advanced airway management & intubation the difference between life and death

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Advanced Airway Management & Intubation The Difference Between Life and Death

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Page 1: Advanced Airway Management & Intubation The Difference Between Life and Death

Advanced Airway Management & Intubation

The Difference Between

Life and Death

Page 2: Advanced Airway Management & Intubation The Difference Between Life and Death

Topics For Discussion

Basic anatomy and physiology.

Advantages of endotracheal intubation.

Indications of intubation. Contraindications of

intubation. Complications of

intubation. Equipment required for

intubation.

Technique of endotracheal intubation.

Rules of endotracheal intubation.

Tube sizes. Rules and principals of

suctioning. Other airway adjuncts. Conclusion. Difficult intubations.

Page 3: Advanced Airway Management & Intubation The Difference Between Life and Death

Anatomy and Physiology

The airways can be divided in to parts namely:

The upper airway.

The lower airway.

Page 4: Advanced Airway Management & Intubation The Difference Between Life and Death

The Upper Airway

Page 5: Advanced Airway Management & Intubation The Difference Between Life and Death

The Lower Airway

Page 6: Advanced Airway Management & Intubation The Difference Between Life and Death

Advantages of Endotracheal Intubation

Cuffed E.T tubes protect the airway from aspiration.

E.T tube provides access to the tracheobronchial tree for suctioning of secretions.

E.T tube does not cause gastric distention and associated danger of regurgitation.

E.T tube maintains a patent airway and assists in avoiding further obstruction.

E.T tube enables delivery of aerosolized medication.

Page 7: Advanced Airway Management & Intubation The Difference Between Life and Death

Indications for Intubation

Inadequate oxygenation(decreased arterial PO2) that is not corrected by supplemental oxygen via mask/nasal.

Inadequate ventilation (increased arterial PCO2).

Need to control and remove pulmonary secretions.

Any patient in cardiac arrest.

Page 8: Advanced Airway Management & Intubation The Difference Between Life and Death

Indications for Intubation

Ant patient in deep coma who cannot protect his

airway.(Gag reflex absent.).

Any patient in imminent danger of upper airway

obstruction (e.g. Burns of the upper airways).

Any patient with decreased L.O.C, GCS <= 8.

Severe head and facial injuries with

compromised airway.

Page 9: Advanced Airway Management & Intubation The Difference Between Life and Death

Indications Cont…

Any patient in respiratory arrest Respiratory failure

Hypoventilation/Hypercarbia Paco2 > 55mmhg

Arterial hypoxemia refractory to O2 Paco2 < 70 on 100% O2

Page 10: Advanced Airway Management & Intubation The Difference Between Life and Death

Contraindications for Intubation

Patients with an intact gag reflex. Patients likely to react with laryngospasm

to an intubation attempt. e.g. Children with epiglottitis.

Basilar skull fracture – avoid naso-tracheal intubation and nasogastric/pharyngeal tube.

Page 11: Advanced Airway Management & Intubation The Difference Between Life and Death

Complications Associated With Intubation

Trauma of the teeth, cords, arytenoid cartilages, larynx

and related structures.

Nasotracheal tubes can damage the turbinates, cause

epistaxis, and even perforate the nasopharyngeal

mucosa.

Hypertension and tachycardia can occur from the

intense stimulation of intubation; This is potentially

dangerous in the patient with coronary heart disease.

Transient cardiac arrhythmias related to vagal

stimulation or sympathetic nerve traffic may occur .

Page 12: Advanced Airway Management & Intubation The Difference Between Life and Death

Complications Continued…

Damage to the endotracheal tube cuff, resulting in a cuff leak and poor seal.

Intubation of the esophagus, resulting in gastric distention and regurgitation upon attempting ventilation.

Baro-trauma resulting from over ventilating with a bag without a pressure release valve( phneumothorax).

Page 13: Advanced Airway Management & Intubation The Difference Between Life and Death

Complications Continued…

Over stimulation of the larynx resulting in laryngospasm, causing a complete airway obstruction.

Inserting the tube to deep resulting in unilateral intubation (right bronchus).

Tube obstruction due to foreign material, dried respiratory secretion and/or blood.

Page 14: Advanced Airway Management & Intubation The Difference Between Life and Death

Equipment Required for Successful Intubation

Page 15: Advanced Airway Management & Intubation The Difference Between Life and Death

Equipment Cont…

Laryngoscope with relevant size blades. Magill forceps. Flexible introducer. 10-20 ml syringe. Oropharangeal airways – all sizes. Tape. ET tubes – relevant sizes. Bag-valve-mask with oxygen connected. Suction unit with Yankauer nozzle and

endotracheal suction catheter.

