7.1. KONTROLʹ DYKHALʹNYKH SHLYAKHIV

(Adaptovano z nastanovy, zasnovanoyi na dokazakh, z vykorystannyam Natsionalʹnoyi modelʹnoyi nastanovy z protsesu dolikarnyanoyi dopomohy).

Povʺyazani nazvy

Astma, obstruktsiya verkhnikh dykhalʹnykh shlyakhiv, respiratornyy dystres, dykhalʹna nedostatnistʹ, hipoksemiya, hipoksiya, hipoventylyatsiya, aspiratsiya storonnikh til, krup, strydor, trakheit, epihlotyt.

Meta nadannya dopomohy

1. Provedennya efektyvnoyi ventylyatsiyi ta kysnevoyi terapiyi.
2. Rozpiznavannya ta likuvannya dykhalʹnykh rozladiv.
3. Shvydke ta bezpechne provedennya neobkhidnykh vtruchanʹ u patsiyentiv, yaki potrebuyutʹ pidtrymky dykhannya.
4. Vchasne vyyavlennya skladnykh dykhalʹnykh shlyakhiv.

Opys patsiyenta

Kryteriyi vklyuchennya

1. Dity ta dorosli z oznakamy vyrazhenoho respiratornoho dystresu/dykhalʹnoyi nedostatnosti.
2. Patsiyenty z oznakamy hipoksemiyi abo hipoventylyatsiyi.

Kryteriyi vyklyuchennya

1. Patsiyenty z trakheostomoyu.
2. Patsiyenty na shtuchniy ventylyatsiyi.
3. Novonarodzheni dity.
4. Patsiyenty, u yakykh adekvatna ventylyatsiya abo oksyhenatsiya zabezpechuyetʹsya cherez kysnevu terapiyu z vykorystannyam prostoyi nazalʹnoyi kanyuli abo dykhalʹnoyi masky.

Nadannya dopomohy patsiyentam

Otsinka stanu

1. Anamnez – otsinitʹ:

a) chas poyavy symptomiv;
b) povʺyazani symptomy;
v) v anamnezi nayavnistʹ astmy abo inshykh rozladiv dykhannya;
h) zadykhannya abo inshi oznaky obstruktsiyi verkhnikh dykhalʹnykh shlyakhiv;
g) poperedni travmy.

2. Fizykalʹne obstezhennya – otsinitʹ:

a) zadyshka;
b) patolohichna CHD ta/abo kharakter dykhannya;
v) vykorystannya dodatkovykh mʺyaziv v akti dykhannya;
h) yakistʹ hazoobminu, vklyuchno z hlybynoyu ta yakistyu dykhalʹnykh shumiv;
g) svyst, sukhi khrypy, khrypy abo strydor;
d) kashelʹ;
e) patolohichnyy kolir shkiry (tsianoz abo blidistʹ);
ye) porushennya psykhichnoho stanu;
zh) oznaky hipoksemiyi;
z) oznaky skladnykh dykhalʹnykh shlyakhiv (korotka shchelepa abo obmezhena tyaha shchelepy, malyy tyreomentarnyy prostir, obstruktsiya verkhnikh dykhalʹnykh shlyakhiv, velykyy yazyk, nadmirna vaha, velyki myhdalyky, shyroka i korotka shyya, cherepnolytsevi anomaliyi, nadmirnyy volosyanyy pokryv na oblychchi).

Likuvannya ta vtruchannya

1. Neinvazyvni metody ventylyatsiyi:

a) pidtrymka prokhidnosti dykhalʹnykh shlyakhiv ta provedennya kysnevoyi terapiyi dlya dosyahnennya saturatsiyi na rivni 94-98%;
b) pry vyrazheniy dykhalʹniy nedostatnosti abo ryzyku zupynky dykhannya, zastosuyte ventylyatsiyu z vykorystannyam postiynoho pozytyvnoho tysku v dykhalʹnykh shlyakhakh (PPTD), dvukhfaznoho postiynoho pozytyvnoho tysku v dykhalʹnykh shlyakhakh (DPPTD), intermituyuchoho pozytyvnoho tysku (IPT), nazalʹnoyi kanyuli vysokoho potoku (NKVP) ta/abo dvofaznoyi nazalʹnoyi kanyuli z postiynyy pozytyvnym tyskom;
v) pry dykhalʹniy nedostatnosti abo zupyntsi dykhannya provodʹte ventylyatsiyu mishkom AMBU. Ventylyatsiya za uchasti dvokh fakhivtsiv systemy EMD ye bilʹsh efektyvnoyu, nizh za uchasti odnoho fakhivtsya i vidtak maye provodytysya za nayavnosti dodatkovykh fakhivtsiv systemy EMD na mistsi podiyi.

