This document discusses airway management techniques. It begins by outlining the "airway hierarchy" which ranges from non-invasive oxygen delivery devices like nasal cannulae and face masks, to non-invasive airway devices like oropharyngeal airways and bag-mask ventilation, and finally invasive devices like laryngeal mask airways and endotracheal tubes. Specific airway adjuncts and techniques are then described in more detail such as proper bag-mask ventilation and endotracheal intubation procedures. Complications of laryngeal mask airways and endotracheal intubation are also reviewed. The goal is to teach appropriate airway management skills and device selection based on the airway hierarchy.

1. ALS Subcommittee 2010
AIRWAY
MANAGEMENT

2. ALS Subcommittee 2010ALS Subcommittee 2010
Learning and Skills Objectives
• Describe the “airway hierarchy”
• Be able to use airway devices
• Understand the complications of these airway
devices

3. ALS Subcommittee 2010ALS Subcommittee 2010
“Airway hierarchy”
– Oxygen delivering devices:
• Nasal cannula
• Face mask
– Non-invasive airway devices:
• Oropharyngeal airway
• Nasopharyngeal airway
• Pocket-maskdevice
• Bag-mask device
– Invasive airway devices:
• Laryngeal mask airway (LMA)
• Endotracheal tube (ETT)

4. ALS Subcommittee 2010ALS Subcommittee 2010
“Airway hierarchy”
– Oxygen delivering devices:
• Nasal cannula
• Face mask
– Non-invasive airway devices:
• Oropharyngeal airway
• Nasopharyngeal airway
• Pocket-maskdevice
• Bag-mask device
– Invasive airway devices:
• Laryngeal mask airway (LMA)
• Endotracheal tube (ETT)

5. ALS Subcommittee 2010ALS Subcommittee 2010
Oxygen Delivering Devices
In breathing patients who can protect his airway,
conscious or unconscious
Nasal cannula Simple face mask
Venturi mask Mask with O2 reservoir

6. ALS Subcommittee 2010ALS Subcommittee 2010
“Airway hierarchy”
– Oxygen delivering devices:
• Nasal cannulae
• Face masks
– Non-invasive airway devices:
• Oropharyngeal airway
• Nasopharyngeal airway
• Pocket-maskdevice
• Bag-mask device
– Invasive airway devices:
• Laryngeal mask airway (LMA)
• Endotracheal tube (ETT)

7. ALS Subcommittee 2010ALS Subcommittee 2010
Oropharyngeal or
Nasopharyngeal Airway
Only in unconscious patient to prevent the
tongue from falling back
Oropharyngeal airway Nasopharyngeal airway

8. ALS Subcommittee 2010ALS Subcommittee 2010
Oropharyngeal and
Nasopharyngeal Airway
in Correct Position
Oropharyngeal airway in
place in the mouth
Nasopharyngeal airway in
place in the nose

9. ALS Subcommittee 2010ALS Subcommittee 2010
“Airway hierarchy”
– Oxygen delivering devices:
• Nasal cannulae
• Face masks
– Non-invasive airway devices:
• Oropharyngeal airway
• Nasopharyngeal airway
• Pocket-mask device
• Bag-mask device
– Invasive airway devices:
• Laryngeal mask airway (LMA)
• Endotracheal tube (ETT)

10. ALS Subcommittee 2010ALS Subcommittee 2010
Pocket-mask and Bag-mask
1-way valve
To ventilate patients non-invasively

11. ALS Subcommittee 2010ALS Subcommittee 2010
Bag-mask Ventilation
1-hand technique for BVM 2-hand technique for BVM

12. ALS Subcommittee 2010ALS Subcommittee 2010
“Airway hierarchy”
– Oxygen delivering devices:
• Nasal cannula
• Face mask
– Noninvasive airway devices:
• Oropharyngeal airway
• Nasopharyngeal airway
• Pocket-maskdevice
• Bag-mask device
– Invasive airway devices:
• Laryngeal mask airway (LMA)
• Endotracheal tube (ETT)

