airway management.pptx

Airway Management-BLS TECHNIQUES-MUKESH SUNDARARAJAN

1. MUKESH SUNDARARAJAN

2. OBJECTIVES: At the end of the class the student will be: To define Airway management. To enlist the clinical features of airway obstruction. To discuss the respiration arrest. To demonstrate the Basic airway maneuvers. To demonstrate the basic air adjuncts. To demonstrate the advance air device. To explain procedure of the Intubation. To elaborate the Adjuncts for intubation. To discuss about the Surgical Airway management.

3. INTROD U CTION Patients in any healthcare setting can quickly become acutely unwell, and assessment and management of the airway is always the priority in any clinical situation (Resuscitation Council UK, 2021). When patients are critically unwell, there is a high risk of respiratory deterioration, and many patients require an artificial airway to facilitate their treatment. Knowing how to assess and manage the airway is a key skill for the nurse working in critical care.

4. INTR O DUCT I ON Airway management is the practice of evaluating, planning and using a wide array of medical procedures and device for the purpose of maintaining or restoring a safe, effective pathway for oxygenation and ventilation. These procedures are indicated in patient with airway obstruction, respiratory failure, or a need for airway protection.

5. DEFINI T ION OF AIRWA Y MANAGEMENT Airway management involves ensuring that the patient has a patent airway through which effective ventilation can take place. Obstruction of the airway may be partial or complete and may occur at any level from the nose to the trachea.

6. CL I NI C A L FEAT U RES OF AIRWAY OBSTRUCTION Complete Airway Obstruction Inability to speak or cough Inaudible breath sounds Paradoxical movement of the chest and abdomen Profound hypoxia Partial airway obstruction Noisy breathing Snoring Stridor Hoarse voice Gurgling from secretions Hypoxia or hypercarbia

7. CLI N ICAL FEATURE S OF AIRWAY OBSTRUCTION Airway obstruction Facial trauma Burn injury and/or inhalational injury Progressive angioedema Known or suspected foreign body aspiration Known laryngeal or pharyngeal cancer Loss of airway protective reflexes Reduced GCS (traditionally ≤ 8) Ability to comfortably tolerate an oral airway Inability to swallow secretions Procedural sedation or general anaesthesia.

8. RES P IRATION ARR EST Definition “Respiratory arrest is the complete cessation of breathing in patients with a pulse.”

9. ETIOLOGY – EXTRAPULMONARY CNS Depression Respiratory muscle weakness External forces Airway obstruc tion

10. ETIOLOGY – PULMONARY Airway Obstru c tion Impaired alveolar diffusion

11. CLI N ICAL FEATUR E OF RES P IRATORY ARREST General Cyanosis Tachycardia Diaphoresis CNS impairment (e.g., altered mental status, agitation, coma) Additional in imminent respiratory arrest Abnormal respiration (eg, gasping, expiratory wheezing, inspiratory stridor) Sternoclavicular and/or intercostal retractions.

12. RESPIRATORY ARREST Diagnostics Clinical evaluation (ABCDE approach) ABG: decreased PaO and increased PaCO Pulse oximetry Management Intubation Mechanical ventilation In case of obstruction, airway opening maneuvers Respiratory and cardiac monitoring Treatment of underlying conditions

13. RES P IRATORY ARR EST Complications Hypoxic organ damage (eg., Hypoxic brain injury) Cardiac arrest

14. BASIC AIRWAY MANEUVERS

15. HEA D - TILT/CH I N - LIF T MANEUVER “A method of opening the airway that involves head and neck repositioning. It should be avoided if there is concern for C-spine injury.” • Technique 1. Tilt the head of the patient posteriorly to 15- 30°. 2. Lift the chin with the fingers to pull the tongue and oropharyngeal soft tissue anteriorly. 3. Use the fingers of the same hand to apply pressure below the lip, slightly opening the mouth. 4. Maintain this "sniffing position" to align the oral, pharyngeal, and laryngeal axes.

