Prehospital Advanced Airway Management

PLEASE NOTE:
These notes are a supplement to the full set of core notes for EMC II.
A.
ENDOTRACHEAL INTUBATION
Despite numerous advances and innovative new devices in the field of respiratory care and
specifically airway management, endotracheal intubation remains the gold standard of airway
maintenance and protection in the critical care setting. Likewise, the technique of
laryngoscopic orotracheal intubation is still the most widely learned and practised intubation
technique.
Intubation in the pre-hospital environment poses its own special problems and complications
(limited equipment, limited space, difficult patient position, poor lighting and lack of hands) in
addition to those that contribute to making intubation in a controlled environment part science,
part art-form and a skill dependent on patience and discipline.
ANATOMY OF THE AIRWAY
Fig 1: Anatomy of the Laryngeal Cartilages
(From Moore KL: Clinically Oriented Anatomy Third Ed. USA; Williams & Wilkins 1992)
Fig 2: Anatomy of the Glottic Opening
Module 2: Core Notes
(From Moore KL: Clinically Oriented Anatomy Third Ed. USA; Williams & Wilkins 1992)
Laryngoscopy will reveal the following anatomical structures in order from most proximal to
most distal:
Hard Palate
This will be revealed as the tongue is lifted. It is

continuous with the soft palate that has the uvula
attached to its distal free edge. Both structures are
covered with a richly vascularised mucous
membrane.
Posterior Pharyngeal Wall
The mucosa of the posterior wall of the pharynx will

be visualised posteriorly and beyond the free edge of
the soft palate.
Tip of the Epiglottis
As the tongue is elevated the tip of the epiglottis will

be visualised lying between the posterior pharyngeal
wall and the base of the tongue.
What is seen hereafter is largely dependant on where the tip of the laryngoscope blade is
placed. Assuming that it is placed between the base of the tongue and the anterior aspect of
the epiglottis (the vallecula), advanced and lifted then the following structures will be
revealed:
Arytenoid Cartilages
Each arytenoid cartilage is triangular in

shape and has points of attachment for
the cricoarytenoid muscles at each
base and for the vocal ligaments
(cords) on the anterior surface of each
cartilage. The arytenoids are not
normally directly visible during
laryngoscopy.
Corniculate and Cuneiform Cartilages
These are embedded in the posterior

portion of the aryepiglottic folds on
either side. A corniculate cartilage is
situated on the apex of each arytenoid
cartilage. The cuneifrom cartilages lie
lateral to the corniculate cartilages.
These cartilages form the two bulges
Emergency Medical Care II

Compiled by C. Stein 2000
in the aryepiglottic folds on either side

of the base of the laryngeal opening
and constitute an important landmark.
Vocal Ligaments (Cords)
As the tongue and epiglottis are

elevated by the laryngoscope blade the
vocal cords will come into view. They
are surrounded on each side by the
aryepiglottic folds.
Fig 3: Laryngoscopic View of the Upper Airway
Tip of the Epiglottis and Posterior Larynx
The Vocal Cords
(From Safar P, Bircher N: Cardiopulmonary Cerebral Resuscitation Third Ed. USA: W.B. Saunders 1988)
Continuing distally down the airway (beyond the limits of direct visualisation) the following
structures are found:
Cricoid Cartilage
This signet ring-shaped cartilage is unique because

it is the only laryngeal cartilage which has a
circumferential structure. External pressure applied
to the anterior part of the cricoid cartilage will
compress and occlude the collapsible oesophagus
(posterior to it) while the laryngeal lumen remains
patent. This form of cricoid pressure is known as
Sellicks manoeuvre.
Trachea
The average adult trachea is approx. 10-20 cm long

and an average of 2.5 cm in diameter. It contains
approx. 16-20 cartilaginous U-shaped rings which
keep it patent throughout the differing pressure
gradients that occur in the thoracic cavity during the
respiratory cycle. Although the catilagenous supports
offer some rigidity, the trachea may still be occluded
by sufficient external pressure (50-70 cmH2O).
Main Bronchi
The trachea bifurcates at the carina approx. 10-20

cm below the vocal cords. The right main bronchus
is shorter, thicker and is orientated at a more vertical
angle than the left main bronchus. As a
consequence, foreign bodies (including endotracheal
tubes!) will tend to enter the right bronchus far more
often than the left.

ANATOMICAL DIFFERENCES OF THE PAEDIATRIC AIRWAY

The structure of the paediatric airway is of such a nature that laryngoscopy and intubation are
more challenging in these patients. The main differences are:
Nose
The external nares of infants and small children are
disproportionately small, bearing in mind their
importance - infants are predominantly nose
breathers up to the age of six months.
Tongue
The paediatric tongue is relatively large in relation to

the size of the oral cavity.
Larynx
The larynx is situated more superiorly (the laryngeal

opening is situated at the level of the C3-4
interspace at birth and is found at the level of C5 at
the age of 6 years).
The epiglottis is more pliable and shorter in relation
to its width than in the adult. As viewed during
laryngoscopy it has an inverted-U shape (it reaches
the adult configuration by the age of 3 years).
The arytenoid, corniculate and cuneiform cartilages
are relatively larger and more prominent than in the
adult.
The anterior attachment of the vocal cords is situated
more inferiorly than the posterior attachment.
There is a progressive reduction in airway diameter
from the hyoid bone to the cricoid cartilage which is
the narrowest level of the airway.
Trachea
The trachea descends into the thorax at a posterior

angle.
THE ADVANTAGES OF ENDOTRACHEAL INTUBATION

This list is by no means exhaustive, but is a simple mnemonic to remember just why we elect
to carry out this procedure and what benefits it is associated with:
A
Airway Protected - only if a cuffed ETT is used
Breathing Assisted
Circulation Improved During CPR (asynchronous compression-ventilation CPR)
Drug Adminstration (narcan, adrenaline, atropine and lignocaine only)
Evacuation of Secretions
Full Vt Achievable
Gastric Distension Prevented
Highest O2 Concentration Possible - only if using bag-valve-mask-reservoir with O2 flow

rate set at 10-15 l/min
IPPV
THE PHYSIOLOGICAL RESPONSE TO INTUBATION

In adults the most common responses to laryngoscopy and intubation are tachycardia and
hypertension. These responses are mediated by vagal afferents, the cardioacceleratory and
vasomotor centers of the brain stem and sympathetic efferents, including the release of
adrenaline from the adrenal medulla. Intubation is also a direct stimulus of CNS activity
causing increases in cerebral metabolic rate and blood flow.
The response to intubation in infants and small children is different, consisting most frequently
of a bradycardia. Although emphasis is often placed on the dangers of vagal stimulation and
bradycardia during laryngoscopy in adults, this response is rarely seen (although it is more
common in the presence of a pre-existing bradycardia).
WHEN TO INTUBATE
Specific indications for intubation:
1. Cardiac Arrest
Intubation is mandatory as a standard part of ACLS. Protection of the airway should be
accomplished as early as possible during resuscitation (see Preoxygenation below) but
should not delay rhythm interpretation and defibrillation (these are always the first priority).
Once a cuffed tube is in situ asynchronous ventilation-compression CPR may be undertaken
and the tube may be used as a route for drug administration. It should be noted that one of
the requirements for the effectiveness of asynchronous ventilation-compression CPR is the
tracheal placement of a cuffed endotracheal tube. This precludes the use of the technique in
paediatric patients intubated with uncuffed tubes.
2. Signs of Hypoxia or severe Respiratory Distress
Inability to maintain an adequate SpO2 (> 94%) with mask O2 is an indication to intubate and
ventilate (remember that, according to the oxyhaemoglobin dissociation curve, an SpO2 of
90% corresponds to a PaO2 of 60 mmHg (if the curve is not significantly shifted). A SpO2 of
90% is not necessarily an indication of an adequately oxygenated patient.)
Remember the Mechanisms of Hypoxia:
Decreased FiO2 - e.g. Altitude/Hypoventilation

V/Q Mismatching - e.g. Pulmonary Oedema/Infection
Shunt (Venous Admixture) - e.g. Atelectasis/Congenital Cardiac Abnormalities
Diffusion Impairment - e.g. ARDS/Cystic Fibrosis
Decreased Carrying Capacity - e.g. Anaemia/CO Poisoning
Decreased Delivery - To Tissue - e.g. Low CO; To Cell - e.g. Cyanide Poisoning
Other signs of severe hypoxia not responding to mask O2 are persistent cyanosis,
restlessness, confusion or a decreased level of consciousness. In assessing oxygenation by
means of pulse oximetry, as mentioned above, remember the limitations of this form of
indirect measurement and the factors responsible for false negative and false positive results:
The Factors Which May Cause Falsely High SpO2 Readings (false negative):
Anaemia

Although a normal SpO2 may be shown on the

pulse oximeter, a patient with a haematocrit of <
10-15% will not have adequate O2 carrying
capacity (SpO2 yields no information about the Hb

concentration, only the percentage of the total Hb
saturated with O2 i.e. SpO2 = {O2Hb/O2Hb+Hb} x
100%). In this situation tissue hypoxia may co-exist
with a Sa02 of 99%.
Hypothermia
Hypothermia will result in a shift of the dissociation

curve to the left resulting in a higher saturation (i.e.
more O2 bound to Hb) for a given PaO2. The net
result is less oxygen delivery to the tissues. Once
again, tissue hypoxia may co-exist with an SpO2 of
99%.(The lowered metabolic rate caused by
hypothermia may confer a degree of protection to
the tissue in question.)
Dyshaemoglobinaemias
The presence of significant amounts of carboxy or methaemoglobin may result in a deceptively

normal SpO2 despite what may amount to severe
tissue hypoxia. This occurs because commercially
available pulse oximeters cannot measure carboxy
- or methaemoglobin as they do not emit light at
the wavelengths required to do this. At the red
wavelength that these instruments do emit light
(660 nm) the absorbtion coefficients of
oxyhaemoglobin and carboxyhaemoglobin are very
similar and the instrument will tend to mistake
carboxyhaemoglobin for oxyhaemoglobin thus
reflecting a high SpO2. The explanation for
methaemoglobin is more complex but the end
result is that the degree of SpO2 aberration will
depend on the [metHb]. Commonly used drugs
which may induce methaemoglobin are:
Nitrates (TNT)
Local anaesthetics (Lignocaine)
Sulphonamides
Metoclopramide (Maxolon)
Signs of severe respiratory distress (use of accessory muscles, intercostal retraction, nasal
flaring, physical exhaustion, severe stridor/wheezing or a silent chest (particularly when facing
a long flight or ambulance transfer),are a firm indication to intubate and ventilate.
3. Hypercapnia
This is a good indication of alveolar ventilation and respiratory status provided it can be
measured. In the pre-hospital/aviation environment in Africa there is usually no access to
ABG analysis. In the patient with acute respiratory insufficiency, a PaCO2 of > 45 mmHg is an
indication for intubation and ventilation.
4. Signs of developing Airway Obstruction
Prophylactic intubation in cases of progressive airway closure is essential to prevent airway
occlusion and respiratory arrest. The following patients justify a high index of suspicion:
Paediatric patients presenting with a febrile illness and respiratory distress.**

Any patient at risk for inhalation burns (see below).
Any patient presenting with signs of a severe allergic reaction and respiratory
distress/dyspnea (particularly with a history of recent exposure to a known allergen).
Any patient presenting with a penetrating neck injury and respiratory
distress/dyspnea.

