AWM Wht How for best to goooof. 2021.ppt

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1. AIRWAY MANAGEMENT
HOSSAM EL-DIN FOUAD RIDA
DEPARTMENT OF ANESTHESIA & SURGICAL
INTENSIVE CARE, FACULTY OF MEDICINE
ALEXANDRIA UNIVERSITY

2. AlexandriaAlexandria
Airway Airway
Management Management
Training TeamTraining Team

3. •PROPER AND EFFICIENT AIRWAY MANAGEMENT IS AN
ESSENTIAL SKILL.
•IT IS THE FIRST STEP WHEN DEALING WITH
UNCONSCIOUS , TRAUMATIZED OR SEVERELY INJURED
PATIENTS.
•LOSS OF PATENT AIRWAY CAN LEAD TO LIFE
THREATENING HYPOXIA.

4. BASIC AIRWAY MANAGEMENT
•AIRWAYS: CONDUCT AIR,
OUTSIDE & INSIDE BODY
(INTO & OUT OF THE LUNGS)
•Inspired OInspired O
2 2 = 20% = 20%
•BRAIN can not tolerate BRAIN can not tolerate
Hypoxia ›4 minHypoxia ›4 min
• Expired OExpired O
22 =16% =16%

5. COMMON CAUSES OF AIRWAY OBSTRUCTION
• UPPER AIRWAY
• TONGUE
• FOREIGN MATERIAL ,SOFT TISSUE OEDEMA
• BLOOD, VOMIT
• LARYNX
• FOREIGN BODY, LARYNGOSPASM
•LOWER AIRWAY
- SECRETIONS, OEDEMA, BRONCHOSPASM,
ASPIRATION,…

6. RESPIRATORY OBSTRUCTION

7. RECOGNITION OF AIRWAY OBSTRUCTION
LOOK, LISTEN & FEEL

8. RECOGNITION OF AIRWAY OBSTRUCTION

LOOK
Chest / Abdominal
Movement

LISTEN
Breath Sounds ,
at mouth and nose
Snoring, gurgling

FEEL
Mouth / Nose
for expired air

9. SIGNS OF RESPIRATORY OBSTRUCTION
1.SNORING OR GURGLE
2.STRIDOR OR ABNORMAL BREATH SOUNDS
3.AGITATION (HYPOXIA)
4.ACCESSORY MUSCLES
5.PARADOXICAL BREATHING
6.CYANOSIS

10. MANAGEMENT OF RESPIRATORY
OBSTRUCTION
• Exclude Foreign BodyExclude Foreign Body
• No SedationNo Sedation
• Urgent TreatmentUrgent Treatment
Open airwayOpen airway
Check for breathingCheck for breathing
• Always ReassessAlways Reassess
Seek helpSeek help

11. MANAGEMENT OF RESPIRATORY
OBSTRUCTION
RespiratoryRespiratory
ObstructionObstruction
Basic Techniques Devices
Basic
Oropharyngeal/ Oropharyngeal/
NasopharyngealNasopharyngeal
AirwayAirway
Advanced

LMALMA

Combi tubeCombi tube

ETTETT
Head tilt-Chin LiftHead tilt-Chin Lift Jaw Thrust

12. OPENING THE AIRWAY
•HEAD TILT / CHIN LIFT OR JAW THRUST
•THEY ARE BASIC MANOEUVRES USED TO MANAGE
AIRWAY OBSTRUCTION CAUSED BY BACKWARD FALL
OF THE TONGUE IN UNCONSCIOUS VICTIM.

14. Head Tilt and Chin Lift

15. AWM BASIC MANAGEMENT

16. JAW THRUST

17. •CAUTION! –JAW THRUST IS DONE IF THERE IS
SUSPECTED CERVICAL SPINE INJURY
•MANUAL IN LINE STABILIZATION BY ASSISTANT MUST BE
DONE.
•DEATH FROM HYPOXIA > FROM CERVICAL SPINAL
CORD INJURY

18. SIMPLE AIRWAY ADJUNCTS
•THE OROPHARYNGEAL AND NASOPHARYNGEAL AIRWAYS ARE
USED TO MANAGE AIRWAY OBSTRUCTION CAUSED BY THE
TONGUE IN UNCONSCIOUS PATIENTS.

19. SIMPLE AIRWAY ADJUNCTS

20. OROPHARYNGEAL AIRWAY

21. SIZING OROPHARYNGEAL AIRWAY

22. OROPHARYNGEAL AIRWAY INSERTION

23. OROPHARYNGEAL AIRWAY
•SIZE THE AIRWAY BY MEASURING THE DISTANCE FROM THE
INCISORS TO THE ANGLE OF THE JAW.
•INSERT THE AIRWAY SO THAT ITS CONCAVE SIDE FACES AWAY
FROM THE TONGUE.
•INSERT THE AIRWAY INTO THE MOUTH TO APPROXIMATELY
ONE-THIRD OF ITS LENGTH. WHILST GENTLY PUSHING THE
AIRWAY FURTHER IN, ROTATE IT 180° AND SLIDE IT IN TO ITS
FULL EXTENT.

