Notes – Airway Management

Airway Management

Patient Safety Considerations

  1. Avoid excessive pressures or volumes during BVM
  2. Avoid endotracheal intubation, unless less invasive methods fail, since it can be associated with aspiration, oral trauma, worsening of cervical spine injury, malposition of the ET tube (right mainstem intubation, esophageal intubation), or adverse effects of sedation, especially in children
  3. Once a successful EGD placement or intubation has been performed, obstruction or displacement of the tube can have further deleterious effects on patient outcome
    1. Tubes should be secured with either a commercial tube holder or tape
  4. Providers who do not routinely use medications for rapid sequence intubation (RSI) should not use RSI on children, since the loss of airway protection with the use of RSI may increase complications
    1. RSI should be reserved for specialized providers operating within a comprehensive program with ongoing training and quality assurance measures

Notes/Educational Pearls

Key Considerations

  1. When compared to the management of adults with cardiac arrest, paramedics are less likely to attempt endotracheal intubation in children with cardiac arrest. Further, paramedics are more likely to be unsuccessful when intubating children in cardiac arrest and complications such as malposition of the ET tube or aspiration can be nearly three times as common in children as compared to adults.
  2. Use continuous waveform capnography to detect end-tidal carbon dioxide (ETCO2). This is an important adjunct in the monitoring of patients with respiratory distress, respiratory failure, and those treated with positive pressure ventilation. It should be used as the standard to confirm EGD and endotracheal tube placement.
  3. CPAP
    1. Contraindications to non-invasive ventilator techniques include intolerance of the device, severely impaired consciousness, increased secretions inhibiting a proper seal, or recent gastrointestinal and/or airway surgery
  4. Bag-valve-mask:
    1. Appropriately-sized masks should completely cover the nose and mouth and maintain an effective seal around the cheeks and chin
    2. Ventilation should be delivered with only sufficient volume to achieve chest rise
    3. Ventilation rate:
      1. During CPR, ventilation rate should be 10 breaths per minute, one breath every 10 compressions (or one breath every 6 seconds). When advanced airway is in place, ideally ventilations should be on upstroke between two chest compressions
      2. In adults who are not in cardiac arrest, ventilate at rate of 12 breaths per minute
      3. In children, ventilating breaths should be delivered over one second, with a two second pause between breaths (20 breaths/minute) in children
  5. Orotracheal intubation
    1. Endotracheal tube sizesScreen Shot 2018-06-09 at 17.47.53
    2. Approximate depth of insertion = (3) x (endotracheal tube size)
    3. In addition to preoxygenation, apneic oxygenation (high-flow oxygen by nasal cannula) may prolong the period before hypoxia during an intubation attempt
    4. Positive pressure ventilation after intubation can decrease preload and subsequently lead to hypotension – consider providing vasopressor support for hypotension
    5. Appropriate attention should be paid to adequate preoxygenation to avoid peri-intubation hypoxia and subsequent cardiac arrest
    6. Prompt suctioning of soiled airways before intubation attempt may improve first pass success
    7. Confirm successful placement with waveform capnography. Less optimal methods of confirmation include bilateral chest rise, bilateral breath sounds, and maintenance of adequate oxygenation. Color change on end-tidal CO2 is less accurate than clinical assessment, and wave-form capnography is superior. Misting observed in the tube is not a reliable method of confirmation. Visualization with video laryngoscopy, when available, may assist in confirming placement when unclear due to capnography failure or conflicting information.
    8. Ongoing education and hands-on practice is essential to maintain skills. This is especially true for children since pediatric intubation is an infrequently utilized skill for many prehospital providers.
    9. Video laryngoscopy may be helpful, if available, to assist with endotracheal intubation
  6. Consideration should be made to dispatch the highest-level provider for an EMS system given the potential need for advanced airway placement for patients with severe respiratory distress or failure

Pertinent Assessment Findings

  1. Ongoing assessment is critical when an airway device is in place
  2. Acute worsening of respiratory status or evidence of hypoxemia can be secondary to displacement or obstruction of the airway device, pneumothorax or equipment failure

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01)

  • 9914133 – Medical-Newborn/Neonatal Resuscitation

Key Documentation Elements

  • Initial vital signs and physical exam
  • Interventions attempted including the method of airway intervention, the size of equipment used, and the number of attempts to achieve a successful result
  • Subsequent vital signs and physical exam to assess for change after the interventions
  • Reasoning for need for sedative and ketamine vs etomidate
  • Presence of peri-intubation hypoxia, bradycardia, hypotension or cardiac arrest
  • Post-intubation with advanced airway, document ETCO2 value and record capnograph wave initially after intubation, with each set of vital signs, when patient is moved, and at the time of patient transfer in the ED

Performance Measures

  • Percentage of providers that have received hands-on airway training (simulation or non-simulation-based) within the past 2 years
  • Respiratory rate and oxygen saturation are both measured and documented
  • Percentage of patients with advanced airway who have waveform capnography used for both initial confirmation and continuous monitoring during transport
  • Percentage of patients who were managed upon arrival to the emergency department (ED) with each of the following: Bag-valve-mask, EGD, or endotracheal intubation
  • Percentage of intubated patients with endotracheal tube in proper position upon ED arrival
  • First pass intubation success without hypoxia or hypotension.
  • Survival upon ED arrival

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