Anything New In The Airway Managment

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Anything New In The Airway Managment

  1. 1. Anything new in Airway Management? Dr Adrian Burger Emergency Medicine Senior Registrar UCT/US
  2. 2. So what do we do? <ul><li>A,B,C’s…… </li></ul><ul><li>A is for clearing, opening and or securing the airway </li></ul><ul><li>Clearing - turn on side </li></ul><ul><li>- suction </li></ul><ul><li>- no more blind finger sweeps! </li></ul>
  3. 3. Opening <ul><li>Jaw thrust </li></ul><ul><li>Head Tilt Chin lift </li></ul><ul><li>Combined </li></ul><ul><li>Remember : C-spine stabilization </li></ul>
  4. 4. Opening or securing the Airway <ul><li>BMV </li></ul><ul><li>OPA/NPA </li></ul><ul><li>LMA </li></ul><ul><li>Combitube® </li></ul><ul><li>ETT </li></ul>
  5. 5. Mask <ul><li>Most basic piece of “airway” kit </li></ul><ul><li>Different types - clear, black </li></ul><ul><li>- cushion around edge </li></ul><ul><li>Won’t maintain airway by self </li></ul><ul><li>Needs head tilt/chin lift or jaw thrust </li></ul><ul><li>Also needs Positive Pressure Ventilation </li></ul>
  6. 6. Mask
  7. 7. Positive Pressure Ventilation <ul><li>Rescuer’s breathing efforts and one-way valve </li></ul><ul><li>Bag Mask Ventilation (BMV) </li></ul>
  8. 8. Mask with one-way valve
  9. 9. Oropharyngeal Airway/Guedel <ul><li>Different colours = different sizes </li></ul><ul><li>Neonate to large adult </li></ul>Yellow 5 Red 4 Orange 3 Green 2 White 1 Black O Blue OO Violet 000 COLOUR SIZE
  10. 10. Oropharyngeal Airways
  11. 11. Oropharyngeal Airway/Guedel <ul><li>Features : </li></ul><ul><li>- single use </li></ul><ul><li>- rounded edges </li></ul><ul><li>- bite block </li></ul><ul><li>- colour coding </li></ul><ul><li>- airway path in centre </li></ul>
  12. 12. Oropharyngeal Airway/Guedel <ul><li>How to size it ???? </li></ul><ul><li>The size of the Guedel airway is the distance </li></ul><ul><li>between the center of the incisors and the angle of the jaw (on the same side!) </li></ul>
  13. 13. Oropharyngeal Airway/Guedel <ul><li>How to put it in: </li></ul><ul><li>Depress tongue </li></ul><ul><li>Slip over spatula with curve caudal direction </li></ul><ul><li>Place bite block between teeth </li></ul><ul><li>NO TWISTING MOVEMENT </li></ul>
  14. 14. Oropharyngeal Airway/Guedel <ul><li>Indications : </li></ul><ul><li>To open and maintain an airway in a </li></ul><ul><li>patient with a depressed level of </li></ul><ul><li>consciousness </li></ul><ul><li>With FMO2 or BMV </li></ul>
  15. 15. Oropharyngeal Airway/Guedel <ul><li>Contra indications : </li></ul><ul><li>Patient won’t accept it </li></ul><ul><li>LOC </li></ul><ul><li>Risk of vomiting & aspiration </li></ul>
  16. 16. Nasopharyngeal Airway <ul><li>For maintaining airway in “more awake” patients </li></ul><ul><li>Sits in nasopharynx and opens airway </li></ul><ul><li>Does NOT protect against aspiration </li></ul>
  17. 17. Nasopharyngeal Airway
  18. 18. Nasopharyngeal Airway <ul><li>How to size it ? </li></ul><ul><li>Estimate by comparing to patients little </li></ul><ul><li>finger </li></ul><ul><li>How to insert it ? </li></ul><ul><li>Lubricate </li></ul><ul><li>Gently push posteriorly towards ear on same side </li></ul><ul><li>Fix with a safety pin </li></ul>
  19. 19. Nasopharyngeal Airway <ul><li>Contra-indications: </li></ul><ul><li>Base of skull fracture </li></ul><ul><li>Serious midline facial fractures </li></ul><ul><li>When definitive airway needed </li></ul>
