Air way mana ص

CPR consists of:
1. Airway Management
2. Basic Life Support (BLS)
3. Advanced Cardiac Life Support (ACLS)
4. Advanced Trauma Life Support (ATLS)
5. CPR in special situations
6. Ethical Issues

,
AIRWAY
MANAGEMENT
REVIEW & UPDATE
Dr. Salah Kamel ashour
Albada General Hospital
Tabuk region
ashour110@hotmail.com
0502617860

AIRWAY MANAGEMENT
Basic & Advanced

Objectives
Review airway anatomy
Identify important anatomical structures
related to the intubation of a patient
Review basic airway maneuvers
Review blind insertion airways
Review advanced airway techniques
Describe the process of opening the airway
and maintaining it
Describe the indications, limitations, proper
sizing, and contraindications of airway
adjuncts

OBJECTIVES
Identify indications for intubation and prepare
the necessary equipment.
Identify the advantages and disadvantages of
various devices for airway management.
Refresh working knowledge of intubation
equipment and airway support adjuncts
Discusse supraglottic and infraglottic aw
device ( LMA& COMBTUBE)
Identify difficult airway.
Identify equipment for difficult airway and
know their use.

Objectives:
Discuss the ten commandments of airway management
Review and demonstrate pediatric and adult
basic/advanced airway techniques
Review techniques for confirmation of tube placement and
ongoing monitoring
Describe the indications, contraindications, advantages,
disadvantages, complications and equipment for sedation
procedures during intubation
Perform needle and surgical cricothyroidotomy procedures

CONTENTS
 Introduction.
 Facts about A/W.
 Procedures of A/W management.
 Initial management of A/W.
Without Tracheal intubation.
 Advanced a/w management with tracheal
intubation.
 Management and protection of A/W. in patient
with head trauma.
 A/W. Management & chest trauma.
 Summary.

Regardless of
certification level, to
Manage a patient's airway in
the most effective way possible
It is the responsibility
of every HEALTH
CARE PROVIDER

Airway anatomy and function.
Evaluation of airway.
Maintenance and ventilation.
Clinical management of the airway.
How to open the A/W.
What should we know about
“airway management”?

♥ A/W control is vital to improve
pulmonary exchange , as well as
, to protect patient's from
aspiration .
♥ The most vital element in
providing functional respiration
is the AIRWAY .
INTRODUCTION

The A/W is the conduit through
which air & o2 must pass before
reaching the lungs .
It include the anatomic
structures extending from the
nose and mouth to the larynx
and trachea.
WHAT IS THE A / W ?

Successful airway
management requires
detailed understanding
of upper and lower
airway structure
(ANATOMY) and
function (PHYSIOLOGY)

Review of Upper
and Lower
Airway
ANATOMY

 Upper
and
 lower
airway
ANATOMY

Anatomy
Upper airway
The upper airway consists of the structures
above the vocal cords.
It is divided into the following regions:
 Nose and oral cavity.. The nose, which is
composed of bone cartilage, is the primary
pathway for normal breathing. The oral
cavity consists of the upper and lower
teeth, the tongue and floor of the mouth,
the hard palate and the openings of the
major salivary glands. The floor of the
mouth is supported by the mylohyoid
muscles.

 Pharynx. In normal size adult males, an
approximately 13-cm long muscular tube located behind
the oral and nasal cavities. It conducts food to the
esophagus and air to the larynx, trachea and lungs. The
pharynx is divided into three sections:
 Nasopharynx: extends from the back of the internal nasal
cavity to the soft palate. Contains the adenoids.
 Oropharynx: Begins at the soft palate and continues to the
level of hyoid bone. Serves as both respiratory and food
passage. Contains the tonsils. The tongue is the principal source
of obstruction, usually because of decreased muscle tone related
to sedation drugs such that the tongue falls backward in a
supine patient.
 Laryngopharynx: Begins at the level of the hyoid bone and
extends downward where it branches into two passages: the
larynx at the front which leads to the lungs; the esophagus at
the back which leads to the stomach.

Pharynx Divided into Three Segments: Nasopharynx,
Oropharynx, and Hypopharynx

Innervation and blood
supply
 The motor and most of the sensory
supply to the pharynx is by the
pharyngeal plexus, is formed by the
pharyngeal branches of the vagus and
glossopharyngeal nerves
 . The pharynx is supplied by branches
of the external carotid (ascending
pharyngeal) and subclavian (inferior
thyroid) arteries

Upper Airway: From Pharynx to
Larynx
Uvula
Epiglottis
Larynx
Midline guidance:
“The uvula points to the epiglottis, the epiglottis leads into the larynx”.
Lingual
Tonsil

Lower airwayThe lower airway encompasses the
structures of the respiratory system below
the larynx.
 Trachea. Rigid tube approximately 10-15 cm
length in the midline of the neck that provides a
passage for air into the lungs.
 Bronchial tree. Branched tree-like tube system
leading from the trachea that conducts air into the
lungs. It is made up of increasingly smaller tubes
terminating in the alveoli.
 Lungs. Paired organs consisting of millions of
small sacs (alveoli) gas exchange occurs. The
lungs occupy most of the space of the thoracic
cavity.

The Larynx
• The larynx is a 5-7
cm long structure.
• Its upper boundary
starts at the tip of
the epiglottis,
opposite the 3rd to
4th, cervical
vertebra.
• Its lower end is at
the lower border of
the cricoid cartilage.
• This lies opposite the 6th
cervical vertebra. www.phon.ox.ac.uk

The Larynx
Superior surface anatomy:
Major Landmarks
to look for - VII
Cartilaginous
Rings of
Trachea
True
Vocal
Cords
Vocal Cord
Sulcus (on
True Vocal
Cords)
Cricoid
Ring
False
Vocal
Cords

Larynx
 . Enlargement at the top of the trachea
which houses the vocal cords.
 The structure contains muscles, ligaments,
and cartilages.
 The epiglottis is a fibrous leaf-like cartilage
that hangs over the laryngeal inlet that
closes during swallowing to prevent
aspiration of gastric contents into the
trachea.
 .

Larynx
 The triangular opening between the vocal
cords is called the glottic opening
and is the entry point to the larynx, It is
the adult airway’s narrowest point.
Patency of the glottic opening is
dependent upon muscle tone

The glottis: open for inspiration
and closed for swallowing
Open Closed

Larynx
 The vocal cords of the
larynx as seen by a
doctor using a
laryngeal mirror. Note
that the inside of the
trachea can be seen
through the open
vocal cords and the
opening to the
esophagus can be
seen lying behind the
larynx .©

The Larynx: Critical Structures
 The Larynx neighbors
major critical structures:
 Carotid arteries and jugular
veins, and the vagus nerve
 Superior and inferior thyroid
arteries
 Superior and recurrent
laryngeal nerves
www.yoursurgery.com

Nerve Supply
Vagus (X)
Superior
Laryngeal
Recurrent
Laryngeal
Continues in Thorax/Abdo to
supply Heart, Trachea,
Lungs, GI Tract (to midgut)
Internal
Branch
External
Branch
Meningeal Branch
Auricular Branch
Pharyngeal Branch

Nerve Supply
Vagus (X)
Superior
Laryngeal
Recurrent
Laryngeal
Cricothyroid
Internal
Branch
External
Branch
All other
Intrinsic
Muscles
Motor Meningeal Branch
Auricular Branch
Pharyngeal Branch

