AIRWAY MANAGEMENT

1
AIRWAY MANAGEMENT

• J.Vijay
• Intern
• Respiratory therapy

2
Definition

• Airway management involves ensuring that the
  patient has a patent airway through which
  effective ventilation can take place.

3
Purpose

• An obstructed airway means that the body is
  deprived of oxygen. If ventilation is not
  reestablished, brain death will occur within
  minutes.
• The primary purpose of airway management is to
  provide a continuously open airway along with a
  continuous source of oxygen.
• When a patient is critically ill and requires an
  artificial airway and mechanical ventilation, it
  is the responsibility of the healthcare
  professionals caring for the patient to ensure
  that the airway is secure.
• Another goal of airway management is to provide
  an artificial airway that is as close to the
  patient's natural airway as possible. This may
  mean mechanically performing physiological
  functions such as humidifying inspired air and
  removing secretions.

4
Precautions

• Airway management is a necessity for any patient
  who has an artificial airway.
• If the patient is restless or agitated, it is
  recommended that activities such as suctioning or
  endotracheal tube care be postponed until either
  the patient is calm or a sedative has been given.
  
• This is to avoid inadvertent removal of the
  airway.
• However, if the patient's respiratory status is
  unstable, suctioning or repositioning the
  endotracheal tube should be done if it will
  stabilize the patient.

5
Humidification

• Humidification of inspired air normally takes
  place in the upper respiratory tract.
• When this area is bypassed by an artificial
  airway (such as an endotracheal or tracheostomy
  tube), humidification must be performed out-side
  the body.
• If supplemental oxygen is used, it will require
  humidification to prevent drying and irritation
  of the respiratory tract and to facilitate
  removal of secretions.
• There are humidification devices available that
  can be attached to oxygen flow meters or
  ventilators.

6
Anatomy and Physiology

• The airways can be divided in to parts namely
• The upper airway.
• The lower airway

7
UPPER RESPIRATORY TRACT
8
Lower respiratory tract
9
The lungs
10
TYPES OF AIRWAYS.

• Oropharangeal airway
• Nasopharangeal airway
• Endotracheal tube
• Tracheostomy
• Laryngeal mask airway
• Kombi-tube.

11
Oropharangeal airways/tubes

• It is otherwise called BITE BLOCK
• Indication.
• Tongue fallback
• Siezures.

12
NASOPHARANGEAL AIRWAY

• Otherwise called as nasal stants
• USES.
• Ensures a patent airway.
• Provides a channel for suctioning and
  bronchoscopy.
• Reduces mucosa trauma.
• Types
• blunt tip.
• beveled tip.

13
Insertion of nasal airway
14
Laryngeal mask airway

• LMA, is an non invasive airway.
• It has a mask at the distal at the end with
  inflatable outer larynx.
• The mask sits on the hypopharynx just above the
  larynx.
• It provides low pressure seal arround the
  glottis.
• Less airway trauma
• Sizes 1-4.

15
Endotracheal tube

• Provides patent airway and route for mechanical
  ventilation.
• Prevents aspiration.
• Route for suctioning.
• Contra indication.
• cervical spine injury
• lower facial injury
• Oral surgery

16
Advantages of Endotracheal Intubation

• Cuffed E.T tube protects the airway, prevents
  aspiration and leak and facilitates mechanical
  ventilation.
• E.T tube provides access to the tracheobronchial
  tree for suctioning of secretions.
• E.T tube does not cause gastric distention
• E.T tube maintains a patent airway and helps in
  avoiding further obstruction.
• E.T tube enables delivery of aerosolized
  medication.

17
Indications for Intubation

• Inadequate oxygenation(decreased arterial PO2)
  that is not corrected by supplemental oxygen via
  mask/nasal.
• Need to control and remove pulmonary secretions.
• Any patient in cardiac arrest.
• Any patient in deep coma who cannot protect his
  airway.(Gag reflex absent.).
• Any patient in imminent danger of upper airway
  obstruction (e.g. Burns of the upper airways).
• Any patient with loss of conscious(L.O.C), GCS lt
  8.
• Severe head and facial injuries with compromised
  airway.
• Respiratory failure
• 1.
  Hypoventilation/Hypercarbia
• A. Paco2 gt
  55mmhg
• 2. Arterial
  hypoxemia refractory to O2
• A. PaO2 lt 70
  on 100 O2

18
Contraindications for Intubation

• Patients with intact gag reflex.
• Patients likely to react with laryngospasm to an
  intubation attempt. e.g. Children with
  epiglottitis.
• Basilar skull fracture avoid naso-tracheal
  intubation and nasogastric/pharyngeal tube.

