EMS REGION 8

CONTINUING EDUCATION

January 2007

LOYOLA EMSS

“Who’s got the Airway?”

 Key Issues and Techniques in

EMS Airway Management

Objectives:

Why Do We Do This?

Paramedics have been intubating since the 70’s-a procedure previously performed only in hospitals.  We know that nothing can be done to reverse hypoxic brain damage once it occurs.  We’ve been taught that maintaining an airway and ensuring adequate oxygenation supersedes everything other than scene safety.  Currently, some are calling for us to revisit why we do this procedure, because in some instances it’s actually harming patients, and we know above all that our goal is “to do no harm”.  Let’s look further at some of the issues.

The Problems

1. Some now questioning if paramedics can safely intubate
2. Some programs have data which shows successful intubations as low as 50%
3. Data which shows intubation may be harmful in head-injured patients (rise in ICP during procedure)
4. Children seem to do better with BLS airway interventions

The Cause Analysis

1. Poor initial training
2. No or minimal OR experience
3. “Fred the Head” training only
4. Not enough field tubes to go around
5. Poor airway rescue procedures
6. Inadequate continuing education requirements

Can We Save Intubation?

1. Become active in your local paramedic education program.  Students need to do at least 10 live intubations before graduating.  You can help with this
2. Develop aggressive airway rescue protocols for failed intubations
3. Insist on mandatory continuing education as frequently as needed, including live intubation recertification requirements
4. Schedule time for airway obstacle courses because they’re fun!

Intubation-The Last Word

1. Paramedics must continue to intubate and can do it well
2. Complacency setting in; don’t let it
3. Training and medical control issues; get involved
4. If we lose expertise in advanced airway management, ALS loses significant value

The Ten Commandments of Airway Management

1. Oxygenation and ventilation are the top priorities
1. Care must center on this.  Becoming overly focused and developing tunnel vision during intubations attempts can  ultimately lead to negative outcomes
2. Airway management does not mean intubation
1. It means to ensure patency, provide adequate ventilation and maintain appropriate oxygenation.  Many times we forget the basics.  Merely providing a chin lift or jaw thrust can open and/or salvage many airways.  The proper use of adjuncts (oral/nasal airways), can convert a difficult-to-ventilate patient into a stable, well-ventilated one.  The appropriate administration of high-flow oxygen, with properly fitted masks, is enormously beneficial.  We must never forget that airway management is a collection of skills and techniques, not just an attempt to place a tube or device into the patient’s mouth or trachea
3. Be an expert at bag-valve-mask (BVM) ventilation
1. BVM ventilation is the most underrated-and perhaps the most under-mastered EMS skill.  Using properly fitted masks, using the correct size bag for your patient, and employing excellent technique are all imperative to good patient care.  Proper technique involves lifting the mandible upward and using an oral/nasal airway during BVM ventilation.  Beware of using high bag volume and pressures; both can cause gastric distention and increase the risk of regurgitation.  It is also important to remember that two or three are better than one when it comes to BVM ventilation.  This technique, with one provider maintaining a good mask seal, another provider bagging, and a third provider providing cricoid pressure, is almost always more effective than one person trying to do it all.
4. Know your equipment
1. That daily check sheet is there for a reason.  Airway equipment is one of the most important items you carry.  Having backups (laryngoscope blades, bulbs, handles, adjuncts) and the ability to troubleshoot equipment are also important.  Assume personal responsibility for all airway equipment and its proper functioning.
5. Know at least one rescue ventilation technique and use it
1. Rescue ventilation can best be described as a ventilation attempt to use in the face of a failed airway (can’t intubate/can’t ventilate) scenario.  The most basic rescue technique is two-person BVM ventilation.  It should be tried immediately when there is difficulty with ventilation.  Next, the use of the CombiTube® is recommended.  It is easy to use, can be inserted quickly and safely, and can accomplish ventilation when previous airway attempts fail.  It allows for blind insertion in the most difficult of patients and situations and provides some protection against aspiration and higher airway pressures.