Nerve Supply
Vagus (X)
Superior
Laryngeal
Recurrent
Laryngeal
Above
cords
Below
cords
Cricothyroid
Internal
Branch
External
Branch
All other
Intrinsic
Muscles
SensoryMotor Meningeal Branch
Auricular Branch
Pharyngeal Branch

Larynx
 Unilateral damage of a recurrent laryngeal
nerve results in paralysis of all the intrinsic
muscles of the larynx except the
cricothyroid, which will tend to adduct the
vocal cord

The larynx has arterial supply by
(1) the superior laryngeal artery
(from the superior thyroid), which
accompanies the internal laryngeal nerve,
(2) the inferior laryngeal artery
(from the inferior thyroid), which
accompanies the recurrent laryngeal
nerve

Cricoids cartilage1
Lungs2
Trachea3
Epiglottis4
Nasopharynx5
Thyroid cartilage6
Alveolus7
Larynx8
Right main bronchus9
Left main bronchus10
Bronchiole11
Oropharynx12
Diaphragm13

BCricoids cartilage
1
ELungs2
CTrachea3
HEpiglottis4
FNasopharynx5
AThyroid cartilage6
MAlveolus7
ILarynx8
DRight main bronchus9
JLeft main bronchus10
LBronchiole11
GOropharynx12
KDiaphragm13

Pediatric Airway
Infant and Child Considerations

Pediatric Airway
 Pediatric vs Adult Upper Airway
 Larger tongue in comparison to size
of mouth
 Floppy epiglottis
 Delicate teeth and gums
 Larynx is more superior
 Funnel shaped larynx due to
undeveloped cricoid cartilage
 Narrowest point at cricoid ring before
10 yoa

Pediatric Airway
 Pediatric vs Adult Upper Airway
 Trachea -
 Infants and children have narrower tracheas
that are obstructed more easily by swelling.
 Trachea is softer and more flexible in infants
and children.
 Diaphragm - chest wall is softer, infants
and children tend to depend more heavily
on the diaphragm for breathing

Pediatric Airway
The Cricoid cartilage
 like other
cartilage in the
infant and child,
the cricoid
cartilage is less
developed and
less rigid. It is
the narrowest
part of the
infant’s or child’s
airway.
Cricothyroid
membrane
Thyroid gland
Thyroid cartilage
Cricoid cartilage

Blood Supply
 The lungs are very vascular organs, meaning they receive
a very large blood supply.
 This is because the pulmonary arteries, which supply
the lungs, come directly from the right side of the heart.
 They carry blood which is low in oxygen and high in carbon
dioxide into the lungs so that the carbon dioxide can be
blown off, and more oxygen can be absorbed into the
bloodstream.
 The newly oxygen-rich blood then travels back through the
paired pulmonary veins into the left side of the heart.
From there, it is pumped all around the body to supply
oxygen to cells and organs.

Basic Physiology
http://www.biology.eku.edu/RITCHISO/301notes6.htm

Airway Functions
Passage that allows air to move from
atmosphere to alveoli
Must remain patent (open) at all times
Anything that blocks airway will cause
decrease in oxygen available to body
Size of obstruction affects available air
exchange

Respiratory Physiology
 The physiology of respiration is a complex
process of gas exchange at the cellular level
(CO2 and O2). When air loaded with oxygen
reaches the alveoli, cellular respiration occurs.
Oxygen inhaled into the lungs is moved into
the alveoli through diffusion at the capillary
level. This oxygen diffuses from areas of
higher concentration to areas of lower
concentration across the cell wall.

Respiratory Physiology
 Oxygenation - blood and the cells become
saturated with oxygen
 Hypoxia - inadequate oxygen being delivered to
the cells
 Signs of Hypoxia
 Increased or decreased heart rate
 Altered mental status (early sign)
 Agitation
 Initial elevation of B.P. followed by a decrease
 Cyanosis (often a late sign)

Alveolar/Capillary Exchange
 Oxygen-rich air enters the alveoli during
each inspiration.
 Oxygen-poor blood in the capillaries passes
into the alveoli.
 Oxygen enters the capillaries as carbon
dioxide enters the alveoli.

Capillary/Cellular Exchange
 Cells give up carbon dioxide to the
capillaries.
 Capillaries give up oxygen to the cells.

Airway management
does
not mean intubation

 It means to ensure patency, provide
adequate ventilation and maintain
appropriate oxygenation.
 Many times we forget the basics.
 Merely providing a chin lift or jaw
thrust can open and/or salvage
many airways.
 The proper use of adjuncts (oral/nasal
airways), can convert a difficult-to-ventilate
patient into a stable, well-ventilated one.

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 patient’s mouth or trachea

Remembering that:
oxygenation is more
important than tracheal
Intubation .
This can be done by:
administering O2 via mask&
bag to improve oxygenation
prior to intubation

IF vomitus or F.B. is visible in the
mouth of unconscious patient , it
should be swept with a hooked index
finger .
Placement of oral or nasal A/W.
may help to maintain a patent
A/W.

1. Relieve airway obstruction (e.g. head tilt-
jaw thrust, finger sweep, suctioning)
2. Prevent aspiration (e.g. blood, foreign
materials, stomach contents > leads to
pneumonitis > 50% mortality rate
3. Maintain adequate ventilation/gas
exchange
Goals of
Airway Management

The Ten Commandments
of Airway Management
1) Oxygenation and ventilation are the top priorities
2) Airway management does not mean intubation :-It means
to ensure patency, provide adequate ventilation and
maintain appropriate oxygenation. Many times we forget
the basics.
3) Be an expert at bag-valve-mask (BVM) ventilation .
4) Know your equipment
1) That daily check sheet is there for a reason. Airway
equipment is one of the most important items you
carry. Having backups (laryngoscope blades, bulbs, handles,
adjuncts) and the ability to troubleshoot equipment are also
important. Assume personal responsibility for all airway
equipment and its proper functioning.

5) Know at least one rescue ventilation technique and use it
 Rescue ventilation can best be described as a ventilation attempt to
use in the face of a failed airway (can’t intubate/can’t ventilate)
scenario. The most basic rescue technique is two-person BVM
ventilation Next, the use of the CombiTube® and LMSis
recommended. It is easy to use, can be inserted quickly and
safely, and can accomplish ventilation when previous airway
attempts fail. It allows for blind insertion in the most difficult of
patients and situations and provides some protection against
aspiration and higher airway pressures.
6) Develop a personal airway algorithm
 Each provider should have an algorithm specific to their skill level and approved scope
of practice. Not all patients and situations you encounter are going to be the
same. Having only one or two airway skills in your repertoire can lead to a potentially
dangerous approach to airway management. Everyone’s algorithm should begin with
the basics. For example, start with BVM ventilation, advance to ET intubation, then
place a Combitube®, and finally perform a surgical cricothyrotomy. This plan should
be calmly practiced and mastered.
7) Don’t let your ego get in the way
 This can be dangerous for your patient, your partner or colleagues, and your
career. Remember, your goal is excellent patient care and a positive outcome, not skill
accumulation or personal success. . Don’t ever forget to ask for assistance when you
need it.

8) Invest time in learning airway skills
 Regularly devote training and practice time to airway
management. Try not to limit yourself to manikin airway trainers if
possible. Work on gaining access to the simulator lab, operating
room or emergency department. Also, read about the latest
techniques and advances in airway management. Attend
conferences and airway obstacle courses for more hands-on
training. :
9) Use CAPNOGRAPH & an end tidal CO2 detector and/or
esophageal detector device to assist you in confirming every
intubation .
10)When seconds count, don’t count on seconds
 Each airway maneuver or intubation attempt should be your best
effort. Often, our best chance at getting a decent airway is the first
attempt. Maximize your chances by leaving nothing to
chance. Being prepared often means the difference between
success and failure.

