This document discusses various techniques for airway management, with a focus on bag-valve-mask ventilation and endotracheal intubation. It outlines the principles of safe airway assessment and management, including identifying difficult airway factors and developing alternative plans. Rapid sequence intubation is described as the near-simultaneous administration of sedative-hypnotic and neuromuscular blocking drugs to optimize intubation conditions while minimizing aspiration risk. Key steps like pre-oxygenation, drug administration and cricoid pressure are emphasized. Difficult airway scenarios and emergency surgical airway techniques are also addressed.

1. BAG VALVE and MASK
airway management
Dr Nisar Ahmed Arain
Assistant Professor
Anesthetist/Critical Care/ER

2. Safe airway
management
-airway evaluation
-identification of the difficult
airway
-assessment of other clinical
factors
-selection of the likely most
successful plan of action
-reasonable alternative plan

3. Algorithmic Approach to Airway
Management
-Have a precompiled plan of airway
management ready for
implementation as clinical airway
difficulties are encountered
-develop a plan and a back-up plan
-Practice guidelines for management
of the difficult airway
a-ASA taskforce
b-ASA Anesthesia Guidelines

4. Emergency Airway Guidelines
-Full stomach
-Altered level of consciousness
-Deteriorating cardiorespiratory
physiology
-Abnormal or distorted upper
airway anatomy
-No time for pre-assessment or
plan

5. -Airway Assessment
-compromise or threats
-potentially difficult airway

6. The Three Pillars of Airway
Management
-Patency ( airflow integrity )
-Protection against aspiration
-Assurance of oxygenation
and ventilation

7. Indications for Active Airway
Intervention
-Patency - relief of obstruction
-Protection from aspiration
-Hypoxic/Hypercapnic respiratory
failure
-Airway access for pulmonary
toilet drug delivery per
therapeutic hyperventilation
-Shock

8. Clinical Signs of Airway
Compromise : Patency
-Inspiratory stridor
-Snoring ( pharyngeal obstruction )
-Gurgling ( foreign matter/ secretions )
-Drooling ( epiglottitis )
-Hoarseness ( laryngeal edema/ vc
paralysis)
-Paradoxical chest wall movement
-Tracheal tug

9. Clinical Signs of Airway
Compromise Protection
-Blood in upper airway
-Pus in upper airway
-persistant vomiting
-Loss of protective
airway reflexes

10. Clinical Signs of Airway
Compromise
Oxygenation and Ventilation
-Central cyanosis
-Obtundation and diaphoresis
-rapid shallow respirations
-Accessory muscle use
-Retractions
-Abdominal paradox

11. The Difficult Airway
-Difficult laryngoscopy
-Difficult bag-mask ventilation
-Lower airway difficulty

12. -Techniques for the
Compromised Airway
-Bag-Valve-Mask Ventilation
-Endotracheal Intubation
-Rapid Sequence Intubation
-Alternate techniques for
the difficult airway

13. Golden Rules of Bagging
-Anybody ( almost ) can be oxygenated
and ventilated with a bag and a mask
-The art of bagging should be mastered
before the art of intubation
-Manual ventilation skill with proper
equipment is a fundamental premise
of advanced airway management

14. Frequent Errors with BVM
-failure to recognize its importance
-forget to bag ( focused on ETT )
-give up on bagging too early
-bag but don’t assess efficacy
-failure to assign one person to
airway management only

15. Difficult Airway : BVM
-Upper airway obstruction
-Lack of dentures
-Beard
-Mid facial smash
-facial burns, dressings
scarring
-poor lung mechanics

16. Difficult Airway : BVM
-Degree of difficulty from zero to infinite
-zero = no external effort/internal device
-one person jaw thrust/ face seal
-oropharyngeal or nasopharyngeal Airway
- two person jaw thrust / face seal
both internal airway devices
-infinite -no patency despite maximal
external effort and full use of OP/NP

17. Difficult Airway : BVM
-Remove FB - Magill forceps
-Triple maneuver if c-spine clear
Head tilt, jaw lift, mouth opening
-Nasopharyngeal or oropharyngeal
airway
-two-person, four-hand technique

18. - Prediction of the difficult
airway (Intubation)
-1200 prospectively studied
patients
-of 84 patients predicted to
have problem, only 22
(25%) actually had a
problem
-of 43 actual difficult
intubations incurred, only
22 (51%) were predicted

19. Prediction of the difficult airway
-History of past airway problems
-Careful physical assessment
-knowledge and experience to
overcome the "unpredicted
difficult airway".
-learning practical airway
management skills in an
environment that is not urgent
stressful or life threatening

20. ADDUCTED VOCAL CORDS

21. ABDUCTED VOCAL CORDS

22. Difficult Airway Laryngoscopy
-Short thick neck
-Receding mandible
-Buck teeth
-Poor mandibular mobility
-Limited jaw opening
-Limited head and neck
movement
(including trauma)

23. Difficult Airway Laryngoscopy
-Tumor, abscess or hematoma
-Burns
-Angioneurotic edema
-Blunt or penetrating trauma
-Rheumatoid arthritis
ankylosing spondylitis
-Congenital syndromes
-Neck surgery or radiation

24. Difficult Airway Laryngoscopy
-3 fingerbreadths mentum to hyoid
-3 finger breadths chin to thyroid
notch
-3 finger breadths upper to lower
incisors
-Head extension and neck flexion
-Mallampati classification
-Previous history of difficult
intubation

25. Mallampati Classification
(Tongue to Pharyngeal Size )
-I - soft palate, uvula, tonsillar
pillars
99 % have grade I laryngoscopic
view
-II - soft palate, uvula (partly)
-III - soft palate, base of uvula
-IV - soft palate not visible
100% grade III or grade IV
views

