Airway equipment

AIRWAY EQUIPMENTS

1. BY DR.VYSHNAVI ESIC MEDICAL COLLEGE & SUPERSPECIALITY HOSPITAL SANATH NAGAR, HYDERABAD AIRWAY EQUIPMENT

2. FACE MASK It allows administration of gases to the patient from a breathing system, without introducing any apparatus to the patients mouth. Schimmelbusch mask Yankauers mask The modern face mask can be made up of black rubber, clear plastics, elastomeric material Parts of the face mask-BODY,SEAL,CONNECTOR

3. 1) Anatomical mask : Has slightly malleable rubber body, a sharp notch for the nose and a curved chin section. 2) Rendell-Baker- Soucek (RBS) mask Designed for children of of less than 10 yrs . triangular in shape and has less dead space . can be used in tracheostomised patients. 3) Endoscopic mask : It has port or diaphragm in the body to allow fibroscope insertion. 4) scented mask : used for induction for children.

4. INDICATIONS Ventilation preceding endotracheal intubation: With anaesthesia circuits or circle systems With AMBU resuscitator bags Failed endotracheal intubation Awake or lightly sedated patient requiring a high inspired oxygen concentration CONTRAINDICATIONS Known increased risk of vomiting , regurgitation Known significant airway obstruction

5. ADVANTAGES Requires less anaesthetic depth than tracheal tube or supraglottic device. No need of muscle relaxants Lower incidence of sore throat DISADVANTAGES Anesthesiologist’s hands are tied up Higher fresh gas flows are often needed. Gastric insufflation common if ventilatory pressures frequently exceed 20 cm H2O, Minimal protection from aspiration of regurgitated gastric contents Often more episodes of oxygen desaturation & require more

6. ORAL AND NASOPHARYNGEAL AIRWAYS Extends from lips to pharynx, fitting between tongue & posterior pharyngeal wall. Its parts are: Flange : at the buccal end, to prevent it from moving deeper into mouth & may also serve to fix airway in place. Bite Portion : it is straight & fits between upper and lower sets of teeth Curved portion : extends backwards to correspond to the shape of tongue & palate.

7. Size Colour 000 Violet 00 Blue Black 1 White 2 Green 3 Orange 4 Red 5 Yellow

8. Special airways Guedel Airway : Guedel Airway Most frequently used airway Has large flange & reinforced bite portion with tubular channel for air exchange & suctioning. Waters airway : Waters airway Metallic hollow OPA with 2 holes at pharyngeal end for attachment of oxygen line and suction Cheap, reusable. Safar Airway : S-shaped OPA consisting of two Guedel -type airways soldered together

9. Cuffed Oro- Cuffed Oro-Pharyngeal Airway (COPA) Modification of Guedel`s Airway with an inflatable cuff designed to seal the oropharynx . Has an integral bite block & a 15mm connector for attachment of the breathing circuit. Patil -Syracuse Endoscopic Airway Designed to aid fiber-optic intubation. Made of aluminium . Has lateral channels & a central groove on the lingual surface to allow passage of fiberscope. A slit in distal end allows fiberscope to be manipulated in antero -posterior direction but limits lateral movements.

10. Berman Intubating Airway : It is tubular along its entire length. Open on 1 side so that it can be split & removed from around a tracheal tube. Can be used as an oral airway or as an aid to fiberoptic or blind oro -tracheal intubation Williams Airway Intubator : Designed for blind tracheal intubation & can also be used for fiberoptic intubation or as an oral airway. Available in 2 sizes #9 & #10 which admit upto 8 & 8.5 mm tracheal tube respectively. The proximal half is cylindrical while distal half is open on lingual surface. Ovassapian Fiberoptic Intubating Airway : Designed for fiberoptic intubation.

11. INSERTION,USES,COMPLICATIONS During insertion Pharyngeal & laryngeal reflexes should be depressed before an oral airway is inserted, to avoid coughing & laryngospasm. Selecting the correct size is important. Correct size is estimated by holding the airway next to pts mouth with the tip at the angle of mandible.

