Emergency Care - Airway Management Principles

airway emergency, airway management

1. Airway Management Principles
For MO

2. 1.Toknowtheanatomyoftheairway
2.ToknowtheimportanceofAirway
3.Knowthevariousadjuvantsintheairwaymanagement
4.Knowandselectcorrectairwaymanagementstrategies
5.Knowhowtoassessadifficultairway
6.Toknowwhentointervene,whentotransfer?
LEARNING OBJECTIVES

3. Aconduitbetweenthelungsandthe
outsideworld
Q.Whatisan
airway?

4. •Theairwayisthepassagewaybywhichair
entersthebodyduringrespiration,orbreathing.
•Apatientcannotsurvivewithoutanopenairway.
•Maintaininganopenairwayisthefirstpriorityof
emergencycare.
IMPORTANCE OF AIRWAY?

5. •Upperairway
•Lowerairway
AirwayDivisions?
AIRWAY ANATOMY REVIEW

6. Thebaseoftheskulltotheesophagushas3
divisions:
1)Nasopharynx-Behindnosetothesoftpalate.
2)Oropharynx-Behindmouth,softpalatetothe
hyoidbone.
3) Laryngopharynx-Hyoid bone to esophagus.
UPPER AIRWAY-PHARYNX
(THROAT)

7. •Small,leaf-shapedcartilage
•Preventsfoodfromenteringthetrachea
duringswallowing
•Glotticopening/vocalcordsdirectlybehind
thethyroidcartilage
•Narrowestpartoftheadultlarynx.An
importantlandmarkforintubation
EPIGLOTTIS & VOCAL CORDS

8. Exchangeofoxygenand
carbondioxidebetween
circulatorysystemand
cells
•Approximately97%oftotalO2isboundtohemoglobin
•O2saturationSpO2
⚬%ofhemoglobinsaturated
⚬Normallygreaterthan94%
OXYGEN IN THE BLOOD

9. Eventually, all cells will die if deprived of Oxygen.
WHY AIRWAY IS IMPORTANT?

10. •Inabilitytospeak
•Unusualraspyqualitytothevoice
•Snoring
•Gurgling
•Drooling
•Inspiratorystridor
•Hoarseness
•Paradoxicalchestwallmovement
•Trachealtug
WHAT ARE THE CLINICAL SIGNS
OF AIRWAY COMPROMISE:
PATENCY?

11. •Centralcyanosis
•Obtundationanddiaphoresis
•Inadequate/shallowrespirations(<10bpm)
•Rapidshallowrespirations(>30bpm)
•Accessorymuscleuse
•Retractions
•Abdominalparadox
•SpO2<94%
WHAT ARE THE CLINICAL SIGNS OF
AIRWAY COMPROMISE: OXYGENATION
AND VENTILATION?

12. •Addressedinprimaryassessment
•Twoquestionsmustbeanswered-
1.Istheairwayclear?Isitopen?
2.Willtheairwaystayclearandopen?
HOW IS THE AIRWAY ASSESSMENT
DONE?

13. A35yearfemalepatientcomestothePHCat10am.
Sheisfeeling:
•Drowsywithsnoringsoundsinthethroat
•WheeledintothePHC,inatrolley
Howdoyouproceed?
CASE 1: CRITICAL THINKING

14. •ABCDEapproach
•Connectmonitors-SpO2,ECG,NIBP
•Suctionready
•Oxygenmask
CASE 1: CRITICAL THINKING
Two questions must be answered
•Is airway patent? NO
•Actions?

15. –Headextension
–Neckflexion
–Pillowontotheshoulders
–20-30degreeangle
ACTIONS: POSITIONING
Aligning Axes of Upper Airway

16. •Unconscious patientsshouldbe
movedasaunit.
•Themostcommonairwayobstructionis
thetongueandepiglottis.
•Snoringrespirationsarecharacteristic
sign
SNORING SOUNDS STILL
HEARD: ACTIONS?

