Basic Airway

Management
 Anatomy
• Upper airway- begins with the face and skeletal
structures. The nasopharynx, tongue and oropharynx help
with air transfer to the lower airways humidifying gases
and clearing debris.

• Middle airway- composed of the larynx soft tissue,

cartilage, thyroid and cricoid membrane. In the larynx lies
the vocal cords. Easily obstructed by secretions edema and
foreign bodies.

• Lower airway- the trachea is made up of incomplete

cartilaginous rings held together by elastic musculature
posteriorly. The trachea travels down the anterior chest
bifurcating into the right and left bronchi.
 When to Manage the Airway
• Always in a code or critical situation
– Agonal breathing can be confused with normal
breathing
• Hypoxemia (not oxygenating)
• Hypoventilation (not ventilating)
• Tissue hypoperfusion (not perfusing)
• Failure to protect the airway (I.e. severe
intoxication, CNS injury, GCS < 8)
• Anatomical disruption (I.e. burns, facial injuries,
epiglottitis, angioedema)
• Logistical considerations
 Basic Principles of Airway
Management
• Always optimize oxygenation
• Assess the airway
• Prepare your equipment
• Position the patient appropriately
• Use airway adjuncts
• Be good at bag-valve-mask ventilation
• Have a backup plan
 Airway Assessment
• History-based assessment (difficult baseline anatomy,
distorted anatomy, previous difficult intubations)
• Mallampati scoring
• Thyromental distance
• Relevant injuries/acute medical problems (facial
fractures, edema, bleeding, emesis)
• Facial hair
• Obesity
• Limited neck mobility
• No teeth/false teeth
• Stiff lungs/ difficult ventilation
 Basic Equipment
• Oxygen source
• Suction
• BVM (appropriate size and fit)
• Oropharyngeal airway (OPA) and/or nasopharyngeal
airway (NPA)
• Laryngoscopy equipment (handle, straight or curved
blade, bulb, magills)
• ETT appropriate size with stylet
• ETT confirmation methods (endtidal CO2, stethoscope,
spo2 monitor)
• Backup/rescue devices (LMA, combitube, bougie, etc.)
 Preoxygenation
• Optimize SaO2 prior to
intubation whenever
possible
• May deliver supplemental
oxygen via non-
rebreather mask or BVM
• Aggressive ventilation
should be discouraged for
patients with suspected
full stomach
BVM
Oropharyngeal Airway
Nasopharyngeal Airway
Laryngeal Mask Airway (LMA)
Combitube
 Endotracheal intubation

• Indications =
– Unable to adequately ventilate with a bag-valve-mask
– Absence of airway protective reflexes
• Complications =
– Prolonged hypoxia time with inexperienced operator
– Placement in esophagus
 Endotracheal intubation
• Remove dentures. Suction and clear oropharynx
of blood vomit and secretions.
• Hold cricoid pressure.
• Position patients head to sniffing position.
Patients with suspected c-spine injuries will have
in-line stabilization through all events.
• Laryngoscope blade is chosen by the intubator.
Curved (Macintosh) blade is better used to
mobilize the tongue. The straight (Miller) blade
is used to lift the epiglottis.
 Endotracheal intubation
• Place laryngoscope blade in the right side of the
patient’s mouth and sweep the tongue away to the left
as you advance.
• Identify the vocal cords.
• Place the ETT through the cords. Stop advancing once
the balloon has passed completely through the cords.
• All intubations should initially be performed with a stylet.
• Inflate the ETT cuff.
• Confirm tube position.
• Release of cricoid pressure.
• Secure the ETT, noting position of the tube at the teeth.
Laryngoscopy
Laryngoscopy
The Cords
 Post-Intubation Management

• Confirm tube placement

• Ventilate via bag valve device
• Monitor respiratory dynamics
• Orogastric tube placement
• Long acting NMB and sedation
• Monitor for signs of inadequate ventilation
• Monitor lipline/position at teeth to guard against
ETT dislodgement
End-Tidal CO2 Detectors
 Other Methods of Confirming
Tube Placement
• Equal breath sounds bilaterally
• Absence of gastric sounds
• SaO2
• Condensation in the ETT
• Balloon detection devices
• Quantitative EtCO2
• Direct visualization
• Chest X-ray
Securing the ETT
 Complications of Airway
Management
• Hypoxia during management
• Unrecognized esophageal intubation
• Aspiration
• Bleeding, edema of the pharynx and/or larynx
• Tracheal injuries
• Pneumothorax
• Barotrauma
• Hyper/hypoventilation
 Advanced Airway Management
• Advanced techniques
– Nasal intubation
– Fiberoptic intubation
– Retrograde intubation
– Cricothyroidotomy
– Light wand
• Medications
– Sedatives
– Paralytics
– Adjuncts (Increased ICP, bronchospasm, pediatrics)
– Rapid Sequence Intubation (RSI)
 Conclusion
• Always manage the airway in a critical situation
• High-flow oxygen via nonrebreather facemask
• Position patient to open airway
• Use airway adjuncts
• Be good at BVM ventilation
• Don’t spend a lot of time trying to intubate
• Be familiar with advanced airway devices
– LMA & combitube
• If intubating, confirm placement & abort if
unsure
Questions?