Module I Final

Cardiopulmonary Resuscitation and Airway Management
Introduction
Cardiac arrest is the main cause of sudden cardiac death1 Many victims of sudden cardiac arrest can survive if bystanders act immediately2
1. 2.
Raki D, Rumboldt Z, Carevi V, Bagatin J, Poli S, Pivac N, et al. In-hospital cardiac arrest and resuscitation outcomes: rationale for sudden cardiac death approach. Croat Med J. 2005 Dec;46(6):907-12. Handley AJ, Koster R, Monsieurs K, Perkins GD, Davies S Bossaert L. European Resuscitation Council Guidelines for Resuscitation 2005. Section 2. Adult basic life support and use of automated external defibrillators. Resuscitation 2005; 67S1: S7-23
Introduction
The optimum treatment for ventricular fibrillation cardiac arrest is immediate cardiopulmonary resuscitation; CPR (combined chest compression and rescue breathing) plus electrical defibrillation
Handley AJ, Koster R, Monsieurs K, Perkins GD, Davies S Bossaert L. European Resuscitation Council Guidelines for Resuscitation 2005. Section 2. Adult basic life support and use of automated external defibrillators. Resuscitation 2005; 67S1: S7-23
Important aspects in CPR

Airway Management Basic life support (BLS)
Handley AJ, Koster R, Monsieurs K, Perkins GD, Davies S Bossaert L. European Resuscitation Council Guidelines for Resuscitation 2005. Section 2. Adult basic life support and use of automated external defibrillators. Resuscitation 2005; 67S1: S7-23
Airway Management
Rationale
Maintenance of the airway is the first step to the successful resuscitation of a compromised patient1 Invasive airway management facilitates oxygenation and ventilation, and protects the patient from aspirating the contents of the stomach, or blood from the upper airway2
1. 2.
Cosar E. Airway management and endotracheal intubation. In: Irwin RS, Rippe JM, editors. Manual of intensive care medicine. 4th ed. Lippincott Williams & Wilkins; 2006. p.3-8. Adnet F, Lapostolle F, Ricard-Hibon A, Carli P, Goldstein P. Intubating trauma patients before reaching the hospital-revisisted. Crit Care. 2001;5:290-1
Airway assessment
Difficult airway
Defined by the existence of clinical factors that complicate either ventilation administered by facemask or intubation performed by experienced and skilled clinicians
Difficult ventilation
Defined as the inability of a trained anesthetist to maintain the oxygen saturation > 90% using a face mask for ventilation and 100% inspired oxygen, provided that the preventilation oxygen saturation level was within the normal range
Reynolds SF, Heffner J. Airway management of the critically ill patient: rapid-sequence intubation. Chest. Apr 2005;127(4):1397-412.
Airway assessment
Difficult intubation
Defined by the need for more than three intubation attempts or attempts at intubation that last > 10 min
Evaluation of the airway

The ability to rapidly evaluate the patients airway before endotracheal intubation is very important The presence of cervical collars, halo devices, trauma to the mandible or neck, morbid obesity and obstructive sleep apnea may signal a difficult airway History of snoring, facial hair, edentulous patients, patients with age > 56 and BMI > 26 are preoperative clinical predictors for difficult mask ventilation
Cosar E. Airway management and endotracheal intubation. In: Irwin RS, Rippe JM, editors. Manual of intensive care medicine. 4th ed. Lippincott Williams & Wilkins; 2006. p.3-8.
Evaluation of the airway

Several clinical criteria can be assessed:
Mouth opening (interincisor gap should be > 4 cm) Mallampati classification Head and neck movement Ability to prognath (i.e., to bring the lower incisors in front of the upper incisors) Thyromental distance (should be > 6.5 cm) Body weight Previous history of difficult intubation
Mallampati classification
Class I

Class III
Class I airway, faucial pillars, soft palate, and uvula can be visualized (left) Class II airway, faucial pillars and soft palate can be visualized but the uvula is masked by the base of the tongue Class III airway, only the soft palate can be visualized. The patient on the right has a class III airway, which is one of the predictors of difficult orotracheal intubation
Airway obstruction
The hallmark of upper airway obstruction is diminished or absent airflow in the presence of continued respiratory effort Airway obstruction can be:
Complete or Partial
The triple manoeuvre

Head tilt Chin lift
Jaw thrust
Nolan JP, Deakin CD, Soar J, Bottiger BW, Smith G. European Resuscitation Council Guidelines for Resuscitation 2005 Section 4. Adult advanced life support. Resuscitation 2005;67S1:S39 86.
Head tilt and chin lift
Jaw thrust
Airway equipment
Masks Laryngeal Mask Airway (LMA) Combitube
Gal TJ. Airway management. In: Miller RD, editor. Millers anesthesia. Vol II, 6th ed. Churchill livingstone; 2005. p. 1617-52.
Masks
Anesthesia facemasks of rubber, plastic or silicon are employed
To administer oxygen and anesthetic gases To ventilate the non-intubated patient
Masks
Adult masks come in small, medium, and large sizes (nos. 3, 4 & 5) Childrens masks come in newborns, infant, and children sizes Transparent masks are being used more often for adults & children
Mask holding technique
Technique for holding the mask with one hand An effort should be made to avoid excessive pressure on the soft tissues of the neck
Mask holding technique
Technique for holding the mask with two hands
Laryngeal mask airway

