What are the indications for intubation

AIRWAY UNC Emergency Medicine Medical Student Lecture Series Created: Benjamin Leacock 6/21/08 Objectives • • • • • • • • Brief anatomy review Indications for airway support Passive oxygen assistance Non-invasive mechanical ventilation Intubation Difficult Airway Mechanical ventilation Pediatric considerations THIS IS INTERACTIVE SO SPEAK UP BWL 9/29/2009 2 Anatomy BWL 9/29/2009 3 Anatomy BWL 9/29/2009 4 What are the indications for intubation? What are some of the situations when you have seen someone intubated? BWL 9/29/2009 5 Airway Support • Intubation » Airway protection • GCS < 8, • Can not handle secretions, • Airway edema (burns, angioedema) » Ventilation » Oxygenation » High metabolic demand from work of breathing • Sepsis BWL 9/29/2009 6 What are the types of passive oxygenation support? (Tubes on your face) How much O2 do they deliver? What are the limitations? BWL 9/29/2009 7 Passive Oxygen Support • NC » » » 2L 4L 6L 29% 37% 45% 24-50% 60% • Venti Mask » 4-10L » 15L • Non-Rebreather – Reservoir bag LIMITATION: You are not ventilating the patient, or protecting their airway. BWL 9/29/2009 8 What is non-invasive ventilation? BWL 9/29/2009 9 Non-Invasive Ventilation • CPAP » Continuous pressure » Settings: Typically 5-10 cm H2O • BIPAP » Inspiratory and expiratory levels » Settings: IPAP set at 10, EPAP set at 3 cm H2O With either setting remember that you are increasing intrathorasic pressure, thus decreasing cardiac output. BWL 9/29/2009 10 What conditions qualify for non-invasive ventilation? What are the contraindications? BWL 9/29/2009 11 Non-Invasive Ventilation • Conditions » » » » Pulmonary Edema COPD Asthma – (Questionable efficacy) Pneumonia – (Questionable efficacy) • Contraindications » Uncooperative patient » Obtunded patient BWL 9/29/2009 12 Bag-Mask-Ventilation How should you hold the BMV? (Note: BMV is not part RSI) BWL 9/29/2009 13 BMV BWL 9/29/2009 14 Airway Adjuncts How do you size and position oral and nasal airways? 9/29/2009 15 Airway Adjuncts Size by looking at angle of jaw 9/29/2009 16 Intubation BWL 9/29/2009 17 Intubation What is RSI? Why do we use RSI? BWL 9/29/2009 18 Intubation - RSI • RSI is administration of a potent induction agent followed immediately by a rapidly acting neuromuscular blocking agent to induce unconsciousness and motor paralysis for tracheal intubation • RSI increases success rates of intubation • RSI decreases aspiration • Limits sympathetic discharge and limits ICP increase. BWL 9/29/2009 19 Intubation What are the basic steps of RSI? BWL 9/29/2009 20 Intubation - RSI 1. 2. 3. 4. 5. 6. 7. 8. Preparation Pre-oxygenation Positioning Pre-induction Induction Paralysis Tube Confirmation BWL 9/29/2009 21 Intubation What equipment do you need to set up? BWL 9/29/2009 22 Intubation - RSI • Preparation: » » » » » » » Ambu bag Suction Blades – check lights Tubes – check cuff Stylette Syringe – 10 cc Capnography • Patient » Needs IV, O2, Monitor BWL 9/29/2009 23 Intubation How do you position the adult patient? BWL 9/29/2009 24 Intubation - RSI • Position: » Place the pt in the “sniff position” » In the adult this means ramping the head up » Align the ear with the sternal notch » Maintain cricoid pressure. • For c-spine precautions: » You can not move the head » An assistant holds the head in position while the front of the collar is removed. BWL 9/29/2009 25 Intubation Why do we pre-oxygenate? How do we do it? How do we not do it? BWL 9/29/2009 26 Intubation – Pre-Oxygenation • We preoxygenate to prevent hypoxia during the apnea that will follow. » 100% for 2 min of normal breathing will permit 8 minutes of apnea in the healthy adult. • This should be done passively if possible » The reason is that bagging the patient will always put air in the stomach – thus increasing the chance of aspiration. BWL 9/29/2009 27 Intubation What