Airway Equipment

CHAPTER 1

Next up what we're going to do is talk about some of the equipment that we stock in our airway carts, or where we store all of our airway equipment. Dr. Pratt, tomorrow will talk about how we've arranged it all so that it's easily accessible. But I wanted to take this opportunity to talk about some of the equipment that we actually stock in the drawers and that we have at our disposal when we have somebody who comes in with an airway issue. So we'll start with some of the basics and then we'll move to more invasive equipment later and just kind of work our way through. This is kind of actually how we approach the airway and how we escalate treatment of an airway issue or a breathing issue.

CHAPTER 2

So starting here on this side we've got some of our basic monitoring equipment. So within our carts we've got ways that we can monitor both the patient's oxygenation and their ventilation. So when a patient breathes, it's accomplishing two things: it's getting oxygen in and it's getting CO₂ out. And so we have ways of measuring both of those things. One is called a pulse-ox. There's a bunch of different forms of these. This one is a sticker that you actually stick on the patient's finger, or on their ear lobe, or on their forehead. And it sort of measures the level of oxygen in the blood. And so we can tell if we're getting enough oxygen in. We also have some ways of telling if the patient is breathing enough CO₂ out. So this is actually a nasal cannula. It's a plastic tube that we can stick… These two prongs go in the nose to give oxygen, and then this detector on the bottom detects how much CO₂ is coming out. So we can get an idea of how much is going in, how much is going out.

CHAPTER 3

And then oftentimes when we're managing an airway, we need to supplement how much oxygen they're giving them. So a lot of times we'll have to do what we call preoxygenation where before we take their airway, we need to make sure they have enough oxygen in their body as possible because we're going to have to stop their breathing to take their airway for a little bit. So we need to get as much oxygen in as we can before we actually do the procedure. We also usually like to have oxygen running as we do the intubation or as we take their airway. And so these are some of the tools we use to do that. One of the most basic is what we call the nasal cannula, which is just this plastic tube. It's got two prongs that kind of sit within the nose, within the nares, like this, and can deliver basically up to 5 L worth of flow of pure oxygen. And that mixes with air, and so you generally get about 40% oxygen into the body. Normally when we breathe we get about 21%. A nasal cannula ups that to about 40. And you get about 5 L of flow. If they're really having trouble preoxygenating, or you can't get the levels up, there's some other things you can escalate to. There are simple face masks, which is just a mask that we hook oxygen to. And that allows basically 10 L of flow and a little bit more oxygenation, so maybe 70–80% oxygen that they're breathing in. And then we also have what's called a non-rebreather mask, which is basically a face mask, but it's got this reservoir that connects directly to the 100% oxygen. So the reservoir stores the 100% oxygen. And then ideally, as long as these valves are intact on the mask, which we're missing one here, but ideally, as long as those valves are intact, we're delivering basically 100% oxygen to the patient. So oftentimes, if the patient is hypoxic and their oxygen is low, we can try to get their oxygen levels up by doing one of these things. And oftentimes, if we're preoxygenating, we really want to get as much oxygen in and flush as much nitrogen out as we can. So we want to start them on something high like a non-rebreather. And so that's usually where we'll start, but we have a bunch of other adjuncts as well. If that's not enough, and we're not getting enough oxygen with just the mask, we can assist the patient's breathing or deliver more oxygen with a bag valve mask. This is a pretty standard bag valve mask. They come in different shapes and sizes for different shapes and sizes of people. They also have different size face masks that you can adjust to the patient's size. But basically what this does is it creates a seal around the patient's nose and mouth, basically around their airway. And it helps us deliver 100% oxygen but also with positive pressure. So if the patient's not breathing on their own, or they need assistance in breathing, we can assist them with this bag by actually forcing air in as opposed to just having them breathe oxygen that we're kind of putting near their face. This actually helps us deliver the oxygen with pressure into the body to help preoxygenate them or help to oxygenate them. It can also help to ventilate, which is how you get CO₂ off. So we have our nasal cannula, mask, non-rebreather, bag valve mask, okay?

