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Airway Management

AWY 1
®
Objectives
• Recognize signs 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
®
Patient Assessment
• Level of consciousness Look, listen, and feel
• Spontaneous efforts vs. apnea
• Airway and cervical spine injury
• Chest expansion
• Signs of airway obstruction
• Breath sounds
• Protective airway reflexes

AWY 3
®
Opening the Airway – the Triple
Airway Maneuver
• Slightly extend neck
(when cervical spine injury
not suspected)
• Elevate mandible
• Open mouth
• Consider adjunctive devices

AWY 4
®
Reassessment
Adequate spontaneous breathing

Provide oxygen supplementation

Proceed to manual assisted ventilation

Apneic patient

Inadequate spontaneous tidal volumes

Excessive work of breathing

Hypoxemia with poor spontaneous ventilation

AWY 5
®
Manual Assisted Ventilation
• Open the airway
• Apply face mask and obtain
seal
• Deliver optimal minute
ventilation from
resuscitation bag
• Consider cricoid pressure
• Monitor with pulse oximetry

AWY 6
®
Single-Handed Method
of Face 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

AWY 7
®
Two-Handed Method of
Face Mask Application
• Helpful when mask
seal difficult
• Fingers placed
along mandible on
each side
• Assistant provides
ventilation

AWY 8
®
Inadequate Mask-to-Face Seal

• 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

AWY 9
®
Airway Adjuncts
• Laryngeal mask airway
– Bowl-shaped cuff that fits in
hypopharynx
– Single or multiple use devices
• Esophageal-tracheal combitube LMA

– May be used in cardiorespiratory arrest


– Requires adequate training

AWY 10
®
Indications for Endotracheal
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
AWY 11
®
Preparation for Intubation
• Assess degree of difficulty for intubation
• Assure optimal ventilation and oxygenation
• Consider gastric decompression
• Analgesia, sedation, amnesia, neuromuscular
blockade as needed

AWY 12
®
Degree of Difficulty Assessment
• Neck mobility
• External face
• Mouth
• Tongue and pharynx
• Jaw
• Consider options for obtaining an
airway that maintain ventilation
• Obtain expert assistance
AWY 13
®
Options for Airway Management
• Awake intubation
• Flexible fiberoptic intubation
• Awake tracheostomy
• Laryngeal mask airway or esophageal-
tracheal combitube
• Needle cricothyrotomy
• Surgical cricothyrotomy
AWY 14
®
Difficult Airway

AWY 15
®
Analgesia, Sedation, Amnesia,
Neuromuscular Blockade
• Analgesia – topical, nerve blocks, sedation
• Sedation/amnesia – rapid acting, short duration, reversible
– Fentanyl: 25–100 µ g 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

AWY 16
®
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

AWY 17
®
Early Complications
• Hemodynamic alterations
– Hypertension
– Tachycardia
– Hypotension
• Consider effects of sedative agents

AWY 18
®
Key Points

AWY 19
®
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

AWY 20
®
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

AWY 21
®
Orotracheal Intubation – Technique

• Proper operator position


• Holding the laryngoscope
handle
• Application of cricoid
pressure
• Mouth opening methods

AWY 22
®
Orotracheal Intubation – Technique

• Insertion of
laryngoscope blade –
tongue control
• Tongue displacement
medially – visualize
epiglottis

AWY 23
®
Orotracheal Intubation – Technique

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

AWY 24
®
Orotracheal Intubation – Technique

• Elevate base of tongue


further to fully expose
glottic opening and
surrounding anatomy

AWY 25
®
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

AWY 26
®
Orotracheal Intubation – Technique

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

AWY 27
®
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

AWY 28
®
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

AWY 29
®
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

AWY 30
®
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 patient’s
small finger
• Uncuffed endotracheal tubes usually used when
patient < 8 yrs old
• Straight laryngoscope blade usually used

AWY 31
®
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

AWY 32
®
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)

AWY 33
®

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