Airway managementBy: Dr. Ruba al-hamad

Anatomy of the airways

Airway obstruction and breathing problems Causes .

Recognition.

Treatment

How to manageA 1)look for the signs of airway obstruction. 2)treat airway obstruction as an emergency . 3)give o2 at high doses .B 1) look , listen , feel 2)count 3)Assess the depth of each breath,rhythm,chest expansion Note chest deformity 4) O2 sat 5)Listen to the pt.breath sound 6)Percuss the chest 7)Auscultate the chest 8)Check the treacheal position. 9)Feel the chestCD

Indications for Definitive Airway

Failure to maintain a patent airway and protect against aspiration - Inadequate gag reflex and inability to handle secretions - Decreased mental status (GCS < 8) not due to a rapidly reversible cause (eg, hypoglycemia, opioid overdose) - Severe maxillofacial trauma Failure to adequately oxygenate or ventilate - Hypoxemia unresponsive to supplemental oxygen, as measured by pulse oximetry with good waveform - Hypercapnea, as measured by ABG or end tidal CO2 (ETCO2) with decreased mental status or other adverse effect

Anticipated clinical deterioration eg Status epilepticus, multiple trauma +/ head injury, certain overdoses (TCA), penetrating neck trauma, tiring asthmatic, etc.

NOTE Be sure to correlate ABG findings with the patients clinical status

AIRWAYS PROTECTION METHODS

Head tilt and chin left

Head tilt and chin left

Jaw thrust

NOTE:

We use jaw thrust if we suspect any cervical spine injury also with should always do manual in line stabilization (MILS )in all trauma pt.

Manual in-line stabilization (MILS)

MILS

Adjunct to basic airway techniquesWe measure the distance between the angle of the mouth (incisors)and the ear lobe (jaw angle)to choose the correct size of the oropharyngeal airway

In nasopharyngeal airway we measure the distance between the nares and the ear lobe

OROPHARYNGEAL AND NASOPHARYNGEAL AIRWAY PLACEMENT

The tongue is the most common cause of upper airway obstruction in the supine unconscious or semiconscious patient

INDICATION Relieve upper airway obstruction from tongue in the unconscious (oropharengeal) or semiconscious patient (nasopharengeal). Adjunct to BVM ventilation

CONTRAINDICATION The oropharyngeal airway should not be used on the patient with an intact gag reflex (risk of vomiting),nasopharyngeal airway shouldnt be used in basal skull #.

COMPLICATIONS Epistaxis and possible laryngospasm (nasopharyngeal airway) Vomiting and aspiration Worsened obstruction from improper placement (oropharyngeal airway)

PROCEDURE Oropharyngeal airway : Insert the device , while inverted rotate 180 once it is well inserted into the mouth advance distal end into the hypopharynx. This technique is not recommended for pediatric patients.(the rotational movement of the device ) so we do the step below. compress the tongue with a tongue depressor and advance the device without inversion.

Nasopharyngeal airway : after putting a good amaout of lubricant , Gently advance the device into a nostril until the flared end is resting against the nasal orifice.

Alternative airway devicesLMA

LARYNGEAL MASK AIRWAY (LMA) The LMA is available in the following sizes: 13: Newborn to 3050 kg child, in .5 increments 4: 5070 kg adult 5: Larger adults INDICATIONS Rescue device for cant intubate situations. CONTRAINDICATIONS Significant oropharyngeal pathology, trauma, or bleeding COMPLICATIONS Aspiration Limited utility in patients who require high pressures to ventilate (eg, obese, severe asthma)

PROCEDURE Open airway via head tilt. Insert LMA with the opening facing the tongue and advance along the hard palate until the tip is well placed into hypopharynx. Inflate cuff with 2040 mL air (amount listed on device). Forms seal around glottic opening With the intubating LMA, an ET tube can be advanced through the lumen of the LMA for blind tracheal intubation.

NOTE : Ease of use and potential to transition to a definitive airway make the LMA useful in the difficult airway but doesnt protect against aspiration.