CHAPTER 4

If we're having trouble getting air in… So say on our airway assessment, we noticed there was a blockage in the airway. We can't get air in through the nose or through the mouth. There's trouble getting air in. There's a few things we can do. There are a couple of maneuvers you can try like lifting the patient's jaw. And if you're not worried about a C-spine injury, sort of repositioning their head. But we also have some other tools we can use to help get air in through the airway. Some of those are nasal airways and oral airways. So a Nasal airway is basically just a rubber tube that gets inserted in through the nostril, and it goes all the way back, kind of behind the pallet, and it's closer to the back of the tongue. So it helps get air past any obstruction that might be in the nose or the mouth. And so it's going to sit in the body kind of like this. It'll go in through the nose, past the tongue, and help deliver air down towards the lower airway. There's also oral airways, or oropharyngeal airways. And these are airways you can stick in through the mouth, again, to help keep the airway from closing, or keep it from obstructing. So if the patient's unconscious, they're unresponsive, maybe the soft tissue in their mouth - their tongue is falling back and blocking the airway, by sticking this in, you can keep the tongue off the back of the airway and help oxygen pass by. So if the patient's unresponsive, they're not keeping their airway open, you can put one of these the nasal airway or the oral airway in while you're bagging to help get air into the body. So these kind of help stent open your airway in different ways. In trauma, there's some special considerations we need to think about. So for a nasal airway for instance, if the patient has evidence of facial fracture or facial deformity, you want to shy away from using a nasal airway because there's really important stuff in the back of the skull. And if there's a break in the skull, and we insert this airway, it could wind up in a place that it's not supposed to be. So it could wind up in the brain if there's a basilar skull fracture. So if there's evidence of skull fracture or fracture in the facial bones, you may want to shy away from doing this. So the oral airways also have some special considerations. For instance if the patient is awake, if we stick this into the patient's throat, they may have a gag reflex. They may vomit, which would introduce other risks to the airway, possible vomit in the airway, which we don't want. So generally, we tend to use the oral airways in people who have a lower level of consciousness or are unresponsive. Okay? So we can use these to help if they're unresponsive or if they don't have a gag reflex. We can use this to help if they don't have any evidence of facial fractures to help kind of stent the airway open.

CHAPTER 5

We also have some tools we can use to help alleviate obstruction such as suction. So, when we talked about assessment, one of the things you're looking for is fluid in the airway whether it's blood, vomit, those are all very common in patients who come in with trauma. So we have several different methods we can use to suction some of that fluid out. One of the most commonly used tools is what we call a Yankauer catheter, or a rigid catheter that we hook up to suction tubing and eventually to a suction canister that will connect to the wall. And we actually have a few set up at the back of the bed there that are hooked up to suction that comes out of the wall. So the suction from the wall goes to the tank. The tube then goes from the tank to the Yankauer catheter, and we can suction out blood, vomit from the airway. They make large bore catheters that can suck out big chunks of vomit if this isn't enough. They also make finer catheters if you need to suction within an ET tube or within a tracheostomy tube. They make different kinds, and we stock them all here.

