What are the indications of What are the indications of intubations??intubations??
(1) failure to maintain or protect the airway(1) failure to maintain or protect the airway (2) failure of ventilation or oxygenation(2) failure of ventilation or oxygenation (3) anticipated need for intubation based on the (3) anticipated need for intubation based on the
patient's clinical course and likelihood of patient's clinical course and likelihood of deterioration. deterioration.
• Status epilepticus
• Severe multiple trauma
• Certain Overdoses
• Penetrating neck trauma
Certain conditions indicate the need for intubation even in the absence of airway, ventilatory, or oxygenation failure.????
Indications of IntubationsIndications of Intubations
ESTABLISHMENT OF AIRWAY PATENCY
Common Obstructing Agents
The tongueDenturesSwollen or distorted tissuesBloodVomitus
Partial airway obstruction in the patient with a decreased level of consciousness is
commonly due to posterior displacement of the tongue.
ESTABLISHMENT OF AIRWAY PATENCY
1. Adequacy of current ventilation
2. Potential for hypoxia
3. Airway patency
4. Need for neuromuscular blockade (muscle tone, teeth clenching, severe obstructive pulmonary disease, or asthma)
5. Cervical spine stability
6. Safety of technique and skill of the operator
Qs before an airway management
Airway Maneuvers
•The neck-lift •head-tilt method•jaw-thrust method•chin-lift method.
lax musculature and tongue occlusion of the posterior pharynx may be overcome by a variety of A/W maneuvers
A jaw-thrust or chin-liftmaneuver should be performed on every unconscious patient.
Neck lift
Chin lift
Jaw thrust
The Jaw-Thrust Maneuver The Chin-Lift Maneuver
Airway Maneuvers
By maintaining airway patency, artificial airways may facilitate
both spontaneous and bag-mask ventilation.
•Better tolerated in the semiconscious or conscious patient. •May cause nasal bleed
Nasopharyngeal Airways
•Extreme caution is indicated in patients with a suspected basilar skull fracture or facial injury.
• Prevent the tongue from obstructing the airway • Prevent teeth clenching.• May cause vomiting
Oropharyngeal
May cause airway obstruction if during its placement the tongue is pushed against the posterior pharyngeal wall
All potentially unstable patients with oral or nasal pharyngeal airways should be observed constantly, because these devices are temporary measures and cannot substitute for tracheal intubation.
•simple and effective.•it can be difficult to perform correctly
•ensure a tight mask seal in situations requiring positive-pressure ventilation.
•often is used with an oropharyngeal or nasopharyngeal airway in place
BVM
A tight mask seal is mandatory to prevent loss of tidal volume and to ensure oxygen delivery during ventilation.
The thumb and index finger provide anterior pressure while the fifth and fourth fingers lift the jaw
Dentures generally should be left in place tohelp ensure a better seal with the mask.
BVM
What are the major problems What are the major problems encountered with BVM ventilation??encountered with BVM ventilation??
Inadequate tidal volumesInadequate tidal volumes Inadequate oxygen deliveryInadequate oxygen delivery Gastric distention. Gastric distention. The foreign material may be insufflated down the The foreign material may be insufflated down the
trachea if it is not cleared before ventilation. trachea if it is not cleared before ventilation. Regurgitation and Aspiration Regurgitation and Aspiration
The application of firm posterior pressure on The application of firm posterior pressure on the cricoid ring helps reduce gastric the cricoid ring helps reduce gastric inflation during BVM ventilation inflation during BVM ventilation
30 year old f. started on ACEI on the floor, became hypoxic and started to have tongue swelling and stridor. IM epi, steroid & fluid were given without any improvement.
What do you want to do????
Difficult AirwayDifficult Airway
Incorrect position of the patient.Incorrect position of the patient. Inadequate or improper equipment.Inadequate or improper equipment. Unusual or abnormal anatomy.Unusual or abnormal anatomy. Pathologic causes Pathologic causes
General Causes
69 y.o.male admitted to the ICU with septic shock received 3 L. of crystalloid, started in inotrpes. remain hypotensive ,ECG shows new ST depression, O2 sat. went down to 85% in 100% O2.PMH: HTN, MI, sever RA on wheelchair on ACEI , lasix, ASA, percocet.
What do you want to do????
Difficult Intubation??Difficult Intubation??