6. Develop a personal airway algorithm
1. Each provider should have an algorithm specific to their skill level and approved scope of practice.  Not all patients and situations you encounter are going to be the same.  Having only one or two airway skills in your repertoire can lead to a potentially dangerous approach to airway management.  Everyone’s algorithm should begin with the basics.  For example, start with BVM ventilation, advance to ET intubation, then place a Combitube®, and finally perform a surgical cricothyrotomy.  This plan should be calmly practiced and mastered.
7. Don’t let your ego get in the way
1. This can be dangerous for your patient, your partner or colleagues, and your career.  Remember, your goal is excellent patient care and a positive outcome, not skill accumulation or personal success.  The “Rule of 2” is a good one to abide by:  If you’re unsuccessful at a skill, give your partner a chance after you’ve failed twice.  Don’t ever forget to ask for assistance when you need it. 
8. Invest time in learning airway skills
1. Regularly devote training and practice time to airway management.  Try not to limit yourself to manikin airway trainers if possible.  Work on gaining access to the simulator lab, operating room or emergency department.  Contact your EMS coordinator or medical director and explain your needs and goals.  View airway anatomy and work on improving your BVM ventilation techniques in this controlled, well-lit environment.  Also, read about the latest techniques and advances in airway management.  Attend conferences and airway obstacle courses for more hands-on training.  Some great websites to check out are:

                                                              i.      www.combitube.org

                                                            ii.      www.theairwaysite.com/home.html

                                                          iii.      www.airwayeducation.com

9. Use an end tidal CO2 detector and/or esophageal detector device to assist you in confirming every intubation
1. For many years, the proper placement of an ET tube was thought to be best confirmed via the physical exam.  The gold standard was thought to be observing the tube passing through the vocal cords, determining the presence of breaths sounds over the chest, condensation in the ET tube and absence of breath sounds over the epigastrium.  However, even with confirmation by all these signs, some patients are still intubated in the esophagus.  Our patients have to be intubated in the worst of conditions and are usually encountered with food in the stomach or blood/emesis in their mouths.  Our intubations are usually performed in uncontrolled settings, like the side of the road, or in poorly lit environments.  End tidal CO2 detectors are required by anesthesia in Operating Rooms, so it’s appropriate that we should use the same aids to confirm intubation.  In one study by Katz and Falk (2001), the rates for unrecognized esophageal intubations by EMS providers were as high as one in four when end tidal CO2 detectors were not used. 
2. The esophageal detector device (EDD), which uses a syringe or bulb in attempt to aspirate air from the trachea or esophagus is a quick and easy way to confirm ET tube placement.  The rigid, cartilaginous trachea won’t collapse around an ET tube, thus allowing the EDD to aspirate fully.  If the tube is improperly placed in the esophagus, the soft tissue of the esophageal wall will collapse around the end of the tube, and little or no air can be aspirated by the EDD.  EDDs can be used in conjunction with end tidal CO2 detectors.  The use of one or both of these devices should become the standard of care for all emergency intubations. 
10. When seconds count, don’t count on seconds
1. Each airway maneuver or intubation attempt should be your best effort.  Often, our best chance at getting a decent airway is the first attempt.  Maximize your chances by leaving nothing to chance.  Being prepared often means the difference between success and failure.

What is the Rule of Two’s?

The rule of 2’s helps EMS providers remember optimal BVM technique

Two people:

The hardest part of performing BVM ventilation is achieving an adequate seal between the mask and the patient’s face.  It’s much easier to achieve and maintaining a seal using the two person technique-one to ventilate, and one to hold the mask. 

Two airways:

Nasal and oral airways are often forgotten in the midst of a chaotic scene with a critical patient, but these simple techniques can make a lifesaving difference.  An OPA and an NPA may be used together, and two NPAs can be used along with an OPA, if necessary.  It’s imperative to make sure these devices are properly sized to each individual patient and inserted correctly.

