airway management

AWY 1®

Airway Management

AWY 1®

AWY 2®

Objectives• Recognize signs of a threatened airway• Describe techniques for establishing an airway

and for mask ventilation• Be familiar with airway adjuncts• Describe proper preparation for endotracheal

intubation• Decribe alternative methods to establish an

airway when intubation is not possible

AWY 2®

AWY 3®

Patient Assessment• Level of consciousness• Spontaneous efforts vs. apnea• Airway and cervical spine injury• Chest expansion• Signs of airway obstruction• Breath sounds• Protective airway reflexes

Look, listen, and feel

AWY 4®

Opening the Airway – the Triple Airway Maneuver

• Slightly extend neck(when cervical spine injury not suspected)

• Elevate mandible• Open mouth• Consider adjunctive devices

AWY 5®

Reassessment• Adequate spontaneous breathing

– Provide oxygen supplementation• Proceed to manual assisted ventilation

– Apneic patient– Inadequate spontaneous tidal volumes– Excessive work of breathing– Hypoxemia with poor spontaneous ventilation

AWY 6®

Manual Assisted Ventilation• Open the airway• Apply face mask and obtain

seal• Deliver optimal minute

ventilation from resuscitation bag

• Consider cricoid pressure• Monitor with pulse oximetry

AWY 7®

Single-Handed Method of Face Mask Application

• Base of mask placed over chin and mouth opened

• Apex of mask over nose• Mandible elevated, neck

extended (if no cervical spine injury), and downward pressure by mask hand

AWY 8®

Two-Handed Method of Face Mask Application

• Helpful when mask seal difficult

• Fingers placed along mandible on each side

• Assistant provides ventilation

AWY 9®

Inadequate Mask-to-Face Seal

• Identify leak• Reposition face mask• Improve seal along cheek(s)• Change mask inflation or size• Slightly increase downward

pressure over face • Use two-handed technique

AWY 10®

Airway Adjuncts• Laryngeal mask airway

– Bowl-shaped cuff that fits in hypopharynx

– Single or multiple use devices• Esophageal-tracheal combitube

– May be used in cardiorespiratory arrest

– Requires adequate training

LMA

AWY 11®

Indications for Endotracheal Intubation

• Airway protection• Relief of obstruction• Need for mechanical ventilation/O2 therapy• Respiratory failure• Shock• Need for hyperventilation• Reduce the work of breathing• Facilitate suctioning/pulmonary toilet

AWY 12®

Preparation for Intubation

• Assess degree of difficulty for intubation• Assure optimal ventilation and

oxygenation• Consider gastric decompression• Analgesia, sedation, amnesia,

neuromuscular blockade as needed

AWY 13®

Degree of Difficulty Assessment• Neck mobility• External face• Mouth• Tongue and pharynx• Jaw• Consider options for obtaining an

airway that maintain ventilation• Obtain expert assistance

AWY 14®

Options for Airway Management• Awake intubation• Flexible fiberoptic intubation• Awake tracheostomy• Laryngeal mask airway or esophageal-

tracheal combitube• Needle cricothyrotomy• Surgical cricothyrotomy

AWY 15®

Difficult Airway

AWY 16®

Analgesia, Sedation, Amnesia, Neuromuscular Blockade

• Analgesia – topical, nerve blocks, sedation• Sedation/amnesia – rapid acting, short duration, reversible

– Fentanyl: 25–100 g iv, titrated to effect– Midazolam: 1 mg iv, titrated to effect– Etomidate: 0.3–0.4 mg/kg iv, titrated to effect– Lidocaine: 1-1.5 mg/kg iv

AWY 17®

Analgesia, Sedation, Amnesia, Neuromuscular Blockade

• Assess need for neuromuscular blockers– Succinylcholine: 1–1.5 mg/kg iv bolus– Vecuronium: 0.1–0.3 mg/kg iv bolus– Rocuronium: 0.6-1.0 mg/kg iv bolus– Cisatracurium: 0.1-0.2 mg/kg iv bolus

AWY 18®

Early Complications

• Hemodynamic alterations– Hypertension– Tachycardia– Hypotension

• Consider effects of sedative agents

AWY 19®

Key Points

AWY 20®

Orotracheal Intubation –Preparation

• Appropriate monitoring – oximetry, ECG, BP– Assemble equipment– Laryngoscope –test light, select blade– Endotracheal tube – test cuff, lubricate– Stylet – insert, angulate– Suction – test– Magill forceps

AWY 21®

Orotracheal Intubation –Preparation

• Don protective garb• Elevate occiput with pad if no cervical

spine injury suspected• Provide anesthesia, sedation, amnesia,

and neuromuscular blockade as required

AWY 22®

Orotracheal Intubation – Technique

• Proper operator position • Holding the laryngoscope

handle• Application of cricoid

pressure• Mouth opening methods

AWY 23®


• Insertion of laryngoscope blade – tongue control

• Tongue displacement medially – visualize epiglottis

AWY 24®


• Advance laryngoscope into position (vallecula for curved blade; under epiglottis for straight blade)

• Elevate base of tongue and expose glottic opening

AWY 25®


• Elevate base of tongue further to fully expose glottic opening and surrounding anatomy

AWY 26®


• Insert endotracheal tube under direct vision to 23–25 cm at lip

• Remove stylet and laryngoscope, inflate tube cuff

• Confirm tube position – breath sounds, CO2 detector

• Secure endotracheal tube• Obtain chest radiograph

AWY 27®


• Straight blade position, elevating the epiglottis

• Be aware of laryngospasm when epiglottis is touched

AWY 28®

Pediatric Considerations• Infections commonly cause airway

obstruction in young children• Because infants are obligate “nose

breathers” until ~ age 6 months, suctioning nares may establish an open airway

• When possible, allow child to assume position of comfort in early respiratory compromise

AWY 29®

Pediatric Considerations• Face mask may agitate child – several delivery

devices should be available• If obtunded or unable to assume a

comfortable position, sniffing position is preferred in infants and young children to minimize airway obstruction from soft tissues (when no cervical spine injury is suspected)

• Overextension of neck may cause airway obstruction

AWY 30®

Pediatric Considerations• Positive pressure during bag-mask

ventilation may cause gastric distention; a nasogastric tube may be needed

• Tongue in infants and children up to ~ age 2 yrs occupies relatively large portion of oral cavity and is likely to cause obstruction during spontaneous breathing and manually assisted ventilation

AWY 31®

Pediatric Considerations for Orotracheal Intubation

• Secure patient for procedure• Pad or towel under shoulders of infant may be better

than elevation of occiput• Endotracheal tube size approximates size of patient’s

small finger• Uncuffed endotracheal tubes usually used when

patient < 8 yrs old • Straight laryngoscope blade usually used

AWY 32®


• Observe cervical spine precautions as needed

• Relatively larger tongue, angle of attachment of epiglottis, anterior and more cephalad position of larynx make exposure of glottic opening more difficult

AWY 33®


Cricoid pressure may improve visualization of glottis

Trachea relatively short so mainstem intubation may occur more easily

Depth of insertion estimated by multiplying internal diameter of endotracheal tube by 3(e.g., 4.0 tube 3 = 12 cm insertion depth)

airway management

Healthcare