Anatomically abnormal facesAnatomically abnormal faces
Neck traumaNeck traumaProminent incisorsProminent incisorsReceding mandibleReceding mandibleCervical spine immobilizationCervical spine immobilizationShort, thick neckShort, thick neckNeck mobility Neck mobility
Difficult AirwayDifficult Airway
There are three specific tests which There are three specific tests which when used together have when used together have almost almost 100%100% reliability in predicting airway reliability in predicting airway difficulty. difficulty.
The Mallampati testThe Mallampati test The Thyromental distanceThe Thyromental distance Extension at the Atlantooccipital joint. Extension at the Atlantooccipital joint.
Difficult Bag/Mask Ventilation Difficult Bag/Mask Ventilation
EdentulousnessEdentulousness
ObesityObesity
History of snoringHistory of snoring
BeardBeard
Age > 55 yearsAge > 55 years
Anatomically Anatomically abnormal faciesabnormal facies
Facial/neck traumaFacial/neck trauma
Obstructive airways Obstructive airways diseasedisease
Third-trimester Third-trimester pregnancypregnancy
Difficult Intubation and Difficult BMV??Difficult Intubation and Difficult BMV??
Anatomically abnormal facesAnatomically abnormal faces
Facial/neck traumaFacial/neck trauma
Morbid obesityMorbid obesity
•Inspect for external markers of difficult intubation, difficult bag/mask ventilation, or both. •Assess cervical spine mobility. •Assess mouth opening (three fingers between the incisors). •Assess oral access (Mallampati scale). •Assess laryngoscopic geometry (mentum to hyoid, laryngeal prominence to floor of mandible). •Evaluate for obstruction.
Evaluation of the Difficult Airway In Summary
Difficult AirwayDifficult Airway
Preparation
preparation
In airway management, failure has ominous
consequences.
Mental, physical, and equipment preparation
maximizes
the chances of success
•preparation
preparation
preparationpreparation
•preparation
•preparation•preparation
preparation
preparation
Difficult AirwayDifficult Airway
Airway Cart
Make your self familiar to its content before you need it
Preparing for Intubation Preparing for Intubation
(1) confirm that the required intubation (1) confirm that the required intubation equipment is available and functioningequipment is available and functioning
(2) position the patient correctly(2) position the patient correctly
(3) assess the patient for difficult airway(3) assess the patient for difficult airway
(4) establish intravenous (IV) access, time (4) establish intravenous (IV) access, time permittingpermitting
(5) draw up essential drugs(5) draw up essential drugs
(6) attach the necessary monitoring devices (6) attach the necessary monitoring devices
PositioningPositioning
The patient should be positioned to optimally The patient should be positioned to optimally align the oral, pharyngeal, and laryngeal axesalign the oral, pharyngeal, and laryngeal axes
with the head extended on the neck and the neck with the head extended on the neck and the neck slightly flexed relative to the torso. slightly flexed relative to the torso.
A small towel under the occiput (to raise it 7 to A small towel under the occiput (to raise it 7 to 10 cm) may facilitate positioning in the adult. 10 cm) may facilitate positioning in the adult.
Positioning of the headPositioning of the head
and and
neck is a critical stepneck is a critical step
suboptimal head suboptimal head
positioning may be positioning may be
a common reason a common reason
for intubation failures.for intubation failures.
LaryngoscopyLaryngoscopy
Laryngoscope Laryngoscope
The tip fits into the vallecula The tip fits into the vallecula and indirectly lifts the and indirectly lifts the epiglottis. epiglottis.
The wider, curved blades are The wider, curved blades are helpful in keeping the tongue helpful in keeping the tongue retracted from the field of retracted from the field of vision, vision,
more room in passing the tube more room in passing the tube in the oropharynxin the oropharynx
generally preferred in generally preferred in uncomplicated adult uncomplicated adult intubations.intubations.
less forearm strength than the less forearm strength than the straight bladestraight blade
Curved (MacIntosh)Curved (MacIntosh)
Straight (Miller) Laryngoscope Straight (Miller) Laryngoscope
The tip goes under the epiglottis and lifts it The tip goes under the epiglottis and lifts it directlydirectly
Pediatric patientsPediatric patients Anterior larynx Anterior larynx Long floppy epiglottisLong floppy epiglottis If larynx is fixed by scar tissue.If larynx is fixed by scar tissue.
It is less effective in Prominent upper teeth.It is less effective in Prominent upper teeth.
