Basic Artificial Airway VS Intubation

[ForNever510]

Hi guys, i'm new EMT student, and i had a quick question.

When is it appropriate to Intubate a patient with an Advanced airway (PtL, ETC,LMA) as opposed to the OPA? Arn't the indications the same?

Help me out please

 

[spinnakr]

This might at least partially depend on protocol. For example: according to the Ohio Revised Code, Ohio EMT-B's may intubate if the patient is apneic AND pulseless, but may place an OPA/NPA if the patient is "merely" apneic.

Other than that, though, it's oftentimes a matter of what's in the best interest of the patient. Example: it makes more sense to tube a patient whose airway would otherwise be in need of constant suction than it would to tube a patient with a clear, unobstructed airway who just needed positioning but requires aggressive management elsewhere.

Although admittedly I'm having a hard time thinking of a specific example of the latter case. Regardless, intubation is much more aggressive than an OPA or NPA, and your patient will experience some discomfort from it (and it isn't pleasant; I've experienced the aftermath firsthand!).

 

[MrBrown]

Any airway adjunct is indicated for a patient who is unable to maintain patency or adequacy of their own airway provided they will accept an adjunct.

What we want to do is 1) keep secretions and foreign thingies out and 2) get air in.

It is important to remember to start small and work your way up.

Most basic adjunct to airway control is head tilt chin lift and the jaw thrust; for some such as postictal seizure or syncope patients who are not deeply unconscious enough to have lost a gag reflex this will probably suffice.

An oropharyngeal or nasopharyngeal airway are the next step up. They both sit in the oropharynx about equal with the bottom of your earlobe - so not very deep into the trachea; this is important as they provide limited (read: no) protection against aspiration and simply keep the tongue out of trachea. Nasopharyngeal airways are used in patients who won't accept an OPA due to trismus (clenched teeth) or gag reflex.

Supraglottic airways like the LMA and King-LT are a meeting point between basic airway adjuncts and intubation. They sit above (supra) to the glottis (vocal cords) in the laryngopharynx, so are often used by crews unable to intubate as they are simple to insert and quite safe because there is no risk of esophageal placement. Despite this they do not totally protect the airway against aspirated material as they do not isolate the trachea; personally I don't like the LMA and believe the King-LT is much better at sealing the esophagus but I would like to see some research on that.

Intubation is the gold standard of airway care (hush you badly designed inflammatory research papers!) as it isolates the trachea.

Speaking generally you place an OPA before an LMA and, maybe, an LMA before intubating the patient.

If you can maintain a good patent airway with just an OPA/NPA and/or bagging / suctioning then there is no reason to move to a more invasive airway however it is appropriate to place a supraglottic airway in a patient who requires more aggressive airway care; for example cardiac arrest or an asthma code (note the very high airway pressure may make getting a seal with the LMA difficult).

Please remember when bagging a patient, 8-10 breaths/min is sufficient (except in life threatening asthma, 6 breaths a minute here (not 5, not 7, but 6) to prevent dynamic hyperinflation and cardiac arrest) just because you squeeze the bag more doesn't mean it helps! (in fact it does the opposite, hyperoxemia at the tissue level causes the precapillary sphincters in the aterioles to constrict which limits blood flow and oxygen delivery)

 

[wyoskibum]

why not do both?

When is it appropriate to Intubate a patient with an Advanced airway (PtL, ETC,LMA) as opposed to the OPA? Arn't the indications the same?

If the patient is unresponsive and without a gag reflex:

1. Place the OPA first as it is quick and easy.
2. Continue your assessment and take care any other life threats
3. Place the advanced airway

 

[spinnakr]

Well if you're going to intubate (without succinylcholine or something else to suppress the gag reflex) you HAVE to place an OPA before intubation to check for a gag reflex, but that's a different story entirely.

Don't assume that, because a patient needs SOME airway management, that the patient needs to be intubated. If you intubate every patient that needs an adjunct, not only will you get a lot of weird looks, but you will have a lot of patients who have an unnecessarily sore throat to add on top of their other problems. Not to mention the fact that you (in this case) risk the patient waking up with a tube and self-extubating, which can be both an extremely painful and harmful process.

Plus, intubating takes TIME, and if it your patient isn't going to require advanced airway management, then don't bother.

Plus, an OPA or NPA can be good "preventative medicine" in some very limited circumstances, when the airway is currently patent but you are concerned that it might not stay that way. Example, thanks to MrBrown - if you have a post-ictal state and a patent airway, you might still place an adjunct. In this case I would personally opt for an NPA, since it's less sensitive to the gag reflex. But I would NOT intubate the patient in this case!

 

[ForNever510]

Thank you all for your Help/Suggestions. They've really been helpful and informative, especially yours Mr Brown, you've really expanded my understanding and i thank you for being so informative !

I guess what i'm trying to do (because this is always how my thinking is) i'm trying to generalize when to used an Advanced airway, as opposed to a Basic Airway, and WHY. I always like to rid myself of the grey area's and have a genreral RULE to things

So all in all it sounds like:

Basic Airways are used primarily for people who arn't in DESPERATE need of aggressive Airway management, and if the OPA or NPA sustains their patentcy and the patient isn't Vomiting, or in Cardiac arrest, or have Asthma or anything in need of MORE direct measures of delivering Oxygen as the body needs, then the OPA or NPA is adequate...Right?


And as for WHEN to use an Advanced Airway: Sounds like it's used for patients who are in SEVERE need of Aggressive measures to get Oxygen Directly into the Trachea and into the body, such as patients, who are pulseless and apneic, patients in cardiac arrest, patients who are asthmatic (but unconscious) and such.

Am i right?


And also Does the NPA keep the tongue out of the throat? i thought only the OPA did.

 

[Shishkabob]

If you have an OPA in, and are bagging without effort and with good compliance, then there is little chance at needing a more advanced airway (certain circumstances exempted)

If you don't have good compliance, and they are getting hard to bag, you might need to do a more advanced airway (Might, because it might be some other reason that it's hard to bag)

If they have burns to their face, they might need to be RSI'd / Intubated as there will probably be laryngeal edema and you want to get a tube in before the trachea closes off and all that you're left with is a surgical airway.

Same goes with anaphalyxis. If it's so far along that they are having difficulty breathing, get a tube in.


With asthma, or other forms of respiratory distress... if they start progressing to respiratory failure you will probably need a tube in.


An advanced airway, be it an ETT or a rescue airway such as the King or Combi, can be put in a CPR because you will no longer have to stop compressions to deliver breaths.





I'm surprised Vent hasn't come in yet... she'll be able to better explain the times you will want a tube in as opposed to a basic adjunct.

 

[usalsfyre]

There are two main reasons to place an endotracheal tube..

...#1 is to protect the airway of a comatose patient. #2 is the initiation of mechanical mechnical ventilation for respiratory compromise. Each has different benchmarks for intubation. Most importantly though, unless you are 100% comfortable with your ability to correctly place an artificial airway, it's best not to attempt it.