Airway management

Dr. Somaya Abd-Elmoneem

Head of Anesthesia department
AlDhaid Hospital

We know that nothing can be done to

reverse hypoxic brain damage once it
occurs.

Weve been taught that maintaining an

airway and ensuring adequate
oxygenation supersedes everything.

Airway management does not necessarily

mean intubation
It means to ensure patency, provide adequate ventilation and
maintain appropriate oxygenation.
Many times we forget the basics. providing a chin lift or jaw thrust
can open airways.
The proper use of adjuncts (oral/nasal airways), can convert a
difficult-to-ventilate patient into an airway that is able to be wellventilated.
The appropriate administration of high-flow oxygen, with properly
fitted masks, is enormously beneficial.
We must never forget that airway management is a collection of
skills and techniques, not just an attempt to place a tube or device
into the patients mouth or trachea.

STEP 1. OPEN AND CLEAR

Clear and Suction

Head and Jaw Positioning

Head tilt
do not use if possible
c-spine injury
combine with chin
lift/jaw thrust to
maximize airway
patency

Chin lift
jaw thrust
In c-spine injury

Suction
Used to clear blood, secretions, vomitous
and foreign bodies from the airway
Most effectively and safely used under
direct visualization

STEP 2. KEEP IT OPEN

Benefits and Limitations
Indications and Contraindications

Airway Adjuncts
Oropharyngeal airway
prevents tongue from
falling onto pharynx
and occluding airway
use only in the
unconscious patient
can obstruct airway if
improperly placed

Airway Adjuncts
Nasopharyngeal
airway
may use in semiconscious or
unconscious patient

STEP 2. KEEP IT OPEN

Sizing and Insertion

Nasopharyngeal Airway
Length:
Length:Nostril
Nostrilto
to
Tragus
Tragus

Contraindications:
Basal skull
fracture
CSF leak
Coagulopathy

STEP 3. VENTILATE
(BLS)
Procedure:
-Attach high flow O2
-Select appropriate mask
(good seal imperative)

STEP 3. VENTILATE
(BLS)
Approximate normal ventilation rates:
>10---- bpm Adult
20 ----bpm Child
25-- bpm Infant

What are the limitations?

STEP 3. VENTILATE
(BLS)
Cricoid Pressure

STEP 3. VENTILATE (BLS)

Why is this helpful in all
manual ventilation?

STEP 4. CONTROL THE

AIRWAY
Intubation
vs.
Open mask v
Why and why not?

Indications for Definitive Airway

Need for Airway Protection

Need for Ventilation

Unconscious

Apnea
Neuromuscular Paralysis
Unconscious

Severe Maxillofacial fxs

Inadequate Respiratory Effort

Tachypneal
Hypoxia
Hypercarbia
Cyanosis

Risk for aspiration

Bleeding
Vomiting

Severe closed head injury with need

for hyperventilation

Risk for obstruction

Neck hematoma
Laryngeal, tracheal injury/burn
Stridor

STEP 4. CONTROL THE

AIRWAY
Pre-Intubation

-Prepare Equipment
-pre-oxygenate

STEP 4. CONTROL THE

AIRWAY
Orotracheal Intubation Procedure

Sweep
Left and
Look

STEP 4. CONTROL THE

AIRWAY
Find Your Landmarks

STEP 4. CONTROL THE

AIRWAY
Find Your Landmarks

STEP 4. CONTROL THE

AIRWAY
Readjusting with Cricoid Pressure

Advantages of Endotracheal
Intubation
Cuffed E.T tubes protect the airway from
aspiration.
E.T tube provides access to the
tracheobronchial tree for suctioning of
secretions.
E.T tube does not cause gastric distention and
associated danger of regurgitation.
E.T tube maintains a patent airway and assists
in avoiding further obstruction.
E.T tube enables delivery of medication.