--laryngospasm --laryngospasm --advanced into the esophagus.--advanced into the esophagus. --The light bulb at the tip that may slightly --The light bulb at the tip that may slightly
hamper visionhamper vision
If the straight blade is placed too deeply, the entire larynx may be elevated anteriorly and out of the field of vision.
Gradual withdrawal of the blade should allow the laryngeal inlet to drop down into view.
If the blade is deep and posterior, the lack of recognizable structures indicates esophageal passage; gradual withdrawal should permit the laryngeal inlet to come into view.
Laryngoscopy Laryngoscopy
Placing the blade in the middle of the tongue and failing to move the tongue to the left are two common errors preventing visualization of the vocal cords
Laryngoscopic View Grades
The "BURP" The "BURP"
External laryngeal manipulation, also called bimanual External laryngeal manipulation, also called bimanual laryngoscopy laryngoscopy
places the right hand on the patient's thyroid cartilage to determine places the right hand on the patient's thyroid cartilage to determine the best position of the larynx from the intubator's perspectivethe best position of the larynx from the intubator's perspective
Levitan RM, Mickler T, Hollander JE: Bimanual laryngoscopy: A videographic Levitan RM, Mickler T, Hollander JE: Bimanual laryngoscopy: A videographic study of external laryngeal manipulation by novice intubators. Ann Emerg Med study of external laryngeal manipulation by novice intubators. Ann Emerg Med 40:38, 2002. 40:38, 2002.
LaryngoscopyLaryngoscopy
Laryngoscopy Laryngoscopy bougie tube bougie tube
If the vocal cords are still not seen, a bougie tube If the vocal cords are still not seen, a bougie tube introducer may be used introducer may be used
It is a long, semirigid introducer that is placed, It is a long, semirigid introducer that is placed, using the laryngoscope, through the laryngeal using the laryngoscope, through the laryngeal inlet and into the trachea.inlet and into the trachea.
The tracheal tube is then passed over the The tracheal tube is then passed over the introducer and the introducer is withdrawn. introducer and the introducer is withdrawn.
Laryngoscopy Laryngoscopy bougie tubebougie tube
A curved or "coude tip" bougie is best suited for A curved or "coude tip" bougie is best suited for aiding in difficult intubations. aiding in difficult intubations.
The curved tip provides tactile feedback as it The curved tip provides tactile feedback as it passes along the tracheal rings. passes along the tracheal rings.
If resistance is met in passing the If resistance is met in passing the tracheal tube, rotate the tube 90° tracheal tube, rotate the tube 90° counterclockwise and advance the counterclockwise and advance the tube.tube.
Crash AirwayCrash Airway
• unresponsive to direct laryngoscopy
ETTETT
The ET tube cuff should be checked for leaks by The ET tube cuff should be checked for leaks by inflating the balloon before attempting inflating the balloon before attempting intubationintubation
flexible stylet down the tube to increase its flexible stylet down the tube to increase its stiffness and enhance control of the tip of the stiffness and enhance control of the tip of the tube.tube.
The tube is then bent in a gradual curve with a The tube is then bent in a gradual curve with a more acute angling in the distal one-third to more acute angling in the distal one-third to more easily access the anterior larynx. more easily access the anterior larynx.
The tip and cuff of the tube are lubricated with The tip and cuff of the tube are lubricated with viscous lidocaine or a water-soluble gel.viscous lidocaine or a water-soluble gel.
ETTETT
Adult men generally accept a 7.5 to 9.0 mm Adult men generally accept a 7.5 to 9.0 mm
women can usually be intubated with a 7.0 to 8.0 women can usually be intubated with a 7.0 to 8.0 mm tube. mm tube.
In most circumstances, tubes smaller than these In most circumstances, tubes smaller than these should not be used because airway resistance should not be used because airway resistance increases as tube size decreases. increases as tube size decreases.
In emergency intubations, particularly if a difficult In emergency intubations, particularly if a difficult intubation is anticipated, many clinicians choose a intubation is anticipated, many clinicians choose a smaller tube and change to a larger tube later. smaller tube and change to a larger tube later.
ETTETT
Cuff pressure should be measured and maintained at 20 to 25 mm Hg.
Capillary blood flow is compromised in the tracheal mucosa when the cuff pressure exceeds 30 mm Hg.
In emergency situations, the balloon may simply be inflated with 10 mL of air and adjusted when the patient's condition has stabilized.
