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Airway Management For Nurses

Todd Lang, MD
Basic Airway Management:
Bag-Mask Ventilation

Slides adapted from: Pat Melanson,

Airway Assessment
• Assessment for airway compromise or
threats and need for interventions
• Understand recent medical conditions,
medicines (blood thinners?), chest/neck
• Examination for the potentially difficult
Consider each patient’s airway in
terms of possible threats and
difficulties in management.
Indications for Active Airway
Intervention: including intubation
• Failure to maintain patency
• Protection from aspiration
• Hypoxic/ hypercapnic respiratory failure
• Airway access for pulmonary toilet, drug
delivery,therapeutic hyperventilation
• Intractable Shock
• Anticipated clinical deterioration
Clinical Signs of Airway Compromise
: Threatened Patency
• Inspiratory stridor
• Snoring ( pharyngeal obstruction )
• Gurgling ( blood/ secretions )
• Drooling ( epiglottitis )
• Hoarseness ( laryngeal edema/ vocal cord
• Paradoxical chest wall movement
• Mass - abscess, hematoma, angioedema
Clinical Signs of Airway Compromise:
Inadequate Protection

• Blood in upper airway

• Pus in upper airway
• Persistent vomiting
• Loss of protective airway reflexes
– swallowing reflex is superior to gag reflex
Clinical Signs of Airway
Oxygenation and Ventilation
• The assessment of oxygenation and
ventilation is a clinical one.

• Arterial blood gases should not be

relied upon to assess whether
intubation is necessary.
Anticipated Course: An elective
airway is better than an
emergency or crash airway.
• Better training and more equipment in the
• In prep for transport (even to CT)
• Leaves time for failure and retry
Techniques for the
Compromised Airway
• Head Positioning
• Jaw Thrust, Chin lift
• Orophryngeal/ Nasopharyngeal airways
• Bag-Valve-Mask Ventilation
• Endotracheal Intubation
• Advanced techniques
– Cric, LMA, Combitube, Retrograde,
Fibreoptic, Light wand, Bouge
BVM Ventilation
• The most important airway skill
• Always the first response to inadequate
oxygenation and ventilation
• The first “bail-out” maneuver to a failed
intubation attempt
• Attenuates the urgency to intubate
Golden Rules of Bagging
• “Anybody ( almost ) can be oxygenated
and ventilated with a bag and a mask”
• Manual ventilation skill with proper
equipment is a fundamental premise of
advanced airway Rx
BVM Ventilation
• Requires practice to master
• One hand to
– maintain face seal
– position head
– maintain patency
• Other hand ventilates
Emergent Airway Management
BVM Ventilation: Technique
• insert oropharyngeal/nasopharyngeal
• “Sniffing”position if C-spine OK
• Thumb + index to maintain face seal
– Stem of mask in thenar webspace
• Middle finger under mandibular symphysis
• Ring/little finger under angle of mandible
• Maintain jaw thrust/mouth open
BVM Ventilation:
Assessment of Efficacy
• Observe the chest rise and fall
• Good bilateral air entry
• Lack of air entering the stomach
• Feeling the bag
• Pulse oximetry
BVM Ventilation:
Mask Seal Tips and Pearls
• Easier to get seals with masks too large
than too small
• Inflate mask collar correctly
• Apply lubricant to beards to “mat
down” hair
• It is easier to bag with dentures in place
• If edentulous insert gauze sponges into
Predictors of a Difficult
Airway : Bag-Valve-Mask
• Upper airway obstruction
• Lack of dentures
• Beard
• Midfacial smash
• facial burns, dressings, scarring
• poor lung mechanics( resistance or
compliance )
Difficult Airway : BVM
• degree of difficulty from zero to infinite
• zero = no external effort or internal device
• one person jaw thrust/ face seal
• oropharyngeal or nasopharyngeal AW
• two person jaw thrust / face seal
– both internal airway devices
• infinite = no patency despite maximal external
effort and full use of OP/NP
Algorithm for Difficulty
• Remove FB - Magill forceps
• Triple maneuver if c-spine clear
– Head tilt, jaw lift, mouth opening
• Nasal or oropharyngeal airways
• two-person, four-hand technique
• Do not abandon bagging unless it is
impossible with two people and both an
OP and NP airway
Difficult Ventilation:
Obese Patients
• excess soft tissue causes obstruction
• Use both OP and NP airways
• Two hands for mask seal and jaw thrust
• Avoid pushing in on soft tissue under jaw
– may force into airway, worsen obstruction
• Place patient in reverse Trendelenburg
– decreases abdo pressure on diaphragm
– lowers amount of pressure needed to bag
Difficult Ventilation :
Edentulous Patients
• Cheeks fall inward; difficult seal
• Inflate mask cuff to maximum
• Allow weight of bag to fall down over
side of leak
• Place gauze at site of leak or inside
mouth to “puff out” cheek
• Two-handed technique using 3rd and
4th fingers to “bunch up” cheek
Difficult Airway Maxims
• The first response to failure of bag-mask
ventilation is always better bag-mask
– optimize airway position
– place OP and NP airways
– two-handed technique
– try lifting head off pillow to open airway
• Generate as much positive pressure as
possible without inflating the stomach
Technique of Laryngoscopy

