Adult emergency trolley 1: equipment to support airway and breathing

Emergency equipment to support adults’ airway and breathing is discussed in the first of two articles on what to include on the adult emergency trolley to support the best resuscitation outcomes. This is a Self-assessment article and comes with a self-assessment test

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This article – the first of two on checking the contents of the emergency trolley to support the resuscitation of adults in an acute hospital setting – focuses on equipment for airway and breathing. It explores quality standards around resuscitation equipment and checking procedures to ensure equipment is immediately available and ready for use. Airway and breathing equipment is described, along with the function and use of each during a resuscitation. The need to maintain the equipment and locate it quickly is emphasised, along with the importance of practitioners operating within their own scope of practice and level of competence, while adhering to local trust policy.

Citation: Cocker S, Whatley L (2023) Adult emergency trolley 1: equipment to support airway and breathing. Nursing Times [online]; 119: 8.

Authors: Sarah Cocker is senior lecturer adult nursing; Lorraine Whatley is senior lecturer simulation and immersive learning technology; both at Oxford Brookes University.

Missing or poorly functioning resuscitation equipment has been highlighted as one element contributing to incidents associated with death (Thomson et al, 2007). In the event of a cardiopulmonary arrest, clinical staff need immediate access to resuscitation equipment and drugs, so they can act quickly to give the patient the best chance of survival. The Resuscitation Council UK (RCUK) has produced quality standards for cardiopulmonary resuscitation to ensure healthcare organisations provide a high-quality resuscitation service. The standards are different for each of the following clinical settings:

Different quality aspects in each clinical setting include organisational structure, staff training, systems and processes for recognising the deteriorating patient and, when resuscitation is required, what equipment and drugs should be available for use (RCUK, 2020b).

This series of two articles focuses on the equipment and drugs required for cardiopulmonary arrest in adults in an acute care setting. Health practitioners must:

Emergency equipment is often stored on an emergency resuscitation trolley (Fig 1). To make sure it can be retrieved quickly in an emergency, the trolley must be easily accessible in a clinical area, and not locked or stored in a locked room. Drugs kept in the trolley should be stored in a tamper- evident container, which should be inspected as part of the trolley checking process (RCUK, 2021a). The RCUK (2020b) recommends standardising trolley equipment throughout an organisation as this makes it easier to locate things quickly in an emergency.

Where possible, equipment should be:

Resuscitation equipment is often stored in different drawers that align with levels of intervention and treatment, for example: airway (basic and advanced); breathing; circulation; and drugs.

Resuscitation equipment should be checked regularly. Benson-Clarke (2022) suggests this should be:

When checking the trolley, practitioners should ensure:

As part of a local risk assessment, an organisation’s resuscitation committee or a designated resuscitation lead should have agreed the contents list of the resuscitation trolley. Contents and stock levels should be adhered to, as overstocking can mean items cannot be seen easily when an emergency occurs (Benson-Clarke, 2022).

As part of the checking procedure, the practitioner must ensure the trolley:

The checking process of emergency equipment should be clearly documented in accordance with local trust policy. A tamper-proof tag may be used to show that the trolley has been checked and is ready for use.

The specific equipment used during a cardiopulmonary arrest may vary and will depend on the skill set and competence of the first responders. It will increase when the resuscitation team arrives and starts advanced life support treatments.

In this article, we look at the equipment required for basic and advanced airway and breathing management during cardiopulmonary arrest. Practitioners must be aware of what the equipment is and why it might be used so they can respond quickly during a resuscitation event.

A pocket mask with oxygen port and filter (Fig 2) enables an initial responder to give mouth-to-mask ventilation to the non-breathing patient. The one-way valve redirects the patient’s expired breath away from the responder. An integrated oxygen port facilitates the addition of supplemental oxygen to optimise oxygenation. The value of the clear mask is that vomit, secretions or blood can be seen.

The one-way valve means that, on inhalation, the patient will inhale the high-flow oxygen while, on exhalation, the valve is closed to the reservoir and the exhalation breath, which is heavy with carbon dioxide (CO2), is lost to the atmosphere. Fig 2 shows the oxygen mask with reservoir bag.

