DR (MAJ) PANKAJ N SURANGE  MBBS,MD,FICMR GRADED SPECIALIST ANAESTHESIA ARTEMIS  HEALTH  INSTITUTE AIRWAY MANAGEMENT
AIRWAY MANAGEMENT <ul><li>Holds The Top Priority In The Practice Of Medicine </li></ul><ul><li>No Organ System Can Be Resu...
ANATOMY OF AIRWAY
SURFACE ANATOMY
INLET OF LARYNX
Reasons To Manage an Airway:-- <ul><li>Obstruction </li></ul><ul><li>None present </li></ul><ul><li>Decompensating  </li><...
AIRWAY ALGORITHM <ul><li>Step 1: Open And Clear </li></ul><ul><li>Step 2: Keep It Open </li></ul><ul><li>Step 3: Ventilate...
<ul><li>Techniques </li></ul><ul><ul><li>Head-tilt/Chin-lift </li></ul></ul><ul><ul><li>Jaw Thrust </li></ul></ul><ul><ul>...
Head-Tilt/Chin-Lift <ul><li>Used when  no  neck injury is suspected </li></ul><ul><li>Temporary procedure </li></ul><ul><l...
Jaw Thrust <ul><li>Used when  spinal injury suspected </li></ul><ul><li>Temporary procedure </li></ul><ul><li>Must be repl...
Suctioning <ul><li>Purpose </li></ul><ul><ul><li>Remove blood, vomit, other liquids, food particles from airway </li></ul>...
Nasal Airways <ul><li>Used on responsive patients who need help keeping tongue out of airway </li></ul><ul><ul><li>Pt with...
Oral Airways <ul><li>Used on  unresponsive  patients  without gag reflex </li></ul><ul><li>Helps hold tongue away from bac...
Adequate Breathing <ul><li>Normal Rate </li></ul><ul><ul><li>Adult: 12 to 20/minute </li></ul></ul><ul><ul><li>Child: 15 t...
VENTILATION TECHNIQUES
Ventilation Techniques <ul><li>Mouth-to-Mask </li></ul><ul><ul><li>Connect mask to oxygen at 15 liters per minute </li></u...
Ventilation Techniques <ul><li>Bag-valve mask </li></ul><ul><ul><li>Self-inflating bag </li></ul></ul><ul><ul><li>One-way ...
Ventilation Techniques <ul><li>BVM Technique (Two Rescuer) </li></ul><ul><ul><li>Open airway, insert oral or nasal airway ...
Ventilation Techniques <ul><li>BVM Technique (One Rescuer) </li></ul><ul><ul><li>Open airway, insert oral or nasal airway ...
Ventilation Techniques <ul><li>If chest does not rise, reevaluate </li></ul><ul><ul><li>If abdomen rises, reposition head ...
LARYNGOSCOPY AND INTUBATION
EQUIPMENTS <ul><li>LARYNGOSCOPE </li></ul><ul><ul><li>Blade Size-1 To 4 </li></ul></ul><ul><li>ETT </li></ul><ul><ul><li>2...
 
PREREQUISITES <ul><li>Patient Positionin </li></ul><ul><ul><ul><li>Neck Flexion- 35° </li></ul></ul></ul><ul><ul><ul><li>H...
Direct Laryngoscopy: <ul><li>1.  Place the patient in the sniffing position.  </li></ul><ul><li>2.  Check the laryngoscope...
INTUBATION:   <ul><li>Lubricate the end of the tube (optional).  </li></ul><ul><li>Insert the stylet, and bend the tube an...
CANNOT INTUBATE CANNOT INTUBATE
STEP 7. ALTERNATIVES TO ETI
Developed in 1981 at the Royal London  Hospital By Dr Archie Brain   When definitive airway management cannot be obtained....
Laryngeal Mask Airway   <ul><li>Weight Based Sizing  </li></ul><ul><li><5kg = Size 1 </li></ul><ul><li>5--10 kg = Size 2 <...
Laryngeal Mask Airway <ul><li>Procedure: </li></ul><ul><li>Hyper oxygenate </li></ul><ul><li>Check cuff  </li></ul><ul><li...