• “Sniffing” position to align oral-pharyngeal-

laryngeal axis
• Flex neck by placing pillow beneath occiput (
raise 10 cm )
• Extend head maximally
• With laryngoscope
– open mouth fully
– push tongue to left out of view
– pull upward at 45 degrees
Adducted vocal cords
Open Cords
Predictors of Difficult
• Short thick neck
• Receding mandible
• Buck teeth
• Poor mandibular mobility/ limited jaw
• Limited head and neck movement
– ( including trauma )
Unsuccessful Intubation
• Bag the patient
• Maximize neck flex/ head ex
• Move tongue out of line of site
• Maximize mouth opening
• ID landmarks and adjust blade
• BURP maneuver (Backwards Upwards Rightwards Pressure on Thyroid Cart.)

• Increasing lifting force

• Consider Miller blade
• Bag the patient
A Nurse Can:
• BURP the patient
• Extend neck
• Bag Patient
• Watch the SaO2
• Suggest another device—tell doc to move on!!!
• Put towel under head
• Make sure the ETCO2 is measured
Difficult Airway Ideas:
• Awake look—sedate don’t
• ??Nasal—not much now
• LMA/Combitube
• Fiber optic intubation
Blind Nasal Intubation
• success rates 65 - 80 % in most series
• high complication rates
– epistaxis
– pharyngeal/ esophageal perforations
– increased incidence of O2 desaturation
• Considered second line approach only
• reserved for when RSI contraindicated
Oral Intubation Without
• Reserved for the completely
unconscious, unresponsive, and apneic
• Arrest situations only
Oral Intubation with Sedation
• proponents argue use of BZ or opioids
– improves airway access
– decreases patient resistance
– avoids risks of neuromuscular blockade
• Generally obtunds patient to point of loss of
protective reflexes and respiratory drive
• lower success rate, higher complications
compared with RSI
Oral Intubation with
Sedation:Use for the
Anticipated Difficult Airway
• if time permits
– topical anesthesia
– careful titrated sedation
– avoid obtundation
• ‘Awake” intubation technique
Emergency Airway Concerns
• “full” stomach
• minimal respiratory reserve
• hemodynamic instability
• acute myocardial ischemia
• increased intracranial pressure
• The “Difficult” Airway
– Laryngoscopy
– bag-mask difficulty
The “Intubation Reflex”

• Catecholamine release in response to

laryngeal manipulation
• Tachycardia, hypertension, raised ICP
• Attenuated by beta-blockers, fentanyl
• ICP rise possibly attenuated by lidocaine
• Midazolam and thiopental have no effect
Rapid Sequence Intubation :
• The near simultaneous administration of
a sedative-hypnotic agent and a
neuromuscular blocker in the presence
of continuous cricoid pressure to
facilitate endotracheal intubation and
minimize risk of aspiration
• modifications are made depending upon
the clinical scenario
Rapid Sequence Intubation :
• Optimizes intubating conditions/
facilitates visualization
• Increased rate of successful intubation
• Decreased time to intubation
• Decreased risk of aspiration
• Attenuation of hemodynamic and ICP
Rapid Sequence Intubation :
• Anticipated difficulty with endotracheal
– anatomic distortion
• Lack of operator skill or familiarity
• inability to preoxygenate
Rapid Sequence Intubation:
• Emergency intubation is indicated
• The patient has a “full” stomach
• Intubation is predicted to be successful
• If intubation fails, ventilation is
predicted to be successful
Rapid Sequence Intubation :
• Pre-intubation assessment
• Pre-oxygenate
• Prepare ( for the worst )
• Premedicate
• Paralyze
• Pressure on cricoid
• Place the tube
• Post intubation assessment
The 10 P’s of RSI
Prepare the patient Assemble the intubation
equipment. Cardiac and O2
saturation monitoring.
Determine meds and
prepare them.
Provide cervical spine Prevent c-spine damage in
immobilization, as trauma patients
Provide 100% oxygen Pre-oxygenate using a bag-
Premedicate, if Lidocaine 1-1.5
appropriate mg/kg IV should be
used if there is
concern about
increased ICP

