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Outline Outline
Upper airwayUpper airway
Lower airwayLower airway
Basic airway managementBasic airway managementAssess for Airway Obstruction!
Difficulty breathing Patient conduct (anxious, combative) Abnormal sounds
Improve/Establish Airway Through Maneuvers Chin lift Jaw thrust
Remove Debris/SuctionAirway Adjuncts:
Nasal airway Oral airwayOral airway Others Others
Opening the Airway
Head tilt-chin lift– Nontrauma
patients, medical patients
Jaw-thrust– Suspected spinal
injury
Airway instrumentsAirway instruments
Face mask
Face maskFace mask
Appropriate size: cover from the bridge of the nose to chin
To get a tight seal: EC-clamp technique The thumb and index finger hold the mask
firmly over the nose and chin (forming a “C”) The third through fifth fingers firmly grasp
the bony mandible (forming an “E”) “sniffing” position
Sniffing position
LaryngoscopeLaryngoscope
Oral airwayOral airway
Keep the tongue from falling back
Unresponsive patient with no gag reflex
Corner of patient’s mouth to the tragus
Oral airway; importance of proper size
Nasopharyngeal airwayNasopharyngeal airway
Inserted into patient's nostrils
Tip of patient’s nose to the earlobe
Avoided in patients with: evidence of fracture of middle third of
face. Base of skull fracture. vascular abnormalities of nose. bleeding disorders. Nasal polyps.
Nasopharyngeal airwayNasopharyngeal airway
Endotracheal tubeEndotracheal tube
PVC Choose appropriate size
Male : 7.5 – 8.0 (ID) Female : 7.0 – 7.5 Pediatric : age/4 + 4
Intubating Stylet
Indications for intubationIndications for intubation
Failure to oxygenate Failure to remove CO2 Neuromuscular weakness CNS failure Cardiovascular failure
Steps to control airwaySteps to control airwayPre-IntubationPre-Intubation
-Prepare equipment-Prepare equipment
-Pre-oxygenate-Pre-oxygenate
Steps to control airwaySteps to control airwayOrotracheal Intubation ProcedureOrotracheal Intubation Procedure
Sweep Sweep Left and Left and
LookLook
Backward, Upward, Right Pressure (B.U.R.P.)Backward, Upward, Right Pressure (B.U.R.P.)
Find Your LandmarksFind Your Landmarks
Steps to control airwaySteps to control airway
Find Your LandmarksFind Your Landmarks
Steps to control airwaySteps to control airway
It may not be perfect!It may not be perfect!
Find Your LandmarksFind Your LandmarksSteps to control airwaySteps to control airway
Find Your LandmarksFind Your LandmarksSteps to control airwaySteps to control airway
Readjusting with Cricoid PressureReadjusting with Cricoid Pressure
Steps to control airwaySteps to control airway
Confirm the airwayConfirm the airway
• ETCO2 (monitor)ETCO2 (monitor)
• Lung expansionLung expansion
Intubation ConfirmationIntubation ConfirmationGood, Better, BestGood, Better, Best
• Direct Direct VisualizationVisualization
• Lung SoundsLung Sounds
• Tube Tube Condensation Condensation
Secure the airwaySecure the airway
TapeTape
Improvised devicesImprovised devices
ImmobilizationImmobilization
Secure Your TubeSecure Your Tube
Good, Better, BestGood, Better, Best
Common MistakesCommon MistakesMaking a difficult intubation more difficultMaking a difficult intubation more difficult
RushingRushing
Poor equipment preparationPoor equipment preparation
Suction (lack there of)Suction (lack there of)
Steps to control airwaySteps to control airway
Other optionsOther options
Blind nasal Fibreoptic intubation Retrograde intubation Trach light Cook airway / Bougie LMA / Combitube / Laryngeal tube Tracheostomy
Gum Gum Elastic Elastic BougieBougie
Helpful adjunctsHelpful adjuncts
Laryngeal Mask AirwayLaryngeal Mask Airway
Developed in 1981 at the Royal London Hospital Developed in 1981 at the Royal London Hospital By Dr Archie BrainBy Dr Archie Brain
Helpful adjunctsHelpful adjuncts
Helpful adjunctsHelpful adjuncts
Indications:Indications:-When definitive airway management -When definitive airway management
cannot be obtained. (ETT)cannot be obtained. (ETT)
Not a substitute for definitive airway Not a substitute for definitive airway managementmanagement