ETTETT The tube should be introduced from the right The tube should be introduced from the right
side of the patient's mouth, advanced toward the side of the patient's mouth, advanced toward the patient's larynx at an angle, not parallel with or patient's larynx at an angle, not parallel with or down the slot of the laryngoscope blade. down the slot of the laryngoscope blade.
This way, the clinician's view of the larynx is not This way, the clinician's view of the larynx is not obstructed by the hand or the tube until the last obstructed by the hand or the tube until the last possible moment before the tube enters the possible moment before the tube enters the larynx. larynx.
If the patient is not chemically paralyzed, the If the patient is not chemically paralyzed, the tube should be passed during inspiration, when tube should be passed during inspiration, when the vocal cords are maximally open. the vocal cords are maximally open.
29 y. o. 36 week pregnant lady 29 y. o. 36 week pregnant lady admitted with multiple trauma after admitted with multiple trauma after mva mva
GCS is 8, O 2 sat is 85% SBP is 60.?GCS is 8, O 2 sat is 85% SBP is 60.?
Any special consideration in Any special consideration in intubation of this pt ?????intubation of this pt ?????
Obstetric Patients Obstetric Patients
Functional residual capacity is significantly Functional residual capacity is significantly reduced causing the rapid desaturation seen in reduced causing the rapid desaturation seen in the preintubation period. the preintubation period.
hypotension in the supine position as a result of hypotension in the supine position as a result of compression of the vena cava by the gravid compression of the vena cava by the gravid uterus. uterus.
Engorgement of oropharyngeal and nasal Engorgement of oropharyngeal and nasal mucosa leads to easily provoked bleeding with mucosa leads to easily provoked bleeding with manipulation. manipulation.
Obstetric PatientsObstetric Patients
The generalized edema including the airway The generalized edema including the airway
use smaller ET tubes (6.0 to 7.0)use smaller ET tubes (6.0 to 7.0)
Advanced gestation has been shown to correlate Advanced gestation has been shown to correlate with higher maternal Mallampati scores.with higher maternal Mallampati scores.
Aspiration during emergency airway procedures. Aspiration during emergency airway procedures.
90 year old male in CHF, awake, hypoxic 84% and 90 year old male in CHF, awake, hypoxic 84% and difficult to ventilate.difficult to ventilate.
No teethNo teeth
Has a beardHas a beard
How do you want to pre oxygenate him for How do you want to pre oxygenate him for intubation ???intubation ???
INTERMEDIATE AIRWAYS INTERMEDIATE AIRWAYS
Allow ventilation across the Allow ventilation across the larynx but do not involve larynx but do not involve complete airway control. complete airway control.
INTERMEDIATE AIRWAYSINTERMEDIATE AIRWAYS
Esophageal obturator airway (EOA)Esophageal obturator airway (EOA) Esophageal gastric tube airway Esophageal gastric tube airway
(EGTA)(EGTA) Laryngeal mask airway (LMA)Laryngeal mask airway (LMA) Esophageal-tracheal Combitube Esophageal-tracheal Combitube
(ETC) airway (Sheridan Catheter (ETC) airway (Sheridan Catheter Corp., Argyle, NY). Corp., Argyle, NY).
INTERMEDIATE AIRWAYSINTERMEDIATE AIRWAYS
(EOA and EGTA), are designed to occlude (EOA and EGTA), are designed to occlude only the esophagus only the esophagus
(LMA) seals the larynx at the hypopharynx (LMA) seals the larynx at the hypopharynx level, level,
(ETC) offers the versatility of use whether (ETC) offers the versatility of use whether placed into the esophagus or the trachea. placed into the esophagus or the trachea.
Esophageal Obturator Airway Esophageal Obturator Airway
Protect the airway by Protect the airway by occluding the esophagus occluding the esophagus to reduce gastric to reduce gastric distention and distention and regurgitation. regurgitation.
Ventilation from the EOA Ventilation from the EOA exits the airway through exits the airway through numerous ports in its numerous ports in its hypopharyngeal portion.hypopharyngeal portion.
As a precaution against pressure-As a precaution against pressure-related complications, it is related complications, it is
recommended that these devices be recommended that these devices be left in place for no longer than 2 left in place for no longer than 2
hours. It must be recognized that the hours. It must be recognized that the EOA is EOA is temporarytemporary form of airway form of airway
control, most suitable for use in out-control, most suitable for use in out-of-hospital settings.of-hospital settings.
