Emergency Airway

Management
 Objective
s
• Recognize when someone needs an
airway
• How to assess an airway
• How to do airway management
techniques- oral/nasal, BVM,
LMA, intubation
• Understand basic medications used
for airway management
 Specific
• Objectives
Discuss Airway Assessment
– Assessing for difficult bag mask ventilation
– Assessing for difficult intubation
– Specific issues when dealing with the critically
ill
• Discuss the 4 Ps of Pre-intubation:
– Preparation
– Pre-oxygenation
– Positioning
– Planning
 Case

50 y.o with End Stage Renal Disease

Missed Hemodialysis
Chief Complaint- Sudden DOB
BP- 70/60 mm Hg
HR 110 bpm
RR 26 cpm
Temp 38C
O2 Sats 88 % in room air
GCS 8
Retractions on Deep Breaths with
Crackles Bibasal
 Hypoxemia
Arterial O2 Saturation of <94%
<8 kpa or 60mm hg

For patients with Lung Disease (COPD)

90% O2 saturation may be normal.
Hemoglobin Dissociation
Curve
 Oxyhemoglobin dissociation curve
shows the relationship between the
hemoglobin saturation (SO2) at
different oxygen tensions (PO2)

 The P50 is the oxygen tension at which

hemoglobin is 50% saturated.
 Decreased P50
Increased Affinity to O2
Decreased Temperature

Decreased PCO2

Decreased 2,3 DPG

Increased PH
 Increased P50
Decreased Affinity to O2

Increased Temperature

Increased PCO2

Increased 2,3 DPG

Decreased pH
 Causes of Hypoxemia
Alveolar hypoventilation

Mismatch between Ventilation and

Perfusion

Pulmonary Diffusuion
Abnormalities
 Causes for Alveolar
Hypoventilation

Airway Obstruction
>Tongue
>Blood
>Vomitt
>Bronchospasm
>Edema of the Airways
Infection and Burns
 Causes for Alveolar
Hypoventilation
CNS Depression
>Drugs/Alcohol Intoxixation
>CNS injury/ Hypothermia

Impaired Mechanics of
Ventilation
>Pain
>Pulmonary Edema/Lung Disease
>Pneumothorax
 Mismatch Between
Ventilation and Perfusion
Perfusion is Less than Ventilation
>Wasted Ventilation.

Ventilation is < than perfusion

> Hemoglobin is with Decreased O2
content
 Pulmonary Diffusion Defects
> Any condition that causes thickening of
the Alveolar Membrane
How Much Oxygen Should
Be Delivered?
 Acutely ill/Toxic Patients
Cardiac Arrest or Peri Arrest
Shock
Sepsis
Anaphylaxis
Severe Head Injury
Carbon Monoxide Poisoning
 Devices used for Delivery of
Oxygen
Hudson Mask
Hudson Mask with Reservior
Nasal Cannula
 Assisted Ventilation
Bag Valve Mask
Bag Valve Mask with
Reservior
 Disadvantages
>Affected by Light
>Unreadable with Certain Hemoglobins
Hemoglobin S, Methhemoglobin
>Unreliable with severe Vasoconstriction
>Affected by extraneous Light
>Unreliable when there is Excessive
Movement
ABG Analysis
 Airway
Assessment
• Can be more challenging in the critically
ill
• Must avoid the “cannot intubate,
cannot ventilate”scenario.
• Must assess
1) Risk for difficult mask ventilation
2) Risk for difficult intubation
3) Risk for physiological deterioration
 Bag Mask
Ventilation
• Crucial airway management skill
• Takes practice to perform correctly
• Gives time for well-planned approach
to definitive airway management
• 3 keys:
1. Patent airway
2. Good mask seal
3. Proper ventilation
 Bag Mask
Ventilation:
1. Patent Airway – airway
maneuvers
Head Tilt and Chin Lift Jaw Thrust

• One hand applies downward • For unstable cervical spine

pressure to forehead and index • Place heels of hands on parieto-occipital
and middle finger of the second area
hand lift at chin. • Grasp angles of mandible with fingers,
• Lifts tongue from posterior and displace jaw anteriorly.
pharynx
 Bag Mask
Ventilation:
1. Patent Airway – airway
positioning
Good alignment Ramping

• Simple measures often make an airway more patent and accessible.

