Airway Management Part I

1
Airway ManagementPart I

• RET 2275
• Respiratory Care Theory 2

2
Manual Resuscitators

• Manual resuscitator
• Portable, hand-held device that allows for the
  delivery of positive pressure and supplemental
  oxygen to the airway
• AKA resuscitator bag, Ambu bag, bag-valve-mask
  (BMV)
• Generic parts
• Self-inflating bag
• Air intake valve
• Nonrebreathing valve
• Exhalation valve
• Oxygen reservoir

3
Manual Resuscitators

• Nonrebreathing Valve Types
• Spring-loaded ball

4
Manual Resuscitators

• Nonrebreathing Valve Types
• Duckbill

5
Manual Resuscitators

• Nonrebreathing Valve Types
• Leaf

6
Manual Resuscitators

• O2 Powered Resuscitators
• Pressure limited devices that work similarly to
  reducing valves
• Demand valve that can be manually operated or
  patient triggered
• Can deliver 100 O2 at flows lt40 L/min
• Inspiratory pressures are limited to 60 cm H2O

7
Ambu SPUR
8
Manual Resuscitators

• Device/Patient interface
• Mask

9
Manual Resuscitators

• Device/Patient interface
• Directly connected to endotracheal tube

10
Manual Resuscitators

• Uses
• Ventilation during a resuscitation effort
• Transport of a ventilator-dependant patient
• Hyperinflation and delivery of enriched oxygen
  mixtures before and after a suctioning procedure
• To generate airway pressures and large tidal
  volume to expand atelectatic lung segments
• Adjunct in directed coughing

11
Upper Airway Obstruction

• Causes of Upper Airway Obstruction
• Soft tissue obstruction
• Loss of muscle tone resulting in the tongue
  falling back against the soft palate
• CNS depression drug overdose, anesthesia
• Cardiac arrest
• Loss of consciousness

12
Upper Airway Obstruction

• Causes
• Laryngeal obstruction more commonly the result
  of
• Muscle spasm (laryngospasm)
• Edema
• Croup
• Epiglottitis
• Foreign material
• Aspirate
• Vomitus
• Blood
• Space-occupying lesions, e.g., tumors

13
Upper Airway Obstruction

• Causes
• Laryngeal obstruction more commonly the result
  of
• Muscle spasm (laryngospasm)
• Edema
• Croup
• Epiglottitis
• Foreign material
• Aspirate
• Vomitus
• Blood
• Space-occupying lesions, e.g., tumors

14
Upper Airway Obstruction

• Clinical Findings
• Noisy inspiratory efforts, e.g., snoring
• Silence complete obstruction
• Retractions
• Intercostal
• Sternal
• Clavicular

15
Upper Airway Obstruction

• Clinical Findings
• Prolonged, partial upper airway obstruction
• Hypoxemia and hypercapnia
• Total airway obstruction
• Death in 5 10 minutes

16
Upper Airway Obstruction

• Positional Maneuvers to Open the Airway
• Head Tilt
• Tilting the head back to relieve soft tissue
  obstruction

17
Upper Airway Obstruction

• Positional Maneuvers to Open the Airway
• Anterior Mandibular Displacement (jaw thrust)
• Grasping the jaw at the ramus on each side and
  lifting the jaw forward
• Treatment of choice for suspected vertebral
  column trauma

18
Manual Resuscitators

• Ventilatory assistance may be administered with a
  manual resuscitator

19
Manual Resuscitators

• Standards
• Have standard 1520 mm (IDOD) adaptors
• Deliver gt 85 oxygen at 15 L/min.
• Volume of bag
• Adult 1600 ml
• Child 500 ml
• Infant 240 ml
• Allow for delivery of PEEP

20
Manual Resuscitators

• Standards
• Allow for attachment of volume and pressure
  monitoring devices
• Child resuscitators should be pressure limited at
  40 ( 10 cm H2O)
• Infant resuscitators should be pressure limit at
  40 ( 5 cm H2O)
• No pressure limiting system for adult
  resuscitators

21
Hazards of Manual Resuscitation

• Gastric distention
• Aspiration
• Diminished cardiac output
• May be avoided by ventilating the patient using
  an inspiratory to expiratory (IE) ration of 12,
  which allows the heart to fill during the
  expiratory phase when there is no pressure in the
  thoracic cavity

22
Airways in Manual Resuscitation

• Pharyngeal Airways
• Specialized devices employed to maintain a patent
  airway

23
Oropharyngeal Airways
24
Oropharyngeal Airways

• Function
• Restores airway patency by separating the tongue
  from the posterior wall of the pharynx
• Insertion
• Orally
• Use jaw lift or tongue displacement
• Correct sizing
• Measure from the corner of the patients mouth to
  angle of the jaw
• Incorrect placement can worsen obstruction!
• Used in comatose patients

25
Oropharyngeal Airways

• Correct Sizing

26
Oropharyngeal Airways

• Correct Sizing

27
Oropharyngeal Airways

• Insertion
• Using a head-tilt-chin-lift, a modified
  jaw-thrust, or by grasping the tongue and jaw by
  placing your thumb in the patient's mouth, move
  the tongue forward. Position the OPA as shown
  with the tip in the patient's mouth and slowly
  insert the OPA. As the OPA is being inserted,
  slight resistance will be felt.

