Basic Emergency

Airway
Management

dhs wahyubroto. 1

Objectives
• Differentiate the Emergency Airway from elective
intubation in the OR
• Assessment of airway compromise
• Indications for airway intervention
• Recognition of the difficult airway
• Bag-Mask Techniques
• Laryngoscopy

dhs wahyubroto. 2

Emergency Airway Management :
Unique Considerations

• Full stomach - high aspiration risk
• Altered level of consciousness
• Deteriorating cardiorespiratory
physiology - (hypotension, hypoxia)
• Abnormal or distorted upper airway
anatomy
• No time for “pre-op” assessment
dhs wahyubroto. 3

4 . Airway Assessment • Assessment for airway compromise or threats and need for interventions • Examination for the potentially difficult airway dhs wahyubroto.

5 .The Three Pillars of Airway Management: ( Assessment of Compromises or Threats ) 1 Patency of Upper Airway – ( airflow integrity ) 2 Protection against aspiration 3 Assurance of oxygenation and ventilation dhs wahyubroto.

6 .therapeutic hyperventilation • Intractable Shock • Anticipated clinical deterioration dhs wahyubroto. drug delivery. Indications for Active Airway Intervention: including intubation • Failure to maintain patency • Protection from aspiration • Hypoxic/ hypercapnic respiratory failure • Airway access for pulmonary toilet.

) dhs wahyubroto.e.. 7 . long transport. etc. Indications for Intubation • Is there failure of airway maintenance ? • Is there failure of airway protection ? • Is there failure of oxygenation or ventilation? • What is the anticipated clinical course ? (i. expected deterioration. long time in radiology.

angioedema dhs wahyubroto. Clinical Signs of Airway Compromise : Threatened Patency • Inspiratory stridor • Snoring ( pharyngeal obstruction ) • Gurgling ( blood/ secretions ) • Drooling ( epiglottitis ) • Hoarseness ( laryngeal edema/ vocal cord paralysis) • Paradoxical chest wall movement • Tracheal tug • Mass .abscess. hematoma. 8 .

Clinical Signs of Airway Compromise: Inadequate Protection • Blood in upper airway • Pus in upper airway • Persistent vomiting • Loss of protective airway reflexes – swallowing reflex is superior to gag reflex dhs wahyubroto. 9 .

10 .Clinical Signs of Airway Compromise: Oxygenation and Ventilation • Central cyanosis • Obtundation and diaphoresis • Rapid shallow respirations • Accessory muscle use • Retractions • Abdominal paradox dhs wahyubroto.

• Arterial blood gases should not be relied upon to assess whether intubation is necessary. 11 . dhs wahyubroto. Clinical Signs of Airway Compromise: Oxygenation and Ventilation • The assessment of oxygenation and ventilation is a clinical one.

Combitube. Retrograde. Bouge dhs wahyubroto. Fibreoptic. Light wand. 12 . LMA. Chin lift • Orophryngeal/ Nasopharyngeal airways • Bag-Valve-Mask Ventilation • Endotracheal Intubation • Advanced techniques – Cric. Techniques for the Compromised Airway • Head Positioning • Jaw Thrust.

13 . The Difficult Airway • Difficult Laryngoscopy – poor visualization of cords • Difficult bag-mask ventilation – unable to oxygenate or ventilate • Lower airway difficulty – severe bronchospasm dhs wahyubroto.

Golden Rules of Bagging • “ Anybody ( almost ) can be oxygenated and ventilated with a bag and a mask “ • The art of bagging should be mastered before the art of intubation • Manual ventilation skill with proper equipment is a fundamental premise of advanced airway Rx dhs wahyubroto. 14 .

BVM Ventilation • The most important airway skill • Always the first response to inadequate oxygenation and ventilation • The first “bail-out” maneuver to a failed intubation attempt • Attenuates the urgency to intubate • Do not abandon bagging unless it is impossible with two people and both an OP and NP airway dhs wahyubroto. 15 .

BVM Ventilation • Requires practice to master • One hand to – maintain face seal – position head – maintain patency • Other hand ventilates dhs wahyubroto. 16 .