17. Followthesesteps:
–Placeheelofonehandonforehead,applyfirmbackwardpressurewith
palm
–Placefingertipsofotherhandunderlowerjaw
–Liftchinupward,withentirelowerjaw
ACTIONS: MANUAL MANOEUVERS
HEAD TILT–CHIN LIFT MANEUVER

18. Ifyoususpectacervicalspineinjury,usethismaneuver
Followthesesteps:
•Placeyourfingersbehindtheanglesofthelowerjaw
•Movethejawupward
•Useyourthumbstohelppositionthejaw
ACTIONS: MANUAL MANOEUVERS
JAW-THRUST
MANEUVER

19. •Snoringsoundsheardwhenjawthrustwasreleased
•RR8bpm,shallowbreathing
CRITICAL THINKING
YES
NO
Action : Artificial Airway
Two questions must be answered
•Was the airway open?
•Will airway stay open?

20. Guedelairway–
Parts–flange,biteportion,
airchannel
SIZING OROPHARYNGEAL
AIRWAYS

21. 1.Insertuntilyoumeetresistance
2.Gentlyrotatetheairway180°sothetipispointing
downintothepharynx
3.Checkthatflangeoftheairwayisagainstthelips
4.Monitorpatientclosely
INSERTING OPA

22. Uses–
1)Tomaintainopenairway
2)Preventendotrachealtubeocclusion
3)Preventtonguebite
4)Facilitatesuction
5)Conduitforpassingdevicesintooropharynx
6)Obtainabettermaskfit
Contraindications–
1)Intactgagreflex
2)Oropharyngealgrowth
OROPHARYNGEAL AIRWAY
Critical Thinking: Patient starts to cough following OPA insertion, Action?

23. •Comeinvarioussizes
•Mustbemeasured
•Patient’snostriltothetipoftheearlobe
•Typicaladultsizes:34,32,30,and28French
NASOPHARYNGEAL AIRWAY (NPA)

24. 1.Lubricateoutsideoftubewithwater-basedlubricantbeforeinsertion
• Parts –flange, airway
channel, bevel.
• Size -inside diameter in
millimeters
• Patients little finger tip
INSERTING NPA

25. 2.Pushtipofnoseupward;keepheadinneutralposition
3.Insertintonostril;
advanceuntil
flangerestsfirmly
againstnostril
INSERTING NPA

26. Advantages
•Nasalairwayisbettertolerated
thananoralairwayifthepatient
hasintactairwayreflexes.
•Looseorpoordentition.
•Traumaorpathologyoftheoral
cavity
•Itcanbeusedwhenthemouth
cannotbeopened
Contraindications
•Anticoagulation
•Basilarskullfracture
•Nasalpathology,sepsis,ordeformityof
thenoseornasopharynx
•Historyofepistaxisrequiringmedical
treatment
NASOPHARYNGEAL AIRWAY

27. 1.AirwayObstruction
2.Trauma
3.TissueEdema
4.UlcerationandNecrosis
5.CentralNervousSystemTrauma
6.Dentaldamage
7.LaryngospasmandCoughing
8.Retention,Aspiration,orSwallowing
9.Devicescaughtintheairway
10.Equipmentfailure
11.Latexallergy
12.Gastricdistention
COMPLICATIONS
OF
ARTIFICIAL
AIRWAY

28. Afternasopharyngealairwayinsertion
•Snoringsoundsstopped
•Gurglingsoundsinthethroatheard
CRITICAL THINKING
NO
NO
How do you proceed to protect the airway?
Two questions
•Is the airway open?
•Is the airway clear?

29. •Acute
⚬Foreignbodies
⚬Vomit
⚬Blood
•Occurringovertime
⚬Edemafromburns,trauma,orinfection
⚬Decreasingmentalstatus
AIRWAY COMPROMISE: PATENCY?
Types of Airway Obstructions?