are the common pre-induction agents? When should you consider them? BWL 9/29/2009 28 Intubation – Pre-Induction LOAD » Lidocaine: 1.5 mg/kg – limits bronchospasm in reactive airways and limits ICP response. » Opioid: Fentanyl 3ug/kg – limits sympathetic response, used in CAD, ICH, ICP or aortic dissection. » Atropine: 0.02 mg/kg in kids under 10 to prevent bradycardia. » Defasciculation: 10% of the planed defasiculationg dose to mitigate succ induced elevated ICP. BWL 9/29/2009 29 Intubation Common inductions agents? BWL 9/29/2009 30 Intubation - Induction • Etomidate – Most often used. » Hemodynamically stable, » No ICP increase » Myoclonus is common • Propofol – Quick on, quick off » No ICP increase » Can cause hypotension • Ketamine – » Sympathometic – may be useful in asthma. » May increase ICP. • Many additional agents: Benzos, barbiturates BWL 9/29/2009 31 Intubation The two basic classes of paralytics? What are the contraindications? BWL 9/29/2009 32 Intubation - Paralytics • Depolarizing - Succinylcholine » Basically two Ach molecules (so it can cause bradycardia) » Works within 60 sec, lasts 6-10 min (resp may occur within 7 min) » Contrainducations many related to K. • Hyperkalemia • Burns, Crush, Stroke, cord injury, intra abdominal sepsis. For all of these must have condition > 5 days • Non-Depolarizing – Rocuronium and vecuronium » Rocuronium is agent of choice when succinylcholine is contraindicated. Give 1mg/kg which works within 60 sec and lasts 50 minutes BWL 9/29/2009 33 Intubation What is the difference between a Mac and Miller blades? Typical tube sizes in adults? BWL 9/29/2009 34 Intubation – Tubes + Blades BWL 9/29/2009 35 Intubation What are the basic steps once you are ready to intubate? BWL 9/29/2009 36 Intubation - Steps Scope in left hand. Scissor teeth open with right hand. Place blade in right of mouth and sweep tongue to left. Insert blade deeper Lift up and away With R hand manipulate head and/or cricoid for the best view 7. Pass tube 1. 2. 3. 4. 5. 6. DO NOT PASS THE TUBE IF YOU CAN NOT VISUALIZE DO NOT LET GO OF THE TUBE UNTIL SECURE BWL 9/29/2009 37 Intubation - Steps BWL 9/29/2009 38 Intubation How do we confirm the tube? BWL 9/29/2009 39 Intubation - Confirmation • Confirm » » » » » Visualization! Capnography – most sensitive Listen – stomach, then lungs X-ray Esophageal Detector DO NOT LET GO OF TUBE UNTIL IT IS SECURED BWL 9/29/2009 40 Intubation Options for the difficult airway? BWL 9/29/2009 41 Intubation – Difficult Airway • Boggie • Glide-Scope – Camera on blade • LMA/ILMA - useful out of hospital but should only be used in ED in failed airway. Does not protect airway. • Lighted Stylet – Primary or rescue • Combitube – difficult to use if C-spine immobilized, should be temporary only. Same indications as LMA. • Retrograde Intubation – The cricothyroid membrane is punctured, wire sent through and retrieved through mouth. • Fiberoptic Intubation – View while you intubate • Transtracheal Jet Ventilation – larger 10g needle inserted through the cricothyroid. Inferior to cricothyrotomy, only use is in children <10 where a cric is difficult. • Surgical Airway BWL 9/29/2009 42 Airway How do you perform a surgical airway? BWL 9/29/2009 43 Surgical Airway BWL 9/29/2009 44 Kids Anatomical differences of kids? BWL 9/29/2009 45 Intubation – Kid Anatomy BWL 9/29/2009 Don’t forget that kids have big heads 46 Kids How do you determine tube size in a kid? How is positioning of the child different? Blades? BWL 9/29/2009 47 Intubation – Kids • Tubes » (Age + 4)/4Width of the nail of the little (5th) finger » The narrowest part of the child’s airway is subglottic so use a tube without a cuff or a low pressure cuff. • Blades » In younger kids the epiglottis is large and floppy so use a Miller blade. • Positioning » Kids have large heads so they typically do not need to be “ramped up.” BWL 9/29/2009 48