Airway management

By: Dr. Ruba al-hamad

Anatomy of the airways

Airway obstruction and

breathing problems
Causes .
Recognition.
Treatment

How to manage

A 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 chest
C
D

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
techniques

We 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 devices

LMA

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 twinlumen 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 <10 years old
Midface trauma or basilar skull fracture
intracranial pressure
Anticoagulation or anticipated need for thrombolysis
Combative patient
Apnea
COMPLICATIONS
Epistaxis
Esophageal intubation
Sinusitis, turbinate damage

Blind nasotracheal intubation cannot be performed on the apneic

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
<8
years old.
Nasal intubation: Use slightly smaller tube
(by 0.5
1.0 mm).
NOTE:
The narrowest part of the adult airway = vocal
cords. The narrowest part of the pediatric airway
= cricoid ring.

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 <10 years old. Allows for
oxygenation,
but ventilation is often inadequate.
INDICATIONS
Rescue device for oxygenation in failed airway
CONTRAINDICATION
Tracheal transection with retraction of the distal end
Cricoid or laryngeal damage
COMPLICATIONS
Common :
Subcutaneous emphysema, catheter kinking/obstruction,
coughing if
patient is conscious, CO2 retention
Uncommon but serious:
Barotrauma, pneumothorax, pneumomediastinum

 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 <10 years old.
Needle cricithyrotomy is a better
choice in this age group.
Surgical cricothyrotomy: Longitudinal
(vertical) skin incision. Horizontal
incision through cricoid membrane.

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 Obstruction
HEIMLICH 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 nonarrest 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