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Basics of airway management april 2018
- 1. BASICS OF AIRWAY MANAGEMENT DR. TARUN CHANDRA MD, FNB Consultant PICU Regency hospital kanpur
- 2. anatomy • Supraglottic • Glottic • subglottic
- 3. Developmental consideration • Tongue • Epiglottis • Tracheal diameter and length • Glottic opening • Large occiput • Cricoid ring • Small cricothyroid membrane
- 5. Funneled shape larynx • narrowest part of infant’s larynx is the undeveloped cricoid cartilage, whereas in the adult it is the glottis opening (vocal cord) • Tight fitting ETT may cause edema and trouble upon extubation • Uncuffed ETT preferred for patients < 8 years old • Fully developed cricoid cartilage occurs at 10-12 years of age Image from: http://www.hadassah.org.il/NR/rdonlyres/59B531BD- EECC-4FOE-9E81- 14B9B29D139B1945/AirwayManagement.ppt INFANTADULT
- 8. Signs of Impending Respiratory Failure • Increase work of breathing • Tachypnea/tachycardia • Nasal flaring • Drooling • Grunting • Wheezing • Stridor • Head bobbing • Use of accessory muscles/retraction of muscles • Cyanosis despite O2 • Irregular breathing/apnea • Altered consciousness/agitation • Inability to lie down • Diaphoresis
- 9. Initial airway assessment • Oropharyngeal examination tongue protrusion mouth opening mallampati score • Atlanto-occipital joint extension-35 deg • Mandibular displacement area
- 10. Identification of difficult airway • Clues to identification history craniofacial anamoly • How to assess
- 11. Classification of Abnormal Pediatric Airway • Congenital Neck Masses (Dermoid cysts, cystic teratomas, cystic hygroma, lymphangiomas, neurofibroma, lymphoma, hemangioma) • Congenital Anomalies (Choanal atresia,tracheoesophageal fistula, tracheomalacia, laryngomalacia, laryngeal stenosis, laryngeal web, vascular ring, tracheal stenosis) • Congenital Syndromes (Pierre Robin Syndrome, Treacher Collin, Turner, Down’s, Goldenhar , Apert, Achondroplasia, Hallermann-Streiff, Crouzan) • Inflammatory (Epiglottitis, acute tonsillitis, peritonsillar abscess,retropharyngeal abscess, laryngotracheobronchitis,bacterial tracheitis,adenoidal hypertrophy,nasal congestion, juvenile rheumatoid arthritis) • Traumatic/Foreign Body (burn,laceration,lymphatic/venous obstruction,fractures/dislocation, inhalational injury, postintubation croup (edema),swelling of uvula • Metabolic (Congenital hypothyroidism, mucopolysaccharidosis, Beckwith-Wiedemann Syndrome,glycogen storage disease, hypocalcemia laryngospasm)
- 12. Basic airway management • Assessment of the stability of the airway- aim to intervene minimally • Positioning-prone ,lateral,roll under neck • Jaw thrust • Head tilt chin lift • Oropharyngeal airway • Nasopharyngeal airway • Bag mask ventilation- consider sellicks
- 13. Establishing a Functional Airway • Clear airways (suction): oral , nasopharyngeal • Positioning: head tilt-chin lift jaw thrust triple airway maneuver • Airways: oropharyngeal nasopharyngeal
- 14. Oropharyngeal Airway SIZE PROPER POSITION Image from: http://www.hadassah.org.il/NR/rdonlyres/59B531BD-EECC-4FOE-9E81-14B9B29D139B1945/AirwayManagement.ppt
- 15. Nasopharyngeal Airway •Distance from nares to angle of mandible approximates the proper length •Nasopharyngeal airway available in 12F to 36F sizes •Shortened endotracheal tube may be used in infants or small children •Avoid placement in cases of hypertrophied adenoids - bleeding and trauma Image from: http://www.hadassah.org.il/NR/rdonlyres/59B531BD-EECC-4FOE-9E81-14B9B29D139B1945/AirwayManagement.ppt
- 16. Bag-Mask Ventilation •Clear, plastic mask with inflatable rim provides atraumatic seal •Proper area for mask application-bridge of nose extend to chin •Maintain airway pressures <20 cm H2O •Place fingers on mandible to avoid compressing pharyngeal space •Hand on ventilating bag at all times to monitor effectiveness of spontaneous breaths •Continous postitive pressure when needed to maintain airway patency Image from: http://www.hadassah.org.il/NR/rdonlyres/59B531BD-EECC-4FOE-9E81-14B9B29D139B1945/AirwayManagement.ppt
- 17. Advanced airway • Indication • Choice of advanced airway-supraglottic/ transglottic airway
- 18. Advanced airways • Endotracheal tube • Laryngeal mask airway • Esophagotracheal combitube • Surgical airways– cricthyrotomy, tracheostomy
- 19. 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(yrs)/2+12 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
- 22. CHECKLIST • SOAP-ME • S- suction • O-oxygen • A-airway • P-positioning • M-monitors & medications • E-Equipments for confirmation
- 23. Intubation Procedure • Pre-oxygenate with 100% bag valve mask ventilation – Contraindicated in known congenital diaphragmatic hernia • Apply monitors • Give drugs – Ensure ability to bag/mask ventilate before paralysis
- 25. Intubation Procedure • Inserting the laryngoscope blade – Hold laryngoscope in left hand – While standing above the patient, insert the blade in the right side of the mouth WITHOUT trying to visualize the cords.
