1.Airway Management | Practice Quiz

Importance of Airway Management

• Inadequate airway preparation leads to difficulties in emergency medicine and critical care.
• Airway management is critical in managing life-threatening injuries and ensuring patient safety.
• Neglecting airway management can lead to a significant burden on medical staff and costly legal implications.

Airway Anatomy

• Visual representations of airway anatomy during intubation help in understanding the process.

Airway Assessment

• Utilize the primary assessment or MARCHE (Medical Assessment of Respiratory, Cardiovascular, and Neurological Emergencies) to evaluate the patient's airway.
• Assess for airway patency, speech, mentation, general appearance, respiratory pattern, and effort, lung sounds, and any airway contaminants.
• Identify immediate or potential life threats based on the assessment.
• Respiratory patterns like rate, depth, regularity, and effectiveness are indicative of underlying pathologies.

Respiratory Patterns

• Kussmaul’s: Deep, rapid, labored breathing associated with metabolic acidosis.
• Biot’s: Irregular breathing with periods of apnea, often seen in patients with increased intracranial pressure.
• Cheyne-Stokes: Alternating periods of deep and shallow breathing with apnea, common in patients with heart failure or neurological conditions.
• Apneustic: Prolonged inspiration followed by a brief pause before expiration, indicating brainstem damage.

Pediatric Airway Assessment

• Pediatric airways have unique characteristics requiring specialized assessments to ensure proper management.

Airway Interventions

• Supplementary Oxygen:
  • Nasal cannula: For low-flow oxygen delivery.
  • Non-rebreather mask: High-flow oxygen delivery with a reservoir bag.
  • Bag valve mask (BVM): Manual ventilation using a mask and a bag, use a PEEP valve and capnography for monitoring.
  • Two thumbs up technique: Improves BVM seal and ventilation effectiveness.
• Extraglottic airways:
  • Supraglottic: Seated around the laryngeal opening, creating a mask seal.
  • Retroglottic: Situated posterior to the glottis in the proximal esophagus.
• High flow nasal cannula: Delivers heated and humidified oxygen, replacing dead space with oxygen.
  • Provides up to 60LPM flow rate.

Indication for Intubation

• Intubation is indicated when less invasive interventions fail to oxygenate or ventilate the patient.
• Consider intubation if the patient's clinical course predicts airway failure or if the airway needs protection.
• Intubation may be required for patient or crew safety.

HEAVEN Criteria

• H: Hypoxia (SpO2 < 90%) despite oxygen therapy.
• E: Exhaustion (respiratory distress, use of accessory muscles).
• A: Altered mental status (confusion, agitation).
• V: Ventilatory failure (inadequate tidal volume, inability to cough).
• E: Evidence of airway obstruction (stridor, wheezing).
• N: Need for airway protection (risk of aspiration).

Rapid Sequence Intubation (RSI)

• Delivers a sedative and paralytic quickly to facilitate endotracheal intubation.

Delayed Sequence Intubation (DSI)

• Introduces a delay between sedation and paralysis to allow for oxygenation and hemodynamic optimization.

Preoxygenation & Passive Oxygenation

• Extends the safe apnea period during intubation.
• Spontaneous breathing patient: 8 vital capacity breaths on 15L NRB (non-rebreather mask).
• Apneic patient: BVM with PEEP using 2-thumbs up technique.
• Passive oxygenation: >15L via regular nasal cannula.

Resuscitate

• Hemodynamic optimization: Achieve MAP > 65mmHg, CVP 8–12mmHg.
• Mental status improvement: Correct hypotension.
• Blood loss: Replace with blood products.
• Fluid loss: Replace with isotonic fluids.
• Loss of vascular tone: Administer pressors.

Positioning/Ramping

• Position the patient with the ear to sternal notch alignment and HOB elevated to 30°.

Intubation Equipment Preparation

• Apneic Oxygenation: Use a regular nasal cannula at 15-25LPM to extend the safe apnea period.
• Direct laryngoscopy (DL): An inexpensive and easy-to-maintain option, not significantly affected by airway contaminants.
• Video laryngoscopy (VL): Facilitates visualization but can be rendered useless by airway contaminants.

Endotracheal Tubes (ETT)

• Sizes range from 2.5mm to 9.0mm in lumen diameter, larger tubes provide better airflow.
• Keep ETTs in their packaging to minimize contamination of the trachea.
• Pre-attach a syringe filled with air or a manometer.

Pediatric Endotracheal Tubes

• Use the formula [(age in years ÷ 4) + 4] to determine the appropriate ETT size.
• Utilize cuffed ETTs for all but the youngest infants.

