Download Digital Intubation

A

patient who needs intubation may be awake.
Need for airway control may necessitate intubation.
 RSI
paralyzes the patient to facilitate
endotracheal intubation.
 Anatomical
Differences
Smaller and more flexible than an adult
 Tongue proportionately larger
 Epiglottis floppy and round
 Glottic opening higher and more anterior
 Vocal cords slant upward, and are
closer to the base of the tongue
 Narrowest part is the cricoid cartilage

A
straight laryngoscope blade is preferred
for most pediatric patients.
 Selecting the appropriate tube diameter for
children is critical.


ETT size (mm) = (Age in years + 16) ÷ 4
Matching it to the diameter of the child’s smallest
finger
 Use
non-cuffed endotracheal tubes with
infants and children under the age of 8
years.
© Scott Metcalfe
© Scott Metcalfe
© Scott Metcalfe
© Scott Metcalfe
© Scott Metcalfe
© Scott Metcalfe
© Scott Metcalfe
© Scott Metcalfe
 Mask
seal can be more difficult
 Bag size depends on age of child
 Ventilate according to current standards
 Obtain chest rise and fall with each breath
 Assess adequacy of ventilations by observing
chest rise, listening to lung sounds, and
assessing clinical improvement
 “Blind”
procedure without direct
visualization of the vocal cords
 Indications include:
Possible spinal injury
 Clenched teeth
 Fractured jaw, oral injuries, or recent
oral surgery
 Facial or airway swelling
 Obesity
 Arthritis preventing sniffing position

 Contraindications




Suspected nasal fractures
Suspected basilar skull fractures
Significantly deviated nasal septum or other nasal
obstruction
Cardiac or respiratory arrest
 Advantages
The head and neck can remain in neutral position
 It does not produce as much gag response and is
better tolerated by the awake patient
 It can be secured more easily than an orotracheal
tube
 The patient cannot bite the ETT

 Disadvantages
More difficult and time consuming
 Potentially more traumatic for patients
 Tube may kink or clog more easily
 Greater risk of infection
 Improper placement more likely
 Requires that patient be breathing

 Field



extubation may be indicated when:
The patient is clearly able to maintain and
protect his airway.
The patient is not under the influence of
sedatives.
Reassessment indicates the problem that led to
endotracheal intubation is resolved.
 Consider
the high risk of laryngospasm
A


dual-lumen airway
The longer, blue port (#1) is the proximal port
The shorter, clear port (#2) is the distal port,
which opens at the distal end of the tube
 Two


inflatable cuffs
100-mL cuff just proximal to the distal port
15-mL cuff just distal to the proximal port
ETC Airway
Tracheal Placement
 Advantages
Provides alternate airway control
 Insertion is rapid and easy
 Does not require visualization of the larynx
 Pharyngeal balloon anchors the airway
 Patient may be ventilated regardless of tube
placement
 Significantly diminishes gastric distention
 Can be used on trauma patients
 Gastric contents can be suctioned

 Disadvantages



Suctioning tracheal secretions is impossible when
the airway is in the esophagus.
Placing an endotracheal tube is very difficult with
the ETC in place.
It cannot be used in conscious patients or in those
with a gag reflex.
 Disadvantages




The cuffs can cause esophageal, tracheal, and
hypopharyngeal ischemia.
It does not isolate and completely protect the
trachea.
It cannot be used in patients with esophageal
disease or caustic ingestions.
It cannot be used with pediatric patients.
Click here to view a video on ETC.
 Two-tube


system:
Proximal cuff seals
oropharynx
Distal cuff seals
either the esophagus
or the trachea
 Advantages
 Disadvantages
 Has
an inflatable
distal end that is
placed in the
hypopharynx and
then inflated
 Blind insertion
 Disadvantage:

Does not isolate
trachea
 It
is designed to
facilitate endotracheal
intubation.
 An epiglottic elevating
bar in the mask
aperture elevates the
epiglottis.
 Tube is directed
centrally and anteriorly.
© LMA North America
 Similar
to the
laryngeal mask

