze--Etomidate
• ??Nasalnot much now
• LMA/Combitube
• Fiber optic intubation

31
Blind Nasal Intubation

• success rates 65 - 80 in most series
• high complication rates
• epistaxis
• pharyngeal/ esophageal perforations
• increased incidence of O2 desaturation
• Considered second line approach only
• reserved for when RSI contraindicated

32
Oral Intubation Without Drugs

• Reserved for the completely unconscious,
  unresponsive, and apneic
• Arrest situations only

33
Oral Intubation with Sedation

• proponents argue use of BZ or opioids
• improves airway access
• decreases patient resistance
• avoids risks of neuromuscular blockade
• Generally obtunds patient to point of loss of
  protective reflexes and respiratory drive
• lower success rate, higher complications compared
  with RSI

34
Oral Intubation with SedationUse for the
Anticipated Difficult Airway

• if time permits
• topical anesthesia
• careful titrated sedation
• avoid obtundation
• Awake intubation technique

35
Emergency Airway Concerns

• full stomach
• minimal respiratory reserve
• hemodynamic instability
• acute myocardial ischemia
• increased intracranial pressure
• The Difficult Airway
• Laryngoscopy
• bag-mask difficulty

36
The Intubation Reflex

• Catecholamine release in response to laryngeal
  manipulation
• Tachycardia, hypertension, raised ICP
• Attenuated by beta-blockers, fentanyl
• ICP rise possibly attenuated by lidocaine
• Midazolam and thiopental have no effect

37
Rapid Sequence Intubation Definition

• The near simultaneous administration of a
  sedative-hypnotic agent and a neuromuscular
  blocker in the presence of continuous cricoid
  pressure to facilitate endotracheal intubation
  and minimize risk of aspiration
• modifications are made depending upon the
  clinical scenario

38
Rapid Sequence Intubation Advantages

• Optimizes intubating conditions/ facilitates
  visualization
• Increased rate of successful intubation
• Decreased time to intubation
• Decreased risk of aspiration
• Attenuation of hemodynamic and ICP changes

39
Rapid Sequence Intubation Contraindications

• Anticipated difficulty with endotracheal
  intubation
• anatomic distortion
• Lack of operator skill or familiarity
• inability to preoxygenate

40
Rapid Sequence Intubation Principles

• Emergency intubation is indicated
• The patient has a full stomach
• Intubation is predicted to be successful
• If intubation fails, ventilation is predicted to
  be successful

41
Rapid Sequence Intubation Procedure

• Pre-intubation assessment
• Pre-oxygenate
• Prepare ( for the worst )
• Premedicate
• Paralyze
• Pressure on cricoid
• Place the tube
• Post intubation assessment

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The 10 Ps of RSI
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Pre-oxygenate ( Time
- 5 Minutes)

• 100 oxygen for 5 minutes
• 4 conscious deep breaths of 100 O2
• Fill FRC with reservoir of 100 O2
• Allows 3 to 5 minutes of apnea
• Essential to allow avoidance of bagging
• If necessary bag with cricoid pressure

46
Preparation (
Time - 5 Minutes )

• ETT, stylet, blades, suction, BVM
• Cardiac monitor, pulse oximeter, ETCO2
• One ( preferably two ) iv lines
• Drugs
• Difficult airway kit including cric kit
• Patient positioning

47
Equipment for Intubation

• Laryngoscope
• Handle
• contains the batteries for the light source
• Blades
• Straight blade Miller
• Curved MacIntosh

48
Intubation Equipment

• Laryngoscope
• batteries
• light source
• Blades
• straight (used more for infants)
• Curved (some believe it reduces dental trauma)

• ET tube
• Adult female 7-8 mm
• Adult male 8-8.5 mm
• Stylet
• 10 cc Syringe
• Water soluble gel

49
Oddly, the peds code cart blades that are
included in the Broslow packs do not fit our
laryngoscopes. You need to use the metal ones in
the top of the cart. The doctor will probably
not know this at VVMC.
50
Intubation Equipment

• Stylet
• Helps conform the endotracheal tube to any
  desired configuration, facilitating insertion of
  the tube into the larynx and trachea.
• The end of the stylet must always be recessed at
  least ½ inch from the distal end of the tube.