30. •Portableorfixedunitshouldhave:
⚬Wide-bore,thick-walled,non-kinkingtubing
⚬Watersupplyforrinsingthetips
•Designedtobeusedwhenarigidtipcannotbeused&for
suctioningthenasopharynx
•Canbeusedinvarioussizesidentifiedbyanumber“French”
•Largerthenumber,biggerthebore
Case 1: Start suctioning airway with flexible catheter

31. •MeasuredinasimilarwayasOPA
•Lengthofthecatheterthatshouldbeinsertedintopatient’s
mouthequalsthedistancebetweenthecornerofpatient’s
mouthandearlobe
•Placetiporcatheterwhereyouwanttobeginsuctioning
•Suctiononthewayout
TECHNIQUES OF FLEXIBLE SUCTION
CATHETER USE

32. Startsuctioningairwaywithflexiblecatheter,butstilllargefood
particlesinthroat.
CASE 1: CRITICAL THINKING
NO
Two questions must be answered
•Is the airway clear?
•What next?

33. •Blood/Pusintheupperairway
•Food/secretionsintheupperairway
•Persistentvomiting
•Lossofprotectiveairwayreflexes
WHAT ARE THE CLINICAL SIGNS OF
AIRWAY COMPROMISE: PROTECTION?

34. •Alsocalled“YankauerTip”
•Largerborethanflexiblecatheters
•Suctiononlyasfarasyoucansee
•Donotlosesightofthedistalend
•Carefulinsertionhelpspreventgagreflexorvagalstimulation
USE RIGID PHARYNGEAL SUCTION TIP
NO
Two questions must be answered
•Is the airway clear?

35. Whenpatientshavesecretionsorvomitusthatcannotbesuctioned
easily-
•Removethecatheterfromthepatient’smouth.
•Logrollthepatienttotheside.
•Clearthemouthcarefullywithaglovedfinger.
WHEN IS SUCTION NOT POSSIBLE?

36. Followingsuctioningandclearingairwaywithlargefoodparticlesin
throat
CASE 1: CRITICAL THINKING
SPO2-83%

37. Neversuctionthemouthornoseformorethan15secondsatonetime
foradultpatients,10secondsforchildren,and5secondsforinfants.
⚬Suctioningcanresultinhypoxia
⚬Ventilate30secs/Oxygenate100%for2minutes
⚬Continuethisalternatingpatternuntilallsecretionshavebeencleared
PRECAUTIONS WHILE SUCTIONING

38. •ABCDEapproach
•ConnectMonitors-SpO2,ECG,NIBP
•SuctionReady
•OxygenMask
CASE 1: CRITICAL THINKING
Why Connect Monitors/Oxygen?

39. • Hypoxia
• Bronchospasm
• Dysrhythmias
• Bradycardia and
hypotension due to
vagal stimulation
• Increased
intracranial pressure
• Local edema
• Hemorrhage
• Tracheal ulceration
• Tracheal infection
WHY CONNECT MONITORS/
OXYGEN?
Complications of Suctioning
CASE 1: CRITICAL THINKING: SPO2-88%, ACTION?

40. •Nasalcannulas
•Non-rebreathingmasks
•Bag-maskdevices
OXYGEN-DELIVERY EQUIPMENT

41. •2-6litresperminutes(lpm)
•25-30%oxygendelivered
•6-10lpm
•35-60%oxygendelivered
OXYGEN
Simple MaskNasal Cannula

42. •Thepreferredwaytogiveoxygenintheprehospitalsetting
•Topatientswhoarebreathingadequatelybutaresuspectedofhaving
hypoxia
•Combinationmaskandreservoirbagsystem
NON-REBREATHING MASKS

43. •Makesurethereservoirbagisfullbeforeplacingthemaskonthe
patient.
•Adjusttheflowratesothebagdoesnotcollapsewhenthepatientinhales
⚬Usually10to15L/min,80-90%FiO2
•Whenoxygentherapyisdiscontinued,removethemask.
NON-REBREATHING MASKS