Two fingers:

Air, like water, will take the path of least resistance.  To maintain optimal airflow to the lungs, resistance in the airway must be minimized and resistance in the esophagus must be maximized.  Resistance in the upper esophagus is increased by using cricoid pressure (Sellick’s maneuver), by using two fingers to perform this pressure.  The cricoid ring, the only complete ring in the trachea, is located below the more obvious laryngeal cartilage.  Pressure on the front of this ring will be transmitted to its back.  The esophagus is then compressed between the back of the cricoid ring and the spinal column.  It’s important to apply firm pressure but not so much that the ring is totally collapsed; this may occlude the airway in small patients.  Also, in the event of vomiting, cricoid pressure must be released to prevent esophageal rupture.  Remember, cricoid pressure applied during intubation may actually impair the intubator’s view of the larynx.  It’s important that cricoid pressure be released if there is difficulty visualizing the vocal cords. 

Two inches:

The sniffing position is the best position to minimize airway resistance during BVM ventilation and it also happens to be the best position in which you can visualize the larynx during intubation.  The combination of forward flexion and extension of the neck is achieved by elevating the head at least two inches.  This can assist with difficult intubations and can be increased with additional padding, if needed.  This position, obviously, is contraindicated in the patient with a suspected cervical spine injury.

Two seconds:

The provider should deliver a slow, gentle ventilation over two seconds, rather than faster ventilation.  Slower ventilations result in more air going into the lungs than the stomach.  It also prevents pressure damage to the lungs (barotrauma) and is a technique emphasized by the American Heart Association (AHA).  The “squeeze-release-release” technique is used to stress this same point.  It’s also important to allow for sufficient time for exhalation, particularly if the patient has bronchospasm, or another condition that impairs the flow of air out of the lungs.

Two PSI:

Overly aggressive ventilation, results in more air entering the stomach, which may eventually impair diaphragmatic movement and subsequent ventilation.  It also predisposes the patient to vomiting with subsequent aspiration and can lead to lung damage as well as impaired venous blood return to the heart.  The lowest possible pressures and tidal volumes that create adequate ventilation should be used.  Two PSI, is not the actual pressure being used, but a useful reminder to minimize these pressures.  Assess for adequate ventilation by observing minimal chest rise or hearing appropriate lung sounds.  In the past few years, target tidal volumes have dropped from the recommended 10-15 cc/kg to 6-10 cc/kg.  This means that a 70 kg adult should receive about 550 cc per breath (8cc/kg), or approximately one-half of a standard adult self-inflating bag.  For many, using one hand to squeeze the bag rather than two will help avoid over-ventilation. 

The Skills Review-Get out those Mannikins!!

Basic Airway Management Techniques

Skill:

1. Roll the patient onto the left so that the head, shoulders, and torso all move at the same time without twisting
2. Place the patient’s extended left arm and right hand under his or her cheek

Opening the airway

Skill:

1. Position yourself at the side of the patient
2. Place your hand closest to the patient’s head on the forehead
3. With your other hand, place two fingers over the underside of the patient’s chin
4. Simultaneously, apply backward and downward pressure to the patient’s forehead and lift the jaw straight up.  Be careful not to depress the submental triangle with your fingers, which causes the tongue to elevate, possibly pushing it against the roof of the mouth

Skill:

1. Position yourself at the top of the patient’s head
2. Place the meaty portion of the base of your thumbs on the zygomatic arches, and hook the tips of your index fingers under the angle of the mandible, in the indent below each ear
3. While holding the patient’s head still, displace the jaw upward and open the patient’s mouth with your thumb tips

            Airway adjuncts

Skill:

1. Approach the patient from the top of the head
2. Select the correct sized airway for the patient by measuring from the corner of the mouth to the angle of the jaw
3. Using your non-dominant hand, tilt the patient’s head back and open the mouth
4. Remove any visible obstructions
5. Insert the device with your dominant hand by placing its distal tip toward the palate and inserting the device until you feel a slight resistance
6. Turn the device 180◦ until the flange comes to rest at the patient’s incisors

Skill:

1. Select the correct sized airway for the patient by placing one end of the device on the tip of the nose and measuring to the earlobe
2. Lubricate the airway with water-soluble lubricant
3. With the bevel towards the septum, gently insert the device straight back (toward the ear, not the eye) until the flange rests at the nostril.  The right nostril is usually the easier one to begin with.

