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Techniques for Nasal Intubation

Algorithms for Emergency Airway Management

Algorithms for emergency laryngoscopy and rapid sequence intubation must be simple and easy to apply in moments of crisis. Although RSI is routinely used for emergency airway management there are some situations when it is contraindicated.  Primary contraindications are when muscle relaxation is not needed (i.e., the patient has no response to laryngoscopy and intubation), or when there is oral or laryngo-tracheal pathology that can prevent rescue ventilation.

 

Laryngoscopy Strategy for First Pass Success

Laryngoscopy is the mainstay of emergency airway management, but it must be performed with a first-pass strategy. Multiple attempts correlate with higher rates of complications and death.

Pocket Guide Image # 244  Practical Emergency Airway Management Algorithm


This algorithm incorporates epiglottoscopy, bimanual laryngoscopy, and head elevation to maximize laryngeal exposure. The morbidyobese cannot be dynamically lifted;ear-to-sternalpositioning must be done first. Straight-to-cuff stylet shaping helps with tube delivery without blocking the line of sight to the target. An optical stylet or bougie (tube introducer) can be rapidly deployed to assist in an epiglottis-only view. If initial laryngoscopy with a curved blade does not permit tracheal intubation, mask ventilation or rescue ventilation using a supraglottic airway may be required. Repetitive laryngoscopy should not be initiated with the patient hypoxic. The primary goal of RSI and emergency airway management is to ensure effective oxygenation–if the patient is hypoxic, ventilation takes priority over persistent efforts at plastic insertion! Straight blade laryngoscopy is useful if the epiglottis can be seen but not elevated. In most adults it is harder to find the epiglottis with the smaller flange of a straight blade, and usually more challenging to deliver the tube compared
to a curved blade.

 

Rapid Sequence Intubation Algorithm

Rapid sequence intubation (RSI) is an airway management technique that is vital in emergency intubation. It produces inducing immediate unresponsiveness (induction agent, i.e., etomidate) and muscular relaxation (neuromuscular blocking agent, i.e., succinyl choline). RSI is the fastest and most effective means of controlling the emergency airway and has become the standard of care in emergency departments and aeromedical programs. Although RSI creates optimal laryngoscopy and ventilation conditions, the cessation of spontaneous ventilation involves considerable risk if the provider does not intubate or ventilate the patient in a timely manner. RSI is particularly useful in the patient with an intact gag reflex, a "full" stomach, and a life threatening injury or illness requiring immediate airway control. Screening tests for prediction of the “difficult airway” (Mallampati scoring, thyromental distance, etc.), work poorly, especially in emergency situations:

 

Shiga T, Wajima Z, Inoue T, Sakamoto A.Predicting difficult intubation in apparently normal patients: a meta-analysis of bedside screening test performance. Anesthesiology. 2005 Aug;103(2):429-37.


Levitan RM, Everett WW, Ochroch EA.Limitations of difficult airway prediction in patients intubated in the emergency department.  Ann Emerg Med. 2004 Oct;44(4):307-13.


Providers using pharmacologic agents (and especially neuromuscular agents) must have a strategy for first-pass intubation success, and redundant methods of ventilation and intubation immediately deployable.

algorithm

1) Patient safety using RSI hinges on a redundancy of safety.
Can you intubate? If intubation fails, can you ventilate? Algorithm (above) focuses on the route of intubation and RSI decision.

2) The colored arrows are contraindications to RSI.
In cardiac arrest (blue box – patient apneic) muscle relaxants are not needed. When there is obvious oral pathology, or intrinsic laryngo-tracheal pathology (green boxes – patient breathing spontaneously), the redundancy of safety does not exist – avoid RSI. When the mouth is blocked (step 2), intubate through the nose or through the neck (cricothyroidotomy). RSI is specifically done to optimize laryngoscopy conditions and permit oral intubation. If it is apparent that the oral route has obvious anatomic problems (not merely potential difficulty), RSI should never be considered. When the oral route is impossible, intubation will need to take place through the nose or neck, and this should be done with the patient awake. Examples include massive angioedema, advanced Lundwig's angina, wired jaw, or readily apparent combinations of airway distortion, disproportion, and dysmobility (cervical spine and mandible), that preclude oral intubation. With intrinsic laryngeal pathology (step 3), safest approach is with the patient breathing spontaneously, using fiberoptic intubation, or a surgical airway (tracheotomy) below the level of the lesion.