• Pillows may suffice in most patients but some patients require
more.
 Bag Mask
1. Ventilation:
Patent Airway –
Adjuncts

• Need to size properly

• Avoid pushing tongue into posterior pharynx.
• Start with curve of OPA inverted and rotate 180 degrees as
tip reaches posterior pharynx.
• Avoid in awake patient aspiration risk
Nasopharyngeal Airway
 Bag Mask
Ventilation
Good mask seal
One-handed techniques Two-handed techniques

Three facial landmarks that must be covered

by
mask:
1. Bridge of the nose
2. Two malar eminences
 Bag Mask
3.Ventilation
Ventilation
technique
• Small tidal volumes
• Squeeze steadily – do
not force air
too quickly
• 10-12
breaths/min
• Assess for rise
and fall of chest
• Assess patient for
Bag Mask

Ventilatio
n
 Airway Assessment:
Difficult Bag Mask
Ventilation
Bones (Fractures/Trauma)
Obese
No Teeth
Elderly
Snoring/ Apnea
 Airway Assessment:
Difficult Bag Mask
Ventilation
• MOANS
• Mask seal: can’t approximate mask
• Obesity: redundant tissues impede airflow
• Age >55: loss of elasticity of tissues
• No teeth: mask does not sit properly
• Stiff (lungs/body): need increased
pressure
• Sleep apnoea/ Snoring
 Why
Intubate?
• Indications for endotracheal intubation
1. inadequate oxygenation or ventilation
2. airway protection in a patient with altered
mental status
3. expectation 1 or 2 will develop soon!!
• Contraindications for endotracheal
intubation
1. Laryngeal Trauma
2. Obstructed Airway (laryngeal edema, epiglottitis, Acute LTB)
 Immediate Intubation
Patient is deteriorating Rapidly
Definitive Airway is Needed with
Minimum Delay
 Urgent Intubation
Basic Airway Techniques can maintain
the Physiology of the patient for a short
period of time.
To prevent Respiratory Failure or
Aspiration (Facial Trauma, Coma with
vomiting,Laryngeal Swelling)
 Observant Situations
No indication for intubation exists and the
patient can be observed for any
deterioration.
 Reversibe Causes of Airway
Obstruction/ Compromise
>Arrythmia
>Seizures
>Rapid Reversal Causes of COMA
Hypoglycemia/Opoid Overdose
>Pneumothorax
>Acute Pulmonary Edema
>Anaphylaxis
 Type 1 Respiratory Failure
Failure of Oxygenation with no CO2
retention.
>Severe Trauma
>Pneumonia/Pulmonary Edema

>Respiratory Drive is determinant for

intubation
>There is V/Q mismatching
It is preferable to intubate the patient
before Type 2 respiratory Failure or
Exhaustion
 Type 2 Respiratory Failure
Failure of Ventilation with CO2 Retention
 COPD
 Coma/ Overdose
 Neuromuscular Disorders

 Hypoventilation with slow respiration

 Non invasive Ventilation may be
appropriate
 Bag mask ventilation may be required
 To optimize conditions and prepare for
intubation
 Airway Assessment:
Difficult Intubation
• Incidence of difficult intubation varies.
• No clear definition - approximately 5%
• Corresponds to glottic view
• Can’t intubate/can’t ventilate = 1 in
10,000
• Strongly associated with adverse
outcomes
– Airway trauma
– Aspiration
– Hypoxemia/Anoxic brain injury
 Assessing the Airway:
Identification Difficult
Intubation LEMON
–L ook
–E valuate 3-3-2
–M allampati
–O bstruction/Obesity
–N eck mobility
 Assessment for Difficult
Intubation
• External “Look”
– Facial trauma
– Unusual
anatomy
• Internal
– Foreign body
– Obstructing
mass
 Assessment for Difficult
Intubation:
Mouth opening “Evaluate”:
distance
3-3-2
Tip of mentum to hyoid bone Rule
Thyromental

Access to airway Can tongue be Predicts location larynx to

and obtaining glottic deflected to base of the tongue. If larynx
view accommodate high angles difficult
laryngoscope
 Assessment for Difficult
Intubation:
• “Modified
Validated, but Mallampati” Score
not as solitary predictor
• Relates amount of mouth opening to size of tongue.
• Provides estimate of space for oral intubation by direct
laryngoscopy.
• Class I or II : easy laryngoscopy
• Class III difficult
• Class IV: extreme difficulty. (10%failure)
 Assessment for Difficult
Intubation:
• Redundant tissue “Obesity”
in upper airway
may obscure
glottis
• Controversial about
how often difficult
airway
• Proper positioning key
• Think of the pressure
on diaphragm
 Assessment for Difficult
Intubation:
• “Neck”
Decreased cervical spine Mobility
mobility compromises sniffing
position.
• Impairs alignment of axes
and glottic view
• Degenerative or
rheumatoid arthritis
• Cervical immobilization
• Test: extending neck/touching
chest
 Additional Considerations in
the Critically Ill
• Complications intubation higher
– Limited physiologic reserve
– Pre-existing hypoxemia or hemodynamic
instability
– Inability to properly assess airway
• Special Considerations: Three Hs:
– Hypoxemia
– H+ (acidosis)
– Hemodynamics
(hypotension/pulmonary hypertension)
Steps for Endotracheal
Intubation
1. The 4Ps:
– Preparation ( assessment, equipments, drugs, people, place,
plan)

