Airway management- INTUBATION.pptx

Airway Management - Intubation

1. AIRWAY MANAGEMENT VIKRAM SINGH RAJAWAT M.Sc (M), M.Sc (N), MBA JNUIMSRC, JAIPUR

2. “ M anagement of the P atient’s A irway ”

3. What should we know about “airway management”? Airway anatomy and function Evaluation of airway Clinical management of the airway Maintenance and ventilation Intubation and extubation Difficult airway management

4. Airway anatomy The term “airway” refers to the upper airway, consisting of Nasal and oral cavities Pharynx Larynx Trachea Principle bronchi

5. Anatomy of upper airway

6. Larynx in laryngoscopic view

7. Nerves V 1 V 2 V 3 IX

8. Vagus nerve Superior laryngeal n External br (Motor) cricothyroid m Internal br (Sensory) area above cord Recurrent laryngeal n - Motor br intrinsic m Sensory br area below cord SL RL

9. Evaluation of the airway History Physical examination Special investigation

10. Evaluation of the airway “History” Previous history of difficult airway Airway-related untoward events Airway-related symptoms/diseases

11. Evaluation of the airway Physical examination Ease of open airway and maintenance Ease of tracheal intubation Teeth Neck movement Intubation hazards Signs of airway distress

12. Evaluation of the airway Anatomic characteristics associated with difficult airway management Short muscular neck Receding mandible Protruding maxillary incisors Long high-arched palate Inability to visualize uvula Limited temporomandibular joint mobility Limited cervical spine mobility Interincisor distance < 2 FB or 3 cm

13. Evaluation of the airway Mallampati’s classification Hyoid-mental distance Thyromental distance Horizontal length of mandible Sternomental distance Assessment of airway associated with difficult airway management > Class III Atlanto-occipital joint extension < 35 O < 3 cm or 2 FB < 6 cm or 3 FB < 9 cm < 12 cm

14. Mallampati’s classificaton Soft palate Fauces Uvula Soft palate Hard palate Soft palate Fauces Uvula Pillar

15. Signs of upper airway obstruction/airway distress Hoarse voice Decreased air in and out Stridor Retraction of suprasternal / supraclavicular / intercostal space Tracheal tug Restlessness Cyanosis

16. How to open the airway? Non equipment With equipment :- head tilt / chin lift / jaw thrust :- oral/nasopharyngeal airway endotracheal intubation laryngeal mask airway (LMA) tracheostomy

17. Basic Airway Management (Manual / Non equipment) Head tilt Chin lift Jaw thrust

18. Face Mask 22 mm orifice Transparent/ black rubber Hook Minimize dead space

19. One-handed face mask technique

20. Two-handed face mask technique

21. Indications for tracheal intubation Airway protection Maintenance of patent airway Pulmonary toilet Application of positive pressure ventilation Maintenance of adequate oxygenation Route for emergency drug during cardiac arrest

22. Technique of Direct Laryngoscopy & Intubation

23. How is the best l ary ngo sc op i c view achieved?

24. “Sniffing Position”

25. 01 / 1 1 / 56 B en c h a r a t an a Y o k u b o l 28 Cormack - Lehane grading system Laryngoscopic view ( LV classification ) Grade I Grade II Grade III Grade IV

26. Oral endotracheal tube size guideline Age Int diameter (mm) Leng t h (cm) Full term 3.5 12 Child 4 + Age/4 12+ Age/2 Adult F e m a l e Male 7.0 – 7.5 7.5 – 8.0 20-23 21-24

27. Preparation for Rigid Laryngoscopy Suction Airway Laryngoscope Endotracheal tube (ET or ETT) Stylet Anesthetic machine / Breathing system / Self- inflating bag Monitoring : Pulse oximeter, Capnograph, ECG Local anesthetics infiltration / spray

28. Stylet

29. Signs of Tracheal Intubation Respiratory gas moisture disappearing on inhalation and reappearing on exhalation Chest rise & fall No gastric distention ICS filling out during inspiration Reservoir bag having the appropriate compliance

30. Signs of Tracheal Intubation Breath sounds over chest wall No breath sounds over stomach Hearing air exit from ET when chest is compressed Large spontaneous exhaled tidal volumes

31. Signs of Tracheal Intubation “More reliable signs” CO 2 excretion waveform Rapid expansion of a tracheal indicator bulb

32. Signs of Tracheal Intubation “ Most reliable signs” ET visualized between vocal cords Fiberoptic visualization of cartilaginous rings of the trachea and tracheal carina

33. Techniques for routine intubation (Preoxygenation) Administration of induction agent Adequate mask ventilation Administration of neuromuscular (NM) blocking agent Continue mask ventilation Intubation Confirm ET in trachea

34. Techniques for “rapid-sequence” (crash) induction and intubation Preoxygenation 5 min ( or 8 deep breaths ) Administration of induction and NM blocking agents Cricoid pressure (Sellick’s maneuver) “No” mask ventilation Intubation Check ET in trachea Release cricoid pressure

35. Cricoid Pressure (Sellick’s maneuver)

36. Complications: During laryngoscopy & intubation While tube in place Following extubation

37. Complications: During laryngoscopy & intubation Malpositions Esophageal intubation Bronchial intubation Trauma Dental damage Lip, tongue, pharyngeal, laryngeal, tracheobronchial injuries Dislocated mandible Retropharyngeal dissection Cervical spine injury Aspiration

38. During laryngoscopy & intubation Physiologic reflexes HT, arrthymia Intracranial HT Intraocular HT Bronchospasm Tube malfunction Cuff perforation Complication:

39. Oropharyngeal airway Nasopharyngeal airway

40. While tube in place Malpositioning Unintentional extubation Endobronchial intubation ET cuff malposition Airway trauma Mucosal inflammation Excruciation of nose Tube malfunction Ignition Obstruction / Kinking Aspiration Complications:

41. Following Extubation Airway trauma Edema, Stenosis Hoarseness / Sorethroat Laryngeal trauma / malfunction Physiologic reflexes Laryngospasm Aspiration Complications:

42. A irway Management

43. Techniques of Intubations Oral/Nasal Airway Insertion Two-person mask ventilation Laryngeal mask airway (LMA) Esophageal-tracheal combitube Surgical airway access

44. Two person Mask Ventilation Se c on d person Three-hand jaw-thrust/mask seal Two-hand jaw-thrust/mask seal First person First person Second person

45. Laryngeal Mask Airway

46. The Esophageal-tracheal combitube

47. Surgical airway management : Percutaneous cricothyrotomy

48. Stylet Awake intubation Blind intubation (oral or nasal) Fiberoptic intubation Illuminating stylet / Light wand Surgical airway access Techniques for Difficult Intubation

49. Stylet

50. Bullard l a r y ngoscop e

51. Illumination Stylet Light wand

52. Supragloltic airway (SGA) Laryngeal mask airway (LMA) Intubation LMA (ILMA) Laryngeal tube

53. Thank you