Hello, my name is Dr. Peter Acker. I'm an Assistant Professor of Emergency Medicine at Stanford University and today I'm joined by Dr. Jennifer Newberry, also a Clinical Professor of Emergency Medicine at Stanford University. Hello, Dr. Acker. Hey, today we are going to be discussing part one of treating the severely dyspneic patient. Some patient’s clinical status will require support beyond that offered by a nasal cannula, face mask oxygen, high flow nasal cannula, or non-invasive positive-pressure ventilation to ensure they maintain an open airway and adequate oxygenation and ventilation like the patient in this video. Dr. Newbury, could you describe your assessment of this patient's airway and respiratory status and what interventions you feel she would benefit from? This patient is taking rapid, shallow breaths and is working hard to do so as noted by her suprasternal retractions. However, the sounds she's making suggests her upper airways obstructed, preventing her from taking a full breath. She would benefit from a maneuver to open her airway and likely bag mask ventilation to support her breathing. Absolutely, many critically ill patients with severe respiratory distress or declining mental status lose the ability to maintain an open airway and breathe adequately. As care providers, we must be prepared to rapidly intervene to help them maintain an open airway and provide effective manual ventilation and oxygenation until further support like intubation and placement on a ventilator is possible. In this lecture, we'll discuss some of the tools available to help providers perform these tasks successfully. First, we'll discuss how to maintain an open airway using airway adjuncts, focusing on nasopharyngeal airways and oropharyngeal airways. Then we'll discuss when and how to perform effective bag mask ventilation. Let's re-examine this patient. Dr. Newberry, you had mentioned she would benefit from an airway opening maneuver. How would you accomplish this? For non-trauma patients, the most effective technique would be a jaw thrust, which helps hold the jaw and tongue forward, opening the airway. Let's see what impact that would have. Can you describe what you see here? Yes. We see the provider performing a jaw thrust and immediately you see fogging in the mask, indicating improved air movement and a decrease in the patient's work of breathing. Yeah, she does appear to be breathing much more comfortably. Now that the airway is open, the provider must move quickly to support the patient's breathing. Likely with bag mask ventilation, however, the provider will require the use of their hands to perform these tasks. Fortunately, we have tools like airway adjuncts to help in these scenarios. Let's talk about those now. Airway adjuncts are tools designed to prop open the upper airway to allow air passage in and out of the lungs in patients who cannot do this for themselves because they're too sick or unconscious. Because these tools ensure a patent upper airway, they allow bag mask ventilation to be performed more effectively as well. We'll be discussing two airway adjuncts, both pictured here. Nasopharyngeal airways, which are placed through the nose, and oropharyngeal airways which are placed in through the mouth. We’ll discuss the indications and sizing for both. The placement technique will be discussed further in a separate lecture. Airway adjunct should be used in all patients who are unable to maintain an open airway independently, like the patient we saw on the video. This may be due to fatigue from prolonged respiratory distress, altered mental status, intoxication, head injury, stroke, or one of many other medical conditions. They should also be used for all patients receiving bag mask ventilation. Let's focus first on nasopharyngeal airways. Dr. Newberry, what are these and what types of patients are they best suited for? Nasopharyngeal airways are soft rubber tubes placed into a patient's nose, creating a patent passage for air to travel between the lungs and the nose. They are best suited for patients with a depressed level of consciousness but who continue to respond to some stimulus. Altered but somewhat responsive patients with the ability to cough or gag will not tolerate an oral pharyngeal airway, so a nasopharyngeal airway is the best choice for them. Excellent. Could you compare these to oropharyngeal airways? Oropharyngeal airwaves are curved, rigid plastic devices with a central air canal placed into a patient's mouth. They're designed to hold the tongue away from the posterior pharyngeal wall to ensure an open path for the air to travel. Because having an item in contact with the posterior pharynx is very irritating to a responsive patient, these are best suited for patients who are unconscious and lack a cough or gag reflex. Here's a video of a patient receiving an oral pharyngeal airway. Could you describe her response and how this situation could be remedied? Yes. This patient does appear to have a depressed level of consciousness. However, she is coughing and gagging when the oropharyngeal airway is placed, meaning she's too alert to tolerate that tool and it shouldn't be placed. She would likely tolerate a nasopharyngeal airway much better and one of these should be placed instead. Got it. Now that we're familiar with means of keeping