CHAPTER 6

If, between the nasal airways, the oral airways, and suctioning we're not able to alleviate the obstruction, or we're not able to keep the patient's airway open, or if the patient has depressed mental status, they're not able to protect their own airway, then we may need to do what we call an invasive airway, which is where we actually sort of take control of the airway or use a device to stick in the airway to ensure that they continue to breathe. There's really four reasons why we do that, whether they can't oxygenate, they can't ventilate, which is getting CO₂ out, they can't protect their airway, so they're vomiting a ton, there's a ton of blood, or just their presumed clinical course. So maybe the patient is super agitated because they have a bad head injury and they don't know what's going on and they're flailing. We need to sedate them. And if we sedate them, we may need to protect their airway. Or if we know they're going to the operating room, and then they're going to need to be intubated, that's another indication to kind of do one of these more invasive measures. So within our airway cart, we've got a lot of different tools we can use to take over the patient's airway and help keep it open for them and help breathe for them. So say your positive pressure bag valve isn't working, or you need a more permanent solution, some of the more simple devices are not quite as invasive are what we call the supraglottic devices, or extraglottic devices. There's a bunch of different types. We stock a couple here. This one is called a King airway, which is basically a plastic tube that we stick in through the mouth. And it basically rests in the back of the throat right above the trachea, right above where the airway opens. And it helps deliver air, oxygen, right to the opening of that airway. So it goes in past your mouth, past your tongue, and helps deliver air right to the airway. Okay? It doesn't actually go in the airway. It just sort of sits above it. And so this is one method you can do. The nice part about the supraglottic airways is you can get them in fast. You don't need to make sure they're placed exactly correctly. The way they're designed, the way they're shaped, will have them sit right over that airway, and so it's an easy device to insert. So if you're in an emergency, you need to get an airway fast, You can throw these in. A lot of prehospital providers, EMS providers, will use these supraglottic devices because they're fast and they're effective. Ideally, if the patient is super sick, and we need to take their airway for one of those four reasons - they're not oxygenating, they're not ventilating, they're not protecting their airway, or their presumed clinical course mandates that we protect their airway. Ideally, we have a more - what we call definitive airway. Or more assured protection of the airway. And for that we're actually sticking a device through the mouth or through the nose, down into the actual trachea itself, or into the windpipe itself. And that is considered more secure and more definitive than say one of these supraglottic devices. And so in our carts, we also stock an array of tools we can use to help get that tube into the actual airway. And I've sort of got some of them displayed here. One of the most basic tools we use is called the laryngoscope. And that's what these are here. It comes with a handle and it comes with a blade. We use the blade to stick into the mouth to move the soft tissue out of the way so that we can see the airway and then stick the tube in. They come in a bunch of different sizes and shapes. And we use them for different purposes. Some of them are curved like this, which helps you kind of get around the tongue, and some are more flat like this, which helps you kind of lift some of the specific structures out of the way. And you use different ones for different scenarios, Dr. Pratt, in a different video, is going to talk about, why we choose one over the other, but we stock both. There are also additional adjuncts we use. So these are direct where you are looking with your own eyes straight into the airway. Recently, they developed a lot of video technology, fiber-optic technology, that allows us to use some more sophisticated measures to get that tube in. So we have a couple of different video assisted options in our carts, and they come with a stand that stands by the bed with a video screen. And basically the video component hooks into these blades, and a camera sticks at the end of this blade. So as you insert it into the mouth, you can look at the TV screen and see exactly what the tip of the blade is seeing. So you can get a better look at the airway through the video screen and on the TV than you might be able to get just looking direct. So we have a couple of different video options, and the blades are shaped for different reasons again. This one is one of the curved blades similar to what you saw on the direct laryngoscope. And then we also have what's called a hyper-curved blade or a D-blade. And if you think about some of the anatomy of the throat, one of the hardest things about intubating is getting past the tongue. So if the patient's lying flat, the tongue falls back. You need something that's going to curve around that tongue and help lift it up. And so that's what this blade does is it's got a really sharp curve to it. So you can actually get around the tongue and lift the tongue up out of the way without having to move the head around so much. And so in trauma patients who are often immobilized, they have a C-collar in place, and we can't manipulate the neck too much. The hyper-curved blade is a good option because it requires less movement of the neck to get past the tongue. So we've got a couple of those different video options with the hyper-curved blade that we can use to help take the airway if we need to. And the goal is to get in this plastic tube, which is called an endotracheal tube or an ET tube. And this basically goes in through the mouth or through the nose into the actual windpipe. And it's got a balloon at the end to help block anything else from going past it. So vomit, blood. This helps protect the airway - or anything getting into the airway. And it also allows us to deliver oxygen in and CO₂ out. They also come in a bunch of different sizes depending on the size of the person. And so you have to sort of select the tube according to body size. Or in the setting of trauma, if you see evidence of swelling or you're worried about swelling, you can choose a much smaller tube to get through that smaller hole. So if there's a lot of swelling around the airway, and the airway is really cinched up, you can select a much smaller tube to get through that smaller opening. So they come in all shapes and sizes. We stock all of those in our carts as well. So we've got all the way from like pediatric sizes to adult sizes and kind of everything in-between.