Airway anatomy and function.
Evaluation of airway.
Maintenance and ventilation.
Clinical management of the airway.
How to open the A/W.
Basic & Advanced
What should we know about
“airway management”?

Procedures of
A/W management
A/W Cane be managed
With(Advanced)
or without
Basic))tracheal Intubation

ALWAYS REMEMBER
THE BASICS
These skills should be used
prior to initiating any advanced
airway technique
 Head-tilt/chin lift
 Jaw thrust
 Modified jaw thrust (for trauma patients)
 Sellick’s maneuver
Basic Airway Maneuvers

[
to open the A/W
Use head tilt
& chin left
or jaw thrust

Techniques of Basic
Airway Management
Non-invasive
-Head positioning
-Removal of foreign body
-Suctioning
-Mask ventilation

Opening and head
positioning
• Jaw thrust
• Head Tilt Chin lift
• Combined
•Remember : C-spine stabilization

Airway management
Manual methods:
Head tilt & Chin lift
Jaw Thrust ( Trauma)

Head-tilt/chin-liftHead-Tilt/Chin-Lift

Head-Tilt/Chin-Lift
Technique
Place one hand on patient’s forehead
Apply firm, backward pressure with
palm causing head to tilt backward
Place fingers of other hand under
bony part of patient’s lower jaw near
chin
Lift jaw upward to bring chin forward
Head-Tilt/Chin-Lift

♥ Loss of
consciousness is
often accompanied by
loss of
submandibular
muscle tone .
♥ Occlusion of the A/W.
by tongue can be
relived by a head- tilt
chin lift ( if no
evidence of c.spine
injury,
Head-Tilt/Chin-Lift

Falling of tongue
backward (
during loss of
consciousness) is the
most common cause of
U/A/W/ obstruction.
which can be relieved
by a head-tilt /chin
lift or jaw- thrust.
Head-Tilt/Chin-Lift

Airway
adjuncts
Oropharyngeal airway
Nasopharyngeal airway

Airway adjuncts

Airway Adjuncts
• Oropharyngeal Airway (OP)
– Helps prevent tongue from obstructing
posterior pharynx
– Potential use in unconscious patient
– Cannot use in patients with intact gag reflex
– SIZING: measure from corner of mouth to
angle of jaw
– PLACEMENT: direct method vs rotation
method.

Airway Adjuncts
• Nasopharyngeal Airway (NP)
– Unconscious or depressed mental status
– SIZING: Measure from the tip of the nares to
the tragus of ear
– CONTRAINDICATIONS: basilar skull fracture,
midface fractures, bleeding disorders
– Relative contraindication: children < 1 year
old

Oropharyngeal Airways
•Features:
- single use
- rounded edges
- bite block
- colour coding
- airway path in centre

How do you
size oral
airways?:

The correct size will vary Oral Airways
with each patient.
To size the OPA, it is measured
against the distance from the corner of
the patient's mouth to the patient's
earlobe.
SIZING THE OPA:

correct size :
• it is measured
against the
distance from
the corner of the
patient's mouth
to the patient's
earlobe.

incorrect size :
• If an airway
is too
small ,it
may obstruct
the airway.

incorrect size :
• If an airway
is too
large ,it
may obstruct
the airway.

Incorrect insertion of
an OPA
can displace the tongue
into hypopharynx ,
causing air-way
obstruction

OPAImproper placement of
oropharyngeal airway

INSERTION OF THE OPA :
• It is the
responsibility of
every provider,
regardless of
certification level,
to manage a
patient's airway in
the most effective
way possible

• Position the casualty on his back.
• Place your thumb and index finger of one hand on the
casualty's upper and lower teeth near a corner of his
mouth so the thumb and finger will cross when the
casualty's mouth is opened.
• Push your thumb and index finger against the
casualty's upper and lower teeth in a scissors-like
motion until his teeth separate and his mouth opens.
• If the teeth do not separate, wedge your index finger
behind the casualty's back molars and force the teeth
apart.
INSERT THE
OROPHARYNGEAL AIRWAY :

Place the tip end of the airway into the casualty's
mouth. Make sure the tip is on top of the tongue. Point
the tip of the airway up toward the roof of the
casualty's mouth.
Slide the airway along the roof of the casualty's mouth,
following the natural curvature of the tongue.
When the tip of the airway reaches the back of the
tongue past the soft palate, rotate the airway 180
degrees so the tip of the airway points toward the
casualty's throat.
INSERT THE

Advance the airway until the flange
rests against the casualty's lips.
The airway should now be positioned
so the tongue is held in place and will
not slide to the back of the casualty's
throat.
INSERT THE

INSERTION OF THE OPA
• Using a head-tilt-
chin-lift, a modified
jaw-thrust, or by
grasping the tongue
and jaw by placing
your thumb in the
patient's mouth,
move the tongue
forward.

• Position the
OPA as shown
with the tip in
the patient's
mouth and
slowly insert the
OPA

• At the point
resistance is
met, insertion
should continue
while
simultaneously
rotating the
OPA 180°.

• Advance the
OPA until the
flange is resting
on or just above
the patient's
teeth .

Blindly inserting the
O/A/W upside down
and turning it 180ْ
once it is in the
mouth may push the
tongue against the
post. Pharynx which
help to open A/W.

Check the casualty's respirations to make
sure he is still breathing adequately and the
oropharyngeal airway is not blocking his
airway.
Adjust the position of the oropharyngeal
airway, if needed
MONITOR A CASUALTY WITH AN
OROPHARYNGEAL AIRWAY IN
PLACE :

♥ The position of the airway in the patient’s
mouth and breath sounds should be assessed
frequently
♥ The oral cavity should be suctioned as
needed .
♥ Mouth care should be done every two to four
hours and as needed.
♥ Mouth care can be done with a moistened
swab.
some tips to care for a patient
with an oropharyngeal airway

If the airway is coated with secretions, it
can be removed and insert a clean airway
If the patient has the oropharyngeal airway
as a long-term measure, the airway should
be cleaned and replaced at least once every
eight hours .
some tips to care for a patient
with an oropharyngeal airway

Contraindicated
in patients with
gag reflex.

Oropharyngeal Airway
SIZE
PROPER
POSITION
Image from: http://www.hadassah.org.il/NR/rdonlyres/59B531BD-EECC-4FOE-9E81-14B9B29D139B1945/AirwayManagement.ppt

Question:
Should you tie or tape the airway in place?
Response:
No.
Question:
What should you do if the casualty begins
to regain consciousness?
Response:
Remove the airway.

