department of anesthesiology uniformed services university of the health sciences airway management...

Department of AnesthesiologyUniformed Services University of the Health Sciences

AIRWAY MANAGEMENTAIRWAY MANAGEMENT

When you can’t breath, nothing else mattersWhen you can’t breath, nothing else matters

Acute Respiratory FailureAcute Respiratory Failure

Respiratory failure: failure of maintenance of Respiratory failure: failure of maintenance of normal arterial blood gas tensionsnormal arterial blood gas tensions

Ventilatory failure: pathological reduction in Ventilatory failure: pathological reduction in alveolar ventilationalveolar ventilation


What are our goals in support of the Respiratory What are our goals in support of the Respiratory system in critically ill patients?system in critically ill patients?

What conditions may lead to prevent us from What conditions may lead to prevent us from achieving these goals?achieving these goals?

What therapies can we offer in support of each of What therapies can we offer in support of each of these goals?these goals?

AIRWAY MANAGEMENTAIRWAY MANAGEMENT

Respiratory Distress vs. Respiratory FailureRespiratory Distress vs. Respiratory Failure

DistressDistress

-Increased work of breathing-Increased work of breathing

--RelativeRelative hypoxia/hypercapnea hypoxia/hypercapnea

--CompensatingCompensating

FailureFailure

-Increased work of breathing-Increased work of breathing

--ProfoundProfound hypoxia/hypercapnea hypoxia/hypercapnea

--DecompensatingDecompensating

It’s a constant reassessment process…


Goal 1: Maintenance of a patent airwayGoal 1: Maintenance of a patent airway CNS alertnessCNS alertness Secretion controlSecretion control Jaw thrustJaw thrust NP airwayNP airway Oral airwayOral airway Noninvasive positive pressureNoninvasive positive pressure ETTETT


Goal 2: Maintenance of adequate respiratory gas Goal 2: Maintenance of adequate respiratory gas exchange (O2 and CO2)exchange (O2 and CO2) Supplemental OxygenSupplemental Oxygen Noninvasive positive pressureNoninvasive positive pressure CMVCMV HFOHFO ECMOECMO


Goal 3: Preservation of normal respiratory Goal 3: Preservation of normal respiratory mechanicsmechanics Secretion controlSecretion control Chest physiotherapyChest physiotherapy ETT suctioningETT suctioning Prone positioningProne positioning


Goal 4: To minimize the metabolic expenditures Goal 4: To minimize the metabolic expenditures of the respiratory systemof the respiratory system Positive pressurePositive pressure

» InvasiveInvasive

» NoninvasiveNoninvasive

SedationSedation Maintenance of patent airwayMaintenance of patent airway Medications: steroids, racemic epi., VentolinMedications: steroids, racemic epi., Ventolin


Goal 5: Occasionally, specific alterations in blood Goal 5: Occasionally, specific alterations in blood gas tensions may be desirable.gas tensions may be desirable. Head injury, avoidance of hypercapneaHead injury, avoidance of hypercapnea Deliberate hypoxia and hypercapnea in cyanotic heart Deliberate hypoxia and hypercapnea in cyanotic heart

disease to limit pulmonary blood flowdisease to limit pulmonary blood flow Pulmonary hypertension: high O2 and low CO2Pulmonary hypertension: high O2 and low CO2


Definitions of Respiratory Failure:Definitions of Respiratory Failure: Depends on what you mean by failure.Depends on what you mean by failure.

In ARDS, PaO2/FiO2 ratio of <200, bilateral In ARDS, PaO2/FiO2 ratio of <200, bilateral infiltrates on CXR, PAWP < 16.infiltrates on CXR, PAWP < 16.

What level of arterial CO2 constitutes respiratory What level of arterial CO2 constitutes respiratory failure?failure?

What level of arterial saturation? What level of arterial saturation?

Establishing A Patent AirwayEstablishing A Patent Airway

• Chin Lift and Jaw Thrust ManeuverChin Lift and Jaw Thrust Maneuver• Oropharyngeal AirwayOropharyngeal Airway• Nasopharyngeal AirwayNasopharyngeal Airway• Laryngeal Mask AirwayLaryngeal Mask Airway

-- The above do not protect against aspiration and The above do not protect against aspiration and laryngospasmlaryngospasm


Mask VentilationMask Ventilation

• Can Deliver A High FIO2Can Deliver A High FIO2• Avoids The Potential Trauma Of IntubationAvoids The Potential Trauma Of Intubation• Does Not Protect Against AspirationDoes Not Protect Against Aspiration• May Result In Gastric DistensionMay Result In Gastric Distension• Laryngospasm Can OccurLaryngospasm Can Occur• Requires Use Of Both HandsRequires Use Of Both Hands


Oral/Nasal IntubationOral/Nasal Intubation

• Safe and Common Practice in Patients Safe and Common Practice in Patients Undergoing General AnesthesiaUndergoing General Anesthesia