Esophageal Obturator Esophageal Obturator Airway andAirway and
Esophageal Obturator AirwayEsophageal Obturator Airway
Indicated when neither BVM ventilation nor Indicated when neither BVM ventilation nor tracheal intubation can be performed safely, tracheal intubation can be performed safely, effectively, and rapidly. effectively, and rapidly.
Cannot be used in the awake patient with an Cannot be used in the awake patient with an intact gag reflexintact gag reflex
Placement of EOA/EGTAPlacement of EOA/EGTA
1.1. The head is in the neutral position.The head is in the neutral position.
2.2. grasps and pulls the jaw forwardgrasps and pulls the jaw forward3.3. insert the assembled airway with the mask insert the assembled airway with the mask
attached. attached. 4.4. tip is directed into the patient's posterior tip is directed into the patient's posterior
pharynx with gentle, steady pressurepharynx with gentle, steady pressure5.5. advance down the esophagus until the mask advance down the esophagus until the mask
rests flush against the face of the patient. rests flush against the face of the patient. 6.6. ventilated with a tight mask seal on the face, ventilated with a tight mask seal on the face,
and auscultate the lungs are. and auscultate the lungs are.
For effective ventilation, the mask For effective ventilation, the mask seal must be tight. seal must be tight.
Breath sounds should be audible Breath sounds should be audible bilaterally.bilaterally.
Placement of EOA/EGTAPlacement of EOA/EGTA
The cuff should lie in the esophagus just distal to The cuff should lie in the esophagus just distal to the carina of the trachea. the carina of the trachea.
The rescuer postpones inflation of the balloon The rescuer postpones inflation of the balloon until proper position is confirmed. until proper position is confirmed.
Tracheal intubation will result in the absence of Tracheal intubation will result in the absence of breath sounds. breath sounds.
The possibility of bronchial or tracheal intubation The possibility of bronchial or tracheal intubation requires removal and replacement of the airway. requires removal and replacement of the airway.
Once satisfactorily placed, the esophageal Once satisfactorily placed, the esophageal balloon is inflated with 20 to 25 mL of air.balloon is inflated with 20 to 25 mL of air.
Placement of EOA/EGTAPlacement of EOA/EGTA
ComplicationsComplications Hypercarbia Hypercarbia Unrecognized tracheal intubation may occur in Unrecognized tracheal intubation may occur in
2.9% to 5% of patients with up to a 100% 2.9% to 5% of patients with up to a 100% mortality due to airway occlusion.mortality due to airway occlusion.
Esophageal injury may also occur, ranging from Esophageal injury may also occur, ranging from small lacerations in 8.5% of patients to small lacerations in 8.5% of patients to esophageal rupture.esophageal rupture.
Placement of EOA/EGTAPlacement of EOA/EGTA
Tracheal intubation should be performed Tracheal intubation should be performed before removal of the EOAbefore removal of the EOA, because vomiting , because vomiting often occurs following deflation of the balloon often occurs following deflation of the balloon and EOA removal. and EOA removal.
If the EOA cuff has been overinflated, it may If the EOA cuff has been overinflated, it may partially occlude the trachea and make partially occlude the trachea and make intubation difficult. In such cases, the balloon is intubation difficult. In such cases, the balloon is partially deflated to facilitate tracheal partially deflated to facilitate tracheal intubation.intubation.
Esophageal Obturator AirwayEsophageal Obturator AirwayContraindicationContraindication
active oropharyngeal bleedingactive oropharyngeal bleeding suspected esophageal injurysuspected esophageal injury caustic ingestioncaustic ingestion history of esophageal disease. history of esophageal disease.
The Laryngeal-Mask AirwayThe Laryngeal-Mask Airway
use in difficult use in difficult intubations and for intubations and for rescue ventilation rescue ventilation
a temporary adjunct a temporary adjunct The mask is intended The mask is intended
to reside in the to reside in the hypopharynx rather hypopharynx rather than on the face. than on the face.
One variation, the Proseal LMA, has a One variation, the Proseal LMA, has a parallel drainage tube attached to the parallel drainage tube attached to the airway tube that is designed to reduce airway tube that is designed to reduce gastric insufflation and allow gastric gastric insufflation and allow gastric drainage by a nasogastric tube, drainage by a nasogastric tube, potentially decreasing the risk of potentially decreasing the risk of aspirationaspiration
The Laryngeal-Mask AirwayThe Laryngeal-Mask Airway
Indications Indications for patients requiring an airway who for patients requiring an airway who
cannot be endotracheally intubated or cannot be endotracheally intubated or cannot be ventilated with a BVM. cannot be ventilated with a BVM.