12. USES Used to prevent patient from biting & occluding ETT. Protect the tongue from biting To facilitate suctioning To obtain better mask fit. COMPLICATIONS iatrogenic trauma and airway hyperreactivity Ulceration and necrosis of oropharyngeal structures Dental injury

13. NASOPHARYNGEAL AIRWAY A nasal airway is better tolerated than oral airway if the patient has intact airway reflexes. It extends from nose to pharynx The pharyngeal end should be below base of tongue but above the epiglottis. When in place, an NPA is less stimulating than an OPA, hence better tolerated in the awake, semicomatose , or lightly anesthetized patient. In cases of oropharyngeal trauma, a nasal airway is often preferable to an oral airway.

14. NASAL AIRWAY Linder Nasopharyngeal Airway It is plastic with large flange & flat distal end and is supplied with introducer which has balloon on its tip. Cuffed Nasopharyngeal Airway Binasal Airway It consists of 2 nasal airways joined together by an adaptor for attachment to the breathing system. Can be used to administer anesthesia.

15. Uses : Indications : Tongue obstruction Inadequate oral opening Oral Surgery

16. Advantages : Well tolerated even in conscious patient Sizes : (Internal Diameter) Large adult :8-9 mm Small adult : 6-8 mm Contraindications – haemorrhagic disorder basilar skull fracture

17. LARYNGOSCOPES A laryngoscope (larynx + scope) is a device that is used to visualize the larynx and adjacent structures mainly for inserting a tube into tracheobronchial tree. USES: Insertion of nasogastric tube and transesophageal echocardiac probe Foreign body removal Upper airway lesion biopsy Visualizing and assessing the upper airway (vocal cords and larynx) TYPES : Direct Rigid laryngoscopes Indirect Rigid laryngoscopes which use fiberoptics , mirrors, prisms, etc. Video laryngoscopes – Rigid, Flexible Optical stylets Flexible fiberoptic endoscopes

18. LARYNGOSCOPES RIGID LARYNGOSCOPE parts include handle and blade The handle is the part that is held in the hand during use. It provides the power source for the light. Most often this is from disposable batteries. Fibreoptic illuminated laryngoscope may use a remote electrically operated light source. The handle is fitted with a hinge pin that fits a slot on the base of the blade. Handles are available in variable sizes & have rough surface for improved grip

19. TYPES OF BLADES There are several types of blades which may be advantageous in particular situations. Macintosh Blade The Macintosh blade is one of the most popular. The tongue has a smooth, gentle curve that extends from the base to the tip Improved vision Macintosh blade The Improved Vision (IV) Macintosh blade is similar to the standard version except that the mid portion of the tongue is concave to allow greater visualization of the larynx. Oxiport Macintosh (Mac/port) The Oxiport Macintosh blade a,conventional Macintosh blade with a tube added to deliver oxygen

20. Tull Macintosh The Tull (suction) blade is a modified Macintosh that has a suction port near the tip. The suction channel extends next to the handle and has a finger controlled valves so that suction canbe controlled by the laryngoscopist Polio Blade The blade is at an obtuse angle to allow intubation of patients in iron lung respirators or body jackets Patients with obesity, breast hypertrophy, kyphosis with severe barrel chest deformity, short neck, or restricted neck mobility

21. Bizarri-Guiffrida Blade The Bizarri-Guiffrida blade is a modified Macintosh. The flange is removed, except for a small part that encases the light bulb. This was made to limit damage to the upper teeth. The blade is useful for patients with a limited mouth opening, prominent incisors, receding mandible, short & thick neck or anterior larynx. Flexible tip blade It has a hinged tip that is controlled by lever attached to the proximal end of the blade When the lever is pushed towards the handle , the tip of the blade is flexed. Eg : Mc-Coy. It may improve the chances of successful intubation by elevating the epiglottis particularly in case of difficult intubation. Less force and less stress response

22. VIDEO LARYNGOSCOPES The Bullard laryngoscope is useful in patients who are difficult to intubate, including those in whom head and neck movement is limited or undesirable; those with limited mouth opening, poor dentition, pharyngeal or laryngeal pathology, or facial fractures; and the morbidly obese proved useful in children with Treacher Collins and Pierre-Robin syndromes WuScope It combines a rigid, tubular blade & a flexible fiberscope. . The fiberscope has short light & image transmitting fibreoptic bundles & tip deflection contro

