2024 Airway Management - NR PDF

Airway Management Nathan Ross (some materials adapted from presentation by Heather Coffin & Dave Parr) Learning Outcomes To know the causes of airway obstruction To be able to recognise airway obstruction Acquire knowledge of basic air manoeuvres and adjuncts Knowledge of Foreign Body Airw...

Airway Management Nathan Ross (some materials adapted from presentation by Heather Coffin & Dave Parr) Learning Outcomes To know the causes of airway obstruction To be able to recognise airway obstruction Acquire knowledge of basic air manoeuvres and adjuncts Knowledge of Foreign Body Airway Obstruction: Risk factors, causes & treatment algorithm Introduction to airway management equipment and use: Suction unit, Magills forceps & laryngoscopy  Airway Anatomy Laryngopharynx Tortora & Derrickson (2009) Olson & Pawlina (2008) Airway obstruction Airway obstruction can occur anywhere between the mouth and the carina Follow a stepwise approach to airway management Carina of trachea (en-academic.com) Causes of airway obstruction Blockage in airway: Narrowing of airway: ▪ TONGUE ▪ laryngospasm ▪ blood ▪ bronchospasm ▪ secretions ▪ vomit Reduced consciousness: ▪ foreign body (dislodged tooth, food) ▪ head injury and intracerebral disease ▪ blocked tracheostomy ▪ hypercarbia ▪ metabolic disorders Infection and oedema: (e.g. hypoglycaemia in diabetic patients) ▪ direct trauma to face or throat ▪ drugs (e.g. alcohol, opioids and ▪ epiglottitis general anaesthetic). ▪ pharyngeal swelling Recognition of airway obstruction partial obstruction Snoring, gurgling, stridor complete obstruction silence ?talking / not talking / change in voice Inability to swallow (painful or obstruction) Signs of choking / distress / attempts at coughing Stridor indicates see-saw respiratory pattern, accessory muscle usage airway narrowing by >50%  Airway obstruction: Associated Symptoms Ineffective Ventilation (hypoxia & hypercapnia) Cyanosis Altered level of consciousness (think ACVPU!) Agitation/Anxiety or Confusion/restlessness Tachycardia (Fast heart rate) Hypertension (High blood pressure) Sweating Popat (2013)  At Risk Patient Groups Pregnant Airway swelling due to Increased maternal Oesophageal vascular engorgement. oxygen consumption and sphincter reduced reserves. insufficiency, delayed gastric emptying Obese Decreased pulmonary Small cardiopulmonary Everything is big and compliance and reserve, can desaturate compressed functional residual quickly capacity Paediatrics Small airways and Keep putting things in narrowing (funnel mouth shaped) Dodson (2022). Thota et al (2022) Popat (2013) Basic manoeuvres and adjuncts Basic Manoeuvres: Head tilt / chin lift Tongue is brought forward and upwards, ensuring an open airway. Keep fingers on chin to maintain. Basic Manoeuvres: Jaw Thrust  Obese patient airway positioning “The ramped position improves ventilation of the obese patient by downward displacement of fat and abdominal contents via gravity, diminishing pressure on the diaphragm and decreasing intrathoracic pressure.” Khosla & Cattano (2013) Oropharyngeal Airways (OPs) Oropharyngeal adjuncts Indications and uses Help breathing to continue in those patients who are unconscious and unable to maintain their own airway To make it easier to use oropharyngeal suction To help control the lips, teeth & tongue in an unconscious patient Method of Sizing The correct method of sizing an OP airway is from angle of the jaw to the mid incisors (centre of the mouth) Teeth should be at level of bite block (coloured area) Ensure it is the right way round. Don’t bend to contour of face (when measuring). Insertion Technique Correct placement: flattened reinforced section between front teeth or gums. Flange rest against the lips. Limitations of OP Airways Not a perfect size for everyone Too small – partially obstruct the airway of the patient Too large – might fall forward