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A patient who needs intubation may be awake. Need for airway control may necessitate intubation. RSI paralyzes the patient to facilitate endotracheal intubation. Anatomical Differences Smaller and more flexible than an adult Tongue proportionately larger Epiglottis floppy and round Glottic opening higher and more anterior Vocal cords slant upward, and are closer to the base of the tongue Narrowest part is the cricoid cartilage A straight laryngoscope blade is preferred for most pediatric patients. Selecting the appropriate tube diameter for children is critical. ETT size (mm) = (Age in years + 16) ÷ 4 Matching it to the diameter of the child’s smallest finger Use non-cuffed endotracheal tubes with infants and children under the age of 8 years. © Scott Metcalfe © Scott Metcalfe © Scott Metcalfe © Scott Metcalfe © Scott Metcalfe © Scott Metcalfe © Scott Metcalfe © Scott Metcalfe Mask seal can be more difficult Bag size depends on age of child Ventilate according to current standards Obtain chest rise and fall with each breath Assess adequacy of ventilations by observing chest rise, listening to lung sounds, and assessing clinical improvement “Blind” procedure without direct visualization of the vocal cords Indications include: Possible spinal injury Clenched teeth Fractured jaw, oral injuries, or recent oral surgery Facial or airway swelling Obesity Arthritis preventing sniffing position Contraindications Suspected nasal fractures Suspected basilar skull fractures Significantly deviated nasal septum or other nasal obstruction Cardiac or respiratory arrest Advantages The head and neck can remain in neutral position It does not produce as much gag response and is better tolerated by the awake patient It can be secured more easily than an orotracheal tube The patient cannot bite the ETT Disadvantages More difficult and time consuming Potentially more traumatic for patients Tube may kink or clog more easily Greater risk of infection Improper placement more likely Requires that patient be breathing Field extubation may be indicated when: The patient is clearly able to maintain and protect his airway. The patient is not under the influence of sedatives. Reassessment indicates the problem that led to endotracheal intubation is resolved. Consider the high risk of laryngospasm A dual-lumen airway The longer, blue port (#1) is the proximal port The shorter, clear port (#2) is the distal port, which opens at the distal end of the tube Two inflatable cuffs 100-mL cuff just proximal to the distal port 15-mL cuff just distal to the proximal port ETC Airway Tracheal Placement Advantages Provides alternate airway control Insertion is rapid and easy Does not require visualization of the larynx Pharyngeal balloon anchors the airway Patient may be ventilated regardless of tube placement Significantly diminishes gastric distention Can be used on trauma patients Gastric contents can be suctioned Disadvantages Suctioning tracheal secretions is impossible when the airway is in the esophagus. Placing an endotracheal tube is very difficult with the ETC in place. It cannot be used in conscious patients or in those with a gag reflex. Disadvantages The cuffs can cause esophageal, tracheal, and hypopharyngeal ischemia. It does not isolate and completely protect the trachea. It cannot be used in patients with esophageal disease or caustic ingestions. It cannot be used with pediatric patients. Click here to view a video on ETC. Two-tube system: Proximal cuff seals oropharynx Distal cuff seals either the esophagus or the trachea Advantages Disadvantages Has an inflatable distal end that is placed in the hypopharynx and then inflated Blind insertion Disadvantage: Does not isolate trachea It is designed to facilitate endotracheal intubation. An epiglottic elevating bar in the mask aperture elevates the epiglottis. Tube is directed centrally and anteriorly. © LMA North America Similar to the laryngeal mask Supraglottic airway “Cobra head” of the airway holds both the soft tissue and the epiglottis out of the way © Engineered Medical Systems, Inc. Indianapolis, IN Supraglottic, singleuse, disposable airway Features a special curve that replicates the natural human airway anatomy © Ambu Inc. Baltimore, MD Alternative airway Large silicone cuff that disperses pressure over a large mucosal surface area Stabilizes the airway at the base of the tongue ©Tracey Lemons/King Systems Corporation, Indianapolis, Indiana Removing an obstructing foreign body using Magill forceps or a suction device You should carry out basic life support maneuvers first. If these fail to alleviate the obstruction, direct visualization of the airway for foreign body removal is indicated. You should use surgical airway procedures only after you have exhausted your other airway skills: Needle cricothyrotomy Surgical cricothyrotomy Indications Massive facial or neck trauma Total upper airway obstruction Contraindications Inability to identify anatomical landmarks Crush injury to the larynx Tracheal transection Underlying anatomical abnormalities Transtracheal jet insufflation is required Complications: Barotrauma from overinflation Excessive bleeding due to improper catheter placement Subcutaneous emphysema Airway obstruction Hypoventilation It is preferred to needle cricothyrotomy when a complete obstruction prevents a glottic route for expiration. Its greater potential complications mandate even more training and skills monitoring. Contraindications: Includes children under 12 Cricothyrotomy Complications: Incorrect tube placement into a false passage Cricoid and/or thyroid cartilage damage Thyroid gland damage Severe bleeding Laryngeal nerve damage Subcutaneous emphysema Vocal cord damage Infection Stabilize