Respiratory Emergencies and Airway Management

Respiratory and Ventilation Abnormalities

• Respiratory insufficiency– Inability of respiratory system to meet body’s

metabolic demands– Respiratory depression

• Respiratory failure– Inability of respiratory system to meet body’s

metabolic needs– Oxygenation failure, ventilatory failure

Basic Airway Management

• Positioning– “Sniffing” position optimal for patient– Manual maneuvers include head tilt–chin lift,

tongue-jaw lift, jaw thrust• Airway adjuncts

– OPA (conscious patient)– NPA (semi- or unconscious patient)

Basic Airway Management

Basic Airway Management

• Suction– Large-bore suction apparatus, suction catheter– Critical care setting will use suctioning while ET

tube is in place

Basic Airway Management

• Oxygen administration– Nasal cannula– Non rebreathing mask

• Supplemental oxygen delivery– Mouth-to-mouth ventilation– Barrier device/resuscitation mask– Bag-mask ventilation

Basic Airway Management

Skill Drill 6-1: Suctioning a Patient With an Endotracheal Tube in Place (1 of 2)

Check, prepare, and assemble your equipment.

Preoxygenate the patient.Lubricate the suction catheter.

Skill Drill 6-1: Suctioning a Patient With an Endotracheal Tube in Place (2 of 2)

Gently insert the catheter into the ET tube until the patient coughs.

Suction in a rotating motion while withdrawing the catheter. Monitor the patient’s cardiac rhythm and oxygen saturation.

Reattach the bag-mask device and resume ventilation and oxygenation.

Indications for ET Intubation

1. Diminished LOC with loss of airway control-Absent or diminished gag reflex, Glasgow Coma

Scale score of 8 or less, aspiration potential2. Respiratory failure

-Hypoxemia, hypercarbia3. Cardiac arrest

– After failed CPR or bag-mask ventilations

Ways to Predict Difficult Airway

• Review anatomic findings, including:– Congenital abnormalities– Recent surgery– Trauma– Infection– Neoplastic disease

• Use LEMON mnemonic to guide assessment.

LEMON

• Look externally• Evaluate using the 3:3:2 rule• Mallampati classification• Obstruction• Neck mobility

Ways to Predict Difficult Airway(2 of 3)

Ways to Predict Difficult Airway(3 of 3)

Intubation (1 of 3)

• Determine method (oral or nasal).• Assemble equipment.• Perform laryngoscopy.

– Limit to 30 seconds or less.– Use Cormack-Lehane grading system to grade

glottis opening.– Use Sellick maneuver )Cricoid pressure (to

minimize passive regurgitation.– Try another tactic if first try fails

Intubation (2 of 3)

Intubation (3 of 3)

Orotracheal Intubation

• Indications :– To control airway (coma, respiratory arrest, cardiac

arrest)– To provide ventilatory support prior to respiratory

failure or prolonged artificial ventilation– For patients without gag reflex– In cases of some medication administration– In cases of impending airway compromise

Skill Drill 6-2: Performing Orotracheal Intubation (1 of 4)

Use BSI precautions. Preoxygenate the patient.

Check, prepare, and assemble your equipment.

Insert the stylet, lubricate the tube, and bend to the desired position. Auscultate breath sounds.

Skill Drill 6-2: Performing Orotracheal Intubation (2 of 4)

Apply cricoid pressure (Sellick maneuver).

Place the patient in a sniffing position if no trauma is involved.

If the patient is a trauma patient, maintain cervical spine immobilization while intubating.

Skill Drill 6-2: Performing Orotracheal Intubation (3 of 4)

Insert the laryngoscope blade into the right side of the mouth, sweep the tongue to the left, and visualize the cords. Insert the ET tube to the appropriate depth.

Inflate the cuff with 10 mL of air and remove the syringe. Check placement with an EDD.

Skill Drill 6-2: Performing Orotracheal Intubation (4 of 4)

Attach the bag-mask device and ETCO2 detector and begin to ventilate.

Auscultate the epigastrium and bilateral chest.

Secure the ET tube with a commercial device or tape.