Push IV sedative •Etomidate or

•Fentanyl with versed
•Ketamine with
atropine and versed

Paralyze •Succinylcholine
Pressure is applied to the Should be applied to prevent
cricoid regurgitation
Pass the tube Should be accomplished
within 30 seconds. If not,
may be attempted again after
Placement is confirmed •Rise and fall of the patient’s
chest, CXR
•Listen over stomach
•Bilateral breath sounds
•Is patient improving?
Post-intubation plan is made •Securing the tube
•Continually assess patient’s
condition/need for sedation
( Time - 5 Minutes)
• 100 % oxygen for 5 minutes
• 4 conscious deep breaths of 100 % O2
• Fill FRC with reservoir of 100 % O2
• Allows 3 to 5 minutes of apnea
• Essential to allow avoidance of bagging
• If necessary bag with cricoid pressure
( Time - 5 Minutes )
• ETT, stylet, blades, suction, BVM
• Cardiac monitor, pulse oximeter,
• One ( preferably two ) iv lines
• Drugs
• Difficult airway kit including cric kit
• Patient positioning
Equipment for Intubation

• Laryngoscope
– Handle
• contains the batteries for
the light source
– Blades
• Straight blade: Miller
• Curved: MacIntosh

• ET tube • Laryngoscope
– Adult female: 7-8 mm – batteries
– Adult male: 8-8.5 mm – light source
• Stylet • Blades
• 10 cc Syringe – straight (used more for
• Water soluble gel
– Curved (some believe it
reduces dental trauma)
Oddly, the peds code cart blades
that are included in the Broslow
packs do not fit our
laryngoscopes. You need to use
the metal ones in the top of the
cart. The doctor will probably
not know this at VVMC.
Intubation Equipment

• Stylet
– Helps conform the
endotracheal tube to any
desired configuration,
facilitating insertion of the
tube into the larynx and
– The end of the stylet must
always be recessed at least ½
inch from the distal end of the
Additional Intubation Equipment

• Magill Forceps
– Helps direct the tip of the
ET tube into the larynx
during intubation and to
remove some foreign
Prepare 8.0 tube for men, and 7.5
for women WITH A STYLET.
Pre-treatment/ Prime
( Time - 2 Minutes )
• Lidocaine 1.5 mg/kg iv
• Defasciculating dose of non-depolarizing
• Beta-blocker or fentanyl
• Induction agent
– Etomidate 0.3 mg/kg
– Midazolam 0.1 - 0.4mg/kg
– Ketamine 1.5 - 2.0 mg/kg
Paralyze ( Time Zero )
• Succinylcholine 1.5 mg/kg iv
• Allow 45 - 60 seconds for complete
muscle relaxation
• Alternatives
– Vecuromium 0.1 - 0.2 mg/kg
– Rocuronium 0.6 - 1.2 mg/kg
• Sellick maneuver
• initiate upon loss of consciousness
• continue until ETT balloon inflation
• release if active vomiting
• Cricoid pressure should be
applied by a second Intubation
rescuer during Procedure
endotracheal intubation in
adults to protect against
regurgitation of gastric
contents and to ensure
placement in the tracheal
• Cricoid pressure should be
maintained until until the
cuff of the endotracheal
tube is inflated

• Don’t bag patient after

Place the Tube
( Time Zero + 45 Secs )
• Wait for optimal paralysis
• Continue cricoid pressure
• Confirm tube placement with ETCO2
• Don’t bag the patient unless first try
Confirmation of ETT Placement:
Clinical Evaluation
• Observation of ETT pacing through cords
• Clear, equal breath sounds bilaterally
• Absence of breath sounds over epigastrium
• Symmetrical rising of chest
• Condensation or “fogging” of ETT
• Chest X-ray
• Pulse oximetry is LATE indicator
Confirmation of ETT Placement