51
Additional Intubation Equipment

• Magill Forceps
• Helps direct the tip of the ET tube into the
  larynx during intubation and to remove some
  foreign bodies

52
Prepare 8.0 tube for men, and 7.5 for women WITH
A STYLET.
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Pre-treatment/ Prime ( Time
- 2 Minutes )

• Lidocaine 1.5 mg/kg iv
• Defasciculating dose of non-depolarizing NMB
• Beta-blocker or fentanyl
• Induction agent
• Etomidate 0.3 mg/kg
• Midazolam 0.1 - 0.4mg/kg
• Ketamine 1.5 - 2.0 mg/kg

54
Paralyze ( Time Zero )

• Succinylcholine 1.5 mg/kg iv
• Allow 45 - 60 seconds for complete muscle
  relaxation
• Alternatives
• Vecuromium 0.1 - 0.2 mg/kg
• Rocuronium 0.6 - 1.2 mg/kg

55
Pressure

• Sellick maneuver
• initiate upon loss of consciousness
• continue until ETT balloon inflation
• release if active vomiting

56
Intubation Procedure

• Cricoid pressure should be applied by a second
  rescuer during endotracheal intubation in adults
  to protect against regurgitation of gastric
  contents and to ensure placement in the tracheal
  orifice
• Cricoid pressure should be maintained until until
  the cuff of the endotracheal tube is inflated
• Dont bag patient after paralyzed

57
Place the Tube (
Time Zero 45 Secs )

• Wait for optimal paralysis
• Continue cricoid pressure
• Confirm tube placement with ETCO2
• Dont bag the patient unless first try fails

58
Confirmation of ETT PlacementClinical Evaluation

• Observation of ETT pacing through cords
• Clear, equal breath sounds bilaterally
• Absence of breath sounds over epigastrium
• Symmetrical rising of chest
• Condensation or fogging of ETT
• Chest X-ray
• ALL SUBJECT TO FAILURE
• Pulse oximetry is LATE indicator

59
Confirmation of ETT Placement

• Placement of ETT in the esophagus is an accepted
  complication of intubation
• However, failure to recognize and correct
  esophageal intubation immediately IS NOT
  ACCEPTABLE
• Either ETCO2 detection or an aspiration technique
  should be used on every emergency intubation

60
The nurse should verify that the tube position is
confirmed multiply.
61
Confirmation of ETT PlacementEnd-tidal CO2
Detection

• Colorimetric
• Small, disposable
• Useful in pre-hospital care
• Changes from purple to yellow if CO2
• 100 specific if bright yellow
• Indeterminate ( brown ) can indicate esophagus
  with carbonated beverage, or low output state

62
Postintubation care

• Secure and verify tube placement
• Sedate and paralyze before drugs wear off
• Be vigilant for misplaced tube
• Chest film and adjust tube depth

63
Intubation Procedure

• Inflate the the cuff with 10-20 ml of air and
  ventilate the patients lungs with a BVM The tube
  is properly positioned when the patients teeth
  are between the 19 and 23 cm marks on the tube,
  placing the tip of the tube 2-3 cm above the
  carina

64
Lower Airway

• The average tube depth in men is 22 cm
• The average tube depth in women is 21 cm

65
Intubation Procedure

• Secure ET tube to non-moving maxillary area of
  face
• During a coding situation ventilation need not be
  synchronized with chest compressions
• It should be performed asynchronously at 12-15
  ventilations per minute with 100 FIO2

66
DRUGS
67
Etomidate and Sux is the most common RSI combo
used at VVMC. You should know the dosing for
both chemicals.
68
Paralyzing Agents

• NMBAs cause skeletal muscle relaxation by
  blocking acetylcholine transmission
• Usually succinylcholine (1.5 to 2mg/kg)
• Can cause transient fasiculations
• onset in about 40 seconds lasting up to 10
  minutes
• Dose generously, you want them paralyzed

69
Succinylcholine Complications

• Inability to secure airway
• Increased vagal tone ( second dose )
• Histamine release ( rare )
• Increased ICP/ IOP/ intragastric pressure
• Hyperkalemia with burns, NM disease
• malignant hyperthermia