24. •NASOPHARYNGEAL
AIRWAY

25. NASOPHARYNGEAL AIRWAY INSERTION

26. NASOPHARYNGEAL AIRWAY
•SIZE THE AIRWAY BY MEASURING THE DISTANCE FROM THE
NOSTRIL TO THE LOBULE OF THE EAR.
•CHOOSE A DIAMETER LIKE THE LITTLE FINGER OF THE VICTIM.
•LUBRICATE AND INSERT.

27. •AFTER MANAGING AIRWAY OBSTRUCTION , IF BREATHING IS
NOT ADEQUATE, WE MUST VENTILATE THE PATIENT.
•WE CAN DO:
•MOUTH TO MOUTH BREATHING,
•USE POCKET MASK OR
•USE AMBU BAG.

28. MOUTH TO MOUTH BREATHING: ( + FACE
SHIELD… ?? )

30. MOUTH TO MASK VENTILATION
ADVANTAGES:
•AVOIDS DIRECT PERSON TO
PERSON CONTACT
•DECREASES POTENTIAL FOR
CROSS INFECTION
•ALLOWS OXYGEN ENRICHMENT
LIMITATIONS:
•MAINTENANCE OF AIRTIGHT
SEAL
•GASTRIC INFLATION WITH AIR.

31. •SELF-INFLATING BAG & MASK

32. BAG-VALVE-MASK, 2-PERSONS

33. •VENTILATION: SELF INFLATING BAG
AdvantagesAdvantages
•Avoids direct personAvoids direct person
to person contactto person contact
•OO
22 supplementation supplementation
•Can be used with Can be used with
Facemask, LMA,Facemask, LMA,
Combitube, trachealCombitube, tracheal
tubetube
LimitationsLimitations
With facemask:With facemask:
•Inadequate Inadequate
ventilationventilation
•Gastric inflation Gastric inflation
with air with air
•Two persons forTwo persons for
optimal useoptimal use

34. ADVANCED DEVICES.
•THE LARYNGEAL MASK AIRWAY
•COMBITUBE , LARYNGEAL TUBE
•ENDOTRACHEAL INTUBATION

35. THE THE
LARYNGEAL MASK AIRWAYLARYNGEAL MASK AIRWAY
LMALMA

36. LMALMA

37. LMA InsertionLMA Insertion

38. Device preparation:
Partial deflation
Lubrication
Patient preparation:
Areflexia
Position
Procedure:
Hold LMA like a pen
Slippery movement against ….
Remove finger
Inflate (LMA) and ventilate (patient)

39. LIMITATIONS
•ASPIRATION RISK
•NOT SUITABLE
WITH VERY HIGH
INFLATION
PRESSURES
•UNABLE TO
ASPIRATE AIRWAY
LMALMA
AdvantagesAdvantages
• Blind insertion Blind insertion
• Rapid & easyRapid & easy
insertioninsertion
• Variable sizesVariable sizes
• Ventilation >Ventilation >
facemaskfacemask
• AvoidsAvoids
laryngoscopylaryngoscopy

41. COMBITUBECOMBITUBE

42. COMBITUBE
ADVANTAGES
•RAPID & EASY
INSERTION
•AVOIDS
LARYNGOSCOPY
•PROTECTS AGAINST
ASPIRATION
•CAN BE USED WITH
HIGH INFLATION
PRESSURES
LimitationsLimitations
• 2 sizes only2 sizes only
• Ventilation via wrongVentilation via wrong
lumenlumen
• Damage to cuffs Damage to cuffs
• TraumaTrauma
• Single useSingle use

43. LARYNGEAL TUBE

45. •THE GOLD STANDARD

47. MAIN INDICATIONS:MAIN INDICATIONS:
PATENT CLEAR AIRWAY (ANAESTHESIA & ICU)PATENT CLEAR AIRWAY (ANAESTHESIA & ICU)
CONTROLLED VENTILATIONCONTROLLED VENTILATION
DRUG ADMINISTRATION (ODRUG ADMINISTRATION (O
22, INHALATIONAL ANAESTHESIA,….), INHALATIONAL ANAESTHESIA,….)
AIRWAY SUCTIONINGAIRWAY SUCTIONING
CUFFED ETT: PREVENT ASPIRATION, ENSURES EFFICIENT VENT.
(WATER TIGHT- AIR TIGHT)

48. EQUIPMENT:
•ENDOTRACHEAL TUBES ( TYPES, SIZES,…)
•LARYNGOSCOPES
•MAGILL FORCEPS
•AIRWAYS ( ORAL, NASAL, SIZES,…)
•OTHERS ( TOPICAL ANALGESIA, SYRINGES,
SUCTION, ADHESIVE TAPE,…..)

