AIRWAY MANAGEMENT

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AIRWAY MANAGEMENT
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OBJECTIVES

• Identify indications for intubation and prepare
  the necessary equipment.
• Identify the advantages and disadvantages of
  various devices for airway management.
• Identify difficult airway.
• Identify equipment for difficult airway and know
  their use.

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INDICATIONS OF INTUBATION

• Cardiopulmonary Arrest
• Patient in coma
• Tachpnea/ Bradypnea
• Progressive cyanosis
• Surgical patients
• Airway protection from any cause

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ADVANTAGES

• Provides an unobstructed airway
• Prevents aspiration of secretions into the lungs
• Facilitates positive pressure ventilation without
  gastric inflation
• Facilitates body positioning and movement
• May be utilized to deliver medication
• Narcan
• Atropine
• Epinephrine
• Lidocaine

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DISADVANTAGES

• Needs advanced training to properly perform the
  procedure
• Bypasses function of the nose to warm and filter
  the inspired air
• Increased incidence of trauma due to neck
  manipulation when spinal cord injury is suspected
  
• May increase respiratory resistance
• Improper placement

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INTUBATION ROLL

• Rigid Laryngoscopes
• Laryngoscope blades different sizes and types
• ETT of various sizes
• Flexible Stylets
• Oral airways
• Exhaled CO2 detector
• ETT fixation device
• Lubricant gel
• Syringe

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ENDOTRACHEAL TUBES

• Types of endotracheal tube (ETT) include oral
  or nasal, cuffed or un-cuffed, preformed (eg RAE
  tube), reinforced tubes, double-lumen tubes and
  tracheostomy tubes. For human use, tubes range in
  size from 2-10.5 mm in internal diameter (ID).

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• Endotracheal tubes are made from red rubber
• and Polyvinylchloride. Those placed in a
  laser field may be flexometallic.

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REINFORCED ETT

• Indications For Usage
• Patient's head is in extended
• or flexed position
• Patient will be turned over
• Long-term cases
• Neurosurgical procedures
• Head and neck procedures

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NASAL AND ORAL RAE

• NASAL

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RAE TUBES II

• Preformed Endotracheal Tubes are designed to
  conveniently position the anesthesia circuit out
  of the surgical field for oral and maxillofacial
  procedures.
• Oral Preformed shape directs tube downward, to
  rest on patients chin
• Cuffed tubes available with Murphy Eye only
• Uncuffed tubes have two Murphy Eyes for enhanced
  patient safety
• Bold marks at the center of bend with distance to
  distal tip indicated

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ENDOBRONCHIAL TUBE

• Indications for usage
• Thoracic surgery
• Broncho-spirometry
• Thoracoscopies
• Differential or selective lung ventilation
• Lung Lavage

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ENDOBRONCHIAL TUBE WITH CPAP SYSTEM

• Indications For Usage
• Thoracic surgery
• Broncho-spirometry
• Thoracoscopies
• Differential or selective
• lung ventilation

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CONFIRMATION OF ETT PLACEMENT
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ETCO2 DETECTORS

• Single use to verify ETT placement
• Reliable carbon dioxide detectors help verify ETT
  placement
• Responds quickly to exhaled CO2 with a simple
  color change from purple to yellow
• Breath-to-breath response
• Constant visual feedback for up to 2 hours

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Correct ET Tube PlacementCapnography

• Purpul

• Yellow

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3-4 cm
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Correct ET Tube Placement
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Correct ET Tube Placement

• Secure ET tube in place, note the number
• Sedate patient with appropriate MAAS
• Avoid accidental, or self extubation

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SECURING THE AIRWAY

• COMFIT ETT Holder
• The tapeless way to secure an ETT
• Completely adjustable
• Wide cotton-lined neckband minimizes skin
  irritation, providing maximum patient comfort
• Minimal plastic loop around the ET tube allows
  access to the oral cavity
• Economical in two ways low initial cost, no
  frequent changing
• Latex-free product

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COMFIT
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EASY CAP II , PEDICAP
Easy Cap II Pedi-Cap
Weight over 15kg Weight 1kg- 15kg
Dead space25cc Dead space3 cc
Time 2 hours Time 2 hours
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Tracheal Tube Cuff Care

• These include bedside sphygmomanometers, special
  aneroid cuff manometers, and electronic cuff
  pressure devices.
• Ideally, most tubes seal at pressures between 14
  and 20 mm Hg (19 to 27 cm H2O).
• Tracheal capillary pressure lies between 20 and
  30 mm Hg
• Impairment in tracheal blood flow seen at 22 mm
  Hg and total obstruction seen at 37 mm Hg

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Sphygmomanometers
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High Volume Low Pressure Tubes
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Minimum Leak Volume Technique

• Air inflation of the tube cuff until the airflow
  heard escaping around the cuff during positive
  pressure breath ceases.
• Place a stethoscope over larynx. Indirectly
  assesses inflation of cuff.
• Slowly withdraw air (in 0.1-mL increments) until
  a small leak is heard on inspiration.
• Remove syringe tip, check inflation of pilot
  balloon

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SECRETION CLEARANCE

• OPEN SUCTION SYSTEM
• Made of non-toxic PVC
• Available coded for size identification Closed
  suction systems
• CLOSED SUCTION SYSTEM
• (CSS) are increasingly replacing open suction
  systems (OSS) to perform endotracheal toilet in
  mechanically ventilated intensive care unit
  patients.

