Airway 911 - Real Life Drama in the ER

Jason Z D’Amore MD FACEP Research Director Director NS-­‐LIJ Advanced Airway Training Center North Shore University Hospital, Manhasset NY Associate Professor Emergency Medicine Hofstra-­‐NSLIJ School of Medicine ¡  It’s never your fault ¡  What did I do? ¡  I really didn’t see this coming…. ¡  How could you do this to me??? ¡ 
Only Four Basic Reasons: §  Respiratory Failure ▪  CHF, Pneumonia, Asthma, Myasthenia Gravis, Sepsis, ALS ▪  May be secondary to intrinsic pulmonary pathology or Muscular Exhaustion ▪  Be cautious about the difference between Type I (Hypoxic) and Type II (Hypercarbic/metabolic) respiratory failure §  Anatomic Obstruction/Defect ▪  Trauma, Infection §  Airway Protection ▪  AMS, Head trauma, Stroke, various intoxicants §  Agitation in Trauma ▪  Occasionaly trauma patients are extremely agitated and though they have neither of the above two conditions they must be intubated to facilitate an expeditious trauma work-­‐up ¡ 
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Definition: Inability of experienced intubator to intubate after three attempts with optimized parameters Reported incidence: <0.1% 1:1000 Failed airway: ‘Can’t intubate Can’t ventilate’ §  <1:1000 (figure at least a few every few thousand) Must be comfortable with BVM skills Must have Alternative Devices and Surgical options at the ready Sagarin MJ, Barton ED, Chng YM, Walls RM, National Emergency Airway Registry Investigators. Airway management by US and Canadian emergency medicine residents: a multicenter analysis of more than 6,000 endotracheal intubation attempts. Ann Emerg Med. 2005 Oct;46(4):328-­‐36 ¡ 
If 95% of your airway encounters are easy…it’s easy to fall into a pattern (besides I’ve got the glidescope): §  Etomidate and Sux for all!!!! ¡ 
So…use an ‘airway formulation’ like you would for solving a ‘CPC’ case §  Anatomic Considerations ▪  Obesity, Dysmorphism/Altered anatomy, Trauma, full stomach §  Physiologic Considerations ▪  Severe Respiratory acidosis, ?metabolic acidosis, Renal failure, trauma/burns >72 hours ¡ 
Don’t Be Dogmatic!!!! ¡ 
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55y M Morbidly obese, COPD Sleep Apnea-­‐CPAP 1 week cough, fevers, sweats, SOB Awake and alert 101 150/110 105 36 91% RA Mod resp distress rhonchi and wheeze EKG normal CXR ?LLL infiltrate ABG: 7.15/80/155/35/94% ¡  Obese Pickwickian Male ¡  Anatomic Considerations §  Morbid Obesity §  No neck §  Unfavorable airway physiognomic assessment ¡  Phsyiologic Considerations §  Severe Respiratory Acidosis with elevated pc02 §  Likely limited FRC ¡  Immediate RSI ¡  Awake fiberoptic intubation ¡  Nebs and steroids admit ¡  Bipap ¡ 
Bipap: ¡ 
Parameters §  Awake and alert §  IPEP: 12 §  Intact airway reflexes §  EPEP: 6 §  Good respiratory effort §  Limit fi02 to maintain sat>95 §  Experience with cpap ¡ 
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Frequent reassessments MUST recheck Pc02 within 45-­‐60min of starting ¡  Patient somnolent ¡  RR 14, shallow ¡  Sp02 87% ¡  Abdomen distended ¡  Ph 7.05 ¡  pC02: 105 ¡  pO2: 65 ¡  Give the Bipap time to work ¡  Immediate RSI ¡  Awake Fiberoptic Nasal Intubation ¡  DSI (Delayed Sequence Intubation) ¡  Anesthesia and ENT were called ¡  Bedside discussion and plan §  Bipap failure §  Sig abd distention…aspiration risk-­‐no fiberoptic ¡  Ketamine 1.5mg/kg ¡  Succinylcholine ¡  Glidescope Intubation without technical difficulty ¡  Patient was started on bipap ¡  Blood gas never rechecked ¡  No MICU consult ¡  Went to floor on Bipap ¡  Arrested 4 hours later ¡  Ph at time of arrest 6.9 ¡  pC02 135 ¡  Patient died 62F AA ¡ 
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On an ACE No family history Normal VS C/O sig swelling No prior episodes Given §  Steroids §  Antihistamines §  FFP ¡ 
Last meal >5hours ago ¡  RR 35 ¡  Respiratory distress ¡  Sat 91% ¡  Stridor ¡  Patient appears panicked!!! ¡  AA Female with ACE-­‐I Induced Angioedema ¡  Mod Resp distress…. ¡  Anatomic Considerations §  Angioedema-­‐Tongue obstructing airway
