AIRWAY MANAGEMENT

IN MECHANICAL
VENTILATION

Yohanes WH George, SpAn

Intensive Care Unit
Pondok Indah Hospital
Jakarta
 MANUAL AIRWAY MANEUVERS
HEAD-TILT/CHIN-LIFT

 The preferred method

 Technique
 Position is at patient’s
side
 One hand on forehead
tilts patient’s head
back by exerting
downward pressure
with the palm
 Other hand grasps
under the chin and lifts
jaw anteriorly
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 BASIC AIRWAY MANAGEMENT
GENERAL PROCEDURES

 Ensure patent airway

 Protect cervical spine in suspected trauma
 Perform manual airway maneuvers for immediate
ventilation and oxygenation
 Use basic airway adjuncts as necessary
 Use advanced airway maneuvers to maintain the
airway effectively
 Use appropriate BSI precautions

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 MODIFIED JAW-
THRUST MANEUVER

 Used with trauma patients

 Head is firmly supported in
neutral position, not tilted back
or turned to the side
 Technique
 Place fingertips of each
hand on the angles of
lower jaw
 Displace the jaw forward

 Use thumbs to retract

patient’s lower lip
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 SELLICK’S MANEUVER

 Used to prevent gastric

distention that can
accompany intubation and
ventilation
 Technique
 Apply slight pressure
anteriorly over cricoid
cartilage
 Closes off esophagus

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 BASIC MECHANICAL AIRWAYS

 Oropharyngeal airway
– Indications
 Unconscious patients without a gag reflex
 Breathing or nonbreathing patients

 Used as a bite block in seizures and with

endotracheal tube in place

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 BASIC MECHANICAL AIRWAYS

 Oropharyngeal airway
– Contraindications
 Presenceof a gag reflex
 Severe maxillofacial injuries

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 OROPHARYNGEAL AIRWAY
ADVANTAGES

 Allows air to pass around and through the device.

 Helps prevent obstruction by teeth and lips.
 Helps manage unconscious patients who are
breathing spontaneously or need mechanical
ventilation.
 Makes suctioning of the pharynx easier.
 Bite block during seizures and ET protection

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 OROPHARYNGEAL AIRWAY
DISADVANTAGES

 Does not isolate the trachea.

 Cannot be inserted when teeth are clenched.
 May obstruct the airway if not inserted properly.
 Can be dislodged easily.
 Should never be inserted in a conscious or
semiconscious patient with a gag reflex.
 May precipitate vomiting and laryngospasm

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 OROPHARYNGEAL AIRWAY
MEASUREMENT/INSERTION

 Sizes range from #0 for infants to #6 for large adults.

 Size the OPA from the corner of the patient’s mouth
to the tip of the earlobe.
 Insert with the curved end facing up until the tip
reaches the level of the uvula, then rotate the airway
180° until it comes to rest over the tongue.
 Sized too long, can press epiglottis against the
entrance to the larynx causing obstruction.
 Sized too short, may force tongue back causing an
obstruction.

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 BASIC MECHANICAL AIRWAYS

 Nasopharyngeal airway
– Indications
 Breathing patients with a gag reflex

 Maxillofacial injuries

 Patients with clenched teeth

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 BASIC MECHANICAL AIRWAYS

 Nasopharyngeal airway
– Contraindications
 Nasal obstructions

 Patients prone to nosebleeds

 Head injuries (basilar skull fractures)

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 NASOPHARYNGEAL AIRWAY
ADVANTAGES

 Can be easily and rapidly inserted

 It bypasses the tongue
 May be used when a gag reflex is present

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 NASOPHARYNGEAL AIRWAY
DISADVANTAGES

 Does not isolate the trachea.