** It should be noted that no attempts should be made at pre-hospital

intubation of a patient suspected of having epiglottitis. Manipulation of
the epiglottis or upper airway in these patients may result in fatal
laryngospasm. If total airway occlusion and apnea does occur, needle
crycothyroidotomy is indicated.
5. Signs or suspicion of Inhalation Burns
As mentioned above, thermal injury of the airway often results in laryngeal oedema and may
cause total airway obstruction, apnea and cardiac arrest. Inhalation burns should be
suspected in the following cases:
Any patient found unconscious after a burn injury.

Any patient with a burn above the level of the xiphoid process.
Any patient burned in a confined space.
Any patient with singed facial/nasal hair.
Any patient coughing up carbonaceous sputum.
Any patient injured in a bomb blast or injured by any other explosive device.
Any patient presenting with dyspnea, stridor or a hoarse voice after a burn injury.
6. Decreased Level of Consciousness

This is a very relative term and not all patients with any decrease in level of consciousness
need to be intubated. Furthermore, the specific cause of a decreased LOC may also be an
important factor in determining the need to intubate and ventilate. A decreased LOC may be
caused by:
Trauma
Medical Conditions
Overdose
Poisoning
Hypoxia, decreased CO, blunt or penetrating

trauma resulting in cerebral contusion,
diffuse white matter lesions, extradural,
subdural or intracerebral haematomas etc.
Hypoxia, decreased CO, CVA, status
epilepticus, metabolic conditions, CNS
infections, tumours, abscesses, hypertensive
encephalopathy etc.
Alcohol, opiates, benzodiazepines,
barbiturates, aspirin etc.
Noxious gases (CO), organophosphates etc.
The two greatest risks related to patients with a decreased LOC are loss of airway reflexes,
allowing aspiration of secretions, blood or gastric contents and hypoventilation resulting in
hypoxia and hypercapnia. The unresponsive patient with no gag reflex on laryngoscopy or
insertion of an oropharyngeal tube requires urgent intubation in order to protect the airway.
Although the presence of a gag reflex sometimes correlates with a GCS score of 8/15 or
more, this is not a fixed rule. The presence or absence of a gag reflex should be tested for in
every unresponsive patient.
7. Combativeness (in a critically ill/injured patient).
Combativeness is usually a manifestation of cerebral hypoxia and , in the case of a critically
injured or ill patient already on the highest FiO2 by mask, this is reason enough to intubate
and ventilate. Combativeness per se is not an absolute indication for intubation but, as
mentioned above, is an important sign of impaired cerebral oxygenation (although it is most
often simply attributed to a difficult or obnoxious patient).
In some patients combativeness may directly compromise the underlying condition. A patient
with raised intracranial pressure or a suspected c-spine injury will aggravate the underlying

injury by physically struggling to overcome restraint. Sedation of this kind of patient will
usually solve the problem of combativeness but may result in hypoventilation and
hypercapnia which would worsen a condition such as raised intracranial pressure. If sedation
is decided on in a combative patient (particularly in the presence of a head injury) ventilation
should be monitored closely. Hypoventilation in this setting is an indication for intubation and
ventilation.
8. Chest Trauma with Dyspnea and Hypoxia
This usually indicates a flail chest, underlying pulmonary contusion, pneumothorax, tension
pneumothorax or haemothorax. (It could also indicate the presence of pericardial
tamponade). Adequate ventilation and oxygenation in these patients will often, at some stage,
become dependent on mechanical ventilation, particularly in the case of pulmonary contusion
and flail chest.
It is critically important to monitor any patient with chest trauma who has been intubated and
ventilated for the presence of a pneumothorax, or the evolution of a simple pneumothorax to
a tension pneumothorax. Positive pressure ventilation (PPV) is often responsible for causing
an acute severe rise in pressure of intrapleural air from pre-existing injury to the lung
parenchyma or tracheo-bronchial tree. Quality and bilateral equality of air entry, neck veins
and tracheal position should be continually assessed. If there is any indication that a
pneumothorax is growing in size or tensioning, the pleural cavity in question should be
decompressed immediately and a proper intercostal drain inserted as soon as possible.
Other problems associated with PPV and chest trauma include the causation of systemic air
emboli (this probably occurs more frequently than is generally realised) and the deleterious
effect of a cyclical high intrathoracic pressure on an already (in many cases) compromised
cardiac output.
9. Clinical signs of Severe Shock
Clinical studies have shown that in the case of severe shock (particularly in trauma patients)
early intubation and ventilation is associated with a better outcome. This is probably one of
the most neglected indications for intubation. Although PPV does have negative effects on an
already compromised cardiac output, early airway protection and proper oxygenation and
ventilation have a more important influence on the final outcome in most cases.
PREPARATION FOR INTUBATION
1.
EQUIPMENT
TUBES
ID (mm)
Prem: 3.0 +/- 0.5

0-6 years: 3.5 + age/3
7-12 years: 4.5 +age/4
Adult male: 9.0 +/- 0.5
Adult female: 8.0 +/- 0.5
** The most practical method is to choose a tube the diameter of which most
closelymatches the diameter of the patients fifth finger.
Length (mm)
Adult: 21-23 cm mark at incisors for orotracheal placement. Add 3 cm for

nasotracheal placement.
** Best method is to check cuff position and note the length marking - use this
as a reference.
Paed:
Infants: Age/2 + 12
Children > 2: Age/2 + 12+age/2
** Tubes less than 5.0 mm I.D. should be uncuffed.

LARYNGOSCOPE HANDLE AND BLADES

Standard Set: Macintosh 4,3,2,1 Miller 1,0
Adult
Macintosh 4 (or 3 for small adults)
Paed
Prem. Infant: Miller 0

Term infant: Miller 0 - 1/Macintosh 1
Infant - 2 years: Macintosh 1 - Miller 2
2 years - 8 years: Miller 2 - Macintosh 2
8 years - 12 years: Macintosh 2 - Macintosh 3
Adolescent: Macintosh 3
OTHER EQUIPMENT
2.
Spare batteries and bulb.

20 ml Syringe.
Catheter mount.
Adult and paediatric size introducers.
K-Y Jelly.
Adult and paediatric size Magill forceps.
Tape.
Oropharyngeal tubes - sizes 00-5.
Suction with adult and paediatric size Yankauer catheters.
Gloves and goggles.
Xylocaine spray
Stethoscope
Adult and Paediatric B-V-M-R with range of mask sizes and O2 source.
Monitoring devices - Pulse oximeter, capnometer and EDD (see below).
PREOXYGENATION
Any attempt at intubation will invariably involve a limited period of apnea or hypoventilation
and for this reason all patients about to undergo the procedure should be well oxygenated
before any attempts at laryngoscopy are made. In the case of a patient in cardiac arrest
intubation is usually carried out immediately (provided the equipment is ready) because, in
this situation there is little to be gained from preoxygenation and potentially much to be
gained from rapid intubation.
To delay intubation during resuscitation from cardiac arrest in favour of preoxygenation
means that the airway will remain unprotected for longer than would be the case if intubation
were carried out immediately, with the attendant risk of gastric insufflation leading to
regurgitation and aspiration of gastric contents.2,4 Furthermore, the amount of cerebral blood
flow produced by cardiac compressions in an unintubated patient without the use of
vasopressors is approx. < 5% of the prearrest value.3 Preoxygenation in this setting will
therefore probably do little to reverse the cerebral hypoxia already caused by cessation of
cerebral blood flow.
Intubation attempts should be limited to a maximum duration of 30 seconds. In this time
period, assuming the patient has been preoxygenated with 100% O2 for at least one minute
and has a SpO2 of 99-100%, the SpO2 will decrease at approx. 1.5-2.0%/min (if the cardiac
output is within normal limits).1 Thus after apnea lasting 30 seconds a SpO2 of 99-100% will
have decreased to approx.97-98%. In the case of an obese patient it should be noted that the
SpO2 will decrease more rapidly. This is because of decreased functional residual capacity

(FRC) resulting in a smaller volume of air in the lungs during apnea. Patients with an
abnormally high shunt fraction will also desaturate more rapidly during apnea.
In the case of an apneic patient preoxygenation will have to be accomplished with PPV using
a bag-valve-mask-reservoir with an oxygen flow rate of at least 10 l/min to provide an FiO2 of
0.9 - 1.0. Opening and maintaining of the airway during ventilation with this device, while
maintaining an adequate mask seal is difficult for one operator to achieve. B-V-M-R
ventilation ideally requires three operators: one to open and maintain the airway with a jaw
thrust while maintaining an airtight mask seal on the patients face, one to compress the bag
and monitor O2 flow rate and one to apply and maintain cricoid pressure (Sellicks maneuvre)
to prevent gastric insufflation of air and resultant regurgitation of gastric contents. In the case
of an apneic patient with a suspected c-spine injury having to be preoxygenated with B-V-M-R
ventilation care must be taken to maintain immobilisation of the head, neck and chest. A jaw
thrust should be performed by the operator maintaining the mask seal in order to keep the
airway open during ventilation.
In the case of a spontaneously breathing patient O2 should be given by mask to provide the
highest FiO2 possible.
3.
POSITIONING
(a) Position of the Patient