16. JA W - THRUS T MANEUVER “The mandible is moved anteriorly to open the airway. May be used in conjunction with head- tilt/chin-lift or alone in patients with suspected C-spine injury.” • Technique 1. With the patient supine, place fingers behind the angles of the lower jaw. 2. Move the jaw anteriorly to pull the base of the tongue and soft tissues away from the airway. 3. Use the thumbs to open the mouth slightly. https: //w ww .youtube.com/watch?v=5iwogajl-n8

17. THE RECOVERY POSITION “ positioning of the patient in a lateral decubitus position with slight neck extension “ Aim Prevention of airway occlusion by the tongue and soft tissues Reduction in the risk of aspiration if patients regurgitate

18. THE RECOVERY POSITION Indications Prehospital settings Temporal airway compromise that can be managed by positioning alone (e.g procedural sedation, alcohol intoxication) Contraindications C-Spine immobilization Anticipated worsening of airway compromise Transportation outside of a monitored environment

19. BAG-MASK VENTILATION “Delivery of oxygen and provider-assisted breaths using a bag-valve-mask unit to patients with inadequate ventilation.” Indications Bridge to intubation - Patients with acute respiratory failure - Preoxygenation prior to general anaesthesia Rescue ventilation: Use after failed intubation attempt (e.g., when safe apnea time has been exceeded) or accidental oversedation. CPR

20. PROCEDUR E OF BMV Create a mask seal EC-clamp technique (one-person technique ): commonly used in elective perioperative situations when the provider is alone. 1. With the patient supine, lift the jaw towards the mask using the 3rd, 4th, and 5th fingers of one hand, forming an E- shape 2. Squeeze the mask onto the face with the thumb and index finger of the same hand, forming a C-shape. 3. Deliver breaths with the second hand.

21. PROCEDUR E OF BMV Two-person bag-mask-ventilation technique: used in emergency settings in which the patient is deteriorating or ventilation is difficult, since it is more effective. 1. One provider makes a seal and opens the airway with both hands: - Squeeze the mask to the face using the eminences of both hands, placed along the sides of the mask with the thumbs pointing inferior - Perform a jaw-thrust maneuver using all 4 fingers of both hands. - A two-handed EC-clamp technique may also be used. 2. The second provider delivers breaths. https://ww w.you tube.com/watch?v=zUGw90iL0Qw

22. PRO C EDUR E OF BMV Provide breaths: Set minute ventilation Aim: Deliver 500-600 mL (6-7 mL/kg) volume at 10-12 breaths/minute. Procedure: Squeeze the bag slowly and gently over approx. 1 second before allowing it to fully reinflate. Repeat every 5 seconds. Adjust based on the clinical situation : E.g., follow compression-to-breath ratio in patients undergoing CPR without an advanced airway (e.g., 30:2). Confirm adequacy of BMV Clinical: No leaks around mask, Bilateral chest rise, Air entry on auscultation of bilateral lung fields Monitoring Oxygen saturations in target range Normal capnometry (waveform and EtCO2 value)

23. ANTICIPATIO N AN D COMPLICATION OF BMV COMPLICATION Poor mask seal or difficulty opening airway: Recommendation: Switch to 2 person BMV technique If this fails, insert a supraglottic device (eg, LMA) for ventilation. Poor chest rise: Reposition, Check for obstruction, Use basic airway adjuncts. Inadvertent hyperventilation Commonly occurs in stressful resuscitation scenarios, can lead to: stomach hyperinflation, vomiting, and aspiration, increase intrathoracic pressure, decease cardiac output. Prevention: maintain steady pressure and depth of bag compression. Hypoxia during apneic period Ensure adequate preoxygenation.

24. BASIC AIRWAY ADJUNCTS These devices may be used alongside bag-mask ventilation or airway opening maneuvers to improve airway patency.