• Atraumatic Intubation requires Knowledge of Atraumatic Intubation requires Knowledge of Anatomy, Appropriate use of Equipment, and Anatomy, Appropriate use of Equipment, and Drugs (Muscle Relaxants)Drugs (Muscle Relaxants)


Preoperative EvaluationPreoperative Evaluation

• Patient HistoryPatient History-- Prior History of Difficult Intubation Prior History of Difficult Intubation

- - Tumor of Head and Neck Tumor of Head and Neck

-- Arthritis Arthritis

- - Pregnancy Pregnancy

-- Trauma - C Spine, Full Stomach Trauma - C Spine, Full Stomach


Preoperative EvaluationPreoperative Evaluation

• Physical ExaminationPhysical Examination-- Tongue versus Pharyngeal Size Tongue versus Pharyngeal Size

-- Atlanto - Occipital Joint Extension Atlanto - Occipital Joint Extension• Cervical Spine Mobility (normal 35 degrees)Cervical Spine Mobility (normal 35 degrees)

-- Anterior Mandibular Space Anterior Mandibular Space• Thyromental distance - normal is 6 cmThyromental distance - normal is 6 cm

-- Dental Examination (Loose Teeth, Prostheses) Dental Examination (Loose Teeth, Prostheses)


Technique For Orotracheal IntubationTechnique For Orotracheal Intubation

• Preparation And Equipment (Always Have Preparation And Equipment (Always Have Suction Available)Suction Available)

• Head Position - Alignment Of Oral, Pharyngeal, Head Position - Alignment Of Oral, Pharyngeal, and Laryngeal Axesand Laryngeal Axes

• Choice Of Laryngoscope And Endotracheal TubeChoice Of Laryngoscope And Endotracheal Tube• Possible Need For Awake Tracheal Intubation Possible Need For Awake Tracheal Intubation

- - Difficult Airway Algorithm Difficult Airway Algorithm


Orotracheal IntubationOrotracheal Intubation

• Patient’s Head At The Level Of The XiphoidPatient’s Head At The Level Of The Xiphoid• Sniffing PositionSniffing Position• Laryngoscope In Laryngoscope In LEFTLEFT Hand Hand• Open MouthOpen Mouth• Hold Tracheal Tube In Right Hand Like A PencilHold Tracheal Tube In Right Hand Like A Pencil


Complications Of Orotracheal Complications Of Orotracheal Intubation (During)Intubation (During)

• Dental And Oral Soft tissue TraumaDental And Oral Soft tissue Trauma• Hypertension And TachycardiaHypertension And Tachycardia• Cardiac Dysrhythmias And Myocardial IschemiaCardiac Dysrhythmias And Myocardial Ischemia• AspirationAspiration• Corneal DamageCorneal Damage


Complications Of Orotracheal Complications Of Orotracheal Intubation (Intubated Patient)Intubation (Intubated Patient)

• Tracheal Tube ObstructionTracheal Tube Obstruction• Endobronchial IntubationEndobronchial Intubation• BarotraumaBarotrauma• Accidental DisconnectAccidental Disconnect• Tracheal Mucosa IschemiaTracheal Mucosa Ischemia• Accidental ExtubationAccidental Extubation


Immediate And delayed Immediate And delayed Complications On ExtubationComplications On Extubation

• LaryngospasmLaryngospasm• AspirationAspiration• PharyngitisPharyngitis• Laryngeal Or Subglottic EdemaLaryngeal Or Subglottic Edema• Vocal Cord ParalysisVocal Cord Paralysis• Arytenoid Cartilage DislocationArytenoid Cartilage Dislocation


Alternatives To Orotracheal Alternatives To Orotracheal Intubation Under AnesthesiaIntubation Under Anesthesia

• Awake Orotracheal IntubationAwake Orotracheal Intubation• Nasotracheal IntubationNasotracheal Intubation

-- Awake Blind Nasal Awake Blind Nasal- - Nasotracheal Intubation After Induction Nasotracheal Intubation After Induction

• Intubation With Fiberoptic BronchoscopeIntubation With Fiberoptic Bronchoscope-- Awake versus Under Anesthesia Awake versus Under Anesthesia-- Orotracheal versus Nasotracheal Orotracheal versus Nasotracheal

• Retrograde IntubationRetrograde Intubation


Verification Of Correct Tube PlacementVerification Of Correct Tube Placement• Symmetric Chest MovementSymmetric Chest Movement• Symmetric Breath SoundsSymmetric Breath Sounds• End tidal Carbon DioxideEnd tidal Carbon Dioxide

-- Greater Than 30 For 3-5 Breaths Greater Than 30 For 3-5 Breaths

• Condensation Of Water In The tubeCondensation Of Water In The tube• Palpation Of Cuff In Suprasternal NotchPalpation Of Cuff In Suprasternal Notch• Fiberoptic BronchoscopyFiberoptic Bronchoscopy


department of anesthesiology uniformed services university of the health sciences airway management...

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