Positioning of the patient for laryngoscopy and intubation will be determined mainly by
whether or not the patient is suspected of having a c-spine injury.
In the case of a suspected c-spine injury, extreme care should be taken not to manipulate the
head or neck during the procedure. Effective and safe intubation of these patients requires
three operators: one to maintain in-line stabilisation of the head and neck, one to apply and
maintain cricoid pressure (from the beginning of laryngoscopy or B-V-M-R ventilation until the
cuff of the endotracheal tube is inflated and correct placement in the trachea has been
confirmed) and one to carry out laryngoscopy and intubation. If a cervical collar has been
fitted prior to intubation it is adviseable to remove this device as it will almost always impede
movement of the mandible which normally occurs during intubation and may make
visualisation of the larynx difficult, if not impossible. Manual immobilisation of the head and
neck during intubation will prevent movement and further injury. Once the tube is correctly
placed a cervical collar should be placed or replaced.
If the patient is not suspected of having a c-spine injury manipulation of the head and neck is
safe and correct positioning of the head should be carried out before any attempt is made to
visualise or intubate the larynx.
The main aim of positioning the head as part of preparation for intubation is to align the oral,
pharyngeal and laryngeal airway axes such that the passageway from the incisors to the
glottis is almost in a straight line. This will be achieved with the patients head and neck in the
sniffing position:
The neck is flexed in relation to the chest by approx. 35 degrees. This can easily be
achieved by elevating the occiput of a supine patient approx 10 cm.
The head is extended at the altlanto-occipital joint so that the frontal plane of the face
is approx. 15 degrees from the horizontal.
Full extension of the head without elevation of the occiput will rotate the larynx anteriorly
resulting in difficulty visualising the vocal cords and a tendency to use the maxillary teeth as a
fulcrum in order to gain more leverage for visualisation. Allowing the patients head to
protrude over the edge of a bed or stretcher and hang down with the neck in maximal
extension should never be done - this will make visualisation of the vocal cords almost
impossible.

10
Due to the large relative size of the occiput in paediatric patients the normal maneuvres
(those described above) used to attain the sniffing position do not apply. Elevating the occiput
will result in hyperflexion of the neck making laryngoscopy more difficult. In these patients
elevating the shoulders by approx. 1-1.5 cm (by placing a flat broad object beneath the
patients shoulders) will result in a natural sniffing position. Slight extension of the neck may
be required to optimise this position for laryngoscopy.
(b) Position of the Intubator
In the pre-hospital environment the position assumed by the intubator is frequently
determined by the position of the patient and not vice versa as in the controlled environment.
In the case of the patient lying supine on the ground, two of the most commonly used
positions for intubation are:
Sitting cross-legged with the patients head in the intubators lap or sitting with legs
extended and the patients head between the intubators legs. This technique is often
illustrated in text books but, bearing in mind the large angle between the axis of sight
and the view required to visualise the larynx, seems awkward, uncomfortable and not
ideally suited to rapid intubation of the difficult airway.
Lying prone facing the patients head. This technique is certainly, intuitively, the best
for optimal visualisation of the larynx (especially under difficult conditions) and close
proximity to the patient. It is, however, reliant on adequate space, the physical ability
to move quickly from standing, kneeling or sitting positions to the prone position and
acceptance of the possibility of having to lie in this position in unpleasant conditions
(mud, dirt, blood, etc.) if need be.
Few studies have been done to identify the superiority of one position over another and, in
the final analysis, personal preference and habit usually determine which position is used.
4.
THE IMPORTANCE OF SELLICKS MANOEUVRE
Although first described in 1961 this technique has only recently begun to enjoy a modicum of
popularity. As an airway management technique it must be one of the cheapest, most helpful,
most versatile and one of the easiest to learn and apply.
Cricoid pressure has three main advantages:
During PPV (whether mouth-to-mouth or via B-V-M-R) it prevents gastric insufflation

of air.
During PPV or intubation it prevents passive regurgitation and pulmonary aspiration

of gastric contents by resulting in occlusion of the oesophagus.
During laryngoscopy it often makes visualisation of the vocal cords easier by resulting
in slight posterior displacement of the lower larynx.
There are, however, some important points to remember about the optimum and safe use of
this manoeuvre:
Dont forget to use it! It is a safe and effective maneuvre for ventilation and intubation
of paediatric patients too.
In the case of B-V-M-R ventilation cricoid pressure must be maintained throughout. If

intubation is going to be attempted immediately after ventilation (preoxygenation),
cricoid pressure should not be released prior to intubation but maintained until
inflation of the cuff of the tube and verification of correct tracheal placement of
the tube (if the tube is misplaced in the laryngopharynx or the right main

11
bronchus and cricoid pressure is released aspiration of regurgitated gastric

contents may still occur).
In the event of a patient actively vomiting, the patient should immediately be

transferred to the lateral position and the cricoid pressure released. Application of
cricoid pressure while vomiting is taking place may result in oesophageal rupture and
later complications such as mediastinitis.
THE TECHNIQUE OF ADULT OROTRACHEAL INTUBATION

o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
All equipment should be within easy access of the operators right hand. The distal end
of the tube should be lubricated with a water soluble jelly and the cuff should be
checked prior to use by test inflation with the required volume of air.
An assistant should apply cricoid pressure throughout laryngoscopy and tube
placement until the cuff of the tube is inflated and correct tracheal tube placement
has been verified.
Holding the laryngoscope in the left hand, open the patients mouth with the right hand.
Introduce the blade of the laryngoscope into the right side of the patients mouth and
advance the tip towards the midline of the base of the tongue, displacing the tongue to
the left.
Use suction to clear secretions or blood as necessary.
At this stage the hard palate, soft palate and tip of the epiglottis should be visible.
Advance the tip of the blade into the vallecula (this is the correct technique when using
a curved larygoscope blade), lifting the blade (in the direction of the long axis of the
laryngoscope handle) in order to visualise.
Once the tip of the blade is in the vallecula, lifting of the blade (in the direction of the
long axis of the laryngoscope handle) will elevate the epiglottis and allow visualisation
of the corniculate and cuneiform cartilages and the vocal cords.
Holding the tube in the right hand, pass the tip and the cuff of the tube between the
vocal cords under direct vision until the proximal end of the cuff is approx. 2 cm distal
to the vocal cords.
Remove the laryngoscope blade from the patients mouth.
With one hand stabilising the tube at all times, inflate the cuff of the tube until moderate
tension is felt in the pilot balloon.
Attach the B-V-M-R to the tube adaptor and ventilate.
Assess correct tracheal placement (see below).
Auscultate for quality and bilateral equality of air entry. If air entry is only heard on the
right side, withdraw the tube slightly and auscultate again. If the problem persists
despite a correctly placed tube consider pneumothorax or tension pneumothorax as a
possible cause of unilateral decreased or absent air entry.
Once the tube is correctly placed, fix in place with tape etc.
An appropriately sized oropharyngeal tube should be inserted to serve as a bite block.
The entire procedure from cessation of preoxygenation to resumption of PPV should
take no longer than 30 seconds.
If intubation cannot be achieved within 30 seconds, the patient should be reoxygenated for a further 2-3 minutes (until SpO2 is at least > 98%) and intubation reattempted.
THE TECHNIQUE OF PAEDIATRIC OROTRACHEAL INTUBATION

o
o
o
o
All equipment should be within easy access of the operators right hand. The distal end
of the tube should be lubricated with a water soluble jelly.
An assistant should apply cricoid pressure throughout laryngoscopy and tube
placement until the cuff of the tube is inflated (if a cuffed tube is used) and correct
tracheal tube placement has been verified.
Holding the laryngoscope in the left hand, open the patients mouth with the right hand.
Introduce the blade of the laryngoscope into the right side of the patients mouth and
advance the tip towards the midline of the base of the tongue, displacing the tongue to
the left.

12
o
o
o
Use suction to clear secretions or blood as necessary.

At this stage the hard palate, soft palate and tip of the epiglottis should be visible.
Advance the tip of the blade beneath the epiglottis and lift the epiglottis directly (this is
the correct technique when using a straight larygoscope blade) to reveal the vocal
cords.
Holding the tube in the right hand, pass the tip and the cuff of the tube between the
vocal cords under direct vision until the proximal end of the cuff is approx. 2 cm distal
to the vocal cords. If an uncuffed tube is being placed, position the tip of the tube
approx. 2-2.5 cm distal to the vocal cords.
Remove the laryngoscope blade from the patients mouth.
With one hand stabilising the tube at all times, inflate the cuff of the tube (if a cuffed
tube is used) until moderate tension is felt in the pilot balloon.
Attach the B-V-M-R to the tube adaptor and ventilate.
Assess correct tracheal placement (see below).
Auscultate for quality and bilateral equality of air entry. If air entry is only heard on the
right side, withdraw the tube slightly and auscultate again. If the problem persists
despite a correctly placed tube consider pneumothorax or tension pneumothorax as a
possible cause of unilateral decreased or absent air entry.
Once tube is correctly placed, fix in place with tape etc.
The entire procedure from cessation of preoxygenation to resumption of PPV should
take no longer than 30 seconds
If intubation cannot be achieved within 30 seconds, the patient should be reoxygenated for a further 2-3 minutes (until SpO2 is at least > 98%) and intubation reattempted
o
o
o
o
o
o
o
o
ASSESSMENT OF ENDOTRACHEAL TUBE PLACEMENT

There are numerous methods of assessing endotracheal tube placement, each with its own
advantages, disadvantages, risks and controversy. The method used will depend, to a large
extent, on what equipment is available.
The meaning of false positive in this context is intended as tube in
the trachea, signs indicate that it is in the oesophagus. Likewise, the
meaning of false negative is intended as tube in the oesophagus,
signs indicate that it is in the trachea.
The signs of tracheal intubation may be divided into:
NON-FAIL-SAFE SIGNS
1.
AUSCULTATION OF THORACIC AIR ENTRY
This is the most versatile and commonly used method. The correct technique is to place the
diaphragm of the stethoscope over the mid-axillary area of the chest wall on each side and
auscultate while providing PPV with a B-V-M-R.
Although usually relied on as the sole sign of correct tube placement, this method is
associated with a high incidence of false negative findings:
In a study conducted by the Committee on Professional Liability of the American

Society of Anaesthesiologists over the last decade 18% of adverse respiratory events
that occurred during anaesthesia involved oesophageal tube placement. In 48% of
these cases auscultation led to the erroneous conclusion that the tube was in the
trachea. (Interestingly, cyanosis preceded the recognition of oesophageal intubation
in only 34% of cases.)
The high flow rate , distribution and volume of gas delivered through the oesophagus
during PPV may mimic breath sounds from the lungs.