– Pre-oxygenation
– Positioning
– Premedication
2. Achieving Intubating Conditions:
Laryngoscopy/Intubation
3. Post-intubation Care
 Preparatio
n
• Airway assessment
– Signs of difficult bag mask ventilation
– Signs of difficult intubation
• Assembling necessary equipment
and medications.
• Developing an airway management
plan
– Back-up plan
– Back-up to back-up plan
 Preparati
on
• S uction Equipmen
• T ools (laryngoscope, blade, extra
t
batteries)
• O xygen
• P ositioning/plan
• M onitors (pulse ox, BP, capnography)
• A mbu bag, airway devices
• I ntravenous access
• D rugs (premeds, induction, NMB)
 Preparation:
Preoxygenati
• onof oxygen reservoir
Establishment
• Bag mask ventilation not needed if
good preoxygenation.
• Preoxygenation often challenging in the
ED
– Nasal cannulas with high flow oxygen
– PEEP
– NIV as bridging
– Do not attempt to forcibly ventilate a
breathing patient
 Preoygenation
The aim of preoxygenation is to replace
the nitrogen content of the functional
residual capacity (FRC) with oxygen –
termed denitrogenation.

Classical preoxygenation involves 3

minutes of tidal volume breathing of 100
percent oxygen.
This serves to maximise the alveolar
oxygen content.
 Preoygenation
Cooperative patients can be asked to
take 8 vital-capacity
breaths (maximal exhalation followed by
maximal inhalation).

This method generally can reduce the

preoxygenation time to approximately 60
seconds.
 Preoxygenation: Apnea Time (VE=
0)

- Time from 90% to

0% MUCH
shorter than
time from 100%
to 90%.
- Obese and
critically- ill
desaturate quicker.
 Preparation:
Pretreatme
nt adverse effects of
Drugs to mitigate
intubation
•L idocaine (reactive airways or elevated ICP)
• O pioids ( blunts sympathetic response
and increased BP)
•A tropine ( bradycardia – mainly kids)
•D efasiculating Agents (low dose competitive
neuromuscular blocker in elevated ICP) –
alternatively, choose them as the main
paralytic
 Preparation:
Head
Positioning
Supine

Head
Elevated

Head Elevated and Neck

Extending = Sniffing
Position
Positioning:
RAMP
• In supine patient access
to airway obstructed.
• With patient propped in
RAMP position, access to
airway improved.
• Imaginary horizontal line
from external auditory
meatus to the sternal notch
 Preparation
The need for a Plan
Supraglottic Airway
 Induction
Agents
• Purpose: Blunt sympathetic responses,
provide amnesia and improve
intubating conditions.
– Rapid Sequence Intubation:
simultaneous administration of
induction agent and a neuromuscular
blocking.
– Patients with crash/ peri-arrest airway often
need very little induction drug or none at all.
 Induction
•
Agents
Midazolam: time to effect >15 minutes;
hypotension
• Etomidate: rapid onset; no hypotension;
no analgesia; concerns with sepsis
unjustified
• Propofol: rapid onset; hypotension; no
analgesia.
• Ketamine: sedation and analgesia; no
hypotension; bronchodilator effect; respiratory
drive preserved; good for “awake look.”
• Thiopental: rapid onset; no analgesia;
 Neuromuscular
Blockade
• Rapid Sequence Intubation
– Goal: quickly obtain intubating conditions
and quickly secure airway.
– Avoid BMV and minimize risk of aspiration.
– Standard of care in ED
 Neuromuscular
•
Blockade
Succinylcholine
– Onset 45-60 seconds; duration 6-10 minutes
– 1-1.5 mg/kg
– Contraindications: Hx of malignant hyperthermia,
neuromuscular disease with denervation (MD, stroke >
72 hours, burns >72 hours) rhabdomyolysis,
hyperkalemia.
• Non-depolarizing neuromuscular blockers
– Rocuronium 0.8 -1.2mg/kg: fast onset, longer
duration than succinylcholine; can be used if
succinylcholine is contraindicated
– Cisatricurium (Nimbex)
 Laryngoscope
s

Macintosh Miller Blade

Blade
Laryngoscopy
Technique
 Direct Laryngoscopy
Opening Mouth and Inserting
Blade