2. Oro- ta nazo- farynhealʹni povitrovody – zastosovuyte (odnochasno abo po odnomu) dlya pidvyshchennya efektyvnosti ventylyatsiyi mishkom AMBU, osoblyvo yakshcho u patsiyenta ye porushennya svidomosti.

3. Nadhortanni dykhalʹni prystroyi abo pozahlotkovi prystroyi: Roz·hlyanʹte vykorystannya nadhortannykh dykhalʹnykh prystroyiv abo pozahlotkovykh prystroyiv, yakshcho mishok AMBU neefektyvnyy u pidtrymtsi oksyhenatsiyi ta/abo ventylyatsiyi.

4. Endotrakhealʹna intubatsiya:

a) koly neinvazyvni metody (mishok AMBU, nadhortanni dykhalʹni prystroyi abo pozahlotkovi prystroyi) neefektyvni, proveditʹ endotrakhealʹnu intubatsiyu dlya pidtrymky oksyhenatsiyi ta/abo ventylyatsiyi;
b) inshymy pokazannyamy ye potentsiyna obstruktsiya dykhalʹnykh shlyakhiv, sylʹni opiky, mnozhynni travmy, porushennya svidomosti abo vtrata normalʹnoho zakhysnoho refleksu dykhalʹnykh shlyakhiv;
v) slidkuyte za klinichnymy oznakamy, pulʹsoksymetriyeyu, sertsevym rytmom, AT ta kapnohrafiyeyu pislya intubatsiyi;
h) video larynhoskopiya mozhe pidvyshchyty shansy na uspishnu intubatsiyu i maye zastosovuvatysʹ za yiyi nayavnosti. Vykorystovuyte buzh u razi: yakshcho video larynhoskopiya nedostupna abo, yakshcho nemaye mozhlyvosti chitkoyi vizualizatsiyi holosovykh zvʺyazok pryamoyu larynhoskopiyeyu.

5. Post-intubatsiynyy kontrolʹ patsiyenta.

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7.1. RESPIRATORY CONTROL

(Adapted from an evidence-based guideline using the National Prehospital Care Process Model Guide).

Related titles

Asthma, upper airway obstruction, respiratory distress, respiratory failure, hypoxemia, hypoxia, hypoventilation, aspiration of foreign bodies, croup, stridor, tracheitis, epiglottitis.

Purpose of assistance

1. Effective ventilation and oxygen therapy.
2. Recognition and treatment of respiratory disorders.
3. Quick and safe implementation of the necessary interventions in patients who need respiratory support.
4. Early detection of difficult airways.

Description of the patient

Inclusion criteria

1. Children and adults with signs of severe respiratory distress/respiratory failure.
2. Patients with signs of hypoxemia or hypoventilation.

Exclusion criteria

1. Patients with a tracheostomy.
2. Patients on artificial ventilation.
3. Newborn children.
4. Patients in whom adequate ventilation or oxygenation is provided through oxygen therapy using a simple nasal cannula or breathing mask.

Providing assistance to patients

Status assessment

1. Anamnesis – evaluate:

a) time of onset of symptoms;
b) related symptoms;
c) history of asthma or other respiratory disorders;
d ) suffocation or other signs of obstruction of the upper respiratory tract;
e) previous injuries.

2. Physical examination – evaluate:

a) shortness of breath;
b) pathological BH and/or pattern of breathing;
c) use of additional muscles in the act of breathing;
d) the quality of gas exchange, including the depth and quality of respiratory sounds;
e) wheezing, dry wheezing, wheezing or stridor;
e) cough;
e) pathological skin color (cyanosis or pallor) ;
g) disturbance of the mental state;
g) signs of hypoxemia;
g) signs of difficult airways (short jaw or limited jaw thrust, small thyromentary space, upper airway obstruction, large tongue, overweight, large tonsils, wide and short neck, craniofacial anomalies, excessive facial hair).

