Basic Principles of Critical Care

1. AIRWAY EQUIPMENT AND
MANAGEMENT
Gradian Health Systems
Basic Principles of Critical Care
RESPIRATORY SYSTEM

2. Disclaimer
Basic Principles of Critical Care Training I Airway Equipment and Management
Disclaimer: Gradian Health Systems cannot provide formal recommendations or indications
regarding medical care and clinical service delivery. The tables, checklists, and other clinical
documents referenced in this training have not been validated in all settings. These documents are
intended to serve as examples only. We recognize that all clinical training content and activities
must be customized to meet the needs of each facility and its clinical staff, factoring in available
resources, practitioner skill level, and other environmental considerations.
For any questions regarding the contents or applications of this training,
please contact Gradian Health Systems:
40 W 25th St, 6th Floor
New York, NY 10010 USA
+1 212-537-0340
training@gradianhealth.org

3. Module 2
Gradian Health Systems
Basics Principles of Critical Care
Respiratory System

4. Module 2: Respiratory System
MODULE OVERVIEW
Lesson 1 I Respiratory System Anatomy and Physiology
Lesson 2 I Oxygen Therapy
Lesson 3 I Evaluation of the Respiratory System
Lesson 4 I Airway Equipment and Management
Lesson 5 I Invasive and Non-invasive Ventilation
Lesson 6 I Basics of Mechanical Ventilation
Lesson 7 I Ventilator Modes and Settings
Lesson 8 I Ventilation Complications
Basic Principles of Critical Care Training I Airway Equipment and Management

5. Components of the Gradian CCV SystemLesson 4: Airway Equipment and Management
Lesson Objectives
• Describe the simple airway adjuncts
• Categorize airway management equipment
• Demonstrate airway management techniques
• Elaborate the role of the nurse in airway management
Basic Principles of Critical Care Training I Airway Equipment and Management

6. Components of the Gradian CCV SystemLesson 4: Airway Equipment and Management
Key Concepts
• At risk airway
• Airway equipment
• Airway management
Basic Principles of Critical Care Training I Airway Equipment and Management

7. Components of the Gradian CCV SystemAirway Equipment and Management
What is airway management?
The evaluation, planning, and use of medical devices to maintain a
patent airway and ensure adequate ventilation. It’s an important skill for
all healthcare providers.
Proficiency in airway management requires repeated practice.
Basic Principles of Critical Care Training I Airway Equipment and Management

8. Components of the Gradian CCV SystemAirway Equipment and Management
How can you identify an at-risk airway?
• Airway obstruction (e.g., foreign body, epiglottitis, laryngospasm)
• Trauma to the face
• Glasgow Coma Scale of <8
• Cardiac and/or respiratory arrest
• Spinal cord injury
Basic Principles of Critical Care Training I Airway Equipment and Management

9. Components of the Gradian CCV SystemAirway Equipment and Management
Airway Assessment: History
• AMPLE mnemonic:
• Allergies
• Medication
• Past medical history
• Last meal
• Events
• Signs and symptoms of airway compromise
• Stridor
• Hoarse voice
• Risk factors (trauma to face and neck,coma, etc.)
Basic Principles of Critical Care Training I Airway Equipment and Management

10. Components of the Gradian CCV SystemAirway Equipment and Management
Airway Assessment: History
• Risk factors for difficult airway
• Inability to open mouth adequately
• Poor neck mobility
• Obesity
• Mouth and neck masses
• Airway trauma
• Short neck
Basic Principles of Critical Care Training I Airway Equipment and Management

11. Components of the Gradian CCV SystemAirway Equipment and Management
Airway Assessment: Physical Examination
• General
• Vital signs
• Level of consciousness
• Head and neck
• Beard
• Mouth opening
• Teeth (prominence, loose)
Basic Principles of Critical Care Training I Airway Equipment and Management

12. Components of the Gradian CCV SystemAirway Equipment and Management
Simple Airway Adjuncts
The airway can be managed with simple airway adjuncts and maneuvers.
Simple airway maneuvers include:
• Head-tilt chin lift
• Jaw thrust
Simple airway adjuncts include:
• Oropharngeal airways
• Nasopharyngeal airways
Head-tilt chin lift should not be used with patients with cervical injury whether
suspected or confirmed.
Basic Principles of Critical Care Training I Airway Equipment and Management

