Advanced Medical Life Support

Chapter 2

Airway Management, Ventilation, and Oxygen Therapy

Introduction
The airway is our channel of life. Without it, other treatments are futile. This chapter presents advanced concepts in airway management. It presumes a commitment to good basic airway care, and an understanding of endotracheal intubation.
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Topics
Anatomy and Physiology
Oxygen Supplementation

Airway Management
Ventilation Equipment and Techniques Endotracheal Intubation
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Topics (continued)
Alternative Methods of Intubation

Alternative Airway Devices

Surgical Techniques of Airway Control

Rapid Sequence Intubation

Guidelines for Airway and Ventilation Support
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C ASE S TUDY
Situation
Call to residence for unconscious, unknown. On scene, a frantic husband says he found his wife unresponsive, along with an open bottle of sleeping pills and a whiskey bottle. You find a middle-aged woman with snoring, shallow respirations of 8, lying next to a puddle of fresh vomitus.

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Anatomy & Physiology

The airway begins at the oral and nasal openings and ends at the alveoli in the lungs. Its major functions are to provide for the uptake of oxygen and the excretion of carbon dioxide. The airway also provides the bodys fastest responses to changes in acid-base balance.
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Respiratory Anatomy
Upper & Lower Airway
Pharynx
Nasopharynx Oropharynx Epiglottis Esophagus

Vallecula Larynx Cricoid cartilage

Trachea Left mainstem bronchus

Carina Right mainstem bronchus

Alveoli

Lungs

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Oropharyngeal Anatomy
Tongue Glosso-epiglottic ligament

Vallecula Epiglottis

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Respiratory Physiology
Major Determinants of Alveolar Content

Inspired fraction of O2
(usually 21% of room air)

Ventilatory rate
(measured via concentration of arterial CO2)

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Phases of Respiration
A. Inspiration (active process)
Intercostal muscles (contract & pull ribs upward & outward) Air flow (induced when respiratory muscles create a vacuum in chest)

Lungs expand

Dome-shaped diaphragm (contracts & flattens, increasing volume of chest)

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Phases of Respiration
B. Expiration (passive process)
Intercostal muscles (relax as ribs return to normal position)
Air flow (produced as chest relaxes & resumes its normal volume)

Lungs recoil Diaphragm (relaxes, moving upward & resuming its normal shape)
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Respiratory Physiology
Physical factors that affect a caregivers ability to ventilate:
RESISTANCE to flow of air in & out of lungs
(produced by changes in cross-sectional diameters of air passages)

COMPLIANCE, or elasticity of lungs

(affected by disorders such as COPD)
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Respiratory Diffusion
Normal
Alveoli

Shunt
Capillaries Clot

Atelectasis

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Oxygen Supplementation
Any patient with a medical condition that impairs respiration warrants the administration of oxygen. (That includes COPD.)

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Airway Management
Indications to Manage the Airway:
Altered mental status (e.g., resulting from
intoxication, head injury, CV A, seizures, etc.)

Signs of hypoxia, respiratory failure A medical condition that may result in airway compromise (e.g., anaphylaxis or
epiglottitis)
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Ventilation Equipment & Techniques

Address ventilatory failure promptly via:
Mouth-to-mask ventilation 2-person BVM ventilation Flow-restricted, oxygen-powered ventilation 1-person BVM ventilation
(may be the least effective method)
Avoid injuring the patient -Dont ventilate too forcefully!
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Cricoid Pressure
Use of the thumb and index finger to apply firm posterior pressure on the cricoid ring & occlude the esophagus
Thyroid Cartilage (Adams apple)

Cricoid Cartilage Trachea Esophagus

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Effect of Cricoid Pressure

Controls regurgitation & gastric distention
Thyroid Cartilage (Adams Apple)

Cricothyroid membrane

Trachea Cricoid cartilage occluding esophagus

Esophagus
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Endotracheal Intubation
Prompt, successful placement of an endotracheal tube is the most reliable method of securing an airway.

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Confirming ET Tube Placement

Listen for sounds in epigastrium. Listen for equal breath sounds. Visualize tube for appearance of mist. Use an end-tidal CO2 detection device or an esophageal detection device. Palpate passage of the tube during application of cricoid pressure
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Orotracheal Intubation
1
Assemble and check the equipment.

Hyperoxygenate the patient.