 Smaller than the oropharyngeal airway
 Difficult to suction through
 Can cause severe nosebleeds
 Can cause pressure necrosis of nasal mucosa
 Difficult to insert if nasal damage is present

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 SUCTIONING

 Equipment for suctioning

– Suction units
 Portable (hand, foot, oxygen, or battery
operated)
 Stationary (electrical or vacuum)

 Must generate vacuum levels of at least 300

mm Hg and flow rate of 30 liters per minute

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 SUCTIONING

 Equipment for suctioning

– Suction catheters
 Hard suction (tonsil tip)

– Rigid tube with holes at distal end

– Used to remove large particles from upper
airway
– Can be inserted along oral airway
– Can cause soft tissue damage

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 SUCTIONING

 Equipment for suctioning

– Suction catheters
 Soft suction (whistle tip)

– Long flexible tube that can extend into the

respiratory tract
– Cannot remove large particles or large
volumes of secretions

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 SUCTIONING

 Hazards
– Hypoxia from prolonged attempts (limit each
attempt to 10 seconds)
– Cardiac dysrhythmias due to hypoxia
– Vagal stimulation causing hypertension and
tachycardia or hypotension and bradycardia
– Stimulation of a cough reflex, reducing cerebral
blood flow

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 VENTILATION

 Goals
– To overcome natural elastic resistance of the lungs
– To maintain a good seal
– To maintain a patent airway
– To deliver adequate ventilatory volumes
– To avoid patient regurgitation

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 PROCEDURES AND DEVICES

 Mouth-to-mouth/mouth-to-nose
– Requires no adjunctive equipment
– Easy to maintain a good seal
– Provides limited oxygen concentration (16-17%)
– Unattractive procedure
– Risk of communicable disease

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 POCKET MASK

 Prevents direct contact with patient’s mouth

 Can be carried in purse, glove compartment
 One-way valve prevents contact with exhaled air
 Supplemental oxygen inlet (50% oxygen possible)

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 BAG-VALVE
DEVICES
 Delivers oxygen or room
air to a patient who cannot
breath independently
 Hyperexpands lungs,
improving alveolar
ventilation
 Prevents hypoxia
 Contains self-inflating bag,
one way valves, reservoir,
and transparent face mask
 Available in various sizes
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 BAG-VALVE CONCENTRATIONS

 Without oxygen - 21%

 With oxygen, no reservoir - 60%
 With oxygen and reservoir - 90 to 95%
 With demand valve attachment - 100%
 Should not contain a pop-off valve

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 DEMAND VALVE

 High-pressure tubing connected to oxygen supply

and activated by push button or lever
 Delivers 100% oxygen
 Easy to operate, manual trigger button
 Attaches to EOA or EGTA
 Often equipped with inspiratory release valve which
allows patient to breath

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 DEMAND VALVE DISADVANTAGES

 Does not provide a feel for chest compliance

 Barotrauma and gastric distention can be caused by
overventilation
 Oxygen tanks quickly drain
 Should not be used with intubated patients

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 ResQ-Valve™
1. It’s a one-way valve that fits
between the airbag -- used to
introduce air into the cardiac arrest
victim -- and the endotracheal
tube placed into the patient's throat
and lungs.
2. The valve can also be used with a
facemask that fits over the patient’s
nose and mouth and
other resuscitation devices.
3. During CPR the one-way valve
creates a small vacuum within the
victim’s chest, increasing the return
flow of blood to the heart
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Endotracheal Tube

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Endotracheal Tube

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Endotracheal Tube

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Endotracheal Tube

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Endotracheal Tube

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 ENDOTRACHEAL TUBE

 STANDARD TUBE: LOW PRESSURE HIGH VOLUME

(PLAIN PVC)
– Pria 8-9 MM: fiksasi pada 21-23 CM TO INCISORS (gigi
taring)
– Wanita 7-8 MM: fiksasi pada 19-21 CM TO INCISORS
– Jangan memotong tube dibawah 26 cm
 DOUBLE LUMEN TUBES: jarang di ICU (kecuali CVVH)
 Tube dari OK/OT harus diganti jika diperkirakan ekstubasi
> 48 HOURS

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Laryngoscopes & Blades

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 Straight (Miller)
Blade
– Visualize anatomy
– Insert from right to
left moving tongue
away
– Lift upward and away
– Blade past vallecula
and over epiglottis
– Lift epiglottis directly