Page 16: Advanced Airway Management & Intubation The Difference Between Life and Death

Tools

Handle Batteries Miller Macintosh

Apple Bulb Fiber Optics

Attaching blade to handle

Page 17: Advanced Airway Management & Intubation The Difference Between Life and Death

Adapter Markings Pilot Cuffs Stylet Cuffs Murphy Eye

ET Tubes

Magill Forceps

Page 18: Advanced Airway Management & Intubation The Difference Between Life and Death

More Tools

BVM Suction GOGGLES/Gloves Correct Size Tube

Measured by I.D. in mm > 6 Cuffed

Sellick’s Maneuver

Alternative Airways Combitube King LT PTL A EOA EGTA LMA OPA/NPA

Page 19: Advanced Airway Management & Intubation The Difference Between Life and Death

The Goal

Align: Oropharynx Glottis

Gently Pass tube 1-2.5 cm past cords ½ to 1” 2-3 cm above cords

Secure Tape Tamer Shoelace Super Glue Staple Gun Vice Grips

Mark Depth 21 – 23 cm at Lips

Page 20: Advanced Airway Management & Intubation The Difference Between Life and Death

Technique of Endotracheal Intubation

Page 21: Advanced Airway Management & Intubation The Difference Between Life and Death

Technique Cont…

Position the patient supine, open the airway with a head-tilt chin-lift maneuver.(Suspected spinal injury, attempt naso-tracheal intubation, spine in neutral position.).

Open mouth by separating the lips and pulling on upper jaw with the index finger.

Hold laryngoscope in left hand, insert scope into mouth with blade directed to right tonsil.

Once right tonsil is reached, sweep the blade to the midline keeping the tongue on the left.

Page 22: Advanced Airway Management & Intubation The Difference Between Life and Death

Technique Cont…

This brings the epiglottis into view.” DO NOT LOOSE SIGHT OF IT!”

Advance the blade until it reaches the angle between the base of the tongue and epiglottis.( volecular space)

Lift the laryngoscope upwards and away from the nose – towards the chest. This should bring the vocal cords into view. It may be necessary for a colleague to press on the trachea to improve the view of the larynx.

Place the ETT in the right hand. Keep the concavity of the tube facing the right side of the mouth.

Insert the tube watching it enter through the cords.

Page 23: Advanced Airway Management & Intubation The Difference Between Life and Death

Technique Cont…

Insert the tube just so the cuff has passed the cords and then inflate the cuff.

Listed for air entry at both apices and both axillae to ensure correct placement using a stethoscope.

Page 24: Advanced Airway Management & Intubation The Difference Between Life and Death

Rules of Intubation

Always have a suction unit available. An intubation attempt should never exceed

30 seconds. Oxygenate the patient pre and post

intubation with a bag-valve-mask.(100% O2). Have sedative medication available if

needed. (e.g. Midazolam 15mg/3ml) Always recheck tube placement manually

guided by oxygen saturation readings.(Spo2).

Page 25: Advanced Airway Management & Intubation The Difference Between Life and Death

Tube sizes

Newborn – to 4 kg - 2.5 mm (uncuffed). 1-6 months 4-6 kg – 3.5 mm (uncuffed). 7-12 months 6-9 kg – 4.0 mm (uncuffed). 1 year 9 kg – 4.5 mm (uncuffed). 2 years 11 kg – 5.0 mm (uncuffed). 3-4 years 14–16 kg - 5.5 mm (uncuffed). 5-6 years 18–21 kg – 6.0 mm (uncuffed). 7-8 years 22-27 kg – 6.5 mm ( uncuffed).

Page 26: Advanced Airway Management & Intubation The Difference Between Life and Death

Tube Sizes 9-11 years 28-36 kg – 7.0 mm(cuffed). 14 to adults 46+ kg – 7.0 – 80 mm (cuffed). Adult female 7.0 – 8.0mm (cuffed). Adult male 7.5 – 8.5 mm (cuffed). The size of the tube may also be determined by

the size of the patients little finger.

Patients below the age of 8 require uncuffed ETT due to damage caused by the cuff in younger

patients. Always monitor the ECG activity during intubation.

Page 27: Advanced Airway Management & Intubation The Difference Between Life and Death

4 Rules of Suctioning

Never suction further than you can see.

Always suction on the way out.

Never suction for longer than15 seconds.

Always oxygenate the patient before and

after suctioning.

Page 28: Advanced Airway Management & Intubation The Difference Between Life and Death

Conclusion

Always oxygenate patient before and after intubation.

Do not attempt intubation unless you are totally skilled, rather perform bag-valve-mask ventilation.

Always monitor the sPO2 readings. Always reconfirm tube placement from

time to time.

Page 29: Advanced Airway Management & Intubation The Difference Between Life and Death

Hyperventilate

Page 30: Advanced Airway Management & Intubation The Difference Between Life and Death

Insert to proper depth

Page 31: Advanced Airway Management & Intubation The Difference Between Life and Death

Sweep left, Pass tube

Page 32: Advanced Airway Management & Intubation The Difference Between Life and Death

Don’t let go of tube

Page 33: Advanced Airway Management & Intubation The Difference Between Life and Death

Confirm placement

Page 34: Advanced Airway Management & Intubation The Difference Between Life and Death

Secure tube, EtCO2

Page 35: Advanced Airway Management & Intubation The Difference Between Life and Death
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Page 39: Advanced Airway Management & Intubation The Difference Between Life and Death

Achieving the Goal