AIRWAY PROCEDURES COURSE - cont'd info

Considerations for oral endotracheal intubation

All of these conditions will make oral intubation difficult and increase the need for a surgical airway

Tracheal fracture or disruption

Inability to extend neck

– C spine fracture requires cervical immobilization
– Fused neck: consider fiberoptic oral intubation

Uncontrolled oropharyngeal hemorrhage

Mandibular fracture, trismus, or limited jaw opening

Complications of endotracheal intubation

Equipment for a Glidescope intubation

• Gloves
• Mask and protective face shield
• Suction system
• Bag-valve mask
• Endotracheal tube with stylet
  • Tube size in children = (age in years + 16)/4 or equal to pinky nail
  • Use uncuffed tube for tube size <6.5 mm or for children 8 years or less
• 10 mL syringe
• End-tidal CO2 detector
• Stethoscope
• Laryngoscope with different sizes of Miller and Macintosh blades
• Eschmann stylet available
• Intermediate airway available

• Hypotension
• Cardiac arrest
• Arrhythmias
• Esophageal intubation
• Laryngospasm
• Vocal cord trauma
• Oral trauma
• Corneal abrasion
• Tracheal perforation (by stylet)
• Aspiration pneumonitis
• Pneumothorax
  

Proper positioning and technique for endotracheal intubation

• Head extended 90°
• Head raised 4 inches off the bed
• Place towel underneath shoulders in infants

Options for difficult airway management

Airway Adjuncts

– Intubating Sylet

Video Laryngoscopy

Intermediate Airway

– LMA
– Combitube
– King Tube

Surgical Airway

– Needle Cricothyroidotomy
– Surgical Cricothyroidotomy

Awake intubations

• Requires cooperative, relatively calm patient
• Ondansetron 4 mg IVP
• Glycopyrrolate 0.2 mg IVP and wait 2 minutes
• Suction out mouth and use 4 x 4’s to dry off tongue
• Place patient in ramp position and reverse Trendelenberg
• Preoxygenate and leave NC at 15 L/ min
  

• Atomize 3-5 mL4% lidocaine onto posterior pharynx and peritonsillar area
• May repeat until 10 mL atomized
• Watch for
  – tinnitus
  – visual disturbance
  – seizures
• Sedation
  – Ketamine 75 mg + propofol 25 mg IVP
• Visualize cords with video laryngoscope

• Spray vocal cords with 3 mL 4% lidocaine using a metered atomizing device
• Give 2- 3 mL additional ketofol if necessary
• Place ETT
  

Rapid sequence intubations

• The Seven ‘Ps” of Rapid Sequence Intubation
• Preparation
• Preoxygenation
• Pretreatment (LOAD)
  – Lidocaine, Opiate, Atropine, Defasciculating agent
• Paralysis (with induction)
• Protection (from aspiration) – ??? cricoid pressure
• Placement of tube with proof
  – Depth of insertion is 3- 4 cm beyond cords
  – EtC02 monitor and breath sounds
• Post-intubation management

Options for the Can’t Ventilate Can’t Intubate scenario

Anticipate and Avoid

– Delay until help arrives
– Awake Intubation
– Video Laryngoscopy

Plan and Proceed

– Intubation Adjuncts
– Video Laryngoscopy
– Intermediate Airway
– Surgical Airway

Airway Adjuncts

– Intubating Stylet

Video Laryngoscopy

Intermediate Airway

– LMA
– Combitube
– King Tube

Surgical Airway

– Needle Cricothyroidotomy
– Surgical Cricothyroidotomy

The use of an intubating stylet (i.e., Eschmann stylet or Bougie) to assist intubation

• Feel for washboard sensation.
• Will stop at carina (hang up sign).
• Need jaw lift (laryngoscope or jaw lift).
• If stuck on arytenoids back up two centimeters and turn 90 degrees counterclockwise.
  

Laryngoscope kept in place
ETT placed on stylet
ETT advanced over styletRemove stylet
Leave ETT in position

Simulation Based Training Improves Airway Management SkillsJoseph Esherick, M.D., FAAFP, FHMSimulation-based procedural training has been shown to improve procedural competence, safety, operator confidence and most importantly patient safety for every bedside procedure studied.  Now, a new systematic review and meta-analysis confirms that simulation-based training in airway management improves procedural competence with direct laryngoscopy, endotracheal intubation, video laryngoscopy, laryngeal mask airway insertion, and King tube airway insertion.[1]Simulation-based procedural training has been shown in prior studies to improve the procedural competence, procedural success rate, operator confidence, and patient safety for a number of procedures:  central line placement, thoracentesis, lumbar puncture, and paracentesis.[2],[3],[4],[5],[6][7]This new meta-analysis analyzing the effect of simulation-based training on airway management skills included 76 studies and over 5,200 clinicians.  The investigators found that simulation-based training compared with nonsimulation learning increased learner satisfaction (standardized mean difference 0.54), improved procedural skills (standardized mean difference 0.64), and improved patient outcomes (standardized mean difference 0.86).  The knowledge of procedures was equal between the two groups.This is another study that demonstrates that simulation-based training is the best way to teach physicians and midlevel providers how to perform bedside procedures.  Simulation-based training has consistently been proven to improve operator confidence, procedural success rate, and patient outcomes.Options for the Can’t Ventilate Can’t Intubate scenario:

Glidescope Intubation 

Indications for endotracheal intubation

• Airway obstruction

• Major facial or neck injury with potential for airway obstruction

• GCS < 8 in the setting of trauma

• Persistent combativeness refractory to medications in the setting of trauma

• Major skin burns of 40% or more of body

• Severe smoke inhalation

• Moderate-severe facial or oropharyngeal burn

• Unable to protect airway
• Hypercapneic respiratory failure
• Hypoxic respiratory failure
• Cardiac arrest
• Need to maintain hyperventilation

– Closed head injury

Considerations for oral endotracheal intubation

All of these conditions will make oral intubation difficult and increase the need for a surgical airway

• • Tracheal fracture or disruption
  • Inability to extend neck

– C spine fracture requires cervical immobilization
– Fused neck: consider fiberoptic oral intubation

• • Uncontrolled oropharyngeal hemorrhage
  • Mandibular fracture, trismus, or limited jaw opening

Complications of endotracheal intubation

Equipment for a Glidescope intubation

• • • Gloves
    • Mask and protective face shield
    • Suction system
    • Bag-valve mask
    • Endotracheal tube with stylet
      • Tube size in children = (age in years + 16)/4 or equal to pinky nail
      • Use uncuffed tube for tube size <6.5 mm or for children 8 years or less
    • 10 mL syringe
    • End-tidal CO2 detector
    • Stethoscope
    • Video Laryngoscope with appropriate blades

• • • Hypotension
    • Cardiac arrest
    • Arrhythmias
    • Esophageal intubation
    • Laryngospasm
    • Vocal cord trauma
    • Oral trauma
    • Corneal abrasion
    • Tracheal perforation (by stylet)
    • Aspiration pneumonitis
    • Pneumothorax

• • • Eschmann stylet available
    • Intermediate airway available

Technique for adult and pediatric Glidescope intubation

• • • The Seven “P’s” of Rapid Sequence Intubation
    • Preparation 
    • Preoxygenation 
    • Pretreatment (LOAD)
      • Lidocaine, Opiate, Atropine, Defasciculating agent
    • Paralysis (with induction) 
    • Protection (from aspiration) – ??? cricoid pressure
    • Placement of tube with proof
      • Depth of insertion is 3-4 cm beyond cords
      • EtCO2 monitor and breath sounds

• • • Lubricate blade
    • Insert video laryngoscope in midline over tongue
    • Look at screen and find epiglottis
    • Insert blade into vallecula
    • Elevate blade to find cords
    • Look at mouth and insert ETT from side until vou see tube on monitor

• • • Rotate tube 90 degrees in line with video laryngoscope blade
    • Watch ETT pass through cords.
    • Withdraw stylet using thumb and simultaneously advance tube to appropriate depth.

• • • Post-intubation management 

Options for Difficult Airway Management

Airway Adjuncts

– Intubating Sylet

Video Laryngoscopy

Intermediate Airway

– LMA
– Combitube
– King Tube

Surgical Airway

– Needle Cricothyroidotomy
– Surgical Cricothyroidotomy

Times to consider video laryngoscopy over direct laryngoscopy

• Video Laryngoscopy (VL) vs Direct Laryngoscopy (DL) in ICU
• Systematic review and meta-analysis of 9 studies and 2133 patients
• VL reduced risk compared with DL of

• • Difficult endotracheal intubation rate(OR = 0.29)
  • Cormack-Lehane grades 3 or 4 views (OR = 0.26)
  • Esophageal intubations (OR = 0.14)
  • VL had higher first pass success rate vs DL (OR = 2.1)

• Single center prospective RCT atBeth Israel Hospital
• 153 consecutive patients
• All intubations by pulmonary and critical care fellows
• Neuromuscular blocking agents were rarely used
• First attempt success rate

• • 74% using video laryngoscopy
  • 40% using direct laryngoscopy

• Evaluated use of Glidescope at two academic medical centers
  operating rooms
• Over 71,000 Glidescope intubations studied
• Overall success rate of intubation was 97%
• Success after failed direct laryngoscopy was 94%
• Predictors of Glidescope intubation failures

• • Altered neck anatomy
  • Previous neck surgery
  • Previous neck radiation
  • Neck or oropharyngeal mass

• Meta-analysis of video laryngoscopy (VL) vs Macintosh intubations for patients in C-spine immobilization
• 24 trials with 1866 patients analyzed
• Improved outcomes for VL vs Mac

– Significant reduction in first- attempt failures for VL vs Mac

• • 9.9% vs 24.5% (RR = 0.53)

– Improved Cormack-Lehane grade visualization

• • 66%CL grade 1 view with VL vs 18%for Mac (RR= 3.44)

– Decreased supraglottic or lip trauma

• • RR 0 3

Options for the Can’t Ventilate Can’t Intubate scenario

Coding for endotracheal intubation

• • • 31500 Endotracheal intubation