Supraglottic airway
 “Cobra
head” of the
airway holds both
the soft tissue and
the epiglottis out of
the way
© Engineered Medical Systems, Inc. Indianapolis, IN
 Supraglottic,
singleuse, disposable
airway
 Features a special
curve that
replicates the
natural human
airway anatomy
© Ambu Inc. Baltimore, MD
 Alternative

airway
Large silicone cuff
that disperses
pressure over a large
mucosal surface area
 Stabilizes
the
airway at the base
of the tongue
©Tracey Lemons/King Systems Corporation, Indianapolis, Indiana
 Removing
an obstructing foreign body using
Magill forceps or a suction device
 You should carry out basic life support
maneuvers first.

If these fail to alleviate the obstruction, direct
visualization of the airway for foreign body
removal is indicated.
 You
should use surgical airway procedures
only after you have exhausted your other
airway skills:
Needle cricothyrotomy
 Surgical cricothyrotomy

 Indications


Massive facial or neck trauma
Total upper airway obstruction
 Contraindications




Inability to identify anatomical landmarks
Crush injury to the larynx
Tracheal transection
Underlying anatomical abnormalities
 Transtracheal
jet insufflation is required
 Complications:





Barotrauma from overinflation
Excessive bleeding due to improper catheter
placement
Subcutaneous emphysema
Airway obstruction
Hypoventilation
 It
is preferred to needle cricothyrotomy
when a complete obstruction prevents a
glottic route for expiration.
 Its greater potential complications mandate
even more training and skills monitoring.
 Contraindications:

Includes children under 12
 Cricothyrotomy
Complications:
Incorrect tube placement into a false passage
 Cricoid and/or thyroid cartilage damage
 Thyroid gland damage
 Severe bleeding
 Laryngeal nerve damage
 Subcutaneous emphysema
 Vocal cord damage
 Infection

Stabilize larynx and make a 1–2 cm
vertical skin incision over
cricothyroid membrane
Using a curved hemostat,
spread membrane incision open
 Terms

Difficult airway


A conventionally trained paramedic experiences difficulty
with mask ventilation, endotracheal intubation, or both
Difficult mask ventilation


Inability of unassisted paramedic to maintain an SpO2 >
90% using 100% oxygen and positive pressure mask
ventilation
Inability of the unassisted paramedic to prevent or
reverse signs of inadequate ventilation during positive
pressure mask ventilation
 Terms

Difficult laryngoscopy


(cont.)
Not being able to see any part of the vocal cords with
conventional laryngoscopy
Difficult intubation

Conventional laryngoscopy requires either (1) more than
three attempts, or (2) more than ten minutes
 Factors
related to difficult airway are
related to historical information,
anatomical, and poor technique
 Historical


Factors:
Patient has had a history of problems with airway
management or anesthesia.
If time and patient condition allows, obtain a
brief airway history.
 Anatomical


Considerations
Anatomy of the upper airway varies significantly
across the human species.
The most frequently used system of preintubation airway assessment is the Mallampati
Classification system.

The tonsillar pillars and the uvula are assessed.

Class 1


Class 2


Upper half of tonsil fossa
visible
Class 3


Entire tonsil clearly
visible
Soft and hard palate
clearly visible
Class 4

Only hard palate visible
The Mallampati classification system is at top.
 Other

Revised Cormack and LeHane classifications



rating systems
Similar to Mallampati
Assigns 4 classes
POGO

The percentage of the glottis that can be visualized is
scored

From 0 to 100%
 Short
neck
 Short mandible
 Thick neck
 Anterior larynx
 Restricted range of
 Obesity
motion
 Anatomical
 Dentition
distortion
 Small mouth
 Patients
who have had a laryngectomy or
tracheostomy breathe through a stoma.
 There are often problems with excess
secretions, and a stoma may
become plugged.

