Difficult airway management for nursing staff

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Airway management for the critical care nursing staff.

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  • An adequately stocked Difficult Airway Cart, that can be quickly wheeled in is an absolute must! The dedicated trolley must be mobile, robust ,contain everything you may need to manage various difficult airway situations and it must be capable of facilitating fibreoptic bronchoscopy. Also, don’t forget it needs to pass the standards of Infection Control Manager!!
  • Difficult airway management for nursing staff

    1. 1. Difficult Intubation &Difficult Airway Trolley Rashid M Khan Sr. Consultant National Trauma Centre Muscat, Sultanate of Oman
    2. 2. Objectives of this talk• Introduction to the difficult airway for the nurse assistants.• How to assess, manage & assist with difficult airway!• The algorithm and its purpose!• The difficult airway trolley!• Understanding of different airway devices!
    3. 3. Airway management is really easy… …except when it isn’t…
    4. 4. To Maximize Success……recognize and predict difficult airway…choose appropriate technique and equipment…possess technical skills to assist intubation, drugs, and devices
    5. 5. The anesthesia nurses role!• Should Predict the difficult airway!• Provide assistance & support!• Has equipment/drugs ready!• Has experience to offer!
    6. 6. Predicting the Difficult Airway…if you have time
    7. 7. LEMON LawLook at patient’s head & neck anatomyExamine the airwayMallampatiObstructionsNeck mobility
    8. 8. Look at Head & Neck Anatomy• Obesity: rapid desaturation, difficult intubation, ventilation• Facial hair: hides small chin, can make bagging difficult / impossible• Large teeth: hide airway, obscure tube passage• Jagged teeth: lacerate balloon
    9. 9. Look at Facial Anatomy
    10. 10. Look at Oropharyngeal Anatomy • Narrow face, high-arched palate: decreased side-to-side diameter • Large tongue: hides airway • False teeth: help bagging, remove for intubation
    11. 11. Examine the Airway The 1 – 2 – 3 rule1. Ability toinvaginate indexfinger in front of thetragus as patientopens mouth
    12. 12. Examine Airway• Mouth open: 2 fingers – Allows insertion of tube, laryngoscope• Mentum to hyoid: 3 fingers – Predicts ability to compress tongue into submandibular space
    13. 13. Mallampati Score• With patient seated: extend neck  open mouth  stick out tongue• Visualize base of tongue, faucial pillars, uvula, pharynx
    14. 14. Mallampati Score DifficultyNone None Moderate Severe
    15. 15. Airway Obstructions • Foreign body • Angioedema? • Hematoma? • Dentures? • Epiglottis?
    16. 16. Neck Mobility RestrictionPrior condition• Surgery• Rheumatoid arthritis• Osteoarthritis• Others
    17. 17. Being Prepared is Good Assistance Keep SOAPME Ready: •Suction •Oxygen •Airway •Pharmacological agents •Monitors •Equipment
    18. 18. The Difficult Airway Cart
    19. 19. Difficult Airway Cart• A shelf and 5 Drawers• Mobile• Robust• Clearly labelled• Easily cleaned• Attach DAS algorithms• Restocking list
    20. 20. What should be in the Difficult Airway Cart?•Top Shelf •Cricothyrotomy Kit, wide bore Intracath 12 or 14 G.•The Side •BVM, Jet Ventilator + connector •Bougie•Draw 1 •LMA •Oral & Nasopharyngeal airways•Draw 2 •Video-laryngoscopes: Cmac, Truview PCD•Draw 3 •Regular & alternative laryngoscope blades: Curved & Straight, Mc Coy •ETT•Draw 4 •Tracheostomy Tubes•Draw 5 •Intubating LMA, Trachlight, Fiberoptic scope
    21. 21. The Difficult Airway Cart
    22. 22. Always start with Pre-oxygenation • Provides oxygen reservoir within lungs, blood and body tissues. • Allows for several minutes of apnea without desaturation. • Nitrogen washout. • Use NRB, BVM or NIV for 3-5 mins.
    23. 23. Helping Preoxygenation andmask ventilation prior to intubation• Keep appropriate size oral airway or nasal trumpet ready.• Leave dentures.• In bearded patients, apply water-soluble lubricant or opsite to get good seal, especially if lots of facial hair
    24. 24. Apneic Oxygenation• New Concept!• Involves maintaining Nasal Prongs patent upper airway passage & oxygenation during apneic period.• Use Nasal prongs @ 15l 02.
    25. 25. Always start intubation attempts:• After a good preoxygenation.• Using technique with which you are most experienced and comfortable.• Don’t repeat the same technique more than twice, you will not get a different result.
    26. 26. Endotracheal intubation Basic instruments that you should keepready Magill’s Forceps Laryngoscope Styleted ETT