13
Sometimes the sound of air movement through the oesophagus may be interpreted
as inspiratory or expiratory wheezes. For this reason it is wise not to rely on
auscultation as a sign of proper tube placement if any adventitious sounds are heard.
Due to the small dimensions of the thorax and the close proximity of the oesophagus to the
anterior chest wall in children and infants there is a high incidence of oesophageal intubation
being mistaken for tracheal intubation on auscultation. Extra care should be exercised with
paediatric patients.
Auscultation of unilateral air entry is a reliable (in fact, the only feasible) method of detecting
right main bronchus intubation. Preferably other corroborative signs of tracheal tube
placement (as discussed below) should be sought before auscultating for equality of air entry
to determine correct placement of the tube within the trachea.
Auscultation should never be relied on as the sole method for verification of tracheal tube
placement.
2.
AUSCULTATION OF THE EPIGASTRIUM
With tube placement in the oesophagus, PPV should produce borborygmi from air bubbling
through the gastric contents.
This method is often combined with thoracic auscultation. In a study of 40 adults who had
both their trachea and oesophagus intubated thoracic auscultation failed to detect
oesophageal tube placement in 15% of cases. When thoracic auscultation was combined with
epigastric auscultation it was found to be significantly more reliable.
3.
OBSERVATION OF CHEST MOVEMENTS
Expansion of the anterior chest wall is an unreliable sign of tracheal tube placement. Inflation
of the oesophagus may easily result in anterior displacement of the heart and upper
mediastinal structures elevating the sternum and ribs. Gastric insufflation may also result in
upward displacement of the diaphragm and outward movement of the lower chest.
This sign should never be relied on to confirm tracheal tube placement.
4.
TUBE CONDENSATION OF WATER VAPOUR
In principle, air emanating from the lungs that passes through a transparent endotracheal
tube is more likely to cause condensation on the tube than air emanating from the stomach.
Unfortunately there is a high incidence of condensation in tubes placed in the oesophagus
(28% in one study and 85% in another) making this sign unreliable in determining tracheal
tube placement.
5.
BAG COMPLIANCE
Compression of a bag resuscitator when it is attached to a tube placed in the trachea will
yield a characteristic feel of the compliance of the lungs and chest wall. The high proportion
of false negative results (attested to in statistics related to law suits) means that this is also an
unreliable sign and should not be used to evaluate tube placement.
6.
PULSE OXIMETRY
Oesophageal intubation will invariably result in a severe decrease in SpO2. The problem with
the use of pulse oximetry to determine tube placement is that a considerable period of time
may lapse before oesophageal intubation is recognised. There are a number of reasons for
this:
As explained under Preoxygenation ventilation of a patient with 100% O2 for 1-4

minutes to yield a SpO2 of at least 99% will result in a decrease in SpO2 during

14
subsequent apnea of only 1.5-2.0%/min. The SpO2 may only reach levels regarded
as indicative of hypoxia 5-7 minutes after preoxygenation has ceased.
A decrease in oxygen consumption or increase in cardiac output (or both) will lead to
an increase in SvO2. This will result in a slower rate of decrease of SpO2 following
oesophageal intubation due to the decreased amount of desaturated blood returning
to the heart.
Manual ventilation of the oesophagus may result in alveolar gas exchange provided
the vocal cords are open. In a study conducted with 20 patients who were intubated
in both the trachea and oesophagus 18 of these showed positive signs of alveolar
ventilation following ventilation of the oesophagus. Respiratory efforts of a
spontaneously breathing patient through the unintubated trachea may also result in a
SpO2 that remains elevated for a prolonged time after oesophageal intubation.
The slow decrease of SpO2 following oesophageal intubation described above is dangerous
because a normal SpO2 immediately after tube placement will create the impression that the
tube is in the trachea. When the SpO2 begins to drop there is a high probability that the
clinician will look for causes other than oesophageal intubation first, convinced that the tube is
correctly placed in the trachea. Not only is this scenario potentially fatal due to ongoing
hypoxia but also due to the fact that, as long as the tube is not correctly placed, the airway is
not properly protected.
Essentially, a normal SpO2 only means that adequate oxygenation of pulmonary blood is
taking place, it yields no definite information concerning how alveolar ventilation is taking
place and is not proof of correct tube placement in the trachea. However pulse oximetry still
remains an extremely useful tool to detect trends in oxygenation of arterial blood.
NEAR-FAIL-SAFE SIGNS
1.
CAPNOGRAPHY AND CAPNOMETRY
Capnometry is the measurement of PCO2 in expired gas, capnography is the instantaneous

display of the CO2 waveform during the respiratory cycle - both evaluate levels of end-tidal
CO2 (PETCO2).
A side-stream analyser is placed between the tube adapter and the B-V-M-R connector,
allowing respiratory gas to be sampled. The CO2 in the exhaled gas mixture is measured by
infrared absorption spectrometry and either a digital or waveform readout is provided. The
concentration of CO2 in exhaled air rises progressively throughout exhalation with the highest
concentration being detected towards the end of exhalation - hence the term end-tidal CO2.
Although detection and monitoring of PETCO2 is widely regarded as the standard for
verification of proper tracheal tube placement false negatives and false positive results do
occur.
False positive results (a low digital readout or lack of waveform when the tube is
correctly placed in the trachea) may occur due to:
Disconnection of the tracheal tube from the ventilator circuit or B-V-M-R.
A kinked or obstructed endotracheal tube.
Severe bronchospasm.
Decreased pulmonary blood flow (CO2 exhalation is dependent on delivery of CO2 to

the alveoli by blood returning to the lungs):
o
o
Low cardiac output

Hypotension

15
o
o
Pulmonary embolism
Pulmonary stenosis
Cardiac arrest
False negative results (a normal digital readout or waveform when the tube is not
correctly placed in the trachea) may occur due to:
Gastric insufflation of exhaled gases during resuscitation attempts prior to intubation

(although the initial ventilations may contain a high PCO2, this will decrease rapidly as
the patient continues to be ventilated).
Presence of carbonated beverages or some antacids (which react with HCl to
produce CO2) in the stomach (the same principle as mentioned above applies here with continuous ventilation the PCO2 will drop and become suggestive of
oesophageal intubation).
Tip of the endotracheal tube situated in the pharynx.
Colorimetric CO2 detectors are widely used in some settings. These devices consist of a
chemical indicator which changes colour in the presence of an increased hydrogen ion
concentration. The same causes for false negative and false positive results outlined above
apply to these devices.
2.
OESOPHAGEAL DETECTOR DEVICE
The oesophageal detector device (EDD) consists of a 50 ml syringe fitted with an adapter that
can be attached to an endotracheal tube connector. The principle of use of the device is
based on the anatomical differences between the trachea and oesophagus.
If the EDD is attached to a tube situated in the trachea and the plunger is withdrawn air will be
aspirated without any resistance apart from that inherent in the device. This is due to the
rigidity of the trachea afforded by the presence of cartilage rings in its walls keeping the
tracheal lumen open despite the negative pressure.
In the case of oesophageal placement, when the plunger is withdrawn the walls of the
oesophagus will collapse around the open end of the tube due to the negative pressure and
resistance will be felt.
Although the use of this device is associated with high specificity and sensitivity for tracheal
and oesophageal intubation, some false positives (tube correctly placed in the trachea but
resistance to aspiration is encountered) have occured due to factors which enhance forces
tending to collapse the trachea during negative intrathoracic pressure:
In infants because the tracheal wall is more pliable and subject to collapse.
Severe bronchospasm.
Intubation of the right main bronchus.
Extremely obese patients.
Pulmonary oedema.
In addition to these factors, kinking or blockage of the tube may also be the cause of a false
positive finding.
A popular (and now commercially available) variation of this technique uses the self-inflating
bulb.
FAIL-SAFE SIGNS
1.
DIRECT VISUALISATION OF THE TUBE BETWEEN THE VOCAL CORDS

16
This is still one of the most reliable methods to ensure correct tube placement. Two simple
manoeuvres will greatly facilitate visualisation of the tube between the vocal cords during and
after intubation.
During intubation, if the tube is introduced from the right side of the patients mouth the tip of
the tube can actually be seen entering the larynx. If the tube is introduced from the mid-line it
will usually obstruct the intubators view of the larynx and direct visualisation will not be
possible.
After intubation the position of the tube in relation to the vocal cords is often obscured, even
when a laryngoscope is used to displace the tongue and epiglottis. Applying gentle pressure
on the tube to displace it posteriorly towards the palate will alter the direction of the tube as it
enters the larynx allowing clear visualisation.
Checking position of the tube once is no guarantee that it will remain
properly situated. Verification of tube position (preferably by
visualisation) should be done often, particularly after the patient has
been moved in any way.
2.
FIBREOPTIC BRONCHOSCOPY
Visualisation of tracheal rings and the carina using a fibreoptic bronchoscope introduced
through the endotracheal tube is a guarantee of correct tube placement. Unfortunately the
cost of these instruments and the considerable expertise needed to operate them precludes
their use in most settings.
COMPLICATIONS OF INTUBATION AND POSITIVE PRESSURE VENTILATION
Intubation of the oesophagus.

Intubation of a main bronchus (usually the right).
Hypoxia from prolonged attempts at intubation or oesophageal intubation.
Pulmonary aspiration of gastric contents.
Trauma to teeth, mucosa, larynx or worsening of a c-spine injury.
Causation of a tension pneumothorax.
Worsening of raised intracranial pressure.
Complications of drugs used to facilitate intubation.
Haemodynamic effects, usually hypertension and tachycardia. In infants, bradycardia.
Deleterious effects of intubation on intracranial pressure.
CAUSES OF SUDDEN HYPOTENSION OR CARDIAC ARREST DURING OR FOLLOWING

INTUBATION
Hypoxia from prolonged intubation attempts.

