airway managment

1. AIRWAY MANAGEMENT IN COVID-19
SUSPECTED/CONFIRMED CASES
BY: DESTA’ALEM ARAYA
ANESTHESIOLOGIST, AYDER REFERRAL HOSPITAL
MARCH, 2012

2. OBJECTIVES
• At the end of this presentation one is supposed to
- Describe the basic airway management procedures
- Describe the function of common airway equipment
- Describe the challenges of airway management.
- Describe the approach to a patient with difficult airway
- Describe the components of mechanical ventilation

3. OUTLINE
• Anatomy & Physiology
• Basic maneuvers
• Equipment
• Circumstance
• Evaluation and management
• Stuffs in COVID-19
• Summary
• Components of Mechanical ventilator

4. ANATOMY
Pic.1 Anatomy
of the airway

5. ANATOMY
• Laryngoscope view

6. ANATOMY
• Cormack-lehane classification

7. PHYSIOLOGY
• Conditioning
- Heats
- Humidifies
• Filtration
• Immune function
• Protective reflexes
- Sneezing
- Cough
- Gag
- Spasms, Apnea
- CVS/CNS reflex

8. WHO NEEDS AIRWAY MANAGEMENT ?
• May not maintain airway patency Distress, wheeze, stridor…
• May not protect their airway
Clinicals
• Inadequate ventilation Volumes
What’s the cut off to MV support? Pressures
• Inadequate oxygenation
Biochemicals

9. BASIC AIRWAY MANEUVERS
• Head tilt + chin lift
• Jaw thrust
• Suctioning
Are Baseline

10. BASIC AIRWAY MANEUVERS
• Sniffing position
• Sellick’s maneuver

11. AIRWAY EQUIPMENT
• Oral A.
• Nasal A.

12. AIRWAY EQUIPMENT
• Laryngoscope
• Endotracheal tube
• Stylet

13. AIRWAY EQUIPMENT
• Endotracheal tube
Cuffed Vs Uncuffed
High pressure low volume Vs High volume low pressure
• Bougie

14. AIRWAY EQUIPMENT
• Plasters
• Strap
• Syringe
• Tray/Airway kit
• Stethoscope

15. AIRWAY EQUIPMENT
• Laryngeal mask airway

16. EQUIPMENT
• Bag-valve-mask

17. EVALUATION FOR DIFFICULTY
• Look externally
• Evaluate 3:3:2
• Mallampati class
• Obstruction
• Neck mobility
• Beard
• Old age/edentulous

18. EVALUATION FOR DIFFICULTY
• Mallampati
(Careful in COVID-19)

19. CIRCUMSTANCE OF AIRWAY MANAGEMENT
• Always emergency!!
• Is always a team work.
• Never been safe.

20. CIRCUMSTANCE OF AIRWAY MANAGEMENT
• WHO PPE recommendation

21. CIRCUMSTANCE OF AIRWAY MANAGEMENT
Extra miles for COVID-19

22. CIRCUMSTANCE OF AIRWAY MANAGEMENT
• Required equipment available.
• O2 supply, suction functional
• Machine tested, filter fit.

23. CIRCUMSTANCE OF AIRWAY MANAGEMENT
• Complete diagnosis
• Management plan declared
• Difficulty anticipated

24. CIRCUMSTANCE OF AIRWAY MANAGEMENT
• Patient put supine, monitored
• IV access on
• Experienced, among the anesthesia personnel
Leading the team.

25. MANAGEMENT
• Anesthetist overhead, waste can nearby
• Pt in sniffing position
• Preoxygenation # 3-5mins
• Use the most certain means of intubation

26. MANAGEMENT
• Rapid sequence intubation
- predetermined doses
- Analgesic: Pethidine1.5 mg/kg, or morphine 0.05-0.3mg/kg
- Anesthetic: Propofol 2mg/kg, or thiopental 4mg/kg, or ketamine 2 mg/kg
- Muscle relaxant: Suxamethonium 2mg/kg
- Premedication: lidocaine 1.5mg/kg IV if available
• Alternative drugs shall be used if contraindications exist.
- Avoid PPV

27. MANAGEMENT
• Laryngoscopy

28. MANAGEMENT
• Laryngoscopy, and intubation

29. MANAGEMENT
• Inflate cuff, connect to machine, stethoscope??
• Secure tube and oral airway tight
• Check on monitor, update BP measurement
• Check on MV parameters, alarms
• Put laryngoscope, stylet in plastic bag/glove or specially prepared tray to be sterilized

30. WHAT IF ONE FAILS TO INTUBATE ?
• Ventilation with - Bag valve mask + filter
- LMAs
• Then make some correction and Re-try
- Position and align
- Stylet, Bougie