Cant visualization of the larynx. Cant visualization of the larynx.
ContraindicationsContraindications inability to open the patient's mouthinability to open the patient's mouth VomitingVomiting Need for high pulmonary inflation Need for high pulmonary inflation
pressures.pressures.
Placement of LMAPlacement of LMA
checked for possible air leaks checked for possible air leaks If the patient has a gag reflex, deep oropharyngeal If the patient has a gag reflex, deep oropharyngeal
topical anesthesia or conscious sedation must be topical anesthesia or conscious sedation must be administered. administered.
the neck and head are held in the neutral position, as the neck and head are held in the neutral position, as would be necessary with cervical spine immobilization.would be necessary with cervical spine immobilization.
The posterior surface of the mask is lubricated and the The posterior surface of the mask is lubricated and the mask is oriented so its opening faces the tongue. mask is oriented so its opening faces the tongue.
•With the index finger of the dominant hand placed With the index finger of the dominant hand placed on the proximal aspect of the mask, the mask is on the proximal aspect of the mask, the mask is inserted into the mouth, firmly against the hard inserted into the mouth, firmly against the hard palate.palate.
•With one smooth motion, the mask is advanced With one smooth motion, the mask is advanced until resistance is encountered. With the tip of the until resistance is encountered. With the tip of the mask thus seated in the upper esophageal sphincter, mask thus seated in the upper esophageal sphincter, the cuff is inflated. The lungs are auscultated to the cuff is inflated. The lungs are auscultated to confirm correct placement.confirm correct placement.
•Preparation for ILMA placement is similar to LMA Preparation for ILMA placement is similar to LMA placement.placement.
Placement of LMAPlacement of LMA
Intubating LMA Intubating LMA
facilitate blind tracheal intubation facilitate blind tracheal intubation while allowing continuous positive-while allowing continuous positive-pressure ventilation. pressure ventilation.
Insertion of the ILMA is easier than Insertion of the ILMA is easier than the standard LMA the standard LMA
ILMA allows for passage of a larger ILMA allows for passage of a larger tracheal tube (up to 8-0).tracheal tube (up to 8-0).
1. Endotracheal tube down the lumen of the LMA2. Tracheal tube exchanger or bougie passed blindly
down the lumen of the LMA and into the trachea.3. Intubation with an LMA in place is via a fiberoptic
scope.
If the LMA must be removed after a tracheal tube has been successfully placed through it, pass a tracheal tube exchanger down the tube, remove the tracheal tube/LMA combination, and replace it with a tracheal
tube.
The Laryngeal-Mask AirwayThe Laryngeal-Mask Airway
ComplicationsComplications1.1. Aspiration is always a possibilityAspiration is always a possibility
2.2. Laryngospasm can occur if adequate anesthesia is not achieved. Laryngospasm can occur if adequate anesthesia is not achieved.
3.3. A significant air leak around the cuff may occur when A significant air leak around the cuff may occur when high airway pressures exist,leading to poor ventilation. high airway pressures exist,leading to poor ventilation.
The Esophageal-Tracheal CombitubeThe Esophageal-Tracheal Combitube
has two lumina running parallel to each has two lumina running parallel to each other. One is perforated at the level of other. One is perforated at the level of the pharynx and occluded at the distal the pharynx and occluded at the distal end, similar to the EOA. The second end, similar to the EOA. The second lumen is open at the distal end, lumen is open at the distal end, resembling an endotracheal tube. resembling an endotracheal tube.
has two balloons: a proximal pharyngeal has two balloons: a proximal pharyngeal balloon that occludes the oropharynx by balloon that occludes the oropharynx by filling the space between the base of the filling the space between the base of the tongue and the soft palate and a smaller, tongue and the soft palate and a smaller, distal cuff that serves as a seal in either distal cuff that serves as a seal in either the esophagus or trachea the esophagus or trachea
..
CombitubeCombitube
The ETC is superior to the EOA because The ETC is superior to the EOA because no face mask seal is necessary and the no face mask seal is necessary and the risk of complications is lower.risk of complications is lower.