Suctioning

1. Apply a pulse oximeter and cardiac monitor if available and practical.  Preoxygenate by ventilating with 100% oxygen for 2-3 minutes
2. Select an appropriate catheter and attach it to the tubing
3. Turn on the suction unit
4. Insert the catheter into the oropharynx.  Occlude the hole and apply suction as you withdraw the catheter in a sweeping motion (flexible catheter only)
5. Hyper-oxygenate the patient
6. Reevaluate airway patency

Positive Pressure Ventilation

            The Sellick maneuver

Skill:

1. Visualize the cricoid cartilage; palpate to confirm its location
2. Apply firm pressure on the cricoid ring with your thumb and index finger on either side of the midline.  Maintain pressure until intubated

Skill:

One-Person BVM (Also practice this technique with two and three persons)

1. Choose the proper mask size to seat the mask from the bridge of the nose to the chin
2. Position the mask on the patient’s face, bringing the face into the mask
3. Open the patient’s airway and hold the mask in place with one hand using the C-E technique (forming a “C” with your thumb/index and an “E” with 3^rd-5^th fingers).  Squeeze the bag completely over 2 seconds with the other hand.  Allow the bag to reinflate slowly and completely

            Automatic Transport Ventilator

Endotracheal Intubation

Skill:

1. Use BSI precautions
2. Preoxygenate the patient whenever possible with a BVM and 100% oxygen
3. Check, prepare and assemble your equipment
4. Place the patient’s head in the sniffing position
5. Insert the blade into the right side of the patient’s mouth, displacing tongue to the left
6. Gently lift the long axis of the laryngoscope handle until you can visualize the glottic opening and the vocal cords
7. Insert ET tube through the right corner of the mouth and place it between the vocal cords
8. Remove the laryngoscope from the patient’s mouth
9. Remove the stylet from the ET tube
10. Inflate the distal cuff of the ET tube with 5-10 ml of air and detach the syringe
11. Attach the end-tidal CO2 detector to the ET tube
12. Attach the bag-valve device, ventilate and auscultate over lungs and stomach
13. Secure the ET tube
14. Place a bite block in the patient’s mouth

            Securing the endotracheal tube with tape/commercial device (TubeTamer®)

1. Note the cm marking on the tube at the level of the patient’s teeth
2. Remove the bag-valve device from the ET tube
3. Tape
1. Move the ET tube to the corner of the patient’s mouth
2. Encircle the ET tube with tape and secure the tape to the patient’s maxilla (using tincture of benzoin to facilitate tape adhesion)
4. Commercial device
1. Position ET tube at center of mouth; place device over ET tube and secure
5. Reattach the bag-valve device and auscultate over the apices and bases of the lungs and over the epigastrium

Blind nasotracheal intubation

1. Take BSI precautions
2. Preoxygenate the patient whenever possible with a BVM and 100% oxygen
3. Check, prepare and assemble your equipment
4. Place the patient’s head in a neutral position
5. Pre-form the ET tube by bending it into a circle
6. Lubricate the tip of the ET tube with a water-soluble gel
7. Gently insert the ET tube into the most compliant nostril with the bevel facing toward the nasal septum and advance the tube along the nasal floor
8. Advance the ET tube through the vocal cords when the patient inspires
9. Inflate the distal cuff of the ET tube with 5-10 ml of air and detach the syringe
10. Attach the end-tidal CO2 detector to the ET tube
11. Attach a bag-valve device, ventilate, and auscultate over the apices and bases of both lungs and over the epigastrium
12. Secure the ET tube

