This presentation is about the various techniques involved with airway management

1. AIRWAY
MANAGEMENT
Moderated by: Dr B. Roy
Presented by: Gauri Bargoti

2. Introduction
◦ The inadequate delivery of oxygenated blood to the brain and other vital structures is the quickest killer
of injured patients.
◦ A protected, unobstructed airway and adequate ventilation are critical to prevent hypoxemia.
◦ In fact, securing a compromised airway, delivering oxygen, and supporting ventilation take priority over
management of all other conditions.
◦ Supplemental oxygen must be administered to all severely injured trauma patients

3. Early preventable deaths from airway problems
after trauma often result from:
◦ Failure to adequately assess the airway
◦ • Failure to recognize the need for an airway intervention
◦ • Inability to establish an airway
◦ • Inability to recognize the need for an alternative airway plan in the setting of repeated failed intubation
attempts
◦ • Failure to recognize an incorrectly placed airway or to use appropriate techniques to ensure correct tube
placement
◦ • Displacement of a previously established airway
◦ • Failure to recognize the need for ventilation

4. Problem Recognition
◦ Airway compromise can be sudden and complete, insidious and partial, and/or progressive and recurrent.
◦ Although it is often related to pain or anxiety, or both, tachypnea can be a subtle but early sign of airway and/or ventilatory
compromise. Therefore, initial assessment and frequent reassessment of airway patency and adequacy of ventilation are
critical.

5. Early Assessment
Rapid assessment should be made to check for any obstruction or
laryngeal/tracheal obstruction; suction to clear the obstruction
Presence of non purposeful motor movement require
definitive airway management
If patient is communicating
verbally, less chance of
airway obstruction
Patient with GCS score of 8
require definitive airway
Cervical spine motion
restriction technique can be
used
Try for jaw- thrust or chin-lift
maneuver if no response
place oropharyngeal tube

7. Maxillofacial Trauma and Airway
◦ Trauma to the face demands aggressive but careful airway management.
◦ This type of injury frequently results when an unrestrained passenger is thrown into the windshield or dashboard during a
motor vehicle crash.
◦ Trauma to the midface can produce fractures and dislocations that compromise the nasopharynx and oropharynx. Facial
fractures can be associated with hemorrhage, swelling, increased secretions, and dislodged teeth, which cause additional
difficulties in maintaining a patent airway. Fractures of the mandible, especially bilateral body fractures, can cause loss of
normal airway structural support, and airway obstruction can result if the patient is in a supine position.
◦ Patients who refuse to lie down may be experiencing difficulty in maintaining their airway or handling secretions

8. Objective sign of airway obstruction
Agitated Patient Cyanosis
Noisy Breathing
Abusive Patient

10. INITIAL ASSESSMENT: RECOGNITION OF AIRWAY
OBSTRUCTION AND BREATHING
◦ The primary goal of the initial assessment is to determine if the injuries sustained have compromised the
airway and/or breathing in the patient.
◦ A failure to recognize the need for an airway or the inability to establish an airway can lead to death.
◦ Injuries that result from direct airway trauma are dynamic and require frequent reexamination

15. Airway
Decision
Scheme

16. AIRWAY MANEUVERS
◦ Once it has been determined that an airway is obstructed because of maxillofacial trauma, basic airway
maneuvers are used.
◦ The most basic airway maneuvers are the chin lift and jaw thrust.
◦ In the case of an unconscious patient, these simple techniques may be enough to restore the airway if the
obstruction was caused by the tongue or relaxed upper airway muscles.
◦ The suctioning of debris such as broken teeth or bones, other foreign objects, or secretions should be
completed once the basic maneuvers have been performed. This is done carefully to avoid gagging a
conscious patient, which could lead to vomiting and a more serious situation

17. Chin-Lift
maneuvers
Jaw- Thrust
maneuvers

18. BAG-VALVE-MASK VENTILATION

21. DEFINITIVE Airway
◦ A definitive airway requires a tube placed in the trachea with the cuff inflated
below the vocal cords, the tube connected to oxygen-enriched
assisted ventilation, and the airway secured in place with an
appropriate stabilizing method.

