AIRWAY MANAGEMENT

IN MECHANICAL
VENTILATION

MANUAL AIRWAY MANEUVERS

HEAD-TILT/CHIN-LIFT

The preferred method

Technique
Position is at patient s
side
One hand on forehead
tilts patients head
back by exerting
downward pressure
with the palm
Other hand grasps
under the chin and
lifts jaw anteriorly

BASIC AIRWAY MANAGEMENT

GENERAL PROCEDURES

Ensure patent airway

Protect cervical spine in suspected trauma
Perform manual airway maneuvers for immediate
ventilation and oxygenation
Use basic airway adjuncts as necessary
Use advanced airway maneuvers to maintain the airway
effectively
Use appropriate BSI precautions

MODIFIED JAWTHRUST MANEUVER

Used with trauma patients

Head is firmly supported in
neutral position, not tilted
back or turned to the side
Technique
Place fingertips of each
hand on the angles of
lower jaw
Displace the jaw forward
Use thumbs to retract
patients lower lip

SELLICKS MANEUVER

Used to prevent gastric

distention that can
accompany intubation
and ventilation
Technique
Apply slight
pressure anteriorly
over cricoid
cartilage
Closes off
esophagus
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BASIC MECHANICAL AIRWAYS

Oropharyngeal airway

Indications
Unconscious patients without a gag reflex
Breathing or nonbreathing patients
Used as a bite block in seizures and with
endotracheal tube in place

BASIC MECHANICAL AIRWAYS

Oropharyngeal airway

Contraindications
Presence of a gag reflex
Severe maxillofacial injuries

OROPHARYNGEAL AIRWAY
ADVANTAGES

Allows air to pass around and through the

device.
Helps prevent obstruction by teeth and lips.
Helps manage unconscious patients who are
breathing spontaneously or need mechanical
ventilation.
Makes suctioning of the pharynx easier.
Bite block during seizures and ET protection

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OROPHARYNGEAL AIRWAY
DISADVANTAGES

Does not isolate the trachea.

Cannot be inserted when teeth are clenched.
May obstruct the airway if not inserted
properly.
Can be dislodged easily.
Should never be inserted in a conscious or
semiconscious patient with a gag reflex.
May precipitate vomiting and laryngospasm

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OROPHARYNGEAL AIRWAY
MEASUREMENT/INSERTION

Sizes range from #0 for infants to #6 for large

adults.
Size the OPA from the corner of the patient s
mouth to the tip of the earlobe.
Insert with the curved end facing up until the tip
reaches the level of the uvula, then rotate the
airway 180 until it comes to rest over the tongue.
Sized too long, can press epiglottis against the
entrance to the larynx causing obstruction.
Sized too short, may force tongue back causing an
obstruction.

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BASIC MECHANICAL AIRWAYS

Nasopharyngeal airway
Indications
Breathing patients with a gag reflex
Maxillofacial injuries
Patients with clenched teeth

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BASIC MECHANICAL AIRWAYS

Nasopharyngeal airway
Contraindications
Nasal obstructions
Patients prone to nosebleeds
Head injuries (basilar skull fractures)

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NASOPHARYNGEAL AIRWAY
ADVANTAGES

Can be easily and rapidly inserted

It bypasses the tongue
May be used when a gag reflex is present

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NASOPHARYNGEAL AIRWAY
DISADVANTAGES

Does not isolate the trachea.

Smaller than the oropharyngeal airway
Difficult to suction through
Can cause severe nosebleeds
Can cause pressure necrosis of nasal mucosa
Difficult to insert if nasal damage is present

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SUCTIONING

Equipment for suctioning

Suction units
Portable (hand, foot, oxygen, or battery
operated)
Stationary (electrical or vacuum)
Must generate vacuum levels of at least
300 mm Hg and flow rate of 30 liters per
minute

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SUCTIONING

Equipment for suctioning

Suction catheters
Hard suction (tonsil tip)
Rigid tube with holes at distal end
Used to remove large particles from
upper airway
Can be inserted along oral airway
Can cause soft tissue damage

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SUCTIONING

Equipment for suctioning

Suction catheters
Soft suction (whistle tip)
Long flexible tube that can extend into
the respiratory tract
Cannot remove large particles or large
volumes of secretions

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SUCTIONING

Hazards
Hypoxia from prolonged attempts (limit
each attempt to 10 seconds)
Cardiac dysrhythmias due to hypoxia
Vagal stimulation causing hypertension and
tachycardia or hypotension and bradycardia
Stimulation of a cough reflex, reducing
cerebral blood flow

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VENTILATION

Goals
To overcome natural elastic resistance of
the lungs
To maintain a good seal
To maintain a patent airway
To deliver adequate ventilatory volumes
To avoid patient regurgitation

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PROCEDURES AND DEVICES

Mouth-to-mouth/mouth-to-nose
Requires no adjunctive equipment
Easy to maintain a good seal
Provides limited oxygen concentration (1617%)
Unattractive procedure
Risk of communicable disease

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POCKET MASK

Prevents direct contact with patients mouth

Can be carried in purse, glove compartment
One-way valve prevents contact with exhaled
air
Supplemental oxygen inlet (50% oxygen
possible)

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Endotracheal Tube

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Endotracheal Tube

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Endotracheal Tube

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Endotracheal Tube

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Endotracheal Tube

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ENDOTRACHEAL TUBE

STANDARD TUBE: LOW PRESSURE HIGH

VOLUME (PLAIN PVC)
Pria 8-9 MM: fiksasi pada 21-23 CM TO
INCISORS (gigi taring)
Wanita 7-8 MM: fiksasi pada 19-21 CM TO
INCISORS
Jangan memotong tube dibawah 26 cm

