airway_mx dsds

Outline Outline

Upper airwayUpper airway

Lower airwayLower airway

Basic airway managementBasic airway managementAssess for Airway Obstruction!

Difficulty breathing Patient conduct (anxious, combative) Abnormal sounds

Improve/Establish Airway Through Maneuvers Chin lift Jaw thrust

Remove Debris/SuctionAirway Adjuncts:

Nasal airway Oral airwayOral airway Others Others

Opening the Airway

Head tilt-chin lift– Nontrauma

patients, medical patients

Jaw-thrust– Suspected spinal

injury

Airway instrumentsAirway instruments

Face mask

Face maskFace mask

Appropriate size: cover from the bridge of the nose to chin

To get a tight seal: EC-clamp technique The thumb and index finger hold the mask

firmly over the nose and chin (forming a “C”) The third through fifth fingers firmly grasp

the bony mandible (forming an “E”) “sniffing” position

Sniffing position

LaryngoscopeLaryngoscope

Oral airwayOral airway

Keep the tongue from falling back

Unresponsive patient with no gag reflex

Corner of patient’s mouth to the tragus

Oral airway; importance of proper size

Nasopharyngeal airwayNasopharyngeal airway

Inserted into patient's nostrils

Tip of patient’s nose to the earlobe

Avoided in patients with: evidence of fracture of middle third of

face. Base of skull fracture. vascular abnormalities of nose. bleeding disorders. Nasal polyps.

Nasopharyngeal airwayNasopharyngeal airway

Endotracheal tubeEndotracheal tube

PVC Choose appropriate size

Male : 7.5 – 8.0 (ID) Female : 7.0 – 7.5 Pediatric : age/4 + 4

Intubating Stylet

Indications for intubationIndications for intubation

Failure to oxygenate Failure to remove CO2 Neuromuscular weakness CNS failure Cardiovascular failure

Steps to control airwaySteps to control airwayPre-IntubationPre-Intubation

-Prepare equipment-Prepare equipment

-Pre-oxygenate-Pre-oxygenate

Steps to control airwaySteps to control airwayOrotracheal Intubation ProcedureOrotracheal Intubation Procedure

Sweep Sweep Left and Left and

LookLook

Backward, Upward, Right Pressure (B.U.R.P.)Backward, Upward, Right Pressure (B.U.R.P.)

Find Your LandmarksFind Your Landmarks

Steps to control airwaySteps to control airway

Find Your LandmarksFind Your Landmarks


It may not be perfect!It may not be perfect!

Find Your LandmarksFind Your LandmarksSteps to control airwaySteps to control airway

Find Your LandmarksFind Your LandmarksSteps to control airwaySteps to control airway

Readjusting with Cricoid PressureReadjusting with Cricoid Pressure


Confirm the airwayConfirm the airway

• ETCO2 (monitor)ETCO2 (monitor)

• Lung expansionLung expansion

Intubation ConfirmationIntubation ConfirmationGood, Better, BestGood, Better, Best

• Direct Direct VisualizationVisualization

• Lung SoundsLung Sounds

• Tube Tube Condensation Condensation

Secure the airwaySecure the airway

TapeTape

Improvised devicesImprovised devices

ImmobilizationImmobilization

Secure Your TubeSecure Your Tube

Good, Better, BestGood, Better, Best

Common MistakesCommon MistakesMaking a difficult intubation more difficultMaking a difficult intubation more difficult

RushingRushing

Poor equipment preparationPoor equipment preparation

Suction (lack there of)Suction (lack there of)


Other optionsOther options

Blind nasal Fibreoptic intubation Retrograde intubation Trach light Cook airway / Bougie LMA / Combitube / Laryngeal tube Tracheostomy

Gum Gum Elastic Elastic BougieBougie

Helpful adjunctsHelpful adjuncts

Laryngeal Mask AirwayLaryngeal Mask Airway

Developed in 1981 at the Royal London Hospital Developed in 1981 at the Royal London Hospital By Dr Archie BrainBy Dr Archie Brain



Indications:Indications:-When definitive airway management -When definitive airway management

cannot be obtained. (ETT)cannot be obtained. (ETT)

Not a substitute for definitive airway Not a substitute for definitive airway managementmanagement



Contraindication/Limitations:Contraindication/Limitations:-Obesity-Obesity

-Non-secure-Non-secure

-Size based-Size based



Weight Based SizingWeight Based Sizing<5kg = <5kg = Size 1Size 15-10 kg = 5-10 kg = Size 2Size 220-30 kg = 20-30 kg = Size 2.5Size 2.5Small Adult= Small Adult= Size 3Size 3Average Adult = Average Adult =

Size 4Size 4 Large Adult = Large Adult = Size 5Size 5



Average Adult Woman = 4Average Adult Woman = 4 Average Adult Male = 5Average Adult Male = 5

*If in doubt, check the LMA*If in doubt, check the LMA



Procedure:Procedure:-Pre oxygenate-Pre oxygenate

-Check cuff -Check cuff

-Lubricate -Lubricate posteriorposterior cuff cuff

-Head in neutral or slightly flexed position-Head in neutral or slightly flexed position

-Insert following hard palate (use index finger to guide)-Insert following hard palate (use index finger to guide)

-Stop when met with resistance-Stop when met with resistance

-Let go and inflate cuff -Let go and inflate cuff

-Confirm and secure-Confirm and secure



Air volume is variable depending on cuff size Air volume is variable depending on cuff size and individual patient anatomyand individual patient anatomy

General Guideline:General Guideline:

Size 1 = 4 mlSize 1 = 4 mlSize 2 = 10 mlSize 2 = 10 mlSize 2.5 = 14 mlSize 2.5 = 14 mlSize 3 = 20 mlSize 3 = 20 mlSize 4 = 30 mlSize 4 = 30 mlSize 5 = 40 mlSize 5 = 40 ml



Common Problems:Common Problems:

-Failure to seat properly-Failure to seat properly

-Sizing difficulties -Sizing difficulties

-Aspiration-Aspiration



(Combitube®)(Combitube®)Dual Lumen AirwayDual Lumen Airway


Indications:Indications:-When definitive airway management -When definitive airway management

cannot be obtained. (ETT)cannot be obtained. (ETT)

Not a substitute for definitive airway Not a substitute for definitive airway managementmanagement

Dual Lumen AirwayDual Lumen Airway


Contraindications/LimitationsContraindications/Limitations::

-No pediatrics-No pediatrics

-Pathological esophageal disease-Pathological esophageal disease

-Non-secure airway-Non-secure airway

-Latex sensitivity-Latex sensitivity

-Toxic or Caustic Ingestions-Toxic or Caustic Ingestions



ProcedureProcedure::

-Pre oxygenate-Pre oxygenate

-Check equipment. -Check equipment.

-Head in neutral position-Head in neutral position

-Insert until to guide lines-Insert until to guide lines



ProcedureProcedure::

Inflate Pharyngeal cuff Inflate Pharyngeal cuff (blue) with 85-100cc of (blue) with 85-100cc of airair

Inflate tracheal cuff Inflate tracheal cuff (white) with 10-15cc of (white) with 10-15cc of airair



42

-Ventilate -Ventilate port 1port 1 (longer, blue tube, #1). (longer, blue tube, #1).

If no lung sounds, switch portsIf no lung sounds, switch ports

-Ventilate -Ventilate port 2port 2 (shorter, white tube, #2) (shorter, white tube, #2)

*You will be either in the esophagus or the trachea*You will be either in the esophagus or the trachea


Lighted StyletteLighted Stylette


AIRWAYAIRWAY

Conclusion 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.

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