23. VIDEO MACINTOSH INTUBATING LARYNGOSCOPE It has macintosh blade attached to the handle. The image- light bundle is threaded through a small guide in the blade & advanced 2/3 of the length of the blade. Provides better view than traditional macintosh laryngoscope. GLIDE SCOPE It has a miniature digital camera underside of a plastic blade. A light emitting device( LED) mounted beside the camera provides illumination. Blade has a 60° bend at the midpoint The Glide Scope is available in adult & pediatric size It causes less cervical movements than macintosh blade

24. COMPLICATIONS OF LARYNGOSCOPY Dental injury/gum injury. Cervical spinal cord injury. Shock or burn. Swallowing/aspiration of foreign body. Laryngoscope malfunction. Circulatory changes. Damage to soft tissues and nerves Laryngoscope malfunctions TMJ dislocation

25. ENDOTRACHEAL TUBES An endotracheal tube is one through which anesthetic gases and respiratory gases are conveyed into and out of the trachea. It has tracheal & machine end The bevel is defined as the slanted part of the tube at the tracheal end. When, an opening in the tube is present on the opposite side of the bevel,it is called as Murphy's tip Standard Markings On an ETT: The markings are situated on the bevel side above the cuff & are read from patient end to machine end Type of the tube: Oral or nasal Size: ID in mm External diameter may also be indicated. Manufacturer's name or trade mark Tube has Graduated markings,showing the distance in cms from the patient end. Precautions are usually noted:Disposable /Do Not Reuse Radio-opaque lines may also be included at the patient end or along full length.

26. Endotracheal tubes

27. REQUIREMENTS OF IDEAL ET TUBE 1) Inertness 2) Smoothness of outer surface to avoid damage to mucosa 3) Inner surface should be smooth and non- wettable to prevent build up of secretions. 4) Non-inflammable 5) Transparent 6) Easily sterilized 7) Non kinking 8) Sufficient strength to allow thin wall construction 9) Thermoplasticity to conform to anatomic passage and to be self centering within the trachea. 10) Non reactive with lubricants or anesthetic agents 11) Latex free 12) Non injurious catheter tip Currently used tubes are manufactured from synthetic rubber, plastic materials and silicone.

28. According to the type of the cuff: There are two types 1. High volume low pressure. : Cuff over a wide area of mucosa ; the pressure exerted varies during the respiratory cycle , but on average is lower than that produced by low-volume cuff. 2. low volume high pressure .: Produce a seal over a smaller areas of tracheal mucosa cells and tend to exert a high pressure on the mucosa ,reducing the capillary blood supply and rendering the cells potentially ischemic. GUIDELINES TO DETERMINE THE SIZE OF ETT: Ideal tube in average Adult male – 8.5mm ID Ideal tube in an average Adult female - 7.5mm ID. Younger than 6 years ---3.5 + age in years/3 = ID in mm Older than 6years ---- 4.5 + age in years / 4 = ID in mm

29. DEPTH OF INSERTION The tube should be in the middle third of the trachea with the head in neutral position. The following calculations can be used. 1) Length in cm = age/2 + 12 2) Length in cm = weight in kg/5 + 12 3) Length in cm = height in cms /10 + 12 4) Length in cm = 3 × ID (mm) In adults, the tube should be passed until the cuff is 2.25 to 2.5cm

30. SPECIFIC TUBES Cole tube : It is uncuffed ETT, designed for pediatric patients. The patient end is smaller in diameter 2mm to 5mm.. for neonatal resuscitation but not for long term intubation. Spiral embedded tubes : Armored tube. metal or nylon spiral woven reinforcing wire covered both internally and externally by rubber, PVC or silicone. A stylet is often needed for intubation. These tubes are esp useful in situations where the tube is likely to be bent or compressed as in head & neck surgery Disadvantages: Insertion through nose & intubating LMA is difficult. Fixation is more difficult. If the patient bites the tube it will cause permanent deformity resulting in obstruction of the tube.

