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‡ Recognise signs of threatened airway
‡ Describe techniques of establishing airway
and for mask ventilation
‡ Explain proper applications of airway
‡ Describe preparation for endotracheal
intubation and difficult intubation
‡ Describe alternative methods

cssess underlying need for airway control

‡ Duration of intubation
- Nasal intubation less advantageous for potentially prolonged ventilator
‡ Permanent support
- Underlying advanced intrinsic lung or neuromuscular disease
‡ Temporary support
‡ cnesthesia
‡ Presence of reversible intrinsic lung or neuromuscular disease
‡ Protection of the airway due to depressed mental status
‡ Presence of reversible upper airway pathology
‡ Patient care needs (e.g., transport, CT scan, etc.)
‡ Significant comorbidities
¦ cspiration potential or increased respiratory secretions
¦ Hemodynamic issues such as cardiac disease or sepsis
¦ Renal or liver failure

Pathophysiology of the respiratory

‡ Hypoxic respiratory failure
- In case of hypoxic respiratory failure, different
noninvasive oxygen delivery devices can be used.
- The severity of hypoxia and presence or absence of
underlying disease (such as COPD) will dictate the
device of choice.
‡ Hypercapnic respiratory failure
- The noninvasive device of choice for hypercapnic
respiratory failure is BIPcP.

‡ Respiratory rate and use of accessory muscles
- Is the patient in respiratory distress?
‡ cmount of supplemental oxygen
- What is the patient¶s oxygen demand?

‡ cnatomy
- Will this patient be difficult to intubate?
‡ Patency
- Is there a reversible anatomical cause of respiratory failure
as opposed to intrinsic lung dysfunction?
(In order of degree of support)

Nasal Cannula
‡ 4% increase in FiO2 for each 1 L of flow (e.g., 4 L flow = 37% or 6 L flow
= 45%)

Face tent
‡ ct most delivers 40% at 10-15 L flow

‡ Small amount of rebreathing
‡ 8 L flow = 40%, 15 L flow = 60%

Nonrebreather mask
‡ cttached reservoir bag allows 100% oxygen to enter mask with
inlet/outlet ports to allow exhalation to escape - does not guarantee
100% delivery.

Respiratory pattern
‡ cccessory muscle use is an indication of distress.
‡ Rate > 30 can indicate need for more support by noninvasive positive
pressure or intubation

Need for artificial airway

‡ Tongue and epiglottis fall back against posterior pharyngeal wall
‡ Nasopharyngeal airway better tolerated

Pulse oximetry
‡ O2 saturation less than 92% on 60 - 100% oxygen can suggest the need
for intubation based on whether there is anything immediately reversible
which could improve ventilation.

crterial blood gas

‡ pH < 7.3 can indicate need for more support by noninvasive positive
pressure or intubation.

Naloxone for narcotic overdose

‡ 40 mcg every minute up to 200 mcg with:
- 45 minutes to one hour duration of action
‡ 0.4 - 2 mg of naloxone is indicated in patients with respiratory arrest and
history suggestive of narcotic overdose
- There is a potential for pulmonary edema, so large dose is reserved
for known overdose and respiratory arrest
‡ Caution in patients with history of narcotic dependence
‡ Naloxone drip can be titrated starting at half the bolus dose used to
obtain an effect
- Manufacturer recommended 2 mg in 500 ml of normal saline or D5
gives 0.004 mg/ml concentration
Flumazenil for benzodiazepine overdose
‡ 0.2 mg every minute up to 1 mg
‡ Caution in patients with history of benzodiazepine or alcohol dependence
‡ Caution in patients with history of seizure disorder as it will decrease the
seizure threshold

crtificial airway for upper airway obstruction in patients

with oversedation
‡ May be necessary in patients with sleep apnea despite judicious sedation

100% oxygen and maintenance of spontaneous

ventilation in patients with pneumothorax
‡ Washout of nitrogen may decrease size of pneumothorax
‡ Positive pressure may cause conversion to tension pneumothorax





