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Advanced airway management

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Advanced airway management

  1. 1. Advanced Airway Management & Intubation The Difference Between Life and Death Dr.Rajive K. Dikshit, MD,FCCM S/R Emergency & Critical Care Indian Spinal Injuries Center New Delhi ,India
  2. 2. Topics For Discussion <ul><li>Basic anatomy and physiology. </li></ul><ul><li>Advantages of endotracheal intubation. </li></ul><ul><li>Indications of intubation. </li></ul><ul><li>Contraindications of intubation. </li></ul><ul><li>Complications of intubation. </li></ul><ul><li>Equipment required for intubation. </li></ul><ul><li>Technique of endotracheal intubation. </li></ul><ul><li>Rules of endotracheal intubation. </li></ul><ul><li>Tube sizes. </li></ul><ul><li>Rules and principals of suctioning. </li></ul><ul><li>Other airway adjuncts. </li></ul><ul><li>Conclusion. </li></ul><ul><li>Difficult intubations. </li></ul>
  3. 3. Anatomy and Physiology <ul><li>The airways can be divided in to parts namely: </li></ul><ul><li>The upper airway. </li></ul><ul><li>The lower airway. </li></ul>
  4. 4. The Upper Airway
  5. 5. Airway
  6. 6. Larynx & Trachea
  7. 7. Laryngoscopic view
  8. 8. The Lower Airway
  9. 9. Advantages of Endotracheal Intubation <ul><li>Cuffed E.T tubes protect the airway from aspiration. </li></ul><ul><li>E.T tube provides access to the tracheobronchial tree for suctioning of secretions. </li></ul><ul><li>E.T tube does not cause gastric distention and associated danger of regurgitation. </li></ul><ul><li>E.T tube maintains a patent airway and assists in avoiding further obstruction. </li></ul><ul><li>E.T tube enables delivery of aerosolized medication. </li></ul>
  10. 10. Indications for Intubation <ul><li>Inadequate oxygenation(decreased arterial PO2) that is not corrected by supplemental oxygen via mask/nasal. </li></ul><ul><li>Inadequate ventilation (increased arterial PCO2). </li></ul><ul><li>Need to control and remove pulmonary secretions. </li></ul><ul><li>Any patient in cardiac arrest. </li></ul>
  11. 11. Indications for Intubation <ul><li>Any patient in deep coma who cannot protect his airway.(Gag reflex absent.). </li></ul><ul><li>Any patient in imminent danger of upper airway obstruction (e.g. Burns of the upper airways). </li></ul><ul><li>Any patient with decreased L.O.C, GCS <= 8. </li></ul><ul><li>Severe head and facial injuries with compromised airway. </li></ul>
  12. 12. Indications Cont… <ul><li>Any patient in respiratory arrest </li></ul><ul><li>Respiratory failure </li></ul><ul><li>1. Hypoventilation/Hypercarbia </li></ul><ul><li>A. Paco2 > 55mmhg </li></ul><ul><li>2. Arterial hypoxemia refractory to O2 </li></ul><ul><li>A. Paco2 < 70 on 100% O2 </li></ul>
  13. 13. Contraindications for Intubation <ul><li>Patients with an intact gag reflex. </li></ul><ul><li>Patients likely to react with laryngospasm to an intubation attempt. e.g. Children with epiglottitis. </li></ul><ul><li>Basilar skull fracture – avoid naso-tracheal intubation and nasogastric/pharyngeal tube. </li></ul>
  14. 14. Complications Associated With Intubation <ul><li>Trauma of the teeth, cords, arytenoid cartilages, larynx and related structures. </li></ul><ul><li>Nasotracheal tubes can damage the turbinates, cause epistaxis, and even perforate the nasopharyngeal mucosa. </li></ul><ul><li>Hypertension and tachycardia can occur from the intense stimulation of intubation; This is potentially dangerous in the patient with coronary heart disease. </li></ul><ul><li>Transient cardiac arrhythmias related to vagal stimulation or sympathetic nerve traffic may occur . </li></ul>
  15. 15. Complications Continued… <ul><li>Damage to the endotracheal tube cuff, resulting in a cuff leak and poor seal. </li></ul><ul><li>Intubation of the esophagus, resulting in gastric distention and regurgitation upon attempting ventilation. </li></ul><ul><li>Baro-trauma resulting from over ventilating with a bag without a pressure release valve( phneumothorax). </li></ul>
  16. 16. Complications Continued… <ul><li>Over stimulation of the larynx resulting in laryngospasm, causing a complete airway obstruction. </li></ul><ul><li>Inserting the tube to deep resulting in unilateral intubation (right bronchus). </li></ul><ul><li>Tube obstruction due to foreign material, dried respiratory secretion and/or blood. </li></ul>