Digital intubation

1. Take BSI precautions
2. Preoxygenate the patient for at least 2 minutes with a BVM and 100% oxygen
3. Check, prepare and assemble your equipment           
4. Bend the ET tube by placing a straight curve at its distal end (like a hockey stick)
5. Place the patient’s head in a neutral position
6. Place a bite block in-between the patient’s molars to prevent the patient biting your fingers
7. Insert your left middle and index fingers into the patient’s mouth and shift the patient’s tongue forward as you advance your fingers toward the patient’s larynx
8. Palpate and lift the epiglottis with your left middle finger
9. Advance the tube with your right hand and guide it in-between the vocal cords with your left index finger
10. Remove the stylet from the ET tube
11. Inflate the distal cuff of the ET tube with a 5-10 ml of air and detach the syringe
12. Attach the end-tidal CO2 detector to the ET tube
13. Attach the bag-valve device, ventilate, and auscultate over the apices and bases of both lungs and over the epigastrium
14. Secure the ET tube

Post-Intubation Procedures

            Performing tracheobronchial suctioning

1. Check, prepare, and assemble your equipment
2. Lubricate the suction catheter
3. Preoxygenate the patient
4. Detach the ventilation device and inject 3-5 ml of sterile water down the ET tube (this practice is controversial; many now  recommend dry suctioning)
5. Gently insert the catheter into the endotrachal tube until resistance is felt
6. Suction in a rotating motion while withdrawing the catheter.  Monitor the patient’s cardiac rhythm and oxygen saturation during the procedure
7. Reattach the ventilation device and resume ventilation and oxygenation

Rescue Airway Techniques

Skill:

1. Take BSI precautions
2. Preoxygenate the patient whenever possible with a BVM device and 100% oxygen
3. Gather your equipment
4. Place the patient’s head in a neutral position
5. Open the patient’s mouth with a tongue jaw-lift and insert the CombiTube in the midline of the patient’s mouth.  Insert the tube until the incisors or alveolar ridge lie between the two reference marks
6. Inflate the pharyngeal cuff to 100 ml of air
7. Inflate the distal cuff with 10-15 ml of air
8. Ventilate the patient through the longest tube (pharyngeal) first.  Chest rise indicates esophageal placement of the distal tip (continue to ventilate)
9. No chest rise indicates tracheal placement (switch ports and ventilate)

Pharmacological Aids in Emergency Intubation

            Topical anesthetics: Benzocaine (Cetacaine™, Hurricaine™, Endocaine™)

These agents are underused in the region for reasons not understood.  Topical anesthetics significantly increase the patient’s level of comfort and the success of intubation (especially when used with midazolam) when the patient is awake or has a gag reflex.  The proper use of topical anesthetics decrease the incidence of gagging and retching, thereby decreasing the risk of vomiting and limiting spikes in intracranial pressure.  Topical anesthetics dull the cardiovascular response associated with upper airway stimulation and are associated with very few complications.  The liquid can be sprayed directly into the posterior pharynx for 1-2 seconds and may be repeated once.  Do not exceed recommended dose. 

            Sedative agents: Sedation, which is also underused in emergency intubation, should be seriously considered anytime you need to intubate a conscious patient.  It can reduce the patient’s anxiety, induce amnesia, and decrease a patient’s gag reflex.  It is useful when a patient is combative, anxious, or agitated.  Using sedatives safely and effectively requires practice and experience.  These medications have a great potential to help but also can hurt the patient if they are not used properly.  Undersedation can result in poor patient cooperation, the complications of gagging (such as trauma, tachycardia, hypertension, vomiting, or aspiration), and can incomplete amnesia of the event.  Oversedation can result in uncontrolled general anesthesia, loss of protective airway reflexes, respiratory depression, complete airway collapse, and hypotension.