▪  Depending on type of angioedema may involve hypopharnygeal and laryngeal structures §  Empty stomach ¡  Physiological Considerations §  None-­‐-­‐-­‐no intrinsic lung or metabolic issues §  Patient is awake, alert, cooperative ¡  RSI ¡  DSI ¡  Awake Nasal Fiber-­‐optic Intubation ¡  Surgical airway ¡  A clear case for awake Nasal Fiber-­‐optic intubation §  Awake and alert §  Can cooperate §  No vomiting §  Empty stomach §  Likely tongue is the obstruction ¡ 
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11m Male Ex 34weeker Hx mild BPD 3d Fever, Cough, Rhinorrhea 2d Wheezing Mild distress today, no PO intake RR 55 sat 91% Distress with Inc WOB +Accessory muscle use RSV + CXR: increased interstitial markings with hyperaeration ¡  Oxygen ¡  Nebs ¡  Racemic ¡  (none of this stuff really works) ¡ 
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RR 35 Sp02 86% Baby lethargic Blood gas QNS ¡ 
11m ex preemie hx BPD now with Severe RSV §  Hypoxic, respiratory distress, increasing lethargy, with respiratory effort fatigue, refractory to conservative therapy ¡ 
Anatomic considerations §  Infant less than one §  Empty stomach ¡ 
Physiologic considerations §  Severe hypoxia…limited FRC §  Evolving hypercapnia §  AMS and lethargy ¡  RSI ¡  Bipap/CPAP ¡  IV EPI ¡  Just intubate ¡  Straight to Intubation
§  No need for sedatives or paralytics §  Lethargic baby §  Flagging resp effort §  Empty stomach Children are very different than adults !!! But they’re still Human!!! ¡  Nose is responsible for 50% of total airway resistance at all ages ¡  Infant: blockage of nose = respiratory distress ¡  Larger, thicker, wider ¡  Loss of tone with sleep, sedation, CNS dysfunction ¡  Frequent cause of upper airway obstruction ¡  Relatively large size in children
¡  Omega shaped
¡  Floppy – not much cartilage ¡  Longer, and more anterior appearing ¡ High position •  Infant : C 1 •  6 months: C 3 •  Adult: C 5-­‐6 ¡ Anterior position Children are different Peripheral airways contribute to total airways resistance: Adult
Child
20% 50% Poiseuille’s law 8 n
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R = Π r4 If radius is halved, resistance increases 16fold Look at the size of his occiput!!! Look how flexed he is in this postion. We never position adults this way. 35yo M Shotgun blast to the face and neck 75yo F Angioedema with significant face and neck swelling stridor and distress 45yo M morbidly obese with sleep apnea and asthma in severe distress Somehow after using all your skills (which you use every day) and failing to successfully intubate after multiple attempts AND having no success in maintaining saturation you are going to perform a successful emergency cricothyrotomy (which you do <1/year) in less than 60seconds with 100% success in a crashing patient. ¡ 
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You have failed to intubate the patient The patient is in absolute extremis: §  Hypoxic §  Bradycardic §  Hypotensive This is one of the most critical clinical situations you will ever encounter In a 25 year career spanning 25-­‐30,000 clinical hours Your total cricothyrotomy experience will total <60min ¡ 
You will not be able to intubate 1-­‐5% of your patients, 1:20 ¡ 
You will not be able to ventilate between 1%-­‐.01%, 1:100 and 1:10000 ¡ 
The same set of clinical conditions and anatomical considerations which lead to the failed airway also predict surgical difficulty § 
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Trauma Obesity Edema Dysmorphisms congenital and acquired Intrinsic anatomical derangements ¡ 
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National Emergency Airway Registry 31 sites, 3 countries 6000 Intubation attempts 1st pass success: 90% Surgical Airway 0.9% time With the advent and high percentage penetrance of video guided laryngoscopy numbers may be even smaller Sagarin MJ, Barton ED, Chng YM, Walls RM, National Emergency Airway Registry Investigators. Airway management by US and Canadian emergency medicine residents: a multicenter analysis of more than 6,000 endotracheal intubation attempts. Ann Emerg Med. 2005 Oct;46(4):328-­‐36 Entire laryngeal complex must be stabilized Must be able to identify thyroid cartilage prominence ¡  Cricoid ring ¡  Cricothyroid membrane ¡  Two methods of successful identification: ¡ 
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§  Down from thyroid cartilage §  Up from the jugular notch (my preference) ¡ 