CHAPTER 7

If we are not able to visualize the airway well using the direct or with a video, which is usually our first line, and the hyper-curved blade, which helps you get past the tongue. If those methods aren't working or they're unsuccessful we have some rescue devices that we can use in case the airway goes wrong, and we keep those in our carts as well. One of them is what call a bougie, which is this sort of plastic flexible rod. And it basically helps us maneuver in the airway if the tube itself is not working. So if we can't get the tube in the right position, or the opening is small, or we can't get a great view, what you can do with the bougie is - it's sort of malleable, it's bendable, and you can stick this in instead of the tube and get it through maybe a smaller airway opening or bend it around a corner that you can't get the tube around. And then because it's so narrow, you can actually - once this bougie is in the airway, slide one of the endotracheal tubes over it and have it guide it into the actual trachea. So this is a tool we use very often. It can be extremely helpful in trauma, again, where you have less mobility of the neck and you may not be able to get a good view up front. If that fails or if there's signs, especially in trauma patients there's a lot of facial fractures. The anatomy is distorted. We're worried about the airway being narrowed due to swelling, or if the airway is swollen from like smoke inhalation, we can run into a lot more difficult airways, narrow airways, or where the anatomy is rough. And in which case we have some fiber-optic cameras that we stock in the emergency department that we can stick in through the nose or through the mouth to help get a good view of the airway and also use this camera to then guide the tube into the correct place. So you can put the T-tube over this camera, insert the camera in, and find the right spot. And then once the camera's in the right spot, slide the tube over it and get it in the right place. So, there are a lot of tools at our disposal that we can use to help control the patient's airway. And we have them all stocked kind of bedside, which Dr. Pratt will take you through a little bit later.

CHAPTER 8

As we escalate through more and more difficult airways, all of our additional equipment, there are cases where we aren't able to get a tube in the airway through the mouth or through the nose. When that happens, sometimes we have to go surgically in through the front of the neck. So when we talked about the assessment, we looked in the nose, we looked in the mouth. We also talked about airway structures being here in the neck, in the windpipe. So if we can't get the tube from up top through the nose or the mouth, sometimes we have to cut into the neck to make an opening to then insert a tube into the airway, right? Because the thing that's going to kill the patient the fastest is not being able to get air in and out. And so to do that, we do what's called a cricothyrotomy, which is where we cut a hole in one of the membranes in the neck, all right? In-between the cricoid cartilage and the thyroid cartilage. And so in our carts, we also stock what we call a cric tray, or a cricothyrotomy tray. And it comes with some very basic equipment. It comes with a knife to make the initial incision in the skin, and also an incision in the membrane. A lot of times it will come with a hook to help keep the airway open. It'll come with something to make the hole bigger so that we can fit a tube in there. It's called a dilator. Okay? And it will also come with some additional tools for managing bleeding and everything when you're cutting into the airway. If a cric trays isn't available, and we try to have one available in each of our bays just because you never know when you're going to need it. So we like to have it all right by the bed. This cric tray actually sits right here at the head of the bed in case we need it. But, for in some instances, if you're not in the hospital setting, or your hospital doesn't make pre-made cric trays, basically all you need is to carry a scalpel with you. And we have those at bedside as well. And you can make the incision with a scalpel, hold the position - the hole open with your finger, insert that same bougie into the airway to hold the space, and then run a tube over that bougie into the airway. So there are other ways to do it. Ideally, you would do it with a cric tray, but if your facility doesn't stock it or it's not available, you can do it with a scalpel, your finger, a bougie, and a tube. Easy enough.

CHAPTER 9

But that's a quick rundown of some of the basics we keep at bedside. So if I'm managing the airway at the head of the bed here, the patient's lying here, I have everything at my disposal within arm's reach or where one of my colleagues can easily pass it to me. And Dr. Pratt will talk a little bit more about how our bay is oriented, and why it's designed that way, and sort of how we chose what to put in the carts. But that's a brief outline of some of the equipment that we use.