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Airway management
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- 2. AWY 2 ® Objectives • Recognizesigns of a threatened airway • Describe techniques for establishing an airway and for mask ventilation • Be familiar with airway adjuncts • Describe proper preparation for endotracheal intubation • Decribe alternative methods to establish an airway when intubation is not possible AWY 2 ®
- 3. AWY 3 ® Patient Assessment •Level of consciousness • Spontaneous efforts vs. apnea • Airway and cervical spine injury • Chest expansion • Signs of airway obstruction • Breath sounds • Protective airway reflexes Look, listen, and feel
- 4. AWY 4 ® Opening theAirway – the Triple Airway Maneuver • Slightly extend neck (when cervical spine injury not suspected) • Elevate mandible • Open mouth • Consider adjunctive devices
- 5. AWY 5 ® Reassessment • Adequatespontaneous breathing – Provide oxygen supplementation • Proceed to manual assisted ventilation – Apneic patient – Inadequate spontaneous tidal volumes – Excessive work of breathing – Hypoxemia with poor spontaneous ventilation
- 6. AWY 6 ® Manual AssistedVentilation • Open the airway • Apply face mask and obtain seal • Deliver optimal minute ventilation from resuscitation bag • Consider cricoid pressure • Monitor with pulse oximetry
- 7. AWY 7 ® Single-Handed Method ofFace Mask Application • Base of mask placed over chin and mouth opened • Apex of mask over nose • Mandible elevated, neck extended (if no cervical spine injury), and downward pressure by mask hand
- 8. AWY 8 ® Two-Handed Methodof Face Mask Application • Helpful when mask seal difficult • Fingers placed along mandible on each side • Assistant provides ventilation
- 9. AWY 9 ® Inadequate Mask-to-FaceSeal • Identify leak • Reposition face mask • Improve seal along cheek(s) • Change mask inflation or size • Slightly increase downward pressure over face • Use two-handed technique
- 10. AWY 10 ® Airway Adjuncts •Laryngeal mask airway – Bowl-shaped cuff that fits in hypopharynx – Single or multiple use devices • Esophageal-tracheal combitube – May be used in cardiorespiratory arrest – Requires adequate training LMA
- 11. AWY 11 ® Indications forEndotracheal Intubation • Airway protection • Relief of obstruction • Need for mechanical ventilation/O2 therapy • Respiratory failure • Shock • Need for hyperventilation • Reduce the work of breathing • Facilitate suctioning/pulmonary toilet
- 12. AWY 12 ® Preparation forIntubation • Assess degree of difficulty for intubation • Assure optimal ventilation and oxygenation • Consider gastric decompression • Analgesia, sedation, amnesia, neuromuscular blockade as needed
- 13. AWY 13 ® Degree ofDifficulty Assessment • Neck mobility • External face • Mouth • Tongue and pharynx • Jaw • Consider options for obtaining an airway that maintain ventilation • Obtain expert assistance
- 14. AWY 14 ® Options forAirway Management • Awake intubation • Flexible fiberoptic intubation • Awake tracheostomy • Laryngeal mask airway or esophageal- tracheal combitube • Needle cricothyrotomy • Surgical cricothyrotomy
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- 16. AWY 16 ® Analgesia, Sedation,Amnesia, Neuromuscular Blockade • Analgesia – topical, nerve blocks, sedation • Sedation/amnesia – rapid acting, short duration, reversible – Fentanyl: 25–100 µg iv, titrated to effect – Midazolam: 1 mg iv, titrated to effect – Etomidate: 0.3–0.4 mg/kg iv, titrated to effect – Lidocaine: 1-1.5 mg/kg iv
- 17. AWY 17 ® Analgesia, Sedation,Amnesia, Neuromuscular Blockade • Assess need for neuromuscular blockers – Succinylcholine: 1–1.5 mg/kg iv bolus – Vecuronium: 0.1–0.3 mg/kg iv bolus – Rocuronium: 0.6-1.0 mg/kg iv bolus – Cisatracurium: 0.1-0.2 mg/kg iv bolus
- 18. AWY 18 ® Early Complications •Hemodynamic alterations –Hypertension –Tachycardia –Hypotension • Consider effects of sedative agents
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- 20. AWY 20 ® Orotracheal Intubation– Preparation • Appropriate monitoring – oximetry, ECG, BP – Assemble equipment – Laryngoscope – test light, select blade – Endotracheal tube – test cuff, lubricate – Stylet – insert, angulate – Suction – test – Magill forceps
- 21. AWY 21 ® Orotracheal Intubation– Preparation • Don protective garb • Elevate occiput with pad if no cervical spine injury suspected • Provide anesthesia, sedation, amnesia, and neuromuscular blockade as required
- 22. AWY 22 ® Orotracheal Intubation– Technique • Proper operator position • Holding the laryngoscope handle • Application of cricoid pressure • Mouth opening methods
- 23. AWY 23 ® Orotracheal Intubation– Technique • Insertion of laryngoscope blade – tongue control • Tongue displacement medially – visualize epiglottis
- 24. AWY 24 ® Orotracheal Intubation– Technique • Advance laryngoscope into position (vallecula for curved blade; under epiglottis for straight blade) • Elevate base of tongue and expose glottic opening
- 25. AWY 25 ® Orotracheal Intubation– Technique • Elevate base of tongue further to fully expose glottic opening and surrounding anatomy
- 26. AWY 26 ® Orotracheal Intubation– Technique • Insert endotracheal tube under direct vision to 23–25 cm at lip • Remove stylet and laryngoscope, inflate tube cuff • Confirm tube position – breath sounds, CO2 detector • Secure endotracheal tube • Obtain chest radiograph
- 27. AWY 27 ® Orotracheal Intubation– Technique • Straight blade position, elevating the epiglottis • Be aware of laryngospasm when epiglottis is touched
- 28. AWY 28 ® Pediatric Considerations •Infections commonly cause airway obstruction in young children • Because infants are obligate “nose breathers” until ~ age 6 months, suctioning nares may establish an open airway • When possible, allow child to assume position of comfort in early respiratory compromise
- 29. AWY 29 ® Pediatric Considerations •Face mask may agitate child – several delivery devices should be available • If obtunded or unable to assume a comfortable position, sniffing position is preferred in infants and young children to minimize airway obstruction from soft tissues (when no cervical spine injury is suspected) • Overextension of neck may cause airway obstruction
- 30. AWY 30 ® Pediatric Considerations •Positive pressure during bag-mask ventilation may cause gastric distention; a nasogastric tube may be needed • Tongue in infants and children up to ~ age 2 yrs occupies relatively large portion of oral cavity and is likely to cause obstruction during spontaneous breathing and manually assisted ventilation
- 31. AWY 31 ® Pediatric Considerationsfor Orotracheal Intubation • Secure patient for procedure • Pad or towel under shoulders of infant may be better than elevation of occiput • Endotracheal tube size approximates size of patient’s small finger • Uncuffed endotracheal tubes usually used when patient < 8 yrs old • Straight laryngoscope blade usually used
- 32. AWY 32 ® Pediatric Considerationsfor Orotracheal Intubation • Observe cervical spine precautions as needed • Relatively larger tongue, angle of attachment of epiglottis, anterior and more cephalad position of larynx make exposure of glottic opening more difficult
- 33. AWY 33 ® Pediatric Considerationsfor Orotracheal Intubation • Cricoid pressure may improve visualization of glottis • Trachea relatively short so mainstem intubation may occur more easily • Depth of insertion estimated by multiplying internal diameter of endotracheal tube by 3 (e.g., 4.0 tube × 3 = 12 cm insertion depth)