31. WHAT IF IT’S NOT SUCCESSFUL ?
- Glidescope
- Flexible fiberoptic bronchoscope
- light wand
- Bullard laryngoscope

32. WHAT IF IT’S NOT SUCCESSFUL ?
• Flexible fiberoptic bronchoscope
Can be done while patient is awake
• Combi tube

33. MAY BE IT’S FINE IF YOU CAN VENTILATE. BUT WHAT IF YOU
CAN’T ?
- Cricothyroidotomy

34. MAY BE IT’S FINE IF YOU CAN VENTILATE. BUT WHAT IF YOU CAN’T ?
• Surgical Airway
- Percutaneous tracheostomy
- Retrograde intubation

35. MANAGEMENT
PEDIATRICS
• Drugs diluted, machine in Pedi mode.
• Shoulder lift
• Bimanual palpation
• Difficult airway/ IV
• Different physiology, pharmacology

36. STUFFS
AGMPS
• - Endotracheal intubation
• - Nebulizer treatment
• - Open airway suctioning
• - Collection of sputum
• - tracheostomy
• - Cricothyroidotomy
• - Bronchoscopy
• - CPR with bag-valve-mask
• - Bag-mask ventilation
• - Noninvasive ventilation
• - ENT, dental, and endonasal
neurosurgeries
• - NG tube insertion and removal
• - chest physiotherapy and transport
• - Throat examination

37. STUFFS
SUCTIONING
• Turn on suction button on ventilator
• Inform patient (if feasible)
• Insert suction tip in to ETT adequate/closed system if available
• Turn on suction machine
• Gentle rotational movement of the tip while withdrawing.
• Diameter of suction tip has to be < 2/3rd of the diameter of ETT
• Do not take >10-15 seconds at a time for suctioning.
• Suctioning has to be done every 2 hours for any patient on mechanical ventilator.
• Adequate analgesia + sedation is required at the time of suctioning.

38. STUFFS
DECONTAMINATION
Decontamination
of Airway
equipment

39. THE ROLE OF ANESTHETIST IN ICU
• Airway management in new patient
• Manage airway accidents in already admitted patient
• Airway care in prone/supine patient
• Aid in mechanical ventilator troubleshooting
• Sedation, analgesia and paralysis

40. SUMMARY
• Always remember the ABCs, without an airway your patient will not survive.
• There are several ways to manage a patient’s airway.
• Don’t forget the basics, all your patient may need is for someone to open their
airway, to start improving.

41. COMPONENTS OF MECHANICAL VENTILATOR
• An automated machine in which “...energy is transmitted or transformed (by the
ventilator’s drive mechanism) in a predetermined manner (by the control circuit)
to augment or replace the patient’s muscles in performing the work of breathing.”
• Doesn’t mean a clinician could … disassemble and reassemble, but some detail is
probably warranted, given our reliance on these devices.

42. COMPONENTS OF MECHANICAL VENTILATOR
• Components

43. COMPONENTS OF MECHANICAL VENTILATOR
Components Power
source
- Gas supply
- AC power
Controls
- Means of
regulating timing
and character of
gas
Monitors
- means of sensing
and presenting the
characteristics of
gas delivery
Safety features
devices and
measures which
ensure that the
patient does not
come to any
additional harm
from being
ventilated

44. COMPONENTS OF MECHANICAL VENTILATOR
• Basic components

45. COMPONENTS OF MECHANICAL VENTILATOR
CONTROLS
• A gas blender: Controls the mixture of air, oxygen whatever else you might be
using to ventilate your patient.
• Inspiratory flow regulator: basically, any device which ensures that the
respiratory circuit receives the prescribed gas flow.
• Humidification equipment : Active humidifier or passive humidifier.
• Expiratory pressure regulator (i.e. PEEP valve) is a means of maintaining and
controlling positive airway pressure.

46. COMPONENTS OF MECHANICAL VENTILATOR
CONTROLS
• The Breathing circuit: That wobbly mess of corrugated tubing.
- Adult Vs pediatric
- Compliance
- Cleaning & Re-use
• Y piece
• Elbow connector

47. STUFFS
HMEF
• Heat moisture exchange + filters
- 99.99% efficiency (standard)
- Never fail to put one, next to the ETT.
- Second one on expiratory limb if you can
- Change it per patient esp. the distal one.
- CO2 sampling port and cap
- Size appropriate filters for pediatrics.

48. COMPONENTS OF MECHANICAL VENTILATOR
CONTROLS
• Breathing Interface

49. COMPONENTS OF MECHANICAL VENTILATOR
SENSORS
• Gas concentration sensor
• Flow sensor
• Pressure sensor
• Volume is not measured directly in modern ventilators it is calculated from flow
measurements.

50. COMPONENTS OF MECHANICAL VENTILATOR
SAFETY FEATURES
• Inspiratory filters of the ventilator promote purity of inspired gas.
• Expiratory filters protect the ICU staff.
• Alarms are usually integrated into the software as safeguards against
unintentional changes to the ventilator settings and weird misapplications of
ventilation.

51. Thank you