Oesophageal intubation.
Displacement of the tube into the right main bronchus.
Deleterious haemodynamic effects of vigorous PPV in the presence of compromised
cardiac output.
Development of a tension pneumothorax.
Systemic air embolism.
Vagal responses, particularly in the presence of a pre-existing bradycardia
Sudden severe respiratory alkalosis causing an acute decrease in [K+] or [Ca2+]
(especially in the case of pre-existing hypokalaemia or hypocalcaemia).
REFERENCES
1.
Benumof J L (Ed.): Airway Management - Principles and Practice. 1996; Mosby; USA.

17
2.
3.
4.
5.
B.
Finucane BT, Santora AH: Principles of Airway Management. Second Edition. USA:
Mosby 1996
Emergency Cardiac Care Committee and Subcommittees, American heart Association:
Guidelines for Cardiopulmonary Resuscitation and emergency cardiac care. JAMA,
1992;268:2172-2183.
Chandra NC: Mechanisms of Blood Flow during CPR. Ann Emerg Med, February 1993;
22 (Pt.2): 281-288.
Emergency Cardiac Care Committee and Subcommittees, American heart Association:
Textbook of Advanced Cardiac Life Support. 1992; USA
THE OESOPHAGEAL/TRACHEAL DOUBLE LUMEN AIRWAY (Combitube)
Although endotracheal intubation remains the gold standard for airway management in the
emergency setting, it may not always be possible to make use of this technique. Competence
in intubation requires intensive training and constant practice. The equipment needed for
endotracheal intubation may not be available at the scene of the emergency. In some cases,
despite the availability of equipment and a skilled practitioner, endotracheal intubation may be
extremely difficult or associated with complications due to patient position, entrapment or
concomitant c-spine or facial injuries. Under such circumstances a simple and efficient means
of airway maintenance and protection is necessary. The Combitube meets these
requirements.
TECHNICAL DESCRIPTION
The Combitube is a double lumen tube. One lumen (the oesophageal lumen) has an open
upper end and a blocked lower end with perforations in the tube at the pharyngeal level. The
other lumen (the tracheal lumen) has both upper and distal ends open. The two lumens are
separated by a partition wall. The combitube has two cuffs:
Pharyngeal Cuff (100 ml capacity)
This is situated proximal to the

pharyngeal perforations and is situated
at the level of the base of the tongue and
soft palate when the tube is correctly
placed.
Laryngeal/Oesophegeal Cuff (5-15 ml capacity)
Situated in the same position as an

endotracheal tube cuff, it will be placed
in either the trachea or the oesophagus.
Printed ring marks on the upper third of the tube indicate depth of insertion. Each cuff is
inflated via a standard inflation line with a pilot balloon and one-way valve. The proximal ends
of both lumens have standard endotracheal tube connectors.
FIGURE 1
Diagram of the Oesophageal Tracheal Double Lumen Airway

(Combitube) From: Benumof J L (Ed.): Airway Management - Principles
and Practice. 1996; Mosby; USA.

18
1. Oesophageal lumen;
2. Tracheal lumen;
3. Perforations at pharyngeal section;
4. Blocked distal end of oesophageal lumen;
5. Oropharyngeal cuff;
6. Open distal end of tracheal lumen;
7. Distal cuff for sealing trachea or oesophagus;
8. Printed ring marks for positioning;
9. Connector for oesophageal lumen;
10. Connector for tracheal lumen.
MECHANISM OF ACTION OF THE COMBITUBE

Efficient alveolar ventilation may be achieved with the Combitube positioned in either the
oesophagus or the trachea.
In the case of oesophageal placement of the tube ventilation via the long connector will
result in air flow occurring through the perforations at the pharyngeal level of the
oesophageal tube. This air will follow the path of least resistance from the pharynx,
through the vocal cords and into the lungs. Air cannot escape through the mouth or nose
because the oro- and nasopharynx are sealed by the large pharyngeal cuff.
In the case of tracheal placement of the tube ventilation via the short connector will result
in air flow occuring through the distal, open end of the tracheal lumen (in exactly the same
manner as occurs in a normal endotracheal tube).
In both cases the airway will be protected. With oesophageal placement inflation of the small
cuff will occlude the oesophagus and prevent regurgitation of gastric contents (and gastric
insufflation of air during ventilation). With tracheal placement the small cuff will occlude the
trachea in a manner identical to that of a standard endotracheal tube.
A main advantage of this device is that the route of ventilation may be changed by simply
connecting the B-V-M-R to a different connector while leaving the tube in the same postion.
ADVANTAGES OF THE COMBITUBE
Works in either the oesophageal or tracheal position.

Blind insertion technique.
Manipulation of the head and neck is not necessary (although use of the device in
patients immobilised with cervical collars was not very successful 13).
Independent of a power supply (batteries not needed).
May be used under difficult circumstances with respect to space and illumination.
INDICATIONS FOR USE OF THE COMBITUBE
Any of the anatomical or pathophysiological features which commonly result in difficulty

managing or intubating the airway (receding chin, short neck, small mouth, extreme
obesity, dentition overbite, large tongue, Down Syndrome, rheumatoid arthritis etc.).
Although protocols vary, attempting intubation in the presence of a difficult airway more
than twice will seldom result in success.
Equipment failure resulting in an inability to use a laryngoscope to visualise the larynx.
Awkward positioning of the patient or entrapment resulting in an inability to access the

patient in the normal way for laryngoscopy.
TECHNIQUE OF INSERTION OF THE COMBITUBE

19
o
o
o
o
o
o
o
o
o
o
o
o
o
Prepare the Combitube by inflating the cuffs (pharyngeal cuff with 100 ml of air and
laryngeal/oesophageal cuff with 5-15 ml of air) and checking that there is no air
leakage.
Lubricate the lower end of the tube with a water soluble jelly.
Lift the patients mandible and tongue and guide the tube smoothly into the patients
mouth with the tubes natural curve pointing anteriorly, following the natural curvature
of the pharynx (Fig 2. A).
Advance the tube until the printed black rings rest between the patients teeth or gums
(if the tube does not advance easily, redirect or withdraw and reinsert it).
Inflate the pharyngeal cuff with 100 ml of air from the large syringe then disconnect the
syringe (inflation may cause the tube to move slightly from the patients mouth) (Fig 2.
B).
Inflate the laryngeal/oesophageal cuff with 5-15 ml of air from the small syringe then
disconnect the syringe (Fig 2. B).
Attach the bag-valve-mask-reservoir (B-V-M-R) to the longer (oesophageal) connector
and ventilate while auscultating for air entry over the axillae and epigastrium (Fig 2. C.).
Disconnect the B-V-M-R from the oesophageal connector and attach it to the shorter
(tracheal) connector. Ventilate while auscultating for air entry over the axillae and
epigastrium (Fig 2. D.).
Ventilate the patient through the connector associated with clear auscultation of air
entry over the axillae and no air entry over the epigastrium.
If intubation cannot be achieved within 30 seconds, the patient should be reoxygenated for a further 2-3 minutes (until SpO2 is at least > 98%) and intubation reattempted.
Secure the tube in position and recheck position afterwards.
If the device is to be removed the patient must be in the lateral position and suction
close at hand because removal is invariably associated with vomiting.
If the patient is being ventilated through the long (oesophageal) connector, a suction
catheter may be passed down the shorter connector into the stomach to suction gastric
contents.
FIGURE 2

20
From: Benumof J L (Ed.): Airway Management - Principles and Practice. 1996; Mosby; USA.
DISADVANTAGES OF THE COMBITUBE
Cost (although it should be remembered that the combitube is intended to be utilised

as a back-up and will therefore not have to be replaced very often).
The combitube cannot be relied on as a route for drug administration during cardiac
arrest unless there is certainty of tracheal placement, in which case it may be used in
the same way as a standard endotracheal tube.
Asynchronous ventilation compression CPR (AVC - CPR) will not be effective and
cannot be undertaken with the combitube placed in the oesophagus. If, however it is
placed in the trachea and the small volume cuff inflated, AVCCPR may be carried out
effectively.
Trauma to the airway and/or oesophagus. A study by Vezina et al. retrospectively

analysed eight patients out of 1139 resuscitated in the pre-hospital setting by basic
EMTs using combitubes for airway management 15. The eight patients all developed
subcutaneous emphysema after combitube use. In two of these patients, autopsy
revealed large lacerations of the anterior oesophageal wall and multiple superficial
lacerations of the oesophagus in another. Oczenski et al. found a significantly higher
incidence of airway haematoma formation, sore throat and dysphagia in patients whose
airways were managed with the combitube compared to those whose airways were
managed with the laryngeal mask airway or tracheal intubation 7. One case has been
reported of piriform sinus rupture during and/or after use of the combitube 18.
These findings do not necessarily show with any certainty that the combitube always
causes major oesophageal trauma and, in some cases, may be more a function of the
skill and expertise of the practitioner than the actual potential of the device to cause
tissue damage. These reports should, however, be remembered when using the device
and close attention should always be paid to insertion technique, lubrication and
avoidance of undue force when resistance to insertion is encountered.
Cardiovascular stress. Although only supported by one study, it appears that use of the
combitube results in a significantly greater elevation of systolic and diastolic arterial
pressures and serum catecholamine levels then use of either the laryngeal mask
airway or tracheal intubation 9. This may have implications for patients with severe left
ventricular failure, shock or increased intracranial pressure although further studies are
necessary to validate these results.
CONTRAINDICATIONS TO USE OF THE COMBITUBE
Patients with an intact gag reflex.

Patients under the age of 16 years or 1.5 m (5 Ft) tall.
Patients who may have ingested caustic substances.
Patients with known oesophageal pathology.
REFERENCES
1.

