Airway management final

Airway Management

1. AIRWAY MANAGEMENT By Dr Siti Salihah

2. OBJECTIVES

3. Review airway anatomy Review basic airway maneuvers Review blind insertion airways R eview advance airways

4. Upper and lower Airway

5. Airway Anatomy Upper airway Pharynx Epiglottis Glottis Vocal cords Larynx Lower airway Trachea Bronchi Alveoli Lung tissue, consisting of lobes and lobules (3 on the right and 2 on the left) Pleura

6. Basic Airway Manouvers These skills should be used prior to initiating any advanced airway technique Head-tilt/chin lift Jaw thrust Modified jaw thrust (for trauma patients) Sellick’s maneuver

7. Airway Manouvers . O ropharyngeal airway. Nasopharyngeal airway LMA C ombitube

8. Oropharyngeal Airway

9. Size is measured from the corner of the mouth to the angle of the jaw Sizes range from 0-6 It holds the tongue away from the posterior pharynx, but does not isolate the trachea

10. - The oral airway is inserted with the curve towards the side of the mouth - Then rotated so that the curve of the airway matches the curve of the tongue

11. Nasopharyngeal airway

12. Soft plastic or rubber tube that is designed to pass just inferior to the base of the tongue. Passed through one of the nares and can be used in patients with an intact gag reflex. CONTRAINDICATED in cases of suspected or possible basilar skull fracture Sizes range from 17-26 cm in length and 6-9 mm internal diameter. Measured from tip of the nose to the corner of the patients ear

13. The nasal airway is lubricated with a water soluble lubricant. The beveled tip is inserted directed towards the septum, with the airway directed perpendicular to the face If resistance is met, rotating the airway may help or the other nare may be used

14. Blind Insertion Airways LMA (Laryngeal Mask Airway ) Combitube Blind insertion airways considered an alternative airway control device to be used when intubation is unsuccessful They do not require visualization of the vocal cords

15. Laryngeal MASK Airway

16. Sits over the glottic openin g Available in different sizes Has a drain tube to aid in gastric suctioning. With some versions an endotracheal tube may be passed through to aid in intubation

17. Combitube

18. - It consists of a cuffed, double-lumen tube that is inserted through the patients mouth to secure an airway and enable ventilation . The distal tube (tube two) enters the esophagus, where the cuff is inflated and ventilation is provided through the proximal tube (tube one) which opens at the level of the larynx Inflation of the cuff in the esophagus allows a level of protection against aspiration of gastric content similar to that found in the laryngeal mask. It is available in two sizes: 37 Fr (for patients 4 to 6  ft or 122 to 183 cm tall) and 41 Fr (for patients more than 5  ft or 152 cm tall ).

19. Endotracheal intubation Surgical airways ADVANCE AIRWAYS

20. Indications of Endotracheal I ntubation 1) Depressed level of consciousness: Stupor / coma, status epilepticus . GCS < 8 . 2) Hypoxemia paO2 < 60mmHg while breathing an inspired O2 concentration ( FiO2) of 50% or greater. Worsening respiratory acidosis, PaC )2 greater than 45mmHg. ( eg : AECOAD ) 3) Airway Obstruction Eg when a foreign body becomes lodged in the airway, or direct injury to the face or neck causing swelling and an expanding hematoma.

21. Endotracheal intubation procedure 1) Assemble all needed equipment, while patient is being ventilated. Choose appropriate ET tube size Check balloon with 10cc of air Assemble laryngoscope and check light Connect and check suction 2) Position patient in “head tilt chin lift” position. IMPORTANT-If C-spine injury is suspected have an assistant hold the patient’s head in a neutral position .

22. 1. Usually female adults:7-8mm Male adults:8-9mm 2. Paediatric ages 1-12 using formula Predicted Size Uncuffed Tube = (Age / 4) + 4 Predicted Size Cuffed Tube = (Age / 4) + 3 3. For children ages 12 and below , use ET tube reference card

23. Assessment of difficult airway intubation 4D approach Dentition : Large or loose teeth, dentures Distortion : presence of vomitus , secretions, blood, bone fragments obscuring airway Disproportion – Receding chin with large tongue, buck teeth Dysmotility : TMJ and neck mobility . Preoxygenation : A lways preoxygenate the patient with 100% oxygen prior to intubation. At least for 5 minutes . )

24. “ Administration of 100% oxygen with non –rebreathing mask for 5 minutes replaces the nitrogen of room air in the Functional residual capacity ( FRC) in the lungs with oxygen, allowing several minutes of apnea time. ( In a healthy 70kg adult, up to 8 minutes of apnea time ”

25. Pretreatment Administration of drugs to mitigate the adverse effects asociated with intubation. .

26. Paralyzing agent:

27. Paralysis with Induction: This is the most vital step of the sequence. Induction agent is given as a rapid push followed immediately by a rapid push of succinylcholine

28. P ositioning: 1) Sellicks manoueuvre or application of cricoid pressure . 2) Patient is then positioned for laryngoscopy. 3) Lift straight up on the blade to expose posterior pharynx . 4) Identify the epiglottis, straight blade should slip over the epiglottis. With further, gentle traction, identify trachea and arytenoid cartilages and vocal cords 5) Insert ET tube along the blade, into the trachea and advance the tube 1-1.5 inches beyond the cords and inflate the cuff . 6) Attempts at intubation should not exceed 30 seconds and 2 attempts. Get expert help if you are unable to intubate.

29. Placement and Proof: Chest rise. Bilateral breath sounds; Tube fogging; Calorimetric end-tidal carbon dioxide; and Continuous waveform capnography .    Post-intubation management: Secure endotracheal tube Initiate mechanical ventilation Do chest X-ray to ensure main stem intubation has not occurred . ( The distal tip of a properly positioned tracheal tube should be located in the mid-trachea, roughly 2 cm (1 inch) above the bifurcation of the carina .)

30. Surgical Airway

31. An emergency surgical airway is only indicated when there is an inability to intubate the trachea in the presence of an unrelieved airway obstruction. Indications for surgical airway : Failure of ETT insertion due to laryngeal oedema. Severe maxillofacial injury that distorts the anatomy. Severe oropharyngeal haemorrhage that prevents vocal cord visualisation

32. 1 . Cricothyroidotomy 2 2.Tracheostomy

33. Thank You