DOUBLE LUMEN TUBES: jarang di ICU

Tube dari OK/OT harus diganti jika
diperkirakan ekstubasi > 48 HOURS

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Laryngoscopes & Blades

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Straight (Miller)
Blade
Visualize anatomy
Insert from right to
left moving tongue
away
Lift upward and
away
Blade past vallecula
and over epiglottis
Lift epiglottis
directly

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Curved
(Macintosh) Blade
Visualize anatomy
Insert from right
to left
Lift upward and
away
Blade in vallecula
Lift epiglottis
indirectly
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Endotracheal Intubation

Endotracheal Intubation
Tube into the trachea to provide
ventilations using BVM or ventilator
Sized based upon inside diameter in
mm
Lengths increase with increased ID

cm markings along length

Cuffed vs Uncuffed
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Endotracheal Intubation

Endotracheal Intubation
Indications
present or impending respiratory failure
apnea
unable to protect own airway

Advantages
secures airway
route for a few medications
optimizes ventilation and oxygenation

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Endotracheal Intubation

These are NOT Indications

Because I can intubate
Because they are unresponsive
Because I cant show up at the hospital
without it

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Endotracheal Intubation

Complications of endotracheal intubation

Bleeding or dental injury

Laryngeal edema
Laryngospasm
Vocal cord injury
Barotrauma
Hypoxia
Aspiration
Dislodged tube or esophageal intubation
Right or Left mainstem intubation
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Endotracheal Intubation

Techniques of Insertion
Orotracheal Intubation by direct
laryngoscopy
Blind Nasotracheal Intubation
Digital Intubation
Retrograde Intubation
Transillumination techniques
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Endotracheal Intubation

Orotracheal Intubation by direct

laryngoscopy
Position & Ventilate patient
Monitor patient
ECG
Pulse oximeter

Assess patients airway for difficulty

Assemble & check equipment (suction)
Hyperventilate patient (30-120 sec)
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Endotracheal Intubation

Orotracheal Intubation by direct

laryngoscopy (cont)

Position patient
Open mouth & insert laryngoscope blade
Attempt to sweep tongue (straight blade)
Identify anatomical landmarks
Advance laryngoscope blade
Vallecula for curved (Miller) blade
Under epiglottis for straight (Miller) blade

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Endotracheal Intubation

Orotracheal Intubation by direct

laryngoscopy (cont)

Elevate epiglottis
Directly with straight (miller) blade
Indirectly with curved (macintosh) blade
Visualize the vocal cords & glottic
opening
Enter the mouth with the tube from
corner of mouth
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Endotracheal Intubation

Orotracheal Intubation by direct

laryngoscopy (cont)
Advance into glottic opening approx. 1/2
inch past vocal cords
Continue to hold tube & note location
Inflate cuff until firm (approx 10 cc)
Ventilate & Auscultate
epigastrium
left and right chest

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Endotracheal Intubation

Orotracheal Intubation by direct

laryngoscopy (cont)
Secure tube
Reassess Ventilation Effectiveness
auscultation
clinical signs
end-tidal CO2
Esophageal detection device

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Endotracheal Intubation

Equipment
Laryngoscope
Handle (lighted) &
Blades
Stylet
Syringe
Magills
Lubricant
Suction
BVM
BNI

Selection
Typical Adult ET
Tube Sizes

Male - 8.0, 8.5

Female - 7.0, 7.5,
8.0

Blade

Mac - 3 or 4
Miller - 3

Tube Depth

Usually 20 - 22 cm
at the teeth

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Endotracheal Intubation

Pediatric Equipment
Differences
Uncuffed tube < 8
yoa
Miller blade
preferred
Tube Size

Premie: 2.0, 2.5

Newborn: 3.0, 3.5
1 year: 4
Then: (age/4)+4

Pediatric
Differences
Anatomic
Differences
Depth (cm)

Tube ID x 3
12 + (age/2)
easily dislodged

Intubation vs BVM
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Endotracheal
Intubation

Patient Positioning
Goal

Align the 3 planes

of view, so that
The vocal cords
are most visible

T - trachea
P - Pharynx
O - Oropharynx
From AHA PALS

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Endotracheal Intubation

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Endotracheal Intubation
Assessing the Possibility of Difficulty in
Intubation
Difficulty

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Endotracheal Intubation

What effect would

the angle of the
mandible have on
intubation
difficulty?

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Tube Positioning

From TRIPP, CPEM

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Endotracheal Intubation

Blind Nasotracheal Intubation

Position & Oxygenate patient
Monitor patient
ECG Monitor
Pulse oximeter

Assess for BNI difficulty or

contraindication
Assemble & check equipment

Lubricate end of tube; Do not warm

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Endotracheal Intubation

Blind Nasotracheal Intubation (cont)

Position patient (preferably sitting
upright)
Insert tube into largest nare
Advance slowly but steadily
Listen for sound of whistle
Advance tube
Inflate cuff & Assess placement
Secure & Reassess
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Endotracheal Intubation

Digital Intubation

Blind technique
Variable probability of success
Using middle fingers to locate epiglottis
Lift epiglottis
Slide lubricated tube along side fingers
Assess tube placement & depth as with
orotracheal intubation
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Combitube
Indications
Contraindications
Height
Gag reflex
Ingestion of corrosive or volatile
substances
Hx of esophageal disease

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Combitube

From AMLS, NAEMT

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Laryngeal Mask Airway (LMA)

Use in OR
Gaining use in
out-of-hospital
Not useful with
high airway
pressure
Not a
replacement for
ETT
Multiple models
& sizes
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LMA

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Laryngeal Mask Airway (LMA)

Fastrach

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The ASA Difficult Airway

Algorithm Using the LMA

difAirLMA1.JPG

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THANK YOU FOR

YOUR
ATTENTION

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