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Special Airway Devices and Techniques for the Difficult or Failed Airway Pat Melanson,MD.

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Presentation on theme: "Special Airway Devices and Techniques for the Difficult or Failed Airway Pat Melanson,MD."— Presentation transcript:

1 Special Airway Devices and Techniques for the Difficult or Failed Airway Pat Melanson,MD

2 Difficult Airway Kit: ASA Recommendations Multiple blades and ETTs ETT guides (stylets, bougé, light wand) Emergency nonsurgical ventilation ( LMA, Combitube, TTJV ) Emergency surgical airway access ( Cricothyrotomy kit, cricotomes ) ETT placement verification Fiberoptic and retrograde intubation

3 ETT Placement Methods Direct vision –laryngoscope –Bronchoscope Indirect indicator –transillumination with light wand –listening for air ( BNTI) –Blind tactile digital intubation Blindly without indicator

4 ETT Guides : Gum Elastic Bougie (ETT Introducer) Long, thin, flexible guide –60 cm long, 15 Fr, distal 3 cm has 40 degree bend –small diameter allows easier passage through cords than ETT Useful with Grade III views (epiglottis only) –direct tip underneath epiglottis and “walk up’ dorsum of epiglottis to anteriorly to cords –feel for “clicks” of tracheal cartilages or resistance at carina –advance ETT over bougie into trachea Useful when neck movement contraindicated

5 ETT Guides : Light Wand uses transillumination of neck soft tissues to guide tube technique is easier to teach, skill easier to maintain than conventional laryngoscopy produces less airway trauma less physiologic disturbance

6 ETT Guides : Light Wand Indications –Impossible Laryngoscopy with adequate Bag-Mask-Ventilation TMJ ankylosis limited C-spine mobility facial trauma Contraindications –Upper airway masses or lesions (blind technique)

7 Light Wand : Technique Load and lubricate ETT on wand Bend ETT just proximal to balloon cuff to near right angle Place head and neck in neutral position Grasp and lift upward the lower alveolar ridge and mentum with non-dominant hand Advance light wand in midline Lift jaw to aid passage under epiglottis Position light wand for maximum well circumscribed glow at anterior neck just below laryngeal prominence Retract rigid stylet and advance ETT

8 Emergency Non-surgical Ventilation: Laryngeal Mask Airway Designed to be placed in the supraglottic area, seal the larynx, and direct gas into trachea Oval inflatable cuff seals larynx Easy to use Does not provide definitive management –does not prevent aspiration –temporizing measure after failed intubation

9 Laryngeal Mask Airway : Technique Lubricate both sides Open airway with head tilt, sniffing position Insert LMA with laryngeal surface down Press device onto hard palate Advance using index finger –Use curve to advance over base of tongue –pushed as far as possible into hypopharynx –Stop when resistance felt(upper esophag. sphincter) Inflate collar and start bag ventilation

10 LMA and the Difficult Airway Consider use early in a can’t intubate, can’t ventilate situation while also getting prepared for a surgical airway or TTJV A temporizing measure but can be used as a conduit for endotracheal intubation –the “Intubating Laryngeal Mask” The LMA is a supraglottic device –Not suitable if the airway difficulty is due to laryngeal problems i.e., (laryngospasm) or local pharyngeal abnormalities ( abscess, hematoma, edema)

11 Emergency Non-surgical Ventilation : Combitube Dual-lumen, dual-cuffed rescue airway device –The two lumens allow ventilation whether placed in trachea or esophagus –If in trachea position, functions like an ETT –If in esophageal position, the two balloons seal hypopharynx proximally and esophagus distally and perforations in esophageal lumen between the cuffs allow for ventilation –Placed blindly

12 Emergency Non-surgical Ventilation: Transtracheal Jet Ventilation Puncture cricothyroid membrane with large- bore (12 or 14 Gauge) kink-resistant catheter connected to 3-way stopcock or to a suction catheter with control vent 50 psi wall oxygen source High pressure tubing Ventilate for 2 seconds (or until chest rise) Release valve for 4 to 5 seconds (exhalation)

13 Emergency Surgical Access : Cricothyrotomy

14 Emergency Surgical Access: Cricotomes Commercially available kits Seldinger technique –Cricothyroid membrane punctured with needle –Guidewire advanced into trachea through needle –Cannula loaded on dilator is advanced over guidewire into trachea

15 Fiberoptic Intubation Indications –Predicted Difficult Airway with adequate oxygenation/ventilation(time required) Distorted upper airway anatomy or C-spine injury Contraindications –Excessive blood and secretions –Inadequate oxygenation

16 Bullard Laryngoscope Indirect fiberoptic laryngoscope with anatomically shaped blade Not necessary to align oral-pharyngeal- laryngeal axis –Useful for C-spine immobility Does not require significant mouth opening

17 Digital Intubation tactile technique operator uses fingers to blindly direct ETT not an easy technique requires large hands

18 Retrograde Intubation Indications –C-spine motion to be avoided and difficulty anticipated with conventional techniques –Failed intubation with adequate bag/mask ventilation and time is not limited Contraindications –infected skin over puncture site –infectious or neoplastic laryngeal lesions

19 Confirmation of ETT Placement: Clinical Evaluation Observation of ETT pacing through cords Clear, equal breath sounds bilaterally Absence of breath sounds over epigastrium Symmetrical rising of chest Condensation or “fogging” of ETT Chest X-ray ALL SUBJECT TO FAILURE Pulse oximetry is LATE indicator

20 Confirmation of ETT Placement Placement of ETT in the esophagus is an accepted complication of intubation However, failure to recognize and correct esophageal intubation immediately IS NOT ACCEPTABLE Either ETCO2 detection or an aspiration technique should be used on every emergency intubation

21 Confirmation of ETT Placement: End-tidal CO2 Detection Colorimetric –Small, disposable –Useful in pre-hospital care –Changes from purple to yellow if CO2 –100 % specific if bright yellow –Indeterminate ( brown ) can indicate esophagus with carbonated beverage, or low output state

22 Confirmation of ETT Placement: End-tidal CO2 Detection Quantitative End-Tidal CO2 Detection –indicates successful tube placement –early indicator of inadvertent extubation –adequacy of ventilation ( CO2 level ) –prognosis in cardiac arrest –monitoring/ therapy guide in arrest ETCO2 detectors can be falsely negative during cardiac arrest (inadequate perfusion for CO2 delivery to lungs)

23 Confirmation of ETT Placement: Esophageal Detection Devices Bulb or Syringe Aspiration Devices – Aspiration of a large volume of air rapidly through an ETT to determine whether the tube is in the esophagus or trachea –Esophagus is soft and will collapse if negative pressure applied –Less than free and immediate ( < 2 sec) aspiration of air should be considered to be esophageal until proven otherwise –Useful in cardiac arrests

24 Confirmation of ETT Placement: Esophageal Detection Devices False positive results –massive gastric insufflation –incompetent lower esophageal sphincter (pregnancy, hiatal hernia)


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