Nasotracheal Intubation

• Indications include patients who:– Are awake and breathing, but in danger of

respiratory failure– Have gag reflex– Are breathing but cannot open mouth

• Contraindications include:– Combativeness, facial trauma (basilar skull

fracture), coagulopathy, upper airway infection

Skill Drill 6-3: Performing Nasotracheal Intubation (1 of 4)

Use BSI precautions (gloves and face shield). Preoxygenate the patient.

Check, prepare, and assemble your equipment.

Place the patient’s head in a neutral position.

Skill Drill 6-3: Performing Nasotracheal Intubation (2 of 4)

Select the proper size ET tube and form it into a circle.

Apply topical anesthetic spray to nostrils and pharynx.

Lubricate the tip of the tube with a water-soluble gel.

Skill Drill 6-3: Performing Nasotracheal Intubation (3 of 4)

Release the circle from the ET tube and gently insert into either nostril with the bevel of the tube toward the septum.

Advance the tube until the tip passes through the nasopharynx. Listen for breath sounds and look for condensation in the tube.

Skill Drill 6-3: Performing Nasotracheal Intubation (4 of 4)

Inflate the distal cuff with 5 to 10 mL of air and detach the syringe. Check placement with an EDD.

Attach an ETCO2 detector to the ET tube.

Attach the bag-mask device and ventilate. Auscultate the chest and secure the ET tube.

Other Forms of Intubation (1 of 2)

• Digital– ET only equipment needed– Patient must be unconscious.

• Retrograde– Used when other attempts unsuccessful– CCTP may be unfamiliar with procedure.

Other Forms of Intubation (2 of 2)

• Face-to-face intubation– “Tomahawk” method– Useful in tight spaces

• Transillumination– Requires specific piece of equipment– May be contraindicated in some obese or short-

necked patients

Skill Drill 6-4: Performing Digital Intubation (1 of 5)

Use BSI precautions (gloves and face shield).

Kneel next to the patient and preoxygenate.

Check, prepare, and assemble your equipment.

Skill Drill 6-4: Performing Digital Intubation (2 of 5)

Bend the ET tube by placing a slight curve at its distal end.

Place the patient’s head in a neutral position.

Place a bite block in between the patient’s molars to prevent the patient from biting your fingers.

Skill Drill 6-4: Performing Digital Intubation (3 of 5)

Insert your left index and middle fingers and shift the patient’s tongue forward as you advance your fingers toward the larynx.

Palpate and lift the epiglottis with your left middle finger.

Advance the tube between your finger into the trachea with your right hand.

Skill Drill 6-4: Performing Digital Intubation (4 of 5)

Remove the stylet from the ET tube.

Inflate the distal cuff of the ET tube with 5 to 10 mL of air and detach the syringe.

Attach the ETCO2 detector to the ET tube.

Skill Drill 6-4: Performing Digital Intubation (5 of 5)

Attach the bag-mask device and ventilate. Auscultate the chest bilaterally and over the epigastrium.

Secure the ET tube.

Skill Drill 6-5: Performing Retrograde Intubation (1 of 4)

Place the patient supine and ventilate the patient. Cleanse the anterior part of the neck and position a fenestrated drape.

Numb the area over the cricothyroid membrane.

Puncture the cricothyroid membrane.

Skill Drill 6-5: Performing Retrograde Intubation (2 of 4)

Identify the tracheal lumen by aspirating the syringe attached to the needle.

Pass the 70-cm guide wire through the catheter until it appears in the oropharynx, mouth, or one of the nares.

If guide wire is in the oropharynx, grasp it with a clamp and pull the wire partially out of the mouth.

Skill Drill 6-5: Performing Retrograde Intubation (3 of 4)

Insert the guide wire emerging from the mouth through Murphy’s eye, and pass it through the lumen of the ET tube.

Advance the ET tube into the trachea.

Auscultate the chest bilaterally and over the epigastrium.

Skill Drill 6-5: Performing Retrograde Intubation (4 of 4)

Secure the ET tube in place and ventilate.

