AIRWAY MANAGEMENT

KANWAL SHAHZAD RRT

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.

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

ENDOTRACHEAL TUBES
Types of endotracheal tube (ETT) include oral or nasal, cuffed or uncuffed, 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).

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

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. 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

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

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

COMFIT

EASY CAP II , PEDICAP
Easy Cap II
Weight over 15kg

Pedi-Cap
Weight 1kg15kg Dead space3 cc Time 2 hours

Dead space25cc

Time 2 hours

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

Sphygmomanometers

High Volume Low Pressure Tubes

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

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.

Endotracheal or Tracheostomy Tube Suctioning

Open Suctioning Disconnection from the ventilator Not recommended when PEEP >10

Closed Suctioning:

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

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. Different modalities to be used in difficult airways situations. Anticipate Difficult Airway. Be Prepared and have many back up plans.

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.

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.

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).

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

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.
.

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.

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

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.

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

VARIOUS SIZES OF LMA
MASK SIZE 1 2 2 1/2 3 4 PATIENT SIZE INFANT CHILD CHILD SMALL ADULT NORMAL ADULT WEIGHT <6.5 KG 6.5-20 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

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

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 age> 15 years , height >5ft.

COMBITUBE

COMBITUBE II

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.

ETT EXCHANGER

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

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.

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

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

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

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 @the handle, the operating end of the device. Excellent visualization of the airway with minimal homodynamic stress when properly performed.

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, lip, tongue, mucosa Increased B.P, HR, ICP, 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

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

THANK YOU
BY KANWAL SHAHZAD RRT

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