13. Oropharyngeal Airway (OPA)
• Also known as Guedel airway
• Used to relieve potential obstruction, especially from the tongue
• Color codes according to size
• Correct sizing much be done by measuring the OPA from the corner of the
mouth to the angle of the mandible
Basic Principles of Critical Care Training I Airway Equipment and Management
Airway Equipment and Management
• When inserting, ensure that the mouth is
adequately opened to prevent trauma
• Cannot be used in patients who are
conscious or have an intact gag reflex or
cough reflex

14. Components of the Gradian CCV SystemAirway Equipment and Management
Nasopharyngeal Airway (NPA)
• Must be correctly sized - measure from tip of patient's nose to the
ear lobe
• Choose a diameter of the NPA that is slightly smaller than the
patient’s nostrils
• Bevel of the tip should be pointing toward the nasal septum and
inserted posteriorly following the nasal curvature
• Water based lubricant can and should be used
• Insert gently to reduce risk of nasal bleeding
• Do not use in patients with nasal fracture or polyps
Basic Principles of Critical Care Training I Airway Equipment and Management

15. Components of the Gradian CCV SystemAirway Equipment and Management
Face mask ventilation
• Anesthetic face mask has a cuff
providing a good seal
• Requires a self-inflating bag (Ambu)
and a source of pressurized oxygen
• Correct size mask covers the bridge of
the nose and the mouth
• Used for bag-mask ventilation (BVM)
Basic Principles of Critical Care Training I Airway Equipment and Management

16. Components of the Gradian CCV SystemAirway Equipment and Management
Supraglottic devices (SADs)
• Can be life saving tool in “can’t intubate, can't ventilate”
situations as rescue airway
• Many difficult airway algorithms incorporate the use of SADs
• Should not be used in patients who have risk of
regurgitation, prone positioning or prolonged ventilation
• Size of LMA are based on weight from pediatric to adult
• First generation: LMA classic; intubating LMA
• Second generation: LMA Proseal; i-gel
• Second generation have design characteristics that allow
positive pressure ventilation and reduce risk of regurgitation
Basic Principles of Critical Care Training I Airway Equipment and Management

17. Components of the Gradian CCV SystemAirway Equipment and Management
Complications of SADs
• Ventilatory failure – may be due to misalignment or dislodgement
• Airway injury – sore throat may occur
• Aspiration of gastric contents
Basic Principles of Critical Care Training I Airway Equipment and Management

18. Components of the Gradian CCV SystemAirway Equipment and Management
Tracheal Intubation
Indications of tracheal intubation
• Respiratory arrest
• Need to maintain a patent airway
• Glasgow Coma Scale <8
• Mechanical ventilation
• Cardiac arrest
Endotracheal intubation requires practice and should be performed by
an experienced healthcare professional
Basic Principles of Critical Care Training I Airway Equipment and Management

19. Components of the Gradian CCV SystemAirway Equipment and Management
Tracheal Intubation Equipment
• Laryngoscope with appropriate blade size and working light
bulb
• Video laryngoscopy can be used, when available
• Endotracheal tube – cuffed (low-pressure high-volume cuff)
• Syringe, to inflate ETT cuff
• Intubation aids – introducer, bougies, Magill forceps, stylet
• Patient monitor – heart rate, SpO2, EtCO2, blood pressure
• Tape, to secure ETT
• Ambu bag and face mask
Basic Principles of Critical Care Training I Airway Equipment and Management

20. Components of the Gradian CCV SystemAirway Equipment and Management
Tracheal Intubation Equipment
• Oxygen supply
• Medications for sedation and/or paralysis
• Suction – must be working with catheters available
• Sterile gauze to wipe secretions
• Gloves
Basic Principles of Critical Care Training I Airway Equipment and Management

