Airway Management - Home - Filer

							Airway Management
     848 FST
                Objectives
• IDENTIFY:

  – Airway emergencies

  – Different modes of airway intervention

  – Procedures for orotracheal intubation
  4 Categories That May Require
       Airway Intervention
• 1. Direct trauma to airway/ obstruction
• 2. Severely wounded (e.g. profound
  bleeding, head injury, comatose, etc.)
  – Requires secure airway
• 3. Resp failure secondary to blast or
  inhalational injury, or exposure to chemical
  agents
• 4. Controlled airway during surgery
  Small Number of Casualties
  Require Airway Intervention

• Vietnam
  – 1.3% casualties arriving from battlefield require
    emergency airway management
  – 0.6% suffered from traumatic airway injury
   Small Number of Casualties
   Require Airway Intervention

• Gulf War
  – 0.4% incidence of airway obstruction due to
    trauma
  – >70% severe head injuries
  – >10% hypovolemic shock
  – >3% chest wounds
3 Goals of Airway Management
• 1. Relieve airway obstruction (e.g. head tilt-
  jaw thrust, finger sweep, suctioning)

• 2. Prevent aspiration (e.g. blood, foreign
  materials, stomach contents > leads to
  pneumonitis > 50% mortality rate

• 3. Maintain adequate ventilation/gas
  exchange
IDENTIFYING AIRWAY
   EMERGENCIES
           S&S of Hypoxia
• Anxiety, tachycardia, decreased level of
  consciousness, sweating

• Lack of air movement from mouth or with
  auscultation

• SaO2 <95%, gray, cyanotic (late sign)
    S&S of Airway Obstruction
• Snoring, grunting, and strider

• Retractions of the suprasternal, intercostal,
  and epigastric regions
                     Causes
• Tongue (most common)
  – Relieved with jaw thrust, oral or nasal airway
  – Also: food, vomit, blood, secretions, teeth
     • Removed with suctioning or finger sweep
  – Also: soft tissue swellings and hematoma
SPECIAL AIRWAY
 MANAGEMENT
CONSIDERATIONS
               Head Injury
• 50% of all trauma-related deaths

• Early recognition of injury and intubation
  will minimize brain injury
                3 Goals
• 1. Provides adequate ventilation and
  oxygenation to medullary respiratory
  centers compromised from increased ICP,
  swelling, or hemorrhage
• 2. Reduce the risk of aspiration
• 3. Induce hypocapnia to decrease ICP
• NOTE: GCS <8 indicate immediate need
  for intubation
          Cervical Spine Injury
• Assume every trauma patient may have cervical
  spine injury until proven otherwise
• May attempt nasotracheal intubation in breathing
  patient
   – With minimal neck extension plus cricoid pressure
   – Contraindicated in pt. With suspected cribiform fossa
     fracture (e.g. raccoon eyes-Laforte III)
• May attempt oral intubation with 20 lbs. Of
  traction to stabilize head
      Consider level of injury
• Diaphragm is innervated at C3-C5
  – Lesions above this require immediate
    intervention
FACIAL FRACTURES
                   Problems
• Normal anatomy may be distorted
• Bone fragments, blood, teeth can obstruct
  airway
• AS BEFORE:
  – Suspected cranial base fracture should never be
    nasally intubated
     • Can push bone fragments into cranial vault and
       cause brain injury or infection
     Laryngotracheal Trauma

• Airway can be better assessed if mechanism
  of injury is known
             Blunt Trauma

• Caused by injuries from blow to neck,
  strangulation, hyperextension
        Signs and Symptoms
• Hoarseness, pain, open laceration, strider

• Sub-Q emphysema, crepitis (rice krispies
  under the skin), bloody sputum, & cough
  may indicate tracheal tear
        Signs and Symptoms
• Because injuries come from structures being
  compressed against the C-spine
  – Should also suspect cervical injury


• Other structures may be injured
  – Esophagus: mediastinitis
  – Arteries: stroke, hematoma, hemorrhage
                Treatment

• If there is any question about the patients
  airway>>INTUBATE IMMIDIATLEY!!
         Penetrating Trauma
• Airway injury usually more obvious than
  blunt trauma

• Life threatening obstruction or massive
  hemorrhage can result from:
  – Stab wounds, GSW, or shrapnel
         Penetrating Trauma
• Airway obstruction results from nearby soft
  tissue injury, displacement of cartilage, or
  edema

• Although the wound may look benign, with
  symptoms of cough, strider, dyspnea, and
  sub-Q emphysema should suggest the need
  for intubation
         Penetrating Trauma
• May involve pleura leading to
  pneumothorax
• Be aware of S&S of tension pneumo after
  intubation
  – Absence of BS on one side after intubation
  – Deviate trachea
  – Distended neck veins
         Penetrating Trauma
• Again: immobilization of the neck during
  intubation is necessary until it is cleared

• Cricothyroidotomy kit should be nearby in
  case of complete obstruction or failed
  intubation
                  Burns
• Pulmonary injury from smoke inhalation is
  the main cause of early death in burn
  patients

• DEFINITION: inhalation injury results in
  damage to the respiratory tract from the
  products of combustion
                   Burns

• Severity and nature of the injury are directly
  related to:
  – Chemical composition of the smoke
  – The extent of exposure
                    Burns
• Damage to the lungs includes:
  –   Inflammation
  –   Mild edema
  –   Necrosis
  –   Mucosal sloughing