2.Nasopharyngeal
Airway
Soft plastic or rubber tube that is designed to
pass just inferior to the base of the tongue
Passed through one of the nares and can be
used in patients with an intact gag reflex
CONTRAINDICATED in cases of suspected or
possible basilar skull fracture
Sizes range from 17-26 cm in length and 6-9 mm
internal diameter
Measured from tip of the nose to the corner of
the patients ear

Nasal Airway continued
The nasal airway is
lubricated with a water
soluble lubricant
The beveled tip is inserted
directed towards the
septum, with the airway
directed perpendicular to
the face
If resistance is met, rotating
the airway may help or the
other nare may be used

Contraindicated
in patients with
basal skull #

Nasal A/W
( Naso-pharyngeal A/W)
 The length is 2 – 4 cm longer than oral A/W
 Used to relieve upper A/W obstruction caused by
tongue or soft palate falling against posterior wall
of the pharynx .
 Suction via this A/W less traumatic than oral
A/W.
 Better tolerated than orally A/W. in awake or
lightly anaesthetized patient.
 After it is lubricated it can be gently inserted
down at an angle  to the face to avoid
traumatizing the turbinate or the roof of the nose

Nasal Airways
• Patients needing nasal airway
–Unresponsive patients who are
snoring
–Unresponsive patients with gag
reflex

It should be alternated every 24 h. between
R& L. nares to minimize complication .
Should not be used in :
*Anticoagulant patient .
* Children with prominent adenoids
Absolute contraindication in skull
fracture base
Sinusitis , otitis media , nasal necrosis , are
possible complication of its use

SIZING THE NPA
• The correct size will vary with
each patient. To size the NPA, it
is measured against the distance
from the patient's nose to the
patient's earlobe

INSERTION OF AN NPA
First, check the nostril for signs of fracture or obstruction then apply
generous amounts of a water-based lubricant to the NPA taking care
not to fill the tip with the lubricant

Orient the bevel end so that it will pass along the inside of
the nasal cavity with minimal effort and insert the NPA
until the flange (the large end of the tube) is seated on the
patient's nose as shown below

Two NPA's can be inserted to provide even better ventilation. Placing the second is
similar in fashion with one difference: The bevel of the second NPA must be oriented
to the nasal septum as was the first but the curvature of the NPA itself indicates
that while being inserted, it must be turned 180° when about 1/2 way into the nasal
cavity

SPECIAL CONSIDERATIONS
 Another acceptable sizing technique is to
match the diameter of the NPA to that of the
patient's little finger
 If significant resistance is felt upon insertion
of the NPA, remove it and attempt
placement in the opposite nostril
 Be prepared for bleeding that may occur
with the placement of the NPA
 Always make efforts to be prepared with
suction devices at the ready with all airway
procedures in the event the patient should
vomit

Potential Hazards Involved in the Use
of Nasopharyngeal airways airways
• Using an airway that is too long; this
may cause the tip to enter the
esophagus.
• Injuring the nasal mucosa causing bleeding.
This can lead to aspiration of blood or clots.
• If nasal airway doesn’t have flange at the
nasal end can lose airway in nose and the
airway.

Bag-valve-
mask
ventilation
(BVM)

Be an expert
at bag-valve-
mask (BVM)
ventilation

INDICATIONS:
The BVM is a device used to
deliver positive pressure
ventilations to patients :-
who are breathing
ineffectively
or not breathing at all.

Bag-mask ventilation is a basic but
critical airway management skill.
It enables clinicians to provide adequate
ventilation for patients requiring airway
support and allows enough time to
establish a more controlled approach to
airway management,.
Because the technique can be difficult to
perform correctly, clinicians performing
the procedure should continually practice
and monitor their technique

Bag-valve-mask
Components of BVM
Ventilation
Self-inflating bag
One-way valve
Face mask
Oxygen reservoir
Must be connected to oxygen to perform
most effectively

Bag-valve-mask
By adding oxygen and a reservoir close to
100% oxygen can be delivered to the patient
When using a BVM an OPA/NPA should be
used if possible
Volume of approximately 1,600 milliliters
Provides less volume than mouth-to-mask
Single Rescuer may have trouble maintaining
seal
Two Rescuer more effective
Available in infant, child, and adult sizes

Bag and mask ventilation is
an important clinical skill to
master
In most resuscitation
settings a self-reinflating
bag
with nonrebreathing valves
(such as that shown) is
used to provide positive
pressure ventilation, usually
using100% oxygen.
This bag fills spontaneously
after being squeezed and
can be used even when
oxygen is unavailable.

Strategies
for
Successful
BVM
Ventilation

APPLYING THE BVM:
The mask of the BVM should be
placed over the patient's nose and
mouth to ensure an adequate seal
between the patient's face and the
mask itself. OPA/NPA's can be used
in conjunction with the BVM to
ensure adequate passage for each
ventilation

Basics skill of
BVM
Paying attention to
the basics of this skill
will make it maximally
effective

Bag-mask ventilation
All healthcare
providers should
be familiar with the
use of the bag-
mask device for
support of
oxygenation and
ventilation.

Successful bag-mask
ventilation depends on
three things:
Patent airway :Airway patency can be
established using basic airway
maneuvers
Adequate mask seal :In order to secure
a good seal, the mask must be placed
and held correctly
Proper ventilation (ie, proper volume,
rate )

In order to secure a good
seal, the mask must be
placed and held correctly
Excessive tidal volumes: A volume just large
enough to cause chest rise (no more than 8 to 10
cc/kg) should be used. During cardiopulmonary
resuscitation (CPR), even smaller tidal volumes
are adequate (5 to 6 cc/kg) due to the reduced
cardiac output of such patients.
Forcing air too quickly: The bag should not be
squeezed explosively. It should be squeezed
steadily over approximately one full second.
Ventilating too rapidly. The ventilatory rate

Ventilation
Techniques
BVM Issues
Single rescuer may have difficulty
maintaining air-tight seal
Two rescuers using device are more
effective
Position yourself at top of patient’s
head for best performance
Oral or nasal airway should be inserted

Ventilation
TechniquesBVM Technique (Two Rescuer)
Open airway, insert oral or nasal airway
Position thumbs over top half of mask, index
and middle fingers over bottom half
Place apex of mask over bridge of nose, lower
mask over mouth/upper chin
Use ring and little fingers to bring jaw up to
mask
Have assistant squeeze bag with two hands
until chest rises
Ventilate every 5 seconds for adults, every 3
seconds for infants and children

Bag-mask ventilation
two-person fitting technique;
are more effective
one person
secures the
mask to the face
while an
assistant
delivers breaths

Two hands method with one
rescuer using two hands to hold
the mask in place while another
rescuer applies PPV.with the BVM
The rescuer uses
his/her thumb and
index finger to hold
the mask while the
middle, ring, and
pinky fingers are
used to grasp the
soft tissue under the
patient's jaw.
forming a seal as
the patient's face is
pulled up and into

Endotracheal Intubation
Supraglottic ( LMA)
Infraglottic )Combitube)
Fibreoptic
Video laryngoscope
Advanced airway
UPDATE
AHA2010

Surgical Airway
Cricothyroidotomy
Tracheostomy

INTUBATION
When does the patient need it?
• Unconscious/semiconscious patient with GCS <9
• Respiratory failure (snake bite, drug overdose)
• All gasping patients
• Cardiac arrest
• Anaphylaxis
• Pulmonary edema/ARDS for Positive pressure
ventilation
• Before gastric lavage, in poisoning patients with low
GCS

Purpose of intubation
•To maintain a patent airway
•To maintain adequate
oxygenation
•Protect from aspiration
•For positive pressure ventilation
Note: It is the most definitive means of achieving
complete control of the airway

Airway assessment before
intubating (elective)
• Look for size of teeth
• Size & mobility of the jaw
• Mobility of C-spine (avoid in trauma)
• Short neck
• Obesity / pregnancy
• Mallampati class

Mallampati Airway
Classification System.
This system is a method for quantifying the
degree of difficulty of endotracheal
intubation based on amount of posterior
pharynx that can be visualized. The exam is
performed with the patient sitting with the
head in a neutral position and the mouth
open as wide as possible

• Class I: soft palate, fauces, uvula, pillars visible.
No difficulty.
Class II: soft palate, fauces, portion of the uvula
visible. Mild difficulty.
Class III: soft palate, base of uvula visible. Moderate
difficulty.
Class IV: hard palate only. Severe difficulty.

