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KANWAL SHAHZAD RRT
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.
INDICATIONS OF INTUBATION
Cardiopulmonary Arrest Patient in coma Tachpnea/ Bradypnea Progressive cyanosis Surgical patients Airway protection from any cause
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 .
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 .
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 .
5 mm in internal diameter (ID).ENDOTRACHEAL TUBES Types of endotracheal tube (ETT) include oral or nasal. preformed (eg RAE tube). reinforced tubes. double-lumen tubes and tracheostomy tubes. For human use. cuffed or uncuffed. tubes range in size from 2-10. .
Those placed in a laser field may be flexometallic. Endotracheal tubes are made from red rubber and Polyvinylchloride. .
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 .
NASAL AND ORAL RAE NASAL .
RAE TUBES II Preformed Endotracheal Tubes are designed to conveniently position the anesthesia circuit out of the surgical field for oral and maxillofacial procedures. 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 . Oral Preformed shape directs tube downward.
ENDOBRONCHIAL TUBE Indications for usage Thoracic surgery Broncho-spirometry Thoracoscopies Differential or selective lung ventilation Lung Lavage .
ENDOBRONCHIAL TUBE WITH CPAP SYSTEM Indications For Usage Thoracic surgery Broncho-spirometry Thoracoscopies Differential or selective lung ventilation .
CONFIRMATION OF ETT PLACEMENT .
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 .
Correct ET Tube Placement: Capnography Purpul Yellow .
3-4 cm .
Correct ET Tube Placement .
Correct ET Tube Placement Secure ET tube in place. note the number Sedate patient with appropriate MAAS Avoid accidental. or self extubation .
providing maximum patient comfort Minimal plastic loop around the ET tube allows access to the oral cavity Economical in two ways: low initial cost.SECURING THE AIRWAY COMFIT™ ETT Holder The tapeless way to secure an ETT Completely adjustable Wide cotton-lined neckband minimizes skin irritation. no frequent changing Latex-free product .
PEDICAP Easy Cap II Weight over 15kg Pedi-Cap Weight 1kg15kg Dead space3 cc Time 2 hours Dead space25cc Time 2 hours .EASY CAP II .
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
High Volume Low Pressure Tubes
check inflation of pilot balloon . Remove syringe tip. Place a stethoscope over larynx.Minimum Leak Volume Technique Air inflation of the tube cuff until the airflow heard escaping around the cuff during positive pressure breath ceases. Indirectly assesses inflation of cuff.1-mL increments) until a small leak is heard on inspiration. Slowly withdraw air (in 0.
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. .
Indicated when PEEP level above 10cmH2O Facilitate .Endotracheal or Tracheostomy Tube Suctioning Open Suctioning Disconnection from the ventilator Not recommended when PEEP >10 Closed Suctioning: continuous mechanical ventilation and oxygenation during the suctioning.
Open Suctioning Technique .
Closed Suctioning Technique .
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 .
ADVANTAGES OF EVAC Helps decrease the rate of ventilatorassociated 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 .
ETT CARE Use of Gause @ 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@ the lip mark and positioning it properly Monitoring the ETT position on CXR from time to time Regular suctioning through ETT .
DIFFICULT AIRWAY LET US SEE… What is a difficult airway ? The importance of difficult airway cart. Anticipate Difficult Airway. Be Prepared and have many back up plans. Different modalities to be used in difficult airways situations. .
Grade lll to lV in both Cormack and Mallampadi Classifications. Requires more than 3 attempts or 10 min. it is a clinical situation in which a trained anesthesiologist experiences difficulty with mask ventilation.WHAT IS A DIFFICULT AIRWAY According to American Association of Anesthesiologist. tracheal intubation or both. to intubate. .
. Short. Receding mandible and protruding teeth. Less than 7 cm distance between mandible and the hyoid bone. Less than 12.PRE-INTUBATION EVALUATION Potentially difficult laryngoscopy includes: Less than 35 degree neck extension. Poorly visualized uvula. thick neck.5 cm sternomandibular distance with head fully extended.
MALLAMPADI CLASSIFICATION Grade I: soft palate. uvula visible. uvula. . tonsillar pillars visible. base of uvula visible. Grade II: soft palate. Grade IV: soft palate not visible (100% Grade lll or Grade lV view). Grade III: soft palate.
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 .
