AIRWAY

MANAGEMENT
AND COMMON
CONDITIONS
The Reality of Airway Management

◦ Adequate ventilation is the Gold Standard of airway management.

◦ Invasive airways pose their own set of risks.
◦ ETI require high level of skill, and skill rust-out is a legitimate concern.
Steps in Airway Management

◦ Positioning, supplemental oxygen

◦ Suctioning

◦ Airway adjuncts

◦ NIPPV or CPAP
◦ Endotracheal intubation!
◦ Surgical airway
Positioning

◦Supine positioning results in a 20% reduction in respiratory capacity.

◦ Exacerbated in the obese Exacerbated in CHF patients
◦Semi Fowler’s aids the patient in managing their own airway and limits the
possibility of aspiration.
◦Oxygen supplementation should be guided by clinical evaluation and pulse
oximetry.
◦Derangements and trends in ventilation are best recognized through clinical
assessment and waveform capnography.
Airway Adjuncts
◦ Oropharyngeal airways

◦ Not possible in the conscious patient

◦ Limited protection against aspiration

◦ Of limited use in subglottic obstruction

◦ Nasopharyngeal airways

◦ Possible in conscious patients

◦ More dependent upon proper positioning.

◦ Limited utility with excessive pulmonary secretions.

◦ Of limited use in subglottic obstructions

NIPPV

◦ Traditionally known as CPAP (Constant Positive Airway Pressure).

◦ Current terminology is NIPPV (Non Invasive Positive Pressure Ventilation).
◦ Maintaining a higher-than-normal airway pressure helps prevent collapse of alveoli and
maximizes:
◦ Alveolar ventilation Pulmonary gas exchange
◦ Very effective intervention for CHF exacerbation or acute pulmonary edema, toxic inhalation,
etc
Endotracheal Intubation

◦ Most invasive
◦ Requires a high degree of skill and training
◦ Requires frequent practice and refresher training
◦ Tubes are cheap, effective training is not!
AIRWAY MANAGEMENT
DOES NOT MEAN
ENDOTRACHEAL
INTUBATION !
What does Airway Management Mean ?
◦ It means to ensure Patency, provide adequate Ventilation
and maintain appropriate Oxygenation.
◦ Many times we forget the basics
◦ Merely providing a chin lift or jaw thrust can open and/or
salvage many airways.
◦ The proper use of adjuncts (oral/nasal airways), can
convert a difficult-to-ventilate patient into a stable, well-
ventilated one.
◦ The appropriate administration of high-
flow oxygen, with properly fitted
masks, is enormously beneficial.
◦ èWe must never forget that airway
management is a collection of skills and
techniques, not just an attempt to place a
tube or device into the patient’s mouth or
trachea
GOALS OF AIRWAY MANAGEMENT

1. Relieve airway obstruction (e.g. head tilt-

◦ jaw thrust, finger sweep, suctioning)
1. Prevent aspiration (e.g. blood, foreign materials,stomach
contents > leads to pneumonitis > 50% mortality rate
2. Maintain adequate ventilation/gas exchange

C-Spine Injury
10 COMMANDMENTS OF AIRWAY
MANAGEMENT
1) Oxygenation and ventilation are the top priorities
2) Airway management does not mean intubation. It means to ensure
patency, provide adequate ventilation and maintain appropriate
oxygenation. Many times we forget the basics.
3) Be an expert at bag-valve-mask (BVM) ventilation .
4) Know your equipment
That daily check sheet is there for a reason. Airway equipment is
one of the most important items you
◦ carry. Having backups (laryngoscope blades, bulbs,
handles, adjuncts) and the ability to troubleshoot equipment are also
important. Assume personal responsibility for all airway
equipment and its proper functioning.
5. Know at least 1 rescue Ventilation technique.