larynx and make a 1–2 cm vertical skin incision over cricothyroid membrane Using a curved hemostat, spread membrane incision open Terms Difficult airway A conventionally trained paramedic experiences difficulty with mask ventilation, endotracheal intubation, or both Difficult mask ventilation Inability of unassisted paramedic to maintain an SpO2 > 90% using 100% oxygen and positive pressure mask ventilation Inability of the unassisted paramedic to prevent or reverse signs of inadequate ventilation during positive pressure mask ventilation Terms Difficult laryngoscopy (cont.) Not being able to see any part of the vocal cords with conventional laryngoscopy Difficult intubation Conventional laryngoscopy requires either (1) more than three attempts, or (2) more than ten minutes Factors related to difficult airway are related to historical information, anatomical, and poor technique Historical Factors: Patient has had a history of problems with airway management or anesthesia. If time and patient condition allows, obtain a brief airway history. Anatomical Considerations Anatomy of the upper airway varies significantly across the human species. The most frequently used system of preintubation airway assessment is the Mallampati Classification system. The tonsillar pillars and the uvula are assessed. Class 1 Class 2 Upper half of tonsil fossa visible Class 3 Entire tonsil clearly visible Soft and hard palate clearly visible Class 4 Only hard palate visible The Mallampati classification system is at top. Other Revised Cormack and LeHane classifications rating systems Similar to Mallampati Assigns 4 classes POGO The percentage of the glottis that can be visualized is scored From 0 to 100% Short neck Short mandible Thick neck Anterior larynx Restricted range of Obesity motion Anatomical Dentition distortion Small mouth Patients who have had a laryngectomy or tracheostomy breathe through a stoma. There are often problems with excess secretions, and a stoma may become plugged. Use extreme caution with any suctioning. Anticipating complications when managing an airway Be prepared to suction all airways to remove blood or other secretions and for the patient to vomit. Tracheostomy cannulae Wear protective eyewear, gloves, and face mask. Preoxygenate the patient. Determine depth of catheter insertion. With suction off, insert catheter. Suction while removing catheter . Ventilate patient. It is sometimes necessary to remove secretions or mucous plugs that can cause respiratory distress. Hypoxia is a concern. Use sterile technique. It may be necessary to instill sterile water to thin secretions. A common problem with ventilating a nonintubated patient is gastric distention. You should place a tube in the stomach for gastric decompression. Nasogastric tube Orogastric tube Indications: The need for decompression because of the risk of aspiration or difficulty ventilating Gastric lavage in hypothermia and some overdose emergencies Complications: Possibility of esophageal bleeding Increased risk of esophageal perforation Procedure Place head in neutral position Measure tube Use topical anesthetic Lubricate and insert tube Encourage patient to swallow Advance to pre-determined mark Verify placement Apply suction Secure in place Device Oxygen Percentage Nasal cannula 40% Venturi mask 24, 28, 35, or 40% Simple face mask 40 – 60% Nonrebreather mask 80 – 95% Small Volume Nebulizer Allows for delivery of medications in aerosol form (nebulization) Oxygen Humidifier Benefits patients with croup, epiglottitis, or bronchiolitis, as well as those patients receiving long-term oxygen therapy Effective ventilatory support requires a tidal volume of at least 800 mL of oxygen at 10 to 12 breaths per minute. Effective artificial ventilation requires: A patent airway An effective seal between the mask and the patient’s face Delivery of adequate volumes Mouth-to-mouth Mouth-to-nose Mouth-to-mask Bag-valve device Demand valve device Automatic transport ventilator Indicated in the presence of apnea when no other ventilation devices are available Limited by the capacity of the person delivering the ventilations Potential for exposing either the rescuer or the patient to communicable diseases Prevents direct contact between you and your patient’s mouth Devices usually have a one-way valve that prevents you from contacting the patient’s expired air. May also provide an inlet for supplemental oxygen Prehospital and emergency department personnel most commonly use the bag-valve device. One, two, or three rescuers may perform bag-valvemask ventilation. © Scott Metcalfe Observe the patient for chest rise, gastric distention, and changes in compliance of the bag with ventilation. Complications: Inadequate volume delivery Barotrauma Gastric distention Flow-restricted, oxygen-powered ventilation device Flow is restricted to 30 cm H2O or less to diminish gastric distention Cannot measure delivered volumes or feel lung compliance Advantages: Typically comes with two or three controls Maintain minute volume Mechanically simple and adapts to a portable oxygen supply Rate Volume Contraindications A significant percentage of claims and lawsuits involve inadequate patient ventilation. Detailed documentation shown could go a long way toward warding off such a claim. It is crucial to document in medically correct and legally sufficient terms exactly what was done in managing the airway. Anatomy of the Respiratory System Physiology of the Respiratory System Respiratory Problems Respiratory System Assessment Basic Airway Management Advanced Airway Management Orotracheal Intubation Pediatric Orotracheal Intubation Nasotracheal Intubation Managing Patients with Stoma Sites Suctioning Gastric Distention and Decompression Oxygenation Ventilation Documentation