Airway management

Anatomy and Physiology

The airways can be divided in to parts namely:�The upper airway.�The lower airway.

Non-instrumental airway managementmanagement

Head Tilt and Chin Lift

Jaw Thrust

Advanced Airway Management & Intubation

Advantages of Endotracheal Intubation

• Cuffed E.T tubes protect the airway from aspiration.

• E.T tube provides access to the tracheobronchial tree for suctioning of secretions.secretions.

• E.T tube does not cause gastric distention and associated danger of regurgitation.

• E.T tube maintains a patent airway and assists in avoiding further obstruction.

• E.T tube enables delivery of aerosolized medication.

Indications for Intubation

• Inadequate oxygenation(decreased arterial PO2) that is not corrected by supplemental oxygen via mask/nasal.

• Inadequate ventilation (increased arterial • Inadequate ventilation (increased arterial PCO2).

• Need to control and remove pulmonary secretions.

• Any patient in cardiac arrest.

Indications for Intubation

• Ant patient in deep coma who cannot protect his airway.(Gag reflex absent.).

• Any patient in imminent danger of upper airway obstruction (e.g. Burns of the upper airways).obstruction (e.g. Burns of the upper airways).

• Any patient with decreased L.O.C, GCS <= 8.• Severe head and facial injuries with

compromised airway.

Indications Cont…

• Any patient in respiratory arrest• Respiratory failure

1. Hypoventilation/HypercarbiaA. Paco2 > 55mmhgA. Paco2 > 55mmhg

2. Arterial hypoxemia refractory to O2

A. Paco2 < 70 on 100% O2

Contraindications for Intubation

• Patients with an intact gag reflex.• Patients likely to react with laryngospasm

to an intubation attempt. e.g. Children with epiglottitis. with epiglottitis.

• Basilar skull fracture – avoid naso-tracheal intubation and nasogastric/pharyngeal tube.

Laryngoscopes

Equipment for intubation

• Laryngoscope with relevant size blades.• Magill forceps.• Flexible introducer.• 10-20 ml syringe.• Oropharangeal airways – all sizes.• Oropharangeal airways – all sizes.• Tape or adhesive plaster.• E.T tubes – relevant sizes.• Bag-valve-mask with oxygen connected. • Suction unit with Yankauer nozzle and endotracheal

suction catheter.

Technique of Endotracheal Intubation

Technique Cont…

• Position the patient supine, open the airway with a head-tilt chin-lift maneuver.(Suspected spinal injury, attempt naso-tracheal intubation, spine in neutral position.).

• Open mouth by separating the lips and pulling • Open mouth by separating the lips and pulling on upper jaw with the index finger.

• Hold laryngoscope in left hand, insert scope into mouth with blade directed to right tonsil.

• Once right tonsil is reached, sweep the blade to the midline keeping the tongue on the left.

Technique Cont…

• This brings the epiglottis into view.” DO NOT LOOSE SIGHT OF IT!”

• Advance the blade until it reaches the angle between the base of the tongue and epiglottis.( volecular space)

• Lift the laryngoscope upwards and away from the nose –• Lift the laryngoscope upwards and away from the nose –towards the chest. This should bring the vocal cords into view. It may be necessary for a colleague to press on the trachea to improve the view of the larynx.

• Place the ETT in the right hand. Keep the concavity of the tube facing the right side of the mouth.

• Insert the tube watching it enter through the cords.

Technique Cont…

• Insert the tube just so the cuff has passed the cords and then inflate the cuff.

• Listed for air entry at both apices and both axillae to ensure correct placement using a axillae to ensure correct placement using a stethoscope.

Insertion of tracheal tube

Rules of Intubation

• Always have a suction unit available.• An intubation attempt should never exceed

30 seconds.• Oxygenate the patient pre and post

intubation with a bag -valve -mask.(100% O2).intubation with a bag -valve -mask.(100% O2).• Have sedative medication available if

needed. (e.g. Midazolam 15mg/3ml)• Always recheck tube placement manually

guided by oxygen saturation readings.(Spo2).

Tube sizes

• Newborn – to 4 kg - 2.5 mm (uncuffed).• 1-6 months 4-6 kg – 3.5 mm (uncuffed).• 7-12 months 6-9 kg – 4.0 mm (uncuffed).• 1 year 9 kg – 4.5 mm (uncuffed).• 1 year 9 kg – 4.5 mm (uncuffed).• 2 years 11 kg – 5.0 mm (uncuffed).• 3-4 years 14–16 kg - 5.5 mm (uncuffed).• 5-6 years 18–21 kg – 6.0 mm (uncuffed).• 7-8 years 22-27 kg – 6.5 mm ( uncuffed).

Tube Sizes

• 9-11 years 28-36 kg – 7.0 mm(cuffed).• 14 to adults 46+ kg – 7.0 – 80 mm (cuffed).• Adult female 7.0 – 8.0mm (cuffed).• Adult male 7.5 – 8.5 mm (cuffed).• Adult male 7.5 – 8.5 mm (cuffed).• The size of the tube may also be determined by

the size of the patients little finger.N.B patients below the age of 8 require uncuffed

ETT due to damage caused by the cuff in younger patients. Always monitor the ECG activity during intubation.

Complications Associated With Intubation

• Trauma of the teeth, cords, arytenoid cartilages, larynx and related structures.

• Nasotracheal tubes can damage the turbinates, cause epistaxis, and even perforate the nasopharyngeal mucosa.mucosa.

• Hypertension and tachycardia can occur from the intense stimulation of intubation; This is potentially dangerous in the patient with coronary heart disease.

• Transient cardiac arrhythmias related to vagal stimulation or sympathetic nerve traffic may occur .

Complications Continued…

• Damage to the endotracheal tube cuff, resulting in a cuff leak and poor seal.

• Intubation of the esophagus, resulting in gastric distention and regurgitation upon attempting distention and regurgitation upon attempting ventilation.

• Baro-trauma resulting from over ventilating with a bag without a pressure release valve( phneumothorax).

Complications Continued…

• Over stimulation of the larynx resulting in laryngospasm, causing a complete airway obstruction.

• Inserting the tube to deep resulting in unilateral • Inserting the tube to deep resulting in unilateral intubation (right bronchus).

• Tube obstruction due to foreign material, dried respiratory secretion and/or blood.

Difficult intubation- ASA definition

• More than 2 attemps by experienced anesthesiologist

• Intubation lasting more than 10 minutes

Alternatives to ET tube –Supraglottic Airway Devices

(SAD)(SAD)

LMA Insertion

Combitube

Advantages over intubation - 1

• Blind insertion from any angle of approach

• No introducer tool required• No introducer tool required

• Limited use of muscle relaxants

• Non-invasive - LM’s do not pass through a

sphinctre

• Low-pressure seal

Advantages over intubation - 2

• Not excessively associated with sore

throats

• Not associated with post-operative nausea

• Not associated with morbidity

• Not associated with mortality

• Rapid post-operative recovery

Advantages of SAD

• Recommended for use in emergency including ALS!

• Can be inserted after short training by every medical professionalevery medical professional

• Easy to learn – good learning curve, good skills keeping