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Advanced Airway Management

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Advanced Airway Management ... By airway opening manoeuvres or artificial airway adjuncts with or without mask ventilation By a tube from environment to below ... – PowerPoint PPT presentation

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Title: Advanced Airway Management


1
Advanced Airway Management
2
AIRWAY MANAGEMENT
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Airway can be managed
  • By airway opening manoeuvres or artificial airway
    adjuncts with or without mask ventilation
  • By a tube from environment to below vocal cords
  • By a tube connected to a mask that seals glottic
    opening, air is delivered to laryngeal inlet
  • By a tube that isolates oesophagus from airway

6
Airway opening techniques
  • Head tilt
  • Head tilt chin lift
  • Head tilt neck lift jaw thrust (Triple airway
    manoeuvre)
  • Thumb jaw lift
  • Modified jaw thrust

7
Artificial adjuncts / pharyngeal intubation
  • Oropharyngeal airway
  • Unconscious patients
  • As bite block in semi conscious patients
  • Nasopharyngeal airway
  • Trismus, IMF, coma
  • Contraindicated in bleeding disorders, nasal
    infections, injury to cribriform plate

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Artificial adjuncts / pharyngeal intubation
  • Suctioning
  • Mask ventilation
  • Beard, snoring, edentulous patients, facial
    deformities, external facial burns, tumours,
    infections
  • In adult with a possible full stomach - X
  • Paediatric airway
  • Problems Pulmonary aspiration

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Translaryngeal tracheal intubation
  • Oral or nasal route
  • Under direct or indirect vision (flexible
    fibreoptic laryngoscope or rigid laryngoscope)
  • In awake or anaesthetised / unconscious state
  • Awake intubations if maintenance of airway not
    possible after induction, hemodynamic
    instability, intestinal obstruction

14
Orotracheal intubation under direct vision
  • Indications
  • Maintenance of patent airway
  • Pulmonary toilet
  • Positive pressure ventilation, oxygenation
  • Contraindications
  • Cervical spine injury
  • Fracture anterior cranial fossa
  • Retropharyngeal swelling
  • Fractured larynx

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Nasotracheal intubation
  • Advantages over oral intubation
  • less chances of dislodgement
  • better tolerated in awake patient
  • no risk of biting over tube
  • easy insertion in neck movement impairment
  • may produce bacteremia
  • Retrograde catheter guided translaryngeal blind
    intubation

18
Confirmation of placement of ETT
  • Intubation under direct vision
  • Inspection of chest expansion, Auscultation
  • Capnometry
  • Fibreoptic bronchoscopy through ETT
  • Negative pressure devices
  • Pulse oximetry, Condensation in tube, movements
    in reservoir bag, CXR, Cuff palpation, Vital
    signs, Tube markings

19
Transtracheal intubation
  • Needle/Catheter cricothyroidotomy for
    transtracheal jet ventilation
  • Emergency cricothyroidotomy
  • Minitracheostomy, percutaneous dilational
    cricothyroidotomy, rapid percutaneous
    tracheostomy

20
Laryngeal mask airway
  • Intermediate in design and function between face
    mask and ETT
  • Applications
  • Primarily meant for awake intubation
  • For emergency airway management after failed
    intubation
  • Children with congenital anomalies
  • Beard, facial deformities, burns, submandibular
    soft tissue non compliance

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Patients more at risk for aspiration
  • Full stomach (lt8 hours fasting)
  • Trauma
  • Intra abdominal pathology
  • Oesophageal disease
  • Pregnancy
  • Obesity

23
Oesophageal airways
  • Indications
  • Medical personnel not trained in ETT insertion
  • ETT intubation equipment not available
  • Attempts at ETT insertion unsuccessful
  • Contraindicated in gag reflex, oesophageal
    injury, caustic ingestion.
  • Types Oesophageal obturator airway, tracheo -
    oesophageal airway, Oesophageal tracheal combitube

24
Difficult airway algorithm
  • 1. Assess basic management problems
  • Difficult intubation
  • Difficult ventilation
  • Difficulty with patient co operation
  • 2. Consider basic management choices
  • Non surgical technique vs surgical technique
  • Awake vs Anaesthetized Intubation
  • Preservation vs ablation of sp. ventilation

25
  • 3. Develop primary and alternative strategies
  • Awake intubation
  • Non surgical intervention
  • Airway secured by surgical access
  • Intubation under anaesthesia
  • - If unsuccessful, return to spontaneous or mask
    ventilation or awaken patient or emergency
    surgical access

