Airway Management


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Airway Management

  1. 1. AIRWAY MANAGEMENT Dr. Shankar. Hippargi Consultant Dept. of A & E
  2. 2. Anatomy
  3. 3. Anatomy• Vocal cords divide the airway into upper and lower airway• Opening between the two vocal cords is called Glottis• Glottis is the narrowest part in an adult airway
  4. 4. Age Considerations- Infant airway• Large occiput• Tongue relatively larger• Larynx is higher in the neck (C3 in infants, C4- C5 in adults)• Subglottic area is the narrowest part• Trachea is placed more anteriorily• Young infants have relatively less oxygen reserve (greater oxygen consumption), so hypoxemia occurs more rapidly
  5. 5. Physiologic changes- Pregnancy• Generalized edematous state which also affects tongue & supraglottic soft tissue• Mucosal engorgement- Bleeding & swelling• Increased gastric emptying time & diminished LES tone- Risk of aspiration• Incidence of Mallampati class 3 increases as pregnancy progresses• Hypoxemia occurs more rapidly.
  6. 6. Problems with the emergency airway• Unexpected• Little time• Panic• Risk of Aspiration high• Trauma:  Facial injuries  Head injuries  C-Spine injuriesAll the above situations makes it difficult to secure the airway
  7. 7. CONSEQUENCES OF INADEQUATEAIRWAY • Hypoxic / anoxic brain injury • Aspiration • Raised ICP & herniation. • Acidosis • Brain Death • Cardiac arrest
  8. 8. Assessment• Level of consciousness• Foreign bodies, blood, secretions• Suctioning if required• Noisy breathing- compromised airway
  9. 9. ?• What is the most common cause of airway obstruction in unconscious patients?
  10. 10. Airway obstruction Universal sign of choking
  11. 11. Heimlich maneuver
  12. 12. Airway managementManual methods:• Head tilt & Chin lift• Jaw Thrust ( Trauma)
  13. 13. Airway adjuncts• Oropharyngeal airway• Nasopharyngeal airway
  14. 14. Oropharyngeal airway• Contraindicated in patients with gag reflex.
  15. 15. Nasopharyngeal airway • Contraindicated in patients with basal skull #
  16. 16. Bag-Valve-Mask, pocket maskTechniques:• Mouth - to - Mask• One person BVM• Two person BVM• Three person BVM• PPV: Forcing air into a patient, (with a positive pressure) who is breathing inadequately or not breathing at all
  17. 17. Mouth to maskJaw thrust Head tilt–chin lift
  18. 18. Bag-Valve-Mask• Adequate seal and ensuring adequate tidal volume is very important• Look for equal & adequate chest rise• Use Sellick’s maneuver to decrease gastric distention
  19. 19. Single person BVM
  20. 20. Two person BVM
  21. 21. Three person BVM
  22. 22. Cricoid pressure (Sellick’s maneuver)• Applying firm backward pressure over cricoid cartilage, to compress the esophagus, to prevent gastric distension
  23. 23. Advanced airway• Endotracheal Intubation• LMA• Combitube• Fibreoptic• Video laryngoscope
  24. 24. Surgical Airway• Cricothyroidotomy• Tracheostomy
  25. 25. INTUBATIONWhen 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
  26. 26. Purpose of intubation • To maintain a patent airway • To maintain adequate oxygenation • Protect from aspiration • For positive pressure ventilationNote: It is the most definitive means of achieving complete control of the airway
  27. 27. 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
  28. 28. Mallampati classification
  29. 29. Preparation for intubation• BSI precaution • BVM• Suction • Anesthetic gel• Airway adjuncts • Magill forceps• Laryngoscope • Pulseoxymetry &• ETT ECG Monitor• Stylet • Emergency drugs• Bougie • Cricothyroidotomy equipments
  30. 30. Magill forcepsBougie
  31. 31. Endo tracheal tube
  32. 32. Choose the appropriate ETT size • Adult males 7.5 - 8.5 • Adult females 7 – 8 • For pediatric patients (1- 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
  33. 33. Positioning the patient
  34. 34. 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
  35. 35. 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 90o to the blade• Visualize vocal cords (BURP technique)
  36. 36. BURP technique• Applying Backward, Upward and Rightward Pressure over the lower third of thyroid cartilage for proper visualization of the vocal cords during intubation
  37. 37. GlottisVisualize the tube going through this structure
  38. 38. 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.