25. OROPHARYNGEAL AIRWAY (OPA) Description: a rigid curved device placed in the mouth to prevent the tongue from occluding the airway Indications Unconscious patients with a large tongue, obstructed nasal passages, or copious nasal secretions Typically used as a bridge to intubation Contraindications: conscious patient with intact gag reflex Sizing rule: from the incisors to the angle of the mandible, or corner of the mouth (oral commissure) to the earlobe Insertion technique: Adults: Insert concave up or concave lateral until past the tongue and then rotate until concave down. Ensure OPA has bypassed the tongue and is not pushing it backwards. Further management: Toleration of an oropharyngeal airway indicates an at-risk airway; preparations should be made for intubation.

26. Procedure Additional information/rationale If too short the airway would not separate the soft palate from the posterior wall of the pharynx; too long may displace the epiglottis. 1. Select appropriate size. 2. Where no risk of cervical spine injury exists, hyperextend the head and neck. Grasp the patient’s jaw and lift anteriorly. Stretches the anterior neck structures to relieve obstruction of the soft palate and epiglottis. 3. Using other hand, hold the OPA at its proximal end and insert it Avoids unnecessary trauma to the delicate tissues in the mouth into the patients mouth with the tip pointing towards the roof of and inadvertent blocking of the airway by pushing the tongue the mouth. back. 4. Once the tip reaches the level of the soft palate, gently rotate the airway 180° until it comes to rest over the tongue. Brings the OPA into the alignment required for use. 5. The flattened, reinforced section of a correctly sized OPA should lie between the patient’s teeth/dentures or gums. The lips should not be pulled over the flange of the OPA as this may cause damage to the labial frenulum. Acts as a bite block. 6. Verify appropriate position by listening for clear breath sounds and looking for chest rise and fall. Ensures correct placement.

27. SIZ E OF OPA

28. https:/ /w w w.youtube.com/watch?v=Hzc_T4QBp4E

29. NASOPHARYNGEAL AIRWAY Description : a long flexible tube inserted into the nostril and down into the nasopharynx to prevent the tongue from occluding the airway Indications: conscious or unconscious patients with current or potential oropharyngeal obstruction Contraindications: facial fractures, basilar skull fractures Sizing rule: nostril to the ipsilateral tragus Equipment required Range of nasopharyngeal airways Sterile gloves Sanitizer Sterile tray Water-based lubricant

30. Procedure 1. Select appropriate size, 7.0 as a starting point for an average adult male and 6.0 for an average adult female. Additional information/rationale Once the selection has been made, measure from the tip of the nose to the tragus of the ear. Insert safety pin to mark the maximum depth of insertion (this should be at the proximal end of the NPA). Where no risk of cervical spine injury exists, hyperextend the head and neck. Lubricate the exterior of the tube with a water-soluble gel. If there is no obvious nasal deformity, it is recommended that the right nostril be used. Where deformity exists, the most patent nostril should be selected. If inserting into the left nostril the bevel is placed alongside the septum and the airway rotated through 180° when it enters the nasopharynx. Insert the tube into the selected nostril and follow the nasal floor parallel to the mouth. It is imperative that the airway is not pushed in a cephalad direction. Avoid pushing against any resistance. If resistance is felt, remove the airway, review technique and reinsert using the other nostril. If too short the airway would not separate the soft palate from the posterior wall of the pharynx; if too long may enter either the larynx or vallecula where the airway could become obstructed. Stretches the anterior neck structures to relieve obstruction of the soft palate and epiglottis. Minimises trauma during insertion. The bevel of the NPA is designed to cause less trauma to the mucosa when inserted into the right nostril. To minimise trauma to the internal nares. This ensures correct location and reduces risk of cranial insertion where basal skull fracture exists. Pushing against resistance may cause bleeding and kinking of the NPA. Verify appropriate position by listening for clear breath sounds and looking for chest rise and fall. Air may also be felt at the proximal end of the airway in the spontaneously breathing patient. Check to make sure there is no blanching of the patient’s nostrils. If there is, remove NPA and select a smaller diameter. Ensures correct placement. Prevents necrosis of the tissues.

