AIRWAY MANAGEMENT

Hery Prayitno, M.Kep

Intensive Care Unit
RS Immanuel - Bandung
 ABC of Resuscitation
Airway: open the
airway
Breathing: provide
positive-pressure
ventilations
Circulation: give chest
compressions
Defibrillation: shock
VF/pulseless VT
 Secondary Survey: ABCD
Airway : provide advanced
airway management
Breathing : confirm tube placement
check for adequate
oxygenation and ventilation
Circulation : obtain IV access
determine rhythm
give medications
Differential Diagnosis : search for, find
and treat reversible causes
 Airway Management
Ensure patent airway
Provide supplemental oxygen
Institute positive-pressure
ventilation when spontaneous
breathing is inadequate or
absent
 Airway Obstruction
Most common cause:
loss of tonicity of submandibular

muscles
posterior displacement of tongue

and/or epiglottis
Basic Techniques to Open
Airway

1. Head tilt
2. Chin Lift Trias
manouvers
3. Jaw Thrust
Head Tilt- Chin Lift
Jaw Thrust
 Airway devices

1. Oropharyngeal Airway
2. Nasopharyngeal Airway
Oropharyngeal Airway
 Technique
Clear the mouth and
pharynx
Place the airway so
that it is turned
backward as it
enters the mouth
As airway
approaches the
posterior wall of the
pharynx rotate 180
degrees
Malposition of Oropharyngeal
Airway
Nasopharyngeal Airway
 Technique

Airway is
lubricated with
anesthetic jelly
Resistance
slight rotation of
the tube
 Provide supplemental oxygen
Without respiratory distress:
2 L / min by nasal cannula
Mild respiratory distress:
5-10 L / min by face mask
Severe respiratory distress or other
serious cases : advanced airway
devices, intubation and 100 %
oxygen
 Devices Used to Administer
Supplemental Oxygen

Oxygen supply
Nasal cannula
Face mask
Face mask with oxygen
reservoir
Venturi mask
 Nasal Cannula
Starting device
Provides up to
44% oxygen
Low flow system
in which the tidal
volume mixes
with room air
 Nasal Cannula
Increasing the oxygen flow by 1 L /
min will increase the inspired oxygen
concentration by approximately 4%:
1 L/min: 24% 4 L/min: 36 %
2 L/min: 28% 5 L/min: 40%
3 L/min: 32% 6L/min: 44%
 Face Mask

O2
concentration
up to 60 % can
be supplied
through face
mask at 6 to
10 L / min
 Face Mask with reservoir
Provides up to 90 %-
100% O2
Each L/min increase
the inspired O2
concentration by
10%
6L/min: 60% O2
7L/min: 70% O2
8L/min: 80% O2
9L/min: 90% O2
10L/min: ~ 100% O2
 Indications of Face Mask
Seriously ill patient who are
responsive with spontaneous
breathing but require high O2
concentration
Acute intervention producing a rapid
clinical effect
 Venturi Mask
Patients with
chronic hypercarbia
(high CO2) and
moderate to severe
hypoxemia
Never withhold oxygen
from patients who have
respiratory distress simply
because you suspect
hypoxic ventilatory drive!
 Ventilate the Patient

1. Mouth to Mouth / Mouth to

Nose
2. Mouth-to-Mask
3. Bag-Mask
 Mouth to Mouth /
Mouth to Nose Ventilation
Mouth-to-Mask Ventilation
Pocket Mask
Device
1-way valve
Port to attach O2
source
 Mouth-to-Mask Ventilation
Advantages
Provides effective ventilation and
oxygenation
Eliminates direct contact

Can administer O2

Eliminates exposure to exhaled

gases
Easy to teach and learn
 Mouth-to-Mask Ventilation
1-rescuer
technique;
performed from
side
Rescuer slides over
for chest
compressions
Fingers: head tilt
chin lift
 Mouth-to-Mask Ventilation
Fingers: jaw thrust Fingers: head tilt
upward chin lift
 Bag-Mask Ventilation
1-Person: 2-Person:
difficult, less easier, more
effective effective
 Bag-Mask Ventilation
Advantages
Provides immediate ventilation and
oxygenation
Operator gets sense of compliance and
airway resistance
May provide excellent short-term support of
ventilation
High oxygen concentrations are possible
Can be used to assist spontaneous
respirations
 Advanced Ventilation

1. Tracheal Intubation
2. Laryngeal Mask Airway
3. Combitube
 Tracheal Intubation

Keeps Airway patent

Ensures delivery of high concentration of
oxygen
Ensures delivery of a selected tidal volume
Isolates and protects the airway from
aspiration of stomach contents
Permits effective suctioning
Provides route for administration of several
medications
 Indications
Cardiac arrest with ongoing chest
compressions
Inability of conscious patient in
respiratory compromise to breathe
adequately
Inability of the patient to protect airway
Inability of the rescuer to ventilate the
unresponsive patient with conventional
methods
 Equipment for Intubation
Laryngoscope with
several blades
Tracheal tubes
Malleable stylet
10-mL syringe
Magill forceps
Suction unit,
catheters, and tubing
Curved vs Straight Blade

Macintosh
Miller
Curved vs Straight Blade
Visualization of Vocal Cords

Tongue
Vallecula
Epiglottis

Glottic Vocal
opening cord
Arytenoid
cartilage
Cricoid Pressure
 Tracheal Intubation
Advantages
Protects airway from aspiration of foreign
material
Facilitates ventilation and oxygenation
Facilitates suctioning of trachea and bronchi
Provides route for drug administration
Prevents gastric inflation if used with cuff
Allows faster chest compressions
 Tracheal Intubation
Indications
Inability to ventilate the unconscious
patient
After insertion of pharyngeal airway

Inability of patient to protect own airway

(coma, areflexia, or cardiac arrest)

Need for prolonged mechanical

ventilation
 Tracheal Intubation
Recommendations
Intubate as soon as possible after ventilation
and oxygenation in cardiac arrest
Intubation should be done by most
experienced person
Do not take longer than 30 seconds per
attempt
Auscultate the thorax and epigastrium
after intubation
 Tracheal Intubation

Complications
Traumateeth, lips, tongue,
mucosa,
vocal cords, trachea
Esophageal intubation

Vomiting and aspiration

Hypertension and arrhythmias

 Esophageal-Tracheal
Combitube
A = esophageal obturator; ventilation into trachea through
side openings = B
E C = tracheal tube; ventilation through open end if proximal
end inserted in trachea
Distal End D = pharyngeal cuff; inflated through catheter = E
F = esophageal cuff; inflated through catheter = G
H = teeth marker; blindly insert Combitube until marker is at
A level of teeth

Proximal End
C H

D B
F

G
Esophageal-Tracheal
Combitube
 Laryngeal Mask Airway
(LMA)

Airway adjunct with a cuffed mask-like projection

at the distal end that is introduced to the pharynx
LMA Introduced Through Mouth
Into Pharynx
THANK
YOU