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 Curved (Macintosh)
Blade
– Visualize anatomy
– Insert from right to
left
– Lift upward and
away
– Blade in vallecula
– Lift epiglottis
indirectly

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 Endotracheal Intubation

 Endotracheal Intubation
– Tube into the trachea to provide
ventilations using BVM or ventilator
– Sized based upon inside diameter in mm
– Lengths increase with increased ID
 cm markings along length
– Cuffed vs Uncuffed

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 Endotracheal Intubation
 Endotracheal Intubation
– Indications
 present or impending respiratory failure
 apnea

 unable to protect own airway

– Advantages
 secures airway
 route for a few medications

 optimizes ventilation and oxygenation

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 Endotracheal Intubation

 These are NOT Indications

– Because I can intubate
– Because they are unresponsive
– Because I can’t show up at the hospital without it

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 Endotracheal Intubation
 Complications of endotracheal intubation
– Bleeding or dental injury
– Laryngeal edema
– Laryngospasm
– Vocal cord injury
– Barotrauma
– Hypoxia
– Aspiration
– Dislodged tube or esophageal intubation
– Right or Left mainstem intubation

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 Endotracheal Intubation

 Techniques of Insertion
– Orotracheal Intubation by direct
laryngoscopy
– Blind Nasotracheal Intubation
– Digital Intubation
– Retrograde Intubation
– Transillumination techniques

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 Endotracheal Intubation
 Orotracheal
Intubation by direct
laryngoscopy
– Position & Ventilate patient
– Monitor patient
 ECG

 Pulse oximeter
– Assess patient’s airway for difficulty
– Assemble & check equipment (suction)
– Hyperventilate patient (30-120 sec)

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 Endotracheal Intubation
 Orotracheal
Intubation by direct
laryngoscopy (cont)
– Position patient
– Open mouth & insert laryngoscope blade
– Attempt to sweep tongue (straight blade)
– Identify anatomical landmarks
– Advance laryngoscope blade
 Valleculafor curved (Miller) blade
 Under epiglottis for straight (Miller) blade

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 Endotracheal Intubation
 Orotracheal
Intubation by direct
laryngoscopy (cont)
– Elevate epiglottis
– Directly with straight (miller) blade
– Indirectly with curved (macintosh) blade
– Visualize the vocal cords & glottic opening
– Enter the mouth with the tube from corner of
mouth

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 Endotracheal Intubation
 Orotracheal
Intubation by direct
laryngoscopy (cont)
– Advance into glottic opening approx. 1/2
inch past vocal cords
– Continue to hold tube & note location
– Inflate cuff until firm (approx 10 cc)
– Ventilate & Auscultate
 epigastrium

 left and right chest

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 Endotracheal Intubation

 Orotracheal
Intubation by direct
laryngoscopy (cont)
– Secure tube
– Reassess Ventilation Effectiveness
 auscultation

 clinical
signs
 end-tidal CO2

 Esophageal detection device

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 Endotracheal Intubation
 Equipment  Selection
– Laryngoscope Handle – Typical Adult ET
(lighted) & Blades Tube Sizes
– Stylet  Male - 8.0, 8.5
 Female - 7.0, 7.5, 8.0
– Syringe
– Magills – Blade
 Mac - 3 or 4
– Lubricant  Miller - 3
– Suction – Tube Depth
– BVM  Usually 20 - 22 cm at
– BNI the teeth

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 Endotracheal Intubation
 Pediatric Equipment  Pediatric Differences
Differences – Anatomic
– Uncuffed tube < 8 Differences
yoa
– Depth (cm)
– Miller blade  Tube ID x 3
preferred
 12 + (age/2)
– Tube Size  easily dislodged
 Premie: 2.0, 2.5
 Newborn: 3.0, 3.5
– Intubation vs BVM
 1 year: 4

 Then: (age/4)+4

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 Endotracheal
Intubation
 Patient Positioning
– Goal
 Align the 3 planes of
view, so that
 The vocal cords are
most visible
– T - trachea
– P - Pharynx
– O - Oropharynx

From AHA PALS

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Endotracheal Intubation

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 Endotracheal Intubation
Assessing the Possibility of Difficulty in Intubation
 Difficulty 

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Endotracheal Intubation

 What effect would

the angle of the
mandible have on
intubation
difficulty?

