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

30. Cases

31. References
Queensland EMS Clinical Practice Procedures: pdf
health-professionals/exacerbation/inpatient-oxygen- therapy/oxygen-delivery-methods.php