44. The5thVitalSign
•Givespercentofhemoglobinsaturated
•Measureofbloodoxygenation
•DoesNOTmeasureadequacyofventilation(pCO2)
•Unreliableinhypotensivepatients
•NormalValues
⚬90%-100%=Normal
⚬<90%=hypoxia
⚬Hypoxiamustbecorrected
PULSE OXIMETRY

45. PatientopenseyesonlytopainfulsimulationSpO2-91%withNRM,RR-8
bpm,shallow,BP90/60mmHg.
Howdoyouclinicallyassessanairwayforcompromiseorthreatsto
airwayintegrity?
CASE 1: CRITICAL THINKING

46. •Bag-Valve-MaskVentilation(BVM)
•EndotrachealIntubation
•Alternatetechniquesforthedifficultairway
TECHNIQUES FOR THE
COMPROMISED AIRWAY

47. •Themostimportantairwayskill
•Alwaysthefirstresponsetoinadequate
oxygenationandventilation,afteropening
theairway
BAG-VALVE-MASK (BVM / AMBU)
VENTILATION

48. •Bridgeofnosetochin
•Maskshouldcovernoseandmouth
•Maskshouldnotcovereyes
PROPER MASK SIZING

49. Threefaciallandmarksthat
mustbecoveredbymask:
1.Bridgeofthenose
2.Twomalareminences
3.Mandibularalveolarridge
Smalltidalvolumes
Squeezesteadily–don’tforceair
tooquickly
10-12breaths/minute
Assessforriseandoffallchest
BAG MASK VENTILATION
TWO-HANDED TECHNIQUESONE-HANDED TECHNIQUE

50. •Look:watchthechestriseandfall
•Listen:hearbilateralairentry
•Feel:Feelingtheeasycomplianceofthebag
•Pulseoximetry:improvedoxygenation
BVM (AMBU) VENTILATION:
ASSESSMENT OF EFFICACY

51. •MaskSeal
⚬Facialhair,deformity,blood
•Obesity/Obstruction
⚬Cancer,lesions,excesstissue
•Age
⚬Youngchildrenandelderlycanbedifficulttoventilate
•Noteeth
⚬TeethkeepfacefromcavinginduringBMV
•Stiff/Snoring
⚬Lungresistanceissues(edema,COPD)
PATIENTS WHO ARE DIFFICULT TO USE
THE BVM (AMBU) “MOANS”

52. •Failuretorecognizeitsimportance
•Forgettobag(focusedonETT)
•Giveuponbaggingtooearly
•Bagbutdon’tassesstheefficacy
•Failuretoassignonepersontoairwaymanagementonly
FREQUENT ERRORS WITH BVM

53. •Patency-reliefofobstruction-failuretomaintainairwaypatency
•Protectionfromaspiration(comawithGCS<8)
•Hypoxic/hypercapnicrespiratoryfailurenoteasilyreversibleby
noninvasivemeans
•Airwayaccessforpulmonarytoilet,drugdeliveryinarrest,therapeutic
hyperventilationifhighICP
•SevereShock
WHAT ARE THE INDICATIONS FOR
ACTIVE AIRWAY INTERVENTION?

54. Is there impending
respiratory failure?
Prepare for intubation &
support of ventilation.

55. MouthopeningTipofmentumtohyoidboneThyromentaldistance
ASSESSMENT FOR DIFFICULT
INTUBATION:
Evaluate: 3-3-2 Rule
Access to airway
and obtaining glottic
view
Can tongue be
deflected
to accommodate
laryngoscope
Predicts location larynx to
base of the tongue. If
larynx high angles difficult

56. Preparationincludes:
1.Suctionready
2.Ambubagassembledandready
3.Laryngoscopebladeandlightchecked
4.Oxygenconnectedandflowing
5.Checkinflationofendotrachealtubecuff
6.Syringeattachedtoinflationportandloadedwith10ccofair
PREDICTS LOCATION LARYNX TO
BASE OF THE TONGUE. IF LARYNX
HIGH ANGLES DIFFICULT