31. https://oxfordmedicaleducation.com/clinical-skills/procedures/nasopharyngeal-airway/

32. SIZE

33. ADVANCE AIRWAY DEVICE

34. SUPRAGLOTTI C AIRWA Y DEVICE Definition: a collection of advanced airway devices that are inserted via the oropharynx to provide ventilation from above the glottis Indications Cardiac arrest (pre-hospital and in-hospital), as they can be inserted by providers untrained in intubation First-line for short durations of anesthesia As an alternative advanced airway if intubation has failed Contraindications: Avoid in conscious patients with an intact gag reflex. Caution: does not offer complete protection against aspiration, unlike an endotracheal tube

35. LARY N GEAL MASK AIRWAY (LMA) The laryngeal mask airway (LMA) comprises a wide-bore tube with an elliptical inflatable cuff designed to seal around the laryngeal inlet. The proximal end of the tube is fitted with a standard 15/22 mm connector. The LMA can be placed blind, requires less skill and is easier to insert than a tracheal tube. The LMA provides for more efficient ventilation than with a bag-valve-mask (BVM)

36. A. LARYNGEAL MASK AIRWAY (LMA) “a supraglottic device consisting of an inflatable mask attached to the end of a tube.” Second-generation LMAs feature safety adaptations such as bite blocks and a drainage tube. Intubating LMAs (ILMA) feature additional adaptations to allow passage of an ET tube through the LMA .

37. B. I-GEL®: a type of supraglottic airway that is similar in structure to the LMA. However, the mask is anatomically-molded, noninflatable, and made of a soft gel-like material.

38. C. LARYNGEAL TUBE AIRWAY (LTA) An airway device consisting of a tube with 2 inflatable c ) uffs and ventilation holes between them. • Intubating LTAs feature additional adaptations to allow passage of an ET tube through the LTA.

39. SIZING OF A LARYNGEAL MASK AIRWAY S i z e Age/weight range Maximum cuff inflation (mL air) 1 1.5 2 2.5 3 4 5 Neonates up to 5 kg Children 5–10 kg Children 10–20 kg Children 20–30 kg Children 30–50 kg Small/normal adults Normal/large adults 4 7 10 14 20 30 40

40. EQUIPMENT REQUIRED LMA – range of sizes 50 mL syringe Tie Lubrication Stethoscope Gloves Sanitizers

41. PROCEDURE 1. Choose the appropriate size for the patient: Small adult: size 3 Medium adult: size 4 Large adult: size 5 LMAs and LTAs: inflate cuffs fully to check for leaks before deflating. Lubricate the tip of the device, being careful not to block ventilatory openings. Place the patient in the sniffing position. Open the patient's mouth wide. Hold the device firmly (at the junction of the tube and mask for an LMA, at the bite block for an i-gel®, or at the connector for an LTA).

42. PROCEDURE 7. Insert the device. LMA and i-gel®: Insert smoothly along the hard palate and downwards with the outlet facing caudally. LTA: Insert the tube rotated at 45-90° from midline (towards concave lateral) until past the base of the tongue, where it should be rotated back to midline (towards concave up). Stop when the device has passed the base of the tongue and resistance is felt (LMA or i-gel®) or the connector reaches the teeth (LTA). LMAs and LTAs: inflate the cuff. confirm supraglottic tube placement.

