Airway Management

Recognition of Airway Obstruction

Systematic method of detecting airway obstruction :

Look, listen and feel Look for chest and abdominal movement Listen and feel for airflow at the mouth and nose.

Recognition of Airway Obstruction

Characteristic sounds in airway obstruction :

Gurgling : liquid or semisolid foreign material in the main airway. Snoring : pharyng is partially occluded by soft palate or epiglottis. Crowing : sound of laryngeal spasm. Inspiratory stridor : obsruction at laryngeal level or above. Expiratory wheeze : obstruction of the lower airway.

Patient Assessment

Level of consciousness Spontaneous efforts vs. apnea Airway and cervical spine injury Chest expansion Signs of airway obstruction Signs of respiratory distress Protective airway reflexes

Opening the Airway the Triple Airway Maneuver

Slightly extend neck (when cervical spine injury not suspected) Elevate mandible Open mouth

Hand Positioning the Triple Airway Maneuver

Reassess Spontaneous Breathing (Ventilation) When Airway Open

Adequate oxygen supplementation

Inadequate manual assisted ventilation

Manual Assisted Ventilation

Apply face mask Oro-/nasopharyngeal airway adjuncts Mouth opening Hand positioning Elevate mandible and chin Resuscitation bag compression volume and frequency

Single-Hand Method of Facemask Application

Base of mask placed over chin and mouth opened Apex of mask over nose Mandible elevated, neck hyperextended (no cervical spine injury), and downward pressure by mask hand

Two-Hand Method of Facemask Application

Indications Demonstration

Inadequate Mask-to-Face Seal

Identify leak Reposition face mask Improve seal along cheek(s) Slightly increase downward pressure over face or neck extension (if no cervical spine injury) Use two-hand technique

Preparation for Endotracheal Intubation

Continue adequate ventilation and hyperoxygenation Decompress stomach Assess degree of difficulty for intubation Analgesia, sedation, amnesia, neuromuscular blockade as needed

Degree of Difficulty

Micrognathia Cervical spine status Facial injury, surgery, scarring Thyromental distance (short neck) Mouth opening and Mallampati classification

Mallampati Classification

Analgesia, Sedation, Amnesia, Neuromuscular Blockade

Analgesia topical, nerve blocks, sedation

Sedation/amnesia rapid acting, short duration, reversible Fentanyl: 25100 g iv, titrated to effect Midazolam: 12 mg iv, titrated to effect Etomidate: 0.30.4 mg/kg iv, titrated to effect

Analgesia, Sedation, Amnesia, Neuromuscular Blockade

Neuromuscular blockers assess need

Succinylcholine: 11.5 mg/kg iv bolus; depolarizing agent

Vecuronium: 0.10.3 mg/kg iv bolus; nondepolarizing agent

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

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

Orotracheal Intubation Technique

Proper operator position Holding the laryngoscope handle Application of cricoid pressure Mouth opening methods

Orotracheal Intubation Technique

Insertion of laryngoscope blade tongue control

Tongue displacement medially visualize epiglottis

Orotracheal Intubation Technique

Advance laryngoscope into position (vallecula for curved blade; under epiglottis for straight blade) Elevate base of tongue and expose glottic opening

Orotracheal Intubation Technique

Elevate base of tongue further to fully expose glottic opening and surrounding anatomy

Orotracheal Intubation Technique

Insert endotracheal tube under direct vision to 2325 cm at lip Remove stylet and laryngoscope, inflate tube cuff

Confirm tube position breath sounds, CO2 detector Secure endotracheal tube Obtain chest radiograph

Orotracheal Intubation Technique

Straight blade position, elevating the epiglottis Be aware of laryngospasm when epiglottis is touched

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

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

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

Pediatric Considerations for 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 patients small finger Uncuffed endotracheal tubes usually used when patient < 8 yrs old Straight laryngoscope blade usually used

Pediatric Considerations for 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

Pediatric Considerations for 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)

Key Points