  20. 20. LMA <ul><li>Advanced airway </li></ul><ul><li>Useful alternative for “difficult intubation” </li></ul><ul><li>Easy to use </li></ul><ul><li>Sits on larynx - Protects lungs? </li></ul>
  21. 21. LMA
  22. 22. LMA <ul><li>Have a range in unit </li></ul><ul><li>Re-use ?20 times </li></ul><ul><li>Part of kit </li></ul><ul><li>Formula for Children : </li></ul><ul><li>The combined widths of </li></ul><ul><li>the patient's index, </li></ul><ul><li>middle and ring fingers </li></ul>>100kg 6 70-100kg 5 50-70kg 4 30-50kg 3 20-30kg 2.5 10-20kg 2 5-10kg 1.5 <5 kg 1 PATIENT SIZE
  23. 23. LMA in Emergency Medicine <ul><li>Indications : </li></ul><ul><li>Unconscious or anaesthetized patients </li></ul><ul><li>AHA Guidelines for adults: </li></ul><ul><li>BLS: alternative to BMV </li></ul><ul><li>ACLS: Optional/alternative to BMV, failed ETT </li></ul><ul><li>Aspiration? </li></ul><ul><li>Paediatrics? </li></ul>
  24. 24. LMA in Emergency Medicine <ul><li>Aspiration ? </li></ul><ul><li>Less than with BMV </li></ul><ul><li>Supraglottic device </li></ul><ul><li>Aspirated from CPR or post LMA? </li></ul><ul><li>Cricoid pressure during CPR </li></ul>
  25. 25. LMA Use in Emergency Paediatrics <ul><li>Little Data </li></ul><ul><li>“ Despite widespread use LMA, there is little data on its effectiveness during positive pressure ventilation in infants and young children “ </li></ul><ul><li>Obstruction </li></ul><ul><li>The LMA appears more likely to cause partial airway obstruction in infants ( < 10kg) than in older children. </li></ul><ul><li>PALS®: Class Indeterminate </li></ul><ul><li>Neonates: “Can’t intubate can’t ventilate” </li></ul>
  26. 26. LMA in Emergency Medicine <ul><li>Benefits : </li></ul><ul><li>Ineffective BMV with failed ETT </li></ul><ul><li>AHA: Alternative to ETT or BMV in CPR </li></ul><ul><li>Blind ETT, by passing ETT through LMA </li></ul><ul><li>Drugs - 27% efficacy </li></ul>
  27. 27. LMA in Emergency Medicine <ul><li>Disadvantages : </li></ul><ul><li>Needs adequate training </li></ul><ul><li>Risk of aspiration </li></ul><ul><li>Limited Paediatric use </li></ul><ul><li>Not always successful </li></ul>
  28. 28. LMA Insertion
  29. 29. LMA Insertion
  30. 30. Combitube®
  31. 31. Combitube® <ul><li>Advantages : </li></ul><ul><li>Protect airway from aspiration </li></ul><ul><li>Easy to use </li></ul><ul><li>AHA: alternative to ETT for CPR </li></ul><ul><li>Disadvantages : </li></ul><ul><li>Trauma to soft tissues </li></ul><ul><li>Not available here in SA </li></ul>
  32. 32. Combitube® <ul><li>Head neutral or slightly flexed </li></ul><ul><li>Hold tongue and jaw between thumb & forefinger and lift </li></ul><ul><li>Gently insert Combitube® in a curved back and downward movement until black markers aligned with teeth </li></ul><ul><li>Inflate (proximal) pharyngeal balloon </li></ul><ul><li>Inflate (distal) tracheal balloon </li></ul><ul><li>Confirm which one of #1 or #2 tube is in lungs by using bag ventilator </li></ul>
  33. 33. Combitube® Insertion
  34. 34. ETT
  35. 35. Equipment for ETT <ul><li>Mask and bag ventilator with O2 </li></ul><ul><li>ETT - checked, lubricated, tape ready </li></ul><ul><li>Laryngoscope </li></ul><ul><li>Drugs: Induction agent & muscle relaxant </li></ul><ul><li>McGills forceps, Bougie </li></ul><ul><li>Primary detection tools </li></ul><ul><li>Other advanced airways </li></ul><ul><li>Surgical airway capability </li></ul>
  36. 36. ETT <ul><li>Advantages : </li></ul><ul><li>Airway patent and protected </li></ul><ul><li>Secretions suction </li></ul><ul><li>O2 </li></ul><ul><li>Medication </li></ul><ul><li>Known tidal volume </li></ul>