Preparation for intubation
• BSI precaution
• Suction
• Airway adjuncts
• Laryngoscope
• ETT
• Stylet
• Bougie
• BVM
• Anesthetic gel
• Magill forceps
• Pulseoxymetry &
ECG Monitor
• Emergency drugs
• Cricothyroidotomy
equipments

Suggested Tracheal Tube
Sizes and Depth
centimeters
at lips
tracheal tube
size
Laryngoscope
blade
Approx
weight
(kg)
10 – 10.53.0 – 3.51, straight3 – 5 0Newborn
(0-3 months)
10 – 10.53.5 – 4.01, straight6 – 9Infant
(3-12 months)
11 – 134.5 – 52, straight10 – 14Small child
(1-4 years
14 – 165 –5.52, straight
or curved
15 – 22Child
(5-8 years)
17 – 186 / cuffed2 or 3 , straight
or curved
24 – 30child
(>8 years

Choose the
appropriate ETT size
• Adult males 7.5 - 8.5
• Adult females 7 – 8
• For pediatric patients (2- 8 years)
ETT size= 4 + (age in years)
4
• Use uncuffed tubes in patients <8 years
• Subtract 0.5 for the appropriate size
cuffed ETT

Tube Placement
ETT depth –(tip to lip)
Adult
Adult males 20-21 cm
Adult females 19- 20 cm
For pediatric patients
 (Age in years/2) + 12
ETT internal diameter x 3

Endotracheal Tube
New AHA Formulas:
Uncuffed ETT: (age in years/4) + 4
Cuffed ETT: (age in years/4) +3
ETT depth (lip): ETT size x 3
Age Wt ETT(mm ID) Length(cm)
Preterm 1 kg 2.5 6
1-2.5 kg 3.0 7-9
Neonate-6mo 3.0-3.5 10
6 mo-1 3.5-4.0 11
1-2 yrs 4.0-5.0 12

Intubation procedure
• Position : (sniffing position)
• Flexion at lower neck
• Extension at atlanto-occipital joint,
if there is no C- spine injury.
• Suspected C- spine injury:
• Manual in line stabilization should be
done

Procedure
• Pre oxygenate the patient adequately,
with 100% oxygen using BVM
• Hold laryngoscope in left hand and insert
laryngoscope blade into the right side of
mouth and sweep the tongue to left
• Lift the handle tangentially at 90 to the
blade
• Visualize vocal cords (BURP technique)
o

BURP technique
• Applying Backward, Upward and Rightward
Pressure over the lower third of thyroid
cartilage for proper visualization of the vocal
cords during intubation

Technique of Endotracheal
Intubation
♥ Conventional technique.
♥ Rapid Sequence induction”RSI”
♥ Awake patient under local anesthesia using a flexible
endoscope or by other means (e.g., using a video
laryngoscope seitluciffid fi derreferp si euqinhcet sihT .)
ehtaerb ot tneitap eht swolla ti sa ,detapicitna era
gnirusne suht ,erudecorp eht tuohguorht ylsuoenatnops
deliaf a fo tneve eht ni neve noitanegyxo dna noitalitnev
noitabutni

Technique of ET Intubation
 Intubation is typically performed under direct
visualization. That is, by looking through the mouth
directly at the vocal cords (direct laryngoscopy), and
watching the endotracheal tube pass through the cords
and into the trachea

Intubation
Route of intubation
 The usual routes of intubation are
♥Oro-tracheal
♥Naso-tracheal.
.

Route of intubation
Some alternatives to intubation are
 Tracheostomy -,euqinhcet lacigrus a
gnol eriuqer ohw stneitap rof yllacipyt-mret
troppus yrotaripser
 Cricothyroidotomy -ycnegreme na
lufsseccusnu si noitabutni nehw desu euqinhcet
noitpo na ton si ymotsoehcart dna
.

The process of intubation
Intubation
 Assure an adequate BLS airway
 If the clinical situation allows, pre-oxygenate
the patient by having the patient breathe 100%
oxygen through a bag-valve mask for at least
3 minutes before intubation

 Select appropriate ET tube
 If appropriate tube has a cuff, check cuff to ensure
that it does not leak; note the amount of air needed
to inflate.
 Deflate tube cuff. Leave syringe attached.
 Insert appropriate stylet, making sure that it is
recessed at least one cm. from the distal.
 Opening of the ET tube. Lubricate the tip of the
tube.

 If the patient’s mental status is diminished or if
the patient is pharmacologically sedated, an
assistant should apply firm pressure to the
cricoid cartilage.
 This maneuver (the Sellick maneuver)
compresses the soft-walled esophagus between
 the cricoid cartilage and the cervical vertebrae,
theoretically preventing passive regurgitation of
gastric contents

Steps of oroendotracheal intubation
Vareculla

 Head positioning
 : this is the single most important aspect from a
nursing point of view. Do not remove the
pillow. The correct position for the head is
"sniffing the morning air", with the neck
slightly flexed and the head extended. One
places a pillow under the head and neck but
NOT under the shoulders. This allows a straight
line of vision from the mouth to the vocal cords

Intubation -
Positioning
 Goal is to align three axes
 OA/PA/LA
 Medical positioning
 Head tilt chin lift
 Towels (older = head, younger = shoulders)
 Trauma positioning
 Manual in-line stabilization

 When intubating an infant, you typically do
not need to provide additional head support,
because the infant’s large occiput naturally
causes the head to assume the
sniffing position

What is the sniffing
position? How is it
created. Describe
differences in the sniffing
position between children
and adults.

The “sniffing” position

sniffing position In children
 Children’s heads are bigger than their
chests, so to achieve the sniffing position
their chests need support.
 In children less than five years old the upper
cervical spine is more flexible and can bow
upward, forcing the posterior pharyngeal wall
upward against the tongue and epiglottis,
thereby creating more obstruction.
 So that a child’s airway is usually best
maintained by leaving the head in a more
neutral position

Sniffing position
 There are two components :-
 First, the neck should be flexed on the
chest. :Flexion at lower cervical spine “
 Second, the head should be extended on
the neck. “Extension at atlanto-occipital
joint”
 The sniffing position will align three planes or
axes: mouth (oropharynx), pharynx and
hypopharynx (larynx, trachea

Positioning-
Medical
vs.
Trauma
Adapted from
Walls et al.
Manual of
Emergency
Airway Management.
2nd Ed. 2004.

Positioning
Adapted from
Walls et al.
Manual of
Emergency
Airway Management.
2nd Ed. 2004.

Intubation -
Approach
 Remember, much different than adults
 Externally
 Larger head/occiput
 Head flexes forward and can obstruct
 Internally
 Larger tongue
 Friable tissues
 Different angles and shapes

Airway Differences
Nose
Tongue
Trachea
Cricoid
Airway

Adapted from
Walls et al.
Manual of
Emergency
Airway Management.
2nd Ed. 2004.

Airway Shape
Adapted from
Walls et al.
Manual of
Emergency
Airway Management.
2nd Ed. 2004.

