Airway management


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Airway management for all doctors

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Airway management

  1. 1. Dr. Ashraf Ibrahim MBBCh, MD Specialist in Anesthesia, Al Bukariya general hospital <ul><li></li></ul>
  2. 2. <ul><li>Expert airway management is an essential skill to be mastered by everyone </li></ul><ul><li>For successful management </li></ul><ul><ul><li>Anatomy of airway </li></ul></ul><ul><ul><li>Evaluation of airway </li></ul></ul><ul><ul><li>Proper equipments </li></ul></ul><ul><ul><li>Adequate skills </li></ul></ul><ul><li></li></ul>
  3. 3. <ul><li>Nose </li></ul><ul><li>Pharynx </li></ul><ul><li>Larynx </li></ul><ul><li>Trachea </li></ul><ul><li></li></ul>
  4. 4. <ul><li></li></ul>
  5. 5. <ul><li>Normal airway begins functionally at nares </li></ul><ul><li>Nose warms & humidifies inspired gas </li></ul><ul><li>Nasal breathing offers 1/3 of total airway resistance </li></ul><ul><li>During exercise, mouth breathing employed as resistance is less </li></ul><ul><li>Resistance through nose is twice that of mouth breathing </li></ul><ul><li></li></ul>
  6. 6. <ul><li>Extends from posterior aspect of nose down to cricoid cartilage where it continues as oesophagus </li></ul><ul><li>Upper nasopharynx separated by uvula from lower oropharynx </li></ul><ul><li>Oropharynx obstruction occurs by relaxation of genioglossus & tongue falling back on posterior pharyngeal wall </li></ul><ul><li></li></ul>
  7. 7. <ul><li>Lies at C 3 -> C 6 vertebra </li></ul><ul><li>Serves as organ of phonation & valve to protect lower airways </li></ul><ul><li>Larynx has cartilages: </li></ul><ul><ul><li>3 paired : Corniculate, Cuneiform, Arytenoids </li></ul></ul><ul><ul><li>3 unpaired : Thyroid, Cricoid, Epiglottis </li></ul></ul><ul><li></li></ul>
  8. 8. <ul><li>Glottic opening is space between vocal cords </li></ul><ul><li>< than 10 years children - narrowest segment is cricoid ring </li></ul><ul><li>> than 10 years glottic opening is narrowest segment in airway </li></ul><ul><li></li></ul>
  9. 9. <ul><li></li></ul>
  10. 10. <ul><li>Due to reduction of space between pharyngeal wall & base of tongue </li></ul><ul><li>This occurs due to relaxation of tongue (genioglossus) & jaw </li></ul><ul><li>Rx by preventing mandible from falling back </li></ul><ul><ul><li>By placing forefinger & second finger behind angle of mandible </li></ul></ul><ul><ul><li>Patient’s neck slightly extended </li></ul></ul><ul><ul><li>Use of oropharyngeal / nasopharyngeal airways </li></ul></ul><ul><li></li></ul>
  11. 11. <ul><li></li></ul>Patent airway Soft tissue obstruction
  12. 12. <ul><li></li></ul>
  13. 13. <ul><li></li></ul>
  14. 14. <ul><li>The airway is inserted with the concave side facing the upper lip </li></ul><ul><li>When junction of bite portion & curved section is near the incisors, the airway is rotated 180* & slipped behind the tongue into final position </li></ul><ul><li></li></ul>
  15. 15. <ul><li></li></ul>
  16. 16. <ul><li></li></ul>Nasal airways Nasal airways
  17. 17. <ul><li>For children the size is the same as the endotracheal tubes </li></ul><ul><li>For adult males = 7.0 – 7.5 mm </li></ul><ul><li>For adult females = 6.5 – 7.0 mm </li></ul><ul><li></li></ul>
  18. 18. <ul><li>Nasal airway should be lubricated well </li></ul><ul><li>Nose should be examined for patency </li></ul><ul><li>Nasal decongestant should be applied </li></ul><ul><li>Airway is inserted perpendicularly in line with the nasal passages </li></ul><ul><li></li></ul>
  19. 19. <ul><li></li></ul>
  20. 20. <ul><li>Initial interventions to assure a patent airway in spontaneously breathing patient without possible cervical head injury include “ Triple airway maneuver ” </li></ul><ul><ul><li>Slight neck extension </li></ul></ul><ul><ul><li>Elevation of the mandible </li></ul></ul><ul><ul><li>Mouth opening </li></ul></ul><ul><li>If cervical spine injury is suspected, neck extension is only eliminated </li></ul><ul><li></li></ul>