43. LARYNGEAL MASK AIRWAY (LMA)

44. LARYNGEAL MASK AIRWAY (LMA)

45. LARYNGEAL TUBE AIRWAY (LTA)

46. https:/ /w w w.youtube.com/watch?v=vNvymbRD5b4

47. CONFIRMATION OF CORRECT PLACEMENT Air movement heard on auscultation of chest Visible chest rise and fall Continuous CO 2 waveform on capnography Stable or improving oxygenation

48. INTUBATION General principles Defined as placement of a cuffed endotracheal (ET) tube below the vocal cords via direct laryngoscopy or videolaryngoscopy Mostly commonly placed orally (orotracheal intubation), although it may be placed nasally (nasotracheal intubation) Typically, sedation and paralysis are required to tolerate the procedure and subsequent mechanical ventilation. Goals: maximize first-pass success, reduce the risk of aspiration Involves the rapid induction of anaesthesia and paralysis, followed by intubation Differs from traditional intubation in few ways: - BMV is not performed (to avoid potential aspiration of stomach contents).

49. INTUBATION Indications for endotracheal intubation Inability (or anticipated inability) to maintain the airway: e.g., general anesthesia, airway obstruction or reduced GCS Failure (or pending failure) of ventilation or oxygenation: e.g., in severe acute asthma or COPD (see "Indications for invasive mechanical ventilation) Conditions in which there is a high risk of deterioration: e.g., multisystem trauma, anaphylaxis, severe septic shock

50. Contraindications Do-not-intubate order Consider adjuncts to intubation or proceed to surgical airway management in: Copious blood/secretions Upper airway distortion Mouth opening limited Severe kyphosis Preoxygenation administration of 100% oxygen prior to induction to denitrogenate air in the lungs .

51. Intubation medications Typically two classes of medication are given prior to intubation, a sedating (induction) agent and neuromuscular blocking agent to paralyze the patient. Induction agents for intubation • Used to induce a state of sedation, which reduces airway reflexes and facilitates intubation • Options include: • Propofol • Etomidate • Ketamine • The choice of induction agent depends on patient characteristics and operator experience. • The duration of bolus doses is typically short (~ 10 minutes) and infusions are required for ongoing sedation

52. Paralytic agents for intubation : Clinical applications • Improving airway visualization by relaxing the jaw muscles • Decreasing the risk of injuries, e.g., vocal cord damage Types • Depolarizing NMJ blockers: e.g., succinylcholine - Widely used due to rapid onset and offset time (spontaneous respirations normally return within 10 minutes) - Rarely, prolonged paralysis occurs in patients with limited cholinesterase activity. • Nondepolarizing NMJ blockers: e.g., rocuronium - Used in patients with contraindications to succinylcholine

53. INTUBATION VIA DIRECT LARYNGOSCOPY • Positioning: Place patient in sniffing position unless C-spine injury is suspected. Head elevated to a height of 10 cm The neck is mildly flexed at the lower cervical vertebrae and extended at the atlanto-occipital joint. • Technique: The majority of patients should have received induction agents and been preoxygenated. Equipment should always be on hand to manage a failed intubation.

54. ARTICLES AND POSITIONING

55. E T T U BE

56. INTUBATION VIA DIRECT LARYNGOSCOPY Wear appropriate PPE. Choose the correct ET tube size. = (22) Gently open the patient's mouth, Insert the laryngoscope blade, using the groove to sweep the tongue aside. Advance steadily until the tip is at the vallecula and the epiglottis is visible below it. Lift gently forward and upward to raise the epiglottis and reveal the arytenoid cartilages and vocal cords. Insert the ET tube with the stylet. Once the tip is at the glottis, remove the stylet and gently advance until the cuff is past the cords. Inflate the cuff to protect the airway from secretions and form a seal around the tube .

57. https:/ /w w w.youtube.com/watch?v=3uvQO6ty5HU

58. CONFIRMATION OF TUBE PLACEMENT Auscultation of bilateral breath sounds over the lungs Consistent condensation visible in the tube upon exhalation Capnometry A visual indicator changes colour from purple to yellow upon contact with CO2. Consistent colour changing with each breath > 3 times correlates with tracheal placement. Capnography: measurement of end-tidal CO2 Direct visualization of endotracheal tube markers Proximal numbered tube markers should indicate approx. 21-23 cm at the patient's teeth. CXR: The distal tip of the endotracheal or tracheal tube should be 2-6 cm above the carina Ultrasound may be used to confirm tube position

59. COMPLICATION OF INTUBATION Early complications Hypoxia Bradycardia Respiratory acidosis Trauma - Dental damage - Tracheal perforation - Hemorrhage Pulmonary aspiration Laryngospasm Bronchospasm Late complications • Vocal cord injuries • Vocal cord granuloma: a complication of endotracheal intubation caused by inflammation and ulceration during the intubation process. Can cause vocal hoarseness that manifests~ 4 weeks after intubation.

