Airway Management: Advanced Techniques

• Unit 5 is about Airway Management
• Objective: Perform advanced airway management

Overview of Airway Management Topics

• Advanced Airway Management
• Needle Cricothyroidotomy
• SAVe II Ventilator

Basic Airway Management

• Assessment includes ensuring a patent airway, looking for spontaneous chest rise and fall, listening for air movement, and feeling for air movement.

Assess Quality of Breathing

• Assess Rate (per minute)
  • Slow is less than 12
  • Normal is 12-20
  • Intermediate is 20-30
  • Fast is greater than 30
• Assess Rhythm; it should be regular
  • Cheyne-Stokes rhythm is associated with disturbance in respiratory center, such as head trauma
  • Cheyne-Stokes rhythm is characterized by progressive increase in rate and volume, then gradually subsiding
  • Agonal respirations are intermittent gasps as a reflex on an apneic patient
• Assess Depth
  • Deep-Kussmaul is a very deep gasping pattern often associated with diabetic coma
  • Shallow can be caused by hyperventilation and guarded respirations due to pain, resulting in incomplete breaths
• Signs of Hypoxic Emergencies
  • Level of consciousness is one of the most sensitive indicators of hypoxia
  • Anxiety/dyspnea
  • Tachycardia is the body's reflex towards maintaining adequate oxygen levels at the cellular levels by speeding up the flow of the remaining oxygenated blood
  • Cardiac dysrhythmias may be caused by myocardial hypoxia
  • Cyanosis is a late sign and not considered dependable for early warning
• Check Breath Sounds
  • They should be present and equal in all fields
  • Abnormal sounds are separated into upper and lower airway

Abnormal Breath Sounds

• Upper Airway
  • Snoring: partial obstruction of upper airway by the tongue
  • Gurgling: accumulation of blood, vomitus or secretions in the upper airway
  • Stridor: harsh, high-pitched, sound heard on inhalation associated with laryngeal edema or constriction
• Lower Airway
  • Rales: Rattling inspiratory breath sound due to fluid in alveoli, which may be a result of CHF, AMI, PE, burns to lower airway, drowning, runaway IV's, or pneumonia
  • Rhonchi: Continuous inspiratory or expiratory rattling sound similar to snoring but with a quieter musical character
  • Wheezing: Expiratory sound caused by air being forced through narrowing bronchioles; may be heard with asthma, anaphylaxis or possible PE
  • Other abnormal sounds are rarely found during emergency care

Considerations for Patient History

• Trauma: always protect C-Spine; review history for indications of trauma to the head, neck, chest, and upper extremities
• Foreign Body aspiration or ingestion such as food, vomit, or blood clots
• Environmental exposure: Allergens, gases and chemical vapors, and burns

Secure the Airway

• Manual Maneuvers
  • Head tilt/chin lift (non-trauma)
  • Jaw thrust (trauma); intended for patients with possibility of cervical spine injuries
• Basic Mechanical Airways: Maintaining the airway/head position is always important when using basic mechanical airways
  • Establish an airway using manual maneuvers prior to mechanical attempts
  • Delays in securing the airway can be life threatening
  • Oropharyngeal and nasal pharyngeal airways (OPA/NPA)
• Oxygenation
  • Supplemental Oxygen should be considered for any patient whose history or condition may lead to respiratory or circulatory collapse (shock)
  • Options for providing oxygen include a nasal cannula, simple face mask, and non-rebreather mask with reservoir
• Ventilation
  • Assisted ventilations are not just for the apneic patient
  • Patients with respiratory rates outside the normal range or with dyspnea will need assisted ventilations to maintain adequate
  • Methods of ventilation include mouth to mask and bag-valve mask (BVM)

Needle Cricothyroidotomy

• Access to the airway is gained through a needle insertion into the cricoid membrane
• The procedure is a temporary means to allow immediate ventilation of the patient with an obstructed airway.
• It does not provide adequate ventilation and is only a temporary solution until a definitive airway can be established
• Followed by surgical insertion of an endotracheal tube