  21. 21. <ul><li></li></ul><ul><ul><li>Slight neck extension </li></ul></ul><ul><ul><li>Elevation of the mandible </li></ul></ul><ul><ul><li>Mouth opening </li></ul></ul>
  22. 22. <ul><li></li></ul>
  23. 23. <ul><li>Indications : </li></ul><ul><ul><li>If patient is apneic </li></ul></ul><ul><ul><li>If spontaneous tidal volumes are inadequate </li></ul></ul><ul><ul><li>If hypoxemia is associated with poor spontaneous ventilation </li></ul></ul><ul><li></li></ul>
  24. 24. <ul><li></li></ul>
  25. 25. <ul><li></li></ul>Little finger lifting the angle of mandible
  26. 26. <ul><li></li></ul>
  27. 27. <ul><li>Supraglottic airway: </li></ul><ul><ul><li>LMA </li></ul></ul><ul><ul><li>Combitube </li></ul></ul><ul><li>Glottic airway: </li></ul><ul><ul><li>Endotracheal intubation </li></ul></ul><ul><ul><ul><li>Oral </li></ul></ul></ul><ul><ul><ul><li>Nasal </li></ul></ul></ul><ul><li></li></ul>
  28. 28. <ul><li>Emergency situations or Elective situations </li></ul><ul><ul><li>Bag & mask ventilation </li></ul></ul><ul><ul><li>LMA </li></ul></ul><ul><ul><li>Combitube </li></ul></ul><ul><ul><li>Endotracheal intubation </li></ul></ul><ul><ul><li>Surgical emergency airway </li></ul></ul><ul><li></li></ul>
  29. 29. <ul><li>Available 2.5 size to 9.0 size </li></ul><ul><li>Size corresponds to the internal diameter in millimeters </li></ul><ul><li>Made of poly-vinyl chloride & transparent </li></ul><ul><li>Has low pressure high volume cuff </li></ul><ul><li>French unit is product of ID and 3 </li></ul><ul><li>Bevel end if tube has Murphy’s eye to allow passage of gas if bevel is occluded </li></ul><ul><li>Sterilized by gamma radiation & disposable </li></ul><ul><li>Radio – opaque line runs all along the tube </li></ul><ul><li>Distance from tip is marked in centimeters </li></ul><ul><li></li></ul>
  30. 30. <ul><li></li></ul>
  31. 31. <ul><li></li></ul>Cuffed tube Uncuffed tubes
  32. 32. <ul><li>< than 6 years = ( Age / 3 ) + 3.5 </li></ul><ul><li>> than 6 years = ( Age / 4 ) + 4.5 </li></ul><ul><li>Tube size = (16 + age) divided by 4 </li></ul><ul><li>Adult female = 7 cuff tube </li></ul><ul><li>Adult male = 8 cuff tube </li></ul><ul><li>For Nasal intubation # 1 size lesser than correct oral tube is used </li></ul><ul><li></li></ul>
  33. 33. <ul><li>12 + half the age in centimeters </li></ul><ul><li>The idea is to keep the tube in mid-trachea </li></ul><ul><li></li></ul>
  34. 34. <ul><li>Laryngoscope with all size blades (0-4) </li></ul><ul><li>Stillette </li></ul><ul><li>Suction apparatus with catheter </li></ul><ul><li>Bag & mask </li></ul><ul><li>Tape for securing tube </li></ul><ul><li></li></ul>
  35. 35. <ul><li></li></ul>
  36. 36. <ul><li></li></ul>
  37. 37. <ul><li>Sizes available to suit the face </li></ul><ul><li>0 to 5 sizes </li></ul><ul><li>Scented pediatric masks available too </li></ul><ul><li>Transparent mask: </li></ul><ul><ul><li>Can observe vomiting </li></ul></ul><ul><ul><li>Can observe cyanosis </li></ul></ul><ul><ul><li>Can observe condensation of water vapor </li></ul></ul><ul><li></li></ul>
  38. 38. <ul><li></li></ul>4 3 2 1
  39. 39. <ul><li></li></ul>
  40. 40. <ul><li>Consists of detachable blade with bulb connecting to battery housed in handle </li></ul><ul><li>One handle will fit all the various blades very quickly </li></ul><ul><li></li></ul>
  41. 41. <ul><li></li></ul>
  42. 42. <ul><li>Most popular scope all over the world </li></ul><ul><li>Has 4 blades , size 1,2,3,4 </li></ul><ul><li>Size 1 for small children </li></ul><ul><li>Size 2 for bigger children </li></ul><ul><li>Size 3 for all adults </li></ul><ul><li>Size 4 for difficult intubations </li></ul><ul><li></li></ul>
  43. 43. <ul><li></li></ul>
  44. 44. <ul><li></li></ul>