Endotracheal Tube Introducers

• Curved tip facilitates guiding the tube into the anterior airway.
• Improves first pass success rate without increasing time or hypoxia risk.

Bougie Tube Exchange

• A technique variation includes the Kiwi technique.
• More practical for a single provider but contaminates the ETT and limits bougie articulation.

SALAD Technique

• Uses suction to clear the oropharynx before blade insertion.
• Aims to prevent contamination of the video laryngoscope and lungs with airway contaminants.

ETT Cuff Pressure

• Safe adult cuff pressure is 20-30 cm H2O.

Importance of Airway Management

• Airway management is essential for patient safety and well-being
• Difficult airways can lead to serious complications including death
• Inadequate airway management can lead to staff mental stress and costly legal issues

Airway Anatomy

• Photos of CMAC blade during intubation illustrate the anatomy of the airway

Airway Assessment

• The MARCHE assessment, a primary assessment tool, includes observation of:
  • Speech
  • Mentation
  • General Appearance
  • Respiratory Pattern & Effort
  • Lung Sounds
  • Airway Contaminants
• Respiratory patterns may indicate underlying pathology
  • Kussmaul’s: deep, rapid breathing
  • Biot’s: periods of rapid followed by irregular breathing
  • Cheyne-Stokes: periods of apnea followed by increasing breaths
  • Apneustic: prolonged inspiration and short expiration
• Pediatric airway assessment requires a thorough examination

Airway Interventions

• Supplementation of Oxygen:
  • Nasal cannula
  • Non-rebreather mask
  • Bag valve mask (BVM) with PEEP valve and capnography
    • Two thumbs up technique for effective ventilation
• Extraglottic Airway Devices:
  • Supraglottic: creates a seal around the laryngeal opening
  • Retroglottic: positioned at the back of the glottis within the esophagus
• High Flow Nasal Cannula:
  • Heated and humidified
  • Replaces dead space with oxygen
  • Up to 60LPM flow

Indications for Intubation

• Failure to oxygenate or ventilate with less invasive interventions
• Predicted clinical course requiring airway protection
• Inability to protect the airway
• Maintaining patient or crew safety
• HEAVEN Criteria: a framework for determining the necessity of intubation

Rapid Sequence Intubation (RSI)

• Simultaneous administration of sedative and paralytic for intubation

Delayed Sequence Intubation (DSI)

• Time between sedative and paralytic to optimize oxygenation and hemodynamics

Preoxygenation and Passive Oxygenation

• Techniques to lengthen the safe apnea period during intubation
  • Spontaneous breathing patient: 8 deep breaths with 15L Non-rebreather mask
  • Apneic patient: BVM with PEEP using two thumbs up technique
  • Passive oxygenation: continuous 15L nasal cannula

Resuscitation

• Achieve hemodynamic stability with a MAP > 65mmHg and CVP 8-12mmHg
• Correct hypotension: Administer fluids or pressors based on the cause of hypotension
  • Blood loss = blood products
  • Fluid loss = isotonic fluids
  • Loss of vascular tone = pressors

Positioning for Intubation

• Ear to sternal notch with HOB at 30 degrees

Intubation Equipment Preparation

• Apneic oxygenation with a nasal cannula at 15-25LPM

Direct Laryngoscopy (DL)

• Inexpensive and easy to maintain
• Not significantly affected by airway contaminants

Video Laryngoscopy (VL)

• Facilitates visualization of the oropharynx
• Susceptible to contamination from airway contaminants

Endotracheal Tubes (ETT)

• Available in sizes 2.5mm to 9.0mm
• Larger tubes improve airflow
• Pre-attach syringe filled with air or manometer

Pediatric Endotracheal Tubes

• ETT size: [(Age in years ÷ 4) + 4]
• Cuffed ETTs for all but “youngest infants”

Endotracheal Tube Introducers

• Curved tip guides into the airway
• Improves first pass success rate without significantly increasing time or hypoxia

Bougie Tube Exchange

• Technique variation: Kiwi technique

SALAD Technique

• Lead with suction to clear the oropharynx before blade insertion
• Park suction in the esophagus on the left side of the mouth
• Insert blade with suction in place
• Benefits:
  • Prevents video laryngoscope contamination
  • Minimizes introduction of contaminants into the lungs

ETT Cuff Pressure

• Safe adult pressure 20-30 cm H2O

This quiz covers the critical aspects of airway management in emergency medicine, focusing on the importance of preparation, anatomy, and assessment techniques. It explores how effective airway management can prevent life-threatening situations and ensure patient safety. Test your knowledge on assessing respiratory patterns and identifying potential threats to airway patency.