Advanced Airway Management

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Advanced Airway Management Intubation

• The Difference Between
• Life and Death

By Norman Wilkinson, NREMT-P Flight
Paramedic EMS/ECC Instructor
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Topics For Discussion

• Basic anatomy and physiology.
• Advantages of endotracheal intubation.
• Indications of intubation.
• Contraindications of intubation.
• Complications of intubation.
• Equipment required for intubation.

• Technique of endotracheal intubation.
• Rules of endotracheal intubation.
• Tube sizes.
• Rules and principals of suctioning.
• Other airway adjuncts.
• Conclusion.
• Difficult intubations.

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Anatomy and Physiology

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

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The Upper Airway
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The Lower Airway
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Advantages of Endotracheal Intubation

• Cuffed E.T tubes protect the airway from
  aspiration.
• E.T tube provides access to the tracheobronchial
  tree for suctioning of secretions.
• E.T tube does not cause gastric distention and
  associated danger of regurgitation.
• E.T tube maintains a patent airway and assists in
  avoiding further obstruction.
• E.T tube enables delivery of aerosolized
  medication.

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Indications for Intubation

• Inadequate oxygenation(decreased arterial PO2)
  that is not corrected by supplemental oxygen via
  mask/nasal.
• Inadequate ventilation (increased arterial PCO2).
• Need to control and remove pulmonary secretions.
• Any patient in cardiac arrest.

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Indications for Intubation

• Ant 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 decreased L.O.C, GCS lt 8.
• Severe head and facial injuries with compromised
  airway.

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Indications Cont

• Any patient in respiratory arrest
• Respiratory failure
• 1.
  Hypoventilation/Hypercarbia
• A. Paco2 gt
  55mmhg
• 2. Arterial
  hypoxemia refractory to O2
• A. Paco2 lt
  70 on 100 O2

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Contraindications for Intubation

• Patients with an 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.

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Complications Associated With Intubation

• Trauma of the teeth, cords, arytenoid cartilages,
  larynx and related structures.
• Nasotracheal tubes can damage the turbinates,
  cause epistaxis, and even perforate the
  nasopharyngeal mucosa.
• Hypertension and tachycardia can occur from the
  intense stimulation of intubation This is
  potentially dangerous in the patient with
  coronary heart disease.
• Transient cardiac arrhythmias related to vagal
  stimulation or sympathetic nerve traffic may
  occur .

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Complications Continued

• Damage to the endotracheal tube cuff, resulting
  in a cuff leak and poor seal.
• Intubation of the esophagus, resulting in
  gastric distention and regurgitation upon
  attempting ventilation.
• Baro-trauma resulting from over ventilating with
  a bag without a pressure release valve(
  phneumothorax).

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Complications Continued

• Over stimulation of the larynx resulting in
  laryngospasm, causing a complete airway
  obstruction.
• Inserting the tube to deep resulting in
  unilateral intubation (right bronchus).
• Tube obstruction due to foreign material, dried
  respiratory secretion and/or blood.

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Equipment Required for Successful Intubation
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Equipment Cont

• Laryngoscope with relevant size blades.
• Magill forceps.
• Flexible introducer.
• 10-20 ml syringe.
• Oropharangeal airways all sizes.
• Tape or adhesive plaster.
• E.T tubes relevant sizes.
• Bag-valve-mask with oxygen connected.
• Suction unit with Yankauer nozzle and
  endotracheal suction catheter.

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Technique of Endotracheal Intubation
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Technique Cont

• 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.

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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.

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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.

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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 manually guided by
  oxygen saturation readings.(Spo2).

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Tube sizes

• Newborn to 4 kg - 2.5 mm (uncuffed).
• 1-6 months 4-6 kg 3.5 mm (uncuffed).
• 7-12 months 6-9 kg 4.0 mm (uncuffed).
• 1 year 9 kg 4.5 mm (uncuffed).
• 2 years 11 kg 5.0 mm (uncuffed).
• 3-4 years 1416 kg - 5.5 mm (uncuffed).
• 5-6 years 1821 kg 6.0 mm (uncuffed).
• 7-8 years 22-27 kg 6.5 mm ( uncuffed).

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Tube Sizes

• 9-11 years 28-36 kg 7.0 mm(cuffed).
• 14 to adults 46 kg 7.0 80 mm (cuffed).
• Adult female 7.0 8.0mm (cuffed).
• Adult male 7.5 8.5 mm (cuffed).
• The size of the tube may also be determined by
  the size of the patients little finger.
• N.B patients below the age of 8 require uncuffed
  ETT due to damage caused by the cuff in younger
  patients. Always monitor the ECG activity during
  intubation.

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4 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.

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Other Airway Adjuncts

• Kombi-tube.
• Oropharangeal airways/tubes.
• Nasopharyngeal airways/tubes.
• Oro-tracheal tubes.
• Naso-tracheal tubes.

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Conclusion

• Always oxygenate patient before and after
  intubation.
• Do not attempt intubation unless you are totally
  skilled, rather perform bag-valve-mask
  ventilation.
• Always monitor the spo2 readings.
• Always reconfirm tube placement from time to
  time.

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