Laryngeal mask airway (LMA) can be used to provide a temporary airway until a more definite airway can be achieved1 This device is available in seven sizes for neonates, infants, young children, older children, and small, normal, and large adults2
1. Cosar E. Airway management and endotracheal intubation. In: Irwin RS, Rippe JM, editors. Manual of intensive care medicine. 4th ed. Lippincott Williams & Wilkins; 2006. p.3-8. 2. Gal TJ. Airway management. In: Miller RD, editor. Millers anesthesia. Vol II, 6th ed. Churchill livingstone; 2005. p. 1617-52.
LMA Insertion
Combitube
A supraglottic airway device that provides an emergency airway when conventional means are not effective or possible Has two lumens so that it can function appropriately whether placed in the trachea or in the esophagus Also possesses an esophageal balloon to provide for protection from aspiration, which may represent an advantage over the LMA
Combitube insertion
Endotracheal intubation
Endotracheal intubation provides a closed ventilation system while ensuring patency and protecting the airway Endotracheal intubation consists of
Oral endotracheal intubation: Placing a tube in the trachea through the mouth Nasal endotracheal intubation: Placing a tube in the trachea through the nose
Rosell Millet P, Muoz Bonet JI; Sociedad Espaola de Cuidados Intensivo Pediatricos. Techniques and complementary techniques. Intubation, sedation and adaptation to mechanical ventilation. An Pediatr (Barc).2003 Nov;59(5):462-72.
Endotracheal intubation
Endotracheal intubation achieves four main goals
Airway protection Provides upper airway patency Pulmonary hygiene Allows mechanical positive pressure ventilation
Head position
PA LA OA
A
OA
PA LA
B
PA OA LA
OA: Oral Axis PA: Pharyngeal Axis LA: Laryngeal Axis
Laryngoscopy
Epiglottis
Epiglottis
Cricoid pressure in laryngoscopy

In unconscious patient who is considered to have a full stomach, laryngoscopy should be performed with cricoid pressure (Sellick maneuver) Cricoid pressure should be applied by using the thumb and forefinger together to push downward on the cricoid cartilage
This maneuver can prevent passive regurgitation of stomach contents into the trachea during intubation
Oral endotracheal intubation

Once the glottic opening is visualized by laryngoscopy, the endotracheal tube is advanced through the vocal cords until the cuff just disappears
Insertion of the tube to 23 cm at incisors in males, and 21 cm in females generally provides optimal endotracheal tube position
Nasotracheal intubation
A well-lubricated, warmed tube with the cuff fully deflated should be inserted via prepared nostrils Once the tube is beyond the nasopharynx, both blind and direct laryngoscopy techniques can be used to accomplish nasotracheal intubations
Complications
During intubation
Laryngospasm Laceration Bruising of lips or tongue Damage to teeth Aspiration Endobroncheal or esophageal intubation Perforation of oropharynx, trachea or esophagus Epistaxis
Complications
Post-extubation
Laryngospasm, sore throat, hoarseness, stridor, glottic or subglottic edema
Long-term intubation may result in tracheal stenosis, tracheomalacia, tracheal mucosal ulceration
Rapid Sequence Induction (RSI)

RSI has become the gold standard for emergency intubation1 RSI consists of:2
a period of preoxygenation administration of a short acting intravenous hypnotic (often an anaesthetic induction agent) followed by a neuromuscular blocking drug
During this sequence, as consciousness is lost, cricoid pressure is applied to reduce the risk of regurgitation and aspiration2
1. 2.
Adnet F, Lapostolle F, Ricard-Hibon A, Carli P, Goldstein P. Intubating trauma patients before reaching the hospital-revisisted. Crit Care. 2001;5:290-1. Carley SD, Gwinnutt C, Butler J, Sammy I, Driscoll P. Rapid sequence induction in the emergency department: a strategy for failure. Emerg Med J. 2002 Mar;19(2):109-13.
RSI: Advantages
Preoxygenation
Reduces the need for facemask ventilation in preparation for intubation Decreases the risks for gastric insufflation Decreases the risks of aspiration of stomach contents
RSI: Factors improving outcomes

Potent induction agent with a neuromuscular blocking drug
Allows the airway to be rapidly controlled Further reduces the risk of aspiration
Adjunctive medications
Reduce the pressor response and other physiologic consequences of laryngoscopy and tracheal intubation
Alternative techniques
Flexible endoscopy is useful in suspected spine injury, known or anticipated difficult airway, morbid obesity, and in patients with high risk of aspiration It may be used in both awake and anesthetized patients via oral or nasal route It may be useful in critically ill patients to evaluate the endotracheal tube patency and position and to change endotracheal tubes in patients with difficult airways
Alternative techniques
The LMA or its variants are other alternative devices to manage the patient with a difficult airway Needle cricothyrotomy and percutaneous dilatational tracheostomy can be done for emergent airway access
Emergency airway management: Ten Commandments

1. 2. 3. 4. 5. 6. 7. 8. 9. Have an organized plan Remain calm First use bag-mask ventilation Call for help early If you cant ventilate, intubate Keep track of time If at first you dont succeed: try again If you cant intubate, ventilate If you cant ventilate with a bag mask and cant intubate, open the neck 10.Practice whenever you can
Editorial. Decision making in airway management. Indian J. Anaesth. 2005;49(4):248-50.
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Module I Final

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Module I Final

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Cardiopulmonary Resuscitation and Airway Management

Important aspects in CPR

Evaluation of the airway

Evaluation of the airway

The triple manoeuvre

Head tilt and chin lift

Mask holding technique

Mask holding technique

Technique for holding the mask with two hands

Laryngeal mask airway

OA: Oral Axis PA: Pharyngeal Axis LA: Laryngeal Axis

Cricoid pressure in laryngoscopy

Oral endotracheal intubation

Rapid Sequence Induction (RSI)

RSI: Factors improving outcomes

Emergency airway management: Ten Commandments

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