Introduce the laryngoscope.

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Orotracheal Intubation
4
Visualize the end of the tube as it passes between the vocal cords.

Check the tube placement. Then, secure the tube and check it again.
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Intubation Assessment Devices

Bulb-type (left) & syringe-type esophageal detection devices

End-tidal CO2 detector

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Complications of Intubation
Esophageal intubation Placement in a mainstem bronchus Mucous plugging Soft tissue injury Placement of tip at glottic opening Bleeding
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Alternative Methods of Intubation

The following are techniques you can use to intubate patients whose anatomy or disease processes preclude the oral approach.

Nasotracheal

Digital
Lighted stylette
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Nasotracheal Intubation
Nasotracheal intubation is indicated for a patient who:
Cannot be placed in supine position Is lethargic but not conscious Has peculiarities of the oropharynx that make visualizing the cords difficult
(e.g., swelling, copious secretions)

Has a clenched jaw

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Nasotracheal Intubation
Pros & Cons
Advantages Disdvantages

+ Variable patient position (semi-sitting, upright)

+ Patient need not be unconscious + Practical w/ seizures & trismus

Requires a breathing patient Lower success rate Soft tissue injuries Infection Limited lumen size
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Nasotracheal Intubation
1
Assemble and check the equipment.

Hyperoxygenate the patient.

Position head, insert lubricated tube into naris.

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Nasotracheal Intubation
4
Advance tube until properly placed.

5
Check tube placement. Then, secure tube & check it again.
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Digital & Lighted-Stylette Intubation

Indicated for a patient who:
Is unresponsive Is in a position that would make orotracheal or nasotracheal intubation difficult or unsafe Has copious secretions that inhibit visualization Has already undergone unsuccessful intubation attempts
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Digital Intubation
Insert index & middle finger into patients mouth, pull base of tongue forward. Locate epiglottis & pull forward.

Use other hand to advance lubricated tube & stylet through mouth, past larynx and into trachea. 2-31

Lighted-Stylet Intubation
Insert index & middle finger into patients mouth, depressing base of tongue.

Advance tube & stylet deep into pharynx & past epiglottis.

Look for distinct, bright light in anterior midline of neck if placement is correct
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Alternative Airway Devices

These devices are inserted using blind techniques that require less skill than endotracheal intubation:
Pharyngotracheal Lumen PtL Airway Esophageal-Tracheal Combitube Airway

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Pharyngotracheal Lumen (PtL) Airway

Slide clamp White port cap deflates both cuffs Pilot balloon
Dental block Neck strap Small (distal) cuff Distal end of short green tube Large (proximal) cuff
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Inflation line to small cuff (distal)

Inflation line to large cuff (proximal)

PtL Airway in Place

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Esophageal Tracheal Combitube Airway

No. 1

. No

No. 1

Combitube in trachea

No. 2 15 ml

No. 1 100 ml

No .2 15 ml

Tracheal tube

Cuff inflation port

. No

Pharyngeal cuff Tracheal or esophageal cuff

N o. 2 15 ml

Esophageal tube
No. 1 100 ml

Combitube in esophagus

.2 No

No. 1

No. 1 100 ml

Surgical Techniques of Airway Control

Surgical techniques may be appropriate for patients in whom endotracheal intubation is complicated by:
Distortion of anatomic landmarks used for intubation (i.e., prior head, neck surgery)
Direct obstruction of upper airway structures
(i.e., infection, anaphylaxis)
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Surgical Techniques (continued)

Percutaneous transtracheal jet ventilation Retrograde intubation Surgical cricothyroidotomy

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Anatomy of the Anterior Neck

Hyoid bone Thyroid cartilage

Epiglottis

Cricoid cartilage

Thyroid gland

Trachea

Cricothyroid membrane
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Percutaneous Transtracheal Jet Ventilation

(Using Modified Oxygen Tubing)

Oxygen IN Oxygen supply Oxygen OUT

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Percutaneous Transtracheal Jet Ventilation

Proper Placement of Catheter
Needle, with syringe attached, is inserted @45o through cricothyroid membrane & into trachea

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Retrograde Intubation
Retrograde Intubation is a technique for introducing a guide wire, via a hollow needle, through the cricothyroid membrane and cranially into the pharynx.
There the guide wire can be grasped with a clamp. The tube is then slid over the guide wire and into position in the trachea.