57. •Bladeinsertedwithlaryngoscope
handlepointedatthepatient’sfeet.
•Tongueandjawaredistracted
downwardtoinserttheblade.
•Minimalforcerequired
•Tipofbladegetsaroundbaseof
tongue,permittingchangeinangleof
liftingandbettermechanicaladvantage.
•Epiglottisedgeliftedoffpharyngeal
wall.(Epiglottisoftencamouflaged
againstmucosaofposteriorpharynx).
LARYNGOSCOPY

58. •Withfullinsertionofcurvedbladeintovalleculatheangleoflifting
changesto~40degreesfromthehorizontal.
•Nowtheliftingforcecanbeincreasedasneeded.
•Tipposition(notforce)isthemaindeterminantofglotticexposure.

59. INSERTING ENDOTRACHEAL TUBE

60. •Ventilatethepatient
•Auscultate
⚬Epigastriumfirst
⚬Midaxillaryandanteriorchestlineonrightandleftsides
⚬Observechestriseandfall
•Verifyplacementbyatleastoneadditionalmethod
⚬ETCO2
⚬Esophagealdetector
⚬Chestx-ray
•Notecmmarkingoftubeatteeth
ET INTUBATION –TECHNIQUE

61. •SecureETtubewithcommercialtube-holder
(preferred)ortape.
•Provideventilatorysupportwithsupplemental
oxygen.
•Aftersecuringthetube,observeandrecordtube
depthatthepatient’steeth.
ET INTUBATION –TECHNIQUE

62. •Unrecognized esophageal intubation is
devastating.
•Clinicalindicatorsalonecannotbereliedupon.
•Capnographygoldstandard.
•Beware-
⚬Esophagealintubationmaygivetransientcolor
change.Need>5breaths.
⚬Cardiacarrestpatientscangivefalsenegative
colorchanges.(Othermethods=syringetest)
PROOF OF PLACEMENT

63. •2personBagMaskventilation
•Maximizeneckflexion/headextension
•Movetongueoutoflineofsite
•Maximizemouthopening
•Lookforlandmarksandadjustblade
•BURPmaneuver
•Increasingliftingforce
UNSUCCESSFUL INTUBATION
CALL FOR HELP:
CONSIDER LMA,
SURGICAL AIRWAY

64. •Openthemouthandpressthetip
ofthecuffupwardagainstthe
palateandflattenthecuffagainstit
•UseindexfingertoguideLMA,
pressingbackwardalongthepalate
towardsearsuntilresistanceisfelt
•Thetipnowrestsinthehypopharynx
LMA INSERTION TECHNIQUE

65. •Useotherhandtopressdownon
LMAtubewhileremovingindex
finger
•Inflatewith2-4mlairtoseal(60cm
H20maximum)
•Don’tholdthetubewhileinflatingthe
balloon,itmovesoutwardalittleasit
seatsproperly
CONTD…

66. Indications
1.UpperAirwayObstructionwithinability
toventilateorintubate
2.Anticipateddifficultintubation–
Cricothyrotomyintubationmaybe
difficulttoperform
3.Proceduresinvolvingtheairway
4.CervicalSpineInjury
NEEDLE CRICOTHYROTOMY

67. Entry by 14 Fr. introducer and 16 G needle.
The position is confirmed by air aspiration.
NEEDLE CRICOTHYROTOMY

68. SURGICAL CRICOTHYROIDOTOMY

69. Contraindications
1.Intrathoracic Airway Obstruction
2.Inability to Locate the Cricothyroid Membrane
3.Complete Airway Obstruction
4.Paediatricpatients
5.Laryngeal pathology
6.Decreased compliance
CRICOTHYROTOMY

70. “Patients do not die from lack of intubation they die from lack
of oxygenation”. Ventilate with bag-mask device connected to
an oxygen source and transfer to a definitive care centre.
TAKE HOME MESSAGE

71. Thank You