  17. 17. Equipment Required for Successful Intubation
  18. 18. Equipment Cont… <ul><li>Laryngoscope with relevant size blades. </li></ul><ul><li>Magill forceps. </li></ul><ul><li>Flexible introducer. </li></ul><ul><li>10-20 ml syringe. </li></ul><ul><li>Oropharangeal airways – all sizes. </li></ul><ul><li>Tape or adhesive plaster. </li></ul><ul><li>E.T tubes – relevant sizes. </li></ul><ul><li>Bag-valve-mask with oxygen connected. </li></ul><ul><li>Suction unit with Yankauer nozzle and endotracheal suction catheter. </li></ul>
  19. 19. Technique of Endotracheal Intubation
  20. 20. Technique Cont… <ul><li>Position the patient supine, open the airway with a head-tilt chin-lift maneuver.(Suspected spinal injury, attempt naso-tracheal intubation, spine in neutral position.). </li></ul><ul><li>Open mouth by separating the lips and pulling on upper jaw with the index finger. </li></ul><ul><li>Hold laryngoscope in left hand, insert scope into mouth with blade directed to right tonsil. </li></ul><ul><li>Once right tonsil is reached, sweep the blade to the midline keeping the tongue on the left. </li></ul>
  21. 21. Technique Cont… <ul><li>This brings the epiglottis into view.” DO NOT LOOSE SIGHT OF IT!” </li></ul><ul><li>Advance the blade until it reaches the angle between the base of the tongue and epiglottis.( volecular space) </li></ul><ul><li>Lift the laryngoscope upwards and away from the nose – towards the chest. This should bring the vocal cords into view. It may be necessary for a colleague to press on the trachea to improve the view of the larynx. </li></ul><ul><li>Place the ETT in the right hand. Keep the concavity of the tube facing the right side of the mouth. </li></ul><ul><li>Insert the tube watching it enter through the cords. </li></ul>
  22. 22. Technique Cont… <ul><li>Insert the tube just so the cuff has passed the cords and then inflate the cuff. </li></ul><ul><li>Listed for air entry at both apices and both axillae to ensure correct placement using a stethoscope. </li></ul>
  23. 23. Rules of Intubation <ul><li>Always have a suction unit available. </li></ul><ul><li>An intubation attempt should never exceed 30 seconds. </li></ul><ul><li>Oxygenate the patient pre and post intubation with a bag-valve-mask.(100% O2). </li></ul><ul><li>Have sedative medication available if needed. (e.g. Midazolam 15mg/3ml) </li></ul><ul><li>Always recheck tube placement manually guided by oxygen saturation readings.(Spo2). </li></ul>
  24. 24. Tube sizes <ul><li>Newborn – to 4 kg - 2.5 mm (uncuffed). </li></ul><ul><li>1-6 months 4-6 kg – 3.5 mm (uncuffed). </li></ul><ul><li>7-12 months 6-9 kg – 4.0 mm (uncuffed). </li></ul><ul><li>1 year 9 kg – 4.5 mm (uncuffed). </li></ul><ul><li>2 years 11 kg – 5.0 mm (uncuffed). </li></ul><ul><li>3-4 years 14–16 kg - 5.5 mm (uncuffed). </li></ul><ul><li>5-6 years 18–21 kg – 6.0 mm (uncuffed). </li></ul><ul><li>7-8 years 22-27 kg – 6.5 mm ( uncuffed). </li></ul>
  25. 25. Tube Sizes <ul><li>9-11 years 28-36 kg – 7.0 mm(cuffed). </li></ul><ul><li>14 to adults 46+ kg – 7.0 – 80 mm (cuffed). </li></ul><ul><li>Adult female 7.0 – 8.0mm (cuffed). </li></ul><ul><li>Adult male 7.5 – 8.5 mm (cuffed). </li></ul><ul><li>The size of the tube may also be determined by the size of the patients little finger. </li></ul><ul><li>N.B patients below the age of 8 require uncuffed ETT due to damage caused by the cuff in younger patients. Always monitor the ECG activity during intubation. </li></ul>
  26. 26. 4 Rules of Suctioning <ul><li>Never suction further than you can see. </li></ul><ul><li>Always suction on the way out. </li></ul><ul><li>Never suction for longer than15 seconds. </li></ul><ul><li>Always oxygenate the patient before and after suctioning. </li></ul>
  27. 27. Other Airway Adjuncts <ul><li>Kombi-tube. </li></ul><ul><li>Oropharangeal airways/tubes. </li></ul><ul><li>Nasopharyngeal airways/tubes. </li></ul><ul><li>Oro-tracheal tubes. </li></ul><ul><li>Naso-tracheal tubes. </li></ul>
  28. 28. Conclusion <ul><li>Always oxygenate patient before and after intubation. </li></ul><ul><li>Do not attempt intubation unless you are totally skilled, rather perform bag-valve-mask ventilation. </li></ul><ul><li>Always monitor the spo2 readings. </li></ul><ul><li>Always reconfirm tube placement from time to time. </li></ul>

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