  37. 37. ETT <ul><li>Disadvantages : </li></ul><ul><li>Training </li></ul><ul><li>Skill lost </li></ul><ul><li>Interrupted CPR </li></ul>
  38. 38. Why ETT? <ul><li>For above benefits </li></ul><ul><li>Inability to BMV or ineffective BMV </li></ul><ul><li>Secure threatened airway </li></ul><ul><li>Certain thoracic injuries </li></ul>
  39. 39. Anatomy
  40. 41. endotracheal tubes <ul><li>cuffed tubes </li></ul><ul><li>uncuffed tubes </li></ul>
  41. 42. placement of ETT <ul><li>length of tube at the larynx (cm) = internal diameter of correct ETT for size </li></ul>
  42. 43. railroad techniques for changing tubes <ul><li>getting the curves right </li></ul>
  43. 44. Tube Placement Confirmation <ul><li>Clinical - visual </li></ul><ul><li>- auscultation </li></ul><ul><li>- laryngoscopy </li></ul><ul><li>Detection devices - CO2 (2a) </li></ul><ul><li>- EDD </li></ul>
  44. 45. Detection Devices <ul><li>Always clinical + device </li></ul><ul><li>No single device specific or sensitive </li></ul><ul><li>CO2 detector : 33%-100% sensitive </li></ul><ul><li>: 97%-100% specific </li></ul><ul><li>: only studied on ETT </li></ul><ul><li>EDD : bulb compressed or syringe pulled </li></ul><ul><li>: High sensitivity </li></ul><ul><li>: Poor specificity </li></ul><ul><li>CXR </li></ul>
  45. 46. Secure the ETT <ul><li>Record depth at front teeth </li></ul><ul><li>Evidence is commercial=tape </li></ul><ul><li>Re-evaluate </li></ul><ul><li>3 Rules - verify placement </li></ul><ul><li>- asynchronous CPR </li></ul><ul><li>- avoid excessive ventilation </li></ul>
  46. 47. BMV <ul><li>Best for last! </li></ul><ul><li>Easy to master </li></ul><ul><li>First line in CPR </li></ul><ul><li>Every unit has one </li></ul><ul><li>Effective </li></ul>
  47. 48. BMV
  48. 49. BMV <ul><li>OLD : ETT ventilation adjunct of choice for </li></ul><ul><li>CPR </li></ul><ul><li>ETT complications - misplaced </li></ul><ul><li>- displaced </li></ul><ul><li>- interrupted CPR </li></ul><ul><li>AHA : BMV or advanced airway for CPR </li></ul><ul><li>Prehospital: BMV=LMA & Combitube® </li></ul>
  49. 50. Failed Intubation <ul><li>Can’t intubate, Can Ventilate </li></ul><ul><li>Don’t panic, call for help </li></ul><ul><li>Reassess need to intubate </li></ul><ul><li>Reposition patient, airway </li></ul><ul><li>Cricoid pressure </li></ul><ul><li>Bougie </li></ul><ul><li>Consider other advanced airways </li></ul><ul><li>Call for help </li></ul>
  50. 51. Failed Intubation <ul><li>Can’t intubate, Can’t Ventilate </li></ul><ul><li>Call for help, don’t panic </li></ul><ul><li>Reassess airway, positioning </li></ul><ul><li>Reassess equipment </li></ul><ul><li>Two person ventilation </li></ul><ul><li>Other advanced airway </li></ul><ul><li>Surgical airway </li></ul><ul><li>CALL FOR HELP </li></ul>
  51. 52. Remember <ul><li>Check your equipment before you need it </li></ul><ul><li>Be prepared </li></ul><ul><li>Don’t panic </li></ul>
  52. 53. Parting shot <ul><li>“ Patients do not die from lack of intubation they die from lack of oxygenation” </li></ul>
  53. 54. References <ul><li>Currents , winter2005-2006 </li></ul><ul><li>JAMA , Feb 9, 2000-Vol 283, No6 p783-790 </li></ul><ul><li>www.aic.cuhk.edu.hk/web8/index </li></ul><ul><li>www.healthsystem.virginia.edu/Internet/Anesthesiology-Elective/airway/anatomy </li></ul><ul><li>www.lmana.com/prod/components/products/lma_classic </li></ul>

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