OTHER CONSIDERATIONS FOR

INTUBATION (cont.)
Difficult tubes

Immobilized trauma patient

Combative patient
Children, esp. Infants
Short neck
Prominent upper incisors
Receding mandible
Limited jaw opening, limited
cervical mobility
Upper airway conditions
Facial, laryngeal trauma

Evaluate for signs of difficult

intubation

Difficult intubation

Assessment
-History
-examination

Endotracheal
Intubation
Indications ORAL
Emergency airway
Advantages

Elective intubation
Cervical spine injury

Larger tube
Less resistance
Less kinking
Easier to insert
Disadvantages

Oral trauma/surgery
More comfortable
Good oral hygiene
Less gagging
Less sedation

More difficult to place

Smaller tube
Epistaxis
Sinusitis, otitis media
C/O in basal skull fracture

Less comfortable
Patient may bite on tube
Oral hygiene difficult
Tube less secure

NASAL

Nasotracheal Intubation

Indications:
Patient still breathing but
in respiratory failure and
in whom oral intubation is
impossible or difficult.

Nasotracheal Intubation
Contraindications:
-Apnea
-Resistance in the nares
-Blood clotting or
anticoagulation
problems
-Basilar Skull Fx (?)

STEP 4. CONTROL THE

AIRWAY
Nasotracheal Intubation

Technique:
-Prepare patient and nostril
-Prepare tube
-Insert on inspiration
-Take your time

Complications:
-Bleeding

STEP 5. CONFIRM THE AIRWAY

Intubation Confirmation
Good, Better, Best
Traditional

Technology Based

ETCO2 (monitor)

Colormetric (cap)

Pulse Ox change

Direct
Visualization

Lung Sounds

Tube
Condensation

STEP 6. SECURE THE

AIRWAY
Secure Your Tube
Good, Better, Best
Tape
Improvised devices
Commercial devices
Immobilization (?)

STEP 7. ALTERNATIVES TO
ETI
Laryngeal Mask Airway

Developed in 1981 at the Royal London Hospital

By Dr Archie Brain

The Laryngeal Mask Airway

Latex-free, silicone
rubber tube connected to
an elliptical mask with an
inflatable outer rim
Standard 15 mm male
adaptor
Pilot tube and balloon
attached to the inflatable
outer rim
Bars cover the connection
between the tube and the
mask
Re-useable up to 40 times
(Autoclave)

Insertion Technique
Procedure:

-Hyper oxygenate
-Check cuff
-Lubricate posterior cuff
-Head in neutral or
slightly flexed position
-Insert following hard
palate (use index finger to
guide)

Insertion Technique
-Stop when met with
resistance
-Let go and inflate
cuff (visualize pop)
-Confirm and secure

LMA in Place

Laryngeal Mask Airway

Weight Based Sizing

<5kg = Size 1
5-10 kg = Size 2
20-30 kg = Size 2.5
Small Adult= Size 3
Average Adult = Size 4
Large Adult = Size 5

Laryngeal Mask Airway

Average Adult Woman = 3

Average Adult Male = 4
*If in doubt, check the LMA

Laryngeal Mask Airway

Air volume is variable depending on cuff size
and individual patient anatomy
General Guideline:
Size 1 = 4 ml
Size 2 = 10 ml
Size 2.5 = 14 ml
Size 3 = 20 ml
Size 4 = 30 ml
Size 5 = 40 ml

Laryngeal Mask Airway

Common Provider Problems:

-Failure to seat properly
-Sizing difficulties
-Aspiration

Can we insert ETT

Intubating laryngeal mask

STEP 7. ALTERNATIVES TO
ETI
Dual Lumen Airway

(Combitube)

What is it?
A double lumen airway device designed for
emergency ventilation of a patient in respiratory
arrest when visualization of the airway and
endotracheal intubation are not possible

Definition
It is blind insertion device with dual lumens to
allow for effective ventilations to be provided
regardless of whether esophageal or tracheal
placement is accomplished.
Dual lumens