CANNOT INTUBATE –CANNOT VENTILATE
STEP 8. SURGICAL AIRWAY
CRICOTHYROTOMY <ul><ul><li>Cannot intubate, cannot   ventilate:  needle cricothroidotomy  for ventilation </li></ul></ul><...
CRICOTHYROTOMY - Identify Cricothyroid membrane - Pierce at 45 Pierce angle - Place catheter or styllette Advance dilator
14 /16G 3.0mm Needle Cricothyrotomy LAST RESORT!
ARE YOU PREPARED
 
 
THANK YOU
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Airway management

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Airway management

  1. 1. DR (MAJ) PANKAJ N SURANGE MBBS,MD,FICMR GRADED SPECIALIST ANAESTHESIA ARTEMIS HEALTH INSTITUTE AIRWAY MANAGEMENT
  2. 2. AIRWAY MANAGEMENT <ul><li>Holds The Top Priority In The Practice Of Medicine </li></ul><ul><li>No Organ System Can Be Resuscited Without Securing The Airway </li></ul><ul><li>Failure To Open Airway And To Ventilate Can Be Catastrophic </li></ul><ul><li>“ Practice Makes A Man Perfect” </li></ul><ul><li>Make A Primary Plan Before Hand And Have A Back Up Plan </li></ul><ul><li>“ Call For Help” </li></ul><ul><li>The Goal Is To Ventilate Adequately Enough To Meet The Patient's Oxygen Demands And Eliminate Carbon Dioxide. </li></ul>
  3. 3. ANATOMY OF AIRWAY
  4. 4. SURFACE ANATOMY
  5. 5. INLET OF LARYNX
  6. 6. Reasons To Manage an Airway:-- <ul><li>Obstruction </li></ul><ul><li>None present </li></ul><ul><li>Decompensating </li></ul><ul><li>Breathing too fast or too slow </li></ul>
  7. 7. AIRWAY ALGORITHM <ul><li>Step 1: Open And Clear </li></ul><ul><li>Step 2: Keep It Open </li></ul><ul><li>Step 3: Ventilate (BLS) </li></ul><ul><li>Step 4: Control The Airway </li></ul><ul><li>Step 5: Confirm The Airway </li></ul><ul><li>Step 6: Secure The Airway </li></ul><ul><li>Step 7: Alternatives To ETI </li></ul><ul><li>Step 8: Surgical Airways </li></ul>
  8. 8. <ul><li>Techniques </li></ul><ul><ul><li>Head-tilt/Chin-lift </li></ul></ul><ul><ul><li>Jaw Thrust </li></ul></ul><ul><ul><li>Suctioning </li></ul></ul><ul><ul><li>Nasopharyngeal airway </li></ul></ul><ul><ul><li>Oropharyngeal airway </li></ul></ul>Opening the Airway
  9. 9. Head-Tilt/Chin-Lift <ul><li>Used when no neck injury is suspected </li></ul><ul><li>Temporary procedure </li></ul><ul><li>Must be replaced with an airway adjunct unless patient begins adequate spontaneous ventilation </li></ul><ul><li>Technique </li></ul><ul><ul><li>Place one hand on patient’s forehead </li></ul></ul><ul><ul><li>Apply firm, backward pressure with palm </li></ul></ul><ul><ul><li>causing head to tilt backward </li></ul></ul><ul><ul><li>Place fingers of other hand under bony </li></ul></ul><ul><ul><li>part of patient’s lower jaw near chin </li></ul></ul><ul><ul><li>Lift jaw upward to bring chin forward </li></ul></ul>
  10. 10. Jaw Thrust <ul><li>Used when spinal injury suspected </li></ul><ul><li>Temporary procedure </li></ul><ul><li>Must be replaced with airway adjunct unless patient begins adequate spontaneous ventilation </li></ul><ul><li>Technique </li></ul><ul><ul><li>Place one hand on either side of patient’s head, resting elbows on surface on which victim is lying </li></ul></ul><ul><ul><li>Grasp angles of patient’s lower jaw, lift with both hands </li></ul></ul><ul><ul><li>If patient’s lips close, retract lower lips with thumbs </li></ul></ul>