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Surgical Cricothyriotomy
Pertinent Anatomy
Laryngeal prominence Tracheal rings
Cricoid cartilage Cricothyroid membrane Thyroid cartilage Hyoid bone
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Surgical Cricothyriotomy
General Procedure
1. Locate the crycothyroid membrane and puncture it with a scalpel blade. 2. Increase the size of the opening, using the handle of the scalpel or a pair of hemostats (rotated and opened forcibly). 3. Insert an endotracheal tube as shown, about 1-2 cm past the cuff.

Rapid-Sequence Intubation
Rapid-sequence intubation is not necessarily rapid at all. It involves emergency intubation of a noncooperative patient, using drugs that sedate, anesthetize and then paralyze the patient.
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Indications for RSI

Need for emergency intubation
(i.e., impending respiratory failure)

Patient who is too awake or combative to tolerate intubation otherwise

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Assess Before Acting...

If RSI will be feasible, you should be able to place 3 fingers between the prominence of the mandible and the hyoid bone.

Mandible

Hyoid bone

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How Tough Will It Be?

Visualize the Posterior Pharynx
NO difficulty NO difficulty

MODERATE difficulty

SEVERE difficulty

Soft palate, uvula, Soft palate, uvula, fauces, pillars fauces visible visible

Soft palate, base of uvula visible

Hard palate only visible

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Rapid-Sequence Intubation
Hyperoxygenate the patient.
Administer medications
(e.g., atropine, lidocaine -- to minimize side-effects)

Administer sedative/hypnotic agent

(e.g., midazolam, etomidate)

Apply cricoid pressure; support ventilations with O2.

Administer a paralyzing agent

(e.g., succinylcholine, vercuronium)

Intubate orally; confirm tube placement.

Monitor patient throughout (especially ECG)
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Rapid-Sequence Intubation
Properties of Pharmacologic Agents

Sedation Paralysis Analgesia Amnesia

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Guidelines for Airway & Ventilation Support

Organize your approach.
(Start with the basics, then proceed to more advanced care.)

Reassess repeatedly.
Know your limitations.
(Stay within your scope of practice.)
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Airway, Ventilation & Oxygenation Treatment Pathway

Scene Size-up Initial Assessment Airway Patent?

NO
Open airway with head-tilt, chin-lift or jaw-thrust maneuver. If patient is unresponsive, insert oropharyngeal or nasopharyngeal airway as appropriate.

YES
Adequate Ventilations?

NO
Provide general supportive measures: 100% O2 via NRB mask, IV access. Monitor ECG & pulse ox.

YES
Assist ventilations via BVM, mouth-to-mask, or demand-valve device

Inability to maintain patent airway? Need for continued ventilatory support? Persistent hypoxia?

(continued)

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Airway, Ventilation & Oxygenation Treatment Pathway

(continued) NO
Continuous patient monitoring: clinical, ECG, pulse ox
Intubate by one of following methods: Orotracheal intubation or lighted stylet intubation Nasotracheal intubation Oral intubation with rapid sequence induction Successful? Digital intubation (patient unconscious)

YES

YES
Continuous patient monitoring: clinical ECG, pulse ox, end-tidal CO2

NO
Initiate one:

Retrograde intubation or needle cricothyroidotomy

Surgical cricothyroidotomy

PtL or Combitube
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C A S E S T U D Y F O L L O W-U P
Situation
Call to residence for unconscious, unknown. On scene, a frantic husband says he found his wife unresponsive, along with an open bottle of sleeping pills and a whiskey bottle. You find a middle-aged woman with snoring, shallow respirations of 8, lying next to a puddle of fresh vomitus.

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C A S E S T U D Y F O L L O W-U P
Findings & Treatment
Immediate head-tilt, chin-lift manuever performed. Fingersweep, then tonsil-tip catheter used to clear upper airway.

No response; patient ventilated via BVM device & O2.

Pulse increases from 50 - 80; O2 saturation rises from 80 - 96%. Mental status & respirations unchanged.

Nasotracheal intubation successful.

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C A S E S T U D Y F O L L O W-U P
Findings & Treatment
Response to Care
Patient transported to hospital . Patients husband sends note later thanking you for helping his wife and letting you know she has recovered from incident and is seeking counseling for some personal problems.

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