Combi tube

ESOPHAGEAL TRACHEAL COMBITUBE An esophageal tracheal combitube consists of a twin-lumen tube with a proximal low-pressure cuff that seals the pharyngeal area, a distal cuff that seals the esophagus (or the trachea), and ports for ventilation in-between The pharyngeal lumen and KING LT supraglottic airways have similar function. It is available in two sizes only. 37F: Small adult/large child 41F: Larger adults INDICATIONS Apneic and unconscious adult with : - Failed intubation - Limited mouth opening

CONTRAINDICATIONS Patient with intact airway reflexes Esophageal disease Caustic ingestion Upper airway obstruction Children 4 feet tall The Combitube can be used in the setting of upper GI bleed, but not if there is expected esophageal pathology. PROCEDURE Grab and elevate the tongue and jaw with nondominant hand. Pass the tube blindly into the pharynx until the marker on the tube is between the patients teeth. Placement is facilitated by neck flexion.

Inflate the pharyngeal balloon with 100 mL of air. Inflate the distal white balloon with 515 mL of air. Begin ventilation through the longer (blue) connector. Air entry to lungs confirms esophageal placement. Air entry into stomach tracheal placement (rare), in which case confirm with ventilation through shorter (clear) tube.

A blue patient is bad: Begin ventilation through the Combitubes blue connector. Air entry into lungs confirms correct (esophageal) placement of device

Tracheal intubation

Tracheal intubation

BLIND NASOTRACHEAL INTUBATION INDICATIONS Spontaneously breathing patient with an anticipated difficult airway CONTRAINDICATIONS Pediatric patient

PROCEDURE Preoxygenate. Administer nasal anesthetic and vasoconstrictor. Administer nasal lubricant. Insert ET tube with bevel away from septum and gently advance until breath sounds are heard best through tube. Advance the tube during inspiration.

If successful, there is usually associated coughing and/or stridor and cessation of vocalization. Inflate cuff and confirm placement

Note : - The nasal approach is better tolerated than the oral approach in fiberoptic awake intubation. - Blind nasotracheal intubation cannot be performed on the apneic patient.

OROTRACHEAL INTUBATION

INDICATIONS Failure to maintain or protect the airway Failure of oxygenation or ventilation Anticipated deterioration

CONTRAINDICATIONS There are no absolute contraindications.

COMPLICATIONS Broken teeth Laryngospasm Mainstem intubation

ENDOTRACHEAL (ET) TUBE Adult male: 7.59.0 mm tube Adult female: 7.08.0 mm tube

Pediatrics: (4 + age in years)/4 Traditional practice is to use uncuffed tube if

PROCEDURE Position the patient. Sniffing position of head Open patients mouth. Insert blade (using left hand) and sweep patients tongue to left. Final positionin vallecula if curved blade Underneath epiglottis if straight blade Elevate epiglottis. Lift the blade upward and forward at a 45 angle in the direction of the handle. Tracheal manipulation BURP: Backward, Upward, Rightward Pressure on thyroid and cricoid cartilages Bimanual laryngoscopy: Intubator moves trachea into view with right hand. Assistant should then hold trachea in preferred position. Brings the larynx further posterior and superior for better visualization of cords Improves visualization by one full grade, on average Insert ET tube through cords. Inflate ET tube balloon.

Depth at teeth: 23 cm for adult males 21 cm for adult females Children = (0.5 age in years) + 12 cm or 3 the ET tube size. Confirm tube placement. ETCO2 = best method. Gold standard = fiberoptic visualization of tracheal rings through ET tube. Esophageal detector device Syringelike aspiration device that is inserted into the end of ET tube No resistance to pulling plunger = tracheal intubation. Resistance = esophageal intubation. Other methods: Direct visualization, physical examination, pulse oximetry, CXR

Needle cricothyrotomy

Needle cricothyrotomy

NEEDLE CRICOTHYROTOMY Surgical airway of choice in children

NOTE:

Advantages of needle cricothyrotomy over surgical: cricothyrotomy: Simpler, faster, less bleeding, fewer long-term complications, can be done in patients of all ages

Needle cricothyrotomy will provide oxygenation, but ventilation may be inadequate.

