anything new in the airway managment

Anything new in Airway Management?

Dr Adrian Burger

Emergency Medicine Senior Registrar

UCT/US

So what do we do?

• A,B,C’s……

• A is for clearing, opening and or securing the airway

• Clearing - turn on side

- suction

- no more blind finger sweeps!

Opening

• Jaw thrust

• Head Tilt Chin lift

• Combined

• Remember : C-spine stabilization

Opening or securing the Airway

• BMV

• OPA/NPA

• LMA

• Combitube®

• ETT

Mask

• Most basic piece of “airway” kit

• Different types - clear, black

- cushion around edge

• Won’t maintain airway by self

• Needs head tilt/chin lift or jaw thrust

• Also needs Positive Pressure Ventilation

Positive Pressure Ventilation

• Rescuer’s breathing efforts and one-way valve

• Bag Mask Ventilation (BMV)

Mask with one-way valve

Oropharyngeal Airway/Guedel

• Different colours = different sizes

• Neonate to large adult

SIZE COLOUR

000 Violet

OO Blue

O Black

1 White

2 Green

3 Orange

4 Red

5 Yellow

Oropharyngeal Airways


• Features:

- single use

- rounded edges

- bite block

- colour coding

- airway path in centre


• How to size it????

The size of the Guedel airway is the distance

between the center of the incisors and the angle of the jaw (on the same side!)


• How to put it in:

Depress tongue

Slip over spatula with curve caudal direction

Place bite block between teeth

• NO TWISTING MOVEMENT


• Indications:

To open and maintain an airway in a

patient with a depressed level of

consciousness

With FMO2 or BMV


• Contra indications:

Patient won’t accept it

LOC

Risk of vomiting & aspiration

Nasopharyngeal Airway

• For maintaining airway in “more awake” patients

• Sits in nasopharynx and opens airway

• Does NOT protect against aspiration


• How to size it?

Estimate by comparing to patients little

finger• How to insert it?

Lubricate

Gently push posteriorly towards ear on same side

Fix with a safety pin


• Contra-indications:

Base of skull fracture

Serious midline facial fractures

When definitive airway needed

LMA

• Advanced airway

• Useful alternative for “difficult intubation”

• Easy to use

• Sits on larynx - Protects lungs?

LMA

• Have a range in unit• Re-use ?20 times• Part of kit• Formula for Children:

The combined widths of

the patient's index,

middle and ring fingers

SIZE PATIENT

1 <5 kg

1.5 5-10kg

2 10-20kg

2.5 20-30kg

3 30-50kg

4 50-70kg

5 70-100kg

6 >100kg

LMA in Emergency Medicine• Indications:

Unconscious or anaesthetized patients

AHA Guidelines for adults: BLS: alternative to BMV

ACLS: Optional/alternative to BMV, failed ETT

• Aspiration?

• Paediatrics?

LMA in Emergency Medicine

• Aspiration?

Less than with BMV

Supraglottic device Aspirated from CPR or post LMA?

Cricoid pressure during CPR

LMA Use in Emergency Paediatrics

• Little Data “Despite widespread use LMA, there is little data

on its effectiveness during positive pressure ventilation in infants and young children “

• Obstruction The LMA appears more likely to cause partial

airway obstruction in infants ( < 10kg) than in older children.

• PALS®: Class Indeterminate• Neonates: “Can’t intubate can’t ventilate”


• Benefits:

Ineffective BMV with failed ETT

AHA: Alternative to ETT or BMV in CPR

Blind ETT, by passing ETT through LMA

Drugs - 27% efficacy


• Disadvantages:

Needs adequate training

Risk of aspiration

Limited Paediatric use

Not always successful

LMA Insertion

Combitube®

Combitube®

• Advantages:

Protect airway from aspiration

Easy to use

AHA: alternative to ETT for CPR

• Disadvantages:

Trauma to soft tissues

Not available here in SA

Combitube®

• Head neutral or slightly flexed• Hold tongue and jaw between thumb &

forefinger and lift • Gently insert Combitube® in a curved back and

downward movement until black markers aligned with teeth

• Inflate (proximal) pharyngeal balloon• Inflate (distal) tracheal balloon• Confirm which one of #1 or #2 tube is in lungs

by using bag ventilator

Combitube® Insertion

Equipment for ETT

• Mask and bag ventilator with O2• ETT - checked, lubricated, tape ready• Laryngoscope• Drugs: Induction agent & muscle relaxant• McGills forceps, Bougie• Primary detection tools• Other advanced airways• Surgical airway capability

ETT

• Advantages:

Airway patent and protected

Secretions suction

O2

Medication

Known tidal volume

ETT

• Disadvantages:

Training

Skill lost

Interrupted CPR

Why ETT?

• For above benefits

• Inability to BMV or ineffective BMV

• Secure threatened airway

• Certain thoracic injuries

Anatomy

endotracheal tubes

• cuffed tubes

• uncuffed tubes

placement of ETT

• length of tube at the larynx (cm) = internal diameter of correct ETT for size

railroad techniques for changing tubes

• getting the curves right

Tube Placement Confirmation

• Clinical - visual

- auscultation

- laryngoscopy

• Detection devices - CO2 (2a)

- EDD

Detection Devices

• Always clinical + device• No single device specific or sensitive• CO2 detector: 33%-100% sensitive : 97%-100% specific : only studied on ETT• EDD: bulb compressed or syringe pulled : High sensitivity : Poor specificity• CXR

Secure the ETT

• Record depth at front teeth

• Evidence is commercial=tape

• Re-evaluate

• 3 Rules - verify placement

- asynchronous CPR

- avoid excessive ventilation

BMV

• Best for last!

• Easy to master

• First line in CPR

• Every unit has one

• Effective

BMV

• OLD: ETT ventilation adjunct of choice for

CPR• ETT complications - misplaced

- displaced

- interrupted CPR• AHA: BMV or advanced airway for CPR

• Prehospital: BMV=LMA & Combitube®

Failed Intubation

• Can’t intubate, Can Ventilate Don’t panic, call for help Reassess need to intubate Reposition patient, airway Cricoid pressure Bougie Consider other advanced airways Call for help

Failed Intubation

• Can’t intubate, Can’t Ventilate

Call for help, don’t panic

Reassess airway, positioning

Reassess equipment

Two person ventilation

Other advanced airway

Surgical airway

CALL FOR HELP

Remember

• Check your equipment before you need it

• Be prepared

• Don’t panic

Parting shot

“Patients do not die from lack of intubation they die from lack of oxygenation”

References

• Currents, winter2005-2006

• JAMA, Feb 9, 2000-Vol 283, No6 p783-790

• www.aic.cuhk.edu.hk/web8/index

• www.healthsystem.virginia.edu/Internet/Anesthesiology-Elective/airway/anatomy

• www.lmana.com/prod/components/products/lma_classic

http://www.aic.cuhk.edu.hk/web8/index.htm

http://www.healthsystem.virginia.edu/Internet/Anesthesiology-Elective/airway/anatomy

http://www.healthsystem.virginia.edu/Internet/Anesthesiology-Elective/airway/anatomy

anything new in the airway managment

Health & Medicine