the airway open, let's discuss bag mask ventilation. Dr. Newberry, what is bag mask ventilation? Bag mask ventilation is a technique by which we can manually provide positive pressure to support the oxygenation and ventilation of patients who were breeding inadequately. This is truly a life-saving procedure. Fantastic. In the next few minutes, we'll go through the indications for bag mask ventilation, how to select the appropriately sized equipment, and set it up. The details of performing the procedure will be discussed in another lecture. So Dr. Newberry, what are some scenarios in which bag mask ventilation is indicated? First, if a patient is apneic, or not breathing at all, they require bag mask ventilation to provide temporary oxygenation and ventilation. Second, if a patient is breathing but their breathing is not effective to provide the oxygenation and ventilation they require, bag mask ventilation can help augment their efforts. How would you identify a patient who's breathing is ineffective? Good question. Patients taking slow and shallow breaths, those with heavily labored breathing, or patients with very low oxygen saturations would all raise my concern that they're breathing was ineffective and would benefit from the support through bag mask ventilation. How would you describe this patient's breathing? She appears to be semi-conscious, taking slow, shallow breaths. Do you think she's breathing effectively? No, I would be concerned that her slow, shallow breaths would not provide adequate oxygenation and ventilation, and she requires additional support. So how would you intervene? I would immediately perform an airway opening maneuver, place an airway adjunct, and begin bag mask ventilation. Excellent. So there are a few sizes of bags and masks to choose from. How do you select the correct size? Providers should use the large size bag for all patients above eight years of age. All children between 1 and 8 years can use a medium bag and the small bag should be used on patients from neonates up to one year. How about mask selection? An appropriate mask is one that when placed on the patient's face, fully covers the patient's nose and mouth but does not cover the patient's eyes and does not extend beyond the chin. Excellent. After correctly selecting the right size, how do you set up the device? To care for patients suspected of having COVID-19, a few special steps are required. The first of these steps is to attach a PEEP valve, if available. PEEP valves allow you to provide PEEP while using bag valve mask, improving oxygenation, especially in those with COVID-19. Twist the valve to set the PEEP and start with at least five of PEEP. The next essential step is to attach a viral filter. The viral filter minimizes the risk of spread of viral particles into the air during bag mask ventilation. This procedures should only be performed with the appropriate PPE, which is covered extensively in lecture two of this series. Once the PEEP valve and the viral filter are attached, the setup should look about like this. The mask is then attached and the device is then connected to the oxygen source. So when you're performing bag mask ventilation, how do you know you're doing it effectively? Well, you'll see visible chest rise and fall, suggesting that you're providing reasonable tidal volumes. You should also hope to see previously noted abnormalities in pulse, oxygen saturation, and skin color improve. What would you do if you didn't see those reassuring signs? Well, if you do not note chest rise and fall or improvement in the previously mentioned clinical indicators, you can one, ensure the mass size fits well, two, look and listen for an air leak around the mask and change the mask position and your grip to fix any noted leaks, three, repeat and accentuate the jaw thrust and head tilt to ensure the airway is open, and finally, if you weren't already using one, place an airway adjunct. Great. Those are some excellent tips to help troubleshoot any challenges encountered during this critical procedure. Alright, having discussed a lot of important information, let's summarize the key points for each of these essential elements of emergency care. So airway adjuncts are tools designed to prop open the upper airway to allow for air passage in and out of the lungs in patients who can't do this for themselves. Oropharyngeal airways are best suited for patients who are unconscious and lack a cough or gag reflex. While nasopharyngeal airways are appropriate for patients with a depressed level of consciousness but who continue to respond to some stimulus. Bag mask ventilation is a technique by which we can manually provide positive pressure to support the oxygenation and ventilation of patients who are breathing inadequately. PEEP valves should be used if available to promote oxygenation. Viral filters paired with appropriate PPE should be used if possible to minimize risk of infection to the staff. And bag mask ventilation can be performed by either one or two providers and should be done while using an airway adjunct whenever possible. Fantastic. Dr. Newberry, thank you so much for your time and expertise. And to all of you watching, thank you for your hard work, your dedication, and the great care you're providing your patients. We hope these skills will be helpful.
