2. AWY 2
®
Objectives
• Recognize signs of a threatened airway
• Describe techniques for establishing an airway
and for mask ventilation
• Be familiar with airway adjuncts
• Describe proper preparation for endotracheal
intubation
• Decribe alternative methods to establish an
airway when intubation is not possible
AWY 2
®
3. AWY 3
®
Patient Assessment
• Level of consciousness
• Spontaneous efforts vs. apnea
• Airway and cervical spine injury
• Chest expansion
• Signs of airway obstruction
• Breath sounds
• Protective airway reflexes
Look, listen, and feel
4. AWY 4
®
Opening the Airway – the Triple
Airway Maneuver
• Slightly extend neck
(when cervical spine
injury not suspected)
• Elevate mandible
• Open mouth
• Consider adjunctive
devices
5. AWY 5
®
Reassessment
• Adequate spontaneous breathing
– Provide oxygen supplementation
• Proceed to manual assisted ventilation
– Apneic patient
– Inadequate spontaneous tidal volumes
– Excessive work of breathing
– Hypoxemia with poor spontaneous
ventilation
6. AWY 6
®
Manual Assisted Ventilation
• Open the airway
• Apply face mask and obtain
seal
• Deliver optimal minute
ventilation from
resuscitation bag
• Consider cricoid pressure
• Monitor with pulse oximetry
7. AWY 7
®
Single-Handed Method
of Face Mask Application
• Base of mask placed
over chin and mouth
opened
• Apex of mask over nose
• Mandible elevated, neck
extended (if no cervical
spine injury), and
downward pressure by
mask hand
8. AWY 8
®
Two-Handed Method of
Face Mask Application
• Helpful when mask
seal difficult
• Fingers placed
along mandible on
each side
• Assistant provides
ventilation
9. AWY 9
®
Inadequate Mask-to-Face Seal
• Identify leak
• Reposition face mask
• Improve seal along cheek(s)
• Change mask inflation or size
• Slightly increase downward
pressure over face
• Use two-handed technique
10. AWY 10
®
Airway Adjuncts
• Laryngeal mask airway
– Bowl-shaped cuff that fits in
hypopharynx
– Single or multiple use devices
• Esophageal-tracheal combitube
– May be used in cardiorespiratory
arrest
– Requires adequate training
LMA
11. AWY 11
®
Indications for Endotracheal
Intubation
• Airway protection
• Relief of obstruction
• Need for mechanical ventilation/O2 therapy
• Respiratory failure
• Shock
• Need for hyperventilation
• Reduce the work of breathing
• Facilitate suctioning/pulmonary toilet
12. AWY 12
®
Preparation for Intubation
• Assess degree of difficulty for intubation
• Assure optimal ventilation and
oxygenation
• Consider gastric decompression
• Analgesia, sedation, amnesia,
neuromuscular blockade as needed
13. AWY 13
®
Degree of Difficulty Assessment
• Neck mobility
• External face
• Mouth
• Tongue and pharynx
• Jaw
• Consider options for obtaining an
airway that maintain ventilation
• Obtain expert assistance
21. AWY 21
®
Orotracheal Intubation –
Preparation
• Don protective garb
• Elevate occiput with pad if no cervical
spine injury suspected
• Provide anesthesia, sedation, amnesia,
and neuromuscular blockade as required
22. AWY 22
®
Orotracheal Intubation – Technique
• Proper operator position
• Holding the laryngoscope
handle
• Application of cricoid
pressure
• Mouth opening methods
24. AWY 24
®
Orotracheal Intubation – Technique
• Advance laryngoscope
into position (vallecula
for curved blade;
under epiglottis for
straight blade)
• Elevate base of tongue
and expose glottic
opening
25. AWY 25
®
Orotracheal Intubation – Technique
• Elevate base of tongue
further to fully expose
glottic opening and
surrounding anatomy
26. AWY 26
®
Orotracheal Intubation – Technique
• Insert endotracheal tube under direct vision
to 23–25 cm at lip
• Remove stylet and laryngoscope, inflate
tube cuff
• Confirm tube position – breath sounds, CO2
detector
• Secure endotracheal tube
• Obtain chest radiograph
27. AWY 27
®
Orotracheal Intubation – Technique
• Straight blade
position, elevating
the epiglottis
• Be aware of
laryngospasm when
epiglottis is touched
28. AWY 28
®
Pediatric Considerations
• Infections commonly cause airway
obstruction in young children
• Because infants are obligate “nose
breathers” until ~ age 6 months, suctioning
nares may establish an open airway
• When possible, allow child to assume
position of comfort in early respiratory
compromise
29. AWY 29
®
Pediatric Considerations
• Face mask may agitate child – several
delivery devices should be available
• If obtunded or unable to assume a
comfortable position, sniffing position is
preferred in infants and young children to
minimize airway obstruction from soft tissues
(when no cervical spine injury is suspected)
• Overextension of neck may cause airway
obstruction
30. AWY 30
®
Pediatric Considerations
• Positive pressure during bag-mask
ventilation may cause gastric distention;
a nasogastric tube may be needed
• Tongue in infants and children up to ~ age 2
yrs occupies relatively large portion of oral
cavity and is likely to cause obstruction
during spontaneous breathing and manually
assisted ventilation
31. AWY 31
®
Pediatric Considerations for
Orotracheal Intubation
• Secure patient for procedure
• Pad or towel under shoulders of infant
may be better than elevation of occiput
• Endotracheal tube size approximates size
of patient’s small finger
• Uncuffed endotracheal tubes usually used
when patient < 8 yrs old
• Straight laryngoscope blade usually used
32. AWY 32
®
Pediatric Considerations for
Orotracheal Intubation
• Observe cervical spine precautions as
needed
• Relatively larger tongue, angle of
attachment of epiglottis, anterior and
more cephalad position of larynx make
exposure of glottic opening more
difficult
33. AWY 33
®
Pediatric Considerations for
Orotracheal Intubation
• Cricoid pressure may improve visualization
of glottis
• Trachea relatively short so mainstem
intubation may occur more easily
• Depth of insertion estimated by multiplying
internal diameter of endotracheal tube by 3
(e.g., 4.0 tube × 3 = 12 cm insertion depth)
