Improving Intubation Just Another Airway… Yawn Success So what if I don’t get it on the first pass… I can just give it another try! Diane M. Birnbaumer, M.D., FACEP Professor of Medicine University of California, Los Angeles Senior Faculty Department of Emergency Medicine Harbor-UCLA Medical Center Decision Point Just Another Airway… Yawn Is Airway Management Indicated? So what if I don’t get it on the first pass… Indications for intubation I can just give it another try! Adverse events with multiple attempts Inadequate oxygenation One attempts 14.2% Inadequate ventilation Two attempts 47.2% Unable to protect airway Three attempts 63.6% Anticipated clinical course Four attempts 70.6% Sakles JC, et al: Acad Emerg Med January 2013;20:71-78. Decision Point Decision Point Is Noninvasive Ventilation an Option? Are There Potential Airway Problems? Does this patient have a difficult airway? What is the underlying process? Difficult BVM? Obesity hypoventilation syndrome? Difficult laryngoscopy? Congestive heart failure? Difficult extraglottic devices? COPD? Difficult surgical airway? Asthma? End of life? Is the patient awake enough? Can the patient cooperate with NIV? 1
Decision Point Decision Point Are There Potential Airway Problems? Are There Potential Airway Problems? Does this patient have a difficult airway? Does this patient have a difficult airway? Difficult BVM? Difficult laryngoscopy? M Mask seal / Male / Mallampati L Look externally O Obstruction / Obesity E Evaluate the 3-3-2 rule A M Age (over 55 years) Mallampati N No teeth O Obstruction / Obesity S Stiff / Snoring N Neck mobility Decision Point Decision Point Are There Potential Airway Problems? Are There Potential Airway Problems? Does this patient have a difficult airway? Does this patient have a difficult airway? Difficult extraglottic devices? Difficult surgical airway? R Restricted mouth opening S Surgery (recent or remote) O Obstruction / Obesity M Mass D Disrupted or distorted airway A Access / Anatomy S Stiff R Radiation (deformity / scarring) T Tumor Using RSI? Decision Point The Timeline Going to Use RSI? Zero minus 10 minutes Prepare P = Preparation Zero minus 5 minutes Preoxygenate P = Preoxygenation Zero minus 3 minutes Pretreat P = Pretreatment * * Time ZERO* * Paralysis with induction P = Paralysis with induction Zero plus 30 seconds Protection P = Protection Zero plus 45 seconds Placement P = Placement of the tube Zero plus 90 seconds Post-intubation management P = Post-intubation management 2
Decision Point Decision Point Can You Optimize RSI? Can You Optimize RSI? P = Preparation P = Preparation The Patient The Patient The Equipment Positioning is key The Personnel Yourself Decision Point Can You Optimize RSI? Position Alignment of the three axes is critical A common problem in missed intubations Landmarks: Align external auditory canal with sternal notch 3
Decision Point Can You Optimize RSI? P = Preparation What is the patient is morbidly obese? Ramp ‘em up! Before… After….. Decision Point Can You Optimize RSI? P = Preparation The Equipment Know and prepare your own equipment Always have at least one backup ready Bougie Extraglottic device Videoscopic device Surgical/percutaneous airway 4
Decision Point Decision Point Can You Optimize RSI? Can You Optimize RSI? P = Preparation P = Preparation The Personnel Yourself Make sure everyone knows what they are doing Troubleshoot the intubation Be sure you take charge Consider “what if” scenarios Tell everyone how YOU want it done Make sure you consider how to optimize intubation for each individual patient Is awake better? Is in the OR better? Use a rescue airway after more than two attempts Decision Point Can You Optimize RSI? P = Preoxygenation 2 major goals Maximizing oxygenation De-nitrogenation ALL ED patients needing intubation should receive preoxygenation Decision Point Decision Point Can You Optimize RSI? Can You Optimize RSI? P = Preoxygenation P = Preoxygenation NRB mask on all spontaneously ventilating Optimizing BVM patients Two person, two-handed technique 3-4 minutes - that’s all you get Surgilube on facial hair Assisted ventilation may maximize oxygen delivery BVM for 8 vital capacity breaths if not breathing spontaneously 5
Decision Point Decision Point Can You Optimize RSI? Can You Optimize RSI? P = Preoxygenation P = Preoxygenation NRB mask on all spontaneously ventilating Can we do anything more? patients Positive pressure oxygen delivery? 3-4 minutes - that’s all you get Position during preoxygenation? Assisted ventilation may maximize oxygen Apneic oxygenation? delivery BVM for 8 vital capacity breaths if not breathing spontaneously Can we do anything more? Decision Point Decision Point Can You Optimize RSI? Can You Optimize RSI? P = Preoxygenation P = Preoxygenation Positive pressure ventilation Apneic oxygenation Consider NIV, CPAP, PEEP on BVM during onset of Nasal cannula at 15 L/minute muscle relaxation if unable to achieve saturation Maintains oxygenation better than without it 93-95% without it – but use with care Put nasal cannula on patients from the get go, Position then turn up rate as patient is induced and paralyzed Head of bed elevation / reverse Trendelenberg Note: Highly consider using nasal airways and using jaw thrust as the patient is paralyzed Decision Point Decision Point Can You Optimize RSI? Can You Optimize RSI? P = Preoxygenation P = Pretreatment Excellent review article on the topic L Lidocaine Weingart SD, Levitan RM: Preoxygenation O Opioids and prevention of desaturation during A Atropine emergency airway management. Ann Emerg D Defasciculation Med 2012;59(3):165-175. 6
Decision Point Decision Point Can You Optimize RSI? Can You Optimize RSI? P = Pretreatment P = Paralysis with induction L Succinylcholine vs. rocuronium Lidocaine O Opioids Bottom line Sux onset faster, duration shorter A Atropine Roc in higher doses similar onset, longer duration D Defasciculation No concern about serious sux side effects if using roc Studies suggest both have similar first attempt success rates– just make your choice thoughtfully Decision Point Decision Point Can You Optimize RSI? Can You Optimize RSI? P = Paralysis with induction P = Protection Induction? Do you need it? Everyone should have the Sellick maneuver, right? Studies show higher intubation success rates when using induction agents Not any more. Even if patient significantly altered, use induction Cricoid pressure may worsen glottic view agents Especially in women Release of cricoid often improves view (up to 50% of the time) Decision Point Decision Point Can You Optimize RSI? Can You Optimize RSI? P = Placement of the tube P = Placement of the tube BURP Bimanual laryngoscopy Backward, Upward, Rightward Pressure on the Visualize the cords with direct laryngoscopy thyroid cartilage Reach around and manipulate the thyroid It works, but can we improve on it? cartilage to maximize visualization of the glottis Have an assistant hold airway in that position 7
Decision Point Decision Point Can You Optimize RSI? Can You Optimize RSI? P = Placement of the tube P = Post-intubation management Don’t forget the simple stuff Don’t forget to sedate Have someone pull the right side of the Consider restraints to prevent extubation patients mouth open for you Continued paralysis may be necessary in Using the straight blade? Consider some patients (depending on underlying rotating it counterclockwise a bit to processes) improve room in the mouth Can We Improve Intubation Success? Meticulously adhere to the steps of Thank you for your intubation attention! Know how to Maximize positioning Preoxygenate / denitrogenate Any questions? Use medications optimally Employ adjunctive devices Prevent extubation 8
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