Treatment and intervention

1. Non-invasive methods of ventilation:

a) maintenance of airway patency and oxygen therapy to achieve saturation at the level of 94-98%;
b) in case of severe respiratory failure or risk of respiratory arrest, apply ventilation using continuous positive airway pressure (CPAP), biphasic continuous positive airway pressure (CPAP), intermittent positive pressure (IPP), high-flow nasal cannula (HFN) and/or biphasic continuous positive pressure nasal cannula;
c) in case of respiratory insufficiency or respiratory arrest, carry out ventilation with an AMBU bag. Ventilation with the participation of two specialists of the EMD system is more effective than with the participation of one specialist and therefore should be carried out in the presence of additional specialists of the EMD system at the scene.

2. Oro- and nasopharyngeal airways – use (simultaneously or one at a time) to increase the effectiveness of ventilation with an AMBU bag, especially if the patient is unconscious.

3. Supralaryngeal breathing devices or extrapharyngeal devices: Consider the use of supralaryngeal breathing devices or extrapharyngeal devices if the AMBU bag is ineffective in maintaining oxygenation and/or ventilation.

4. Endotracheal intubation:

a) when non-invasive methods (AMBU bag, supralaryngeal breathing devices or extrapharyngeal devices) are ineffective, perform endotracheal intubation to maintain oxygenation and/or ventilation;
b) other indications there is potential for airway obstruction, severe burns, multiple injuries, impaired consciousness, or loss of normal protective airway reflex;
c) monitor clinical signs, pulse oximetry, heart rate, BP, and capnography after intubation;
d) video laryngoscopy can increase the chances of successful intubation and should be used when available. Use a bouge in case: if video laryngoscopy is not available or if it is not possible to clearly visualize the vocal cords by direct laryngoscopy.

5. Post-intubation control of the patient.

5.1. Confirm endotracheal tube/epiglottic device placement by assessing capnography, absence of stomach sounds, and bilateral breathing.

5.2. Monitor capnograph readings continuously during treatment and transport.

5.3. Manually control the fixation of the intubation tube, until it is fixed with a plaster, bandage or a special fixing device:

a) pay attention to the markings on the tube, which are usually located on the patient’s gum line, thanks to which you can detect its movement/dislocation;
b) immobilization of the cervical region and /or the use of a cervical collar can limit neck movement and reduce the risk of tube dislocation.

5.4. Inflate the cuff of the endotracheal tube with the minimum amount of air to seal the airway – a special manometer on the cuff of the endotracheal tube can be used to measure and adjust the pressure in the cuff, the recommended pressure is 20 cm H2O.

5.5. Ventilation:

a) respiratory volume:

• • • • ventilate with the minimum volume that provides chest rise, approximately 7 mg/kg at ideal body weight;
      • excessive ventilation can have negative consequences;

b) frequency:

• • • • adults: 10-12 breaths/min;
      • children: 20 breaths/min;
      • infants: 30 breaths/min;

c) constant monitoring of exhalation CO2 to maintain the indicator at the level of 35-40 mmHg. – in case of head injury with signs of herniation (unilateral dilated pupil or decerebrate posture), moderately hyperventilate to ETCO2 30 mmHg.

5.6. Consider sedation with sedatives or opioids if agitated.

6. Gastric decompression can improve ventilation and saturation, so it should be performed in case of obvious gastric distension.

7. If adequate ventilation and/or oxygenation cannot be achieved by the above methods, the rescuer should perform a conicotomy if the risk of death from lack of airway control is greater than the risk of procedural complications.

8. Take the patient to the nearest reception department to stabilize the patency of the respiratory tract if it is not possible to solve the problem of respiratory arrest at the pre-hospital stage.

Patient safety

1. Avoid excessive pressure or volume when using the AMBU bag.
2. Do not perform endotracheal intubation as long as non-invasive control methods are working, as this may be associated with the risk of injuring the larynx during intubation, additional injury to the cervical spine, malposition of the endotracheal tube (in the right bronchus or stomach), or side effects from sedation, especially in children.
3. In the event of successful insertion of supralaryngeal devices and intubation, obstruction or dislodgment of the tube may have fatal consequences for the patient.
   Tubes should be fixed using commercial special devices or plaster
4. Professionals who do not have sufficient skills in performing rapid sequence induction during intubation should not perform this procedure on children because loss of airway control can cause complications.
   Rapid sequence induction during intubation should be performed by specially trained professionals who underwent in-depth training and quality assurance measures.