21
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
Airway and Ventilation Management Working Group of the European Resuscitation

Council: Guidelines for the advanced management of the airway and ventilation during
resuscitation. Resuscitation 1996 ;31: 201-230). (Concentrate on pp 201-204).
Frass M, Frenzer R, Zahler J, Ilias W, Leithner C: Ventilation via the esophageal
combitube in a case of difficult intubation. Journal of Cardiothoracic Anesthesia
1987;6:565-568.
Frass M, Frenzer R, Mayer G, Popovic R, Leithner C: Mechanical ventilation with the
esophageal tracheal combitube (ETC) in the intensive care unit. Arch Emerg Med
1987;4:219-225.
Frass M, Frenzer R, Rauscha F, Weber H, Pacher R, Leithner C: Evaluation of the
esophageal tracheal combitube in cardiopulmonary resuscitation. Crit Care Med
1986;15:609-611.
Frass M, Frenzer R, Rauscha F, Schuster E, Clogar D: Ventilation of the esophageal
tracheal combitube in cardiopulmonary resuscitation. Chest 1988;93:781-784.
Oczenski W et al. Complications following the use of the combitube, tracheal tube and
laryngeal mask airway. Anaesthesia 1999;54:1161-1165.
Doerges V, Sauer C, Ocker H, Wenzel V, Schmucker P: Airway management during
cardiopulmonary resuscitation a comparative study of bag-valve-mask, laryngeal mask
airway and combitube in a bench model. Resuscitation 1999:41:63-69.
Oczenski W et al. Hemodynamic and catecholamine stress responses to insertion of the
combitube, laryngeal mask airway or tracheal intubation. Anesth Analg 1999;88:13891394.
Calkins MD, Robinson TD: Combat trauma airway management: endotracheal intubation
versus laryngeal mask airway versus combitube use by Navy SEAL and Reconnaisance
combat corpsmen. J Trauma 1999;46:927-932.
Vezina D, Trepanier CA, Lessard MR, Bussieres J: Esophageal and tracheal distortion
by the esophageal-tracheal combitube: A cadaver study. Can J Anaesth 1999;46:393397.
Yardy N, Hancox D, Strang T: A comparison of two airway aids for emergency use by
unskilled personnel. The combitube and laryngeal mask. Anaesthesia 1999;54:181-183.
Mercer MH, Gabbott DA: Insertion of the combitube airway with the cervical spine
immobilised in a rigid cervical collar. Anaesthesia 1998;53:971-974.
Blostein PA, Koestner AJ, Hoak S: Failed rapid sequence intubation in trauma patients:
Esophageal tracheal combitube is a useful adjunct. J Trauma 1998;44:534-537.
Vezina D, Lessard MR, Bussieres J, Topping C, Trepanier CA: Complications associated
with the use of the esophageal-tracheal combitube. Can J Anaesth 1998;45:76-80.
Butler BD, Little T, Drtil S: Combined use of the esophageal-tracheal combitube with a
colorimetric carbon dioxide detector for emergency intubation/ventilation. J Clin Monit
1995;11:311-316.
Mercer MH, Gabbott DA: Insertion of the combitube airway with the cervical spine
immobilised in a rigid cervical collar. Anaesthesia 1998;53:971-974.
Richards CF: Piriform sinus perforation during esophageal-tracheal combitube
placement. J Emerg Med 1998;16:37-39.

22
C.
THE LARYNGEAL MASK AIRWAY
The laryngeal mask airway (LMA) has been described as a missing link between the bagvalve-mask-reservoir device and the endotracheal tube. It was developed in the early eighties
in England primarily for use in anaesthesia. The LMA is currently recommended by the
International Liaison Committee on Resuscitation (ILCOR) as an acceptable alternative for
airway management in an emergency situation if intubation has failed (together with the
combitube) 2. Although this device has not met with universal approval for use in emergency
care, its pre-hospital use is becoming more widespread.
TECHNICAL DESCRIPTION
The device is manufactured from silicone and consists of a tube with an elliptical cuff fitted at
the distal end. This cuff is inflated by means of a cuff inflation line and pilot balloon. At the
distal end of the tube, where it joins the cuff, two vertically placed bars of silicone prevent the
epiglottis from obstructing the lumen of the tube. The LMA is available in five sizes: 1 (pt.
weight < 6.5 kg), 2 (pt. weight 6.5 20 kg), 2.5 (pt. weight 20 30 kg), 3 (pt. weight 30 60
kg), 4 (pt. weight > 60 kg). A size 5 LMA has also been introduced for large adults.
Fig. 1
Fig. 2
MECHANISM OF ACTION OF THE LMA

When the LMA is correctly positioned its anterior margin lies at the base of the hypopharynx
with the tip of the device placed in the opening of the oesophagus (against the upper
oesophageal sphincter). The lateral borders of the elliptical cuff lie in the piriform fossae. The
upper border lies at the base of the tongue. The soft cuff can mould and conform to the
tissues of the upper airway and thus form a relatively good seal. If correctly placed, the tip of
the cuff passes between the tip of the epiglottis and the posterior pharynx so that, when the
cuff is inflated, the epiglottis assumes its normal position.
It is possible to intubate a patient through the laryngeal mask, if correctly placed 9-12. A 6.0
mm or 7.0 mm endotracheal tube (depending on the size of mask used) can be advanced
down the tube section, through the apertures at the distal end of the tube and into the trachea
as indicated in Fig. 3 on the next page.
This has been found to be a relatively effective way of intubating patients with difficult
airways with up to 90% success rates, although it requires additional skill in placement of the
endotracheal tube. A variation of the standard LMA called the intubating laryngeal mask
(Fastrach) has become available and has had success in a few small clinical trials.

23
Fig. 3
Fig. 4
ADVANTAGES OF THE LMA
Does not require visualisation of the vocal cords.

As a skill, placement of the LMA is easily learned, more easily then orotracheal or
nasotracheal intubation and more effective than bag-valve-mask ventilation 5,13,14,20.
Manipulation of the head and neck is not necessary. Placement with the head and neck in
the neutral position does not appear to complicate the procedure significantly.
Independent of a power supply (batteries not needed).
May be used under difficult circumstances with respect to space and illumination.
Is not associated with as much cardiovascular stress (tachycardia and/or hypertension)
during insertion as endotracheal intubation or use of the combitube 8,9.
INDICATIONS FOR USE OF THE LMA
Any of the anatomical or pathophysiological features which commonly result in difficulty

than twice will seldom result in success.
Equipment failure resulting in an inability to use a laryngoscope to visualise the larynx.
Awkward positioning of the patient or entrapment resulting in an inability to access the

patient in the normal way for laryngoscopy.
TECHNIQUE OF INSERTION OF THE LMA

o
First, select the correct size of LMA for the patient: 3 small
adult; 4 normal (average) adult; 5 large adult. The LMA
should be prepared for use by removal of all air from the cuff
as shown in Fig. 5. The LMA should also be lubricated with a
water-soluble jelly. Please note that only
the rear surface of the mask should be
lubricated.
The patient should be in a supine
position and should have been preoxygenated (if possible) as specified in
section A Endotracheal Intubation. If
not contra-indicated, apply gentle neck
flexion with one hand as shown in Fig.
6.
Grasp the LMA tube as close to the cuff
as possible. With the aperture facing
forwards, place the tip of the (deflated)

Fig 6
Fig 5
24
o
o
o
o
cuff against the inner surface of the

patients incisors or gums.
The mask tip should now be pressed
against
the
hard
palate
and
simultaneously advanced into the oral
cavity. It is important to keep the mask
tip pressed upwards against the hard
palate.
If the mask tip begins to roll over it
should be withdrawn and the procedure
started again.
Once the mask has been advanced a
short distance against the hard palate
without rolling over, the index finger
should be placed opposite the mask
aperture at the junction of the mask and
the tube. The mask should then be
advanced into the pharynx and behind the tongue by downward pressure of the index
finger in this position.
If resistance to movement is felt as the
mask is slid over the tongue it should be
withdrawn
and
the
procedure
reattempted (with a pause for preoxygenation if necessary). NEVER
FORCE THE LMA IF RESISTANCE IS
FELT.
As the mask tip locates in the upper
oesophageal sphincter resistance will
be felt. Insertion should be stopped at
this point.
Hold the tube firmly with the other hand
and remove the index finger from the
patients pharynx. Maintain gentle
downward pressure to ensure that the
mask remains firmly seated in its
position.
Inflate the cuff as follows: size 3 up to
20 ml; size 4 up to 30 ml; size 5 up to
40 ml. These figures are maximum
amounts and should not be exceeded.
The chest should be auscultated to
confirm adequate, equal air entry.
The tube should be secured using tape
in such a way that the tube connector
faces inferiorly. The black line on the
spine of the tube should face superiorly.
A bite block (usually an oropharyngeal
tube) should be placed once correct
placement of the LMA has been confirmed. From: Benumof J L (Ed.): Airway Management - Principles and
Practice. 1996; Mosby; USA.
DISADVANTAGES OF THE LMA
Asynchronous compression-ventilation CPR is not possible with the LMA unless a cuffed
endotracheal tube has been successfully passed through the mask and is suitably
positioned.
Drug administration is not possible via the LMA unless a cuffed endotracheal tube has
been successfully passed through the mask and is suitably positioned.

25
It may be associated with a higher risk of pulmonary aspiration then endotracheal

intubation, although this statement has been contested 17-20. Studies conducted to assess
the extent of aspiration during LMA use have had varying results. In one study conducted
using spontaneously breathing patients during anaesthesia, aspiration rates as high as
25% were recorded. In a very similar study, however, no patients breathing
spontaneously through a LMA were reported as having aspirated (in both cases, these
patients were compared to a group breathing spontaneously through a face mask and
oropharyngeal tube).
The rates of aspiration were found to be equal in a study comparing spontaneously
breathing patients and those undergoing positive pressure ventilation with the LMA. A
more recent study using measurements of gastric pH reported a significantly higher
aspiration rate with the LMA than with a face mask. Most studies undertaken so far have
been in a theatre setting and have yielded equivocal results. Thus, the true incidence of
aspiration associated with LMA use remains unknown.
The only large, multicentre study assessing LMA use in resuscitation so far has indicated
an aspiration rate of 0.6% 2.
Air leakage during positive pressure ventilation. This has been suggested to occur in 1015% of cases. Provided the chest rises, the tidal volume delivered should be adequate.
Most air leaks appear to be small and clinically insignificant. Large leaks may interfere
with alveolar ventilation and cause gastric insufflation of air. A ventilation technique
should be used which minimises peak inspiratory pressures (in fact, such a technique
should ALWAYS be used, whether or not the patient is being ventilated via a LMA) 15,16.
Difficulty with placement of the device. A number of studies have supported the notion
that the LMA is an easy device to learn to use 5,13,14,20. Even so, some problems can occur
with attempted placement:
1.
If the patient still has a gag reflex or any other upper airway reflexes, placement
may be difficult and even dangerous. In such cases, the LMA should not be used.
2.
Deflection of the mask anteriorly (instead of along the posterior pharyngeal wall)
may result in inferior displacement of the epiglottis and airway obstruction. The
same result is obtained if the cuff is not adequately deflated prior to insertion.
3.
Curling of the tip of the cuff may occur if the LMA is not introduced correctly. If this
is the case, advancing the mask will tend to catch the epiglottis and deflect it
inferiorly causing airway obstruction.
REFERENCES
1.
2.
3.
4.
5.
6.
7.
Kloeck W, Cummins R, Chamberlain L, Bossaert V, Callanan P, Carli P, Christenson J,
Connolly B, Ornato J, Sanders A, Steen P: The universal ALS algorithm. An advisory
statement by the adnanced life support working group of the international liaison
committee on resusucitation. Resusucitation 1997;34:109-111.
Davies RF, Tighe SQ, Greenslade GL: Laryngeal mask airway and the tracheal tube
insertion by unskilled personnel. Lancet 1990;336:977-979.
Baskett PJ: The use of the laryngeal mask airway by nurses during cardiopulmonary
resuscitation. Anaesthesia 1994;49:3-7.
Brimacombe JR: Problems with the laryngeal mask airway: prevention and
management. Int Anesthesiol Clin 1998;36:139-154.
Berry AM, Brimacombe JR, Verghese C: The laryngeal mask airway in emergency
medicine, neonatal resuscitation and intensive care medicine. Int Anesthesiol Clin
1998;36:91-109.
Greene MK, Roden R, Hinchley G: The laryngeal mask airway. Two cases of
prehospital trauma care. Anaesthesia 1992;47:688-689.

