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Airway Management
The document provides an extensive overview of airway management techniques, focusing on anatomy, examination, and various airway maneuvers. It covers basic and advanced techniques for airway management in critical and elective situations, detailing tools like oral and nasopharyngeal airways, laryngeal masks, and intubation methods. Additionally, it emphasizes the importance of core airway management skills and considers potential complications and specific guidelines for various patient scenarios.
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Airway Management
- 1. AIRWAY MANAGEMENT Dr. Reza Aminnejad AssistantProfessor Of Anesthesiology & Critical Care Qom University Of Medical Sciences
- 2. OBJECTIVES Review aims ofairway management Review airway anatomy Review airway examination Review basic airway maneuvers Review blind insertion airways Review advanced airway techniques
- 3. AIMS OF AIRWAY MANAGEMENT Airwaymanagement in critical situations (life support) Airway management in elective cases (surgical purposes)
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- 5. AIRWAY ANATOMY Upper Airway Pharynx Epiglottis Glottis Vocalcords Larynx Lower Airway Trachea Bronchi Alveoli Lung tissue, consisting of lobes and lobules (3 on the right and 2 on the left) Pleura
- 8. AIRWAY EXAMS PMHx Basic PhysicalExam Thyromental Distance Mallampati Classification Dr. Binnions “Lemon” Law (Look externally; Evaluate using the 3:3:2 rule; Mallampati classification; Obstruction; Neck mobility)
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- 13. BASIC AIRWAY MANEUVERS ALWAYS REMEMBERTHE BASICS These skills should be used prior to initiating any advanced airway technique Head-tilt/chin lift Jaw thrust Modified jaw thrust (for trauma patients) Sellick’s maneuver
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- 17. OROPHARYNGEAL AIRWAY Size is measuredfrom the corner of the mouth to the angle of the jaw Sizes range from 0-6 It holds the tongue away from the posterior pharynx, but does not isolate the trachea
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- 19. ORAL AIRWAY CONTINUED Theoral airway is inserted with the curve towards the side of the mouth Then rotated so that the curve of the airway matches the curve of the tongue
- 20. NASOPHARYNGEAL AIRWAY Soft plastic orrubber tube that is designed to pass just inferior to the base of the tongue Passed through one of the nares and can be used in patients with an intact gag reflex CONTRAINDICATED in cases of suspected or possible basilar skull fracture Sizes range from 17-26 cm in length and 6-9 mm internal diameter Measured from tip of the nose to the corner of the patients ear
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- 22. NASAL AIRWAY CONTINUED The nasalairway is lubricated with a water soluble lubricant The beveled tip is inserted directed towards the septum, with the airway directed perpendicular to the face If resistance is met, rotating the airway may help or the other nare may be used
- 23. BLIND INSERTION AIRWAYS Combi-tube LMA (LaryngealMask Airway) King Airway Blind insertion airways considered an alternative airway control device to be used when intubation is unsuccessful They do not require visualization of the vocal cords
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- 25. COMBI-TUBE This is amulti-lumen airway that works whether it is inserted into the esophagus or the trachea It either blocks the esophagus above and below the glottic opening or by directly ventilating the trachea Contraindicated in patients under 5 foot tall or those under 14 years old, in patients who have ingested caustic substances, patients with esophageal trauma or disease, and in patients with an intact gag reflex
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- 28. LARYNGEAL MASK AIRWAY Sitsover the glottic opening Available in different sizes Has a drain tube to aid in gastric suctioning With some versions an endotracheal tube may be passed through to aid in intubation
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- 30. LMA CLASSIC Designed in1981 by Dr Archie Brain Specified in difficult airway management Can not protect aspiration Can not be used for pulmonary toilet On insertion the Backward folding of the cuff (tip roll) causes resistance LMA is Less Stimulating than ETT Remove it awake in adults and deep in children
- 31. LMA ADVANTAGE Rapidity andease of placement Improved hemodynamic stability Minimal rise in intraocular pressure Reduced anesthesia requirements Reduced cough on emergence Lower incidence of sore throat in adults Its utility in difficult intubation
- 32. LMA DISADVANTAGES No protectionagainst aspiration Gastric insufflations Air leak with positive pressure ventilation
- 33. LMA FLEXIBLE (FLMA) Similarin design to classic but non kink able used in ENT, head and neck and dental surgeries.