60. Surgical airway management

61. SURGICAL CRICOTHYROTOMY Definition: an emergency procedure in which an incision is made through the skin, cervical fascia, and median cricothyroid ligament (cricothyroid membrane) to obtain airway access. Indications: CICV scenario (if orotracheal intubation has failed or is contraindicated) Failure to maintain oxygenation or ventilation in between intubation attempts or after 3 attempts at intubation May be required in: Severe oropharyngeal edema Foreign body aspiration causing complete occlusion of the upper airway Severe oropharyngeal/nasal haemorrhage Acute epiglottitis Severe maxillofacial trauma

62. SURGICAL CRICOTHYROTOMY Contraindications Young children and infants Some airway injuries: e.g., tracheal transection or laryngeal fracture o Obstruction distal to the cricothyroid membrane o Inability to identify anatomical landmarks Tumor or infection at the incision site

63. EQUIPMENT

64. https:// www.youtube.com/watch?v=bRfQeHtv7pM

65. Planned Surgical Airway

66. TRACHEOSTOMY Definition: a permanent or temporary opening (stoma) in the cervical trachea created through a surgical incision below the cricoid cartilage Indications For emergency indications, same as for cricothyroidotomy Long-term mechanical ventilation (> 3 weeks) Malignancy Options Percutaneous tracheostomy (typically under bronchoscopy guidance) Open surgical tracheostomy

67. HT TPS://W WW .YOUTU BE.C OM/WATCH?V=78B- UNUYWR8

68. LARYNGECTOMY Definition: the removal of all of the laryngeal structures, including the epiglottis and part of the upper trachea, with the trachea brought to the front of the neck to create a stoma Indications: laryngeal cancer Caution: As the upper airway is no longer connected to the trachea, patients with a laryngectomy cannot be oxygenated or intubated through the upper airway.

69. COMPLICATION OF SURGICAL AIRWAY Early complications Bleeding Creation of a false lumen Laceration of the back wall of the trachea Damage to the surrounding structures: e.g., esophageal, mediastinal, or thyroid perforation, vocal cord injury, or recurrent laryngeal nerve injury Pneumothorax Subcutaneous emphysema Late complications Dysphonia Scarring Stenosis Tracheomalacia

70. CHEC K LIS T FO R EQUIPMEN T REQUIRED FOR MANAGING AIRWAY. PPE Monitor connection to patient- BP, SPO2, PR, IV access, tourniquet, cannula. Oxygen face mask, tubing's. OPA, NPA BMV device Suction device Laryngoscope and blades- all size.

71. NURSI N G RES P ONSIBI L ITY Assess the airway for patency. Use manual methods to open an obstructed airway. Use basic airway adjuncts to intervene if the airway is compromised, eg: suction. Assist in the maintenance of the airway using advance airway adjuncts, e.g. intubation, surgical airway. Deliver O2, when required, using appropriate methods. Continually assess airway patency and ventilatory status of the patient using clinical observation and relevant monitoring. Monitor GCS. Maintain correct tube placement, proper cuff inflation. Maintain and monitor ventilation status. (ABG) Providing mouth care. Fostering communication and comfort.

72. TO SUMMARISE… Always check airway patency for any patient. Always bear in mind- Look, listen and feel. Assign the role of team leader, airway nurse and IV nurse. All Equipment's and drugs should be checked regularly. Knowledge regarding different airway device, drugs and team work are essential for the better management of the patient.

73. THANK YOU