and push the tongue back in to the pharynx May stimulate the patient’s gag reflex causing them to vomit and potentially aspirate their stomach contents into their lungs Safety Checks Always clear the mouth and pharynx before inserting an airway Always check to see if air is passing through it after insertion Once the airway is inserted you must maintain observation of the patient for any sign of obstruction of the lumen and if present, use suction If a patient shows any sign of rejecting the airway, i.e. gag reflex, remove it Nasopharyngeal Airways A specially designed airway made of soft plastic material with a flange collar at its proximal end Usually size 6 & 7 available on ambulance General sizing: 6 = average female 7 = average male Indications for use Semi-conscious patient Status epilepticus Trismus Maxillofacial injuries Only for use if concerned about patency of airway Insertion Technique Select correct size of airway Lubricate liberally (no dipping!) Introduce into the right nostril (can use left if right not possible) Directing the tube backwards to 90 degrees (in line with the hard palate NOT towards bridge of nose) Insert using a slight side-to-side rotation and gentle pressure until inserted fully Check for unimpeded air flow through the airway Insertion Technique Contraindications Bilaterally obstructed or deformed nasal passages Severe mid-face fractures, particularly maxillary fractures Known septal haematoma Hazard and limitations Severe nasal haemorrhage Damage to nasal mucosal membrane, bone or cartilage Inadvertent passage into cranial cavity through fractured cribiform plate (very rare!) Provocation of retching, vomiting or laryngospasm CHOKING POTENTIAL CHOKING HAZARDS Foreign body Airway Obstruction (FBAO) (aka: Choking) Foreign Body Airway Obstruction - FBAO “Sudden onset of respiratory distress accompanied by coughing, stridor, wheezing, or gagging warrants emergent action and should illicit a high suspicion for FBAO” DODSON & COCK (2022)  Death by Choking Statistics in the U.K. The Office of National Statistics Report 2018-2022: Survey including all deaths with ‘Choking’ as the cause of death from the 01/01/2018 – 31/12/2022. Choking occurred in a variety of different places. Included death by inhalation or ingestion of food, and inhalation and ingestion of other, non-food related objects. Choking – A Time Critical Emergency Igarashi et al. (2022)  Epidemiology & Risk Factors Adults Paediatrics Alzheimer disease Food is most common Parkinsons (especially round foods) Prior stroke Choking rate is highest Intellectual or in under 1s developmental disability Over 75% of paediatric Poor dentition choking incidents are in under 3s. Intoxication / psychotropic medications Dysphagia In 2022 - choking is the 4th leading Advanced age cause of unintentional death in all age ranges in the U.S. – National Safety Council Chatterjee (2020) Dodson (2022)  Causes of choking: Paediatrics Adults Food 59.5% Meat 71% Non-food items, such as coins, marbles, Bread 12% balloons, and paper - 31.4%. Unknown - 9.1% Fruit & Vegetables 7% Other/unknown 10% Dodson (2022)  Choking Algorithm JRCALC (2022) RCUK (2021)  Abdominal Thrusts Abdominal Thrusts Chest thrusts (Infants) Stand or kneel behind the patient. Turn the infant into a head-down, supine Encircle their torso (underarm). position (place your arm along the infant’s back and encircling the occiput Place clenched fist between the with the hand). umbilicus and the xiphisternum. Rest your arm against a solid surface or Grasp this hand with the other hand your thigh. and pull sharply inwards and upwards. Identify the landmark for chest (Ensure that pressure is not applied to compression (lower sternum, xiphoid process or lower rib cage as this approximately a finger’s breadth above may result in abdominal trauma). the xiphisternum) Short, sharp upwards thrusts (i.e. towards the head) JRCALC (2022) RCUK (2021) Adults & Paed >1 Infants 1< Back Slap & Chest Thrusts Foreign Body Airway Obstruction (FBAO) Choking PLEASE SEE CANVAS FOR VIDEOS Suction Unit Suction only as far as you can see: Use a sweeping motion Adjust patient position if possible Recommend 150mmHg (Hand-held suction units should only be used as a back-up as they are less effective.) LSU – Test Values PLEASE SEE CANVAS PAGE FOR VIDEO Laryngoscopy: Laryngoscope Blades Curved (Macintosh) Straight (Miller) Nutbeam & Boylan (2013)  Laryngoscopy: anatomy Vallecula Brown et al (2017) Morris (2021), https://doctorlib.info/medical/airway/4.html  Laryngoscopy: technique Slide right to left then lift Don’t rotate or straight up lever on teeth Brown et al (2017) Morris (2021), HOLD IN LEFT HAND https://doctorlib.info/medical/airway/4.html Laryngoscopy “The concept of direct laryngoscopy is simple— to create a straight line of sight from the mouth to the larynx in order to visualize the vocal cords.” Brown et al (2017)  Magill Forceps LIKE THIS HOLD IN RIGHT HAND EMSAirway (2022)  Magill Forceps – technique is important EMSAirway (2022) Grabbing life by the handles: Optimal utilization of the Magill Forceps. [Online]. Available at: https://emsairway.com/2022/05/31/grabbing-life-by-the-handles- optimal-utilization-of-magill-forceps/#gref EMSAirway (2022)  Any Questions? Learning Outcomes To know the causes of airway obstruction To be able to recognise airway obstruction Acquire knowledge of basic air manoeuvres and adjuncts Knowledge of Foreign Body Airway Obstruction: Risk factors, causes & treatment algorithm Introduction to airway management equipment and use: Suction unit, Magills forceps & laryngoscopy References & Further Reading Brown, Calvin A., et al. The Walls Manual of Emergency Airway Management, Wolters Kluwer, 2017. Chatterjee, A (2020) Foreign body aspiration. BestPractice. BMJ. [Online] Available at:https://bestpractice.bmj.com/topics/en-gb/653 EMSAirway (2022) Grabbing lifer by the handles: Optimal utilization of the Magill Forceps. [Online]. Available at: https://emsairway.com/2022/05/31/grabbing-life-by-the-handles-optimal-utilization-of-magill-forceps/#gref Dodson H, Cook J. (2022) Foreign Body Airway Obstruction. [Updated 2022 May 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan Available from: https://www.ncbi.nlm.nih.gov/books/NBK553186/ Igarashi, Y., Norii, T. Sung-Ho, K. Nagata, S. Yoshino, Y. Hamaguchi, T. Nagaosa, R. Nakao, S. Tagami, T. and Yokobori, S. (2022) Airway obstruction time and outcomes in patients with foreign body airway obstruction: multicentre observational choking investigation, Acute Medical and Surgery, 9(1), e741, pp. 1-8. Available at: https://doi.org/10.1002/ams2.741 JRCALC (2022) Foreign Body Airway Obstruction. JRCALC [Online] Available at: https://jrcalcplusweb.co.uk/guidelines/G0130 Khosla & Cattano (2013) 'Airway Assessment' The Difficult Airway: A Practical Guide (New York, 2013; online edn, Oxford Academic 1 Aug. 2013),  References & Further Reading Nickson, Chris (2022) Airway Assessment. [Online] Available at: https://litfl.com/airway-assessment/ Nutbeam, T., Boylan, M. and ProQuest (2013) ABC of prehospital emergency medicine. Oxford: Wiley-Blackwell. Olson, T., & Pawlina, W. (2008). A.D.A.M. Student Atlas of Anatomy. Cambridge: Cambridge University Press Popat, Mansukh (2013), Difficult Airway Management, Oxford Anaesthesia Library, Oxford, Tortora J., Derrickson B., (2009) Principles of Anatomy and Physiology, 12th edition, Asia: Wiley Thota, B., Jan, K. M., Oh, M. W., & Moon, T. S. (2022). Airway management in patients with obesity. Saudi journal of anaesthesia, 16(1), 76–81. https://doi.org/10.4103/sja.sja_351_21  Mentimeter Feedback Survey https://www.menti.com/alpuohyfm46u Please complete the three feedback questions using mentimeter. You can also email me any questions, comments, feedback etc. at [email protected]