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Advanced Airway Management University of Colorado Medical School Rural Track 2013.

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Presentation on theme: "Advanced Airway Management University of Colorado Medical School Rural Track 2013."— Presentation transcript:

1 Advanced Airway Management University of Colorado Medical School Rural Track 2013

2 Advanced Airway Management Basic Airway Management Basic Airway Management Airway Suctioning Airway Suctioning Oxygen Delivery Methods Oxygen Delivery Methods Laryngeal Mask Airway Laryngeal Mask Airway ET Intubation ET Intubation Oropharyngeal Airway Oropharyngeal Airway Nasopharyngeal Airway Nasopharyngeal Airway Cricothyrotomy Cricothyrotomy

3 Basic Airway Management For patients unable to protect their own airway For patients unable to protect their own airway Jaw thrust/head tilt technique Jaw thrust/head tilt technique This technique itself can open the airway This technique itself can open the airway If concern for c-spine injury, use jaw thrust without head tilt If concern for c-spine injury, use jaw thrust without head tilt Excessive head tilt can occlude trachea in infants, consider padding under shoulders Excessive head tilt can occlude trachea in infants, consider padding under shoulders

4 Basic Airway Management

5 Padding under shoulders for infant Padding under shoulders for infant

6 Airway Suctioning Obstruction of airway by secretions, blood, vomitus can lead to aspiration Obstruction of airway by secretions, blood, vomitus can lead to aspiration Rigid catheters (Yankeur), soft catheters (Y suction) Rigid catheters (Yankeur), soft catheters (Y suction) Complications include airway trauma, coughing or gagging, delay in ventilation, vagal stimulation  bradycardia, hypotension Complications include airway trauma, coughing or gagging, delay in ventilation, vagal stimulation  bradycardia, hypotension

7 Airway Suctioning Yankeur Rigid Catheter Y Suction Catheter Yankeur Rigid Catheter Y Suction Catheter

8 Oropharyngeal Suctioning- Procedure Adults Adults Preoxygenate Preoxygenate Check connection to tubing Check connection to tubing Occlude side port to test for adequate suction Occlude side port to test for adequate suction Insert catheter into oropharynx under direct visualization Insert catheter into oropharynx under direct visualization Neonates Neonates Insert y-suction catheter into nasopharynx Insert y-suction catheter into nasopharynx Occlude sideport while withdrawing catheter Occlude sideport while withdrawing catheter Repeat for oropharynx Repeat for oropharynx

9 Oxygen Delivery Methods Nasal Cannula: flow rate 1-6 LPM (FiO2 24-40%) Nasal Cannula: flow rate 1-6 LPM (FiO2 24-40%) Simple face mask: flow rate 5-10 LPM (FiO2 40-60%) Simple face mask: flow rate 5-10 LPM (FiO2 40-60%) Non-rebreather mask: flow rate 10-15 LPM (FiO2 60-90%) Non-rebreather mask: flow rate 10-15 LPM (FiO2 60-90%) BiPAP/CPAP BiPAP/CPAP

10 Oxygen Delivery Methods Bag Valve Mask- flow rate >15 LPM (FiO22 >90%) Bag Valve Mask- flow rate >15 LPM (FiO22 >90%)

11 Laryngeal Mask Airway Supraglottic airway Supraglottic airway Doesn’t require laryngeal visualization Doesn’t require laryngeal visualization Can precipitate vomiting or aspiration Can precipitate vomiting or aspiration SizeWeight guidePopulation 1<5 kgInfant 210-20 kgSmall Child 330-50 kgSmall Adult 450-70 kgAverage Adult 570-100 kgLarge Adult

12 Laryngeal Mask Airway Prepare LMA: ensure patent cuff, apply water-based lubricant Prepare LMA: ensure patent cuff, apply water-based lubricant Place patient in sniffing position Place patient in sniffing position Insert tip of LMA into mouth Insert tip of LMA into mouth Advance into laryngopharynx until Advance into laryngopharynx until resistance is met Ensure black line on tubing in line with upper lip Ensure black line on tubing in line with upper lip Inflate cuff Inflate cuff Confirm tube misting, auscultation, EtCO2 Confirm tube misting, auscultation, EtCO2 Consider placement of bite block Consider placement of bite block