23. Surgical
Nasotracheal
Orotracheal
Types of
definitive
airway

24. Intubation
◦ 1. Is there a failure of airway maintenance or protection? A loss of airway reflexes, pooling secretions signifying the
inability to swallow, and tolerance of the placement of nasopharyngeal airway or oropharyngeal airways indicate a
patient’s inability to maintain and protect their airway.
◦ 2. Is there a failure of oxygenation? This is illustrated by clinical symptoms of cyanosis, obtundation, restlessness or
agitation, and by low oxygen saturation as measured by a pulse oximeter. A lack of oxygen can cause irreversible
damage to human tissues in only minutes.
◦ 3. Is there a failure of ventilation? This can be observed through the patient’s mental status and observing the patient’s
respirations. The inability to release carbon dioxide from the body adequately leads to altered mental status and
respiratory acidosis.
◦ 4. Is there an anticipated need for intubation? It is absolutely imperative that providers assess the likely progression of
symptoms and anticipate impending airway compromise whenever possible

25. Contraindications of intubation
◦ The only major contraindication to intubation is the ability to maintain a patent airway in a less
invasive manner.
◦ If it is possible to maintain a patent airway through basic adjuncts and maneuvers, advanced
airway measures should be avoided.
◦ Possible cervical spine injury is not a contraindication for intubation; however, immobilization
of the cervical spine should be maintained throughout the procedure in cases in which the
patient’s spine has not been cleared of injury

26. Adjuncts

29. Direct Laryngoscopy
◦ A direct laryngoscopy is a procedure that uses a short rigid instrument to deflect
the tongue and jaw, allowing for a view of the larynx and the
placement of a tube within the trachea

30. Equipment for laryngoscopy
◦ • Laryngoscope handle with various blades
◦ • Endotracheal tubes of various sizes
◦ • Stylet
◦ • Introducer
◦ • Oropharyngeal and nasopharyngeal airways
◦ • Rescue airway devices—laryngeal mask airway, Combitube
◦ • Monitors—blood pressure, heart, pulse oximeter, end-tidal carbon dioxide
◦ • Esophageal detector
◦ • Tape

31. Steps for airway
◦ S: Suction
◦ T: Tools (e.g., blade, handle.)
◦ O: Oxygen
◦ P: Positioning
◦ M: Monitors (electrocardiogram [ECG], O2, CO2, blood pressure [BP])
◦ A: Assessment, airway devices, assistant
◦ I: IV access D: Drugs

33. Nasotracheal Intubation
◦ In most cases of maxillofacial trauma, nasotracheal intubation is
contraindicated because of the potential risk of brain injury.
◦ The tube should be warm and lubricated before it is advanced into the larger
naris along the nasal floor.
◦ To minimize potential damage to the Kiesselbach plexus, the bevel of the tube
should face the septum.
◦ The tube is advanced past the vocal cords and eventually down into the larynx
on inspiration, where a cough indicates proper placement

36. Drug-Assisted Intubation
◦ 1. Have a plan in the event of failure that includes the possibility of performing a surgical
airway. Know where your rescue airway equipment is located.
◦ 2. Ensure that suction and the ability to deliver positive pressure ventilation are ready.
◦ 3. Preoxygenate the patient with 100% oxygen.
◦ 4. Apply pressure over the cricoid cartilage.
◦ 5. Administer an induction drug (e.g., etomidate, 0.3 mg/kg) or sedative, according to local
protocol.
◦ 6. Administer 1 to 2 mg/kg succinylcholine intravenously (usual dose is 100 mg

37. After the patient relaxes:
7. Intubate the patient orotracheally.
8. Inflate the cuff and confirm tube placement by auscultating the patient’s chest and
determining the presence of CO2 in exhaled air.
9. Release cricoid pressure.
10. Ventilate the patient

38. Surgical Airway
◦ The inability to intubate the trachea is a clear indication for an alternate airway plan, including
laryngeal mask airway, laryngeal tube airway, or a surgical airway.
◦ A surgical airway (i.e., cricothyroidotomy or tracheostomy) is indicated in the presence of
edema of the glottis, fracture of the larynx, severe oropharyngeal hemorrhage that obstructs
the airway, or inability to place an endotracheal tube through the vocal cord