Midazolam (Versed™): Adult dose=4 mg IV/IO initial bolus, then 2 mg IV/IO up to 10 mg total

Pediatric dose=0.05mg/kg IV/IO up to 0.2 mg/kg maximum

This is a fast acting benzodiazepine with CNS depressant, muscle relaxant, amnesic and anticonvulsant effects.  Respiratory depression and slight hypotension are side effects.

Etomidate (Amidate™):

Head Injury intubation dose=0.6 mg/kg rapid IVP; no repeat dose

Medical intubation dose=0.3 mg/kg rapid IVP; may repeat 0.3 mg/kg rapid IVP after 1 minute

This is a non-barbiturate hypnotic without analgesic properties.  It has minimal effects on the cardiorespiratory systems; however, a high incidence of uncomfortable myoclonic muscle movement is associated with its use.  Etomidate is useful in patients with coronary artery disease, increased intracranial pressure, or borderline hypotension/hypovolemia.

______________________________________________________________________________

Pediatric Airway Management

            Suctioning with a bulb syringe

1. Squeeze the bulb away from the infant to remove air
2. Open the infant’s mouth and insert the tip of the syringe at the side of the mouth.  Advance the syringe tip into the mouth to suction thin secretions.  Do not insert the syringe tip into the soft tissues at the back of the mouth
3. Open the infant’s nostril slightly and suction the nose.  Insert the tip of the syringe straight back into the nostril

            Opening the airway

1. Head tilt-chin lift and Jaw-thrust maneuvers (same as adult)

      Oropharyngeal Airway

1. Measure the oropharyngeal airway
2. Point the tip of the airway toward the roof of the patient’s mouth (the hard palate) and depress the tongue with the curved portion of the airway
3. Place the oropharyngeal airway into the patient’s mouth until the flange rests against the lips.  When the flange is at the lips, gently rotate the airway 180◦

Nasopharyngeal Airway

1. Measure the nasopharyngeal airway
2. Lubricate the airway tip
3. Advance the airway along the floor of the nares
4. Advance the airway until the flange is against the outside of the nostril

            Bag-valve-mask ventilation

1. Position the head
2. Measure the mask from the bridge of the nose to the cleft of the chin
3. Perform the EC-clamp, pulling the chin into the mask
4. Say “squeeze, release, release” while ventilating and watching the chest rise
5. Consider using the two-rescuer technique

            Performing cricoid pressure

1. Locate the cricoid ring by palpating the trachea for a prominent horizontal band below the thyroid cartilage and cricothyroid membrane
2. Apply gentle downward pressure using one fingertip in infants and the thumb and index finger in children.  Avoid excessive pressure as this can cause tracheal compression and airway obstruction.

            Endotracheal intubation

1. Take BSI precautions
2. Check, prepare, and assemble your equipment
3. Manually open the child’s airway and insert an adjunct if needed
4. Preoxygenate the child with a BVM device and 100% oxygen for at least 30 seconds
5. Insert the laryngoscope blade into the right side of the mouth and sweep the tongue to the left.  Lift the tongue with firm, gentle pressure.  Avoid using the teeth or gums as a fulcrum
6. Identify the vocal cords; if they aren’t visible, instruct your partner to apply cricoid pressure
7. Introduce the ET tube in the right corner of the patient’s mouth
8. Pass the ET tube through the vocal cords to approximately 2-3 cm below the vocal cords.  Inflate the cuff if a cuffed tube is used
9. Attach and end-tidal CO2 detector, the BVM and ventilate
10. Auscultate for equal breath sounds over each lateral chest wall high in the axillae.  Ensure absence of breath sounds over the abdomen
11. Secure the endotracheal tube, noting the placement of the distance marker at the patient’s teeth or gums and reconfirm tube placement
12. Consider apply a cervical collar to prevent tube movement with transfers

