The document describes the assessment and management of a 69-year-old man presenting with severe shortness of breath and unresponsiveness due to COPD exacerbation. It outlines the ACLS approach for airway management, including basic airway adjuncts, bag-mask ventilation, advanced airways like endotracheal intubation, laryngeal mask airway, and esophageal-tracheal combitube. The proper techniques and equipment for establishing a secure airway are discussed.

1. Case 1
Respiratory
Emergencies
© 2001 American Heart Association
1
1

2. Case Presentation
Patient = 69-year-old man,
smoker (4 packs/day)
PMHx = severe COPD
CC = severe shortness of breath;
“hungry for air!”
VS = not obtained; patient suddenly
becomes unresponsive
2

3. Learning and Skills Objectives
Describe ACLS Approach (Primary and
Secondary ABCD Surveys) in CPR
Describe and demonstrate the “airway hierarchy”:
• Supplemental oxygen:
– Nasal cannulae
– Face masks
• Noninvasive airway devices:
– Nasopharyngeal airway
– Oropharyngeal airway
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4. Learning and Skills Objectives
The airway hierarchy (cont’d)
• Recommended invasive airway devices:
– Laryngeal mask airway (LMA)
– Esophageal-tracheal (Combitube) tube
– Tracheal tube
• Primary/secondary confirmation of tracheal
tube placement:
– Physical exam criteria
– End-tidal CO2 detection
– Devices to detect esophageal placement
• Devices to prevent TT dislodgment
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5. Primary ABCD Survey
Focus: Basic CPR and Defibrillation
• Check responsiveness
• Activate emergency response system
• Call for defibrillator
A = Airway: open the airway
B = Breathing: check breathing, provide
positive-pressure ventilations
C = Circulation: check circulation,
give chest compressions
D = Defibrillation: assess for and shock
VF/pulseless VT
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6. Secondary ABCD Survey
A = Airway: insert advanced airway device as soon as able
(new: 3 types)
B = Breathing: confirm placement by PE (primary
tube confirmation)
PLUS
B = Breathing: confirm placement with esophageal
detector device or end-tidal CO2 detector or
both (secondary tube confirmation)
B = Breathing: use a commercial tube holder
to prevent dislodgment
B = Breathing: confirm effective oxygenation/ventilation
by 02 sat, CO2 levels, pH
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7. Anatomy of Airway
7

8. Airway Obstruction
Most common cause: tongue and/or epiglottis
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9. Opening the Airway
Jaw thrust Head tilt–chin lift
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10. The Oropharyngeal Airway
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11. Malposition of
Oropharyngeal Airway
Too short
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12. Nasopharyngeal Airway
Insertion technique
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13. Barrier Devices
Oral airway: inserts in patient
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14. Pocket-Mask Devices
1-way valve
Port to attach O2 source
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15. Mouth-to-Mask Ventilation
Advantages
• Eliminates direct contact
• Enables positive-pressure
ventilation
• Oxygenates well if
O2 attached
• Easier to perform than
bag-mask ventilation • 1-rescuer technique; performed from side
• Rescuer slides over for chest
• Best for small-handed compressions
rescuers • Fingers: head tilt–chin lift
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16. Mouth-to-Mask Ventilation
Fingers: jaw thrust upward Fingers: head tilt–chin lift
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17. Bag-Mask Ventilation
Key—ventilation volume: “enough to produce
obvious chest rise”
1-Person: 2-Person:
difficult, less effective easier, more effective
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18. Cricoid Pressure
Thyroid
Cartilage
Cricoid
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19. Bag-Mask Ventilation
Advantages
• Provides immediate ventilation and oxygenation
• Operator gets sense of compliance and airway resistance
• May provide excellent short-term support of ventilation
• High oxygen concentrations are possible
• Can be used to assist spontaneous respirations
Potential complications
• Hypoventilation
• Gastric inflation
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20. Airway Adjunct Devices
Nasal cannula Face mask with O2 reservoir,
24%-44% O2 concentration 60%-100% O2 concentration
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21. Types of Portable Suction
Courtesy of Laerdal Medical Corporation, Armonk, NY
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22. Equipment for Intubation
Laryngoscope with
several blades
Tracheal tubes
Malleable stylet
10-mL syringe
Magill forceps
Water-soluble lubricant
Suction unit, catheters, and tubing
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23. Curved Blade Attaches to
Laryngoscope Handle
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24. Curved Blade Attached to
Laryngoscope Handle
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25. Curved Blade Laryngoscope
Inserted Against Epiglottis
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26. Straight-Blade Laryngoscope
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27. Straight-Blade Laryngoscope
Inserted Past Epiglottis
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28. Cricothyroid Membrane With
Horizontal Cricothyrotomy Incision
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29. Aligning Axes of Upper Airway
Mouth
A
A B
B
C
C
Pharynx
Trachea
Extend-the-head-on-neck (“look up”): aligns axis A relative to B
Flex-the-neck-on-shoulders (“look down”): aligns axis B relative to C
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30. Visualization of Vocal Cords
Anatomy
Tongue
Vallecula
Epiglottis
Vocal
cord
Glottic Arytenoid
opening cartilage
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31. Tracheal Intubation
Advantages
• Protects airway from aspiration of foreign material
• Facilitates ventilation and oxygenation
• Facilitates suctioning of trachea and bronchi
• Provides route for drug administration
• Prevents gastric inflation if used with cuff
• Allows faster chest compressions
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32. Tracheal Intubation
Indications
• Inability to ventilate the unconscious patient
• After insertion of pharyngeal airway
• Inability of patient to protect own airway (coma,
areflexia, or cardiac arrest)
• Need for prolonged mechanical ventilation
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33. Tracheal Intubation
Recommendations
• Intubate as soon as possible after ventilation
and oxygenation in cardiac arrest
• Intubation should be done by most
experienced person
• Do not take longer than 30 seconds per attempt
• Auscultate the thorax and epigastrium
after intubation
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34. Tracheal Intubation
Complications
• Trauma—teeth, lips, tongue, mucosa,
vocal cords, trachea
• Esophageal intubation
• Vomiting and aspiration
• Hypertension and arrhythmias
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35. Esophageal-Tracheal Combitube
A = esophageal obturator; ventilation into trachea through side openings = B
E C = tracheal tube; ventilation through open end if proximal end inserted in trachea
D = pharyngeal cuff; inflated through catheter = E
Distal End
F = esophageal cuff; inflated through catheter = G
H = teeth marker; blindly insert Combitube until marker is at level of teeth
A
C
H Proximal End
B
D
F
G
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36. Esophageal-Tracheal Combitube
Inserted in Esophagus
A
H
D
D
B F
A = esophageal obturator; ventilation into
trachea through side openings = B
D = pharyngeal cuff (inflated)
F = inflated esophageal/tracheal cuff
H = teeth markers; insert until marker lines at
level of teeth
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37. Laryngeal Mask Airway
(LMA)
The LMA is an adjunctive airway that consists of a tube
with a cuffed mask-like projection at distal end.
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38. LMA Introduced Through
Mouth Into Pharynx
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39. LMA in Position
Once the LMA is in position, a clear, secure airway is present.
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40. Anatomic Detail
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41. Esophageal Detector Device
(Bulb-Type)
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42. Confirmation:
Tracheal Tube Placement
End-tidal colorimetric CO2 indicators
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43. Tracheal Tube Holders:
Adult and Infant
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44. Qualitative End-Tidal
CO2 Detector
What should the operator’s next action be?
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