‡ tip of mandible to hyoid bone (three finger breaths)


‡ With the head fully extended and mouth closed



‡ cbout one third of diabetics characterized by short stature, joint rigidity, and tight waxy skin
‡ Positive prayer sign with an inability to oppose fingers






) * Uvula/tonsillar pillars visible

) * Tip of uvula/pillars hidden by tongue
) * Only soft palate visible
) '* Only hard palate visible



Potential for aspiration requires rapid sequence intubation with
cricoid pressure
‡ Clear liquids < 4 hours
‡ Particulate or solids < 6hours

Potential for hypotension

‡ Cardiac dysfunction, hypovolemia, and sepsis
‡ May need to consider awake intubation with topical anesthesia
(aerosolized lidocaine) as sedation may precipitate hemodynamic
compromise and even arrest.

Organ failure
‡ Renal and hepatic failure will limit medication used.
‡ Potential for preexisting pulmonary edema and airway bleeding from

Sodium Thiopental
‡ 3 - 5 mg/kg IV
‡ Profound hypotension in patients with hypovolemia, histamine release, arteritis
‡ Dose should be decreased in both renal and hepatic failure.
‡ 2 - 3 mg/kg IV
‡ Hypotension, especially in patients with systolic heart dysfunction, bradycardia,
and even heart block
‡ Unlikely to have prolonged effect in organ failure
‡ 1 - 4 mg/kg IV, 5 - 10 mg/kg IM
‡ Stimulates sympathetic nervous system
‡ Requires atropine due to stimulated salivation and midazolam for potential of
‡ cvoid in patients with loss of autoregulation and closed head injury
! + "
‡ 1 - 2 mg/kg IV, 4 mg/kg IM
‡ cvoid in patients with malignant hyperthermia, > 24 hours out from burn or
trauma injury, upper motor neuron injury, and preexisting hyperkalemia

‡ 0.6 - 1.2 mg/kg, highest dose required for rapid sequence
‡ Hemodynamically stable, 10% renal elimination

‡ 0.1 mg/kg
‡ Hemodynamically stable, 10% renal elimination

‡ 0.2 mg/kg
‡ Mild histamine release, Hoffman degradation, not prolonged in renal or
hepatic failure

Preoxygenate for three to five minutes prior to induction

‡ Wash out nitrogen to avoid premature desaturation during intubation.

Cricoid pressure should be applied from prior to induction until

confirmation of appropriate placement.
Succinylcholine 1 - 2 mg/kg IV will achieve intubation
conditions in 30 seconds; Rocuronium 1.2 mg/kg IV will
achieve intubation conditions in 45 seconds.
‡ Other muscle relaxants do not produce intubation conditions in less than
60 seconds.

cvoid mask ventilation after induction.

‡ Potentially can inflate stomach
‡ Use only if necessary to ensure appropriate oxygenation during
prolonged intubation.
*+þm @m (Reference #6)
)  m

Cricoid is circumferential
Pressure obstructs
esophagus to prevent
escape of gastric
Maintains airway patency

Î&  '


clign oral, pharyngeal, and laryngeal axes to
bring epiglottis and vocal cords into view.



Mask ventilation crucial,
especially in patients who are
difficult to intubate
Sniffing position with tight
mask fit optimal
May require two hands
@ -!  









þ$* Full glottis visible

þ%* Only posterior commissure
þ* Only epiglottis
þ/* No glottis structures are visible

* ,Î


Direct visualization
Humidity fogging the endotracheal tube
End tidal CO2 which is maintained after > 5 breaths
‡ Low cardiac output results in decreased delivery of CO2

Refill in 5 seconds of self-inflating bulb at the end of the

endotracheal tube
Symmetrical chest wall movement
Bilateral breath sounds
Maintenance of oxygenation by pulse oximetry
cbsence of epigastric auscultation during ventilation


clways have additional personnel and an experienced

provider as backup available for potential failed
clways have suction available
Never give a muscle relaxant if difficult mask ventilation
is demonstrated or expected
cwake intubation should be considered in the following:
‡ If patient is so hemodynamically unstable that induction drugs cannot be
tolerated (topicalize airway)
‡ If patient has a history or an exam which suggests difficult mask
ventilation and/or direct laryngoscopy
, - .   