17 . BVM Ventilation: Technique • Insert oropharyngeal/nasopharyngeal • “Sniffing”position if C-spine OK • Thumb + index to maintain face seal • Middle finger under mandibular symphysis • Ring/little finger under angle of mandible • Maintain jaw thrust/mouth open dhs wahyubroto.

Predictors of a Difficult Airway : BVM • Upper airway obstruction • Lack of dentures • Beard • Midfacial smash • Facial burns. 18 . scarring • Poor lung mechanics – resistance or compliance dhs wahyubroto. dressings.

Difficult Airway : BVM • degree of difficulty from zero to infinite • Zero = no external effort or internal device required • one person jaw thrust/ face seal • oropharyngeal or nasopharyngeal AW • two person jaw thrust / face seal – both internal airway devices • Infinite = no patency despite maximal external effort and full use of OP/NP dhs wahyubroto. 19 .

Algorithm for Difficulty “Bagging” • Remove Foreign Bodies . four-hand technique dhs wahyubroto.Magill forceps • Triple maneuver if c-spine clear – Head tilt. jaw lift. 20 . mouth opening • Nasal or oropharyngeal airways • Two-person.

21 . BVM Ventilation: Mask Seal Tips and Pearls • Easier to get seals with masks too large than too small • Inflate mask collar correctly • Apply lubricant to beards to “mat down” hair • If edentulous insert gauze sponges into cheeks dhs wahyubroto.

22 . Head extension dhs wahyubroto. Prediction of the Difficult Airway: Laryngoscopy • History of past airway problems – check previous OR anesthesia records if time permits – cricothyroidotomy scar • Careful physical assessment – mouth opening – tongue to pharyngeal size – hyo-mental distance – Neck flexion.

Technique of Laryngoscopy • “Sniffing” position to align oral-pharyngeal- laryngeal axis • Flex neck by placing pillow beneath occiput ( raise 10 cm ) • Extend head maximally • With laryngoscope – open mouth fully – push tongue to left out of view – pull upward at 45 degrees dhs wahyubroto. 23 .

24 .Adducted vocal cords dhs wahyubroto.

dhs wahyubroto. 25 .

26 . Predictors of Difficult Laryngoscopy • Short thick neck • Receding mandible • Buck teeth • Poor mandibular mobility/ limited jaw opening • Limited head and neck movement – ( including trauma ) dhs wahyubroto.

ankylosing spondylitis • Congenital syndromes • Neck surgery or radiation dhs wahyubroto. Difficult Airway : Laryngoscopy • Tumor. abscess or hematoma • Burns • Angioneurotic edema • Blunt or penetrating trauma • Rheumatoid arthritis. 27 .

28 . Predictors of Difficult Laryngoscopy • 3 fingerbreadths mentum to hyoid • 3 fb chin to thyroid notch • 3 fb upper to lower incisors • Head extension and neck flexion • Mallampati/mallimpadi classification • Previous history of difficult intubation dhs wahyubroto.

soft palate.soft palate. 29 . base of uvula • IV .soft palate not visible – 100% grade III or grade IV views dhs wahyubroto. Mallimpadi Classification (Tongue to Pharyngeal Size) • I . uvula visible • III . uvula.soft palate. tonsillar pillars visible – 99 % have grade I laryngoscopic view • II .

vomitus. alanto-occipital. C-spine) • Disproportion – thyomental.The 4 D’s of Difficult Intubation • Distortion – ( edema. blood. Mallimpadi. 30 . etc • Dentition – prominent upper teeth dhs wahyubroto. infection) • Dysmobility of joints – ( TMJ. tumor.

31 . Unsuccessful Intubation • Bag the patient • Maximize neck flex/ head ex • Move tongue out of line of site • Maximize mouth opening • ID landmarks and adjust blade • BURP maneuver (Backwards Upwards Rightwards Pressure on Thyroid Cart.) • Increasing lifting force • Consider Miller blade • Bag the patient dhs wahyubroto.