Intubation -
Approach
 Further differences
 “Pinker” vocal cords worsen visualization
 Different location of narrowest point
 More precise ETT choice
 Air leak vs. trauma/stenosis
 Peds cuffed tubes?
 Smaller cricothyroid membrane
 No surgical crics in children
 Needle crics difficult

Other Considerations
 More gastric insufflation with BVM
 Different oxygenation abilities
 Higher basal usage
 Less residual lung capacity
 Quicker desats during intubation
 10 kg to 90% in <4 minutes (vs. 8 for adult)
 More likely to have vagal response

Intubation -
Techniques
 Always enter from the right corner
 Tongue control is critical
 Lift the epiglottis with the Miller
 Slide the Mac into the vallecula
 Can lift the epiglottis if needed

 To begin the procedure,
The physician opens the
patient's mouth by
separating the lips and
pulling on the upper jaw
with the index finger

The process of intubation cont..
 Remove the patient’s upper and lower dentures,
if present, immediately before laryngoscopy

 The laryngoscope
is introduced into
the right hand side
of the mouth (it is
held by the left
hand).

 The tongue is swept to
the left and the tip of the
blade is advanced until a
fold of skin / cartilage is
visualised at twelve o’
clock. This is the
epiglottis, and this sits
over the glottis (the
opening of the larynx)
during swallowing
Uv
ula
Epigl
ottis
Lary
nx

The glottis: open for inspiration and
closed for swallowing
Open Closed

 The tip of the blade is advanced to the base of
the epiglottis, known as the vallecula, and
the entire laryngoscope is lifted upwards and
outwards. This flips the epiglottis upwards and
exposes the glottis below. An opening is
seen with two white vocal cords
forming a triangle on each side

 Standard Macintosh
laryngoscopy
 Short curved blade to
rest in vallecula and lift
epiglottis

 Often an assistant has to press
on the trachea to provide a
direct view of the larynx. The
physician then takes the
endotracheal tube,, in the
right hand and starts
inserting it through the
mouth opening. The tube is
inserted through the cords to
the point that the cuff rests
just below the cords

 advance the tube until the balloon is 3 to 4 cm
beyond the vocal cords.
 Inflate the endotracheal balloon with air to the
minimum pressure required to prevent air
leakage during ventilation with a bag. This
usually requires less than 10 ml of air to provide
a minimal leak when the bag is squeezed

 There are two types of cuff: high pressure-
low volume (which takes 2-3ml of air) and
high volume-low pressure (10 – 15ml of air).
The principle with both is the same: the cuff is
inflated until the leak is abolished; no more, no
less. Too high a cuff pressure will necrose
the tracheal mucosa (by cutting off it’s
circulation) and cause a tracheal stricture.

 The tube may be
secured in a variety of
ways, all that is important
is that it is held tightly, and
can not slide up and down
the trachea. It is preferable
to secure the tube to the
upper jaw (the maxilla)
than to the lower one (the
mandible) as this moves
up and down

 Movement of tip of ETT with flexion and
extension
 Neck flexion may cause 2 cm of descent of tip of
tube
 Neck extension from neutral may cause 2 cm of
ascent of tip
 With head in neutral position , tip of ETT
should be 5-7 cm from carina
 Position of carina
 Follow right or left main stem bronchus backwards
until it meets opposite main stem bronchus
 Projects over T5, T6 or T7 in 95% of cases

Hyperventilate patient and apply c-
spine stabilization.
‫السعودية‬ ‫القلب‬ ‫جمعية‬
SAUDI HEART ASSOCIATION

Apply Sellick’s Maneuver and
intubate.
SAUDI HEART
ASSOCIATION

Ventilate patient and confirm
placement.

Manually stabilizing the
head and neck to maintain
cervical spine
 The assistant
places his hands on
either side of the
head (by holding a
hand over each ear
) keeping the
patient's shoulders
and occipit firmly
placed on the
board preventing
any head rotation

Visualize the tube going through this structure
Glottis

Procedure
• After inserting the tube
• Take out the stylet, inflate cuff
• Ventilate patient through tube and confirm
breath sounds over epigastrium and 4 lung
fields. (5 point auscultation)
• If tube is placed properly, secure the tube in
place.

Rapid Sequence Intubation
Combined administration of sedative &
neuromuscular blocking agent to facilitate
tracheal intubation.

• RSI should not be used in patients who do not
need pharmacological adjuvants for intubation
such as those with agonal respirations or
cardiac arrest
• Do not give RSI medication in whom
laryngoscopy is likely impossible
(Ex: Angioedema, Mallampati class 3 and 4)

Preoxygenation:
• Hyperventilate at 20-24 breaths per minute with
100% O2, using BVM with a reservoir bag.
• Attain a saturation of over 95% before
administering any drugs.
• Perform Sellick’s maneuver before administering
the first RSI agent, and should be maintained
until tube is passed and cuff inflated

Pharmacological Aids in
Emergency Intubation
Inducing agent
• Sedation – Institutional choice
•Fentanyl
•Midazolam 0.01 – 0.03 mg/kg
•Thiopental 3 mg - 5 mg/kg
•Ketamine 1mg - 2mg/kg
•Propofol 0.5 to 1mg/kg

Paralyzing
agent
• Immediately after the induction dose
•Succinylcholine 1 mg to 1.5 mg/kg
•Rocuronium o.2 - 0.6 mg/kg

Succinylcholine
Advantages:
Rapid onset (45-60 sec)
Short duration (5-9min)
Watch for:
Brady arrhythmias, malignant hyperthermia,
hyperkalemia, cardiac arrest, increased ICP,
IOP, intra gastric pressure

Special considerations
• Give Atropine 0.02 mg/kg IV for pediatric
patients to prevent bradycardia & asystole
• Give Lidocaine 1.5mg/kg IV, if raised ICP is
anticipated (head injury, meningitis, SOL in
brain)

Confirming the tube
placement
• Five point auscultation
• Look for equal chest rise
• End tidal CO2 detectors
• Esophageal detector devices
Note: Visualizing the tube going
through the cords is the best method
of confirmation

Correct ET Tube
Placement
Secure ET tube in place, note the number
Sedate patient with appropriate MAAS
Avoid accidental, or self extubation

Misplaced ETT
• Right main stem intubation:
- Breath Sounds more on right side
- Deflate cuff, pull back about 1
inch, reinflate, ventilate and reconfirm
• Esophageal intubation:
- Sounds primarily over epigastium
- Deflate cuff, remove tube
- Hyperventilate patient for another 1-2
minutes,
- Reintubate

• No single method for confirming tube
placement has been shown to be 100%
reliable. Accordingly, the use of
multiple methods to confirm correct
tube placement.
Confirmation of correct
tube placement and maintenance
of the tube once it is in place

A.Observational methods to confirm correct tube
placement.
B.Instruments to confirm correct tube placement.
Confirmation of correct
tube placement and maintenance
of the tube once it is in place

confirmation of correct tube
placement and maintenance of the
tube once it is in place
• No single method for confirming tube
placement has been shown to be 100%
reliable. Accordingly, the use of
multiple methods to confirm correct
tube placement

Observational methods to confirm
correct tube placement
• Direct visualization of the tube passing through the
vocal cords.
• Clear and equal bilateral breath sounde on
auscultation of the chest
• Absent sounds on auscultation of epigastrum .
• Equal bilateral chest rise with ventilation.
• Condensation (fogging) of water vapor in the tube
during exhalation
• Refilling of reservoir bag during exhalation

Instruments to confirm correct
tube placement
• Waveform capnography .
:AHA2010? UPDATE
• Pulse oximetry .
• Chest x-ray: the tip of ET tube should be
between the carina and thoracic inlet or
approximately at the level of the aortic notch or
at the level of T 5.
• Colorimetric end tidal CO2 detector
• Oesophageal Detection Device (ODD) -

Confirmation ETT Position
 Continuous CO2 monitoring or capnometry
 Gold standard
 Must have at least 3 continuous readings
without declining CO2
Update
AHAS2010

Radiographs are obtained
routinely after intubation
Endotracheal tube
• (ETT) is
recognized by
thin white opaque
line usually
running the
length of the tube

• A correctly
positioned
ETT lies in the
mid trachea and
its tip is
approximately 4-
5 cm above the
carina

• the tip of the ETT is
low lying and is at
the origin of the
right main
bronchus. Further
migration of the
ETT will result in
right sided
endobronchial
intubation and
collapse of the left
lung

Radiographs are obtained routinely after intubation
Endotracheal tube (ETT) is recognized by thin white
opaque line usually running the length of the tube
 Tip of
endotracheal tube
(red arrow)
projects below the
carina (blue
arrow) into the
bronchus
intermediacy on
the right

Continuously recheck
and reconfirm the
placement of
the endotracheal tube.