Once tube placement is confirmed, remove the guide wire by pulling on the distal end.

If tube placement is incorrect, remove the tube and start over or switch to a different technique.

Complications of Intubation (1 of 2)

• Misplaced ET tube– Breath sounds not heard: extubate, suction,

repeat– Breath sounds heard on right side only: deflate

cuff, retract ET tube until breath sounds auscultated bilaterally

Complications of Intubation (2 of 2)

• Failed intubation– Perform BLS airway maneuvers with OPA

or NPA, bag-mask device– Use LMA

The LMA

• Advantages include:– Ease of insertion– Superior oxygenation and ventilation

• Disadvantages include:– Risk of aspiration– Difficulty with obtaining adequate seal

Skill Drill 6-6: LMA Insertion (1 of 3)

Check the cuff of the LMA, then deflate the cuff completely.

Apply a water-soluble lubricant to the base of the device.

Preoxygenate the patient. Ventilation should not be interrupted for more than 30 seconds.

Skill Drill 6-6: LMA Insertion (2 of 3)

Insert the LMA along the roof of the mouth.Place the head in the sniffing position. Insert your finger between the cuff and the tube. Place your index finger in the notch between the tube and the cuff. Open the patient’s mouth.

Skill Drill 6-6: LMA Insertion (3 of 3)

Attach the bag-mask device and begin to ventilate the patient. Check for chest rise and lung or epigastrium sounds.

Inflate the cuff with the amount of air indicated for that size airway

Supraglottic Airways

• Esophageal tracheal Combitube– Used when ET intubation not possible or

unsuccessful, or as rescue airway in failed intubation

• King LT airway– Single-lumen, dual-cuff

• Cuffed oropharyngeal airway– OPA with high-volume, low-pressure cuff

Skill Drill 6-7: Insertion of the Combitube (1 of 4)

Assemble and check equipment.

Use BSI precautions (gloves and face shield).

Preoxygenate the patient.

Skill Drill 6-7: Insertion of the Combitube (2 of 4)

Apply water-soluble lubricant to the tube. Place the patient’s head in the sniffing position.

Open the patient’s mouth with the tongue-jaw lift maneuver and insert the Combitube.

Inflate line 1 leading to the pharyngeal cuff with 100 mL of air and remove syringe.

Skill Drill 6-7: Insertion of the Combitube (3 of 4)

Inflate line 2 leading to the distal cuff with approximately 15 mL of air and remove syringe.

Ventilate the patient through the pharyngeal tube first. Look for chest rise and listen for breath sounds and epigastric sounds.

Skill Drill 6-7: Insertion of the Combitube (4 of 4)

If the chest does not rise and epigastric sounds are present, this indicates tracheal placement. Attempt ventilation through the shorter, clear tube. If it has entered the trachea, the chest should rise.

Confirm placement by auscultating for breath sounds over the lungs and gastric sounds over the abdomen.

Skill Drill 6-8: Performing Needle Cricothyrotomy (1 of 4)

Use BSI precautions (gloves and face shield).

Attach a 14- to 16-gauge IV catheter to a 10-mL syringe containing sterile saline or water.

Palpate for and locate the thyroid cartilage, cricothyroid membrane, and suprasternal notch.

Skill Drill 6-8: Performing Needle Cricothyrotomy (2 of 4)

Cleanse the area with an iodine-containing solution.

Attach the syringe to the needle. Stabilize the larynx and insert the needle into the cricothyroid membrane.

Push the needle until it “pops” into trachea. Aspirate with the syringe to determine correct catheter placement.

Skill Drill 6-8: Performing Needle Cricothyrotomy (3 of 4)

Slide the catheter off of the needle until the hub of the catheter is flush with the patient’s skin.

Place the syringe and needle in a puncture-proof container.

Connect one end of the oxygen tubing to the catheter and the other end to the jet ventilator.

Skill Drill 6-8: Performing Needle Cricothyrotomy (4 of 4)

Open the release valve on the jet ventilator and adjust the pressure accordingly.

Auscultate the apices and bases of both lungs and over the epigastrium.