31. SPECIAL TUBES Preformed tubes/Ring-Adair- Elwyn (RAE): There is a preformed bend to facilitate the head & neck surgeries. The tubes are available in cuffed, uncuffed ,nasal and oral version. Each tube has a rectangular mark at the center of the bend. Distance from this mark to the distal tip is printed on each tube. Laryngectomy tube : Designed for insertion into a tracheostomy site. The tube is preformed in a J configuration at the pt end. This allows the part of the tube external to the patient to be directed away from the surgical field. The tip may be short and/or without a bevel to avoid inadvertent advancement into a bronchus.

32. Microlaryngeal tracheal surgery tube : 4, 5 or 6mm Designed for microlaryngeal tracheal surgery. The small diameter provides better surgical access The problems with this tube are incomplete exhalation & occlusion. Tubes with extra lumens: They are useful for respiratory gas sampling, airway pressure monitoring, injection of fluids and drugs & jet ventilation .

33. Laser-shield II Tracheal Tube : It is designed for use with CO2 and KTP lasers. Made from silicone with an inner aluminium wrap and a smooth Teflon outer coating. The cuff is not laser resistant & contains methylene blue crystals and should be inflated with water or saline solution. Laser tubes : This is made of white rubber & has a cuff-within-a cuff design. . The inner cuff is filled with air & outer with water or saline. It is recommended for use with argon, NdYAG , CO2 lasers.

34. Indications for ETT: Increased risk of vomiting or regurgitation High airway pressures anticipated Inaccessibility of airway during the procedure Need for prolonged controlled ventilation, lung isolation Advantages :A patent airway by oral, nasal or tracheal routes 2. Controlled ventilation with up to 100% oxygen 3. Ventilation with high airway pressure 4. Airway protection from aspiration 5. Removal of secretions 6. Lung isolation 7. Administration of medication including anesthetic gases

35. Disadvantages difficult to place than others Most stimulating to the patient during placement Coughing during and after extubation and emergence Usually requires neuromuscular blocking drugs to place Can lead to death if esophageal misplacement unrecognized Complications: Coughing and straining at emergence and extubation Post- extubation laryngospasm, Hypertension/tachycardia, Bronchospasm, Hoarseness of voice, sore throat Unrecognized esophageal intubation

36. BOUGIE,STYLET,LIGHT WAND These encompass a series of solid or hollow, semimalleable stylets that may be blindly manipulated in to the trachea The Eschmann introducer(gum elastic bougie ) , was introduced in 1949. It is 60 cm long, 15Fr-gauge, and angled 40degrees 3.5 cm from its distal end It very helpful when the larynx cannot be visualized with laryngoscopy Once it has entered the larynx and trachea distinctive “clicking” feel is elicited as the tip passes over the cartilaginous structures

37. The Frova Intubating Introducer is a disposable device, with an optional “stiffening” stylet and a hollow bore. The internal lumen allows for the insufflation of oxygen, the detection of carbon dioxide, and the use of a self-inflating bulb to detect inadvertent esophageal placement. Light wand: malleable stylet with light emanating from distal tip. dim lights in OR and pass wand blindly 1.glow in lateral neck:tip in pyriform fossa 2.glow in anterior neck:correctly positioned in trachea 3.glow diminishing slowly:tube in oesophagus .

38. SUPRA GLOTTIC AIRWAY DEVICES Supra glottic airway devices are those which are placed above the glottis and thereby helps in providing adequate ventilation. Easy to operate. Helpful in difficult airway conditions. INDICATIONS Difficult intubation conditions Small procedures CPR Essential part of difficult airway trolley CONTRAINDICATIONS Airway edema,local pathology in upper airway Stridor,trismus,restricted mouth opening Active vomiting Caustic ingestion Pregnants,obese patients Reduced lung complaince