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Endotracheal or Tracheostomy Tube Suctioning

• Closed Suctioning
• Facilitate continuous mechanical ventilation and
  oxygenation during the suctioning.
• Indicated when PEEP level above 10cmH2O

• Open Suctioning
• Disconnection from the ventilator
• Not recommended when PEEP gt10

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Open Suctioning Technique
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Closed Suctioning Technique
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ETT WITH EVACUATION LUMEN

• INDICATIONS
• For airway management by
• oral/nasal intubation of the
• trachea and for evacuation
• or drainage of secretion from
• the subglottic space

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ADVANTAGES OF EVAC

• Helps decrease the rate of ventilator-associated
  pneumonia (VAP) in the hospital and to reduce VAP
  related costs
• Convenient and safe method for suctioning
  accumulated secretions in the subglottic space
• Large elliptical evacuation port located on
  dorsal side proximal to cuff provides effective
  evacuation
• Integral suction lumen allows continuous
  suctioning without risking trauma to the vocal
  cords as with manual catheter suctioning

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ETT CARE

• Use of Gause _at_ the angles of mouth to prevent
  damage to mucosa
• Moving ETT Q NOC from one to the other side to
  avoid damage to mucosa
• Monitoring the correct position of ETT_at_ the lip
  mark and positioning it properly
• Monitoring the ETT position on CXR from time to
  time
• Regular suctioning through ETT

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DIFFICULT AIRWAY

• LET US SEE
• What is a difficult airway ?
• The importance of difficult airway cart.
• Different modalities to be used in difficult
• airways situations.
• Anticipate Difficult Airway.
• Be Prepared and have many back up plans.

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WHAT IS A DIFFICULT AIRWAY

• According to American Association of
  Anesthesiologist, it is a clinical situation in
  which a trained anesthesiologist experiences
  difficulty with mask ventilation, tracheal
  intubation or both.
• Requires more than 3 attempts or 10 min. to
  intubate.
• Grade lll to lV in both Cormack and Mallampadi
  Classifications.

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PRE-INTUBATION EVALUATION

• Potentially difficult laryngoscopy includes
• Less than 35 degree neck extension.
• Less than 7 cm distance between mandible and the
  hyoid bone.
• Less than 12.5 cm sternomandibular distance
  with head fully extended.
• Poorly visualized uvula.
• Short, thick neck.
• Receding mandible and protruding teeth.

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MALLAMPADI CLASSIFICATION

• Grade I soft palate, uvula, tonsillar pillars
  visible.
• Grade II soft palate, uvula visible.
• Grade III soft palate, base of uvula visible.
• Grade IV soft palate not visible (100 Grade lll
  or Grade lV view).

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DIFFICULT AIRWAY CART

• Necessary equipment needed for an anticipated
  or unexpected difficult airway
• LMAs
• Combitube
• Bougie
• Oral and nasopahryngeal airways
• Fast Track
• Cricothyrotomy kit
• Tube Exchangers
• Fiberoptic bronchoscope

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INTUBATING STYLET

• A stylet for intubating an endotracheal tube is
  like medico-surgical tube comprising of a
  bendable metal rod sealed in a tubular plastic
  sheath. The ends of the sheath are molded in a
  smoothly rounded closed shape.
• Passed through an ETT, can be bend to give ETT
  the shape of a hockey stick.
• .

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STYLET

• ADVANTAGES
• Alow intubation of the trachea with minimal
  visualization of the vocal cords.
• Easy to learn.
• Helps in stablizing the ETT for intubation
• DISADVANTAGES
• May be incorrectly inserted and can damage
  tracheal tissues.

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VARIOUS STYLETS

• Shikani seeing stylet
• Bonfils fiberscope
• Machida Portable Stylet Fibersopce
• Video-Optical Intubation Stylet
• Aeroview
• Schroeder Stylet
• Nanoscope
• Many Others..

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LMA

• The Laryngeal Mask Airway is an
• alternative airway device used for
• anesthesia and airway support. It consists
• of an inflatable silicone mask and rubber
• connecting tube. It is inserted blindly into
• the pharynx, forming a low-pressure seal
• around the laryngeal inlet and permitting
• gentle positive pressure ventilation. All
• parts are latex-free.

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LARYNGEAL MASK AIRWAY
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LMA

• INDICATIONS
• The Laryngeal Mask Airway is an appropriate
  airway for short procedures and in emergency
  situations.
• Can be used as rescue airway and fiberoptic
  conduit when intubation is difficult.
• Can be used for bronchoscopy in awake patients.