Needle Cricothyroidotomy Procedure

• Indications include upper airway obstruction prohibiting ventilation or intubation and cervical spine injuries considered unacceptable for intubation
• Identify Landmarks includes the Cricoid cartilage, Thyroid cartilage, and Cricothyroid membrane
• Identify vital structures such as the carotid arteries, esophagus, and trachea which may be injured by incorrect technique
• Place patient supine, with the neck straight and not angulated
• Time permitting, apply provident-iodine solution to the skin
• Ventilate with BVM connected to O2 while gathering supplies

Gather Supplies for Needle Cricothyroidotomy

• PPE
• 16G or larger sheathed needle catheter
• 3 ml syringe
• Adaptor from the end of a 7-mm endotracheal tube
• O2 source at 15 L/min connected by tubing with a Y connector or fashioned with side hole
• A BVM may be substituted but not optimal

Perform Needle Cricothyroidotomy

• Stand to side of patient at level of neck
• Locate cricothyroid membrane
• Attach 3ml syringe to catheter (16 gauge or larger)
• Introduce the catheter into the subcutaneous tissue at a 90-degree angle to the skin
• Aspirate gently while advancing catheter over the needle
• When air returns (indicating entry into the airway), change angle to 45 degrees and advance catheter into larynx
• Withdraw needle and syringe
• Disconnect 3ml syringe from
• Withdraw plunger from 3mm syringe and attach plunger-less 3ml syringe barrel to the catheter in the neck
• Attach the adapter from end of 7mm ETT into the empty syringe barrel and inflate balloon
• Attach the O2 source to the adapter and start ventilation w/ a 100% O2 source
• The operator must hold the catheter securely, as it can become displaced with minimal movement
• Stabilization is maintained by the operator until choice of airway is established, using either tracheostomy or orotracheal or nasotracheal intubation (if possible)
• Dressings are not necessary

SAVe II Ventilator

• Purpose: If a patient has diminished function of their lungs or the inability to breath on their own, then a ventilator can assist with breathing or completely breath for them.
• Delivers oxygen and pressure to the patient, and can be configured
• It is important to have knowledge of basic terminology and mechanics to understand how the ventilator works

Terminology for SAVe II Ventilator

• Positive End-Expiratory Pressure (PEEP): Positive pressure that will remain in the airway at the end if the respiratory cycle that is greater than the atmospheric pressure or the pressure outside the body
• Tidal Volume (TV): A measurement of the amount of air an individual inhales and exhales during a normal breath
• Peak Pressure: Pressure generated by the ventilator to overcome airway resistance and alveolar resistance to attain peak inspiratory flow and to deliver desired tidal volume
• Fraction of Inspired Oxygen (Fi02): The percentage or concentration of oxygen that is inhaled
• Emergency Mainstream Analyzer (EMMA): Emergency Capnometer for proof-of-intubation and short-term C02 monitoring in emergency transports/situations
  • Measures end-tidal CO2 and respiratory rate
• Heat and Moisture Exchanger (HME): Humidifies and filters air to help reduce mucus production and coughing

SAVe II Ventilator Overview

• Components indicated on the device include the power button, alarm silence, height selection, single manual breath, respiratory rate, tidal volume, PEEP, peak pressure limit, and confirmation button.

SAVe II Ventilator Start-Up

• Press power
• Select patient height
• Press confirm
• Add PEEP/Start Ventilator
  • Press confirm
  • Increase PEEP to 5
  • If different Tidal Volume is desired, refer to the chart to determine the correct setting

Supplemental Oxygen for SAVe II Ventilator

• Remove black cap (do not discard cap or white filter)
• Attach green side of large bore tubing to vent
• Fully extend large bore tubing
• Attach small bore tubing to O2 and turn flow to 6 LPM

Monitoring the Patient on SAVe II Ventilator

• Maintain end tidal CO2 between 35-45 mmHg
• Increase respiratory rate (RR) or tidal volume (TV) to lower end tidal CO2
• Decrease RR or TV to raise end tidal CO2
• Maintain SpO2 above 94%
• Increase FiO2 or PEEP to raise

Recommended Adjunct Placement

• Suction
• EMMA
• HME
• Metered-dose in
• Nebulizer (NEB)