39. BASED ON SEALING MECHANISM

40. BASED ON NUMBER OF LUMEN SINGLE LUMEN DEVICES : LMA classic, LMA unique, LMA flexible, ILMA, C trach , LAD, PAX,CPLA, LT, SLIPA DOUBLE LUMEN DEVICES : Proseal LMA, Combitube , LTS, Airway management device (AMD ) TRIPLE LUMEN DEVICES : Elisha airway device (EAD)

41. ADVANTAGES Increased speed and ease of placement. Less requirement of Inadequate positive expertise. Improved hemodynamic stability at induction and during emergence of anesthesia. Minimal IOP and ICP changes during insertion. Increase airway tolerance. Lower frequency of coughing during emergence DISADVANTAGES Vascular compression and nerve damage Sore throat Gastric aspiration chances are high High airway pressures.

42. The Laryngeal Mask Airway Comprised of three main components – Airway Tube,mask,inflation line Mask designed to conform to the contours of the hypopharynx with its lumen facing the laryngeal opening. Made of silicone, it can be autoclaved and reused many times. Seal pressure =25cmH2O

43. TYPES OF LMA LMA UNIQUE Single use , PVC made , cheaper. Tube – stiffer , Cuff- less compliant. Less rise of intracuff presuure with N2O. More difficult to insert. Size same as cLMA . FLEXIBLE LMA Flexometallic tube- narrower & longer. Has a rigid preformed angle at the cuff. Seal pressure=20cmH2O Introducer helps to stabilize the airway tube during insertion & it is removed once mask is in place. It has a less incidence of dislodgement once placed. More useful in head & neck surgeries, ENT and upper torso procedures where need to reposition the airway is prevalent

44. TYPES OF LMA AMBU AURA LARYNGEAL MASK Ambu Auraonce - single-use LM with a preformed curve. The Ambu Aura40 is the reusable, silicone version of the Ambu AuraOnce . The Ambu Aura-i designed to facilitate intubation like ILMA. Three parts- an airway tube, a mount area, and a bowl including the inflatable cuff.. A reinforced tip reduces the risk of the device folding back during insertion. SOFT SEAL LARYNGEAL MASK similar to the single-use LMA. The ventilation orifice is wider and Cuff is more elliptical.. A maximum intracuff pressure of 60 cm H2O is recommended. may be used as an intubation conduit.

45. PERI LARYNGEAL AIRWAY(COBRA) single use, PVC made, latex free . It has a breathing tube with a large inner diameter Novel head design- Grill of soft bar with Cobra head shape.Lies infront of laryngeal inlet. Tip deflects epiglottis. Bars allow ventilation & instrumentation. I-LMA A modification of the c-LMA. A rigid (stainless steel) anatomically curved,short & wide bored shaft that follows the anatomical curve of the palate and the post pharyngeal wall. An epiglottic elevator bar at the mask aperture. Armoured flexible ET tube with a longitudinal and a horizontal black line coincides with the epiglottic elevating bar. The Stabilizer Rod of 25cm. Seal pressure=60cmof H20

46. PRO-SEAL LMA Reusable , silicon made , modification of c-LMA Modifications:- (i) oesophageal drain tube (ii) posterior inflatable cuff (iii) reinforced airway tube (iv) integral bite block (v) introducer Higher leak pressure(35cm of H2O) than c-LMA(25cm of H2O). Size- in 7 sizes (1-5) like the C-LMA with drainage tube of 8,10,10,14,16,16&18 Fr respectively

47. LMA SUPREME Single use, PVC made 2nd generation LMA. Has features of P-LMA, I-LMA & LMA unique. (i) Single use , PVC (iii) Oesophageal drain tube (iv) Preformed semi-rigid tube Pharyngeal seal is intermediate between cLMA and PLMA(26–30 cm H2O) LMA C-TRAC Enables combined ventilation, visualization, and intubation. High first attempt intubation success rate of 91%. Fiberoptic technology allows real time visualization of the glottic opening and of the ET tube passing through the vocal cords. Ideal in rescue/difficult airway situations . Completely portable and wireless system less weight

48. LARYNGEAL TUBE Laryngeal tube introduced in 1999. Consists of silicon reusable airway tube with two cuffs ( pharyngeal&esophageal ) and a single ballon for pressure control and a 15 mm standard male adapter. Short & J shaped ; blind tip,average diameter 11.5mm. Sizes -0,1,2,3,4,5. Both cuffs are high volume & low pressure to avoid ischemic damage Wedge shaped block closes the tip of the tube which divert the air into trachea Single inflation line 2 or 3 side eyelets- for collateral ventilation

49. LARYNGEAL SUCTION TUBE Laryngeal tube suction(LTS) is a double lumen silicon tube . 2 nd lumen helps in gastric suctioning & insertion of nasogastric tube.