            ALS Foreign-body airway management

1. Open the child’s mouth by using your thumb to apply downward pressure to the chin
2. If the FB is not visible, suction the oropharynx to improve visibility while being careful not to push the FB deeper into the airway
3. Insert the laryngoscope blade in the mouth to visualize the posterior pharynx and vocal cords or to visualize the FB in the airway
4. Insert the Magill forceps with the tips closed into the right side of the mouth
5. Open the Magill forceps around the foreign object and attempt to grasp the object
6. Grasp the object and carefully remove it from the mouth

Surgical and Non-surgical Airways

            Performing an open cricothyroidotomy

1. Take BSI precautions
2. Check, assemble, and prepare the equipment
3. With the patient’s head in a neutral position, palpate for and locate the cricothyroid membrane
4. Cleanse the area with an iodine-containing solution
5. Stabilize the larynx and make a 1-2 cm vertical incision over the cricothyroid membrane
6. Puncture the cricothyroid membrane and make a horizontal cut 1 cm in each direction from the midline
7. Spread the incision apart with curved hemostats
8. Insert the tube into the trachea
9. Inflate the distal cuff of the tube
10. Attach an end-tidal CO2 detector in-between the tube and the bag-valve device
11. Ventilate the patient and confirm correct tube placement by auscultating the apices and bases of both lungs and over the epigastrium
12. Secure the tube with a commercial device or gauze/tape.  Reconfirm correct tube placement and resume ventilations at the appropriate rate

            Performing a needle cricothyroidotomy

1. Take BSI precautions
2. Attach a 14-16 gauge IV catheter to a 10 ml syringe containing approximately 3 ml of sterile saline
3. With the patient’s head in a neutral position, palpate for and locate the cricothyroid membrane
4. Cleanse the area with an iodine-containing solution
5. Stabilize the larynx and insert the needle into the cricothyroid membrane at a 45◦ angle towards the feet
6. Aspirate with the syringe to determine correct catheter placement
7. Slide the catheter off of the needle until the hub of the catheter is flush with the patient’s skin
8. Place the syringe and needle in a sharps container
9. Auscultate the apices and bases of both lungs and over the epigastrium to confirm correct tube placement
10. Secure the catheter with gauze/tape.  Continue ventilations while frequently assessing for adequate ventilations and any potential complications

Special Situations

            Suctioning of a stoma

1. Take BSI precautions
2. Preoxygenate the patient with the BVM and 100% oxygen
3. Inject 3 ml of sterile saline through the stoma and into the trachea
4. Instruct the patient to exhale and insert the catheter (without providing suction) until resistance is felt (no more than 12 cm)
5. Suction while withdrawing the catheter as you instruct the patient to cough or exhale

            Replacing a dislodged tracheostomy tube

1. Take BSI precautions
2. Lubricate the same sized tracheostomy tube or an endotracheal tube (at least 5.0 mm)
3. Instruct the patient to exhale and gently insert the tube approximately 1-2 cm beyond the balloon cuff
4. Inflate the balloon cuff
5. Ensure that the patient is comfortable and confirm patency and proper placement of the tube by listening for air movement from the tube and noting the patients’ clinical status

References

Gausche-Hill M, Henderson DP, Goodrich SM, Koenig W, & Doil-Poore P. Pediatric Airway Management for the Prehospital Provider. Jones & Bartlett. Sudbury, MA, 2004

Katz SH & Falk JL. “Misplaced endotracheal tubes by paramedics in an urban emergency medical services system”, Annals of Emergency Medicine. 37: 62-64, 2001

Margolis GS. AAOS Airway Management Paramedic. Jones & Bartlett. Sudbury, MA, 2004

Slovis CM & High K. “Ten commandments of airway management: simple lessons to guide oxygenation and ventilation”, Journal of Emergency Medical Services, Vol 30(7): 42-54, 2005

Stewart CE. Brady Advanced Airway Management. Pearson Education, Inc. Upper Saddle River, NJ, 2002

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