• These all lead to total airway obstruction

• MANAGEMENT: early detection and
  intubation
            Thermal Injury
• Amount of injury is related to the temp of
  the inhaled gas

• The most severe thermal burns are caused
  by:
  – Steam
  – Soot
  – Fumes from combustible materials
         Chemical Inhalation

• Dangers not only from local irritation, but
  from systemic poisoning as well
          Soluble Agents
(e.g. chlorine, ammonia, & sulfur)

• ―Stink‖ or foul smelling

• Short exposure time

• Inflammation of the upper airway
       Poorly Soluble Agents

• Lead to damage of the lower airways
  – Pulmonary edema
Combustion of Synthetic Materials
    (e.g. CO, cyanide, hydrogen
sulfate, methyl bromide, & arsenic)

• Don’t necessarily have caustic effect on
  lungs but are bad when systemically
  absorbed
  – Interrupt O2 transport in the blood
                 Diagnosis

• Important details to know:
  – H/O exposure of fire in an enclosed space
  – Loss of consciousness
  – Type of inhalation agent present
              Physical Signs
•   Facial burns
•   Singed nose hairs
•   Coughing
•   Wheezing
•   Dyspnea
•   Rales
    – YOU NEED TO ACT QUICKLY!!
                Treatment
• Supportive therapy

• Early intubation protects airway against
  swelling that occurs in the first 2-8 hours

• Distal airway burns are seen within 12-92
  hours and resemble pulmonary edema
      Other Reasons for Early
            Intubation
• Difficulty clearing secretions

• Compromise from strictures caused by
  circumferential chest burns

• Protecting the comatose patient from
  aspiration
  Modes of Airway Intervention

• NOTE: the tongue is the most common
  cause of airway obstruction in the comatose
  patient
         Chin Lift/Jaw Thrust
• Used to move the tongue away from the
  posterior pharynx
  – Chin lift
        – Place two fingers under the mandible and lift up
        – Neck should not hyperextend
        – Contraindicated in pts with suspected c-spine injury
  – Jaw thrust
     • Lift the angle of the mandible
       Oropharyngeal Airway
• Holds tongue from the post pharynx

• Prevents patient from biting tube and makes
  suctioning easier

• 80-90mm is the acceptable size in most
  adults
                Technique

• Put in mouth backwards until it hits the soft
  palate then turn it 180 degrees

• Can use a tongue blade
             Complications
• If too long, can push the tongue against the
  larynx producing obstruction

• May induce vomiting and laryngospasm in
  an awake patient
      Nasopharyngeal Airway
• Used when oral airway fails

• Used in semiconscious patients

• 28-34 french is acceptable size for most
  adults
                 Technique
• Lubricate

• Slide straight back along the floor of the
  nostril

• Do not force
             Complications
• May be too long and slide into the
  esophagus
  – Insufflate stomach during bag ventilation


• Can cause bleeding
       Intervention Continued
• NOTE: the provider should always check
  respirations after intervention to assure
  patent airway

• If airway is not patent, then move to the
  next intervention
MODES OF OXYGEN
   DELIVERY
             Nasal Cannula
• 3-4% incr. in FiO2 per liter flow rate up to 6
  L/min

• Provides a supplemental O2 source in
  spontaneous breathing pt
                Face Mask
• Simple face mask
  – FiO2 35-60% with flow rate 5-8 L/min
  – <5 L/min, re-breathe CO2
  – Mixes O2 with ambient room air

• Partial and nonrebreathing face masks
  – FiO2 80-100% with rate >10L/min
  – Reservoir bag fills with O2
  – Does not allow breathing of ambient room air
                Face Mask

• Air-entrainment masks
  – FiO2 25-50% with flow rate >10 L/min
  – Can dial in flow rate of O2 that mixes with
    ambient room air (e.g. venturi mask)
                 Bag-Valve
                  Devices
• Consists of self-inflating bag and
  nonrebreathing valve

• Corrugated reservoir allows you to deliver
  100% O2 with each squeeze of the bag

• Volume of bag about 1500cc
  – Sufficient ventilation for most pts
  – Technique must be good
             Complications
• Insufflate stomach causing vomiting &
  potential aspiration

• Poor mask fit wastes effort

• Airway must not be obstructed by tongue,
  soft tissues, or debris
        Orotracheal Intubation
• REASONS:
  – Isolate airway (e.g. infection, hemothorax, one-sided
    lung injury)
  – Patent airway
  – Decrease risk of aspiration
  – Suctioning of airway
  – Delivery of 100% FiO2
  – Administering drugs
  – Delivery of vent. to maintain adequate lung inflation
        Things to Remember
• Standard tube sizes
  – Male—8.0mm ID
  – Female—7.0 mm ID


• Depth of tube
  – 20-24 cm at teeth
      Assessing Tube Placement
•   Condensation on tube
•   Bilateral/equal breathe sounds
•   Absence of gurgle over epigastrum
•   ETCO2
•   Rising SaO2
    Complications of Orotracheal
            Intubation
• Lips/tongue lacerated by teeth or blade
• Chipped teeth
• Lacerated trachea from stylet
• Sloughing, bleeding, hematoma of tracheal
  mucosa
• Injury to vocal cords
• Vomiting and aspiration of stomach contents
   Complications of Orotracheal
           Intubation
• Awake patient
  – Increase release of catecholamines
     • HTN
     • Incr. HR
     • Arrhythmias


• Right mainstem intubation

• Unrecognized esophageal intubation

• Death
  Questions




Ed Alexander CPT