The ETC should be used in an The ETC should be used in an unresponsive person who requires an unresponsive person who requires an airway when tracheal intubation is not airway when tracheal intubation is not successful or practical. successful or practical.
Intact gag reflexIntact gag reflex younger than 16 years or shorter than 5 younger than 16 years or shorter than 5
feet tall. feet tall.
IndicationsIndications
ContraindicationsContraindications
It is contraindicated in suspected caustic poisonings or It is contraindicated in suspected caustic poisonings or proximal esophageal disorders.proximal esophageal disorders.
CombitubeCombitube
The device is held in the dominant hand and gently advanced caudally into the pharynx The device is held in the dominant hand and gently advanced caudally into the pharynx The tube is passed blindly along the tongue to a depth that positions the printed rings on the The tube is passed blindly along the tongue to a depth that positions the printed rings on the
proximal end of the tube between the patient's teeth or alveolar ridge.proximal end of the tube between the patient's teeth or alveolar ridge.
CombitubeCombitube
If resistance is met in the hypopharynx, the tube should be If resistance is met in the hypopharynx, the tube should be removed and bent between the balloons for several seconds to removed and bent between the balloons for several seconds to facilitate insertion.facilitate insertion.
After insertion, the pharyngeal balloon is filled with 100 mL of air, After insertion, the pharyngeal balloon is filled with 100 mL of air, and the distal cuff is subsequently filled with 10 to 15 mL of air.and the distal cuff is subsequently filled with 10 to 15 mL of air.
One must remember to first inflate the oropharyngeal balloon One must remember to first inflate the oropharyngeal balloon before inflating the distal balloon. Although unlikely, esophageal before inflating the distal balloon. Although unlikely, esophageal injury is theoretically possible with overinflation of the distal injury is theoretically possible with overinflation of the distal balloon.balloon.
CombitubeCombitube
The large pharyngeal balloon serves to securely The large pharyngeal balloon serves to securely seat the ETC in the oropharynx and to create a seat the ETC in the oropharynx and to create a closed system in the case of esophageal placement.closed system in the case of esophageal placement.
ventilation is begun through the longer (blue ventilation is begun through the longer (blue plastic) connector associated with the esophageal plastic) connector associated with the esophageal lumen. lumen.
Chest rise and good breath sounds without gastric Chest rise and good breath sounds without gastric insufflation confirm effective placement in the insufflation confirm effective placement in the esophagus. esophagus.
CombitubeCombitube
Gastric insufflation without breath sounds and Gastric insufflation without breath sounds and chest rise indicate a tracheal positioning of the chest rise indicate a tracheal positioning of the tube and require changing the ventilation to tube and require changing the ventilation to the shorter (clear plastic) tracheal lumen. the shorter (clear plastic) tracheal lumen.
Auscultation of breath sounds over the lateral Auscultation of breath sounds over the lateral lung fields confirms endotracheal placement of lung fields confirms endotracheal placement of the Combitube. the Combitube.
If the tube is in the esophageal position, If the tube is in the esophageal position, gastric suctioning can be accomplished by gastric suctioning can be accomplished by passing a catheter through the open lumen passing a catheter through the open lumen into the stomach while the patient is being into the stomach while the patient is being ventilated via the other port.ventilated via the other port.
CombitubeCombitube
attach an aspirating device to the tracheal or attach an aspirating device to the tracheal or clear plastic shorter tube. The inability to clear plastic shorter tube. The inability to easily aspirate air confirms esophageal easily aspirate air confirms esophageal placement, necessitating ventilation via the placement, necessitating ventilation via the longer blue esophageal tube. longer blue esophageal tube.
CO2 detector devices also may be useful.CO2 detector devices also may be useful.
Bullard Laryngoscope Bullard Laryngoscope
No manipulation of the neck is No manipulation of the neck is necessarynecessary
Cervical spine injury. Cervical spine injury. Found to cause less head Found to cause less head
extension and cervical spine extension and cervical spine extension than the conventional extension than the conventional laryngoscopelaryngoscope
Lighted Stylet Intubation Lighted Stylet Intubation
a blind approacha blind approach avoide in patients with avoide in patients with
expanding neck masses and expanding neck masses and patients with airway patients with airway compromise presumed due compromise presumed due to a foreign body.to a foreign body.