40. Needle cricothyrotomy

41. Surgical Cricothyrotomy
◦ Surgical cricothyroidotomy is performed by making a skin incision that extends
through the cricothyroid membrane .
◦ Insert a curved hemostat or scalpel handle to dilate the opening, and then
insert a small endotracheal or tracheostomy tube (preferably 5 to 7 ID) or
tracheostomy tube (preferably 5 to 7 mm OD

43. Perioperative Complications
◦ The most common perioperative complications include hemorrhage, improper
placement of the tube, and prolonged execution time.
Bleeding during the procedure is not usually severe, and
can be controlled by ligation, cautery, or packing with
gauze

44. Postoperative Complications
◦ Postoperative complications of cricothyrotomy include haemorrhage, infection, aspiration,
tube occlusion, paralysis of the vocal cords, persistent stoma,
dysphonia and hoarseness, and subglottic stenosis

45. Tracheostomy
• The hyoid bone attaches to the base of the skull, tongue,
and mandible by muscles.
• It is the most stable portion of the airway and can be a
useful anatomic landmark throughout the procedure.
• The thyroid cartilage is palpable superficially and
superiorly.
• The cricothyroid membrane and cricoid cartilage are
identified inferior to the thyroid cartilage.

46. ◦ Once the trachea reaches this level, it is 1 to 1.5 cm deeper than the cricoid cartilage, emphasizing the
technical expertise required to perform a tracheostomy safely.
◦ The neck is prepped with an antiseptic solution and a local anesthetic, such as 1% lidocaine, is injected
into the incision site.
◦ In an elective tracheostomy, the horizontal incision is preferred for better cosmetic results. A 4- to 5-cm
horizontal incision is made approximately 2 cm below the cricoid cartilage
◦ Like the vertical incision, it is carried through subcutaneous tissue and platysma muscle until the
superficial layer of the deep cervical fascia is identified.
◦ Once it has been determined that the tube is in the right location, a tracheostomy gauze dressing
should be placed under the tracheostomy tube phalanges and around the cannula

47. Complications
◦ Overall, the incidence of complications from tracheostomy ranges from 2.7% to 48%.
◦ Haemorrhage, pneumothorax, subcutaneous emphysema, pneumomediastinum, hypoxia through false passage, obstruction,
and extubating are perioperative complications common to both procedures.
◦ Complications specific to tracheostomy include recurrent laryngeal nerve injury, tracheoesophageal fistula, and death.
Postoperative complications caused by tracheostomy are also similar to those associated with cricothyrotomy and include
hypoxia, infection, hemorrhage, tracheal stenosis, tracheal erosion, tracheomalacia, and unsatisfactory cosmesis

48. TIPS FOR SPECIFIC INTUBATION PROCEDURES
ON CHILDREN
◦ 1. Direct laryngoscopy: The straight blade is used with younger children; the curved blade is used for older children.
◦ 2. ETT selection: Proper tube size can be determined by the following equation199: Tube size = + 4 (child’s age/4) a. Newborn,
no. 3.0 or 3.5 ETT b. 6-year-old child, no. 5.5 ETT
◦ 3. Needle cricothyrotomy with transtracheal jet ventilation: This is the preferred surgical airway method in children because it is
straightforward and provides a patent airway for close to an hour.
◦ 4. Cricothyrotomy: This procedure has a high complication rate and should not be done in children younger than 10 years.
◦ 5. Tracheostomy: This should also be avoided in children because it is a time-consuming procedure. However, in emergent
cases, if needle cricothyrotomy with transtracheal jet ventilation has failed in a very small child, a tracheostomy may be
performed

49. Conclusion
◦ 1. Clinical situations in which airway compromise is likely to occur include head trauma, maxillofacial trauma, neck trauma,
laryngeal trauma, and airway obstruction due to other reasons.
◦ 2. Actual or impending airway obstruction should be suspected in all injured patients. Objective signs of airway obstruction
include agitation, cyanosis, abnormal breath sounds, hoarse voice, stridor tracheal displacement, and reduced responsiveness.
◦ 3. Recognition of ventilatory compromise and ensuring effective ventilation are of primary importance.

50. References
◦ ATLS® Advanced Trauma Life Support
◦ Oral and maxillofacial trauma 4th edition