70
Succinylcholine Contraindications

• Hyperkalemia - renal failure
• Active neuromuscular disease with functional
  denervation ( 6 days to 6 months)
• Extensive burns or crush injuries
• Malignant hyperthermia
• Pseudocholinesterase deficiency
• Organophosphate poisoning

71
An ICU or ER nurse should know the
contraindications to sux and etomidate and be
able alert the arriving team.
72
Rocuronium

• Also known as Zemuron with dosing of 1mg/kg
• Rapid onset in 2-3 minutes
• Lasts a little longer than SUX
• NOT IN RSI BOX at VVMC

73
Vecuronium

• Also known as Norcuron with dosing of .15 mg/kg
  IV
• Duration of about 30 minutes
• Use this after intubation till patient is settled
  and well sedated to prevent vomiting

74
Etomidate

• Etomidate (.2-.6 mg/kg IV) is rapidly becoming
  the most commonly used induction med.
• It takes effect in about 1 minute, lasting up to
  5 minutes
• Preferred in trauma patients, because it doesnt
  cause an increase in ICP nor has it been shown to
  exacerbate hypotension.
• May produce myoclonus (resembling small seizures)
  but requires no treatment.
• Contraindicated in pregnant patients

75
Depolarizing dose

• Some people believe that it is useful to give a
  tenth of the dose of vecuronium before giving
  sux, to blunt the depolarizing fasciculations
  that it causes and their possible effects on ICP
  or C-spine.
• Not universally done

76
Fentanyl

• 3-5 mcg/kg IV
• Onset is immediate and protects against increased
  ICP and cardiac stress (MI patient)
• May lower blood pressure
• Give as premedication or as induction agent
  rarely.

77
Midazolam (Versed)

• Short acting benzodiazepine
• IV dose .07-.3 mg/kg IV
• Time of onset 1 - 5 minutes
• Duration of action ½-2 hours
• Preferred agent for sedation of less than 24
  hours
• Good amnesia
• High doses for intubation (5-20mg)

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Ketamine

• dosing of 1-2 mg/kg IV
• Has a bronchodilating effect and should be
  administered with atropine (.02mg/kg) and versed
• Rarely used, but perhaps in COPD/Asthma
• Does not stop breathing

79
Propofol (Diprivan)

• Fast acting highly lipid-soluble
  sedative-hypnotic
• A reasonable choice for intubation, but not
  nearly as common as etomidate
• Often lowers BP, creates coma and may stop
  breathing
• Generally started as the sedation drip after
  intubation

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Lidocaine

• 1.5 mg/kg
• May be used to decrease ICP response
• May decrease bronchospastic response

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The Difficult or Failed Airway
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Difficult Airway Maxims

• It is preferable to use superior judgement -- to
  avoid having to use superior skill.

83
The Difficult Airway

• Must be able to assess or anticipate the degree
  of difficulty
• Then select method most likely to succeed
• If properly assessed and felt to be intubatable
  without significant difficulty
• 1-4 /1000 will be impossible intubations (O.R.)
• 1 / 280 obstetrical patients
• 1 /10,000 impossible to intubate or
  ventilate(O.R.)
• 1-2 cricothyroidotomy rate in ED

84
Difficult Airway Maxims

• Use judicious sedation and topical airway
  anesthesia to have a quick look in doubtful cases
• In certain situations a paralytic agent and RSI
  may still be the best choice

85
The Difficult Airway

• Not all airway management failures are avoidable
  or predictable
• Attempt to minimize failures
• Have several definite back-up plans ready for the
  Failed Airway

86
You and your team must have a plan B and know how
and when to execute it. Period.
87
Difficult Airway Maxims

• The first response to failure of Bag-Mask
  Ventilation is always better BVM
• optimize airway position
• place both OP and NP airways
• two-handed, two-person technique
• try lifting head off pillow to open airway
• Generate as much positive pressure as possible
  without inflating the stomach

88
Plan B Response to Unanticipated Difficulty

• Difficult laryngoscopy and intubation
• Cant intubate but Can ventilate
• Cant intubate and Cant ventilate
• Difficult Mask Ventilation