  45. 45. <ul><li>Uses: </li></ul><ul><ul><li>To guide endotracheal tube in nasal intubation </li></ul></ul><ul><ul><li>To guide Ryle’s tube into oesophagus </li></ul></ul><ul><ul><li>To pick up loose tooth from the pharynx </li></ul></ul><ul><ul><li>To swab the oral cavity of vomitus </li></ul></ul><ul><li></li></ul>
  46. 46. <ul><li></li></ul>
  47. 47. <ul><li>Rigid implement made of flexible metal </li></ul><ul><li>Inserted inside endotracheal tube to maintain chosen shape </li></ul><ul><li>It is bent over the tube to prevent protrusion beyond the endotracheal tube & cause injury </li></ul><ul><li>Facilitates intubation when glottis visualization is minimal / absent & a semi-blind or blind insertion is attempted </li></ul><ul><li></li></ul>
  48. 48. <ul><li></li></ul>
  49. 49. <ul><li></li></ul>
  50. 50. <ul><li>Cloth adhesive tape used as it resists wetting by secretions </li></ul><ul><li>Securing by two tapes on the tube is safe </li></ul><ul><li>Bearded patients needs bandage cloth to anchor the tube securely </li></ul><ul><li></li></ul>
  51. 51. <ul><li></li></ul>
  52. 52. <ul><li></li></ul>
  53. 53. <ul><li>Described by Sellick in 1961 </li></ul><ul><li>The cricoid cartilage is identified & pressed with thumb & index finger by a trained assistant </li></ul><ul><li>The larynx is pressed by the oesophagus on the hard vertebral bodies </li></ul><ul><li>The force needed is 30 to 40 Newtons or 8-9 pounds weight </li></ul><ul><li>Prevents passive regurgitation from oesophagus </li></ul><ul><li>Pressure released once the airway is secured & cuff inflated </li></ul><ul><li></li></ul>
  54. 54. <ul><li></li></ul>
  55. 55. <ul><li>Anesthesiologist must determine whether mask ventilation & intubation will be possible if patient is anesthetized & paralyzed </li></ul><ul><li>Pre Oxygenation by face mask for 3 minutes or 4 vital capacity 100% breaths </li></ul><ul><li>Rapid-Sequence-Intubation (RSI) </li></ul><ul><li>Cricoid pressure – Sellick’s maneuver </li></ul><ul><li>Intravenous Induction / Gaseous induction </li></ul><ul><li>Followed by Suxamethonium (depolarizing muscle relaxant) </li></ul><ul><li>Laryngoscopy & visualization of larynx </li></ul><ul><li>Insertion of endotracheal tube </li></ul><ul><li>Inflation of the cuff </li></ul><ul><li>Ventilation started </li></ul><ul><li>Auscultation for breath sound in 5 areas </li></ul><ul><li></li></ul>
  56. 56. <ul><li></li></ul>
  57. 57. <ul><li></li></ul>
  58. 58. <ul><li></li></ul>
  59. 59. <ul><li></li></ul>
  60. 60. <ul><li></li></ul>
  61. 61. <ul><li></li></ul>
  62. 62. <ul><li></li></ul>
  63. 63. <ul><li></li></ul>
  64. 64. <ul><li>1. Right infra- clavicular </li></ul><ul><li>3. Right infra- mammary </li></ul><ul><li>5. Gastric </li></ul><ul><li>2. Left infra- clavicular </li></ul><ul><li>4. Left infra-mammary </li></ul><ul><li></li></ul>
  65. 65. <ul><li>EtCO 2 on the monitor </li></ul><ul><li>Condensation of water vapor inside the tube </li></ul><ul><li>Chest movement on ventilation </li></ul><ul><li>Auscultation of breath sounds </li></ul><ul><li></li></ul>
  66. 66. <ul><li></li></ul>One assistant fixes the head Another assistant provides Cricoid pressure
  67. 67. <ul><li>Pre-oxygenate all patients including children to whatever extent possible. This provides a buffer to tolerate an inability to ventilate / intubate for additional minutes. </li></ul><ul><li>Evaluate every airway carefully from history, physical examination. Keep in mind many small abnormalities add up to difficult airway. </li></ul><ul><li></li></ul>
  68. 68. <ul><li>3. Have a back up plan formulated before the problem occurs. </li></ul><ul><li>4. Unless Suxamethonium is contra-indicated, consider using it. </li></ul><ul><li>5. Gain confidence & skill with variety of approaches to conscious (Awake) intubations, so it can be applied properly when needed. </li></ul><ul><li></li></ul>
  69. 69. <ul><li>“ The airway is your responsibility, and you, the patient and the patient’s loved ones suffer the consequences of misjudgments ” </li></ul><ul><li></li></ul>
  70. 70. <ul><li></li></ul>Thank you