The bag valve mask (BVM) (Fig 2) is a self-inflating bag for delivering manual, positive-pressure ventilation to the non-ventilating, or poorly ventilating, patient. It can be attached to an oxygen source (running at 10-15L) via the oxygen tubing, which inflates the bag with high-concentration oxygen. When used with a face mask to support ventilation, it requires significant technique and skill from a single responder to achieve a gas-tight seal, so its use as a two-person tool is preferable (RCUK, 2021b).

When used by two people, one person places the detachable mask over the patient’s nose and mouth to ensure an effective seal, while simultaneously opening the airway using a jaw thrust. The second rescuer then squeezes the bag so the valve over the mask opens, giving the patient ventilation with a high concentration of oxygen (>90%). As the patient exhales, the bag relaxes and the valve closes; this ensures the exhaled breath is diverted out of the oxygen reservoir, rather than being redirected into it – which would dilute its concentration.

The device can be used without an oxygen source to deliver ventilation, but oxygen delivery to the patient will be much lower because room air contains 21% oxygen (RCUK, 2021b). The detachable mask can be removed, and the bag and valve attached to a supraglottic airway device or endotracheal tube, to give positive-pressure ventilation.

Clear cushioned face masks are detachable masks available in a variety of sizes for attachment to the BVM. Fig 2 shows the BVM with a clear cushioned face mask in place. The mask size needs to be assessed to make sure there is an optimal seal when ventilating. Sizing landmarks are the:

Commonly, adult patients require a size 4 mask but, if a good seal proves difficult to achieve, a smaller or larger mask may be needed.

Oropharyngeal airways (Fig 2) are often known as guedel airways or OP airways, and are designed to maintain the airway in a patient who has a reduced level of consciousness. As the consciousness level deteriorates, the patient’s soft tissue and tongue can become flaccid, dropping backwards and obstructing an airway. The rigid structure of the OP airway will help to support this tissue and reduce its impact on airway patency.

Correct sizing is vital, otherwise the OP airway becomes an obstruction itself by sitting on the tongue. To correctly size an OP airway, the practitioner should:

The nasopharyngeal airway (Fig 2), also known as the NP airway or NPA, is inserted into one nostril to give a patent airway into the posterior pharynx for a patient who has an obstructed upper airway. NP airways are usually available in two sizes – 6 and 7 – for adult patients. A water-based lubricant is used to help insertion. Some models require a safety pin to be inserted through the flange so the patient does not inhale the device, but most have flanges that are large and rigid enough to avoid this.

NP airways are often more easily tolerated by patients whose level of consciousness is too high to tolerate an OP airway. They are also helpful when a patient’s mouth is difficult to open or access – for example, in cases of trismus, fitting or angioedema.

A supraglottic airway device (SAD) can be used during cardiac arrest to enable more effective ventilation (RCUK, 2021b). The two types of SAD usually found on resuscitation trolleys are the i-gel and laryngeal mask airway (LMA) (Fig 2). SADs also provide some level of protection to the airway, and their insertion requires less skill, training and experience than that needed to insert an endotracheal tube during a cardiac arrest. However, training and competency assurance in both devices are essential before use in the clinical environment. Health staff may access training to insert these devices through their local mandatory resuscitation training service. Choice of supraglottic device provision depends on local trust policy; the two main types are described below.

i-gelThe i-gel is commonly used to support the patency of airway and optimise airway and ventilation during resuscitation in many pre-hospital and acute inpatient settings. It has a soft, gel-like non-inflatable cuff that, once inserted into position, should provide a reliable perilaryngeal seal (Fig 3). Other features are a reinforced bite block and a portal for gastric access. A water-based lubricant, endotracheal tie tape or a non-stretch ribbon gauze is needed to insert and secure the placement of the i-gel.

Laryngeal mask airwayThe LMA consists of a wide-gauge tube with an inflatable cuff. The LMA is inserted into the patient’s pharynx and, as with the i-gel, sits over the laryngeal inlet to form a seal (Fig 4). To help insertion, a 50ml luer lock syringe (to inflate the cuff) and a water-based lubricant are needed. Endotracheal tie tape or a non-stretch ribbon gauze is required to secure the placement of the LMA. A range of sizes (3, 4 or 5) may be provided, and the patient’s weight should be used to identify the size that is most appropriate.