• Placement of ETT in the esophagus is an

accepted complication of intubation
• However, failure to recognize and
correct esophageal intubation
• Either ETCO2 detection or an aspiration
technique should be used on every
emergency intubation
The nurse should verify that the
tube position is confirmed
Confirmation of ETT Placement:
End-tidal CO2 Detection
• Colorimetric
– Small, disposable
– Useful in pre-hospital care
– Changes from purple to yellow if CO2
– 100 % specific if bright yellow
– Indeterminate ( brown ) can indicate
esophagus with carbonated beverage, or
low output state
Postintubation care
• Secure and verify tube placement
• Sedate and paralyze before drugs wear off
• Be vigilant for misplaced tube
• Chest film and adjust tube depth
Intubation Procedure
• Inflate the the cuff with 10-20 ml of air and
ventilate the patient’s lungs with a BVM The tube
is properly positioned when the patient’s teeth are
between the 19 and 23 cm marks on the tube,
placing the tip of the tube 2-3 cm above
the carina
Lower Airway
• The average tube
depth in men is 22
• The average tube
depth in women is 21
Intubation Procedure

• Secure ET tube to non-moving

maxillary area of face
• During a coding situation
ventilation need not be
synchronized with chest
• It should be performed
asynchronously at 12-15
ventilations per minute with
100% FIO2
Etomidate and Sux is the most
common RSI combo used at
VVMC. You should know the
dosing for both chemicals.
Paralyzing Agents
• NMBA’s cause skeletal muscle relaxation by
blocking acetylcholine transmission
• Usually succinylcholine (1.5 to 2mg/kg)
• Can cause transient fasiculations
• onset in about 40 seconds lasting up to 10
• Dose generously, you want them paralyzed
Succinylcholine :
• Inability to secure airway
• Increased vagal tone ( second dose )
• Histamine release ( rare )
• Increased ICP/ IOP/ intragastric
• Hyperkalemia with burns, NM disease
• malignant hyperthermia
: Contraindications
• Hyperkalemia - renal failure
• Active neuromuscular disease with
functional denervation ( 6 days to 6
• Extensive burns or crush injuries
• Malignant hyperthermia
• Pseudocholinesterase deficiency
• Organophosphate poisoning
An ICU or ER nurse should
know the contraindications to
sux and etomidate and be able
alert the arriving team.
• Also known as Zemuron with dosing of
• Rapid onset in 2-3 minutes
• Lasts a little longer than SUX


• Also known as Norcuron with dosing of
.15 mg/kg IV
• Duration of about 30 minutes
• Use this after intubation till patient is
settled and well sedated to prevent
• Etomidate (.2-.6 mg/kg IV) is rapidly becoming the
most commonly used induction med.
• It takes effect in about 1 minute, lasting up to 5
• Preferred in trauma patients, because it doesn’t cause
an increase in ICP nor has it been shown to
exacerbate hypotension.
• May produce myoclonus (resembling small seizures)
but requires no treatment.
• Contraindicated in pregnant patients
Depolarizing dose
• Some people believe that it is useful to
give a tenth of the dose of vecuronium
before giving sux, to blunt the depolarizing
fasciculations that it causes and their
possible effects on ICP or C-spine.
• Not universally done
• 3-5 mcg/kg IV
• Onset is immediate and protects against
increased ICP and cardiac stress (MI
• May lower blood pressure
• Give as premedication or as induction
agent rarely.
Midazolam (Versed)
• Short –acting benzodiazepine
• IV dose: .07-.3 mg/kg IV
• Time of onset: 1 - 5 minutes
• Duration of action: ½-2 hours
• Preferred agent for sedation of less than 24
• Good amnesia
• High doses for intubation (5-20mg)
• dosing of 1-2 mg/kg IV
• Has a bronchodilating effect and should
be administered with atropine (.02mg/kg)
and versed
• Rarely used, but perhaps in
• Does not stop breathing
Propofol (Diprivan)
• Fast acting highly lipid-soluble sedative-
• A reasonable choice for intubation, but not
nearly as common as etomidate
• Often lowers BP, creates coma and may stop
• Generally started as the sedation drip after
• 1.5 mg/kg
• May be used to decrease ICP response
• May decrease bronchospastic response
The Difficult or Failed
Difficult Airway Maxims