49. ENDOTRACHEAL INTUBATION
TECHNIQUE:
• PRE-OXYGENATION
•30 SECONDS ONLY FOR ATTEMPT
•INSERT TUBE THROUGH LARYNX UNDER DIRECT VISION
•IF IN DOUBT OR DIFFICULTY, RE-OXYGENATE BEFORE FURTHER
ATTEMPTS
A PATIENT MAY BE HARMED BY FAILURE OF OXYGENATION,
NOT FAILURE OF INTUBATION!

50. • OPTIMAL PATIENT POSITION
• USUALLY UNDER GENERAL ANESTHESIA
(IV INDUCTION, MUSCLE RELAXATION & IPPV )
• OROTRACHEAL / NASOTRACHEAL
• EXTUBATION

51. 
HEAD POSITIONING: HEAD POSITIONING: "SNIFFING THE MORNING AIR", "SNIFFING THE MORNING AIR", THE NECK THE NECK
SLIGHTLY SLIGHTLY FLEXED FLEXED AND THE HEAD AND THE HEAD EXTENDED. EXTENDED. A PILLOW UNDER A PILLOW UNDER
THE HEAD AND NECK BUT THE HEAD AND NECK BUT NOTNOT UNDER THE SHOULDERS. UNDER THE SHOULDERS.

A STRAIGHT LINE OF VISIONA STRAIGHT LINE OF VISION
FROM THE MOUTH TO THEFROM THE MOUTH TO THE
VOCAL CORDSVOCAL CORDS

52. AWM BASIC COURSE

53. •ENDOTRACHEAL INTUBATION ENDOTRACHEAL INTUBATION
LARYNGOSCOPY AND TUBE INSERTION

55. CONFIRMING CORRECT ETT PLACEMENT:CONFIRMING CORRECT ETT PLACEMENT:
• DIRECT VISUALISATION AT LARYNGOSCOPYDIRECT VISUALISATION AT LARYNGOSCOPY
• AUSCULTATION:AUSCULTATION:
•- BILATERALLY, MID-AXILLARY LINE- BILATERALLY, MID-AXILLARY LINE
•- OVER THE EPIGASTRIUM- OVER THE EPIGASTRIUM
• SYMMETRICAL MOVEMENT OF THE CHEST SYMMETRICAL MOVEMENT OF THE CHEST
• OESOPHAGEAL DETECTOR DEVICEOESOPHAGEAL DETECTOR DEVICE
• CAPNOMETRYCAPNOMETRY

56. CAPNOGRAPHYCAPNOGRAPHY

57. •ENDOTRACHEAL INTUBATION
AdvantagesAdvantages
• Ventilation withVentilation with
up to 100% Oup to 100% O
22
• Isolates airway,Isolates airway,
preventingpreventing
aspirationaspiration
• Allows AirwayAllows Airway
aspirationaspiration
•Alternative routAlternative rout
for drugfor drug
administrationadministration
LimitationsLimitations
• Training & experience Training & experience
• Failed insertion,Failed insertion,
oesophageal placementoesophageal placement
• Potential to worsenPotential to worsen
cervical cord or headcervical cord or head
injuryinjury

58. ENDOTRACHEAL INTUBATION: ENDOTRACHEAL INTUBATION:
COMPLICATIONSCOMPLICATIONS
•TRAUMA, REFLEX DISTURBANCES
• BRONCHIAL / ESOPHAGEAL INTUBATION
• TUBE KINKING / OBSTRUCTION
• LARYNGEAL SPASM, ASPIRATION OF SECRETIONS,…
• HOARSENESS OF VOICE, SORE THROAT,
GRANULOMA OF THE LARYNX,……

59. Cricothyrotomy

60. Needle cricothyroidotomy
Is the simplest and fastest access
This is notnot a "real life" procedure

61. NEEDLE CRICOTHYROIDOTOMY
INDICATION
•FAILURE TO PROVIDE AN AIRWAY
BY ANY MEANS
•(CICO SITUATION)
COMPLICATIONS
•MALPOSITION OF CANNULA
•EMPHYSEMA
•HAEMORRHAGE
•OESOPHAGEAL PERFORATION
•HYPOVENTILATION
•BAROTRAUMA

62. • Loss of a patent patient airway
can lead to life- threatening
hypoxia within two to three
minutes.
To sum up…

63. • Airway management (AWM)
skills are very essential for all
physicians dealing with
anesthetized, unconscious,
traumatized or critically ill
patients.

64. He, who fails to prepare ,
prepares to failure!

(Knowledge, skills and facilities)