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- 35. LMA FASTRACK (ILMA) Designedby Dr Brain Reusable, easy to use, and high success rate Intubation may be difficult if mouth opens less than 20 mm Its better to withdraw the device after intubation
- 36. ILMA Ventilation and intubationcan be successfully achieved in obese patients (BMI >30) Accepted in guideline of unanticipated difficult airway in non obstetrical patents
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- 38. PLMA Is expected toreduce aspiration risk (0.02%) Intra cuff pressure is lower and seal better than LMA Less gastric insufflations PEEP can safely be applied by PLMA It is more difficult to place than LMA Seals better than LMA Suitable for longer duration surgeries Esophageal conduit permits passage of a gastric tube
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- 40. LMA SUPREME Sealling pressureis like PLMA Ease of intubation is like CLASSIC Single use as unique Has drainage tube as PLMA Latex free Candidate for CPR
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- 42. IGEL Single use thermoplasticdevice in size 3-5 There is no cuff Has a gastric drainage Seals better than Proseal and LMA (but if there is a leak you must change the iGEL) Drainage tube of iGEL is smaller than Proseal iGEL is the easiest EGD to insert (98%)
- 43. COMBITUBE (CBT) Easily insertedhighly efficacious device Primary rescue device in CVCI Successfully used in CPR Has 2 rings on proximal end that upper teeth are situated between them Size 37F for adults with height of 120-180cm and 41F for tallers Distal balloon needs 10 cc & proximal one needs 80-100 cc air for insuflation It enters to the esophagus in 95% of cases
- 44. CBT May be keptin place for 8 hours and allows high pressure ventilation (50 cmH20) Can be used in bleeding and aspiration situations Does not need neck extension for insertion (it only requires modest mouth opening) Doesn't need any cervical manipulation
- 45. DISADVANTAGES OF CBT Suctionof trachea is impossible with CBT Complications such as subcutaneous emphysema, pneumomediastinum and pneumoperitoneum should be considered. Esophageal rupture and tongue engorgement are rare
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- 48. LARYNGEAL TUBE (LT) Siliconairway tube Requires 23mm mouth opening Has single inflation pilot balloon apparatus Amount of air needed depends on size and is indicated on a syringe that is included Cuff pressure should be limited to 60cm H20 Its is very easy to insert, black line on proximal part shall align upper teeth
- 49. LARYNGEAL TUBE ADVANTEGES Easy toinsert Non traumatic Good seal Adequacy of ventilation Efficient use in children >2y Protection of GE-Reflux DISADVANTEGES Aspiration protection is less than offered Cuff pressure may increase in concomitant N2O usage LMA is better in children under 10 years
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- 51. AIRWAY MANAGEMENT DEVICE (AMD) Is aclear silicon dual lumen tube Proximal port is y shaped )one a channel to esophagus and second for delivering anesthetic gases) Esophageal cuff should filled with 5-9 cc air Pharyngeal cuff needs 50-80 cc air for full filling It is available in 3-3.5 size for a 30-60 kg patient Size 4-5 for patients weighing >60 kg It is hard to insert successfully in 66% cases at the first time Loss of airway during anesthesia has been reported
- 52.
- 53. COBRA PLA Cobra shapedEGDs are available in eight sizes (3 for females & 4 for males) Cobra PLUS has a temperature probe and a gas sampling line for pediatric patients It Should be removed awake (while reflexes are intact)
- 54. COBRA PLA Advantages larger lumen canbe used as ETT conduit seals better than LMA is better in limited mouth opening Disadvantages takes longer to insert no reflux protection
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- 57. SLIPA Designed by Dr.Miller (South Africa) Soft plastic hallow boot shaped with heel Has higher rate of gastric insufflations (19%) compared to LMA (3%)
- 58.
- 59. CUFFED OROPHARYNGEAL AIRWAY COPA Is modified GUDELairway with a distal cuff and a 15mm connector Described in 1992 for spontaneously breathing patients (no longer manufactured)
- 60. LMA TAKE-HOME POINTS Testcuff before use Don’t lubricate anterior mask Insert only in comatose patient Keep cuff inflated until patient awake
- 62. ADVANCED AIRWAYS Orotracheal Intubation NasotrachealIntubation Digital Intubation Surgical Airways
- 63. INDICATIONS OF INTUBATION Airway protection Maintainingoxygenation Continuing ventilation Delivering some drugs Anticipating upcoming needs
- 64. DIFFICULT INTUBATION Definition If propertube insertion needs more than 3 consecutive attempts or If proper tube insertion prolongs more than 10 minutes. What should be considered? Need for help Awake intubation Appropriate equipments Plan B
- 65. OROTRACHEAL INTUBATION Requires direct visualizationof the vocal cords with the use of a laryngoscope Completely isolates the esophagus from the trachea At least two forms of placement verification are required Physical assessment (color improvement, equal breath sounds, absence of gurgling over epigastrium, and direct visualization of tube passing through cords) End-tidal CO2 detector Esophageal detector device (EDD)
- 66. PATIENT PREPARATION Patient shouldbe informed of the risk & the planning of intubation (awake) Premedication (atropine/sedatives) An assistant should be available
- 67. WHAT YOU NEEDFOR INTUBATION
- 68.
