Backup Airways New Hampshire Division of Fire Standards & Training and Emergency Medical Services 2011
Purpose • It is vital that the prehospital crew be confident and comfortable with the rescue airways approved for their level of licensure. • During this module you will review and practice the back up airways for your level of licensure.
Purpose • Review Backup Airway Devices (Rescue Airways) • BVM • LMA • King-LT-D • Combitube
What do we do when we have a difficult airway?
The Basics • Position • OPA • BVM • Suction Most difficult airways will still be manageable using basic airway maneuvers!
The Need for Oxygen • 0 – 1 minute: cardiac irritability • 0 – 4 minutes: brain damage not likely • 4 – 6 minutes: brain damage possible • 6 – 10 minutes: brain damage very likely • > 10 minutes: irreversible brain damage
Oxygen and Carbon Dioxide Exchange • Oxygen-rich air is inhaled to alveoli • O2 exchanged at alveolocapillary level • Perfusion to capillary beds • O2/CO2 exchange at cellular level • Perfusion from capillary beds • CO2 exhanged at alveolocapillary level • CO2 exhaled
Assessment of Respiration • Patients level of consciousness • Respiration quality • Pulse quality • Respiratory rate • Pulse rate • SPO2 • EtCO2 • Blood pressure • Glasgow coma score
Every TRUE life saving intervention performed by EMS reverses one or more failing components of respiration
Inadequate Breathing • Fast or slow rate • Irregular rhythm • Abnormal lung sounds • Reduced tidal volume • Use of accessory muscles • Cool, pale, diaphoretic, cyanotic skin
Head Tilt-Chin Lift • One hand on the forehead • Apply backward pressure • Tips of fingers under mandible • Lift the chin
Jaw-Thrust Maneuver • Place fingers behind the angle of the jaw • Use thumbs to open mouth
Look, Listen, and Feel • Assess that Airway!
Basic Airway Adjuncts • Oropharyngeals • Keeps tongue from blocking oropharynx • Eases suctioning • Used with BVM • Patients without gag reflex • Nasopharyngeals • Maintains patency of oropharynx • Patients with gag reflex • Should not be used with head trauma
Oxygen • Nonrebreathing mask • Provides up to 90% oxygen • Used at 10 to 15 L/min • Nasal cannula • Provides 24% to 44% oxygen • Used at 1 to 6 L/min
Oxygen • Nasal cannula • 24-40% at 1-6 liters • Non-rebreather mask • Up to 90% at 15 liters • BVM • 21% atmosphere • Up to 100% at 15 liters with reservoir
Artificial Ventilation • Mouth to mask • BVM – one person • BVM – two person
Ventilation Rates • Adults: 8 - 10 breaths per minute • Approximately one breath every 6 – 8 seconds • Pediatric: 12 – 20 breaths per minute • Approximately one breath every 3 – 6 seconds
Bag O2 Reservoir Valve Mask Bag Valve Mask • Delivers > 90% oxygen • Requires practice and proficiency • Use with airway adjuncts and/or advanced airways
BVM-Problems encountered • Inattentiveness • Poor mask seal = poor ventilatory ability • Varying ventilatory rates • Varying expiration rates • Varying tidal volumes • Often excessive airway pressure • Often hyper-ventilation Mastering the BVM overcomes these obstacles!
BVM – One person • Insert an oral/nasal airway • Seal mask by placing the apex over the bridge of the nose and lower portion of the mask over the mouth and upper chin. • Make a “C” with your index finger and thumb around the mask. • Maintain the airway with your middle, ring and little finger, creating a “E”, under the jaw to maintain the chin lift. • Squeeze the bag with your other hand slowly at a rate of one breath every 6–8 seconds. • Monitoring SpO2
BVM – Two Person • Insert oral/nasal airway • First provider hold the bag portion of the BVM with both hands. • Second provider seals the mask with apex over the bridge of the nose and base at the upper chin. • Using two hands the second provider places his/her thumbs over the top half of the mask; index and middle finger over bottom half; ring and little finger under jaw. • Second provider also maintains chin-lift • First provider squeezes bag every 6–8 seconds • Monitoring SpO2.
Adequate Ventilation • Equal chest rise and fall • Appropriate rate • Heart rate returns to normal
Inadequate Ventilation • Minimal or no chest rise • Ventilating too fast or too slow • Heart rate does not return to normal
Asthma and COPD • These patients complicate the traditional RSI approach due to the difficulty encountered when mask ventilating • Alveolar hyperinflation secondary to underlying pathophysiology must be considered and adequate passive ventilation time must be ensured • Tidal volumes should be reduced, initially, to reduce likelihood of barotrauma and air trapping
Gastric Distention • Air fills the stomach from too forceful or too frequent ventilations • Airway may be blocked and ventilations are re-routed to stomach • Decreases lung capacity • May cause patient to vomit
Airway Obstructions • Tongue • Vomit • Blood, clots, traumatized tissue • Swelling • Foreign objects
Recognizing an Obstruction • Partial or complete? • Can patient speak? Cough? • If unconscious, deliver artificial ventilation • Does air go in? Does the chest rise?
Removing an Obstruction • Heimlich maneuver • Suction • Magills (paramedics)
Suctioning • Turn on unit and ensure proper suctioning pressure (300 mmHg) • Select proper tip and measure • Insert with suction off • Suction on the way out • Suction for no more than 15 seconds
Continuous Positive Airway Pressure (CPAP) Is the patient a candidate for CPAP?
CPAP Indications • Any patient in respiratory distress associated with CHF with any of the below obvious signs and symptoms or a history of CHF: • Bibasilar or diffuse rales • Respiratory rate greater than 25 • Pulse oximetry below 92% • Retractions or accessory muscle use • Abnormal capnography (rate, waveform, CO2 levels)
RSI Indication • Immediate severe airway compromise in the context of trauma, drug overdose, status epilepticus, etc. where respiratory arrest in imminent.
Always have a back-up plan. • Plans “A”, “B”, and “C” • Know the answers before you begin
Plan “A”: (ALTERNATIVES) • Different: • Size of blade • Type of blade • Miller • Macintosh • Specialty • Position (patient & provider) • Hockey stick bend in ETT or Directional tip ETT • Remove the stylette as you pass through the cords • “BURP” (aka “ELM”) • Gum Elastic Bougie • 2-person technique • “cowboy” or “skyhook” • Have someone else try
Viewmax Scope • Easy of use • Can be used like a Mac or Miller • Should improve your view by one grade
“BURP” – a.k.a. “External Laryngeal Manipulation” • Backward, Upward, Rightward Pressure: manipulation of the trachea • 90% of the time the best view will be obtained by pressing over the thyroid cartilage Differs from the Sellick Maneuver
Plan “B”: (BVM and BACK UP Airways) • Can you ventilate with a BVM? • (Consider two NPA’s and an OPA, + Cricoid pressure w/ gentle ventilation) • KING–LT-D • Combitube • LMA