Use extreme caution with any suctioning.
 Anticipating
complications when
managing an airway

Be prepared to
suction all airways to
remove blood or
other secretions and
for
the patient to vomit.
Tracheostomy cannulae
 Wear
protective eyewear, gloves, and face
mask.
 Preoxygenate the patient.
 Determine depth of catheter insertion.
 With suction off, insert catheter.
 Suction while removing catheter .
 Ventilate patient.
 It
is sometimes necessary to remove
secretions or mucous plugs that can cause
respiratory distress.
 Hypoxia is a concern.
 Use sterile technique.
 It may be necessary to instill sterile water
to thin secretions.
A
common problem with ventilating a
nonintubated patient is gastric distention.
 You should place a tube in the stomach for
gastric decompression.


Nasogastric tube
Orogastric tube
 Indications:


The need for decompression because of the risk
of aspiration or difficulty ventilating
Gastric lavage in hypothermia and some overdose
emergencies
 Complications:


Possibility of esophageal bleeding
Increased risk of esophageal perforation
 Procedure
Place head in neutral position
 Measure tube
 Use topical anesthetic
 Lubricate and insert tube


Encourage patient to swallow
Advance to pre-determined mark
 Verify placement
 Apply suction
 Secure in place

Device
Oxygen
Percentage
Nasal cannula
40%
Venturi mask
24, 28, 35, or 40%
Simple face mask
40 – 60%
Nonrebreather mask
80 – 95%
 Small

Volume Nebulizer
Allows for delivery of medications in aerosol form
(nebulization)
 Oxygen

Humidifier
Benefits patients with croup, epiglottitis, or
bronchiolitis, as well as those patients receiving
long-term oxygen therapy
 Effective
ventilatory support requires a tidal
volume of at least 800 mL of oxygen at 10 to
12 breaths per minute.
 Effective artificial ventilation requires:



A patent airway
An effective seal between the mask and the
patient’s face
Delivery of adequate volumes
 Mouth-to-mouth
 Mouth-to-nose
 Mouth-to-mask
 Bag-valve
device
 Demand valve device
 Automatic transport ventilator
 Indicated
in the presence of apnea when no
other ventilation devices are available
Limited by the capacity of the person delivering
the ventilations
 Potential for exposing either the rescuer or the
patient to communicable diseases

 Prevents
direct contact between you and
your patient’s mouth
 Devices usually have a one-way valve that
prevents you from contacting the patient’s
expired air.
 May also provide an inlet for supplemental
oxygen
 Prehospital
and
emergency
department
personnel most
commonly use the
bag-valve device.
 One, two, or three
rescuers may
perform bag-valvemask ventilation.
© Scott Metcalfe
 Observe
the patient for chest rise, gastric
distention, and changes in compliance of
the bag with ventilation.
 Complications:



Inadequate volume delivery
Barotrauma
Gastric distention
 Flow-restricted,
oxygen-powered
ventilation device
 Flow is restricted
to 30 cm H2O or
less to diminish
gastric distention
 Cannot measure
delivered volumes
or feel lung
compliance

Advantages:



Typically comes with two
or three controls



Maintain minute volume
Mechanically simple and
adapts to a portable oxygen
supply
Rate
Volume
Contraindications
A
significant percentage of claims and
lawsuits involve inadequate patient
ventilation.
 Detailed documentation shown could go a
long way toward warding off such a claim.
It is crucial to document in medically correct and legally sufficient
terms exactly what was done in managing the airway.

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





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

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Anatomy of the Respiratory System
Physiology of the Respiratory System
Respiratory Problems
Respiratory System Assessment
Basic Airway Management
Advanced Airway Management
Orotracheal Intubation
Pediatric Orotracheal Intubation
Nasotracheal Intubation
Managing Patients with Stoma Sites
Suctioning
Gastric Distention and Decompression
Oxygenation
Ventilation
Documentation