Rescue ventilation can best be described as a ventilation attempt to use in the face of a
failed airway (can’t intubate/can’t ventilate) scenario. The most basic rescue technique is
two-person BVM ventilation. Next, the use of the SGA is recommended. It is easy to use,
can be inserted quickly and safely, and can accomplish ventilation when previous airway
attempts fail. It allows for blind insertion in the most difficult of patients and situations and
provides some protection against aspiration and higher airway pressures.
6. Develop a personal airway algorithm

Each provider should have an algorithm specific to their skill level and approved scope of
practice. Not all patients and situations you encounter are going to be the
◦ same. Having only one or two airway skills in your repertoire can lead to a
potentially dangerous approach to airway management. Everyone’s algorithm
should begin with the basics. For example, start with BVM ventilation,
advance to ET intubation, then place a SGA, and finally perform a surgical
cricothyrotomy. This plan should be calmly practiced and mastered.
7. Don’t let your ego get in the way

This can be dangerous for your patient, your partner or colleagues, and your
◦ career. Remember, your goal is excellent patient care and a positive outcome, not
skill accumulation or personal success. . Don’t ever forget to ask for assistance when
you need it.
8. Invest time in learning airway skills
Regularly devote training and practice time to airway management. Try not to limit yourself to manikin
airway trainers if possible. Work on gaining access to the simulator lab,operating room or emergency
department. Also, read about the latest techniques and advances in airway management. Attend
conferences and airway obstacle courses for more hands-on training. :
9. Use CAPNOGRAPH & an end tidal CO2 detector and/or
esophageal detector device to assist you in confirming every
intubation .

10. When seconds count, don’t count on seconds.

Each airway maneuver or intubation attempt should be your best
effort. Often, our best chance at getting a decent airway is the first
attempt. Maximize your chances by leaving nothing to chance.
Being prepared often means the difference between success and
failure.
“I don’t Always Intubate …

But when I do I use RSI”

 Rapid sequence intubation (RSI)

Is an airway management technique/protocol that

produces immediate unresponsiveness (induction agent)
and muscular relaxation (neuromuscular blocking agent)
and is the fastest and most effective means of controlling
the emergency airway.

RSI is particularly useful in the patient with an intact gag

reflex, a “full” stomach, and a life threatening injury or
illness requiring immediate airway control.
 Remembered as the 9Ps of RSI:

Plan
Preparation (drugs, equipment, people, place)
Protect the cervical spine
Positioning (some do this after paralysis and induction)
Preoxygenation
Pretreatment (optional; e.g. atropine, fentanyl and
lignocaine)
Paralysis and Induction
Placement with proof
Postintubation management
Airway Disease

A mother brings in her three year old child saying she is having
problems breathing.
The child is drooling but has normal lung sounds.
When she cries, however, you note inspiratory stridor.
Upper Airway Conditions Causing Respiratory Difficulty

D/D –
Croup
Epiglottitis
Foreign Body
Retropharyngeal Abscess
Angioedema/Anaphalaxsis
Soft Tissue Lateral of Neck
Abnormal or Normal?
Foreign Body Lodged in Esophagus
In evaluating a lateral neck Xray, start by
following the tongue to its base, the
vallecula –yellow dots.
The soft-tissue structure projecting
cephalad is the epiglottis –red dots.
The hyoid bone is outlined in green dots.
The pre-vertebral soft tissue below C3 is
thicker than above because it includes
the esophagus.
The foreign body is located in front of C5
in the esophagus.
Normally air is not visible in the
esophagus, if present, it may indicate a
radiolucent foreign body.
What history might result in this Xray?
Croup

A history of a barking
cough and URI
symptoms for the
past few days is likely.
Note air in the ventricle of
the false vocal cords and
the subglottic narrowing.
Croup
Note subglottic
steeple sign –
the ‘empire state
building’ upper
trachea as opposed
to the ‘squared off’
upper trachea.
What’s the history?
 Retropharyngeal Abscess
As in croup , this is most likely to
occur in 6 month to 3year olds.
Patients are usually febrile and
toxic appearing.
Elderly alcoholics are also prone
to these abscesses.
Remember, in young children, the
pre-vertebral soft tissue may
appear falsely widened if the
Xray was taken during the
expiratory phase of respiration.
If in doubt, repeat an inspiratory
lateral neck Xray with the neck
in extention.
History?
Epiglottitis

Acutely febrile, toxic

appearing child who most
likely did not receive
immunizations.
Note both the thickened
epiglottis and thickened
aryepiglottic folds.