Airway Management

Table of Contents

(Adapted from an evidence-based guideline created using the National Prehospital Evidence-Based Guideline Model Process)

Aliases

Asthma, upper airway obstruction, respiratory distress, respiratory failure, hypoxemia, hypoxia, hypoventilation, foreign body aspiration, croup, stridor, tracheitis, epiglottitis

Patient Care Goals

  1. Provide effective oxygenation and ventilation
  2. Recognize and alleviate respiratory distress
  3. Provide necessary interventions quickly and safely to patients with the need for respiratory support
  4. Identify a potentially difficulty airway in a timely fashion

Patient Presentation

Inclusion Criteria

  1. Children and adults with signs of severe respiratory distress/respiratory failure
  2. Patients with evidence of hypoxemia or hypoventilation

Exclusion Criteria

  1. Patients with tracheostomies
  2. Chronically ventilated patients
  3. Newborn patients
  4. Patients in whom oxygenation and ventilation is adequate with supplemental oxygen alone, via simple nasal cannula or face mask

Patient Management

Assessment                 

  1. History – Assess for:
    1. Time of onset of symptoms
    2. Associated symptoms
    3. History of asthma or other breathing disorders
    4. Choking or other evidence of upper airway obstruction
    5. History of trauma
  2. Physical Examination – Assess for:
    1. Shortness of breath
    2. Abnormal respiratory rate and/or effort
    3. Use of accessory muscles
    4. Quality of air exchange, including depth and equality of breath sounds
    5. Wheezing, rhonchi, rales, or stridor
    6. Cough
    7. Abnormal color (cyanosis or pallor)
    8. Abnormal mental status
    9. Evidence of hypoxemia
    10. Signs of a difficult airway (short jaw or limited jaw thrust, small thyromental space, upper airway obstruction, large tongue, obesity, large tonsils, large neck, craniofacial abnormalities, excessive facial hair)

Treatment and Interventions

  1. Non-invasive ventilation techniques
    1. Maintain airway and administer oxygen as appropriate with a target of achieving 94-98% saturation
    2. For severe respiratory distress or impending respiratory failure, use continuous positive airway pressure (CPAP)
      1. Bronchospasm (COPD/Asthma) – PEEP Max of 5 cm H2O
      2. Edema (CHF/Pneumonia) – PEEP Max of 10 cm H2O
    3. Use bag-valve mask (BVM) ventilation in the setting of respiratory failure or arrest. Two-person, two-thumbs-up BVM ventilation is more effective than one-person technique and should be used when additional providers are available
      1. Infants < 1 years old – Use Infant BVM. Squeeze BVM until Chest Rise
      2. Patients > 1 years old – Use Pediatric BVM. Squeeze BVM until Chest Rise
      3. Adult BVM may be an acceptable alternative if Pediatric BVM not available or not functioning for patient.
      4. If patient’s pathophysiology requires PEEP, may use BVM with PEEP valve
        1. Requires continuous facial with two hands on mask or EGD/ETT
        2. PEEP Ranges:
          1. During Cardiac Arrest: 0 cm H2O
          2. Post ROSC: 0 – 5 cm H2O
          3. Bronchospasm: 0 – 5 cm H2O
          4. Pulmonary Edema/Pneumonia/Aspiration: 5 – 20 cm H2O
          5. Monitor for Tension Pneumothorax and/or Hypotension from impaired preload
            1. Remove PEEP Valve if hypotension develops
  2. Oropharyngeal airways (OPA) and nasopharyngeal airways (NPA) – Consider the addition of an OPA and/or NPA to make BVM ventilation more effective, especially in patients with altered mental status
    1. It is acceptable to use more than one adjunct at a time
  3. Preoxygenation/Apneic Oxygenation – Consider using a nasal cannula with oxygen at 10 – 15 LPM prior to and during EGD/ETT placement.
    1. Goal: 94 – 98% Saturation before/during advanced airway placement
    2. May combine with BVM with PEEP valve to reverse hypoxia prior to advanced airway placement
  4. Extraglottic devices (EGD) – Consider the use of an EGD if BVM is not effective in maintaining oxygenation and/or ventilatio
    1. If no gag reflex present, BLS providers may place these.
    2. This is especially important in children since endotracheal intubation is an infrequently performed skill in this age group and has not been shown to improve outcomes
  5. Endotracheal intubation
    1. When less-invasive methods (BVM, EGD placement) are ineffective, use endotracheal intubation to maintain oxygenation and/or ventilation
    2. Other indications may include potential airway obstructions, severe burns, multiple traumatic injuries, altered mental status or loss of normal protective airway reflexes
    3. Monitor clinical signs, pulse oximetry, cardiac rhythm, blood pressure, and capnography for the intubated patient
    4. The Bougie/Endotracheal Tube Introducer should be used on ALL INTUBATION ATTEMPTS, especially when video laryngoscopy is unavailable and glottic opening is difficult to visualize with direct laryngoscope
  6. Medication-Assisted Advanced Airway Placement – EGD or ETT
    1. The paramedic must choose the most appropriate sedative prior to advanced airway placement based on the patient’s history, physical exam, and pathophysiology
    2. Attempt to correct hypotension and hypoxia before sedation [See Shock guideline]
    3. Ketamine – 1 mg/kg slow IVP/IO
    4. Etomidate – 0.3 mg/kg slow IVP/IO
    5. If additional medications required, contact direct medical oversight
  7.  Ventilation
    1. Tidal volume
      1. Ventilate with minimal volume to initiate chest rise, approximately 6-7 mL/kg ideal body weight
        1. Over-inflation may be detrimental
      2. Rate
        1. Adult: 10-12 breaths/minute
        2. Child: 20 breaths/minute
        3. Infant: 30 breaths/minute
      3. Titrate PEEP as mentioned above
  8. Post-advanced airway management
    1. Confirm placement of advanced airway (EGD or endotracheal tube) with waveform capnography, absent gastric sounds, and bilateral breath sounds
    2. Continuously monitor placement with waveform capnography during treatment and transport
      1. Maintain ETCO2 of 35-40 mmHg – in head injury with signs of herniation (unilateral dilated pupil or decerebrate posturing), modestly hyperventilate to ETCO2 30 mmHg
    3. Continuously secure tube manually until tube secured with tape, twill, or commercial device
      1. Note measurement of tube at incisors or gum line and monitor frequently for tube movement/displacement
      2. Cervical collar and/or cervical immobilization device may help reduce neck movement and risk of tube displacement
    4. Inflate endotracheal tube cuff with minimum air to seal airway
  9. Post-Airway Placement Analgesia/Sedation
    1. Fentanyl 1 mcg/kg slow IVP, max single dose of 100 mcg, every 5 mins if RASS +4 to -1
  10. When patients cannot be oxygenated/ventilated effectively by previously mentioned interventions, the provider should consider cricothyrotomy if the risk of death for not escalating airway management seems to outweigh the risk of a procedural complication
  11. Transport to the closest appropriate hospital for airway stabilization when respiratory failure cannot be successfully managed in the prehospital setting
  12. Ensure that the ED physician visualizes waveform capnography prior to patient transfer if EGD or ETT in place.

Notes – Airway Management