19
Complication

• Reflex larngospasm.
• Perforation of oesophagus.
• Reflex bradycardia or tachycardia.
• Hypotension.
• Bronchospasm.
• Aspiration.
• Laceration of pharynx.
• Vocal cord injury.
• Nosocomial infection.

20
Equipment Required for Successful Intubation
21
Techniquesfor intubation

• Position the patient supine, open the airway with
  a head-tilt chin-lift maneuver.(Suspected spinal
  injury, attempt naso-tracheal intubation, spine
  in neutral position.).
• Open mouth by separating the lips and pulling on
  upper jaw with the index finger.
• Hold laryngoscope in left hand, insert scope into
  mouth with blade directed to right tonsil.
• Once right tonsil is reached, sweep the blade to
  the midline keeping the tongue on the left.

22
Technique Cont

• This brings the epiglottis into view. DO NOT
  LOOSE SIGHT OF IT!
• Advance the blade until it reaches the angle
  between the base of the tongue and epiglottis.(
  volecular space)
• Lift the laryngoscope upwards and away from the
  nose towards the chest. This should bring the
  vocal cords into view. It may be necessary for a
  colleague to press on the trachea to improve the
  view of the larynx.
• Place the ETT in the right hand. Keep the
  concavity of the tube facing the right side of
  the mouth.
• Insert the tube watching it enter through the
  cords.

23
Technique Cont

• Insert the tube just so the cuff has passed the
  cords and then inflate the cuff.
• Listed for air entry at both apices and both
  axillae to ensure correct placement using a
  stethoscope.

24
Rules of Intubation

• Always have a suction unit available.
• An intubation attempt should never exceed 30
  seconds.
• Oxygenate the patient pre and post intubation
  with a bag-valve-mask.(100 O2).
• Have sedative medication available if needed.
  (e.g. Midazolam 15mg/3ml)
• Always recheck tube placement by observing chest
  movement, auscult for air entry and post
  intubation x ray.

25
Rules of Suctioning

• Never suction further than you can see.
• Always suction on the way out.
• Never suction for longer than15 seconds.
• Always oxygenate the patient before and after
  suctioning.
• Monitor SpO2, ECG ,Blood pressure continously.

26
Suctioning

• Suctioning consists of inserting a sterile
  catheter into the endotracheal or tracheostomy
  tube in order to remove secretions.
• This is an extremely important part of caring for
  a patient with an artificial airway, since the
  reflex of coughing, which would normally remove
  these secretions, is not effective.
• The patient will experience respiratory distress
  if the tube is obstructed by sputum.
• Suctioning should be performed only when the
  patient needs it however, the need should be
  assessed at least every two hours.

27
Suctioningcontd

• There are now closed suction systems available
  that are attached to the ventilator tubing on one
  end and to the artificial airway on the other.
• The catheter remains protected inside a sterile
  plastic sleeve that is changed every7days.
• This system limits the amount of times the tubing
  must be disconnected from the airway, thus
  reducing exposure of the trachea to environmental
  contaminants and control infection.

28
Suctioningcontd

• Suctioning causes oxygen deprivation for the time
  that the suction is applied.
• Hypoxemia can be minimized by preoxygenating the
  patient with 100 oxygen prior to suctioning and
  between each pass of the suction catheter. (This
  can be done by either pushing the 100 oxygen
  button on the ventilator or by using a
  bag-valve-mask device.)
• The patient's pulse oximetry should be monitored
  while suctioning.
• The duration of each suction pass should be
  limited to 10 seconds and the number of passes
  should be limited to three or less if possible.
• This decreases hypoxemia and airway trauma.

29
Health care team roles

• The nurse and respiratory therapist are equally
  responsible for monitoring and managing
  artificial airways.
• Both perform sterile suctioning and both
  document their assessment of the patient's
  respiratory status.
• The respiratory therapist is generally
  responsible for managing the ventilator, adding
  humidification, and changing ventilator tubing.
• The respiratory therapist is generally
  responsible for ventilating the patient with a
  bag-valve-mask device until reintubation
  (reinsertion of the airway), while the nurse
  gathers equipment, administers medications, and
  monitors the patient's pulse oximetry, vital
  signs, and cardiac rhythm.

30
Health care team roles

• The nurse and respiratory therapist are also
  responsible for finding alternative means for the
  patient to communicate.
• Artificial airways are inserted through the vocal
  cords, making speaking impossible.
• The patient should be encouraged to try
  alternative methods such as mouthing words,
  writing, or pointing to letters, words, or
  pictures on a communication board.
• Communicating with these patients takes great
  patience and creativity, as well as dedication to
  helping them feel like their needs are being met.

31
THANK YOU