13 Other Airways King Tube King Tube Combitube Combitube

14 Endotracheal Intubation Placing orotracheal tube under direct vision through larynx into trachea Placing orotracheal tube under direct vision through larynx into trachea Protects airway, enables ventillation Protects airway, enables ventillation Complications of laryngoscopy Complications of laryngoscopy direct trauma to mucous membranes, teeth, larynx direct trauma to mucous membranes, teeth, larynx bradycardia from vagal stimulation bradycardia from vagal stimulation Raised intracranial pressure Raised intracranial pressure

15 Endotracheal Intubation Complications of Intubation Complications of Intubation Prolonged apnea  hypoxia Prolonged apnea  hypoxia Esophageal or right mainstem bronchus intubation Esophageal or right mainstem bronchus intubation Inadequate tube size  excessive leak, high pressures Inadequate tube size  excessive leak, high pressures Aspiration Aspiration Complications of Ventilation Complications of Ventilation Barotrauma  pneumothorax Barotrauma  pneumothorax Hypoventilation  hypoxia, hypercarbia Hypoventilation  hypoxia, hypercarbia Hyperventilation  hypocarbia, cerebral hypoxia Hyperventilation  hypocarbia, cerebral hypoxia Reduction in preload  hypotension Reduction in preload  hypotension

16 Endotracheal Intubation Preparation Preparation Pre-oxygenation Pre-oxygenation Ensure IV access and patency, cardiac monitoring Ensure IV access and patency, cardiac monitoring Assess for predictors of technical difficulty (LEMON) Assess for predictors of technical difficulty (LEMON) Look (obesity, pregnancy, airway, facial, neck trauma) Look (obesity, pregnancy, airway, facial, neck trauma) Evaluate 3-3-2 rule (small mouth, receding jaw, short neck) Evaluate 3-3-2 rule (small mouth, receding jaw, short neck) Manual inline stabilization/Mallampati score Manual inline stabilization/Mallampati score Obstruction (airway burn, protruding teeth, foreign body) Obstruction (airway burn, protruding teeth, foreign body) Neck mobility Neck mobility

17 Endotracheal Intubation Preparation of equipment Preparation of equipment Suction Suction Oxygen Oxygen BVM device BVM device Airway adjuncts: OP airways, LMA Airway adjuncts: OP airways, LMA Laryngoscope with appropriate blade, check light source Laryngoscope with appropriate blade, check light source ETT: right size ETT: right size Bougie Bougie Monitoring and EtCO2 Monitoring and EtCO2

18 Endotracheal Intubation Tools: Laryngoscope Tools: Laryngoscope Macintosh blade- curved blade, rests on epiglottic vallecula Macintosh blade- curved blade, rests on epiglottic vallecula Miller blade- straight blade, lifts epiglottis directly Miller blade- straight blade, lifts epiglottis directly BladeSizePatient Miller0Infant Miller1Small child Macintosh2Large child Macintosh3Small adult Macintosh4Large adult

19 Endotracheal Intubation Tools: ET tube Tools: ET tube AgeUncuffed ETT (mm) Cuffed ETT (mm) Depth at lips (cm) Newborn3.0-3.53.09-10 1-5 mths3.53.0-3.510 6-11 mths3.5-43.511 1 yr4.0-4.54.012 2-3 yrs4.5-5.04.0-4.512-13 4-5 yrs5.0-5.54.5-5.013-15 6-9 yrs5.5-6.05.0-5.515 10-12 yrs6.5-7.06.0-6.517 13+7.0-7.56.5-7.019

20 Endotracheal Intubation Place head in sniffing position (MILS if c-spine injury) Place head in sniffing position (MILS if c-spine injury) Open mouth, inspect oral cavity Open mouth, inspect oral cavity Remove dentures or debris Remove dentures or debris Place laryngoscope with left hand into the right side of patient’s mouth, sweeping tongue to left Place laryngoscope with left hand into the right side of patient’s mouth, sweeping tongue to left Lift mandible without levering on teeth until direct visualization of the larynx Lift mandible without levering on teeth until direct visualization of the larynx