An endotracheal tube (ETT) (Fig 5) is considered the ‘gold standard’ of airway management. The wide-gauge tube facilitates ventilation. Once inserted into the trachea, the inflated cuff provides a seal, which:

Most resuscitation trolleys will contain an ETT in sizes 6, 7 and 8, which are an appropriate fit for most adults. The preferred size should be identified by the inserting practitioner.

ETT insertion must only be attempted by experienced and trained practitioners, such as anaesthetists, and theatre, critical care and emergency health practitioners. Incorrect tube placement into the oesophagus that goes unrecognised is often associated with poor patient outcomes (Baker et al, 2022).

The two types of introducers that may be found on the resuscitation trolley are the stylet and bougie (Fig 5), with the choice depending on local trust policy. Both are used to aid a difficult intubation, such as when oedema or laryngospasm is present and the view of the vocal cords is obscured.

A stylet may be used to provide a firm structure to a soft ETT and reshape it as needed to direct the lumen towards the laryngeal inlet. It is inserted into the ETT lumen before insertion into the trachea, and withdrawn once tracheal intubation has been achieved.

A bougie is a softer, more flexible introducer. The narrow tip is passed through the vocal cords and the ETT lumen is taken over the bougie to guide placement into the trachea. Once the ETT is in place, the bougie is carefully removed.

The laryngoscope is used to aid endotracheal intubation. It consists of a handle and separate blade (Fig 5). The blade is clipped into position and provides a light source for visualising the larynx and displacement of the tongue to allow room for the ETT tube to be inserted. Laryngoscope blades may be curved (such as the McIntosh blade, often known as the Mac blade) or straight (Miller blade). Although provision is guided by local policy, the McIntosh is most commonly used in adults. The size of the blade that is needed is identified by the intubating practitioner.

Magill forceps (Fig 5) are long, angled forceps that are used to guide ETT or NT tube insertion or remove foreign bodies from the oropharynx.

Capnography using a capnometer (Fig 5) is the measurement of expired CO2. A capnograph reading can give feedback on ventilation of the patient and, crucially, will identify unrecognised oesophageal tube placement. This makes it an essential requirement of intubation (Royal College of Anaesthetists, 2023).

A variety of devices are available. A single-use colorimetric capnometer fits between the airway device and the ventilation device, and changes colour in the presence of CO2. Increasingly, however, more-sophisticated capnometres are available that are linked to monitoring equipment, such as defibrillators and patient monitoring systems, via tubes to give a constant CO2 measurement in electronic or waveform representation. This latter type of capnometer and tubing is shown in Fig 5.

Catheter mounts (Fig 5) are extensions between an airway device and a ventilation device, such as a BVM. They are flexible tubing that allows movement and flexibility between the devices, thereby protecting the patient’s airway from external forces. A heat and moisture exchanger filter (Fig 5) may be included between the connections to replicate the function of the patient’s upper airway, conserving heat and moisture in the lower airways.

A portable suction unit (Fig 6) should be available on all resuscitation trolleys for when piped suction is unavailable or not stored close to the incident. When not in use, the unit should be plugged in and continuously charging. Staff should be trained in its operation, as well as in the daily checking procedure.

A yankauer is a rigid suction tube that attaches to the portable suction device (Fig 6). It is used to clear secretions from the oropharynx. A selection of longer, deeper suction tubes must also be provided for endotracheal suction. Practitioners must undertake training to ensure the delivery of safe suctioning techniques.

If piped oxygen is unavailable or inaccessible at the scene of the incident, a portable oxygen cylinder will ensure oxygen can be given to the patient. This cylinder may be attached to the resuscitation trolley or located next to it. Practitioners need to be familiar with how to check and operate the oxygen cylinder. Cylinders only contain a limited amount of oxygen so practitioners must make sure they monitor this and know how to get more oxygen supplies.

All practitioners need training in resuscitation that is appropriate to their scope of practice and role, so they can respond effectively when an emergency occurs. Immediate access to familiar, well-maintained emergency equipment will support the delivery of high-quality resuscitation care. Practitioners must not act outside of their level of competence and skill set, and must follow local policy and guidance when using and checking resuscitation equipment.

This procedure should be undertaken only after approved training, supervised practice and competency assessment, and carried out in accordance with local policies and protocols.

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