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Airway management

Med 5: Anaesthesia Module

Summary of skills
1. Resusc. Bag:
2. Airway obstruction:
3. Bag & Mask ventilation:
4. Laryngoscope:
5. Intubation of trachea:
6. Induction sequence:
7. Verify position of tracheal tube:

Resuscitation Bag Oxygen supply
connected here
10 L/min

1. Bag - self-inflating
2. Valve – unidirectional
3. Oxygen supply / reservoir
4. Face mask

Know how to assemble!

To transfer patients 2. Backup.Kept in theatre on wall 1. if machine fails .

Familiarize yourself with parts .

An relic of days of inflammable anaesthetic gases. . The carbon prevents static electricity (antistatic) and sparks. such as ether. Old style “size 4” face masks Note the air filled rubber seal which is contoured to fit the patient’s face They are black because the rubber contains carbon.

Mask held to show contours of face Recess angle of mouth Nose Cheek .

Finger positions when holding a face mask Fingers: Thumb & Index hold mask Middle & Ring under the jaw Little finger at angle of jaw Together they lift the jaw .

despite respiratory efforts. .  Eventually the patient will become hypoxic. Air cannot be moved in and out of the lungs. cyanosed and eventually arrest. Airway Obstruction  Patient cannot breath.  The patient may be very distressed.

Airway Obstruction & Level of Consciousness Conscious: Unconscious:  Natural tone of  Tone is lost & tissues muscles of pharynx collapse  [airway patent]  [airway obstructs]  Sleep:  Overdose  Loss of coordination  Snore / sleep apnea  Head injury  Stroke or MN disease  GCS < 8/15  Bulbar palsy .

Airway Obstruction  Functional: Patient is unconscious  Tongue & epiglottis falling backwards  When patient lies supine  Tongue impinging on roof of mouth  Mechanical: Blockage of the lumen  Foreign bodies (vomit / blood)  Swelling of soft tissues (infection)  Enlarged tongue of tonsils .

Patient position (Supine to lateral)  Recovery position (tongue falls forward) 2. Airway Obstruction  How is functional obstruction treated? 1. Airway devices that provide a patency :  Oral airway  Laryngeal mask airway  Endotracheal tube (ETT) . Jaw (lift) / neck (extension) maneuver  Lifts up the tongue & epiglottis 3.

Head in neutral position c. Patient lies supine b.Obstructed Airway a. Tongue & epiglottis fall backward onto the posterior pharyngeal wall .

Jaw lift / Head tilt b. Unobstructed Airway a a. Tongue & Epiglottis a now clear of posterior pharyngeal wall b .

A Resuscitation Annie is used to practice bag & mask skills. including jaw lift & head tilt and ventilation .

Neutral position Airway Obstructed Unable to ventilate Note position of hand on mask Two (2) fingers hold mask Three (3) fingers hold jaw Mask in tight contact with face .

bag .Jaw (lift) & Neck (extended) Airway now patent Tongue & epiglottis lifted up Able to ventilate lungs No resistance when squeezing resusc.

Ventilation  Rate: 12-15 per minute  Volume: reasonable chest movement  (~500 ml: Resusc. . Bag 2 litres)  It is important to observe (& auscultate) the chest (& abdomen) to confirm that you are ventilating the lungs and the tidal volume is acceptable.

Airway maneuvers:  Jaw (lift) & Head (tilt) {neck extended}  3. Providing a patent airway  1. Positioning of patient:  Recovery (lateral) position  2. Adjuncts to the airway:  Oral airways  LMA (laryngeal mask airway)  ETT (endotracheal tube)  4. By-pass the larynx:  Tracheostomy .

Oral airways can be used to overcome obstruction due to the tongue lying against the roof of the mouth 4 3 2 Oral airways come in different sizes .

The correct size needs to be selected. . Thus the ideal length of an oral airway is from the corner of the mouth to ear hole. Note the pharynx lies in same vertical plane as the ear and auditory canal.Cut away model shows how an oral airway provides a patent pathway to pharynx.

1. The correct sized oral airway is selected Note that the airway is orientated in the position it will take up when inserted into the mouth .

2: This one (size 3) is the correct size .

3: The head is tilted to open the jaw and the airway is inserted towards the hard palate to avoid the tongue Note that for insertion the airway has been rotated 180o .

4: The airway is rotated back to its correct orientation as advanced into the mouth .

Inflatable cuff (25-30 ml air) 2. The LMA (laryngeal mask airway) 2 3 1 1. Pilot balloon (with syringe) 4. Stalk with universal (15 mm) connector 3. Plastic / reused < 40 times .

LMA with cuff inflated

The LMA is a relatively new innovation
in anaesthesia, introduced in the late 1980s

Placement of an LMA in an anaesthetized patient

The LMA is inserted into the mouth of the unconscious patient
and advanced into the pharynx until it will go no further. Then
the cuff is inflated with 25-30 ml of air. It is then checked for
patency and the ability to ventilate both lungs.

Cut away model showing how
the LMA is positioned over the
laryngeal opening in pharynx
when its cuff is inflated

Design of ETT (endotracheal tube)
Plastic:
a
Clear, disposable & non-allergy
Cuff with Pilot balloon (5-10 ml air)
Seal to keep air (in) / vomit (out)
Connector (a):
Universal size 15 mm
Markings:
Size, length & position

Cut away model showing position of ETT in airway Mark on ETT to help position it at level of vocal cords .

Close up view of the inflated cuff & pilot balloon and the markings (a) that denote the placement level with respect to the vocal cords a .

Some more unusual airway tubes Armoured non-kinking tube Old style red rubber double lumen tube used for lung surgery Armoured preformed tracheostomy tube for intra-operative use Latex nasal airway .