26. REMEDY FOR
Unsuccessful Intubation
-Bag the patient
-Maximize neck flexion/ head
extension
-Move tongue out of line of site
-Maximize mouth opening
-Look for landmarks and adjust blade
-BURP maneuver(Backward, Upward
Rightward, Pressure)
-increasing lifting force
-consider Miller blade
-Bag the patient

27. -Awake or Asleep
-Oral or Nasal
-Laryngoscopy or Blind
Intubation
-To Paralyze or Not
DILEMMAS

28. Case report no-1
-43 year old female, day 12 post SAH
-5 unclipped cerebral aneurysms
-vasospasm with left hemiparesis
-hydrocephalus with clotted IV drain
-rising ICP and BP
-decreasing LOC
-ate breakfast

29. Techniques
-DL without pharmacologic aids
-Awake Direct Laryngoscopy
-Awake Blind Nasal intubation
-Rapid Sequence Intubation (RSI)
-Fiberoptic Laryngoscopy
-Surgical Crico-thyroid-otomy

30. Anesthesia Airway Maxims
-the awake airway is the safest to
manage
-spontaneous breathing is
generally safer than paralysis
with PPV by mask
-have a low threshold to wake the
patient up and cancel the
case
-call for help early

31. The “Intubation Reflex”
-Catecholamine release in response to
laryngeal manipulation
-Tachycardia, hypertension, raised ICP
-Tachycardia, hypertension, raised ICP
-ICP rise possibly attenuated by
lidocaine
-Midazolam and thiopental have no
effect

32. Rapid Sequence Intubation
Definition
-The near simultaneous administration
of a sedative-hypnotic agent and a
neuromuscular blocker in the
presence of continuous cricoid
pressure to facilitate endotracheal
intubation and minimize risk of
aspiration
-modifications are made depending
upon the clinical scenario

33. *Rapid Sequence Intubation
Advantages
-Optimizes intubating conditions and
facilitates visualization
-Increased rate of successful
intubation
-Decreased time to intubation
-Decreased risk of aspiration
-Attenuation of hemodynamic and
ICP changes

34. Rapid Sequence Intubation
Contraindications
-Anticipated difficulty with
endotracheal intubation
anatomic distortion
-Lack of operator skill or
familiarity
-inability to preoxygenate

35. Rapid Sequence Intubation
Procedure
-Pre-intubation assessment
-Pre-oxygenation
-Prepare ( for the worst )
-Paralyze
-Premedicate
-Pressure on cricoid
-Place the tube
-Post intubation assessment

36. Pre-oxygenate Time
5 Minutes
-100 % oxygen for 5 minutes
-4 conscious deep breaths of 100 % O2
-Fill FRC with reservoir of 100 % O2
-Allows 3 to 5 minutes of apnea
-Essential to allow avoidance of
bagging
-If necessary bag with cricoid pressure

37. Preparation Time 5 Minutes
-ETT, stylet, blades, suction, BVM
All should be ready
-Cardiac monitor, pulse oximeter,
ETCO2, should be ready
-One ( preferably two ) iv lines should
be placed
-All required drugs should be ready
-Difficult airway kit including cric kit
(This is kit which carries all the items to
deal with the emergency situation)
-Patient positioning is important

38. Pre-treatment
Prime Time 2 Minutes
-Lidocaine 1.5 mg/kg iv
-De-fasciculating dose of
non-depolarizing NMB drugs
-Beta-blocker or fentanyl
-Induction agent
-Thiopental 3 - 5 mg/kg
-Midazolam 0.1 - 0.4mg/kg
-Ketamine 1.5 - 2.0 mg/kg
-Fentanyl 2 - 30 mcg/kg

39. Paralyze (Time Zero)
-Succinylcholine 1.5 mg/kg iv
-Allow 45 - 60 seconds for complete
muscle relaxation
-Alternatives
Vecuromium 0.1 - 0.2 mg/kg
Rocuronium o.6 - 1.2 mg/kg

40. -Pressure
-Sellick maneuver
-initiate upon loss of
consciousness
-continue until ETT balloon
inflation
-release if active vomiting

41. Place the Tube (Time
Zero + 45 Secs)
-Wait for optimal paralysis
-Confirm tube placement
with ETCO2

42. -Post-intubation Hypotension
-Loss of sympathetic drive
-Myocardial infarction
-Tension pneumothorax
-Auto-peep

43. -Succinylcholine
Contraindications
-Hyperkalemia - renal failure
-Active neuromuscular disease
with functional denervation
( 6 days to 6 months)
-Extensive burns or crush injuries
-Malignant hyperthermia
-Pseudo cholinesterase deficiency
-Organophosphate poisoning

44. Succinylcholine
Complications
-Inability to secure airway
-Increased vagal tone
( after second dose )
-Histamine release ( rare )
-Increased ICP/ IOP/ intragastric
pressure
-Myalgia’s
-Hyperkalemia with burns, NM
disease
-Malignant hyperthermia

45. -Difficult Airway Kit
-Multiple blades and ETTs
-C(LMA, Combitube, TTJV(Trans
Tracheal-Jet-Ventillation)
-Emergency surgical airway
access(Cricothyrodotomy
kit-Cricitomes
-ETT placement verification
-Fiberoptic and retrograde intubation

46. Emergency Surgical
Airway Maxims
they are usually a bloody mess, but….
(a bloody surgical airway is better
than an arrested patient with a nice
looking neck)

47. Second Case Report
-42 year old female
-right Pancoast tumor
-RUL, RML, RLL collapse
-ARDS on left
-hypoxemic respiratory
failure
FOR HOME WORK

48. THANK YOU