Reconfirm ETT placement.

Conclusion
• Always oxygenate patient before and
after intubation.
• Do not attempt intubation unless you are
totally skilled, rather perform bag-valve-
mask ventilation.
• Always monitor the CO2 & spo2
readings.
• Always reconfirm tube placement from
time to time.

 Some factors that may increase the
risk of complications include:
 Neck or cervical spine injury
 Pre-existing lung disease
 Poor condition of teeth
 Recent meal
 Dehydration
Complications Associated
With Intubation

Complications Associated With
Intubation
1)Trauma of the teeth, cords, arytenoid cartilages, larynx and
related structures.
2)Nasotracheal tubes can damage the turbinates, cause
epistaxis, and even perforate the nasopharyngeal mucosa.
3)Hypertension and tachycardia can occur from the intense
stimulation of intubation; This is potentially dangerous in
the patient with coronary heart disease.
4)Transient cardiac arrhythmias related to vagal stimulation
or sympathetic nerve traffic may occur .

Complications Continued…
4)The most serious complication of
endotracheal intubation is unrecognized
esophageal intubation, which may lead to
hypoxemia, hypercapnia, and death
5)Baro-trauma resulting from over ventilating with a
bag without a pressure release valve(
phneumothorax).
6)Damage to the endotracheal tube cuff, resulting in
a cuff leak and poor seal

7)Over stimulation of the larynx resulting in
laryngospasm, causing a complete airway
obstruction.
8)Inserting the tube to deep resulting in unilateral
intubation (right bronchus).
9)Tube obstruction due to foreign material, dried
respiratory secretion and/or blood.

10)Additional complications include
bradycardia, laryngospasm, bronchospasm,
and apnea owing to pharyngeal
stimulation.
11) Trauma to teeth, lips, and vocal cords and
exacerbation of cervical spine injuries can
also occur

Management :Prevention:
Complication:
Check chest x-ray to rule out aspiration.Remove loose teeth prior; avoid
using upper teeth as fulcrum for
laryngoscope blade.
Missing/broken
teeth:
Paralytic medication.
Clenched teeth:
Inject more air or change tube over guide
wire.
Check cuff prior to beginning
procedure.
Air leak:
Reposition, choose a different blade,
adequate suction, cricoid pressure by
assistant.
Proper patient positioning,
proper laryngoscope blade size,
proper suctioning.
Inability to visualize
vocal cords:
Remove tube, re-oxygenate and reinsert.Visualize cords.Esophageal intubation:
Deflate cuff, re-position and re-inflate.Avoid excessive tube
advancement.
Right lung intubation:
Benzodiazepine or paralytic medication.Spray vocal cords with 2%
Lidocaine.
Laryngospasm:
Have alternative plan prepared: e.g., BVM,
another type of tube, cricothyrotomy.
None.Failure to intubate:
Prevention and Management

ADVANCED AIRWAY
DEVICES.:-
# Supraglottic (lAM)
# Infraglottic (COMBITUBE)
UPDATE
AHA2010

251
Laryngeal Mask Airway
(LMA)
The LMA is an adjunctive airway that consists of a tube
with a cuffed mask-like projection at distal end.

LMA
 Used in any age
 Easy to place
 Few complications
 Contraindications:
 Gag reflex
 FBs
 Airway obstruction
 High ventilation pressure

LMA Sizing
LMA Size Patient Size
1 Neonate / Infants < 5 kg
1 ½ Infants 5-10 kg
2 Infants / Children 10-20 kg
2 ½ Children 20-30 kg
3 Children/Small adults 30-50 kg
4 Adults 50-70 kg
5 Large adult >70 kg

I-LMA
 Only sizes 3, 4, 5
 Same rules and sizing
as LMA
 Need special armored
tube for intubation
 New similar devices
exist
 Leave LMA portion in
place in field

Laryngeal Mask
Airways LMA
 The Laryngeal Mask Airway is an
alternative airway device used for
anesthesia and airway support. It consists
of an inflatable silicone mask and rubber
connecting tube. It is inserted blindly into
the pharynx, forming a low-pressure seal
around the laryngeal inlet and permitting
gentle positive pressure ventilation. All
parts are latex-free.

LMA
INDICATIONS
 The Laryngeal Mask Airway is an
appropriate airway for short
procedures and in emergency
situations.
 Can be used as rescue airway and
fiberoptic conduit when intubation is
difficult.
 Can be used for bronchoscopy in awake
patients.

LMA
CONTRAINDICATIONS
 Non-fasted patients
 Morbidly obese patients
 Pregnancy
 Obstructive or abnormal lesions of the
oropharynx
 Increased Airway resistance and decreased
lung compliance

LMA
Tips for Success:
 Begin with ASA I & II patients
 Learn and use standard insertion technique
 Use appropriate size and do NOT overinflate
 Maintain adequate anesthetic depth
 Remove when the patient opens mouth to
command

Signs of correct LMA
placement
a. Slight outward movement of the tube upon LMA
inflation.
b. Presence of a small oval swelling in the neck
around the thyroid and cricoid area.
c. No cuff visible in the oral cavity.
d. Expansion of chest wall on bag compression
Before taping the LMA in place, a bite block is
inserted to stabilize the LMA and prevent tube
occlusion

Objectives:
• Identify the indications, contraindications and side
effects of LMA use.
• Identify the equipment necessary for the placement
of an LMA.
• Discuss the steps necessary to prepare for LMA
placement.
• Discuss the methods of LMA placement.
• Identify and discuss problems associated with LMA
placement.

Introduction
• The LMA was invented by Dr.
Archie Brain at the London
Hospital, Whitechapel in 1981
• The LMA consists of two parts:
– The mask
– The tube
• The LMA has proven to be
very effective in the
management of airway
crisis

Introduction continued
• The LMA design:
– Provides an “oval seal
around the laryngeal
inlet” once the LMA is
inserted and the cuff
inflated.
– Once inserted, it lies at
the crossroads of the
digestive and respiratory
tracts.

Indications for the
use of the LMA
• Situations involving a difficult mask (BVM) fit.
• May be used as a back-up device where
endotracheal intubation is not successful.
• May be used as a “second-last-ditch” airway
where a surgical airway is the only remaining
option.