3) At step 4, the decision to use RSI is a matter of judgment, not a strict contraindication.
The four Ds (distortion, disproportion, dysmobility, dentition) may make direct laryngoscopy with standard equipment impossible. Is an “awake” approach feasible? Will you be able to rescue ventilate? How fast are intubation and patient control needed? What are the risks of delay vs. the potential risks of RSI?

4) After crossing the RSI line, patient safety often depends on first pass success at laryngoscopy, since many patients requiring emergent intubation have very short safe apneic periods.
Pre-oxygenation is only marginally effective in critically ill patients.

Mort TC. Preoxygenation in critically ill patients requiring emergency tracheal intubation.  Crit Care Med. 2005 Nov;33(11):2672-5.

 

5) Respiratory recovery following a 1mg/kg IV dose of succinylcholine averages 9 minutes. If laryngoscopy fails, and mask ventilation is difficult or impossible, a rescue ventilation device (LMA, King LT, etc.) may be needed.

 

Drug Dosages for RSI

DISCLAIMER:  The authors and publisher have made every effort to ensure that the patient care recommended herein is in accord with accepted standards and practice at the time of publication. In view of the possibility of human error and the changing nature of medical care neither the authors nor publisher warrants that the information contained herein is complete or accurate in every respect, and they disclaim all responsibility for any errors or omissions or for the results obtained from use of the information in this work.  Using medications to facilitate intubation is a complex medical skill.  It should only be undertaken after formal instruction in using those medications, and hands-on procedural training with intubation and ventilation.


Muscle Relaxants:

Sedation/Induction Agents:

Etomidate 0.3-0.4 mg/kg

Succinylcholine 1-2 mg/kg

Fentanyl 2-10 mcg/kg

Rocuronium 0.6-1.2 mg/kg

Midazolam 0.1-0.3 mg/kg
Vecuronium 0.15-0.25 mg/kg
Propofol 1-2.5 mg/kg
Thiopental 3-5 mg/kg

 

Preparing for RSI

SOAP–ME:   A mnemonic to prepare for intubation during rapid sequence intubation.

 

Suction: Yankauer suction catheter on the right side of the patient's head, within reach of the operator's right hand during laryngoscopy. When properly connected, the suction is audible and palpable when the tip of the catheter is touched against the hand.

 

Oxygen: Bag valve mask resuscitator connected to an oxygen source at 15 lpm. The flow of oxygen should be audible and high enough to fill the reservoir bag or tubing. Squeeze bag against hand to verify positive pressure.

 

Airways: Oral and nasal airways and rescue ventilation devices, such as the LMA (#4, 5) and Small Adult Combitube. The cuff of the tracheal tube should be checked and fully deflated. The tracheal tube should be styletted with a straight-to-cuff shape. Tip of stylet should stop at or before distal edge of cuff, leaving the last 2-3 cm of tube flexible.

 

Positioning and Pre-Oxygenation: Ear-to-sternal notch positioning as described. Except in instances when laryngoscopy is done immediately (such as cardiac arrest and near arrest) pre-oxygenation with a well fitting non-rebreather mask and high flow oxygen (15 lpm) should be done for 4 minutes prior to rapid sequence intubation (RSI). Patients with inadequate spontaneous ventilation require bag mask ventilation as preparations for laryngoscopy are made.

 

Monitoring equipment and Medications: In patients without a pulse, laryngoscopy will occur immediately as monitoring is also being established. With RSI, the patient should have continuous pulse oximetry and cardiac monitoring, and pre- and post-procedure blood pressure monitoring. All medications should be drawn and labeled. The laryngoscopist should clearly communicate with all members of the care team regarding the sequence and timing of medications.

 

End-tidal CO2 device and Esophageal Intubation Detector: To verify tracheal placement after the tube has been placed, all patients require end-tidal CO2 monitoring, either by capnography, capnometry, or colorimetric testing. An esophageal intubation detector is useful for verifying tube location in cardiac arrest. 

 

SOCIETY PUBLISHED AIRWAY GUIDELINES:

 

DIFFICULT AIRWAY SOCIETY (United Kingdom) GUIDELINES

 

American Society Anesthesiologists PRACTICE GUIDELINES MANAGEMENT OF DIFFICULT AIRWAY

 

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