Useful information for training

Key points

1. Compared to the management of adults with cardiac arrest, paramedics are less likely to use endotracheal intubation in children with cardiac arrest. In addition, the probability of unsuccessful intubation of a child with cardiac arrest and complications such as ET malposition or aspiration is three times higher than in adult patients.

2. Use wave capnography to measure exhaled CO2 (ETCO2). It is an important adjunct to monitoring in respiratory disorders, respiratory failure, and during continuous positive pressure therapy. This device should be used as a standard means of checking the correct placement of supralaryngeal devices, as well as an endotracheal tube.

3. PPTD, DPPTD, IPT, NCVP.
Contraindications for these non-invasive methods ventilation is intolerance to the device, profoundly impaired consciousness, excessive secretions that prevent a snug fit of the mask/cannula, recent gastrointestinal and/or airway surgery.

4. AMBU bag:

a) a properly selected mask should cover the nose and mouth and provide a tight fit around the cheeks and chin;
b) the ventilation volume should be sufficient to lift the chest;
c) frequency of ventilation:

• • • • during CPR, the rate should be 10 breaths/min, i.e. 1 breath every 10 compressions (or 1 breath every 6 seconds). In the case of using supralaryngeal devices or intubation, ventilation ideally occurs between two chest compressions;
      • in adults without cardiac arrest, ventilation with a frequency of 12 breaths/min;
      • in children, the frequency is 20 breaths/min (the duration of inhalation and exhalation is 1 second followed by a 2-second pause.

5. Orotracheal intubation:

a) dimensions of the endotracheal tube;

b) insertion depth – (3) x (ET size);
c) in addition to preoxygenation, oxygen therapy using a nasal cannula can delay the onset of hypoxia during an attempt intubation;
d) ventilation with PPTD after intubation reduces preload and can lead to hypotension – use vasopressors to avoid hypotension;
e) sufficient attention should be paid to adequate preoxygenation to avoid post-intubation hypoxia and subsequent cardiac arrest;
/>e) proper sanitation of the respiratory tract can increase the chances of successful intubation on the first attempt;
e) confirm the success of the placement with the help of a wave capnograph. A less optimal method of verification is the presence of bilateral elevation of the chest walls, the presence of bilateral breathing, and the maintenance of an adequate level of oxygenation. The color change on the color capnograph is less accurate than the clinical assessment, while the wave capnograph is the most accurate. The presence of fogging inside the tube is not a reliable way to confirm the correct location. Visualization with the help of video laryngoscopy (if possible) can help to confirm the correctness of the position in case of malfunction of the capnograph or contradictory data on the monitor;
j) constant training and practice are the key to maintaining skills. This especially applies to working with children, since intubation is very rarely performed by EMD specialists at the pre-hospital stage;
g) video laryngoscopy, if available, can contribute to endotracheal intubation.

6. In case of severe respiratory insufficiency or respiratory arrest and the need for potential professional control of the respiratory tract, it is necessary to send for the help of specialists of the EMD system with the highest level of qualification.

Corresponding evaluation results

1. Continuation of inspection is critical if auxiliary ducting is installed.
2. Progressive respiratory distress or signs of hypoxemia may be secondary to airway displacement or obstruction, pneumothorax, or device malfunction.

Key elements of documentation

1. Initial vital signs and results of physical examination.
2. Attempts of interventions, including airway control interventions, size of equipment used, and number of attempts to achieve a successful outcome.
3. Follow-up vital signs and physical examination results to detect changes after interventions.
4. Presence during intubation of hypoxia, bradycardia, hypotension or cardiac arrest.
5. After intubation, document the ETCO2 value and record the capnographic wave immediately after intubation, the spectrum of vital signs as the patient is moved and during the patient’s movement in the EMD unit.

Criteria for the effectiveness of aid provision

1. Percentage of EMD system specialists who have undergone practical training in airway patency control (with or without simulations) during the past 2 years.
2. BP and saturation should be measured and recorded in the patient’s card.
3. Percentage of patients in whom a wave capnograph was used after intubation for initial confirmation of correct positioning and subsequent monitoring during transport.
4. Percentage of patients whose airway control upon arrival at the reception department was provided by the following: AMBU bag, supralaryngeal devices or endotracheal intubation.
5. Percentage of intubated pa patients in whom an endotracheal tube is correctly positioned at the time of arrival at the EMD department.
6. Successful intubation on the first attempt without hypoxia or hypotension.
7. Survival rate after arrival at the EMD department.