  11. 11. Suctioning <ul><li>Purpose </li></ul><ul><ul><li>Remove blood, vomit, other liquids, food particles from airway </li></ul></ul><ul><ul><li>May not be adequate for removing large, solid objects (teeth, foreign bodies, food) </li></ul></ul><ul><ul><li>Should be performed immediately when gurgling is heard with spontaneous or artificial ventilation </li></ul></ul><ul><li>Techniques </li></ul><ul><ul><li>Insert catheter into oral cavity without suction </li></ul></ul><ul><ul><li>Insert only to base of tongue. </li></ul></ul><ul><ul><li>Apply suction, move catheter from side to side </li></ul></ul><ul><ul><li>Suction no longer than 15 seconds in adults, 10 seconds in children, 5 seconds in infants </li></ul></ul><ul><ul><li>Rinse catheter with saline or water to prevent obstruction </li></ul></ul><ul><ul><li>ADVANCED AIRWAY </li></ul></ul><ul><ul><ul><li>Preoxygenate </li></ul></ul></ul><ul><ul><ul><li>Pass beyond distal tip </li></ul></ul></ul><ul><ul><ul><li>½ of ID </li></ul></ul></ul><ul><ul><ul><li>Limit to 10-15 sec </li></ul></ul></ul>
  12. 12. Nasal Airways <ul><li>Used on responsive patients who need help keeping tongue out of airway </li></ul><ul><ul><li>Pt with gag reflex </li></ul></ul><ul><ul><li>Maxillofacial injury </li></ul></ul><ul><li>Technique </li></ul><ul><ul><li>Measure from tip of nose to tragus of ear </li></ul></ul><ul><ul><li>Ensure airway will fit through nostril </li></ul></ul><ul><ul><li>Lubricate with water-soluble lubricant or anesthetic jelly </li></ul></ul><ul><ul><li>Insert with bevel toward base of nostril or septum </li></ul></ul><ul><ul><li>If resistance is met, try other nostril </li></ul></ul><ul><ul><li>Do not use in patients with mid-face trauma or possible basilar skull fractures </li></ul></ul>
  13. 13. Oral Airways <ul><li>Used on unresponsive patients without gag reflex </li></ul><ul><li>Helps hold tongue away from back of throat </li></ul><ul><li>Technique </li></ul><ul><ul><li>Measure from corner of mouth to earlobe or angle of jaw </li></ul></ul><ul><ul><li>In adults insert with tip facing roof of patient’s mouth, advance until resistance encountered, turn 180o until flange comes to rest on patient’s teeth </li></ul></ul><ul><ul><li>In infants and children use tongue depressor to lift tongue, insert oral airway right side up </li></ul></ul><ul><ul><li>Too long –press epiglottis </li></ul></ul><ul><ul><li>Too short-force tongue back </li></ul></ul>
  14. 14. Adequate Breathing <ul><li>Normal Rate </li></ul><ul><ul><li>Adult: 12 to 20/minute </li></ul></ul><ul><ul><li>Child: 15 to 30/minute </li></ul></ul><ul><ul><li>Infant: 25 to 50/minute </li></ul></ul><ul><li>Regular Rhythm </li></ul><ul><li>Adequate Quality </li></ul><ul><ul><li>Movement of air at mouth, nose </li></ul></ul><ul><ul><li>Chest expansion adequate, symmetrical (equal) </li></ul></ul><ul><ul><li>Breath sounds present, equal </li></ul></ul><ul><ul><li>Minimum effort of breathing </li></ul></ul><ul><ul><li>Adequate tidal volume (depth) </li></ul></ul>
  15. 15. VENTILATION TECHNIQUES
  16. 16. Ventilation Techniques <ul><li>Mouth-to-Mask </li></ul><ul><ul><li>Connect mask to oxygen at 15 liters per minute </li></ul></ul><ul><ul><li>Kneel directly above patient’s head </li></ul></ul><ul><ul><li>Apply mask to patient’s face </li></ul></ul><ul><ul><li>Place thumbs along sides of mask, index fingers of both hands under patient’s mandible </li></ul></ul><ul><ul><li>Lift jaw into mask, tilt head if neck injury not suspected </li></ul></ul><ul><ul><li>Blow into one-way valve slowly over 2 seconds until patient’s chest rises </li></ul></ul>