• “It is preferable to use

superior judgement -- to
avoid having to use superior
The Difficult Airway
• Must be able to assess or anticipate the degree
of difficulty
• Then select method most likely to succeed
• If properly assessed and felt to be intubatable
without significant difficulty
– 1-4 /1000 will be impossible intubations (O.R.)
– 1 / 280 obstetrical patients
– 1 /10,000 impossible to intubate or ventilate(O.R.)
– 1-2 % cricothyroidotomy rate in ED
Difficult Airway Maxims
• Use judicious sedation and topical
airway anesthesia to have a quick look
in doubtful cases
• In certain situations a paralytic agent
and RSI may still be the best choice
The Difficult Airway
• Not all airway management failures
are avoidable or predictable
• Attempt to minimize failures
• Have several definite back-up plans
ready for the “Failed Airway”
You and your team must have a
plan B and know how and when
to execute it. Period.
Difficult Airway Maxims
• The first response to failure of Bag-
Mask Ventilation is always better BVM
– optimize airway position
– place both OP and NP airways
– two-handed, two-person technique
– try lifting head off pillow to open airway
– Generate as much positive pressure as
possible without inflating the stomach
Plan B :
Response to Unanticipated
• Difficult laryngoscopy and intubation
– Can’t intubate but Can ventilate
– Can’t intubate and Can’t ventilate
• Difficult Mask Ventilation
Unsuccessful Intubation : Plan B
• Bag the patient
• Maximize neck flex/ head ex
• Move tongue out of line of site
• Maximize mouth opening
• ID landmarks and adjust blade
• BURP maneuver
– (Backwards Upwards Rightwards Pressure on Thyroid Cartilage)

• Increasing lifting force

• Consider Miller blade
• Bag the patient
Unsuccessful Intubation : Plan B

• An optimal or best attempt at difficult

laryngoscopy should consist of :
– use of optimal sniffing position
– no significant muscle tone
– use of optimum external laryngeal
manipulation (BURP)
– one change in length of blade
– one change in type of blade
– a reasonably experienced laryngoscopist
Unsuccessful Intubation : Plan B

• Remember, the first response to failure

to intubate should always be to Bag-
Mask-Ventilate the patient
• The first response to failure of bag-
mask-ventilation is always better bag-
The Failed Intubation:
• Three failed attempts to intubate
– by an experienced intubator

• Inability to ventilate with BVM

• Inability to oxygenate
The Failed Intubation
• If can’t intubate but can ventilate with
BVM have time to consider options
– Light guided technique (Lighted stylet)
– Combitube
– Fiberoptic techniques
– Retrograde intubation
– Cricothyrotomy
The Failed Intubation
• If can’t intubate, can’t ventilate , must
act immediately
– Cricothyrotomy
– Percutaneous Transtracheal Jet Ventilation
– Combitube
– The last three are temporizing measures and
not definitive airway management
It is part of your job as a nurse to
move the team to Plan B when
needed: Especially after three
failed laryngoscopy attempts.
Difficult Airway Kit
• Is being made now and will be brought
to intubations in the future.
VVMC Difficult Airway Options
• Combitube
• Cricothyrotomy
• Fiber Optic

• Maybe getting: gum elastic bougie

Laryngeal Mask Airway :
• Lubricate both sides
• Open airway with head tilt, sniffing position
• Insert LMA with laryngeal surface down
• Press device onto hard palate
• Advance using index finger
– Use curve to advance over base of tongue
– pushed as far as possible into hypopharynx
– Stop when resistance felt(upper esophag.
• Inflate collar and start bag ventilation
LMA and the Difficult Airway

• Consider use early in a can’t intubate, can’t

ventilate situation while also getting prepared
for a surgical airway or TTJV
• A temporizing measure but can be used as a
conduit for endotracheal intubation
– the “Intubating Laryngeal Mask”
• The LMA is a supraglottic device
– Not suitable if the airway difficulty is due to
laryngeal problems i.e., (laryngospasm) or local
pharyngeal abnormalities ( abscess, hematoma,
Emergency Non-surgical Ventilation :
• Dual-lumen, dual-cuffed rescue airway device
– The two lumens allow ventilation whether placed in
trachea or esophagus
– If in trachea position, functions like an ETT
– If in esophageal position, the two balloons seal
hypopharynx proximally and esophagus distally
and perforations in esophageal lumen between the
cuffs allow for ventilation
– Placed blindly

Multilumen airways
should be considered
when conventional
tracheal intubation
measures are unsuccessful
or unavailable

• Esophageal and tracheal placement of a pharyngeal tracheal lumen

(PTL) airway
Digital Intubation

• Laryngeal mask airway (LMA)

Emergency Non-surgical Ventilation:
Transtracheal Jet Ventilation
• Puncture cricothyroid membrane with large-
bore (12 or 14 Gauge) kink-resistant catheter
connected to 3-way stopcock or to a suction
catheter with control vent
• 50 psi wall oxygen source
• High pressure tubing
• Ventilate for 2 seconds (or until chest rise)
• Release valve for 4 to 5 seconds (exhalation)
Emergency Surgical Airway
• they are usually a bloody mess, but ...
• a bloody surgical airway is better than
an arrested patient with a nice looking
Emergency Surgical Access :
• We are buying these kits. I have never
seen one outside the ER.
You must know where the Cric
kit is.
Thanks for
Any questions?