21. Components of the Gradian CCV SystemAirway Equipment and Management
Endotracheal Intubation Medications
Medication is used to achieve patient and provider comfort. Laryngoscopy
produces physiological responses that may be detrimental to the patient and
should not be done on an awake or minimally sedated patient. The only
exception is in the case of a planned/performed intubation for a difficult airway, in
which case topical analgesia is used (nebulized 4% lidocaine,10% lidocaine
spray).
Basic Principles of Critical Care Training I Airway Equipment and Management

22. Components of the Gradian CCV SystemAirway Equipment and Management
Intubation Medications
Sedatives and/or analgesic
Short acting IV drugs are usually used:
• Propofol 1.5-3mg/kg
• Ketamine 1-2mg/kg
• Etomidate 0.3mg/kg
• Fentanyl 2-5mcg/kg
Paralytic drugs
• Succinylcholine 1-2mg/kg
• Rocuronium 1mg/kg
Basic Principles of Critical Care Training I Airway Equipment and Management

23. Components of the Gradian CCV SystemAirway Equipment and Management
Endotracheal Intubation Complications
• Trauma
• ETT dislodgement
• ETT obstruction
• Failed intubation
Confirmation of correct ETT placement
• Visual confirmation
• Capnometry
• Visible chest rise and breath sounds on auscultation of the chest
• SpO2
• Chest X-ray
Basic Principles of Critical Care Training I Airway Equipment and Management

24. Components of the Gradian CCV SystemAirway Equipment and Management
Surgical Airway
Can be achieved as an emergency or elective
• Emergency surgical airway techniques include:
• Open cricothyroidotomy
• Needle cricothyroidotomy
• Percutaneous cricothyroidotomy using the Seldinger technique
• Elective surgical airway:
• Tracheostomy –commonly done in ICU for patients who may
need medium- to long-term ventilation (>3 weeks)
• Tracheostomy may be done as an emergency, but its use is
dependent on providers judgement and expertise
Basic Principles of Critical Care Training I Airway Equipment and Management

25. Components of the Gradian CCV SystemAirway Equipment and Management
Emergency Surgical Airway Indications
• Inability to open the mouth (e.g. trismus, trauma, tumors etc.)
• Obstruction in the upper airway (e.g., foreign body, tumor, abscess, edema)
• Trauma to the neck
• Difficult intubation
Basic Principles of Critical Care Training I Airway Equipment and Management

26. Components of the Gradian CCV SystemAirway Equipment and Management
Emergency Surgical Airway Complications
• Failure to obtain an airway
• Incorrect execution, resulting in injury to the cartilaginous structure
• Hemorrhage
• Subcutaneous emphysema
• Pneumothorax
• Hypoxia
• Airway soiling – blood and debris
• Airway stenosis – a long term complication; subglottic stenosis can occur after
cricothyroidotomy – it is recommended that the surgical cricothyroidotomy be
converted to a tracheostomy within 72 hours
Basic Principles of Critical Care Training I Airway Equipment and Management

27. Components of the Gradian CCV SystemAirway Equipment and Management
Role of the Nurse during Endotracheal Intubation
Intubation of the trachea is the responsibility of a trained medical practitioner.
However, the nurse assists in the procedure by preparing the patient, keeping
articles ready for use, and providing follow up care.
Basic Principles of Critical Care Training I Airway Equipment and Management

28. Components of the Gradian CCV SystemAirway Equipment and Management
Role of the Nurse after Endotracheal Intubation
• Never leave the patient alone
• Watch and maintain an open airway
• Remove secretions by effective suctioning
• Prevent displacement of the tube
• Watch for complications such as laryngeal edema, tracheal stenosis, and
hemorrhage
• Maintain adequate nutrition of the patient with IV fluids
• Record vital signs
• Keep an emergency tracheostomy tray, including tracheostomy tubes of
correct sizes, at patient bedside for emergency use
Basic Principles of Critical Care Training I Airway Equipment and Management

29. Components of the Gradian CCV SystemLesson 4: Summary
Basic Principles of Critical Care Training I Airway Equipment and Management
• Patient ventilation and oxygenation are key in airway management
• It is important to understand the indications of each airway management
technique
• ICU providers need to be confident in BVM and tracheal intubation