Distal Balloon

Pharyngeal Balloon

Indications
Respiratory failure in an unconscious patient
without an intact gag reflex
Secondary method of airway management for
paramedics when orotracheal intubation is
not possible

Equipments
Esophageal Tracheal Airway (Combitube),
100ml syringe, 20ml syringe, fluid deflector
attachment

Insertion Procedures
Place the patient
in a supine
position
Provide artificial
ventilation via
BVM and
hyperventilate the
patient with 100%
oxygen prior to
device insertion

Insertion Procedures
Inflate both
balloons prior to
insertion to test
the integrity of the
balloons
Should either
balloon fail after
insertion,
maintenance of the
patients airway
cannot be assured

Insertion Procedures
Position the patients
neck in a neutral
position.
Lubricate the tube
with sterile, water
soluble lubricant
Lift the tongue and
lower jaw upward to
open the oropharynx

Insertion Procedures
Insert the
Combitube so
that it curves in
the same
direction as the
natural curvature
of the pharynx
If resistance is
met, withdraw
tube and attempt
to reinsert

Insertion Procedures
Advance tube until
the patients teeth
are between the
two black lines

Insertion Procedures
Inflate the #1
blue cuff with
100ml of air
from the large
syringe

Insertion Procedures
Inflate the #2
white cuff
with 15ml of
air from the
small
syringe

Insertion Procedures
If auscultation of breath sounds is absent
and gastric inflation is positive, then begin
ventilation through the shorter clear tube
labeled #2

Esophageal Placement
If the Combitube is placed
in the esophagus, the distal
balloon will occlude the
esophagus.
Ventilations are provided
through perforations in the
side of the pharyngeal
tube.

Tracheal Placement
If placed in the trachea, it
functions as an
endotracheal tube, with
the distal balloon
preventing aspiration.
Ventilations are provided
via the hole in the end of
the tube.

Dual Lumen Airway

Contraindications/Limitations:
-No pediatrics
-Pathological esophageal disease
-Latex sensitivity
-Toxic or Caustic Ingestions

Light stylet intubation

SURGICAL AIRWAYS
Indications
-Obstruction
-Facial Trauma
-Intubation or other
alternatives impossible
-Trismus (clenching)
->8 years old (for open
procedures)

LAST RESORT!

STEP 8. SURGICAL AIRWAYS

Needle Cricothyrotomy
Commercial Needle
Cricothyrotomy Devices

Quick Trach

Pertrach

Airway & Ventilation Methods

Surgical Cricothyrotomy
Indications
absolute need for a definitive airway AND
unable to perform ETT due for structural or anatomic
reasons, AND
risk of not intubating is > than surgical airway risk
OR
absolute need for a definitive airway AND
unable to clear an upper airway obstruction, AND
multiple unsuccessful attempts at ETT, AND
other methods of ventilation do not allow for effective
ventilation and respiration

 Contraindications (relative)
Age < 8 years (some say 10)
evidence of fx larynx or cricoid cartilage
evidence of tracheal transection

Airway & Ventilation Methods

Needle Cricothyrotomy & Transtracheal Jet
Ventilation
Indications
Same as surgical cricothyrotomy along with
Contraindication for surgical cricothyrotomy

Contraindications
caution with tracheal transection

Airway & Ventilation Methods:

Jet Ventilation
Usually requires highpressure equipment
Ventilate 1 sec then
allow 3-5 sec pause
Hypercarbia likely
Temporary: 20-30
mins
High risk for
barotrauma

Retrograde Tracheal
Intubation (RTI):
Indications
Abnormal anatomy
Pt. W/ epiglottitis
Severe kyphosis
Cervical spondylosis
Trauma
Reasonable alternative to Surg and Needle
Crike

Dailey; The airway: emergency management

SURGICAL AIRWAYS
RTI (cont...):
Contraindications
Trismus (w/o paralytic)
Coagulopathy
Enlarged thyroid

Procedure:
Supplemental O2
Catheter over needle into CTM
Insert guidewire through catheter
Visualize guidewire and pass tube