Alternative Airway Knowledge

CraigB-RN, MSN, RN · Mar 21, 2009

I agree with your statement of "intubate at all cost" Interstingling I just read a blog entry to I think Dr Bledsoe asking whether ET is out of place in todays pre-hospital environment.

Unfortunatly, most ER nuses exposure to all forms of airway management in crisis situation is through ACLS. And since ACLS has changed over the past years (understatment of the day?) it is probably inapropriate to depend on it so much in the ICU and ER environments. The only reason I and a few of my co-workers have knowledge of them is the flight and/or prehospital experience we had before ending up in out current work place.

As a new CNS, that is one of my published goals is to move out education, out of the standard fall back positions of ACLS, PALS and TNCC.

Of course, I have to find a way to change the MD's perspective. We won't discusse the number of times I've had to get forcefull and get the MD to stop his/her attempt at intubation. If the person is circling the drain and the king air is getting the job done. leave it. Now if the patient needs to go to the ICU, then it needs to be changes. As to LMA's, I've used them, but in our environment, I don't think it's the best choice. To much patient movement. However, when you need an airway now, well and airway is an airway.

GilaRRT · Mar 21, 2009

Thanks for the reply. It does seem that we ship people off to a one day ACLS class, then expect them to provide care in every sort of emergency based on that one day class every two years. I am glad to see you looking at proactive changes.

I see us performing RSI in the ER all the time; however, how many people are taught to perform an airway assessment, predict difficult airway, transition to options other than RSI, deal with the failed airway, and deal with a physician that may be killing a patient.

I think nurses are a rather pro-active bunch and many ER nurses would most likely benefit and take to airway education, ultimately bringing that experience into their practice. However, I suspect some of the problem is with physicians as well. We must be proactive and push for our physicians to use the newest techniques and realize the harm in falling into the age old "intubate at ay cost" trap.

I can honestly say, up until a few years ago, my way of practicing was quite different. It was not until I took the SLAM course, that I really had my eyes opened to the fact that the current way of doing things was in fact harmful. A couple of years later, I found my self loading a patient into my helicopter with a combitbe in place because we had a failed airway situation. The patient was saturating well, with stable vital signs, and waveform capnography.

RedCell · Mar 21, 2009

LMAs, Air-Qs and kings all have their usefulness in the failed intubation algorithm. Unfortunately, they do not always work. However, having the ability and skill to mask ventilate someone is one of the most useful resources a nurse or physician can possess in this kind of situation. Mask ventilation is a skill thought to be had by many, though many times when utilized it is done incorrectly. Practitioners often have a bad seal or are using too much positive pressure. I believe this is something ACLS should spend a lot more time on. Proper mask ventilation gives the team time to regroup and come up with alternative options or in worst case scenarios, to wait for someone with more airway expertise to arrive.

GilaRRT · Mar 21, 2009

I agree, in fact the ability or predicted ability to perform effective mask ventilation should be on of the most important considerations in our airway management decision tree. I am not sure ACLS is the course that should be teaching this knowledge however. Since ACLS is ECC guideline based, very little about intubation applies, especially in light of emphasized compressions and de-emphasized advanced airway techniques.

CraigB-RN, MSN, RN · Mar 22, 2009

Definitely agree that ACLS isn't the way.

Medic09, BSN, RN, EMT-P · Mar 22, 2009

Gila,

Hope you're keeping your head down.

I'd bet that in most places, the nurses' role in airway managment is limited to bagging and handing the doc the intubation or LMA stuff. When I oriented to the ER, alternative devices were rather quickly covered. As it was, many of the orientees with me had never inserted an OPA of NPA. I'm sure if EMS comes in with a Combitube or King device in place they won't know what it is.

During intubations or other airway management, our docs intitiate and run the show. The only reason I even get included in their considerations is because they know I do this 'outside'. Most of them will at least consider and answer me if I speak up (uh, do you want laryngeal manipulation or maybe the bougie).

As for what we've got, our ER crash carts have intubation supplies with LMAs for backup, and a fiberscope cart nearby. If it comes down to it, anesthesiology isn't far away.

I don't know if the docs have a clearly agreed upon plan for progressive (regressive?) airway complications. At UNM, as you've probably seen, the trauma bays have a big algorithm on the wall as a reminder. We have no such thing, and I've never asked the docs if they all work according to an agreed upon airway plan. I was educated on Walls/Airway 911, so I like to see such things at least as a reminder and possible guide.

Stay safe, take good care of the patients!

mwboswell · Mar 22, 2009

I agree with the above posters - ACLS airway content needs to be straightforward and simple; defaulting to the "if you get effective ventilations with the BVM -then carry on"....

TNCC/TANTC is not theplace either as the focus of these is trauma patients and the specific manipulations and considerations for the trauma airway.

