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. Today we are going to be going over the details of procedures used while treating the severely dyspneic patient. We’ll discuss the placement of two types of airway adjuncts, nasopharyngeal and oropharyngeal airways, as well as bag mask ventilation techniques. We'll start with airway adjuncts. Dr. Newberry, can you remind us what type of patient is most appropriate for each of these tools? Yes, nasopharyngeal airways are best suited for semi-conscious patients who are still somewhat responsive with a gag or cough reflex. Oropharyngeal airways are more irritating and thus are only appropriate for truly unresponsive patients. Thanks. Let's now go through the steps of placing a nasopharyngeal airway. There are a variety of sizes of nasopharyngeal airways. How do you pick the correct size for your patient? In order to select the correct size, pick one that reaches from the tip of the nose to the patient's ear lobe. Coat with lubricant, if available, or water prior to inserting. Once you've selected the correct size, can you describe the process and placing the nasopharyngeal airways? Absolutely. First, examine the patient and identify the larger nostril, then insert the lubricated airway into the larger nostril with the bevel facing the septum. Gently advance the airway. If you’re using the left nostril, insert until you meet resistance, then rotate 180 degrees to match the curve of the airway to the curve of the nasal passage. Continue until the wide flange rests against the nostril. If you meet significant resistance or obstruction, remove and insert into the other nostril. Here's a video demonstrating placement of a nasopharyngeal airway into the right nare. The provider first measures the airway noting it spans past the ear lobe and is thus too long. The provider then selects a shorter version, which measures correctly, and lubricates it. As you can see now, when the airway is placed into the right nare, in order to have the bevel facing the septum, it's oriented such that downward curve of the airway is directed towards the patient's feet. The airway is gently advanced until the flanges are flush with the rim of the nostrils. This video shows the technique for placement in the left nare. In this video, the provider has already selected the correct size airway and lubricated it. As was mentioned, when the airway’s placed into the left nare, in order to place a bevel towards the nasal septum, The airway must be oriented such that the downward curve of the airway is directed toward the top of the patients head initially. The provider gently inserts the airway until resistance is met and rotates 180 degrees before fully inserting it. Ok, now let's go through the steps of placing an oropharyngeal airway. First, can you tell us how to pick the correctly sized oral airway? Yes. The correct size oropharyngeal airway is one that reaches from the corner of the mouth to the angle of the mandible. If it's too short, it'll not be able to properly open the airway and if it's too long, it may cause damage to the upper airway structures. Excellent. Can you take us through the process of inserting an oropharyngeal airway? The first step is to open the patient's mouth. This is done using the scissor technique. While standing at the head of the patient, the provider crosses their thumb and second third fingers of the non-dominant hand. Placing on thumb and the patients lower teeth and the second or third fingers on the upper teeth, you then push in the opposite directions to open the mouth. While scissoring the mouth open with the non-dominant hand, the provider then holds the oropharyngeal airway in the dominant hand with the curve oriented towards the top of the patient's head. The provider inserts the airway with a tip facing the roof of the mouth and slides it in towards the back of the mouth until it reaches the roof of the mouth. Once the tip of the airway contacts the roof of the mouth, the airway must be rotated 180 degrees, flipping it over the tongue with the curve now oriented toward the patient's feet. Insert the airway until the flange rests on the patient's lips. Here's a video showing a provider going through the entire process of sizing and placing an oropharyngeal airway. The provider first attempts to size the airway. Both the first and second airways he chooses are too long as they span past the angle of the mandible. The provider then selects an appropriately sized oropharyngeal airway, opens the mouth using the scissors technique, and places the airway in the mouth facing towards the top of the head, rotating it 180 degrees once it touches the roof of the mouth, and advancing it until the flanges rest on the patient's lips. Now that we're familiar with airway adjunct placement, let's discuss bag mask ventilation. Dr. Newberry, can you remind us when 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 they're breathing is not effective to provide the oxygenation and ventilation they require, bag mask ventilation can help augment their efforts. Would you be able to go through the steps of performing bag mask ventilation? Certainly. Prior to beginning the actual procedure, if possible the provider should place an airway adjunct. The next step is to correctly place the face mask on the patient's face. Begin by sealing the top of the mask on the bridge of the patient's nose. Once this is done, lower the bottom portion of the mask onto the patient's chin. Keep the bag centered over the mask to avoid pulling the mask edges off the patient's face. At this point, the technique differs slightly depending on the number of providers available to perform the procedure, one provider or two. Let's go through the single provider technique first. Sounds good. In a setting where a single provider’s performing bag mask ventilation, after placing the mask on the patient's face, the provider must grip the mask to create a gapless seal between the mask and the patient's face while also opening the airway. To accomplish this, the provider places the third, fourth, and fifth digits of their non-dominant hand behind the angle of the patient's mandible. These fingers perform a jaw thrust, opening the patient's airway. The first and second digits form a ring around the top of the mask, providing pressure to create a good mask seal. Once a good seal’s created, a head tilt can be performed help ensure the airway’s open. This video demonstrates the full procedure performed by a single provider. As you can see, they've already placed an oropharyngeal airway. The provider places the mask on the bridge of the nose and then lowers it onto the chin. They tuck their third through fifth fingers under the jaw and perform a jaw thrust, while securing the mask to the face with their first second fingers, and then perform a head tilt before beginning ventilation. Let's now discuss the two provider technique. How does it differ? If two providers are available, the initial steps of setup and mask placement are the same. However, one provider can then dedicate both hands to ensuring a good mask seal is made and the airway is open, while the other one can perform the ventilation. With both hands available, I recommend that provider places second through fifth fingers of both hands behind the jaw to perform an effective jaw thrust while placing both thumbs parallel to one another on top of the mask to create an excellent seal. This technique capitalizes on the strong muscles in the hand, allowing it to be done more successfully and for longer periods of time without fatigue. The second provider is responsible for squeezing the bag to provide ventilation. This video showcases the two provider technique. Here, again, they've already placed an oral airway. The mask placement technique is familiar. These providers use an alternate hand position to the one just described to create the mask seal, a two-handed version of the single provider technique, which is an option but is slightly more challenging, and once the first provider has created the mask seal and opened the airway, the second provider begins to ventilate. How should providers actually ventilate? an adult patient. The goal should be to provide about 12 breaths per minute. This means one ventilation every five seconds. The breaths should go in over about second. Excellent. Having discussed a lot of important information, let's summarize the key points for each of these procedures. Airway adjuncts are helpful tools for maintaining an open airway in patients unable to do so on their own. A correctly sized nasopharyngeal airway reaches from the patient’s nare to the ear lobe, while a correctly sized oropharyngeal airways reaches from the corner of the mouth to the angle of the jaw. Effective bag mask ventilation requires selecting an appropriately size bag and mask, creating an excellent mas seal with the appropriate one or two provider mask grip, paired with an effective airway opening maneuver are essential steps to successful bag mask ventilation. Fantastic. Well, thank you for your time and thank you for watching and listening. Keep up the great work.