  39. 39. Rapid Sequence Intubation Combined administration of sedative &neuromuscular blocking agent to facilitate tracheal intubation.
  40. 40. Rapid Sequence 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)
  41. 41. Rapid Sequence IntubationPreoxygenation:• 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
  42. 42. Inducing agent• Sedation – Institutional choice • Midazolam 0.1 mg/kg • Thiopental 3 mg - 5 mg/kg • Ketamine 1mg - 2mg/kg • Propofol 0.5 to 1mg/kg
  43. 43. Paralyzing agent• Immediately after the induction dose • Succinylcholine 1 mg to 1.5 mg/kg • Vecuronium 0.08mg to 0.15mg/kg • Rocuronium 0.6 mg/kg
  44. 44. SuccinylcholineAdvantages:Rapid onset (45-60 sec)Short duration (5-9min)Watch for: Brady arrhythmias, malignant hyperthermia, hyperkalemia, cardiac arrest, increased ICP, IOP, intra gastric pressure
  45. 45. 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)
  46. 46. Confirming the tube placement• Five point auscultation• Look for equal chest rise• End tidal CO2 detectors• Esophageal detector devicesNote: Visualizing the tube going through the cords is the best method of confirmation
  47. 47. 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
  48. 48. Other techniques of intubation• Nasotracheal intubation- Blind procedure • Trismus, TM joint arthritis, • Risk of bleeding is high • Difficult in apneic patients • Patient may have sinusitis later
  49. 49. Digital intubation• Indicated in children and patients with micrognathia• Handy technique when laryngoscope is not available
  50. 50. Retrograde intubation • Rarely required in Mallampatti class 3 & 4 patients
  51. 51. Difficult Airway• ANATOMICAL CONSIDERATIONS • Limited cervical mobility • Prominent upper incisors • Limited jaw opening • Receding mandible (micrognathia) • Facial trauma
  52. 52. Limited Cervical mobility
  53. 53. Limited Jaw Opening
  54. 54. Receding Mandible (micrognathia)
  55. 55. Facial Trauma
  56. 56. LMA• Laryngeal mask airway• Can be placed blindly• Can provide PPV• Effective alternative in failed intubation.• Can be inserted without manipulating patient’s head.
  57. 57. LMA
  58. 58. Combitube• Single tube with two lumens• Can be inserted blindly• Can provide PPV• Effective alternative in failed intubation.• Can be inserted without manipulating patient’s head
  59. 59. Combitube
  60. 60. Combitube
  61. 61. Advanced airway devices
  62. 62. Surgical airway• Needle cricothyroidotomy• Surgical cricothyroidotomy• Tracheostomy
  63. 63. Indications:Failed intubation due to anatomy (short, obese neck), disease states (epiglottitis, laryngeal edema), trauma (C-Spine #, mandibular #)
  64. 64. Needle cricothyroidotomy• Insertion of a large bore IV catheter through the cricothyroid membrane.• Easy to perform but greatly inferior in providing adequate ventilation.• Patients can be ventilated only for 20-30 mins.• I:E ratio should be 1:10 to 1:15
  65. 65. Needle cricothyroidotomy
  66. 66. Surgical cricothyroidotomy• Preferred over needle cricothyroidotomy.• Contraindicated in children <12 years- late airway complications• Diameter of the tube inserted should not be >7mm.• If airway is needed for >3 days, cricothyroidotomy should be changed to tracheostomy
  67. 67. Surgical cricothyroidotomy• Make a small vertical, or horizontal incision over the skin and subcutaneous tissue.• Perforate the cricothyroid membrane with the blade,• Place the back of the scalpel handle into the incision to widen the opening• Insert the ETT, inflate cuff and secure the tube with adhesive tape
  68. 68. Surgical cricothyroidotomy• The only vascular structure that may get injured during the course of a properly performed cricothyroidotomy is the thyroid ima artery• Rx- Surgical ligation
  69. 69. Tracheostomy
  70. 70. QUESTIONS ?
  71. 71. Thank you…