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Membrane is calcified and only @1 sq cm Emerging role of Ultrasound to identify membrane SURGICAL ¡ 
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4 Step technique: Cut, Puncture, Dilate, Place Pros: quick, simple equipment: SELDINGER ¡ 
§  Scalpel, shiley or ETT, ?bougie ¡ 
Cons: If initial incision is off mayem ensues ¡ 
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Membrane initially punctured with neede….wire placed into trachea. Incision made onto wire, dilate over wire. Place tube over wire. Pros: Central line crossover skill set Cons: Dilation can be problematic, placement over wire can be difficult Randomized cadaver crossover study (n=15) 93% vs 87% seldinger vs open 0.5cm vs 2.5cm incision length seldinger vs open (p<.001) ¡  No difference in completion times or complication rates ¡  Completion time mean @60s with ranges up to 120s ¡  93% preferred seldinger ¡ 
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Chan TC, Vilke GM, Bramwell KJ, Davis DP, Hamilton RS, Rosen P. Comparison of wire-­‐guided cricothyrotomy versus standard surgical cricothyrotomy technique. J Emerg Med. 1999 Now-­‐Dec;17(6):
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Surgical/Open vs Seldinger/Melker vs Portex (needle based) in a porcine model (n=20) Success: 100% Melker vs 55% surgical vs 30% Portex (p<0.02) No significant difference in median success times 50-­‐60s with ranges up to 150s Surgical (@25%) and Portex (@55%) techniques with posterior tracheal wall injury None with Melker Take home point: we love looking at means and medians but the RANGES tell the real story in surgical airway management…You want to be a game day player you must consider and prepare for the worst case scenario Mariappa V, Stachowski E, Balik M, Clark P, Nayyar V. Cricothyrotomy: comparison of three different techniques on a porcine airway. Anaesth Intensive Care. 2009 Nov;37(6):961-­‐7. ¡ 
@150 human cadaver cricothyrotomies over the past 4 years ¡ 
Seldinger/Melker technique is faster 50-­‐60s vs 70-­‐90s with lower complications BUT: §  Ranges for any approach when technical difficulty is encountered (@30-­‐40%) §  Can exceed 2.5minutes!!! §  Contrary to what the literature tells you a real Melker/Seldinger approach MUST be augmented in many cases with a surgical dilation to aid placement Cook Universal Cricothyrotomy Kit: Surgical and Melker ¡ 
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Introduced in the 1950s Initially associate with hypercapnia, hypoxia, SQ emphysema Modern approaches have eliminated many of these problems Many newer devices work off a standard 50psi wall source (no pressure regulator) Lower respiratory rates with an I:E ratio of 1:2.5-­‐3 more effective than older High frequency approach 80-­‐90% success rate in the failed airway 100% success rate in a series of 50 ENT procedures with failed airways Patel R. Percutaneous transtracheal jet ventilation: a safe, quick, and temporary way to provide oxygenation and ventilation when conventional methods are unsuccessful. Chest. 1999 Dec;116(6):1689-­‐94 Ross-­‐Anderson DJ, Ferguson C, Patel A. Transtracheal jet ventilation in 50 patients with severe airway compromise and stridor. Br J Anaesth. 2011 Jan;106(1):140-­‐4 ¡  First, puncture the membrane with a needle and aspirate air ¡  Introduce a catheter ¡  Attach an oxygen flow modulator ¡  Ventilate until oxygen saturation is improved ¡  Remove the flow modulator, insert a wire ¡  Complete the cricothyrotomy ¡  What would that procedure look like…???? Cricothyroid membrane punctured with ENK catheter needle (15g/5.5fr Cook ENK Oxygen Flow Modulator attached to catheter Cook ENK Oxygen Flow Modulator replaced with Seldinger wire ENK catheter needle removed Vertical incision made at insertion site . MelkerTM Airway-­‐Dilator assembly placed over wire Assembly positioned prior to removal of dilator and wire Manikin Group Cadaver Group Sample Size (n) 48 26 Success Rate (%) 100% 100% Median T1 (s), 95% CI (s) 10.7 (9.7-­‐11.5) 12.3 (10.0-­‐14.4) Median T2 (s), 95% CI (s) 58.6, (56.5-­‐64.0) 71.0 (62.0-­‐92.0) Min T1 (s) 5.0 8.9 Max T1 (s) 25.9 23.5 Min T2 (s) 39.5 39.0 Max T2 (s) 103 200