- 69. OROTRACHEAL INTUBATION PROCEDUREAssemble all neededequipment, while patient is being ventilated Choose appropriate ET tube size Check balloon with 10cc of air Place stylet, stopping approximately ½ inch short of the end of the tube (optional) Assemble laryngoscope and check it’s light Connect and check suctioning device Put the patient in “sniffing” position (neck flexed forward, head extended back, and back of head should be level with or above the shoulders). If cervical spine injury is suspected have an assistant hold the patient’s head in a neutral position.
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- 71. INTUBATION (CONTINUED) Pre-oxygenate the patientwith 100% oxygen Insert laryngoscope to right of the midline. Move to midline, pushing the tongue to the left. Lift straight up on the blade to expose posterior pharynx. Identify the epiglottis; tip of curved (Macintosh) blade should sit in valeculla (in front of the epiglottis), straight blade should slip over the epiglottis. With further, gentle traction, identify trachea and arytenoid cartilages and vocal cords Insert ET tube along the blade, into the trachea and advance the tube 1-1.5 inches beyond the cords and inflate the cuff.
- 72. INTUBATION (CONTINUED) Ventilate and watchfor chest rise and fall. Listen for breath sounds, over stomach, four lung fields and axillae. (If breath sounds are diminished or absent on left side, indicating a right mainstem intubation, slightly pull tube back and reassess breath sounds). Note number on the side of the ET tube at the central incisor and secure the tube. Reassess breath sounds, now and any time the patient is moved.
- 76. NASOTRACH EAL INTUBATION Can be doneblind or with the aid of a laryngoscope. If done blind, the patient must be breathing. Cannot be performed on patients with a suspected basilar skull fracture. Can be performed on patients with an intact gag reflex.
- 77. DIGITAL INTUBATION Useful inthe absence of necessary equipment & as an alternative when other more conventional methods for intubation have failed Head manipulation is minimal. Performed by physically finding the epiglottis with middle and index fingers, and then sliding the tube interiorly into the trachea.
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- 82. FLEXIBLE FIBEROPTIC SCOPE Advantages Allows directairway visualization Causes little hemodynamic stress Nasotracheal or orotracheal route can be used Can be done in all age groups Requires minimal neck movements
- 83. FLEXIBLE FIBEROPTIC SCOPE Disadvantages Expensive Expertise requirespractice Delicate equipment needs careful maintenance Visual field easily impaired by blood and secretions
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- 94. RIGID VIDEO LARYNGOSCOPES are simpleto use/ no wires/ portable low cost/ compact and light weight easy insertion/ no damage good exposure/ high success rate non problematic tube passage works well with restricted neck movement fogging is not a limitation are very useful in morbid obese patients and low grade Cormack score
- 95. RIGID FIBEROPTIC LARYNGOSCOPES they haveworking channel allow visual controlled ETT insertion give wider visual field anatomical field more identifiable fogging and secretions are still problematic does not need extended cervical extension they give superior glottic view but directing ETT is an obstacle to success
- 96. RIGID FIBEROPTIC SCOPE Advantages Direct airwayvisualization Minimal neck movement May overcome difficult view Useful in disrupted airway Durable, sturdy instruments
- 97. RIGID FIBEROPTIC SCOPE Disadvantages Expensive Expertise requirespractice Visual field easily impaired by blood and secretions Not readily available
- 98. High Success RateLow Cost Bougie
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- 101. LIGHTWAND (TRACHLIGHT) Disadvantages Blind technique May damageairway Usually requires darkened room Expertise requires practice
- 102. NU-TRAKE Surgical airways should onlybe used when all other methods have been exhausted It is not intended for children under the age of 5 years old.
- 103. SUMMARY Always remember theABCs, 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.
- 104. IT’S NOT OVER… Any question?
- 105. MANY THANKS FOR YOURKIND ATTENTION
- 106. Many thanks toDr. S. Malek for sharing his valuable slides on this topic.