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LMA

• CONTRAINDICATIONS
• Non-fasted patients
• Morbidly obese patients
• Pregnancy
• Obstructive or abnormal lesions of the oropharynx
  
• Increased Airway resistance and decreased lung
  compliance

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VARIOUS SIZES OF LMA
MASK SIZE PATIENT SIZE WEIGHT CUFF VOLUME
1 INFANT lt6.5 KG 2-4 ML
2 CHILD 6.5-20 KG UP TO 10 ML
2 1/2 CHILD 20-30 KG UP TO 15 ML
3 SMALL ADULT gt30 KG UP TO 20 ML
4 NORMAL ADULT UP TO 30 ML

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LMA

• Tips for Success
• Begin with ASA I II patients
• Learn and use standard insertion technique
• Use appropriate size and do NOT overinflate
• Maintain adequate anesthetic depth
• Remove when the patient opens mouth to command

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COMBITUBE

• Consists of two fused tubes with a 15 mm
  connector at proximal end.
• Contains 2 cuffs, 100 cc proximal and 15 cc
  distal.
• Distal lumen usually lies in esophagus so the gas
  through blue tube will ventilate Trachea.
• If Combitube enters trachea, ventilation is
  through clear tube. Available in only one
  disposable size for agegt 15 years , height gt5ft.

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COMBITUBE
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COMBITUBE II
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BOUGIE

• A semi-rigid stylette-like device with bent tip
• that can be used when intubation is
• difficult.  During laryngoscopy the
• bougie is carefully advanced into
• the larynx and through the cords
• until the tip enters a mainstem
• broncus.  While maintaining the
• laryngoscope and Bougie in position,
• an assistant threads an ETT over the
• end of the bougie, into the larynx. 
• Once the ETT is in place,
• the bougie is removed.

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ETT EXCHANGER
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AIRWAY EXCHANGE CATHETERS
SIZE (ID) LENGTH
2.5-4.0 56 cm
4.0-6.0 56 cm
6.0-8.5 81 cm
7.5-10.0 81 cm
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ETT EXCHANGER

• Facilitates quick, efficient endotracheal tube
  exchange or replacement without using a
  laryngoscope
• Flexible material, frosted surface and depth
  marks aid precise placement and minimize drag
• Internal lumen allows for spontaneous breathing
  during tube exchange
• Longer size allows exchange of the ETT while
  exchanger is still in the trachea
• These devices allow insufflation of O2 and jet
  ventilation.

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ETT EXCHNAGER

• ADVANTAGES
• Relatively short learning time
• Allow changing endotracheal tube with
• guide still in the trachea e.g. in case of
• ruptured ETT cuff
• DISADVANTAGE
• Improper placement of ETT may still occur with
  these devices if guide is not placed completely
  in the trachea

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CRICOTHYROTOMY

• Kits that allow introduction of some type of tube
  into the trachea via cricothyrotomy .Most of the
  kits are designed as temporary airway and need to
  be replaced by a tracheostomy tube after
  establishment of ventilation and stabilization of
  patient

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CRICOTHYROTOMY KIT

• ADVANTAGES
• Rapid access to subglottic area
• Does not require visualization of the larynx.

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FLEXIBLE FIBEROPTIC BRONCHOSCOPE

• The fibreoptic bronchoscope is constructed of
  fibreoptic bundles and cables encased in a
  slender, waterproof sheath from the handle to the
  tip.
• The cable system permits manipulation of the tip
  of the bronchoscope by adjustments _at_the handle,
  the operating end of the device.
• Excellent visualization of the airway with
  minimal homodynamic stress when properly
  performed.

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FIBEROPTIC BRONCHOSCOPE
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FIBEROPTIC II

• Disadvantages
• Expensive
• Requires careful maintenance
• Presence of blood or secretion
• Impairs visualization.

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COMPLICATIONS OF INTUBATION

• During intubation
• Esophageal intubation
• Endobronchial intubation
• Damage of tooth, lip, tongue, mucosa
• Increased B.P, HR, ICP, IOP
• Laryngospasm
• Unanticipated difficult airway
• Pt can code and die

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COMPLICATIONS OF INTUBATION

• While ETT in place
• Unintentional extubation
• Endobroncial intubation
• Obstruction
• Mucosal inflammation and ulceration
• ETT malfunction

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COMPLICATIONS OF INTUBATION

• Following extubation
• Edema and stenosis of glottic, subglottic and
  trachesl regions
• Hoarse of voice due to vocal cord paralysis
• Laryngospasm

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REFERENCES

• CLINICAL ANESTHESIOLOGY by G.Edward Morgan and
  Maged S. Mikhail
• www.nellcor.com
• TEXTBOOK OF ADVANCED CARDIAC LIFE SUPPORT

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THANK YOU

• BY
• KANWAL SHAHZAD RRT