Secure the catheter with a 4 x 4 gauze pad and tape. Continue ventilations.

Surgical Airways (1 of 2)

• Needle cricothyrotomy– Indications: intubation not feasible or does not

relieve obstruction; as field temporary airway– Contraindication: severe airway obstruction below

site of catheter insertion

Surgical Airways (2 of 2)

• Surgical cricothyrotomy– Indications: intubation not feasible or does not

relieve obstruction; as field temporary airway– Contraindications: inability to identify anatomic

landmarks, patients under age 8

open cricothyrotomy modified cricothyrotomy

Skill Drill 6-9: Performing Surgical Cricothyrotomy (1 of 4)

Use BSI precautions (gloves and face shield).

Check, assemble, and prepare the equipment.

With the patient’s head in a neutral position, palpate for and locate the cricothyroid membrane from the left side.

Skill Drill 6-9: Performing Surgical Cricothyrotomy (2 of 4)

Cleanse the anterior part of the neck and position a fenestrated drape.

With a scalpel in your dominant hand, make a 1- to 2-cm vertical skin incision over the cricothyroid membrane.

Puncture the cricothyroid membrane and make a horizontal incision 1 cm in each direction from the midline.

Skill Drill 6-9: Performing Surgical Cricothyrotomy (3 of 4)

Place a curved hemostat through the incision before removing the scalpel. Open the hemostats.

Insert the ET tube between the tips of the open hemostats, advancing the balloon about 1.0 to 1.5 cm.

Inflate the cuff on the tube with 8 to 10 mL of air and remove the syringe.

Skill Drill 6-9: Performing Surgical Cricothyrotomy (4 of 4)

Attach an ETCO2 detector in between the tube and the bag-mask device.

Ventilate the patient and auscultate the chest bilaterally and over the epigastrium.

Secure the tube to the neck and reconfirm correct tube placement. Continue to ventilate.

Rapid Sequence Intubation (RSI)

• Prehospital use new, but increasing• Includes many of same indications for ET

intubation • Uses sedatives and paralytics to remove

patient’s ability to breathe

Skill Drill 6-10: Performing Rapid Sequence Intubation (1 of 2)

Prepare and assemble the equipment. Preoxygenate the patient. Administer medications to premedicate, sedate, and paralyze the patient.

Apply posterior cricoid pressure.

Skill Drill 6-10: Performing Rapid Sequence Intubation (2 of 2)

Intubate the patient Confirm ET tube placement. Release cricoid pressure.

RSI Pharmacologic Agents (1 of 3)

• Sedative/induction agents– Ultra-short acting barbiturates – Benzodiazepines– Ketamine– Propofol– Lidocaine and atropine

RSI Pharmacologic Agents (2 of 3)

• Depolarizing agents– Neuromuscular blocking agents– Succinylcholine

• Nondepolarizing agents– Neuromuscular blocking agents– Vecuronium, pancuronium, rocuronium,

cisatracurium– Used three different ways

RSI Pharmacologic Agents (3 of 3)

Tracheostomy Management

• Patients undergoing transport may have tracheostomy in place due to:– Facial trauma– Significant tracheal trauma– Head injury– Failure to wean/long-term ventilator support

• Placement does not typically occur in field.

Common Mechanical Ventilator Characteristics (1 of 2)

• Power source– External

• Cycling– Which variable terminates inspiratory phase of

breath• Breath delivery

– Either positive or negative pressure

Common Mechanical Ventilator Characteristics (2 of 2)

• Parameters– Mode, tidal volume, respiratory rate, flow, FIO2,

PEEP selected by clinician• Ventilator circuit

– External• Alarms

– Vary in type– Set for individual patient, never disabled

Normal Ventilation

Positive-Pressure Ventilation

• Tidal Volume is the amount of air delivered with each breath. • Respiratory Rate For most patients, an initial respiratory rate between 12

and 16 breaths per minute is reasonable• Positive End-Expiratory Pressure (PEEP) Applied PEEP is generally added to mitigate end-

expiratory alveolar collapse. A typical initial applied PEEP is 5 cmH2O. However, up to 20 cmH2O may be used in patients undergoing low tidal volume ventilation for acute respiratory distress syndrome (ARDS)