  17. 17. Ventilation Techniques <ul><li>Bag-valve mask </li></ul><ul><ul><li>Self-inflating bag </li></ul></ul><ul><ul><li>One-way valve </li></ul></ul><ul><ul><li>Face mask </li></ul></ul><ul><ul><li>Oxygen reservoir </li></ul></ul><ul><li>BVM Issues </li></ul><ul><ul><li>Single rescuer may have difficulty maintaining air-tight seal </li></ul></ul><ul><ul><li>Two rescuers using device are more effective </li></ul></ul><ul><ul><li>Provides less volume than mouth-to-mask </li></ul></ul><ul><ul><li>Position yourself at top of patient’s head for best performance </li></ul></ul><ul><ul><li>Oral or nasal airway should be inserted </li></ul></ul>
  18. 18. Ventilation Techniques <ul><li>BVM Technique (Two Rescuer) </li></ul><ul><ul><li>Open airway, insert oral or nasal airway </li></ul></ul><ul><ul><li>Position thumbs over top half of mask, index and middle fingers over bottom half </li></ul></ul><ul><ul><li>Place apex of mask over bridge of nose, lower mask over mouth/upper chin </li></ul></ul><ul><ul><li>Use ring and little fingers to bring jaw up to mask </li></ul></ul><ul><ul><li>Have assistant squeeze bag with two hands until chest rises </li></ul></ul><ul><ul><li>Ventilate every 5 seconds for adults, every 3 seconds for infants and children </li></ul></ul>
  19. 19. Ventilation Techniques <ul><li>BVM Technique (One Rescuer) </li></ul><ul><ul><li>Open airway, insert oral or nasal airway </li></ul></ul><ul><ul><li>Form a “C” around ventilation port with thumb, index finger </li></ul></ul><ul><ul><li>Use middle, ring, little fingers under jaw to maintain chin lift, complete seal </li></ul></ul><ul><ul><li>Squeeze bag with other hand until chest rises </li></ul></ul><ul><ul><li>Ventilate every 5 seconds for adults, every 3 seconds for infants and children </li></ul></ul>
  20. 20. Ventilation Techniques <ul><li>If chest does not rise, reevaluate </li></ul><ul><ul><li>If abdomen rises, reposition head or jaw </li></ul></ul><ul><ul><li>If air escapes under mask, reposition fingers and mask </li></ul></ul><ul><ul><li>Check for obstruction </li></ul></ul><ul><ul><li>If chest still does not rise and fall use another method of ventilation </li></ul></ul>
  21. 21. LARYNGOSCOPY AND INTUBATION
  22. 22. EQUIPMENTS <ul><li>LARYNGOSCOPE </li></ul><ul><ul><li>Blade Size-1 To 4 </li></ul></ul><ul><li>ETT </li></ul><ul><ul><li>2.5mm-9mm </li></ul></ul><ul><ul><li>7-7.5mm-women, 8.0-8.5mm –men </li></ul></ul><ul><ul><li>LENGTH: 20-21cm-women, 22-23cm -men </li></ul></ul><ul><ul><li>Children's- 4+Age/4 </li></ul></ul><ul><ul><li>IMPORTANT ACCESSORIES </li></ul></ul><ul><ul><ul><li>Pillow 6-8 Cm </li></ul></ul></ul><ul><ul><ul><li>Sticking Plaster </li></ul></ul></ul><ul><ul><ul><li>Bag & Mask </li></ul></ul></ul><ul><ul><ul><li>O2 </li></ul></ul></ul><ul><ul><ul><li>Stylet </li></ul></ul></ul><ul><ul><ul><li>Suction </li></ul></ul></ul>
  23. 24. PREREQUISITES <ul><li>Patient Positionin </li></ul><ul><ul><ul><li>Neck Flexion- 35° </li></ul></ul></ul><ul><ul><ul><li>Head Extension- 15° </li></ul></ul></ul><ul><li>Preoxygenate </li></ul><ul><li>Suction </li></ul><ul><li>Monitors </li></ul><ul><li>I.V Access </li></ul><ul><li>Drugs-inducing Agents, Ms Relaxants &Emergency Drugs </li></ul><ul><li>Ensure Ventilation Before Giving Muscle Relaxant </li></ul>