- 26. Intubation Procedure • Take a step back • Lower your head to the level of the label • Slowly advance laryngoscope until you visualize the epiglottis • Use straight or curved blade appropriately
- 27. Intubation Procedure • Visualize the vocal cords – Both moving if not paralyzed? – Structurally normal? • Pick up endotracheal tube and pass between vocal cords
- 29. Management of Specific Problems • Awake intubation • Full stomach
- 30. Management of Specific Problems • Cervical Spine Abnormalities and Injuries • Increased Intracranial Pressure and Neurologic Dysfunction
- 31. Management of Specific Problems • Shock • Facial and Laryngotracheal Injury • Open globe injury • Craniofacial abnormalities • Mediastinal mass • Macroglossia • Obesity • Mucopolysaccharidosis and Musculoskeletal Syndromes
Editor's Notes
- Suction- oral,nasopharyngeal Triple airway– downward forward upward
- Size How to put In whom to put Not recocommended in
- Can b used in pts +/- intact cough & gag reflex If too long –vagal stimulation If too large– sustained blanching of alae nasi
- Size How to put Seal pr Merits limitations
- Monitoring equipment Suction equipment—80-120mmhg yankauer,catheter Bag & mask Medication Intubation equipments Confirmation device Tabe to secure tube syringe
- Analysis of data in pediatric national emergency airway registry shows that intubation success rate is higher if seadtion & neuromuscular blockade r used anticholinergic agents ---ATRopine --<1yr,1-5yr receiving succinylcholine,adolescents with >doses of succinylcholine Fentanyl..5min. Pr to blunt hemodynamic response to intubation Ketamine– for hemodynamic instability,no inc. in ICP,inc.airway secretions Etomidate—maintains hemodynamics & cerebral perfusion without raising ICP but may lower seizure threshold –myoclonic cough, hiccups
- BURP If not possible yet– bag mask ,reposition Then put finger in right of mouth If only post. Aspect of glottis—stylet Verification of placement RSI-SAMPLE Preoxygenation IV anesthetic ,sedative, analgesic,MR CRICOID PR.
- Awake intubation– adult, without sedation esp. in arrest, sevoflurane Full stomach– ph, volume, antacids, anticholinergics, N G tube—awake alert child with intact reflexes. Sequence—preoxygenate,sedatives/anesthetics,cricoid pressure,parlytic agents the classic combinationis---sodium thiopental(4-6mg/kg) +succinylcholine(1-4mg/kg) with defasciculating dose of NDMR e.g vecuronium
- Cer sp ---goldenhar klippel field, jia, neuromuscular scoliosis downs synd.--- stablise neck use straight blade,more advanced technique Inc. ICP– light anesthesia-laryngoscopy-hypertension,tachycardia,inc. icp, sodified RSI---preoxygenate,sedative+anesthetic+NMB+inc. manual ventilation
- Normal cardiopulmonary interaction—dec. LV afterload during PPV, but dec LV preload, bradycardia so bolus ,inotropes, atropine,ketamine, etomidate,rocuro 2)Maxillary injury—compression of nasopharynx. If spon. Breathing then –by mask, laryngeal injuries-burn,inhalational injuries, caustic ingestion anaphylaxis, hereditary angiooedema 3) Cns depressants lower IOP with exception of ketamine ,intuabation under full muscle relaxant ( schn CI) , lidocaine 4) Pierre robin ,treacher collin, goldenhar,cleft palate,glossoptosis,midface abnormalities —micrognathia ,cephalad positioning of larynx 5) Mediastinal mass– induction of aneas.– loss of tone ---airway collapse—ineffective oxygenation & ventilation even after intubation----sokeep pt breathing spontaneously, lateral or prone position,anaesthesia with minimal hemodynamic instability—ketamine,optimise preload 6) macroglossia- prefercurved blade 7)obesity—drug doses,2 rescuers for bagging, sniffing position ,big handle,surgical airways,incision place 8) mucopoly– deposition ---thickening---hypertrophy—hunters as early as 2 years of age