26
Complications of laryngoscopy and intubation
  • Tooth dislodgement, Soft tissue injury
  • Coughing, laryngospasm, vomitting, aspiration
  • Injury trachea, spinal cord, Oesophageal
    intubation
  • Hypoxemia, hypercarbia
  • Hypertension, tachycardia, arrhythmia,
    bradycardia
  • Myocardial ischaemia, Brain stem herniation
  • Complications of nasal intubation

27
Airway maintenance in maxillofacial injuries
  • Obstruction by blood clot, vomit, saliva, bone,
    teeth dentures
  • Inhalation of any of the above
  • Relationship of head injury to hypoxia, with
    blood loss resulting in hypovolemia
  • Fractures of mandible maxilla (fig)

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Mnemonic in ATLS
  • Airway maintenance with cervical spine control
  • Breathing
  • Circulation with haemorrhage control
  • Discerning the neurological status
  • Complete physical evaluation

31
Recognition of acute respiratory failure
  • Examinations should include
  • Mandibular mobility
  • Size and mobility of tongue
  • State and fragility of dentition
  • Amount and viscosity of secretions
  • Presence of haemorrhage or masses
  • Auscultation and percussion of lung fields

32
Systematic approach to airway management
  • Recognize airway obstruction
  • Clear airway (manual suction)
  • Reposition patient
  • Artificial airway
  • Perform ET intubation
  • Cricothyroidotomy
  • Tracheostomy

33
Tracheostomy
  • Semiconscious after head injury
  • To facilitate adequate tarcheo bronchial toilet
  • Management of concomitant problems
  • Need for prolonged positive pressure ventilation
  • when injuries are severe enough to cause
    hypercarbia or hypoxia
  • for control of cerebral oedema

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Tracheostomy
  • Landmarks
  • Complications
  • Tracheal stenosis, bleeding, obstruction of tube,
    mucosal ulceration, cartilaginous necrosis
  • Haemorrhage, hypoxia, pneumothorax, subcutaneous
    emphysema, tracheo oesophageal fistula, damage to
    recurrent laryngeal nerves
  • Haemorrhage, infection, aspiration

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Cricothyroidotomy
  • Advantages
  • More rapid
  • Less complications
  • Improved cosmetic result
  • Less soft tissue thickness to pass through
  • Contraindicated in children, laryngeal infection

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Modified Forms of Respiration
  • Reflexes which act to protect the respiratory
    system
  • Cough- forceful, spasmodic exhalation of a large
    volume of air
  • Sneeze- sudden forceful exhalation from the nose
  • Hiccough- sudden inspiration caused by spasmodic
    contraction of the diaphragm glottic closure
  • Gag reflex- spastic pharyngeal esophageal
    reflex caused by stimulation of posterior pharynx
  • Sighing- hyperinflation of lungs, opens atelectic
    alveoli

40
  • The ability to breathe and the ability to
    protect the airway are not always the same.

41
ASSESSMENT
  • BSI/ scene safety
  • General impression
  • Identify and correct any life threatening
    conditions
  • Responsiveness/ c-spine
  • Airway
  • Breathing
  • Circulation

42
GENERAL IMPRESSION
  • POSITION
  • Tripod
  • Bolt upright
  • COPD
  • CHF
  • Able to speak in sentences

43
AIRWAY
  • Is it patent?
  • Snoring, gurgling or stridor may indicate
    potential problems
  • Secretions, objects, blood, vomitus present
  • Neck
  • JVD (jugular vein distention)
  • TD (tracheal deviation, tugging)

44
BREATHING
  • Adequacy?
  • Rate and quality?
  • Spontaneous regular
  • effortless
  • Chest rise
  • Equal and present excursion
  • Deformity/ crepitus
  • Ecchymosis
  • Subcutaneous emphysema
  • Paradoxical (asymmetric)
  • Flail chest

45
BREATHING EFFORT
  • Normal
  • Labored/ dyspnic
  • Tachypnic/ bradypnea
  • Accessory muscle use
  • Intercostal retractions
  • Suprasternal
  • Abdominal muscle use
  • Pediatrics
  • Grunting
  • Nostril flaring

46
BREATH SOUNDS
  • CTA bilat
  • Diminished
  • Rhonci
  • Rales
  • Wheezing

47
RESPIRATORY PATTERNS
  • Cheyne Stokes
  • Regular pattern of increasing rate volume
    followed by gradual decrease and a short period
    of apnea
  • Brain stem insult
  • Kussmauls
  • Deep, gasping regular respirations
  • Diabetic coma

48
  • Biots
  • Irregular rate volume with intermittent periods
    of apnea
  • Increased ICP
  • Central Neurogenic Hyperventilation
  • Regular, deep and rapid
  • Increased ICP
  • Agonal
  • Slow, shallow, irregular
  • Brain hypoxia