28
Oropharyngeal Airways

• Insertion
• At the point resistance is met, insertion should
  continue while simultaneously rotating the OPA
  180. Advance the OPA until the flange is resting
  on or just above the patient's teeth.

29
Nasopharyngeal Airways
30
Nasopharyngeal Airways

• Function
• Restores airway patency by separating the tongue
  from the posterior wall of the pharynx
• Used when oral placement is not possible
• Insertion
• Nasally
• Necessary to check placement
• Correct sizing
• Measure from the patients earlobe to the tip of
  the nose
• Incorrect placement can worsen obstruction!
• Used in awake patients

31
Nasopharyngeal Airways

• Correct Sizing of NPA

32
Nasopharyngeal Airways

• Correct Sizing of NPA

33
Nasopharyngeal Airways

• Insertion of NPA
• First check the nostril for signs of fracture or
  obstruction then apply generous amounts of a
  water-based lubricant to the NPA taking care not
  to fill the tip with the lubricant
• Orient the bevel end so that it will pass along
  the inside of the nasal cavity with minimal
  effort

34
Nasopharyngeal Airways

• Insertion of NPA
• Insert the NPA until the flange (the large end of
  the tube) is seated on the patient's nose

35
Nasopharyngeal Airways

• Proper placement of the nasopharyngeal airway

36
Ventilation with Manual Resuscitator
37
Ventilation with Manual Resuscitator

• Place the patient supine
• Open the airway manual maneuver
• Insert pharyngeal airway
• Place the mask on the patients face
• Bridge of the nose first
• Securing a tight seal below the lower lip
• Maintain the mask position with thumb and index
  finger of one hand, use the third, forth and
  fifth fingers to hook under the mandible,
  displacing it anteriorly to maintain a patent
  airway

38
Ventilation with Manual Resuscitator
39
Ventilation with Manual Resuscitator

• Two-man ventilation with manual resuscitator

40
Ventilation with Manual Resuscitator

• Ventilate the patient at a rate of 8 16
  breaths/min.
• Watch for chest expansion to ensure adequate
  volume
• IE ration of 12 or better
• If the patient has spontaneous respiratory
  efforts, match your ventilation efforts with the
  patients efforts

41
Endotracheal Tubes

• Function
• Relieve airway obstruction
• Facilitate secretion removal
• Protect against aspiration
• Provide positive pressure ventilation
• Insertion Site
• Nasally
• Orally
• Placement
• In the trachea
• 3 5 cm above the carina

42
Endotracheal Tubes

• Placement of the ET Tube

43
Endotracheal Tubes
Standard adapter with a 15 mm external diameter
Radiopaque Strip (visible on x-ray)
Pilot tube
Body
Pilot balloon
Cuff
Beveled distal tip
44
Endotracheal Tubes
Length makings (distance in cm from beveled tube
tip)
Z-79 or IT (Tissue toxicity testing)
Inner diameter
45
Endotracheal Tubes

• Murphys eye
• Provides an alternate pathway for gas to flow in
  the event the distal tip become obstructed

Beveled distal tip
46
Endotracheal Tubes

• Reinforced Wire-Wrapped ET Tube
• Helical reinforcing wire imbedded into the PVC
  material helps prevent kinking when used in a
  tortuous airway

47
Hi-Lo EVAC Endotracheal Tube
48
Indwelling Hi-Lo EVAC Tube
49
Double Lumen ET Tube

• Function
• Independent lung ventilation
• Unilateral lung disease
• Properties
• 2 proximal 15 mm ventilator connections
• 2 inner lumens for gas flow
• 2 cuffs
• Larger cuff seal trachea
• Smaller cuff seals bronchial lumen
• 2 distal openings
• Fiberoptic bronchoscopy needed to verify placement

50
Double Lumen ET Tube

• Proper placement

51
Indications for Endotracheal Intubation

• Relieve airway obstruction
• Facilitate secretion clearance
• Facilitate mechanical ventilation
• Protect lower airway

52
Orotracheal Intubation

• Safely performed by
• Physicians
• Respiratory Therapists
• Nurses
• Paramedics

53
Orotracheal Intubation

• Step 1 Assemble and Check Equipment
• Suction Equipment
• Suction regulator, canister, tubing, catheters,
  Yankauer (tonsil tip)
• Manual resuscitator bag and mask
• O2 flowmeter and tubing