  24. 25. Direct Laryngoscopy: <ul><li>1. Place the patient in the sniffing position. </li></ul><ul><li>2. Check the laryngoscope and blade for proper fit, and make sure that the light works. </li></ul><ul><li>3. Make sure that all materials are assembled and close at hand. </li></ul><ul><li>4. Curved blade technique: </li></ul><ul><li>a. Open the patient's mouth with the right hand, and remove any dentures. </li></ul><ul><li>b. Grasp the laryngoscope in the left hand </li></ul><ul><li>c. Spread the patient's lips, and insert the blade between the teeth, being careful not to break a tooth. </li></ul><ul><li>d. Pass the blade to the right of the tongue, and advance the blade into the hypopharynx, pushing the tongue to the left </li></ul><ul><li>and advanced the tip towards vallecula. </li></ul><ul><li>e. Lift the laryngoscope upward and forward, </li></ul><ul><li>without changing the angle of the blade, </li></ul><ul><li>to expose the vocal cords. </li></ul>
  25. 26. INTUBATION: <ul><li>Lubricate the end of the tube (optional). </li></ul><ul><li>Insert the stylet, and bend the tube and stylet gently into a crescent shape </li></ul><ul><li>Tip of the stylet at least 1 cm proximal to the end of the tube. </li></ul><ul><li>When visualizing the glottis and vocal cords, gently pass the tube next the laryngoscope blade through the vocal cords into trachea, far enough so that the balloon is just beyond the cords. BURP maneuver </li></ul><ul><li>Withdraw the stylet. </li></ul><ul><li>Connect the bag-valve combination, and begin ventilation with 100% oxygen. </li></ul><ul><li>Confirm position </li></ul><ul><ul><ul><li>Stomach </li></ul></ul></ul><ul><ul><ul><li>B/L chest </li></ul></ul></ul><ul><li>Inflate the cuff with the 10-ml syringe until there is </li></ul><ul><li>no air leak around the tube when positive pressure </li></ul><ul><li>Is applied. </li></ul><ul><li>Wrap adhesive tape around the tube </li></ul>
  26. 27. CANNOT INTUBATE CANNOT INTUBATE
  27. 28. STEP 7. ALTERNATIVES TO ETI
  28. 29. Developed in 1981 at the Royal London Hospital By Dr Archie Brain When definitive airway management cannot be obtained. (ETT) Laryngeal Mask Airway (LMA)
  29. 30. Laryngeal Mask Airway <ul><li>Weight Based Sizing </li></ul><ul><li><5kg = Size 1 </li></ul><ul><li>5--10 kg = Size 2 </li></ul><ul><li>20--30 kg = Size 2.5 </li></ul><ul><li>Small Adult= Size 3 </li></ul><ul><li>Average Adult = Size 4 </li></ul><ul><li>Large Adult = Size 5 </li></ul>
  30. 31. Laryngeal Mask Airway <ul><li>Procedure: </li></ul><ul><li>Hyper oxygenate </li></ul><ul><li>Check cuff </li></ul><ul><li>Lubricate posterior cuff </li></ul><ul><li>Head in neutral or slightly flexed position </li></ul><ul><li>Insert following hard palate </li></ul><ul><li>(use index finger to guide) </li></ul><ul><li>Stop when met with resistance </li></ul><ul><li>Inflate cuff </li></ul><ul><li>Confirm and secure </li></ul>
  31. 32. CANNOT INTUBATE –CANNOT VENTILATE
  32. 33. STEP 8. SURGICAL AIRWAY
  33. 34. CRICOTHYROTOMY <ul><ul><li>Cannot intubate, cannot ventilate: needle cricothroidotomy for ventilation </li></ul></ul><ul><ul><li>Difficult intubation : needle cricothroidotomy for reterograde intubation </li></ul></ul>
  34. 35. CRICOTHYROTOMY - Identify Cricothyroid membrane - Pierce at 45 Pierce angle - Place catheter or styllette Advance dilator
  35. 36. 14 /16G 3.0mm Needle Cricothyrotomy LAST RESORT!
  36. 37. ARE YOU PREPARED
  37. 40. THANK YOU

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