• Flow Rate The peak flow rate is the maximum flow

delivered by the ventilator during inspiration. Peak flow rates of 60 L per minute may be sufficient, although higher rates are frequently necessary. An insufficient peak flow rate is characterized by dyspnea, spuriously low peak inspiratory pressures, and scalloping of the inspiratory pressure tracing

Inspiratory Time: Expiratory Time Relationship (I:E Ratio)

• During spontaneous breathing, the normal I:E ratio is 1:2, indicating that for normal patients the exhalation time is about twice as long as inhalation time.

• If exhalation time is too short “breath stacking” occurs resulting in an increase in end-expiratory pressure also called auto-PEEP.

• Depending on the disease process, such as in ARDS, the I:E ratio can be changed to improve ventilation

Fraction of Inspired Oxygen

• The lowest possible fraction of inspired oxygen (FiO2) necessary to meet oxygenation goals should be used. This will decrease the likelihood that adverse consequences of supplemental oxygen will develop, such as absorption atelectasis, accentuation of hypercapnia, airway injury, and parenchymal injury

Modes of Ventilation

• Assist-Control )continuous mandatory )Ventilation (CMV)

The use of controlled mechanical ventilation requires the patient be completely unconscious, either pharmacokinetic ally or otherwise in a

coma. Volume Control Pressure Control

• Pressure Support Ventilation The patient initiates every breath and the ventilator

delivers support with the preset pressure value. With support from the ventilator, the patient also regulates their own respiratory rate and their tidal volume.

• Synchronized Intermittent Mandatory Ventilation)SIMV) in which the ventilator breaths are synchronized with

patient inspiratory effort

Volume Control Pressure Control

Positive-Pressure Ventilators

• Categorized by variable that terminates inspiratory phase of breath– Pressure ventilators– Volume ventilators– Flow-cycled ventilators– Time-cycled ventilators(Cycling is the method for

how a ventilator knows to give a breath and stop a breath)

Noninvasive ventilationCPAP, BiPAP

• CPAP is a pressure applied at the end of exhalation to keep the alveoli open and not fully deflate

• Biphasic/bilevel(BiPAP) ventilation it delivers a preset inspiratory positive airway pressure (IPAP) and

expiratory positive airway pressure (EPAP). BPAP can be described as a Continuous Positive Airway Pressure system with a time-cycled change of the applied CPAP level

• Respiratory minute volume (or minute ventilation or expired minute volume) is the volume of gas inhaled (inhaled minute volume) or exhaled (exhaled minute volume) from a person's lungs per minute. It is an important parameter in respiratory medicine due to its relationship with blood carbon dioxide levels.

MV=RR xTidal volume

Ventilator Parameters

Skill Drill 6-11: Using a Portable Ventilator (1 of 2)

Initiate power. Attach ventilator circuit. Adjust continuous flow.

Skill Drill 6-11: Using a Portable Ventilator (2 of 2)

Select the ventilator rate, inspiratory rate, flow rate, and oxygen concentrations.

Make mode selections: CPAP

and PEEP )Positive end-expiratory pressure, IMV/SIMV, assist control. (

Portable Ventilator Management (1 of 2)

• Indications for use– Impending/actual respiratory failure; inadequate

respiratory drive, apnea, gas exchange; decreased work of breathing

• Complications for use– Patient anxiety– Mechanical failure– Improper settings

Portable Ventilator Management (2 of 2)

• Air transport requires electronic-controlled ventilators

• Troubleshooting includes:– Having manual resuscitator available– Checking battery/power source, or for low-pressure or

high-pressure

Skill Drill 6-12: Troubleshooting a Ventilator Low-Pressure Alarm

Quickly inspect the ventilator-patient interface for a disconnection. Tighten all connections.

If the alarm is still sounding, disconnect the ventilator and bag the patient.

Place a gloved finger over the patient ventilator connector and observe the next ventilator breath cycle.