Massive obesity is the most Massive obesity is the most common cause for failure common cause for failure with this technique because with this technique because of the difficulty of the difficulty transilluminating the transilluminating the generous soft tissue generous soft tissue
CHANGING TRACHEAL TUBES
65 y o in cardiac arrest, just after 65 y o in cardiac arrest, just after you intubated him the RT told you you intubated him the RT told you the ETCO2 is low????the ETCO2 is low????
65 year in cardiac arrest intubated O2 sat initialy 65 year in cardiac arrest intubated O2 sat initialy was 100 % with normal Etco2. O2 sat start to go was 100 % with normal Etco2. O2 sat start to go down now to 50.down now to 50.
In patients with spontaneous circulation and the tracheal tube cuff inflated, the sensitivity and specificity rose to 100%.
cardiac arrest secretions can interfere with the color change.
esophageal intubation.
cardiac arrest pt. should be ventilated for a minimum of 6 breaths before taking a reading.
recent ingestion of carbonated beverages
glottic positioning of the ET tube tip.
End-Tidal CO2 Detector Devices
(1) a dislodged tube, either in the esophagus or in (1) a dislodged tube, either in the esophagus or in the right mainstem bronchusthe right mainstem bronchus
(2) Tube obstruction(2) Tube obstruction
(3) a tension pneumothorax(3) a tension pneumothorax
(4) equipment failure.(4) equipment failure.
50 y.o.f. asthmatic intubated for respiratory failure, O2 sat. after intubation was 100% ,30 minutes later you get called for decreasing O2 saturation???
Failure to achieve adequate ventilation and Failure to achieve adequate ventilation and oxygenation is the most serious complication of oxygenation is the most serious complication of tracheal intubation (hypoxia)tracheal intubation (hypoxia)
Irreversible cerebral anoxia. Irreversible cerebral anoxia. attempts at intubation should be halted for bag-attempts at intubation should be halted for bag-
mask ventilation whenever the O2 saturation mask ventilation whenever the O2 saturation drops below 92%.drops below 92%.
vomiting following removal of a tube from the vomiting following removal of a tube from the esophagus. esophagus.
Right mainstem bronchus intubation may cause Right mainstem bronchus intubation may cause hypoxia as well as unilateral pulmonary edema.hypoxia as well as unilateral pulmonary edema.
Cardiac decompensation.Cardiac decompensation. Profound bradycardia or asystoleProfound bradycardia or asystole laryngospasm, bronchospasm, and apnea.laryngospasm, bronchospasm, and apnea.
Loose, missing or avulsed teeth Loose, missing or avulsed teeth Broken teeth Broken teeth Laceration of the mucosa of the lips, especially the Laceration of the mucosa of the lips, especially the
lower lip, may also occur. lower lip, may also occur.
Tracheal or bronchial injuries are rare but serious, Tracheal or bronchial injuries are rare but serious, usually occurring in infants and the elderly as a usually occurring in infants and the elderly as a result of decreased tissue elasticity.result of decreased tissue elasticity.
Vomiting with aspiration of gastric contents is Vomiting with aspiration of gastric contents is another serious complication that can occur during another serious complication that can occur during intubation.intubation.
Exacerbation of a cervical spine injury remains Exacerbation of a cervical spine injury remains largely a theoretical concern. largely a theoretical concern.
a persistent air leak. a persistent air leak. Tracheal strictureTracheal stricture
Drug: action Indications IV dose
Lidocaine: reduces intracranial response to laryngoscopy and bronchospastic response to laryngoscopy and intubation
Patients with elevated intracranial pressure (ICP) or penetrating globe injury who are receiving succinylcholine; reactive airway disease
1.5 mg/kg
Atropine: mitigates bradycardic response to succinylcholine
Children under 10 years old
0.02 mg/kg
Indications for Pretreatment Agents
Fentanyl: reduces sympathetic (heart rate, blood pressure) response to laryngoscopy and intubation
Elevated ICP, intracranial hemorrhage, berry aneurysm, ischemic heart disease, aortic dissection
3 μg/kg
AgentInitial
IV Dose Duration ofAction
Morphine 3-5 mg 2-3 hours
Meperidine 25-50 mg/kg 2-4 hours
Fentanyl 2-3 μg/kg 0.5-1 hours
Sufentanil 0.1-0.4 μg/kg 20-45 minutes
Alfentanil 10-15 μg/kg 30 minutes
Commonly used intravenous opioids
Cricothyrotomy