As a former EMT instructor, i'd love to see a stand-alone respiratory/airway program for ER/CC nursing, probably along the lines of a 6-8 hour day, similar to the EMT curricula that follows National Registry Guidelines in as much as other airway adjuncts, backup airways and alternate airways.

To comment on the other poster who said they thought their ER staff wouldn't know what to do with a PHEMS King/combitube - I say, I don't even know if mine would know what it is!

What I have seen however, is that we, as a pretty large Emergency Dept (over 50 Emergency MD's in the group), the new guys (IE: young and fresh AND Board Certified!) are bringing in some of the changes in airway thinking. I can definitely see it when one night my attending is one of the "old guard" versus one who is a "newbie". We're starting to use the bougie more and more even during our initial approaches with direct laryngoscopy. Personally I haven't worked with the bougie, but I'm always looking for the opportunity.

Also, we're talking about budgetary constraints. It's hard enough to get our staff RN's to their "mandatories" (BLS, ACLS, TNCC et al) let alone needing to add another course (airway). I am sure it would pay off dividends in the end, but that's my opinion as a clinician; NOT as a manager, director or administrator who has to balance a bottom line.

Overall, I think we're heading in the right direction. I think for a lot of ED RN's it becomes a "trial by fire" or "O-J-T" to learn about the new airway paradigm.

Maybe we can even look to our in-house CNS/CNE staff to at least try to introduce some entry-level knowledge even on these topics during things like our annual skills fairs etc.

good posts everyone! Keep up thegood work!

-MB

alterego33 · Mar 22, 2009

They advocated a technique that involved cutting off both pilot balloons at the same time, thus deflating both cuffs at the same time for rapid removal. You cannot make this stuff up.
?

Anyone who cuts off the pilot tube of any airway device is a sloppy practitioner, in my opinion. Deflate it with a syringe. Cowboys belong on the range, not taking care of patients. Finesse is an art and is what separates the good from the marginal practitioners.

I have been intubating and extubating patients for years and have never cut off the pilot tube.

AE

CraigB-RN, MSN, RN · Mar 22, 2009

CUtting the pilot tube falls into the same lazy pattern/Looks Kewl mode that a lot of nuses/md's/RT's fall into. That is one of the reasons policies and procedures are required for so much of what we do. I can remember the Critical Care Fellow, suposadly an experienced surgeon who was talking, reached down and cut the line, unfotunatly he wasn't paying attention and cut the swan. Back in my days running an AF Urology clinic, I can tell you it's pain to pop a baloon on a foley when someone cut the line to the baloon and somthing had kinked and kept it from inflating. They actually tried to pull an inflated baloon out of the patient. They didn't know it was inflated, because they had cut the balloon.

I think why a course like the one we're talking about now hasn't been developed for nurses is the wide scope of practive for ER nurses. What would the focus be, and to who would we market it. If anyone has any specific suggestions, I'd be game to help develop. I've done some course develpment for conferences in the past. Companies like Med-Ed and PESI would prob buy off on it.

mwboswell · Mar 23, 2009

I think why a course like the one we're talking about now hasn't been developed for nurses is the wide scope of practive for ER nurses. What would the focus be, and to who would we market it. If anyone has any specific suggestions, I'd be game to help develop. I've done some course develpment for conferences in the past. Companies like Med-Ed and PESI would prob buy off on it.

"Scope of practice"?...

I disagree, I think the reason that there isn't a dedicated airway course for nurses is that most people feel the paltry exposure they get during ACLS is adequate - and spending the extra money on yet another JC merit badge course is not financially budgeted for by many nsg education departments in today's tight financial times.

***

Personally I wouldn't sell my soul to either of those two companies.

If you take the time to research, edit, publish and then present it - DO NOT give up the rights to it to some other company. Copyright your material and protect your investment.

Besides working for yourself lets YOU dictate when and where you deliver the goods, you can negotiate your own course contracts, set up repeat/recurring business etc.

Yes, I know you really don't give your rights over to those companies --- but there are non-compete clauses and you're not working for yourself; BEWARE.

-good original post.

CraigB-RN, MSN, RN · Mar 23, 2009

Why would anyone develop a program when probably 95% of the nruses out there will never drop a tube, because it's not in their scope of practice was the point I was making. Those of us who drop them go to SLAM and difficult airway classes, Get tortured in ATNC and things like that.

I just be happy if my co workers now even knew what an oral and nasal airway were and how to use them.

As to Med-Ed and PESI, for some people that is the easest way to get it done. I personally dont' have the time or money anything under my name. Ideally you sell the program to a preconference session at a national conference, get a good name and get invited to do it somewhere else.

As your BEWARE comment, you need to beware anytime you put anything out there. Ive started using the Creative Commons License myself, but that is a whole different thread and topic.