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Tube Positioning

From TRIPP, CPEM 62

 Endotracheal Intubation
 Blind Nasotracheal Intubation
– Position & Oxygenate patient
– Monitor patient
 ECG Monitor
 Pulse oximeter

– Assess for BNI difficulty or contraindication

– Assemble & check equipment
 Lubricate end of tube; Do not warm

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 Endotracheal Intubation

 Blind Nasotracheal Intubation (cont)

– Position patient (preferably sitting upright)
– Insert tube into largest nare
– Advance slowly but steadily
– Listen for sound of whistle via BAAM
– Advance tube
– Inflate cuff & Assess placement
– Secure & Reassess

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 Endotracheal Intubation
 Digital Intubation
– Blind technique
– Variable probability of success
– Using middle fingers to locate epiglottis
– Lift epiglottis
– Slide lubricated tube along side fingers
– Assess tube placement & depth as with
orotracheal intubation

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Endotracheal Intubation
Digital Intubation

From AMLS, NAEMT

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Airway & Ventilation Methods

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 Surgical Cricothyrotomy
– Indications
 absolute need for a definitive airway AND
– unable to perform ETT due for structural or anatomic
reasons, AND
– risk of not intubating is > than surgical airway risk
 OR

 absolute need for a definitive airway AND

– unable to clear an upper airway obstruction, AND
– multiple unsuccessful attempts at ETT, AND
– other methods of ventilation do not allow for effective
ventilation and respiration

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 Surgical Cricothyrotomy

– Contraindications (relative)
 No real demonstrated indication
 Risks > benefits

 Age < 8 years (some say 10)

 evidence of fx larynx or cricoid cartilage

 evidence of tracheal transection

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 Surgical Cricothyrotomy

– Tips
 Know your anatomy
 Short incision, avoid inferior trachea

 Incise, Do not saw

 Work quickly. Have a plan

 Be prepared with a backup plan

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 Needle Cricothyrotomy &
Transtracheal Jet Ventilation

– Indications
 Same as surgical cricothyrotomy along with
 Contraindication for surgical cricothyrotomy

– Contraindications
 None when demonstrated need
 caution with tracheal transection

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Jet Ventilation

– Usually requires
high-pressure
equipment
– Ventilate 1 sec then
allow 3-5 sec pause
– Hypercarbia likely
– Temporary: 20-30
mins
– High risk for
barotrauma

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 Alternative Airways

– Multi-Lumen Devices (CombiTube, PTLA)

– Laryngeal Mask Airway (LMA)
– Esophageal Obturator Airways (EOA,
EGTA)
– Lighted Stylets

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Pharyngeal Tracheal Lumen
Airway (PTLA)

From AMLS, NAEMT

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From AMLS, NAEMT
No
.2
No 15
. ml
15 2
ml
No
2.

No
.
2
No. 1
No. 1

No. 1 100 ml

No. 1
100 ml
Combitube®
 Combitube®

– Indications
– Contraindications
 Height

 Gag reflex
 Ingestion of corrosive or volatile substances

 Hx of esophageal disease

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 Laryngeal Mask Airway (LMA)
–  Use in OR
– Gaining use in out-
of-hospital
– Not useful with
high airway
pressure
– Not a replacement
for ETT
– Multiple models &
sizes

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LMA

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Laryngeal Mask Airway (LMA)
“Fastrach”

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The ASA Difficult Airway
Algorithm Using the LMA

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Esophageal Obturator Airway &
Esophageal Gastric Tube Airway

– Used less frequently today

– Increased complication rate
– Significant contraindications
– Better alternative airways are now available

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Esophageal Gastric Tube Airway
(EGTA)

From AHA ACLS 83

 Lighted Stylette

– Not yet widespread use

– expensive
– Another method of visual feedback re.
placement in trachea

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Lighted Stylette

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THANK YOU FOR
YOUR
ATTENTION

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