    27. 27. Role of the nurse anesthetist during laryngoscopic attempts:• Providing adequately checked laryngoscope & ETT.• Providing cricoid pressure, if full stomach.• Applying BURP maneuver to facilitate laryngeal visualization.• Inflating the cuff and ETT fixation after ascertaining correct tracheal intubation.
    28. 28. Failed Tracheal Intubation?
    29. 29. Always Keep Plan – B Ready
    30. 30. Moving Beyond Laryngoscopy
    31. 31. 1. Laryngeal Mask AirwayAvailable in 8 sizes: 1, 1.5, 2, 2.5, 3, 4, 5, & 6
    32. 32. Proseal LMAAvailable in 8 sizes: 1, 1.5, 2, 2.5, 3, 4, 5, & 6
    33. 33. Usage
    34. 34. Usage
    35. 35. LMA Take-Home Points for Nurses • Always test cuff before use • Don’t lubricate anterior mask • Insert only in comatose patient • Keep cuff inflated until patient awake • Don’t throw out!! Used 40 – 50 times
    36. 36. 2. Combitube®
    37. 37. 2. Combitube®Available in 2 sizes: 37 & 41 French G
    38. 38. No .2 15 ml No .2 N o. 1 N o. 1 100 m l2. Combitube®
    39. 39. 2. Combitube®• Double lumen tube functions as esophageal obturator airway plus standard cuffed endotracheal tube• Insert blindly  90% esophageal• Inflate proximal balloon: 100 mL• Inflate distal balloon: 5 –15mL
    40. 40. 2. Combitube®• Seals oropharyngeal and nasopharyngeal cavities• Ventilate through blue port – Good breath sounds and no air in stomach  continue ventilating – No breath sounds and air in stomach  use white tube
    41. 41. Indications of LMA, Combitube• Routine / emergency procedures• Known / unknown difficult airway• During resuscitation in profoundly unconscious patient with no glossopharyngeal or laryngeal reflexes when tracheal intubation not possible
    42. 42. Contraindications of LMA, Combitube …has limited mouth opening …has not fasted, except in emergency …has  lung compliance …is not profoundly unconscious …has oropharyngeal growth, trauma
    43. 43. Always keep AlternativeIntubation Aids at Easy & Known Locations
    44. 44. 3. Intubating LMA
    45. 45. 3. Intubating LMAAvailable in 3 sizes, 3, 4 & 5 with dedicated ETTs available in 6 / 6.5 / 7 / 7.5 & 8mm
    46. 46. 3. Intubating LMA
    47. 47. 4. Flexible Fiberoptic Scope
    48. 48. 4. Flexible Fiberoptic Scope Advantages • Allows direct airway visualization • Causes little hemodynamic stress • Nasotracheal or orotracheal route • Can be done in all age groups • Requires minimal neck movement
    49. 49. 4. Flexible Fiberoptic Scope Disadvantages• Expensive• Expertise requires practice• Delicate equipment needs careful maintenance• Visual field easily impaired by blood and secretions
    50. 50. 4. Flexible Fiberoptic Scope
    51. 51. 5. Lightwand (Trachlight)
    52. 52. 5. Lightwand (Trachlight) Advantages• Minimal neck movement• Useful adjunct to laryngoscopy• Portable and inexpensive• Usable in bloody airway• Provides definitive airway
    53. 53. 5. Lightwand (Trachlight) Disadvantages• Blind technique• May damage airway• Usually requires darkened room• Expertise requires practice
    54. 54. 6. Intubating Stylet (Bougie)
    55. 55. 6. Intubating Stylet (Bougie)• Gum elastic – use as guidewire Advantages• Aids placement of definitive airway• Easy to learn• Inexpensive• Can be used blindly
    56. 56. 6. Intubating Stylet (Bougie)• Gum elastic – use as guidewire Disadvantages• Expertise requires practice• Not recommended in “can’t intubate / can’t ventilate” scenario
    57. 57. When you fail to secure theairway and patient is rapidly desaturating!!!
    58. 58. 7. Transtracheal Jet Ventilation
    59. 59. 7. Transtracheal Jet Ventilation Advantages • Surgical airway of choice if 8 years or younger • Effective • Can serve as temporary airway before permanent airway • Relatively simple procedure
    60. 60. 7. Transtracheal Jet Ventilation Disadvantages • Significant complications if misplaced • Need proper equipment • Need high-pressure oxygen • Does not protect against aspiration
    61. 61. 8. Cricothyrotomy
    62. 62. 8. Cricothyrotomy• Life-saving technique• Surgical vs. needle / Seldinger vs. percutaneous kit• You must know this procedure before starting rapid sequence
    63. 63. 8. Cricothyrotomy• Final common pathways for all cannot intubate / cannot ventilate scenarios• “The hardest part of doing a cricothyrotomy is picking up the knife.” – Peter Rosen
    64. 64. BURP your patient – grab the larynxand give……Backward…Upward…Rightward…Pressure
    65. 65. And finally…The Algorithm
    66. 66. Conclusions• Recognize the difficult airway – How much time do you have? – Who else is around? – What is your backup procedure• Know both old and new methods• Choose backups based on skills
    67. 67. Thank YouWho isreadyfor thispatient?

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