Dr. Ashraf Ibrahim MBBCh, MD

Specialist in Anesthesia,Al Bukariya general hospital

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Expert airway management is an essential skill to be mastered by everyone

For successful management Anatomy of airway Evaluation of airway Proper equipments Adequate skills

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Nose PharynxLarynxTrachea

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Normal airway begins functionally at naresNose warms & humidifies inspired gasNasal breathing offers 1/3 of total airway

resistanceDuring exercise, mouth breathing employed

as resistance is lessResistance through nose is twice that of

mouth breathing

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Extends from posterior aspect of nose down to cricoid cartilage where it continues as oesophagus

Upper nasopharynx separated by uvula from lower oropharynx

Oropharynx obstruction occurs by relaxation of genioglossus & tongue falling back on posterior pharyngeal wall

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Lies at C 3 → C 6 vertebraServes as organ of phonation & valve to

protect lower airwaysLarynx has cartilages:

3 paired : Corniculate, Cuneiform, Arytenoids3 unpaired : Thyroid, Cricoid, Epiglottis

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Glottic opening is space between vocal cords< than 10 years children - narrowest

segment is cricoid ring> than 10 years glottic opening is narrowest

segment in airway

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Due to reduction of space between pharyngeal wall & base of tongue

This occurs due to relaxation of tongue (genioglossus) & jaw

Rx by preventing mandible from falling backBy placing forefinger & second finger behind

angle of mandiblePatient’s neck slightly extendedUse of oropharyngeal / nasopharyngeal

airways

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•11Patent airway Soft tissue obstruction

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The airway is inserted with the concave side facing the upper lip

When junction of bite portion & curved section is near the incisors, the airway is rotated 180* & slipped behind the tongue into final position

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Nasal airways Nasal airways

For children the size is the same as the endotracheal tubes

For adult males = 7.0 – 7.5 mmFor adult females = 6.5 – 7.0 mm

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Nasal airway should be lubricated wellNose should be examined for patencyNasal decongestant should be appliedAirway is inserted perpendicularly in line

with the nasal passages

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Initial interventions to assure a patent airway in spontaneously breathing patient without possible cervical head injury include “ Triple airway maneuver ”Slight neck extensionElevation of the mandibleMouth opening

If cervical spine injury is suspected, neck extension is only eliminated

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•Slight neck extension

•Elevation of the mandible

•Mouth opening

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Indications :If patient is apneicIf spontaneous tidal volumes are inadequateIf hypoxemia is associated with poor

spontaneous ventilation

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•25Little finger lifting the angle of mandible

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Supraglottic airway:LMACombitube

Glottic airway:Endotracheal intubation

Oral Nasal

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Emergency situations or Elective situationsBag & mask ventilationLMACombitubeEndotracheal intubationSurgical emergency airway

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Available 2.5 size to 9.0 size Size corresponds to the internal diameter in

millimeters Made of poly-vinyl chloride & transparent Has low pressure high volume cuff French unit is product of ID and 3 Bevel end if tube has Murphy’s eye to allow

passage of gas if bevel is occluded Sterilized by gamma radiation & disposable Radio – opaque line runs all along the tube Distance from tip is marked in centimeters

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Cuffed tube Uncuffed tubes

< than 6 years = ( Age / 3 ) + 3.5> than 6 years = ( Age / 4 ) + 4.5Tube size = (16 + age) divided by 4Adult female = 7 cuff tubeAdult male = 8 cuff tube For Nasal intubation # 1 size lesser than

correct oral tube is used

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12 + half the age in centimeters

The idea is to keep the tube in mid-trachea

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Laryngoscope with all size blades (0-4)StilletteSuction apparatus with catheter Bag & maskTape for securing tube

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Sizes available to suit the face0 to 5 sizesScented pediatric masks available tooTransparent mask:

Can observe vomitingCan observe cyanosisCan observe condensation of water vapor

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4 3 2 1

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Consists of detachable blade with bulb connecting to battery housed in handle

One handle will fit all the various blades very quickly

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Most popular scope all over the worldHas 4 blades , size 1,2,3,4Size 1 for small childrenSize 2 for bigger childrenSize 3 for all adultsSize 4 for difficult intubations

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Uses:To guide endotracheal tube in nasal

intubationTo guide Ryle’s tube into oesophagusTo pick up loose tooth from the pharynxTo swab the oral cavity of vomitus

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Rigid implement made of flexible metalInserted inside endotracheal tube to maintain

chosen shapeIt is bent over the tube to prevent protrusion

beyond the endotracheal tube & cause injuryFacilitates intubation when glottis

visualization is minimal / absent & a semi-blind or blind insertion is attempted

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Cloth adhesive tape used as it resists wetting by secretions

Securing by two tapes on the tube is safeBearded patients needs bandage cloth to

anchor the tube securely

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Described by Sellick in 1961 The cricoid cartilage is identified & pressed with

thumb & index finger by a trained assistant The larynx is pressed by the oesophagus on the

hard vertebral bodies The force needed is 30 to 40 Newtons or 8-9

pounds weight Prevents passive regurgitation from oesophagus Pressure released once the airway is secured & cuff

inflated

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Anesthesiologist must determine whether mask ventilation & intubation will be possible if patient is anesthetized & paralyzed

Pre Oxygenation by face mask for 3 minutes or 4 vital capacity 100% breaths

Rapid-Sequence-Intubation (RSI) Cricoid pressure – Sellick’s maneuver Intravenous Induction / Gaseous induction Followed by Suxamethonium (depolarizing muscle

relaxant) Laryngoscopy & visualization of larynx Insertion of endotracheal tube Inflation of the cuff Ventilation started Auscultation for breath sound in 5 areas

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1. Right infra- clavicular

3. Right infra- mammary

5. Gastric

2. Left infra- clavicular

4. Left infra-mammary

EtCO2 on the monitorCondensation of water vapor inside the tube Chest movement on ventilation Auscultation of breath sounds

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One assistant fixes the head

Another assistant provides Cricoid pressure

1. Pre-oxygenate all patients including children to whatever extent possible. This provides a buffer to tolerate an inability to ventilate / intubate for additional minutes.

2. Evaluate every airway carefully from history, physical examination. Keep in mind many small abnormalities add up to difficult airway.

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3. Have a back up plan formulated before the problem occurs.

4. Unless Suxamethonium is contra-indicated, consider using it.

5. Gain confidence & skill with variety of approaches to conscious (Awake) intubations, so it can be applied properly when needed.

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“The airway is your responsibility, and you, the patient and the patient’s loved ones suffer the consequences of misjudgments ”

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