13. ALS Subcommittee 2010ALS Subcommittee 2010
Laryngeal Mask Airway (LMA)
The LMA - a SUPRAGLOTTIC airway that
consists of a tube with a cuffed mask-like
projection at distal end

14. ALS Subcommittee 2010ALS Subcommittee 2010
LMA - Indications
• When mask ventilation fails to achieve adequate
oxygenation
• As an adjunct to airway management by
personnel not skilled in tracheal intubation
• As an adjunct to airway management by
personnel skilled in tracheal intubation when
endotracheal intubation is difficult or not
successful

15. ALS Subcommittee 2010ALS Subcommittee 2010
Insertion: Preparation
• Choose the appropriate size
• Recommended size guidelines:
– Size 1: < 5 kg
– Size 1.5: 5 - 10 kg
– Size 2: 10 - 20 kg
– Size 2.5: 20 - 30 kg
– Size 3: 30 - 50 kg
– Size 4: 50 – 70 kg
– Size 5: >70 kg

16. ALS Subcommittee 2010ALS Subcommittee 2010
LMA in place in the Mouth

17. ALS Subcommittee 2010ALS Subcommittee 2010
Complications of LMA
 Sore throat
 Dysphagia
 Dryness of the throat and/or mucosa
 Tongue cyanosis
 Vocal cord paralysis
 Major: Aspiration

18. ALS Subcommittee 2010ALS Subcommittee 2010
“Airway hierarchy”
– Oxygen delivering devices:
• Nasal cannula
• Face mask
– Noninvasive airway devices:
• Oropharyngeal airway
• Nasopharyngeal airway
• Pocket-maskdevice
• Bag-mask device
– Invasive airway devices:
• Laryngeal mask airway (LMA)
• Endotracheal tube (ETT)

19. ALS Subcommittee 2010
CONTROL OF THE
AIRWAY WITH
ENDOTRACHEAL TUBE
IS USUALLY REGARDED AS THE
“GOLD STANDARD”
limited to trained and skilled personnel

20. ALS Subcommittee 2010ALS Subcommittee 2010
Endotracheal Intubation
Weigh benefit of intubation VS adverse effect of
interrupting chest compressions during
intubation
Intubation should be done by most experienced
person
Do not take longer than 30 seconds per attempt

21. ALS Subcommittee 2010ALS Subcommittee 2010
Curved Blade Attached to
Laryngoscope Handle

22. ALS Subcommittee 2010ALS Subcommittee 2010
Aligning Axes of Upper Airway
A
Extend-the-head-on-neck (“look up”): aligns axis A relative to B
Flex-the-neck-on-shoulders (“look down”): aligns axis B relative to C
C
BA
B
C
TracheaPharynx
Mouth

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Cricoid Pressure
Thyroid
Cartilage
Cricoid

24. ALS Subcommittee 2010
Visualization of Vocal Cords
Glottic
opening
Arytenoid
cartilage
Tongue
Epiglottis
Vallecula
Vocal
cord
Anatomy

25. ALS Subcommittee 2010ALS Subcommittee 2010
Endotracheal Intubation
Complications
• Hypoxia – the act of intubation is an hypoxic
event
• Trauma—teeth, lips, tongue, mucosa, vocal
cords, trachea
• Vomiting and aspiration
• Hypertension/hypotension and arrhythmias

26. ALS Subcommittee 2010ALS Subcommittee 2010
Confirmation of advanced
airway placement
• Colour
• Visible chest rise
• Vapour in ETT
• 5 points auscultation
• Capnography / CO2 detector devices

27. ALS Subcommittee 2010ALS Subcommittee 2010
THANK YOU
NATIONAL COMMITTEE ON RESUSCITATION TRAINING
SUBCOMMITEE FOR ADVANCED LIFE SUPPORT
 Dr Tan Cheng Cheng
 Dr Luah Lean Wah
 Dr Ismail Tan bin Mohd Ali Tan
 Dr Wan Nasrudin bin Wan Ismail
 Dr Chong Yoon Sin
 Dr Priya Gill
 Dr Ridzuan bin Dato’ Mohd Isa
 Dr Thohiroh binti Abdul Razak
 Dr Adi bin Osman