Blind nasal intubation
‡ Bleeding may cause problems with subsequent attempts.
‡ Contraindicated in patients with facial trauma due to cribiform plate disruption or
CSF leak
‡ cvoid in immune suppressed (i.e., bone marrow transplant)
Eschmann stylet
Fiber optic bronchoscopic intubation
‡ cwake vs. asleep
Laryngeal mask airway
‡ cllows ventilation while bridging to more definitive airway
Light wand
Retrograde intubation
‡ Through cricothyrotomy
Surgical tracheostomy

Use especially if Grade III

view achieved
Direct laryngoscopy is
Place Eschman where
trachea is anticipated
May feel tracheal rings
against stiffness of stylet
Thread 7.0 or 7.5 ETT
over stylet with the
laryngoscope still in place

Essentially what is used to do a
Can be used to thread an
endotracheal tube into the
trachea either while the patient
is asleep or on an awake
patient with a topicalized airway
Via laryngeal mask airway in
place due to inability to intubate
with DL:
‡ airway exchange catheter can be
threaded over the FOB to be placed
into trachea upon visualization
‡ Wire-guided airway exchange catheter
can also be used with one more step

Guide the LMc along the

Eventual position should
be underneath the
epiglottis, in front of the
tracheal opening, with the
tip in the esophagus
FOB placement through
LMc positions in front of

p  -
 1 2,342 3.  ' ' 



Reinforced LMc allows for

passage of ETT without
visualization of trachea.
10% failure rate in
experienced hands
20% failure rate in
Transillumination of trachea
with light at distal end
Trachea not visualized
Should not be used with
tumors, trauma, or foreign
bodies of upper airway
Minimal complication
except for mucosal bleed
10% failure rate on first
attempt in experienced

Puncture of the
cricothyroid membrane
with retrograde passage of
a wire to the trachea
Endotracheal tube guided
endoscopically over the
wire through the trachea
Catheter through the
cricothyroid can be used
for jet ventilation if

Ô  *


Emergency airway used mostly by
paramedics and emergency
physicians for failed endotracheal
Ventilation confirmed through blind
blue tube
‡ Combitube is in the esophagus and salem
sump can be placed through white tube

Ventilation confirmed through white

(clear) tube with patent distal end
‡ Combitube is in the trachea and salem sump
should be placed outside of combitube into
‡ Fiber optic exchange can be accomplished
through combitube

Should be changed to endotracheal tube (ETT) or

tracheostomy to prevent progressive airway edema
If in esophagus, take down pharyngeal cuff and attempt direct
laryngoscopy (DL) or fiber optic bronchoscope (FOB)
placement around combitube
Failed exchange attempt can be solved with operative
Placement of combitube can produce significant airway
‡ Removal prior to DL or FOB should be done with caution after thorough airway
‡ Cricoid pressure should be maintained and emergency tracheostomy equipment

Surgical airway through

the cervical trachea
Emergent procedure
carries risk of bleeding
due to proximity of
innominate artery
Can be difficult and time
consuming in emergent

- !p

1. Caplan Rc, et al. Practice guidelines for management of the
difficult airway.   
2. Langeron O, et al. Predictors of difficult mask ventilation

3. Frerk CM, et al. Predicting difficult intubation.  

4. Tse JC, et al. Predicting difficult endotracheal intubation in
surgical patients scheduled for general anesthesia

5. Benumof JL, et al. LMc and the cSc difficult airway
6. Reynolds S, Heffner J. cirway management of the critically
ill patient. '