1. Airway Management

3. Anatomy Review

5. Anatomy of the Upper Airway

6. Internal Anatomy-Upper Airway
Be very familiar with this anatomy when performing a cricothyrotomy.
Point out the Thyroid cartilage, Crico-thyroid membrane (Intrinsic ligament in this slide) and the Cricoid cartilage.

7. Internal Anatomy-Upper Airway
Be very familiar with this anatomy when performing a cricothyrotomy.
Point out the Thyroid cartilage, Crico-thyroid membrane (Intrinsic ligament in this slide) and the Cricoid cartilage.

8. Start with the Basics Start with the simple steps
Positioning - Clear the airway
Nasal adjuncts
Oral adjuncts
BIAD (AKA: Blind Insertion Airway Devices)
Intubation
Cricothyrotomy
Remember this class can not intubate or perform cricothyrotomy

9. Airway Maneuvers

10. Head-Tilt Chin-Lift
Be very familiar with this anatomy when performing a cricothyrotomy.
Point out the Thyroid cartilage, Crico-thyroid membrane (Intrinsic ligament in this slide) and the Cricoid cartilage.

11. Head-Tilt Chin-Lift Indication Without suspected spinal injury
Unresponsive patient that can not protect their own airway
Simple, safe and non-invasive
Does not protect from aspiration

12. Head-Tilt Chin-Lift Method
Tilt head back with hand on patient’s forehead
Fingers of other hand under bony part of lower jaw and lift chin forward
AHA standard for non-injury patient

13. Head-Tilt Chin-Lift Maneuver

14. Jaw Thrust

15. Jaw Thrust Indication Method
Used in suspected spinal injury/history of cervical injury or fusion, etc
Method
Grasp angle of lower jaw
Lift with both hands and displace mandible forward while tilting the head back
Figure 12-28

16. Jaw Thrust Maneuver

17. Airway Adjuncts

18. OPA
Indications
Hold tongue away from the posterior wall of the pharynx
Unconscious, semi-conscious without a gag
Infant to adult sizes

19. Oropharyngeal Airway

20. OPA Method Measure Clear airway Upside-down or at 90-degree angle
Rotate until against posterior wall of oropharynx
Confirm placement

21. OPA Disadvantages Does not protect from aspiration
May stimulate vomiting and laryngospasm if gag present
If not inserted properly, pushes tongue back and causes airway obstruction

22. Measuring an OPA

23. Inserting OPA
If it is too short, it will not hold the tongue forward. If it is too long, be aware of a gag reflex and it can press against the epiglottis causing an airway obstruction.

24. Nasopharyngeal Airways

25. NPA Indications Semiconscious or patient unable to maintain own airway
Unconscious where OPA not used
Seizures
C-spine Injury
Before nasotracheal intubation
Guide for inserting a nasogastric tube

26. NPA Advantages Well tolerated in those with a gag reflex
Inserted rapidly
Used when OPA is contraindicated (facial trauma, gag reflex)

27. NPA Disadvantages Longer length may enter esophagus
Laryngospasm and vomiting
Injury to nasal mucosa, bleeding, or obstruction
Small diameters can become obstructed with vomit, mucus, or blood
Does not protect from aspiration
Can’t suction through

28. NPA Method Measure Lubricate with water-soluble lubricant
Bevel tip toward nasal septum
Use natural curvature of nasal passage
Should rest in posterior pharynx

29. Measuring a Nasal Airway

30. Bag-Valve Mask

31. BVM Indications and Advantages Self-inflating and non-rebreathing
Use with airway maintenance device
Use with apnea or ineffective effort
Provides blood/body fluid barrier
Room air (21%) to 100% FiO2
Sense of lung compliance

32. BVM
Disadvantages
Difficult to master – tidal volume dependent on mask seal
Inadequate tidal volume from poor technique, poor mask seal, and gastric distention

33. BVM Method Position at patient’s head Clear airway
Head tilt chin lift or jaw thrust
BLS or ALS airway
Tight seal on mouth with E-C positioning
One and two person options

34. BIADs

35. Forms low pressure seal over laryngeal inlet
Laryngeal Mask Airway: LMA
Invented by dr archie brain, british anesthetist in 1983
shaft (tube)
proximal 15 mm connector
distal end with broad elliptical inflatable cuff — upper smooth surface to prevent pharyngeal secretions entering the larynx and an under surface with an orifice with linear bars that sits over the larynx to create a seal
pilot balloon
Types:
Reusable (silicon)
Intubating LMA with endotracheal tube (e.g. FastTrackTM) (disposable)
LMA with gastric suction channel (e.g. ProSealTM) (disposable)
Sizes:
0 (infant) to 6 (large adult)
size 3 (females) or 4 (males) commonly used in adults
Forms low pressure seal over laryngeal inlet

36. LMA Indications Situations involving a difficult mask fit
Cannot be intubated, can be ventilated
ETT can be passed through LMA
May be used as a “second-last-ditch” airway where a surgical airway is the only remaining option

37. LMA Contraindications Cannot open mouth
Airway obstruction or abnormalities
High risk of aspiration (obesity, late pregnancy, not NPO, etc)

38. LMA
Method
Have all equipment ready, select appropriate size (sizes 1-5)
Test cuff inflation/deflation system (reference point: Size 4 (adult)-30ml)
Apply a water-soluble lubricant to the back of the mask

39. LMA
Method
Grasp the LMA by the tube, holding it like a pen as near as possible to the mask end.
Place the tip of the LMA against the inner surface of the patient’s upper teeth

40. LMA
Method
Under direct vision press the mask tip upwards against the hard palate to flatten it out
Using the index finger, keep pressing upwards as you advance the mask into the pharynx to ensure the tip remains flattened and avoids the tongue

