Advanced Airways
Today we’re reviewing the use of Advanced Airways. When we should consider using an advanced airway, their advantages, which one we should use, and how we assess the patient before and after insertion will all be discussed in today’s Pass ACLS tip topic.
Placement of an advanced airway is not a priority when running a code. Insertion of an advanced airway can/should wait until an experienced provider with advanced airway skills arrives. Most patient’s airway can be adequately managed with manual maneuvers and insertion of a basic airway such as an OPA or NPA which are covered in other Pass ACLS Tip of the Day episodes.
Reviewing the cardiac arrest algorithm, you’ll see that “Consider Advanced Airway” is in the box after administration of epinephrine. For a patient with a shockable rhythm, this is after the second shock, at least two minutes into a code. For a non-shockable rhythm, such as PEA or Asystole, considering an advanced airway is still in the same box after administration of epi. For non-shockable rhythms, epi should be administered as soon an IV is established. In either case, doing good CPR including adequate ventilations with 100% oxygen, hooking up the monitor, and starting an IV so we can administer epi should all be done before worrying about inserting an advanced airway.
Types of Advanced Airways
While placement of an endotracheal (ET) tube is the gold standard of airway maintenance; there are other advanced airways that can be used including:
- a Laryngeal Mask Airway (LMA); and the
- Laryngeal Tube airway.
Advantages of an Advanced Airway
All three of these airways:
- protect the airway from aspiration;
- have a 15 mm universal adapter that attaches to a BVM or vent circuit; and
- allows for end tidal CO2 (ETCO2) monitoring.
Placement of an advanced airway makes it easier for staff that don’t bag patients that often to get good chest rise because we:
- are no longer required to maintain a good mask seal to the patient’s face;
- can use both hands to squeeze the bag; and
- the dead space of the nose, mouth, & pharynx is minimized – meaning more of what we squeeze out of the bag makes it into the trachea.
In cases where IV or IO access hasn’t been established but the patient has been intubated – the ET tube can be used as alternative route for some of our first-line medications such as epi, Narcan, and lidocaine. IO and ETT as alternative routes for medication administration is covered in another Pass ACLS tip of the day episode.
After an advanced airway is placed, we’ll change our CPR from “cycles” of 30 compressions & 2 breaths to continuous compressions and give 1 breath every 6 seconds to deliver approximately 10 breaths per minute. No longer pausing chest compressions to deliver breaths helps us achieve a chest compression fraction (CCF) greater than 80%.
Insertion of an Advanced Airway
Depending on the environment in which you work, as well as your level of licensure, some; all, or none of these devices may be options.
Some hospitals may restrict intubating to physicians and mid-level providers. Only experienced providers with training to insert an advanced airway and who are performing within their scope of practice should do so.
In some areas, insertion of a LMA or Laryngeal Tube Airway can be done with minimal training and is carried along with an AED by first responders for prehospital use. Paramedics are trained in Advanced Life Support and are able to intubate or perform emergency surgical airway procedures pre-hospital when their local protocols allow.
We should not interrupt chest compressions longer than 10 seconds to insert an advanced airway. It’s easy to lose track of time when your focus is concentrated on all the skills needed to intubate. If the person inserting an advanced airway asks for chest compressions to stop for an intubation attempt, the CPR coach or code scribe should speak up as we approach the 10 second mark.
Assessment & Monitoring
After insertion of an advanced airway we should assess for bi-lateral breath sounds and confirm placement with a secondary device. Most places use end-tidal capnography to confirm tube placement as well as a tool to assess the adequacy of CPR. When good CPR is being delivered, we should see a CO2 wave form above 10 mm Hg. ETCO2 monitoring can be done using any of the advanced airways, not only an ET tube. I go into more details on end-tidal capnography in another tip of the day episode.
We should not stop CPR to confirm ET tube placement via x ray. If we hear bi-lateral breath sounds and have a CO2 wave form; the ET tube is in the trachea.
If the patient had good bilateral breath sounds before being intubated, but now only has sounds on one side (usually the right), it’s likely the tube was inserted too far and is in the main stem bronchus. If this happens, the tube is in the trachea, it’s just in too far. After ensuring the cuff isn’t inflated, pull the tube back a few centimeters and reassess breath sounds. For most adults, a depth of 21-23 cm when measuring to the patient’s incisors will ensure the cuff is beyond the vocal cords and the tip is above the carina. The tube depth should be documented and double checked after we lift or move the patient.