26
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
Calder I, Ordman AJ, Jackowski A, Crockard HA: The Brain laryngeal mask airway. An
alternative to emergency tracheal intubation. Anaesthesia 1990;45:137-139.
Oczenski W et al. Hemodynamic and catecholamine stress responses to insertion of
the combitube, laryngeal mask airway or tracheal intubation. Anesth Analg
1999;88:1389-1394.
Wood ML, Forrest ET: The haemodynamic response to insertion of the laryngeal mask
airway: a comparison with laryngoscopy and tracheal intubation. Acta Anaesthesiol
Scand 1994;38:510-513.
Samarkandi AH, Seraj MA, el Dawlatly A, Mastan M, Bakhamees HB: The role of the
laryngeal mask airway in cardiopulmonary resuscitation. Resuscitation 1994;28:103106.
Shung J, Avidan MS, Ing R, Klein DC, Pott L: Awake intubation of the difficult airway
with the intubating laryngeal mask airway. Anaesthesia 1998;53:645-649.
Fukutome T, Amaha K, Nakazawa K, Kawamura T, Noguchi H: Tracheal intubation
through the intubating laryngeal mask airway (LMA-Fastrach) in patients with difficult
airways. Anaesth Intensive Care 1998;26:387-391.
Ellis DS, Potluri PK, OFlaherty JE, Baum VC: Difficult airway management in the
neonate: a simple method of intubating through a laryngeal mask airway. Paediatr
Anaesth 1999;9:460-462.
Parr MJ, Gregory M, Baskett PJ: The intubating laryngeal mask. Use in failed and
difficult intubation. Anaesthesia 1998;53:343-348.
Pennant JH, Walker MB: Comparison of the endotracheal tube and laryngeal mask in
airway management by paramedical personnel. Anaesth Analg 1992;74:531-534.
Tolley PM, Watts AD, Hickman JA: comparison of the laryngeal mask and face mask
by inexperienced personnel. Br Journal Anaesth 1992;69:320-321.
Devitt JH, Wenstone R, Noel AG et al.: The laryngeal mask airway and positive pressure ventilation. Anaesthesiology 1994;80:550.
Graziotti PJ: Intermittent positive pressure ventilation through a laryngeal mask airway:
is a nasogastric tube useful? Anaesthesia 1992;47:1088.
Barker P, Langton JA, Murphy PJ et al.: Regurgitation of gastric contents during
general anaesthesia using the laryngeal mask airway. Br J Anaesth 1992;69:314.
El Mikatti N, Luthra AD, Healy TE et al.: Gastric regurgitation during general
anaesthesia in the supine position with the laryngeal and face mask airways [abstract].
Br J Anaesth 1992;69:529.
Akhtar TM, Street MK, Risk of aspiration with the laryngeal mask. Br J Anaesth
1994;72:447.
Joshi GP, Morrison SG, Okonkwo N et al.: Continuous hypopharyngeal pH monitoring:
use of the laryngeal mask airway versus tracheal tube [abstract]. Anaesthesiology
1994;81:A1281.
Baskett PJ, Brain AI: The use of the LMA in cardiopulmonary resuscitation. UK:
Intavent Research Limited 1994.

27
D.
NEEDLE CRICOTHYROIDOTOMY AND TRANSLARYNGEAL JET VENTILATION
Effective ventilation, using a 16g needle inserted into the trachea through the cricothyroid
membrane, a high-pressure oxygen source and non-compliant tubing was first demonstrated
in a canine laboratory model in 1971. Since then this method of airway management and
ventilation has been proven to be effective in cases of upper airway obstruction and
cardiopulmonary arrest. It has also been used in cases of failed endotracheal intubation, as
an alternative means of airway maintenance and ventilation when surgical cricothyroidotomy
was not utilised.
MECHANISM OF ACTION OF TRANSLARYNGEAL JET VENTILATION
Insufflation of air, under sufficient pressure, through a 14 or 16g cannula percutaneously
placed in the trachea will result in sufficient air flow to effectively ventilate any adult or
paediatric patient. Flow of gas through a hollow tube is directly proportional to the driving
pressure and inversely proportional to the resistance to flow. Resistance is dependent on
many factors, one of the most important being the radius of the tube (flow is inversely
proportional to the fourth power of the radius of the tube): the narrower the tube, the greater
the resistance (this is an exponential relationship). Intuitively, the resistance of a 14g cannula
would seem to be so great that it would prevent the kind of air flow necessary to provide an
adequate minute volume for an adult (10 ml/kg - 700 ml in a 70 kg adult x 12 breaths/min =
8.4 l/min). If the driving pressure is increased, at a certain point it will overcome resistance
inherent in the tube and flow will increase in a manner proportional to the increase in driving
pressure. Adequate flow through a 14g cannula is possible provided the driving pressure is
great enough to overcome the resistance of the cannula.
FLOW RATES USING A DRIVING PRESSURE OF 50 psi WITH NORMAL LUNG
COMPLIANCE 1
20g CANNULA
400 ml/sec
16g CANNULA
500 ml/sec
14g CANNULA
1600 ml/sec
The minimum driving pressure required to provide adequate ventilation is 50 psi. Although a
driving pressure as low as 0.5 psi (35 cmH2O) can generate enough flow through a 14g
cannula to oxygenate a patient in the short term, the flow rate produced is not enough to
produce adequate alveolar ventilation. Laboratory studies using animals have shown that lowflow ventilation through a 14g cannula can provide enough oxygenation to sustain life for 1.52 hours after which time lethal hypercapnia and acidosis caused hypotension and eventually
cardiac arrest 1.
This means that a high-flow system is necessary to provide enough alveolar ventilation to
maintain the PACO2 and PaCO2 within normal limits. Furthermore, consideration must be
given to the route and efficacy of passive exhalation in order to prevent life-threatening
hypercapnia. Exhalation following delivery of a jet ventilation must occur through the patients
natural airway because the driving pressure generated by recoil of the patients lung tissue is
not sufficient to overcome the resistance of a 14g cannula and provide adequate flow for a full
exhalation through this device.
INDICATIONS FOR NEEDLE CRICOTHYROIDOTOMY AND TRANSLARYNGEAL JET
VENTILATION
This technique of airway management is indicated only in situations where all other measures
that could be used to open and maintain the airway have failed due to:

28
Any of the anatomical or pathological features which commonly result in difficulty

than twice will seldom result in success. Therefore it is usually recommended that
cricothyroidotomy (surgical or needle) be used to provide an airway and ventilation
after two failed intubation attempts.
Foreign bodies which cannot be removed or displaced at laryngoscopy to allow

placement of an endotracheal tube.
Facial or neck trauma resulting in an inability to ventilate or place an oro- or

nasotracheal tube due to anatomical deformity, haemorrhage resulting in an inability to
visualise the anatomy or a haematoma presenting a physical narrowing and obstruction
of the airway.
Neoplasms of the oral cavity, pharynx or upper larynx resulting in inability to ventilate or
place an endotracheal tube.
Laryngeal oedema or inflammation due to any physical, haemodynamic or infectious

cause resulting in an inability to ventilate or place an endotracheal tube.
Surgical cricothyroidotomy is contraindicated in children and infants. Needle

cricothyroidotomy is the procedure of choice in these patients
It should also be noted that translaryngeal ventilation, although life-saving in the cases
mentioned above, should be avoided as a means of ventilation for prolonged periods of time.
Once the patients condition has been stabilised an alternative means of placing a large bore
tube (endotracheal, nasotracheal or tracheostomy) should be sought as a matter of urgency.
Needle cricothyroidotomy and translaryngeal jet ventilation are only a means of averting a
crisis and buying time until a definitive airway and ventilation method can be applied.
EQUIPMENT NEEDED FOR NEEDLE CRICOTHYROIDOTOMY AND TRANSLARYNGEAL
JET VENTILATION
A standard 14g over-the needle intravenous catheter or any one of a variety of

specially manufactured products for use in the technique of percutaneous
cricothyroidotomy.
A high-pressure (at least 50 psi) oxygen source and a high-flow (approx. 320 l/min)
regulator.
Alternatively a low flow (15 l/min) regulator may be used bearing in mind the limitations
of the use of a decreased driving pressure mentioned above (oxygenation possible but
inadequate ventilation and resultant hypercapnia). In most settings the low flow
regulators are more readily available.
Non-compliant tubing.
A jet ventilation toggle switch.
Oxygen tubing.
All relevant bore-compatible connectors.
A 20 ml syringe.
Tape
The above list should highlight one of the greatest problems with the technique of jet
ventilation: non-availability of a pre-assembled system. If this technique of ventilation is to be
effectively used, provision must be made beforehand to assemble a useable system and
have it available and in working order at all times. The only item that is usually readily
available in most settings is a 14g IV catheter. Trying to assemble a jet ventilation system
from odds and ends in a crisis situation will invariably result in frustration and may have fatal
consequences.