The light is housed in the handle with an optical conduit in the blade. .Machintosh Laryngoscope: Upper scope is ready for use with light switched on. Lower scope is in off position.

Disassembled Laryngoscope a Identify: Handle. blade. light source (a) & batteries with housing Note that the blade has a optical conduit to transfer light source Older style scopes had a screw in light bulb on the blade .

Laryngoscope held in LEFT hand. Person intubating stands at head end of patient Note (a) how the handle is grasped and (b) The orientation of blade in the mouth Note: Too much pressure on upper teeth .

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View of larynx from above: Be able to identify: Base of tongue Epiglottis Vocal cords Trachea Arytenoids Oesophagus .

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Identify structures .

Identify structures Note nodule on closed vocal cords .

Identify structures .

.Laryngoscope blade is positioned at the valecula (base of tongue) superior to the epiglottis Note that the blade is inserted carefully into the mouth and walked down the tongue to be positioned at its base.

However much he tries you cannot see the larynx!! .

Outline of upper airway TONGUE Posterior tongue & epiglottis obstruct view of larynx. During laryngoscopy they are displaced forward by scope blade .

A: The pathway from the mouth to larynx is a right angle in the neutral position .

B: But when the neck is extended The pathway becomes a straight line The tongue & epiglottis remain a problem and have to be displaced by using a laryngoscope .

A: Neutral position: Laryngoscope blade only reveals posterior wall of pharynx .

B: With neck extended and scope blade used to displace tongue forward. the larynx is visualized .

Induction of anaesthesia  You need to learn how to bag & mask ventilated a patient’s lungs and then successfully intubate the patient following the induction of anaesthesia. .

Have the correct equipment 2. Intubation (+ inflate cuff) 6. Pre-oxygenate & Induce anaesthesia 3. Laryngoscopy 5. Check position of tube . Sequence of events 1. Bag & mask the patient (± oral airway) 4.

An Airway Trainer is used .

1: It is important to have all the equipment you need ready and checked before you start .

Equipment required  Ventilation:  Intubation:  Resuscitation bag  Laryngoscope  Face mask  Endotracheal tube  Stylet  10 ml syringe  Airway obstruction:  Tube position:  Selection of airways  Stethoscope  ETCO2 monitor .

2: The patient is pre-oxygenated before induction .

This provides a store of oxygen in the lungs that will last up to 3-5 minutes if any problem is encountered during ventilation & intubation .

(Muscle relaxation follows) . Intravenous anaesthetic is injected and it takes 30-60 seconds for the drugs to reach the brain and the patient to fall asleep.Anaesthesia & unconsciousness are induced.

One must check that the patient is fully anaesthetized and not rousable before continuing .

3: The patient’s lungs are ventilated using a bag & mask to assure oxygenation. This is usually done for 3 minutes to allow muscle relaxants to take full effect Rate = 12-15 breaths per min .

Occasionally difficulty (obstruction) is encountered whilst ventilating and an oral airway is needed .

4: When you are ready (after 3 min) you can attempt laryngoscopy. Remember to visualize the cords first .

You may experience difficulty with the trainer when passing the tube .5: Now intubate the trachae.

You should use a metal stylet to make the tube firmer .

The stylet is passed through the lumen of the tube .

You can also spray silicone lubricant on the tube tip After using silicone lubricant your hands may feel sticky! Wash them afterwards .

This co-insides with the mark at the cords .The endotracheal tube should be inserted to ~22 cm at the lips.

you end up ventilating one lung .If you insert tube is insert to far (>22 cm).

This leads to lung collapse (left) and hypoxia .Only the right side lung is being ventilated.

This prevents air leakage during ventilation Balloon feels firm Note the valve that has to be depressed to admit air into the system .The cuff is inflated with 5-10 ml of air.

Auscultate both lungs & stomach (oesophagus) .6: You must check that the tube is in the trachea.

Also check that CO2 is detected in the expired gas .

. Oesophageal Intubation  The tube is easily put in the oesophagus:  This is a potential disaster!!!  The patient receives no oxygen  However. after 3-5 min  The patient’s stomach is blown up with gas  The patient is likely to regurgitate / vomit  Lungs are unprotected from aspiration  If uncorrected the patient will arrest & die. hypoxic is delayed (pre-O2)  Problems become manifest later.

oesophageal intubations can be identified and the tube correctly positioned .An oesophageal Intubation: Note the position of ET tube By checking the position of the tube after intubation.

An Oesophageal Intubation: ET tube in oesophagus .

Workshop  You will practice these skills at an airway management workshop and on patients in the operating theatre during this attachment  Thanks to Eric Ng (Elective Student) who helped with the photographs .

Appendix .

lung abscess and even death. . Cricoid Pressure (Slide 1)  In some cases presenting for anaesthesia the stomach is not fully empty and there is a risk during induction of anaesthesia that the patient may regurgitate and stomach contents will be aspirated into the lungs leading to pneumonia.  Patients at risk tend to be emergency cases who have not been adequately fasted.

Cricoid Pressure (Slide 2)  To prevent aspiration in such cases induction of anaesthesia is modified:  A rapid sequence of induction followed by intubation. without lung ventilation. . is performed.  Cricoid pressure involves pressing on the patient’s larynx (cricoid) with the objective of closing off the oesophagus.  To prevent regurgitation a procedure called cricoid pressure is done during intubation.

Notice the position with respect to the oesophagus a b .Larynx showing thyroid cartilage (a) and cricoid (b).

Downward pressure is applied to the cricoid which is transferred to the oesophagus Oesophagus is closed off .

Demonstration of Cricoid Pressure on a model .