21 Endotracheal Intubation

22 Introduce bougie through cords Introduce bougie through cords Advance ET tube over bougie until cuff passes through cords Advance ET tube over bougie until cuff passes through cords ETT length at lips for women 20-21, men 22-24 ETT length at lips for women 20-21, men 22-24 Remove bougie Remove bougie Connect BVM, commence ventilation Connect BVM, commence ventilation Inflate cuff Inflate cuff Confirm placement Confirm placement EtCO2 capnography, attach detector proximal to filter EtCO2 capnography, attach detector proximal to filter Auscultation in axillae and over stomach Auscultation in axillae and over stomach

23 Glidescope

24 Post-intubation management Secure ETT with a cloth tie Secure ETT with a cloth tie Manually ventilate for EtCO2 35-40 mmHg Manually ventilate for EtCO2 35-40 mmHg Post-intubation sedation as needed Post-intubation sedation as needed Continue comprehensive monitoring and ETCO2 Continue comprehensive monitoring and ETCO2

25 Oropharyngeal Airway Prevents the tongue from occluding the airway, bite block Prevents the tongue from occluding the airway, bite block Should reach from the mouth to the angle of the jaw Should reach from the mouth to the angle of the jaw Insertion (Adults) Insertion (Adults) Ensure concavity facing roof of the mouth Ensure concavity facing roof of the mouth Insert 1/3, rotate 180 degrees over the tongue Insert 1/3, rotate 180 degrees over the tongue Advance until flange against lips Advance until flange against lips Insertion (Pediatrics) Insertion (Pediatrics) Concavity follows the curve of the tongue to avoid hard and soft palate trauma Concavity follows the curve of the tongue to avoid hard and soft palate trauma

26 Oropharyngeal Airway SizeColorSuggested Population 000ClearNeonate (under 6 wks) 00BlueInfant (1-6 months) 0BlackOlder infants/toddlers 1WhiteSmall child (3-10 years) 2GreenAdolescent/adult female 3YellowAdult male 4RedLarge adult male

27 Nasopharyngeal Airway Useful in patients with airway obstruction, especially if oropharyngeal airway is inappropriate Useful in patients with airway obstruction, especially if oropharyngeal airway is inappropriate Correct size reaches from tip of patient’s nose to ear lobe Correct size reaches from tip of patient’s nose to ear lobe Sizes 6,7 & 8 mm Sizes 6,7 & 8 mm Lubricate end of tube with lubricating jelly Lubricate end of tube with lubricating jelly Insert into nostril (usually right) with bevel facing nasal septum Insert into nostril (usually right) with bevel facing nasal septum Advance device along floor of nasopharynx, following curvature until flange rests against the nostril Advance device along floor of nasopharynx, following curvature until flange rests against the nostril

28 Nasopharyngeal Airway

29

30 Cases

31 References Queensland EMS Clinical Practice Procedures: https://ambulance.qld.gov.au/medical/pdf/02_cpp_airway. pdf Queensland EMS Clinical Practice Procedures: https://ambulance.qld.gov.au/medical/pdf/02_cpp_airway. pdf https://ambulance.qld.gov.au/medical/pdf/02_cpp_airway. pdf https://ambulance.qld.gov.au/medical/pdf/02_cpp_airway. pdf http://www.thoracic.org/clinical/copd-guidelines/for- health-professionals/exacerbation/inpatient-oxygen- therapy/oxygen-delivery-methods.php http://www.thoracic.org/clinical/copd-guidelines/for- health-professionals/exacerbation/inpatient-oxygen- therapy/oxygen-delivery-methods.php http://www.thoracic.org/clinical/copd-guidelines/for- health-professionals/exacerbation/inpatient-oxygen- therapy/oxygen-delivery-methods.php http://www.thoracic.org/clinical/copd-guidelines/for- health-professionals/exacerbation/inpatient-oxygen- therapy/oxygen-delivery-methods.php


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