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Advanced Airway Management

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Presentation on theme: "Advanced Airway Management"— Presentation transcript:

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

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

3 Basic Airway Management
For patients unable to protect their own airway Jaw thrust/head tilt technique This technique itself can open the airway If concern for c-spine injury, use jaw thrust without head tilt Excessive head tilt can occlude trachea in infants, consider padding under shoulders Jaw thrust without head tilt. The jaw is lifted without tilting the head. This is the airway maneuver of choice for a victim suspected of having sustained a cervical spine injury.

4 Basic Airway Management

5 Basic Airway Management
Padding under shoulders for infant

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

7 Airway Suctioning Yankeur Rigid Catheter Y Suction Catheter

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

9 Oxygen Delivery Methods
Nasal Cannula: flow rate 1-6 LPM (FiO %) Simple face mask: flow rate 5-10 LPM (FiO %) Non-rebreather mask: flow rate LPM (FiO %) BiPAP/CPAP Nasal cannula: flow rate 1-6 LPM, percent oxygen concentration, (one source says 25-45%) victims with difficulty breathing, sometimes used for victims unable to tolerate a mask. Available in adult and pediatric sizes. Resuscitation mask: flow rate LPM, percent oxygen concentration, victims with difficulty breathing and non-breathing victims
Non-rebreather mask: flow rate LPM, up to 90 percent oxygen concentration, (one source says 60 to 95%) breathing victims only
BVM: flow rate 15 LPM or more, 90+ percent oxygen concentration, victims with difficulty breathing and non-breathing victims

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

11 Laryngeal Mask Airway Supraglottic airway
Doesn’t require laryngeal visualization Can precipitate vomiting or aspiration Size Weight guide Population 1 <5 kg Infant 2 10-20 kg Small Child 3 30-50 kg Small Adult 4 50-70 kg Average Adult 5 kg Large Adult

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

13 Other Airways King Tube Combitube

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

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

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

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

18 Endotracheal Intubation
Tools: Laryngoscope Macintosh blade- curved blade, rests on epiglottic vallecula Miller blade- straight blade, lifts epiglottis directly Blade Size Patient Miller Infant 1 Small child Macintosh 2 Large child 3 Small adult 4 Large adult

19 Endotracheal Intubation
Tools: ET tube Age Uncuffed ETT (mm) Cuffed ETT (mm) Depth at lips (cm) Newborn 3.0 9-10 1-5 mths 3.5 10 6-11 mths 3.5-4 11 1 yr 4.0 12 2-3 yrs 12-13 4-5 yrs 13-15 6-9 yrs 15 10-12 yrs 17 13+ 19

20 Endotracheal Intubation
Place head in sniffing position (MILS if c-spine injury) Open mouth, inspect oral cavity Remove dentures or debris 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

21 Endotracheal Intubation

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

23 Glidescope

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

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

26 Oropharyngeal Airway Size Color Suggested Population 000 Clear
Neonate (under 6 wks) 00 Blue Infant (1-6 months) Black Older infants/toddlers 1 White Small child (3-10 years) 2 Green Adolescent/adult female 3 Yellow Adult male 4 Red Large adult male

27 Nasopharyngeal Airway
Useful in patients with airway obstruction, especially if oropharyngeal airway is inappropriate Correct size reaches from tip of patient’s nose to ear lobe Sizes 6,7 & 8 mm Lubricate end of tube with lubricating jelly Insert into nostril (usually right) with bevel facing nasal septum 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 health-professionals/exacerbation/inpatient-oxygen- therapy/oxygen-delivery-methods.php


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