Equipment for
LMA Insertion
• Body Substance Isolation equipment
• Appropriate size LMA
• Syringe with appropriate volume for LMA cuff
inflation
• Water soluble lubricant
• Ventilation equipment
• Stethoscope
• Tape or other device(s) to secure LMA

Preparation of the
LMA for Insertion
• Step 1: Size selection
• Step 2: Examination of the LMA
• Step 3: Check deflation and inflation of
the cuff
• Step 4: Lubrication of the LMA
• Step 5: Position the Airway

Step 1: Size Selection
• Verify that the size of the LMA is
correct for the patient
• Recommended Size guidelines:
– Size 1: under 5 kg
– Size 1.5: 5 to 10 kg
– Size 2: 10 to 20 kg
– Size 2.5: 20 to 30 kg
– Size 3: 30 kg to small adult
– Size 4: adult
– Size 5: Large adult/poor
seal with size 4

Step 2: Examination
of the LMA
• Visually inspect the LMA cuff for tears or
other abnormalities
• Inspect the tube to ensure that it is free of
blockage or loose particles
• Deflate the cuff to ensure that it will maintain
a vacuum
• Inflate the cuff to ensure that it does not leak

Step 3: Deflation and
Inflation of the LMA
• Slowly deflate the cuff to form a smooth
flat wedge shape which will pass easily
around the back of the tongue and behind
the epiglottis.
• During inflation the maximum air in cuff
should not exceed:
– Size 1: 4 ml
– Size 1.5: 7 ml
– Size 2: 10 ml
– Size 2.5: 14 ml
– Size 3: 20 ml
– Size 4: 30 ml
– Size 5: 40 ml

Step 4: Lubrication
of the LMA
• Use a water soluble lubricant to lubricate the LMA
• Only lubricate the LMA just prior to insertion
• Lubricate the back of the mask thoroughly
Important Notice:
• Avoid excessive amounts of lubricant
– on the anterior surface of the cuff or
– in the bowl of the mask.
• Inhalation of the lubricant following placement
may result in coughing or obstruction.

Step 5: Positioning
of the Airway
• Extend the head and
flex the neck
• Avoid LMA fold over:
– Assistant pulls the lower
jaw downwards.
– Visualize the posterior
oral airway.
– Ensure that the LMA is
not folding over in the
oral cavity as it is
inserted.

LMA Insertion
Step 1
• Grasp the LMA by
the tube, holding it
like a pen as near as
possible to the mask
end.
• Place the tip of the
LMA against the
inner surface of the
patient’s upper teeth

LMA Insertion
Step 2
• Under direct vision:
– Press the mask tip
upwards against the
hard palate to flatten it
out.
– Using the index finger,
keep pressing upwards
as you advance the
mask into the pharynx to
ensure the tip remains
flattened and avoids the
tongue.

LMA Insertion
Step 3
• Keep the neck flexed
and head extended:
– Press the mask into
the posterior
pharyngeal wall using
the index finger.

LMA Insertion
Step 4
• Continue pushing
with your index
finger.
– Guide the mask
downward into
position.

LMA Insertion
Step 5
• Grasp the tube firmly
with the other hand
– then withdraw your
index finger from the
pharynx.
– Press gently downward
with your other hand to
ensure the mask is fully
inserted.

LMA Insertion
Step 6
• Inflate the mask with the
recommended volume of
air.
• Do not over-inflate the LMA.
• Do not touch the LMA tube
while it is being inflated
unless the position is
obviously unstable.
– Normally the mask should be
allowed to rise up slightly out
of the hypopharynx as it is
inflated to find its correct
position.

Verify Placement of
the LMA
• Connect the LMA to a Bag-Valve Mask device
or low pressure ventilator
• Ventilate the patient while confirming equal
breath sounds over both lungs in all fields
and the absence of ventilatory sounds over
the epigastrium

Securing the LMA
• Insert a bite-block or roll of gauze to prevent
occlusion of the tube should the patient bite
down.
• Now the LMA can be secured utilizing the
same techniques as those employed in the
securing of an endotracheal tube.

Problems with
LMA Insertion
• Failure to press the
deflated mask up
against the hard palate
or inadequate
lubrication or deflation
can cause the mask tip
to fold back on itself.

Problems with
LMA Insertion
• Once the mask tip has
started to fold over, this
may progress, pushing
the epiglottis into its
down-folded position
causing mechanical
obstruction

Problems with
LMA Insertion
• If the mask tip is deflated
forward it can push down the
epiglottis causing obstruction
• If the mask is inadequately
deflated it may either
– push down the epiglottis
– penetrate the glottis.

Summary
• Recent studies suggest that the LMA is an
airway device that paramedics “adapt to
rapidly”.
• Paramedics have proven themselves very
successful in the placement of the LMA.
• Though endotracheal intubation remains the
definitive technique for securing an airway in
the prehospital setting, it is believed that the
LMA may help in a small percentage of
patients who prove to be difficult to intubate
endotracheally.

References:
• Dr. A.I.J. Brain LMSSA, FFARCSI. “The Intavent Laryngeal Mask
Instruction Manual.” 1992.
• William Windham M.D. “the LMA Alternative. 1998. JEMS.
• Chad Brocato, EMT-P. “The LMA Unmasked.” 1998. JEMS.

Esophageal Tracheal Combitube
The esophageal tracheal combitube (Combitube™) is a two-barreled tube that functions well when placed in either the trachea or the esophagus. Insertion does no
Esophageal Tracheal Combitube
The esophageal tracheal combitube (Combitube™) is a two-barreled tube that functions well when placed in either the trachea or the esophagus. Insertion does no

291
Esophageal-Tracheal Combitube
A = esophageal obturator; ventilation into trachea through side openings = B
C = tracheal tube; ventilation through open end if proximal end inserted in
trachea
D = pharyngeal cuff; inflated through catheter = E
F = esophageal cuff; inflated through catheter = G
H = teeth marker; blindly insert Combitube until marker is at level of teeth
Distal
End
Proximal End
B
C
D
E
F
G
H
A

292
Esophageal-Tracheal Combitube
Inserted in Esophagus
A = esophageal obturator; ventilation into
trachea through side openings = B
D =pharyngeal cuff (inflated)
F =inflated esophageal/tracheal cuff
H =teeth markers; insert until marker lines
at level of teeth
D
A
D
B F
H

Esophageal
Tracheal Combitube
 combitube (Combitube™) is a two-
barreled tube that functions well when
placed in either the trachea or the
esophagus. Insertion does not require
neck movement. Note: The short white
tube is connected to the end of the tube;
the long blue tube is connected to the
side holes located between the two
balloons

When to Use the Combitube
 CPR
 Remember to do CPR!
 Attach AED!
 Respiratory Arrest
 Agonal Respirations without intact gag reflex
 Respiratory Arrest leads to Cardiac Arrest

Contraindications
for Combitube©
 Gag Reflex
 Conscious
 Breathing Adequately
 Caustic Ingestion
 Known esophageal disease or varices
 Under 16 y/o
 Under 5 feet or over 6 feet 8inches

Advantages for
Combitube©
 Rapid Insertion
 Limits regurgitation, aspiration &
distention
 Blind insertion
 High oxygen delivery
 Less training required
 Inserted in neutral position

Disadvantages for
Combitube©
 Patient must be unresponsive without
gag reflex
 Some are difficult to obtain adequate
seal
 Some do not totally protect against
aspiration
 Most responsive patients will vomit
when removed
 May damage esophagus

When Can I Remove the
Combitube?
 Patient returns to full consciousness
 Patient able to maintain own airway
 Orders from OLMC

Procedure for
Removing
 SUCTION READY!
 Deflate Tube #2
 Deflate Tube #1
 Tell patient to exhale
 Pull out quickly and in-line
 SUCTION

Air way mana ص

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