4 Airway Management And Mainteance

18 AIRWAY MANAGEMENT / MAINTENANCE I. Ensuring maintenance of an adequate airway is of primary importance for all patients transported by San Antonio AirLIFE. Criteria for advanced airway procedures may include: A. Acute respiratory failure, obvious respiratory distress B. Oxygen saturations < 92% on 100% oxygen C. Glasgow coma score 8 in trauma patients suspected of head injury D. Significant oral / facial burns or edema of the neck, face and / or oral mucosa E. Significant smoke or toxic inhalation associated with carbonaceous sputum or impending respiratory compromise F. Obtunded patients with poor airway reflex (AVPU score of P or U) G. Infants with cyanotic CHD who are ductal dependent, have right to left shunting or who have had a Blalock shunt or other central shunts will have SpO2 saturations of 70 – 85% and should not routinely be intubated unless also suffering from significant respiratory distress or metabolic / respiratory acidosis. Consult Medical Control if necessary H. Newborn receiving Prostin – consider intubation prior to transport if any events of apnea have been witnessed II. Treatment A. Perform assessment and determine Mallampati Classification (Class I – IV) of airway, assess jaw mobility and thyroid-mentum distance. B. Provide C-Spine stabilization for suspected trauma patients. C. Pre-oxygenate with oxygen via non-rebreather or bag valve mask device to enhance oxygenation and induce nitrogen washout. Spontaneously breathing patients, with adequate Minute Volume, should be administered oxygen via non-rebreather mask for a minimum of 2 – 3 minutes prior to intubation attempts. Patients requiring BVM ventilations should be ventilated for a minimum of 2 minutes prior to intubation attempts. D. Sedation / Pre-medication 1. Consider analgesic / sedation / hypnotic administration with fentanyl, Versed, or etomidate as per guideline. Extreme caution is required for sedation of patients who are hemodynamically unstable (i.e. cardiogenic or hypovolemic shock). Sedatives may cause or worsen hypotension. Fentanyl and etomidate cause less adverse hemodynamic effects than other medications utilized for pharmacology-assisted intubation (PAI) carried by San Antonio AirLIFE (i.e. Versed, Valium). Patients who are completely obtunded and who are hemodynamically compromised may be intubated without medications. 19 2. Pre-medicate pediatric patients (≤8 y/o) with Atropine 0.02mg/kg IVP (minimum dose of 0.1mg) and a maximum

dose of 0.5mg. E. Pharmacological Agents for Airway Procedures 1. Consider etomidate per guideline for all patients but especially those with Class III or Class IV Mallampati airways in lieu of paralytics. 2. Consider the non-depolarizing paralytics Zemuron (rocuronium) or Norcuron (vecuronium) with sedation as per guideline. EXTREME CAUTION with Mallampati Class III airways. Paralytics have a relative contraindication for use in Mallampati Class IV airways until the trachea has been intubated. F. Intubation Procedure 1. Provide cricoid pressure (Sellick’s Maneuver) following administration of pharmacological agents above. 2. Intubation may be performed by either the oral or nasaltracheal route. (*Nasal intubation requires the patient to be spontaneously breathing.*) 3. Select appropriate laryngoscope blade. Lubricate stylette prior to placing it in tube and lubricate tube prior to intubation. 4. A Bougie may be utilized in place of a stylette. Confirmation of Bougie placement should be verified by the presence of tracheal clicking (vibration caused by the device rubbing over the cricoid rings. 5. Note Cormac – Lehane Airway Classification (Grade I – IV) during laryngoscopy. 6. Intubate the trachea with cuffed ETT. Ensure pilot balloon is below the level of the vocal cords. 7. Surgical cricothyroidotomy may be performed if patient condition mandates (i.e. severely distorted airway anatomy, kyphosis, entrapment, can’t intubate – can’t ventilate situations, etc.) G. Confirm Intubation 1. Visualize ETT passing through and below level of vocal cords. 2. Auscultate breath sounds. Compare bilaterally.

3. Ensure no ventilation sounds over epigastric region. 4. Apply ETCO2 Detector (Quantitative (Color-metric) or Qualitative (continuous waveform monitoring)) and ensure 20 presence of ETCO2. Absence of ETCO2 indicates incorrect tube placement or severe, deadly, hypo-perfusion states. 5. If there is any doubt regarding tube placement, it should be removed and BLS ventilation procedures initiated. H. Unsuccessful Endotracheal Intubation Attempt(s) 1. Ventilate patient with BVM utilizing oral-airways and nasal-pharyngeal-airways as necessary. Re-attempt procedure. After two unsuccessful intubation attempts by an individual, they should relinquish next attempts to their partner. Consider switching size and type of laryngoscope blade. 2. Consider use of External Laryngeal Manipulation (ELM). ELM of the laryngeal structure such as 1) increased Sellick’s Maneuver, 2) Backwards-Upward-RightwardPressure (BURP) may enhance visualization of airway structures. 3. If not utilized during prior attempts, endotracheal intubation should be attempted via Bougie assist. 4. Consider use of the Laryngeal Mask Airway (LMA). The LMA is a low-pressure ventilation device and attempts to provide too much positive pressure ventilation may interrupt seal of laryngeal mask rendering it less effective. I. Can’t Intubate / Can’t Ventilate Situations 1. Consider use of the Laryngeal Mask Airway (LMA). The LMA is a low-pressure ventilation device and attempts to provide too much positive pressure ventilation may interrupt seal of laryngeal mask rendering it less effective. OR 2. Perform insertion of an oral-pharyngeal airway (OPA) and bilateral nasal-pharyngeal airways (NPA). Provide aggressive mask seal while lifting mandible. Apply Sellick’s Maneuver while performing BVM ventilations. OR

3. Consider Surgical Cricothyroidotomy for patient’s ≥10 y/o. 4. Consider Needle Cricothyroidotomy for patient’s ≤10 y/o. J. Securing Airway Adjunct 1. Secure device with tape, commercial tube-restraint, tube tamer, twill tape, or other appropriate device. K. Post Intubation Management 21 1. Consider analgesic, anxiolytic, or paralytic administration for optimal airway control as needed. 2. The ventilator should be considered for inter-facility flights or flights > 15 minutes in duration. The initial tidal volume (Vt) will be 6 – 10 mL/kg (ideal body weight). Respiratory rate (RR) should be set to administer a Minute Volume (MV) of 6 – 10 L/min. (Vt x RR = MV) 3. Ventilator Management for infants/children: 4. Volume and rate to maintain normal ETCO2. 5. FiO2 – Adjust to maintain acceptable SpO2 saturations for disease condition. L. When transferring care of the patient to the receiving facility, placement of the ETT should be checked and verified prior to relinquishing care of the airway by the AirLIFE Medical Crew. Continuous ETCO2 monitoring shall be performed throughout transport and until delivery of the patient to the receiving bed at the receiving institution. Confirmation of ETT placement upon relinquishment of care should be documented in the AirLIFE patient care record. Reviewed/Revised: 10/98, 4/2001, 6/2002, 01/04, 03/05, 03/07, 02/09