89
Unsuccessful Intubation Plan B

• Bag the patient
• Maximize neck flex/ head ex
• Move tongue out of line of site
• Maximize mouth opening
• ID landmarks and adjust blade
• BURP maneuver
• (Backwards Upwards Rightwards Pressure on Thyroid
  Cartilage)
• Increasing lifting force
• Consider Miller blade
• Bag the patient

90
Unsuccessful Intubation Plan B

• An optimal or best attempt at difficult
  laryngoscopy should consist of
• use of optimal sniffing position
• no significant muscle tone
• use of optimum external laryngeal manipulation
  (BURP)
• one change in length of blade
• one change in type of blade
• a reasonably experienced laryngoscopist

91
Unsuccessful Intubation Plan B

• Remember, the first response to failure to
  intubate should always be to Bag-Mask-Ventilate
  the patient
• The first response to failure of
  bag-mask-ventilation is always better
  bag-mask-ventilation

92
The Failed Intubation Definition

• Three failed attempts to intubate
• by an experienced intubator
• Inability to ventilate with BVM
• Inability to oxygenate

93
The Failed Intubation

• If cant intubate but can ventilate with BVM have
  time to consider options
• Light guided technique (Lighted stylet)
• Combitube
• LMA
• Fiberoptic techniques
• Retrograde intubation
• Cricothyrotomy

94
The Failed Intubation

• If cant intubate, cant ventilate , must act
  immediately
• Cricothyrotomy
• Percutaneous Transtracheal Jet Ventilation
• Combitube
• LMA
• The last three are temporizing measures and not
  definitive airway management

95
It is part of your job as a nurse to move the
team to Plan B when needed Especially after
three failed laryngoscopy attempts.
96
Difficult Airway Kit

• Is being made now and will be brought to
  intubations in the future.

97
VVMC Difficult Airway Options

• Combitube
• Cricothyrotomy
• Fiber Optic
• LMA
• Maybe getting gum elastic bougie

98
Laryngeal Mask Airway Technique

• Lubricate both sides
• Open airway with head tilt, sniffing position
• Insert LMA with laryngeal surface down
• Press device onto hard palate
• Advance using index finger
• Use curve to advance over base of tongue
• pushed as far as possible into hypopharynx
• Stop when resistance felt(upper esophag.
  sphincter)
• Inflate collar and start bag ventilation

99
LMA and the Difficult Airway

• Consider use early in a cant intubate, cant
  ventilate situation while also getting prepared
  for a surgical airway or TTJV
• A temporizing measure but can be used as a
  conduit for endotracheal intubation
• the Intubating Laryngeal Mask
• The LMA is a supraglottic device
• Not suitable if the airway difficulty is due to
  laryngeal problems i.e., (laryngospasm) or local
  pharyngeal abnormalities ( abscess, hematoma,
  edema)

100
Emergency Non-surgical Ventilation Combitube

• Dual-lumen, dual-cuffed rescue airway device
• The two lumens allow ventilation whether placed
  in trachea or esophagus
• If in trachea position, functions like an ETT
• If in esophageal position, the two balloons seal
  hypopharynx proximally and esophagus distally and
  perforations in esophageal lumen between the
  cuffs allow for ventilation
• Placed blindly

101
Multi-lumen airways
Multilumen airways should be considered when
conventional tracheal intubation measures are
unsuccessful or unavailable

• Esophageal and tracheal placement of a pharyngeal
  tracheal lumen (PTL) airway

102
Digital Intubation

• Laryngeal mask airway (LMA)

103
Emergency Non-surgical Ventilation Transtracheal
Jet Ventilation

• Puncture cricothyroid membrane with large-bore
  (12 or 14 Gauge) kink-resistant catheter
  connected to 3-way stopcock or to a suction
  catheter with control vent
• 50 psi wall oxygen source
• High pressure tubing
• Ventilate for 2 seconds (or until chest rise)
• Release valve for 4 to 5 seconds (exhalation)

104
Emergency Surgical Airway Maxims

• they are usually a bloody mess, but ...
• a bloody surgical airway is better than an
  arrested patient with a nice looking neck

105
Emergency Surgical Access Cricothyrotomy

• We are buying these kits. I have never seen one
  outside the ER.

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You must know where the Cric kit is.
107
Thanks for listening!Any questions?