29
Bag-valve-mask-reservoir ventilation through a 14g cannula is largely an exercise in

frustration, although in the absence of any other options it may provide a way of maintaining
enough arterial oxygenation in the short term to prevent irreversible cerebral damage and
should be undertaken if no other way can be found to ventilate the patient. The equipment
necessary for this technique is:
A 14g over-the-needle intravenous catheter

A 3.0 mm I.D. endotracheal tube connector.
A bag-valve-reservoir resuscitator and oxygen source.
Fig. 1
Fig. 2
In Fig. 1 a 3.0 mm I.D. ETT connector has been fitted to the proximal connection of a 14g IV
cannula. Once this has been done the patient may be ventilated in the normal way by
compressing the bag resuscitator (although there will be significantly increased resistance
and each ventilation will take 3-4 seconds). In Fig. 2 a 7.0 mm ID endotracheal tube has been
placed in the barrel of a 20 ml syringe and the cuff inflated. The 14 g cannula can now be
attached to the syringe nozzle.
Alternatively, a low pressure jet ventilation device may be fashioned from the following pieces
of equipment if they are available:
A high-capacity fluid administration set.

A 15 l/min oxygen source.
A 14g over-the-needle intravenous catheter.
Fig. 3
Fig. 4
One end of the admin. set should be attached to the oxygen regulator outlet and the other
end to the proximal connector of the cannula in the normal way as shown in Fig. 3. In order to
improvise a toggle switch to allow intermittent ventilation, the rubber stopper of the y-injection
site should be removed as shown in Fig. 4 (circled). When the oxygen flow is set at 15l/min,
30
occlusion of the y-injection site will result in flow being directed through the cannula into the
trachea. When the y-injection site is opened pressure in the tubing will be lost allowing for
passive exhalation (provided there is a viable route for escape of expiratory gases). The
patient is ventilated by intermittent occlusion of the y-injection site.
THE TECHNIQUE OF NEEDLE CRICOTHYROIDOTOMY AND TRANSLARYNGEAL JET
VENTILATION
o
o
o
o
o
Position the patient with the neck in extension, have an assistant maintain this position
if necessary.
All equipment should be accessible at the operators right hand. The 14g catheter
should have a small-angle bend placed 2.5 cm from the distal end in advance.
Standing alongside the patient, facing cephalad, identify the cricothyroid membrane
(the depression immediately below the laryngeal prominence and above the cricoid
cartilage) with the index finger while stabilising the entire larynx with the thumb and
middle finger of the same hand (positioning, in relation to the patient, is not a critical
issue. In the photograph below, the practitioner is positioned at the patients vertex).
Holding the 14g cannula in the other hand (while maintaning the position of the
cricothyroid membrane and stability of the larynx), puncture the cricothyroid membrane
by introducing the needle at an angle approx. 30 degrees from the perpendicular,
pointing caudad (towards the patients lower half).
Once the needle has punctured the cricothyroid membrane, attach a 20 ml syringe
(while constantly stabilising the catheter) and pull back on the plunger: if there is no
resistance and at least 10 ml of air is freely aspirated, the catheter tip is correctly
placed in the lumen of the trachea. If resistance is felt and air cannot be freely
aspirated then the tip of the catheter is situated in tissue (usually the trachealis muscle
or overlying mucosa). The catheter should be slightly withdrawn and aspiration should
be attempted again until air is aspirated freely.
Once positioning in the trachea has been positively identified, the cannula should be
carefully advanced while the needle is held still. If any resistance to cannula
advancement is encountered, the cannula should be withdrawn (with the needle)
slightly and re-advanced.
On full advancement of the cannula (until the hub of the cannula reaches the skin line)
the needle should be completely removed and the 20 ml syringe reattached to the
cannula. Air should be aspirated again to check for correct final placement of the
cannula in the lumen of the trachea.
Attach the jet ventilation tubing and open the toggle switch to allow a short burst of high
pressure oxygen flow while watching the patients anterior chest wall and auscultating
for adequate and bilaterally equal air entry. The toggle switch should be closed as soon
as the anterior chest wall rises enough to indicate the insufflation of an adequate tidal
volume.
During exhalation an assistant should maintain as much patency of the natural airway
as possible by using a jaw thrust, double or triple airway manouevres, oropharyngeal
tube or nasopharyngeal tube in order to facilitate passive exhalation.
The cannula should be fixed in place with tape as soon as possible but in addition to
this, someone should be given the task of holding the cannula in place at all times.
COMPLICATIONS OF NEEDLE CRICOTHYROIDOTOMY AND TRANSLARYNGEAL JET

VENTILATION
The most potentially damaging complication which may occur during translaryngeal jet
ventilation (even if the cannula is correctly placed) stems from the fact that the airway is not
protected by this technique. Regurgitation and pulmonary aspiration of gastric contents may
occur if the patient is ventilated in the supine position. It is important to position these
patients laterally in order to prevent this complication.
In addition several other complications have been reported in studies dealing with this
particular technique:

31
Cases of subcutaneous and mediastinal emphysema have been reported.
Impedance of expiratory flow was encountered in 14% of patients in one study. This
may lead to pulmonary hyperinflation and increased risk of barotrauma such as
pneumothorax and tension pneumothorax both of which have been reported albeit not
frequently. Total airway obstruction will create a signinificantly increased risk of
pulmonary barotrauma.
Complications of catheter insertion such as arterial perforation, tracheal mucosal
damage, oesophageal perforation, haemorrhage, haematoma formation and
haemoptysis have been reported.
None of the complications mentioned above proved to be fatal.

Some authors consider total airway obstruction to be a contraindication to the use of
translaryngeal jet ventilation. It should be noted, however, that in the kind of situation where a
patient is apneic, becoming progressively more hypoxic and there is no other alternative
means of opening the airway and ventilating the patient, there can be no absolute
contraindications to the use of needle cricothyroidotomy and translaryngeal jet ventilation as a
short-term life-saving technique.
REFERENCES
1. Benumof J L (Ed.): Airway Management - Principles and Practice. 1996; Mosby; USA.
2. Walls RM: Cricothyroidotomy. Emerg Med Clin North Am 1988 Nov;6 (4): 725-36.
3. Spaite DW, Joseph M: Prehospital cricothyrotomy: An investigation of indications,
technique, complications and patient outcome. Ann Emerg Med 1990 Mar;19 (3): 279-85.
4. Salvino CK, Dries D, Gamelli R, Murphy-Macabobby M, Marshall W: Emergency
cricothyroidotomy in trauma victims. J Trauma 1993;34:503-505.
5. DeLaurier GA, Hawkins ML, Treat RC, Mansberger AR: Acute airway management. Role
of cricothyroidotomy. Am Surg 1990;56:12-15.
6. Burkley B, Esclamado R, Morganroth M: The role of cricothyroidotomy in airway
management. Clin Chest Med 1991;12:561-671.
7. Leibovici D, Fredman B, Gofrit ON, Shemer J, Blumenfeld A, Shapira SC: Prehospital
cricothyroidotomy by physicians. Am J Emerg Med 1997;15:91-93.
8. Deakin CD: Prehospital management of the traumatised airway. Eur J Emerg Med
1996;3:233-243.

32

Prehospital Advanced Airway Management

Încărcat de

Informații document

Drepturi de autor

Formate disponibile

Partajați acest document

Partajați sau inserați document

Opțiuni de partajare

Vi se pare util acest document?

Este necorespunzător acest conținut?

Drepturi de autor:

Formate disponibile

Prehospital Advanced Airway Management

Încărcat de

Drepturi de autor:

Formate disponibile

PLEASE NOTE:

Fig 1: Anatomy of the Laryngeal Cartilages

Fig 2: Anatomy of the Glottic Opening

Module 2: Core Notes

This will be revealed as the tongue is lifted. It is

Posterior Pharyngeal Wall

The mucosa of the posterior wall of the pharynx will

Tip of the Epiglottis

As the tongue is elevated the tip of the epiglottis will

Each arytenoid cartilage is triangular in

Corniculate and Cuneiform Cartilages

These are embedded in the posterior

Emergency Medical Care II

Module 2: Core Notes

in the aryepiglottic folds on either side

As the tongue and epiglottis are

Fig 3: Laryngoscopic View of the Upper Airway

Tip of the Epiglottis and Posterior Larynx

The Vocal Cords

This signet ring-shaped cartilage is unique because

The average adult trachea is approx. 10-20 cm long

The trachea bifurcates at the carina approx. 10-20

Emergency Medical Care II

Module 2: Core Notes

ANATOMICAL DIFFERENCES OF THE PAEDIATRIC AIRWAY

The paediatric tongue is relatively large in relation to

The larynx is situated more superiorly (the laryngeal

The trachea descends into the thorax at a posterior

THE ADVANTAGES OF ENDOTRACHEAL INTUBATION

Airway Protected - only if a cuffed ETT is used

Circulation Improved During CPR (asynchronous compression-ventilation CPR)

Drug Adminstration (narcan, adrenaline, atropine and lignocaine only)

Gastric Distension Prevented

Highest O2 Concentration Possible - only if using bag-valve-mask-reservoir with O2 flow

THE PHYSIOLOGICAL RESPONSE TO INTUBATION

Emergency Medical Care II

Module 2: Core Notes

Remember the Mechanisms of Hypoxia:

Decreased FiO2 - e.g. Altitude/Hypoventilation

Emergency Medical Care II

Although a normal SpO2 may be shown on the

Module 2: Core Notes

capacity (SpO2 yields no information about the Hb

Hypothermia will result in a shift of the dissociation

The presence of significant amounts of carboxy or methaemoglobin may result in a deceptively

Paediatric patients presenting with a febrile illness and respiratory distress.**

Emergency Medical Care II

Module 2: Core Notes

** It should be noted that no attempts should be made at pre-hospital

Any patient found unconscious after a burn injury.

6. Decreased Level of Consciousness

Hypoxia, decreased CO, blunt or penetrating

Emergency Medical Care II

Module 2: Core Notes

Prem: 3.0 +/- 0.5

Adult: 21-23 cm mark at incisors for orotracheal placement. Add 3 cm for

** Tubes less than 5.0 mm I.D. should be uncuffed.

Emergency Medical Care II

Module 2: Core Notes

LARYNGOSCOPE HANDLE AND BLADES

Macintosh 4 (or 3 for small adults)

Prem. Infant: Miller 0

Spare batteries and bulb.

Emergency Medical Care II