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Face Mask Ventilation

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Laryngoscopy Strategies for First Pass Success

Surgical Airways and Their Role in Emergency Airway Management

Face Mask Ventilation

Ventilation and oxygenation are at the heart of patient safety in emergency airway management. Mask ventilation is used as an immediate means of oxygenation in cardiac arrest, and in preparation for endotracheal intubation in both emergent and elective cases. The use of anesthestic agents and muscle relaxants, and the time necessary for laryngoscopy or other intubation techniques, mandates patients to be effectively ventilated and oxygenated prior to intubation in order to prevent hypoxemia. Pre-oxygenation for 4 minutes, at 15 lpm with a well fitting mask, will maximize oxygenation and prevent hypoxemia during intubation in most patients. In the critically ill, and in many emergency airway situations, however, preoxygenation is only marginally effective.

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

In such instances, mask ventilation is often needed prior to intubation efforts, and during the onset phase of muscle relaxants (60 seconds for succinyl choline, for example). Intubation in these settings should be accomplished on first-pass to maximize patient safety.

NO DESAT: Nasal Oxygen During Efforts Securing A Tube

A Novel, Radically Simple, Ridiculously Effective Way to Improve Patient Safety During Emergency Airways!

High flow nasal oxygen (15 lpm) in ADDITION to 15 lpm face mask oxygenation dramatically improves the inspired FiO2, eliminating the build up of exhaled gas in the nasopharynx. Flushing the nasopharynx makes pre-oxygenation much more effective. The nasal cannula is then left on (and running) during mask ventilation (induction), and then during apnea while intubating through the mouth. During intubation efforts the pulse ox in your patients never drops, and even goes up! This is due to the remarkably effective ability of the alveoli to entrain and absorb oxygen from the upper airway very effectively, even during apnea following RSI.

Click HERE for Dr. Levitan's article on this technique in Emergency Physician's Monthly Dec 2010.

Mask Ventilation 2 Person Technique:

1) Proper positioning – ear-to-sternal notch alignment, unless contraindicated by cervical spine immobilization.

2) Jaw thrust – lift up on mandible and submandibular tissues.

3) Press mask down on the nasal bridge.

4) Oral and/or nasal airways. Curvature of oral airway must be fully inserted behind the curvature of the tongue. These should be ready to use at the head of bed for every airway.

5) Work together to create a patent airway, not to force air in. Extra hands are better used under the jaw and lifting the submandiblar tissue, as opposed to squeezing bag harder, or pushing mask down on mandible (occluding airway).

6) Small, slow, easy squeeze of bag: 6-7 cc/kg, over 1-2 seconds, using low pressure. 70 kg patient requires only 420-490 cc per breath. Rate should not exceed 12 breaths per minute in adults.

7) Over-ventilation, high volume, and high pressure increase regurgitation, decrease coronary perfusion and blood pressure.

Pocket Guide Image #2

“JAWS”

J – Jaw thrust
A – Airways (oral/nasal)
W – Work together
S – Slow, small squeeze

Mask Ventilation Difficulty: O. B. E. S. E.

    Obesity: Critical to achieve proper ear-to-sternal notch positioning before starting.

    Beards: use water-soluble lubricant over beard to flatten hair or use clear occlusive plastic over face with hole over mouth opening.

    Edentulous patients: easier to mask with dentures in place; easier to intubate with dentures removed.

    Sleep Apnea: upper airway obstruction occurs at hypopharynx, base of tongue, and perilaryngeal structures; in addition to proper positioning, make sure oral and nasal airways, as well as supraglottic airways are immediately available.

    Elderly

Additional mask ventilation challenges: Vomitus, bleeding, major midface and mandible trauma. Have suction ready (and working!). Surgical airways, while patient is spontaneously ventilating, may be best initial intubation approach with major lower facial injury.

Difficult mask ventilation rates in OR settings: ~5%; impossible <0.1%.
Supraglottic airways (LMA, King, Combitube, etc.) bypass face, and create seals within upper airway; see menu to left.

Head Elevation:

Upper airway patency is improved by jaw thrust
(top) and flexion of the neck on the chest (bottom):

1) Top fluoroscopic images show the effect of jaw
thrust on the upper airway. In left image epiglottis
and tongue lie against posterior pharyngeal wall and occlude airway. Jaw thrust lifts base of tongue and epiglottis and opens hypopharyngeal space (white circle). Images by George Kovacs, MD, and Adam Law, MD, Dalhousie University, Halifax.

2) Extreme atlanto-occipital extension in bottom
left radiograph shows how base of tongue
(asterisk) is pushed backward, narrowing upper
airway. Neck flexion (right), achieved with
ear-to-sternal notch positioning, maximizes
dimensions of hypopharyngeal space (circle).
Patients in respiratory distress position
themselves in ear-to-sternal notch position to
maximize airway patency.

Ear to Sternal Notch:

Proper positioning for ventilation and laryngoscopy aligns the ear with the sternal notch:

1) The head is flexed relative to the chest, reproducing the position that patients in respiratory distress use, but with a supine orientation. Face plane should be approximately horizontal.

2) Maximizes upper airway patency and improves the mechanics of ventilation, both with spontaneous breathing and with mask ventilation.

3) In massive obesity, this position lengthens the apneic time period to critical hypoxia and shortens the time needed with mask ventilation to return to normal oxygen saturation

4) Prepare proper ramp (head and shoulder support) for obese patients before transferring onto stretcher and before attempting laryngoscopy. Dynamic lifting during laryngoscopy is impossible in very large patients.

Proper positioning for ventilation and laryngoscopy aligns the ear with the sternal notch and is independent of age and size:

1) The large occiput of this small child causes the head to be flexed relative to the chest, without the need for additional head elevation.

2) In infants, the large occiput may cause excessive neck flexion. Supporting the shoulders may be required to achieve ear-to-sternal notch positioning.

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DISCLAIMER: The procedures discussed at this website, to be performed properly, rely on complex medical skills and should only be undertaken after formal instruction and hands-on clinical training with appropriate supervision, and after receiving professional certification and authorization to do so. The content presented herein is meant to serve as just one of many resources that trainees and health care professionals should consult in the course of the their skill acquisition and ongoing practice. Airway Cam Technologies, Inc., its authors, officers, agents and assigns, disclaim any and all responsibility for any adverse outcomes and or harmful acts committed by others persons who may have consulted this website or relied on information contained herein.

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Mask Ventilation 2 Person Technique:

“JAWS”

Mask Ventilation Difficulty: O. B. E. S. E.

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