50. STREAMLINED LINER OF THE PHARYNX AIRWAY SLIPA –named because looks like a slipper. Developed by DR.Donald miller. Low cost Commercially available since 2004.

51. It is a soft plastic with an anatomically preformed shape that lines pharynx. Parts –hollow , blow molded chamber shaped lile a boot with a >toe > bridge >heel Design aims at relieving pressure & prevents damage to hypoglossal & rec laryngeal nerve. Minimization of aspiration risk with out cuff necessicite doubling in size of devices. Sizes – 47,49,51>females:53,55,57>males. ADVANTAGES Simple device. Inexpensive. Less risk of aspiration compared to other SGA. Doesn’t require relaxant or laryngoscope. No cuff. Controlled or spontaneous ventilation. Less incidence of sore throat. DISADVANTAGE --selection of correct size.(width of thyroid cartilage ) correct size

52. ELISHA AIRWAY DEVICE Reusable one. Functions ventilation, blind or fiberoptic intubation without interruption of ventilation, gastric tube insertion. Main advantage : drain gastric contents by gastric tube.

53. PHARYNGEAL AIRWAY XPRESS Paxpressa Used during routine procedurs Parts curved tube with anatomically shaped grilled tip, a large oropharyngeal cuff, open 3.5cm hooded window between these two. Hood is to lift the epiglottis forward. Blind insertion. Flexible gilled tip fits into hypopharynx. High volume low pressure cuff placed below uvula  better airway seal. Used in spontaneous or controlled ventilation. Main advantage  fiberoptic bronchoscope or 7.5 size ET tube can be inserted

54. I-GEL Unique , single use. Made from thermoplastic elastometer . Designed non inflatable,anatomic seal of airway structures. Available in 3 sizes ( red,green,yellow ). ADVANTAGES Ease of insertion, Less incidence of trauma, Gastric channel, Integral bite block reduces the possibility of airway obstruction, Less incidence of down folding of epiglottis & obstruction.

55. COMBITUBES This design, named the Tracheal Esophageal Combitube , is functional if introduced into the esophagus (ventilation being achieved through the esophageal lumen, via the hypopharyngeal perforations) or in the trachea (ventilation being achieved through the tracheal lumen, via the distal aperture). The device is available in two sizes: the 41Fr size is used for larger adults (height >5.5 feet) and the 37Fr size is used for adults 4 to 6 feet tall Though a single-use device, Combitube reprocessing and reuse has been reported The oropharyngeal balloon is inflated with 100 mL of air through a blue plastic pilot balloon (85 mL in the small adult size) while the distal cuff is inflated with 5 to 15 mL (via a white pilot balloon).

56. USES massive upper gastrointestinal bleeding or vomiting, a rescue device in failed rapid-sequence induction or unanticipated difficult intubation. useful in the morbidly obese, in acute bronchospasm, during cardiopulmonary resuscitation, and for prolonged ventilation after airway rescue. rapid airway control, airway protection from regurgitation, ease of use by the inexperienced operator, no requirement to visualize the larynx, and being able to maintain the neck in a neutral position

57. AIR Q-SP The Air-Q is a new supraglottic airway device designed for airway maintenance and also as a conduit for endotracheal intubation during general anaesthesia . advantage of the device design is that conventional PVC endotracheal tube can be passed through the Air-Q ILA to intubate the trachea (up to 7.5 and 8.5 mm ID through Air-Q size 3.5 and 4.5, respectively) without the use of conventional laryngoscope. Armoured endotracheal tubes can also be used with Air-Q ILA as conduit.

58. Thank u