Respiratory

Rapid Review

Pearls

Deep Dive

Rapid Review

• Background
  • Procedure that involves placing a tube through an incision in the cricothyroid membrane to establish a patent airway, typically during life threatening situations.
• Indications
  • Necessary when airway cannot be secured using nonsurgical methods (ex. Intubation, supraglottic); typically in the presence of severe facial trauma, swelling, or distorted anatomy. 
• Contraindications
  • Patients under the age of 12. No absolute contraindications for adults.
• Complications
  • Bleeding, thyroid injury, esophageal/mediastinal perforation, incorrect placement.

Pearls

Deep Dive

• The Sphincter Series: Emergent Cricothyrotomy (emDOCs)

Rapid Review

• Background
  • Continuous positive airway pressure (CPAP) is a noninvasive ventilatory modality that can deliver mechanically assisted breaths without the need for intubation/surgical airway. 
• Indications
  • Asthma, COPD, CHF (treatment of associated pulmonary edema), pneumonia.
• Contraindications
  • Respiratory arrest, uncooperative patients, risk of aspiration, burns/facial trauma.
• Complications
  • Decreased cardiac output, gastric distention, barotrauma

Pearls

• Medications, such as albuterol and ipratropium, can also be administered through CPAP
• Patients may need to be mildly sedated (ex. lorazepam), in order to tolerate the device

Deep Dive

• Non-invasive Ventilation (WikEM)

Rapid Review

• Background
  • Placement of an endotracheal tube using direct visualization for establishment of definitive airway.
• Indications
  • Failure to ventilate/oxygenate; inability to protect airway. May be placed in anticipation for future clinical courses (impending airway compromise, need for transport, etc.)
• Contraindications
  • No absolute contraindications. However, benefits/risks of intubation should be considered in parallel with other airway strategies (supraglottic airways, surgical airways, NIPPV)
• Complications
  • prolonged hypoxia, right main stem placement, esophageal placement.

Pearls

Deep Dive

• How To Intubate the Critically Ill Like a Boss (REBEL EM)

Rapid Review

Pearls

Deep Dive

Rapid Review

Pearls

Deep Dive

Rapid Review

• Background
  • Nasopharyngeal Airway (NPA) is a soft rubber/plastic airway adjunct passed through the nose and into the posterior pharynx,  assisting with oxygenation and ventilation.
  • Similar function to the oropharyngeal airway (OPA), but does not cause a gag reflex.
• Indications
  • Ideal for patients in need of oxygenation/ventilation who are awake or semiconscious w/ intact gag reflex.
• Contraindications
  • Signs of basilar skull fractures or trauma to the midface/nasopharynx
• Complications
  • Few complications. Most often damage to nasal mucosa. 
  • NPA’s that are too long for the patient may extend into the esophageal route and cause gastric distension. 
  • Few reported cases of NPA placement through basilar skull fractures into the brain.

Pearls

Deep Dive

• Nasopharyngeal Airway (PubMed)

Rapid Review

• Background
  • Airway adjunct used to open the oropharynx and prevent the tongue from blocking the epiglottitis; thus improving BVM ventilation
• Indications
  • Unresponsive patients w/o a gag reflex
• Contraindications
  • Conscious patients or those with intact gag reflex
• Complications
  • May induce vomiting, increasing the risk of aspiration. May also worsen airway obstruction if inappropriately sized.

Pearls

Deep Dive

• Oropharyngeal Airway (PubMed)

Rapid Review

• Background
  • Also known as “extraglottic airways”. These devices are inserted through the oropharynx to provide temporary airway ventilatory management, without passing the vocal cords. Common brands include the laryngeal mask airway (LMA), King Airway, and I-Gel.
• Indications
  • Commonly used as a rescue device after failed intubation attempts, but may also be useful as a conduit for intubation or first-line for prehospital cardiac arrest. 
• Contraindications
  • Gag reflex, spontaneous respirations, facial trauma
• Complications
  • Ineffective placement, aspiration of gastric contents, pharyngeal edema

Pearls

Deep Dive

• Supraglottic Airway Review (emDOCs)