41. LMA
Method
Keeping the neck flexed and head extended, press the mask into the posterior pharyngeal wall using the index finger

42. LMA
Method
Continue pushing with your index finger and guide the mask downward into position.

43. LMA
Method
Grasp the tube firmly with the other hand then withdraw your index finger from the pharynx
Press gently downward with your other hand to ensure the mask is fully inserted

44. LMA Method Inflate the mask with the recommended volume of air
Do not touch the LMA tube while inflating unless the position is unstable
The mask can rise up slightly out of the hypopharynx as it is inflated to find its correct position

45. LMA Placement
Cline DM et al. Tintinelli’s Emergency Medicine Manual, 7th Edition:
LMA
sniffing position
partially inflated cuff
lubricate mask surface
aperture facing towards laryngeal inlet or posteriorly with a 180 degrees twist once behind tongue
inflate cuff with 20-40mL of air
Complications: inability to achieve seal and ventilatie, regurg and aspiration, gas isuffliation, trauma to upper airway, malposition

46. LMA Method Attach to BVM Perform standard evaluation of lung sounds
Insert a bite-block or roll of gauze to prevent occlusion of the tube should the patient bite down
Secure with tape or ET tube holder

47. LMA Helpful Tidbits If you can’t ventilate, remove it
Avoid excessive lubricant on anterior surfaces
Avoid LMA fold over

48. King Airway

49. Primary Ventilatory Opening
Pilot Balloon
Primary Ventilatory Opening
Proximal Cuff
Stabilizes tube & seals oropharynx
Bilateral Ventilation Eyelets
Distal Tip & Cuff
Anatomically shaped to assist in passage behind larynx and normally collapsed esophagus
Distal Opening of Gastric Access Lumen
Multiple Distal Ventilatory Openings
Proximal Opening of Gastric Access Lumen
LTS-D allows gastric channel, LT-D no gastric channel
Why King over Combitube: simpler design, single inflation port, single syringe, smaller size, easier insertion, lower potential for unrecognized esophageal ventilation
Levitan RM, Airway Cam Pocket Guide to Intubation, 2nd Ed., Airway Cam Tech.Inc., Wayne PA, 2007;

50. King Airway
Comes in 3 sizes:
#3: 4–5 ft
#4: 5–6 ft
#5: > than 6 ft

51. King Airway Indications
When tracheal intubation indicated, but unsuccessful or unavailable.
Access to the patient is limited (e.g., trauma patients, entrapment, etc.).
Difficult or emergent airways
Cardiopulmonary arrest (optional).

52. King Airway Contraindications Presence of gag reflex Caustic ingestion
Obstructed airway
Esophageal trauma or disease

53. King Airway
Method
Have all equipment ready, select appropriate size (#3, #4, or #5)
Test cuff inflation system for leaks
Apply a water-soluble lubricant to the posterior distal tip of the device

54. King Airway
Method
Hold King Airway in dominant hand at proximal connector
Perform tongue-jaw lift while keeping head in a neutral position

55. King Airway
Method
Rotate King laterally degrees (blue orientation line is touching the corner of the mouth)
Introduce tip into mouth and advance behind base of the tongue
As the tube passes under the tongue, rotate the tube back to midline (blue orientation line faces chin)

56. King Airway
Method
Advance tube until connector is aligned with teeth and/or gums.

57. King Airway Method #3: 45-60ml #4: 60-80ml #5: 70-90ml
Using a syringe, inflate the cuffs with the appropriate volume of air.
#3: 45-60ml
#4: 60-80ml
#5: 70-90ml

58. King Airway Method Attach BVM
While ventilating, simultaneously withdraw until ventilation is easy and free-flowing.
There should be good tidal volume with minimal resistance.

59. King Airway Method Perform standard evaluation of lung sounds
Attach and utilize end-tidal CO2 monitoring
Readjust cuff inflation as needed
Consider securing with tape or ET tube holder

60. King Airway Helpful Tidbits If you can’t ventilate, remove it
If water soluble lubricant used, do not apply near ventilatory openings
Be prepared to add another 10–15 cc in the event of air leakage
Insertion depth is critical

61. King Airway LTS-D allows gastric channel, LT-D no gastric channel
Why King over Combitube: simpler design, single inflation port, single syringe, smaller size, easier insertion, lower potential for unrecognized esophageal ventilation
device is inserted as deep as possible (after picking the correct size, to flange if possible), the balloons inflated, and then the device is gently withdrawn until ventilation is achieved.

62. ETTs

63. Endotracheal Intubation
Indications
Respiratory or cardiac arrest
GCS < 8
Risk of aspiration
Obstruction due to foreign bodies, trauma, burns, or anaphylaxis.
PTX or hemothorax with distress
Need for mechanical ventilation

64. Endotracheal Intubation
Complications
Equipment malfunction
Teeth breakage and soft tissue lacerations
Hypoxia
Esophageal intubation
Endobronchial intubation (right mainstem)
Tension pneumothorax

65. Endotracheal Intubation
Advantages
Isolates trachea and permits complete control of airway
Impedes gastric distention
Eliminates need to maintain a mask seal
Offers direct route for suctioning
Permits administration of some medications

66. Endotracheal Intubation
Disadvantages
Requires training and experience
Requires specialized equipment
Requires direct visualization of vocal cords
Bypasses upper airway’s functions of warming, filtering, and humidifying the inhaled air

67. Endotracheal Intubation
Method
Pre-ventilate patient
Position patient
Assemble and check equipment
Insert laryngoscope
Visualize larynx and insert ETT
Confirm placement
Secure ETT