The ends of the sheath are molded in a smoothly rounded closed shape. .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. Passed through an ETT. can be bend to give ETT the shape of a hockey stick. .
STYLET ADVANTAGES Alow intubation of the trachea with minimal visualization of the vocal cords. . Helps in stablizing the ETT for intubation DISADVANTAGES May be incorrectly inserted and can damage tracheal tissues. Easy to learn.
.VARIOUS STYLETS Shikani seeing stylet Bonfils fiberscope Machida Portable Stylet Fibersopce Video-Optical Intubation Stylet Aeroview Schroeder Stylet Nanoscope Many Others………..
forming a low-pressure seal around the laryngeal inlet and permitting gentle positive pressure ventilation.LMA The Laryngeal Mask Airway is an alternative airway device used for anesthesia and airway support. . All parts are latex-free. It is inserted blindly into the pharynx. It consists of an inflatable silicone mask and rubber connecting tube.
LARYNGEAL MASK AIRWAY .
.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.
LMA CONTRAINDICATIONS Non-fasted patients Morbidly obese patients Pregnancy Obstructive or abnormal lesions of the oropharynx Increased Airway resistance and decreased lung compliance .
5-20 KG 20-30 KG >30 KG CUFF VOLUME 2-4 ML UP TO 10 ML UP TO 15 ML UP TO 20 ML UP TO 30 ML .5 KG 6.VARIOUS SIZES OF LMA MASK SIZE 1 2 2 1/2 3 4 PATIENT SIZE INFANT CHILD CHILD SMALL ADULT NORMAL ADULT WEIGHT <6.
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 .
If Combitube enters trachea. ventilation is through clear tube. height >5ft. 100 cc proximal and 15 cc distal.COMBITUBE Consists of two fused tubes with a 15 mm connector at proximal end. . Distal lumen usually lies in esophagus so the gas through blue tube will ventilate Trachea. Available in only one disposable size for age> 15 years . Contains 2 cuffs.
COMBITUBE II .
Once the ETT is in place. During laryngoscopy the bougie is carefully advanced into the larynx and through the cords until the tip enters a mainstem broncus.BOUGIE A semi-rigid stylette-like device with bent tip that can be used when intubation is difficult. While maintaining the laryngoscope and Bougie in position. the bougie is removed. an assistant threads an ETT over the end of the bougie. into the larynx. .
ETT EXCHANGER .
5 7.0-6.5-4.0 6.5-10.0-8.0 LENGTH 56 cm 56 cm 81 cm 81 cm .0 4.AIRWAY EXCHANGE CATHETERS SIZE (ID) 2.
.ETT EXCHANGER Facilitates quick. 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. efficient endotracheal tube exchange or replacement without using a laryngoscope Flexible material.
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 .
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 .CRICOTHYROTOMY Kits that allow introduction of some type of tube into the trachea via cricothyrotomy .
CRICOTHYROTOMY KIT ADVANTAGES Rapid access to subglottic area Does not require visualization of the larynx. .
. waterproof sheath from the handle to the tip.FLEXIBLE FIBEROPTIC BRONCHOSCOPE The fibreoptic bronchoscope is constructed of fibreoptic bundles and cables encased in a slender. the operating end of the device. Excellent visualization of the airway with minimal homodynamic stress when properly performed. The cable system permits manipulation of the tip of the bronchoscope by adjustments @the handle.
FIBEROPTIC BRONCHOSCOPE .
FIBEROPTIC II Disadvantages Expensive Requires careful maintenance Presence of blood or secretion Impairs visualization. .
COMPLICATIONS OF INTUBATION During intubation Esophageal intubation Endobronchial intubation Damage of tooth. mucosa Increased B. lip. HR. ICP. tongue.P. IOP Laryngospasm Unanticipated difficult airway Pt can code and die .
COMPLICATIONS OF INTUBATION While ETT in place Unintentional extubation Endobroncial intubation Obstruction Mucosal inflammation and ulceration ETT malfunction .
COMPLICATIONS OF INTUBATION Following extubation Edema and stenosis of glottic. subglottic and trachesl regions Hoarse of voice due to vocal cord paralysis Laryngospasm .
Mikhail www.nellcor.com TEXTBOOK OF ADVANCED CARDIAC LIFE SUPPORT .REFERENCES CLINICAL ANESTHESIOLOGY by G.Edward Morgan and Maged S.
THANK YOU BY KANWAL SHAHZAD RRT .
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