49
PULSUS PARADOXUS
  • Decrease in systolic BP gt 10 mm HG during
    inspiration
  • Caused by increase in intrathoracic pressure
  • COPD
  • Interference with ventricular filling
  • Results in decreased BP

50
DEFINITIONS
  • Hypoxemia
  • Reduction of O2 in arterial blood
  • Hypoxia
  • Insufficient O2 available to meet O2
    requirements
  • Hypercarbia
  • Increased level of CO_at_ in blood

51
Monitoring
  • Pulse oximetry
  • End tidal CO2
  • Quantitative
  • capnography
  • Qualitative
  • Colormetric
  • Purple to yellow

52
CAPNOGRAPHY- EtCO2
  • Standard of care in hospital
  • Immediate response to extubation
  • Stand up in court to prove intubation
  • Waveform indicative
  • Normal
  • Obstructed airway- do you NEED a B-2 agonist?

53
WAVEFORM
  • Normal
  • Acute upstroke- exhalation
  • Acute down stroke- inhalation
  • Straight across
  • Shark fin- lower airway obstruction

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Advanced Airway Management
  • Manual airway control
  • Ventilation
  • Oxygenation
  • Proceed to advanced management
  • Allows for correction of
  • Profound hypoxia
  • hypercarbia

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  • Followed by advanced adjunct placement ASAP
  • Prevent gastric inflation
  • Prevent aspiration

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  • Endotracheal tube
  • Combitube
  • PtL
  • LMA

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Endotracheal Intubation
  • When ventilating an unresponsive patient through
    conventional methods cannot be achieved
  • Protect the airway
  • Prolonged artificial respiration required
  • Patients with or likely to experience upper
    airway compromise
  • Decreased tidal volume- bradypnea
  • Airway obstruction

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Advantages
  • Controls the airway
  • Facilitates ventilation/ O2
  • Prevents gastric inflation
  • Allows for direct suctioning
  • Medication administration

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Disadvantages
  • Requires extensive and ongoing training for
    proficiency
  • Requires specialized equipment
  • Bypasses physiological function of upper airway
  • Warm
  • Filter
  • Humidify

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Complications with Intubated Patients
  • Displacement
  • Obstruction
  • Pneumothorax
  • Equipment failure
  • Contraindicated in epiglottitis

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Possible Occurring Complications
  • Bleeding
  • Laryngeal swelling
  • Laryngospasm
  • Vocal cord damage
  • Mucosal necrosis
  • Barotrauma
  • Dental trauma
  • Laryngeal trauma
  • Esophageal placement

62
Laryngoscope
  • Move tongue and epiglottis
  • Allows visualization of cords and glottis
  • Miller- straight
  • Lift epiglottis
  • pediatrics
  • Macintosh- curved
  • Fits in valeculla
  • More room for visualization
  • Reduced trauma/ gag reflex

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ETT
  • 15mm universal adapter
  • 2.5-9.0mm diameter
  • 12-32cm length
  • Male- 23cm 8.0-8.5mm
  • Female- 21cm 7.5-8.0mm
  • Balloon cuff
  • Occludes tracheal lumen
  • Pilot balloon
  • magill forceps

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  • Direct observation
  • Breathing apneic
  • BSI- goggles gloves
  • Position- sniffing
  • Preoxygenate
  • Replace nitrogen stores with O2
  • Assemble check equipment

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Verify Placement
  • Esophageal intubation detector
  • CO2 detector
  • Auscultation
  • EtCO2 Capnography
  • 35-45mm Hg
  • Hyperventilation in head injury with herniation
    30-35mm HG

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ASPIRATION
  • Partially dissolved food
  • Protein dissolving enzymes
  • Hydrochloric acid

67
Pathophysiology
  • Increased interstitial fluid due to injury
  • Pulmonary edema
  • Destruction of alveoli
  • ARDS
  • Impaired gas exchange
  • Hypoxemia
  • Hypercarbia
  • Increased mortality

68
Prevention
  • Cricoid pressure
  • Suctioning
  • Tonsil tip
  • Whistle tip
  • Positioning

69
Hazards of Suctioning
  • Cardiac dysrhythmias
  • Increased BP/ HR
  • Decreased BP/ HR
  • Gag reflex
  • Cough
  • Increased ICP
  • Decreased CBF

70
Multilumen Airways
  • Combitube
  • Pharyngotracheal Lumen Airway

71
Advantages
  • Blind insertion
  • Facial seal is not necessary
  • Can be placed in esophagus or trachea

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Contraindications
  • lt 16 years old
  • lt 5 feet tall or gt 6 ft 7 in tall (4 ft combi)
  • Ingestion of caustic substances
  • Esophageal disease
  • Presence of gag reflex
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