Opening Mouth with Scissors

Technique
 Lifting the
Scope

Ye No
s
 Laryngoscopy:
Optimizing Glottic View

Cormack-Lehane Scoring of Glottic View

Cricoid
Pressure
Sellick maneuver or
BURP

Avoid passive
regurgitation of
esophageal &
gastric contents

Imaging studies
undermine
theory
 Optimizing Glottic View:
Bimanual Laryngoscopy

1)Drives tip of blade into proper position

optimizing mechanics of indirect
epiglottis elevation.
2) Moves larynx downward into line of
sight.
 Inserting Endotracheal
Tube
Yes,
good

No,
bad
First shot is often the Best
SHot
 Proof of
• Placement
Unrecognized
esophageal intubation
devastating
• Clinical indicators alone
cannot be relied upon
• Capnography gold
standard
• Beware
– Esophageal intubation
may give transient color
change Need >5 breaths
– Cardiac arrest patients
can give false negative
color change
 Rescue
• Strategies
Return to spontaneous
breathing
• Review plan before reattempts
• Always maintain oxygenation
• Bougie, Video laryngoscopy
• Airway Ajuncts
• Cricothyroidotomy
 The Failed Airway
1.Failure to maintain acceptable oxygen
saturation during or after one or more
failed laryngoscopic attempts

2. Three failed attempts at orotracheal

intubation by an experienced intubator,
even when oxygenation can be
maintained or,

3. The single ‘best attempt’ at intubation

fails.
Questions?
Difficult BVM =
BONES Difficult LMA = RODS
Beard Restricted mouth
Obese opening Obstruction
No Distorted airway
teeth Stiff lungs or c-spine
Elderly
• Difficult intubation • Difficult surgical airway
Sleep
= LEMON = SHORT
Apnea /
• Look externally • Surgery
Snoring
• Evaluate 3-3-2 rule • Hematoma
• Mallampati score • Obesity
• Obstruction • Radiation distortion
• Neck Mobility or other deformity
• Tumour
 Preoxygenatio
•
n
Recommendation: Preoxygenation extends the duration of safe apnea and is
recommended for every ED tracheal intubation.
• Recommendation: Standard reservoir facemasks with the flow rate of oxygen set as
high as possible are the recommended source of high FiO2 for preoxygenation in the
ED.
• Recommendation: Patients with an adequate respiratory drive should receive
preoxygenation for 3 minutes or take 8 breaths, with maximal inhalation and
exhalation.
• Recommendation: CPAP masks, non-invasive positive pressure ventilation, or PEEP
valves on a bag-valve-mask device should be considered for preoxygenation and
ventilation during the onset phase of muscle relaxation in patients who cannot
achieve saturations greater than 93% to 95% with high FiO2.
• Recommendation: Patients should receive preoxygenation in a head-elevated
position whenever possible. For patients immobilized for possible spinal injury,
reverse Trendelenburg position can be used.
 Preoxygenatio
• n
Recommendation: Apnoeic oxygenation can extend the duration of safe apnea when used after the
administration of sedatives and muscle relaxants. A nasal cannula set at 15 L/minute is the most
readily available and effective means of providing apnoeic oxygenation during ED tracheal
intubations
• Recommendation: The risk/benefit of active ventilation during the onset phase of muscle relaxants
must be carefully assessed in each patient. In patients at low risk for desaturation (95% saturation),
manual ventilation is not necessary. In patients at higher risk (91% to 95% saturation), a risk-benefit
assessment should include an estimation of desaturation risk and the presence of pulmonary
pathology. In hypoxemic patients, low-pressure, low-volume, low-rate ventilations will be required
• Recommendation: In patients at high risk of desaturation, rocuronium may provide a longer
duration of safe apnea than succinylcholine.
 Remember the 7 P’s of RSI
1.Preparation (Planning),
2.Pre-Oxygenation,
3.Pre-Treatment,
4.Paralysis (with induction),
5.Protection & positioning,
6.Placement & proof,
7.Post-Intubation management.
 Scenario
50 y.o with End Stage Renal Disease
Missed Hemodialysis
Chief Complaint- Sudden DOB
BP- 70/60 mm Hg
HR 110 bpm
RR 26 cpm
Temp 38C
O2 Sats 88 % in room air
GCS 15
Retractions on Deep Breaths with
Crackles Bibasal
A 62-year-old woman is brought to the
emergency department (ED) with
increasing swelling of her tongue after
she begins taking a newly added
antihypertensive agent (an angiotensin-
receptor blocker [ARB]).

The swelling of her tongue and pharynx is

causing her some dyspnea.
BP 150/90 mm hg
HR-110
RR- 27
GCS15

Wheezes appreciated on both lung fields

Retractions are also noted