Laryngeal Mask AirwayLaryngeal Mask Airway
Helpful adjunctsHelpful adjuncts
Contraindication/Limitations:Contraindication/Limitations:-Obesity-Obesity
-Non-secure-Non-secure
-Size based-Size based
Laryngeal Mask AirwayLaryngeal Mask Airway
Helpful adjunctsHelpful adjuncts
Weight Based SizingWeight Based Sizing<5kg = <5kg = Size 1Size 15-10 kg = 5-10 kg = Size 2Size 220-30 kg = 20-30 kg = Size 2.5Size 2.5Small Adult= Small Adult= Size 3Size 3Average Adult = Average Adult =
Size 4Size 4 Large Adult = Large Adult = Size 5Size 5
Laryngeal Mask AirwayLaryngeal Mask Airway
Helpful adjunctsHelpful adjuncts
Average Adult Woman = 4Average Adult Woman = 4 Average Adult Male = 5Average Adult Male = 5
*If in doubt, check the LMA*If in doubt, check the LMA
Laryngeal Mask AirwayLaryngeal Mask Airway
Helpful adjunctsHelpful adjuncts
Procedure:Procedure:-Pre oxygenate-Pre oxygenate
-Check cuff -Check cuff
-Lubricate -Lubricate posteriorposterior cuff cuff
-Head in neutral or slightly flexed position-Head in neutral or slightly flexed position
-Insert following hard palate (use index finger to guide)-Insert following hard palate (use index finger to guide)
-Stop when met with resistance-Stop when met with resistance
-Let go and inflate cuff -Let go and inflate cuff
-Confirm and secure-Confirm and secure
Laryngeal Mask AirwayLaryngeal Mask Airway
Helpful adjunctsHelpful adjuncts
Air volume is variable depending on cuff size Air volume is variable depending on cuff size and individual patient anatomyand individual patient anatomy
General Guideline:General Guideline:
Size 1 = 4 mlSize 1 = 4 mlSize 2 = 10 mlSize 2 = 10 mlSize 2.5 = 14 mlSize 2.5 = 14 mlSize 3 = 20 mlSize 3 = 20 mlSize 4 = 30 mlSize 4 = 30 mlSize 5 = 40 mlSize 5 = 40 ml
Laryngeal Mask AirwayLaryngeal Mask Airway
Helpful adjunctsHelpful adjuncts
Common Problems:Common Problems:
-Failure to seat properly-Failure to seat properly
-Sizing difficulties -Sizing difficulties
-Aspiration-Aspiration
Laryngeal Mask AirwayLaryngeal Mask Airway
Helpful adjunctsHelpful adjuncts
(Combitube®)(Combitube®)Dual Lumen AirwayDual Lumen Airway
Helpful adjunctsHelpful adjuncts
Indications:Indications:-When definitive airway management -When definitive airway management
cannot be obtained. (ETT)cannot be obtained. (ETT)
Not a substitute for definitive airway Not a substitute for definitive airway managementmanagement
Dual Lumen AirwayDual Lumen Airway
Helpful adjunctsHelpful adjuncts
Contraindications/LimitationsContraindications/Limitations::
-No pediatrics-No pediatrics
-Pathological esophageal disease-Pathological esophageal disease
-Non-secure airway-Non-secure airway
-Latex sensitivity-Latex sensitivity
-Toxic or Caustic Ingestions-Toxic or Caustic Ingestions
Dual Lumen AirwayDual Lumen Airway
Helpful adjunctsHelpful adjuncts
ProcedureProcedure::
-Pre oxygenate-Pre oxygenate
-Check equipment. -Check equipment.
-Head in neutral position-Head in neutral position
-Insert until to guide lines-Insert until to guide lines
Dual Lumen AirwayDual Lumen Airway
Helpful adjunctsHelpful adjuncts
ProcedureProcedure::
Inflate Pharyngeal cuff Inflate Pharyngeal cuff (blue) with 85-100cc of (blue) with 85-100cc of airair
Inflate tracheal cuff Inflate tracheal cuff (white) with 10-15cc of (white) with 10-15cc of airair
Dual Lumen AirwayDual Lumen Airway
Helpful adjunctsHelpful adjuncts
42
-Ventilate -Ventilate port 1port 1 (longer, blue tube, #1). (longer, blue tube, #1).
If no lung sounds, switch portsIf no lung sounds, switch ports
-Ventilate -Ventilate port 2port 2 (shorter, white tube, #2) (shorter, white tube, #2)
*You will be either in the esophagus or the trachea*You will be either in the esophagus or the trachea
Dual Lumen AirwayDual Lumen Airway
Lighted StyletteLighted Stylette
Helpful adjunctsHelpful adjuncts
AIRWAYAIRWAY
Conclusion Conclusion Always oxygenate patient before and
after intubation. Do not attempt intubation unless you
are totally skilled, rather perform bag-valve-mask ventilation.
Always monitor the Spo2 readings. Always reconfirm tube placement
from time to time.