54
Orotracheal Intubation

• Step 1 Assemble and Check Equipment
• Laryngoscope with assorted blades
• Ensure light on blade is functioning
• Endotracheal tubes
• Inflate cuff and check for leaks

55
Orotracheal Intubation

• Step 1 Assemble and Check Equipment
• Stylet
• Magil forceps (nasal intubation)

56
Orotracheal Intubation

• Step 1 Assemble and Check Equipment
• Tongue depressor
• Tape
• Syringe
• Lubricating jelly
• Local anesthetic (spray)

57
Orotracheal Intubation

• Step 1 Assemble and Check Equipment
• Towels (for positioning)
• Stethoscope
• CDC barrier precaution
• Gloves, gowns, masks, eyewear

58
Orotracheal Intubation

• Step 2 Position the Patient
• Must align the mouth, pharynx and larynx
• Place one or more rolled towels under the
  patients head

59
Orotracheal Intubation

• Step 3 Preoxygenate the Patient with
  Resuscitator / Mask
• Provides a reserve of oxygen during intubation
  attempts
• Intubation attempts should not last greater than
  30 seconds
• If attempt fails, ventilate and oxygenate for 3-5
  minutes before reattempting to intubate

60
Orotracheal Intubation

• Step 4 Insert the Laryngoscope
• Laryngoscope in left hand while right hand opens
  the mouth
• Insert the laryngoscope into the right side of
  the mouth and move it toward the center,
  displacing the tongue to the left
• Advance the tip of the blade along the curve of
  the tongue until you visualize the epiglottis

61
Orotracheal Intubation

• Step 5 Visualize the Glottis

62
Orotracheal Intubation

• Step 6 Displace the Epiglottis
• MacIntosh Blade displaces the epiglottis
  indirectly by advancing the tip of the blade into
  the vallecula
• Miller Blade displaces the epiglottis directly
  by advancing the tip of the blade over the its
  posterior surface and lifting the laryngoscope up
  and forward

63
Orotracheal Intubation

• Step 7 Insert the Tube
• Insert the tube from the right side of the mouth
• Advance tube through the glottis until the cuff
  passes the vocal cords
• Inflate the cuff to seal the airway
• Ventilate and oxygenate

64
Orotracheal Intubation

• Step 8 Assess Tube Position (3 - 5 cm above
  carina)
• Auscultation bilateral breath sounds
• Observation of chest movement
• Tube length ( approximately 22 cm to teeth for
  adults)
• Colorimetry

65
Colorimetry - CO2 Detector
Negative for CO2
Positive for CO2
66
Orotracheal Intubation

• Step 8 Assess Tube Position (3 - 5 cm above
  carina)
• Capnometry (End-Tidal CO2)
• Light wand
• Fiberoptic laryngoscope
• Esophogeal detection device
• Chest x-ray

67
Orotracheal Intubation

• Step 9 Secure the Endotracheal Tube

68
Intubation Videos
Oral Intubation Procedure Routine Points to
Remember
69
Hazards of Endotracheal Intubation

• Post-extubation mucosal edema
• Trauma
• Aspiration
• Bleeding
• Infection
• Tube problems (pilot balloon, kinking etc.)

70
Cuff Pressure Monitoring Techniques

• Auscultate over trachea
• Minimal Occluding Volume inflate cuff until
  cuff air leak stops
• Minimal Leak Technique inflate cuff until cuff
  air leak stops, then withdraw enough air to allow
  a small air leak at peak inspiration

71
Cuff Pressure Monitoring Techniques

• Cuff Pressure Measurement
• Cufflator
• Checked once per shift
• Pressures not to exceed
• 27 34 cm H2O (20 25 mm Hg)
• Excessive pressures my cause tracheal damage if
  cuff pressures are greater than tracheal
  perfusion pressures

72
Combitube Airway

• Double lumen airway
• Esophageal gastric airway
• Endotracheal tube
• Effective whether in the esophagus or the trachea
• Designed to be inserted blindly
• Used for difficult intubation
• Short-term

73
Combitube Airway

• Correct insertion and placement

74
Laryngeal Mask Airway (LMA)

• Designed to form a low-pressure seal in the
  laryngeal inlet by means of an inflated cuff
• Maintains a patent upper airway and facilitates
  ventilation
• Designed to be inserter blindly
• Used for difficult intubation
• Short-term

75
Laryngeal Mask Airway (LMA)

• Correct insertion and placement

76
Laryngeal Mask Airway (LMA)

• Correct insertion and placement

77
Laryngeal Mask Airway (LMA)

• This tube, when inserted into the larynx and the
  laryngeal cuff inflated, provides a closed seal
  system to ventilate the lower airway and protect
  against aspiration.

Insertion video