Approach To Airway And Ventilation Management

Airway soiling

For gross soiling, it is often better to use gravity. Turn patients on their side and remove excess fluid, water, blood and vomit. The Yankeur suction catheter is good for fluid and blood but will often get obstructed with vomit / blood clots. The soft Y-Suction catheters are good for thin fluids, can suction down OPA, NPA, and down both the airway and gastric ports of i-Gel®.

Ventilation

ARC guidelines state “ventilation volume should not exceed any more than visible chest rise and fall.” The Resuscitation Academy suggests that during practice using the 3-finger squeeze technique is an effective way to achieve adequate ventilation volume. Lower tidal volumes during resuscitation do not appear to significantly affect the arterial partial pressure of oxygen (PaO2). Excessive ventilation volumes have proven negative effects of reducing cardiac output and increasing the risk of gastric insufflation. The infant Bag-Valve-Mask (BVM) resuscitator in the maternity kit is designed for children <6 months old. The adult BVM is used for all patients from 6> months of age to adult. Take care when ventilating infants and children with the adult BVM.

Ventilation and Airway Adjuncts

In adults, evidence suggests that in the very first period following a cardiac arrest (apart from a hypoxic arrest secondary to a respiratory or obstructive cause) passive ventilation (gas exchange through the mechanics of chest compression) is acceptable while commencement of CPR is undertaken, and an airway is secured. It is during this phase that we place greater emphasis on the value of compressions over ventilations. It would be reasonable to expect an AED analysis, defibrillation and a 2-minute cycle all commence while an i-Gel® is inserted for adult patients. The i-Gel® SGA has a recorded average of 11 seconds to insert and a 90% first-time insertion success rate. Because of the quick and easy nature of the i-Gel®, and the fact that it can be inserted while compressions continue, it is reasonable to insert this adjunct in cardiac arrest in the first instance (instead of an OPA or NPA) unless no one qualified to insert an i-Gel® is on site.

i-Gel®

A majority of SAAS volunteer respondents to the post i-Gel® use survey reported successfully insertion on the first attempt. Quick insertion can be achieved especially by those AOs who frequently practice the technique on airway manikins. The i-Gel® device ensures all ventilations are performed through an advanced airway (reducing the risk of gastric insufflation). Once secured the i-gel can reduce the cognitive load of the clinician ventilating. Remember in paediatrics, ventilate ASAP due to the likelihood of hypoxia being a reversible cause. This will be discussed further in Adult vs. Child resuscitation choreography later in this module.

Covid-19 CPP 54 indicates best practice is to place the HME filter on the i- Gel® and cover the Gastric port with tape prior to insertion to reduce the chance airborne particle from the respiratory tract entering the environment. When possible, placing the patient’s head in the “sniffing the morning air” position increases the chance of successful insertion. The device must be adequately lubricated on all sides to ensure a greater chance of successful insertion. While transpore tape can be used to secure the device, if the patient has soiling on the face (e.g. vomit, blood) or has facial hair, using a traditional cotton tie may provide better securing of the device. The i-Gel® Clinical Practice Procedure has been updated to reflect that ICPs and Paramedics are now using the device. Note: While AR/AOs may suction via the ventilation and gastric channels of the i-Gel® device using a standard soft Y suction catheter, ONLY ICP/Paramedics may use the longer orogastric tube and 50ml syringe. Likewise only ICP/Paramedics are authorised to attach the end-tidal (ETC02) device to the i-Gel®.

Note This video includes a “simulated” cardiac arrest scenario using a live actor patient. During a real cardiac arrest, quality chest compressions expected of SAAS crews would be of the correct depth (1/3 of chest depth), rate (110 per minute) and recoil (complete release of the chest between each compression) Both the airway channel and gastric channel can be suctioned as required. Size 10FG soft Y suction catheter is the most common one to use. Remember to lubricate the y-suction catheter before insertion into the gastric channel then suction as required. The suction catheter can remain insitu. If airway soiling is significant remove the i-Gel® to clear the airway.

i-Gel® Training Video [08:00 minutes] https://player.vimeo.com/video/216935522

Clinical Practice Procedure - i-Gel® Supraglottic Airway [CPPRO-020]

Adult

During adult BLS CPR - Ventilate initially with Bag-Valve-Mask (BVM) using two-person BVM technique without an OPA/NPA. As soon as possible (any time after first AED analysis and shock/no-shock advice) insert an i-Gel® SGA airway. Don’t delay by inserting an OPA/NPA first. If the i-Gel® cannot be inserted after 2 attempts use an OPA/NPA.

Paediatric

During Paediatric BLS CPR - Ventilate with Bag-Valve-Mask (BVM) using two-person BVM technique with an OPA or NPA. The insertion of the i-Gel® SGA airway is delayed until further resources (beyond the initial primary 2-person crew) become available on site to assist (e.g. another SAAS responder/crew, other emergency services or suitable first aider capable of assisting with high-performance CPR). This ensures quality compressions and ventilations can occur during the preparation and insertion attempt of the i-Gel®.