Surgical cricothyrotomy

Surgical Cricothyrotomy :Equipment needed at a minimum: Scalpel, tracheal hook, 5.5 or 6.0 cuffed endotracheal tube INDICATIONS Failed airway CONTRAINDICATIONS Difficult to perform in patients < 10 years old COMPLICATIONS More likely in pediatric population due to lack of laryngeal prominence, superior larynx, and small cricothyroid membrane Bleeding Airway injury

Surgical cricothyrotomy is difficult to perform in children

PROCEDURE Locate the cricothyroid membrane with nondominant hand. Make a midline longitudinal skin incision at the level of the cricothyroid membrane. Stabilizing the larynx with thumb and middle finger of nondominant hand, make an horizontal incision in the cricothyroid membrane. Use the tracheal hook to maintain control of trachea. Bluntly widen the cricothyroid membrane orifice with finger or blunt end of scalpel/hemostat. Insert the tracheostomy or endotracheal tube. Confirm placement with ETCO2.

tracheostomy

Tracheostomy:a surgical airway of choice in patients with tracheal injury but not done in ER because its time consuming, the risk of massive bleeding & the need of equipment.

Management of Airway ObstructionHEIMLICH MANEUVER INDICATION Complete airway obstruction due to tracheal foreign body

CONTRAINDICATION Breathing/coughing patient with adequate oxygenation PROCEDURE Child/adult : Subdiaphragmatic thrusts (Arms wrapped around victim if conscious) Infant/small toddler: 5 back blows followed by 5 chest thrusts Direct laryngoscopy with foreign body removal, when available

NOTES :Do not perform the Heimlich maneuver on a patient who is breathing or coughing and appears to have adequate oxygenation.

Abdominal thrusts are relatively contraindicated in pregnant patients. Use chest compressions instead

BREATHING AND VENTILATION

O2 MASKS

Nasal canula

1 )Administration of Supplemental Oxygen

a- Nasal cannula delivers O2 at concentration of 25-45% at the flow rate 1-6 L/min & may be used for conscious patients with COPD in a non- arrest setting

b- Simple (standard face mask) its a plastic mask with side holes that allow inhalation & exhalation of room air & supplemental O2, the recommended flow rate 8-10 L/min which gives O2 concentration of 40-60% not used in an arrest setting. c - Ventori mask is similar to simple face mask but is modified to allow more precise delivery of O2 used in conscious COPD patients in whom tight control of O2 concentration is required, not used in arrest setting.

d - Non-rebreather mask: a one way exhalation valve prevents a mixing of room air & expired air with a reservoir bag of 100% oxygen in order to be effective the patient must have spontaneous respiration, the mask fit tightly & the reservoir bag must be completely filled (oxygen flow rate of 10-15 L/min).

A non rebreather mask is a first line method for the delivery of oxygen at concentration approaching 100% in a patient with spontaneous respiration.

2)ASSESSTED VINTILATION

Noninvasive methods of ventilation

Noninvasive Ventilation - Requirements: Patent airway, patient cooperation, and intact respiratory drive - Allows time to treat the cause of respiratory distress, avoid ET intubation and its associated complications, and length of stay CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP) Provides constant airway pressure to prevent upper airway collapse Need properly fitted mask Reduces work of breathing, increases oxygenation and CO2 clearance BI-LEVEL POSITIVE AIRWAY PRESSURE (BIPAP) It is a combination of CPAP and inspiratory assist. Inspiratory positive pressure (810cm H2O) exceeds that of expiratory positive pressure (35cm H2O) provided. It provides extrinsic PEEP. Each cycle is triggered by patient initiation of inhalation

COMPLICATIONS Volutrauma, pressure necrosis of the skin from an ill-fitting mask, gastric distention, delayed definitive airway management

NOTE :BiPAP is a combination of CPAP and inspiratory assist

Invasive methodes of ventilation

Mechanical Ventilation Initial ventilator setting should be based on review of the underlying pulmonary process

COMPLICATIONS 1 )Volutrauma Overdistention of alveoli Prevented by using smaller tidal volumes

2 ) Barotrauma Caused by excessive pressure Prevented by lowering inspiratory pressures

3) Ventilator associated pneumonia Risk increases exponentially in relationship to duration of intubation. Decrease risk by sitting patients up in bed by at least 30 degrees if not contraindicated. Early pneumonias (< 72 hours postintubation): Community acquired pathogens Late pneumonias (> 72 hours postintubation): Nosocomial pathogens, more resistant strains

4) Hemodynamic instability High respiratory rate, PEEP, or inverse ratio ventilation may increase intrathoracic pressure, decreasing venous return decreased cardiac output hypotension. May also increase cerebral venous pressure cerebral ischemia