Page 144 - JSOM Fall 2020

TABLE 1 TCCC Airway Management Adjuncts (Consider Basic Adjuncts First)
Skill Level
Pharm Reqs to (NM: Non-Medic;
Device/Techniques Pros Cons Maintain (0/+/++) M: Medic)
Head-tilt/chin-lift Easy Requires hands-on continuously 0 NM
Recovery position Easy; tactically feasible May limit patient assessment or 0 NM
(TCCC/MASCAL) ongoing management
Sit up/lean forward Easy and practical (may be May indicate impending airway 0 NM
position of comfort) loss
Nasopharyngeal airway (NPA) Easy Risk of nosebleeds with placement 0 NM
Oropharyngeal airway (OPA) Easy Not tolerated in conscious patient + NM
Supraglottic airway (SGA) Easy Not tolerated in conscious patient ++ M
Oral endotracheal tube (ETT) Familiar to trained Skill sustainment challenging, ++ M+
airway providers; Definitive; No requires neuromuscular blockade
surgical incision needed (rapid-sequence intubation) for
best success, may require suction
to visualize vocal cords, requires
sedation (potential limitation in
PFC)
Cricothyrotomy (Cric) Definitive; Better tolerated Invasive procedure, high failure + M
than oropharyngeal (OP), rate in some studies 4,5
SGA, or ETT. May require
less sedation to sustain
once in place
For Pharm Reqs: Maintain: 0 = no additional medications; + = some or intermittent dosing medications required; ++ = continuous or multiple
medications required.

The patient’s condition dictates the available time for a pro- SUCTION
vider to consider all items on this checklist. A rapidly deterio- • Minimum: Improvised suction (i.e., syringe + nasopha-
rating patient with airway disruption or compromise will need ryngeal airway [NPA]) and patient positioning if not
the airway procedure first and follow-on considerations later. contraindicated
If a patient can be more appropriately classified as semi-ur- • Better: Manual suction bulb with adapter
gent (e.g., worsening respiratory status due to an underlying • Best: Powered commercial suction with oral tip and in-
pulmonary cause) the provider will have more time to con- line endotracheal tube suction adapter
sider the algorithm and prepare. Logistic considerations, and
sometimes considerable time constraints, will affect prepara- Suction should be available when establishing and maintaining
tion for advanced procedures. Recommendations follow the an airway to remove excessive secretions or blood. It is partic-
“minimum, better, best” format. ularly important to utilize suction to facilitate view of the vo-
cal cords during endotracheal intubation. In addition, suction
MACHINE should be available for routine patient care and maintenance
(Equipment required post-intubation) requirement for any intubated patients. Suction should be uti-
• Minimum: Bag-valve-mask (BVM) with positive end- lized as needed to remove secretions, mucous or blood from
expiratory pressure (PEEP) valve the airway device or oropharynx. In the event of high airway
• Better: Automated portable ventilator (preferably with pressures, suction may be used to remove mucus/mucus plugs
PEEP); oxygen concentrator or to clear obstructions. In the case of thick secretions, a saline
• Best: Full-feature portable ventilator (e.g., several venti- flush of 1–2 mL followed by in-line suctioning of the endotra-
latory modes, PEEP); supplemental oxygen if available cheal tube may be useful.
Note: During in-line suctioning of tubes, the suction should
Managing ventilators or advanced equipment unfamiliar only be applied when withdrawing the catheter and not upon
to a provider presents challenges. Initiate telemedicine consul- initial insertion.
tation for best guidance.
MONITOR
PEEP is important for prolonged ventilation. PEEP is the pres- (Monitoring and telemedicine support)
sure in the airway at the end of the expiratory phase which • Minimum: Pulse oximeter (SpO ), assistant to monitor
prevents the alveoli of the lung from completely collapsing. In respirations and record manual vital signs. Trending vital
2
a spontaneously breathing person, this pressure is maintained signs documentation. PFC flowsheet is recommended.
by closing the glottis, clearing the throat, coughing, sighing, Refer to PFC Documentation CPG. Voice or data con-
7
etc. With an invasive airway, the glottis is bypassed with the nections to perform telemedicine communication
tube and “natural” PEEP is lost.
• Better: Portable Capnometry (ETCO )/capnography in
2
addition to SpO . Transmit photographs from smart-
PEEP should therefore be introduced into the ventilated pa- phones or personal devices to augment telemedicine
2
tient using a PEEP valve on the BVM or using the PEEP setting communications.
on a ventilator. When using BVM or ventilator, provide PEEP • Best: Automatic vital signs monitor with SpO , ETCO /
(recommended initial setting is 5cm H O). 6 2 2
2 waveform capnography, +/– electrocardiogram (ECG);
142 | JSOM Volume 20, Edition 3 / Fall 2020