1. Department of Anesthesiology Uniformed Services University of the Health Sciences AIRWAY MANAGEMENT When you can’t breath, nothing else matters

2. Acute Respiratory Failure è Respiratory failure: failure of maintenance of normal arterial blood gas tensions è Ventilatory failure: pathological reduction in alveolar ventilation

3. Acute Respiratory Failure è What are our goals in support of the Respiratory system in critically ill patients? è What conditions may lead to prevent us from achieving these goals? è What therapies can we offer in support of each of these goals?

4. AIRWAY MANAGEMENT Respiratory Distress vs. Respiratory Failure Distress -Increased work of breathing -Relative hypoxia/hypercapnea -Compensating Failure -Increased work of breathing -Profound hypoxia/hypercapnea -Decompensating It’s a constant reassessment process…

5. Acute Respiratory Failure è Goal 1: Maintenance of a patent airway X CNS alertness X Secretion control X Jaw thrust X NP airway X Oral airway X Noninvasive positive pressure X ETT

6. Acute Respiratory Failure è Goal 2: Maintenance of adequate respiratory gas exchange (O2 and CO2) X Supplemental Oxygen X Noninvasive positive pressure X CMV X HFO X ECMO

7. Acute Respiratory Failure è Goal 3: Preservation of normal respiratory mechanics X Secretion control X Chest physiotherapy X ETT suctioning X Prone positioning

8. Acute Respiratory Failure è Goal 4: To minimize the metabolic expenditures of the respiratory system X Positive pressure »Invasive »Noninvasive X Sedation X Maintenance of patent airway X Medications: steroids, racemic epi., Ventolin

9. Acute Respiratory Failure è Goal 5: Occasionally, specific alterations in blood gas tensions may be desirable. X Head injury, avoidance of hypercapnea X Deliberate hypoxia and hypercapnea in cyanotic heart disease to limit pulmonary blood flow X Pulmonary hypertension: high O2 and low CO2

10. Acute Respiratory Failure è Definitions of Respiratory Failure: X Depends on what you mean by failure. è In ARDS, PaO2/FiO2 ratio of <200, bilateral infiltrates on CXR, PAWP < 16. è What level of arterial CO2 constitutes respiratory failure? è What level of arterial saturation?

11. Establishing A Patent Airway Chin Lift and Jaw Thrust ManeuverChin Lift and Jaw Thrust Maneuver Oropharyngeal AirwayOropharyngeal Airway Nasopharyngeal AirwayNasopharyngeal Airway Laryngeal Mask AirwayLaryngeal Mask Airway - The above do not protect against aspiration and laryngospasm Department of Anesthesiology Uniformed Services University of the Health Sciences

12. Mask Ventilation Can Deliver A High FIO2Can Deliver A High FIO2 Avoids The Potential Trauma Of IntubationAvoids The Potential Trauma Of Intubation Does Not Protect Against AspirationDoes Not Protect Against Aspiration May Result In Gastric DistensionMay Result In Gastric Distension Laryngospasm Can OccurLaryngospasm Can Occur Requires Use Of Both HandsRequires Use Of Both Hands Department of Anesthesiology Uniformed Services University of the Health Sciences

13. Oral/Nasal Intubation Safe and Common Practice in Patients Undergoing General AnesthesiaSafe and Common Practice in Patients Undergoing General Anesthesia Atraumatic Intubation requires Knowledge of Anatomy, Appropriate use of Equipment, and Drugs (Muscle Relaxants)Atraumatic Intubation requires Knowledge of Anatomy, Appropriate use of Equipment, and Drugs (Muscle Relaxants) Department of Anesthesiology Uniformed Services University of the Health Sciences

14. Preoperative Evaluation Patient HistoryPatient History - Prior History of Difficult Intubation - Tumor of Head and Neck - Arthritis - Pregnancy - Trauma - C Spine, Full Stomach Department of Anesthesiology Uniformed Services University of the Health Sciences

15. Preoperative Evaluation Physical ExaminationPhysical Examination - Tongue versus Pharyngeal Size - Atlanto - Occipital Joint Extension Cervical Spine Mobility (normal 35 degrees)Cervical Spine Mobility (normal 35 degrees) - Anterior Mandibular Space Thyromental distance - normal is 6 cmThyromental distance - normal is 6 cm - Dental Examination (Loose Teeth, Prostheses) Department of Anesthesiology Uniformed Services University of the Health Sciences

16. Department of Anesthesiology Uniformed Services University of the Health Sciences

17. Department of Anesthesiology Uniformed Services University of the Health Sciences

18. Department of Anesthesiology Uniformed Services University of the Health Sciences

19. Technique For Orotracheal Intubation Preparation And Equipment (Always Have Suction Available)Preparation And Equipment (Always Have Suction Available) Head Position - Alignment Of Oral, Pharyngeal, and Laryngeal AxesHead Position - Alignment Of Oral, Pharyngeal, and Laryngeal Axes Choice Of Laryngoscope And Endotracheal TubeChoice Of Laryngoscope And Endotracheal Tube Possible Need For Awake Tracheal IntubationPossible Need For Awake Tracheal Intubation - Difficult Airway Algorithm Department of Anesthesiology Uniformed Services University of the Health Sciences

20. Department of Anesthesiology Uniformed Services University of the Health Sciences

21. Orotracheal Intubation Patient’s Head At The Level Of The XiphoidPatient’s Head At The Level Of The Xiphoid Sniffing PositionSniffing Position Laryngoscope In LEFT HandLaryngoscope In LEFT Hand Open MouthOpen Mouth Hold Tracheal Tube In Right Hand Like A PencilHold Tracheal Tube In Right Hand Like A Pencil Department of Anesthesiology Uniformed Services University of the Health Sciences

22. Department of Anesthesiology Uniformed Services University of the Health Sciences

23. Department of Anesthesiology Uniformed Services University of the Health Sciences

24. Department of Anesthesiology Uniformed Services University of the Health Sciences

25. Department of Anesthesiology Uniformed Services University of the Health Sciences

26. Department of Anesthesiology Uniformed Services University of the Health Sciences

27. Department of Anesthesiology Uniformed Services University of the Health Sciences

28. Complications Of Orotracheal Intubation (During) Dental And Oral Soft tissue TraumaDental And Oral Soft tissue Trauma Hypertension And TachycardiaHypertension And Tachycardia Cardiac Dysrhythmias And Myocardial IschemiaCardiac Dysrhythmias And Myocardial Ischemia AspirationAspiration Corneal DamageCorneal Damage Department of Anesthesiology Uniformed Services University of the Health Sciences

29. Complications Of Orotracheal Intubation (Intubated Patient) Tracheal Tube ObstructionTracheal Tube Obstruction Endobronchial IntubationEndobronchial Intubation BarotraumaBarotrauma Accidental DisconnectAccidental Disconnect Tracheal Mucosa IschemiaTracheal Mucosa Ischemia Accidental ExtubationAccidental Extubation Department of Anesthesiology Uniformed Services University of the Health Sciences

30. Immediate And delayed Complications On Extubation LaryngospasmLaryngospasm AspirationAspiration PharyngitisPharyngitis Laryngeal Or Subglottic EdemaLaryngeal Or Subglottic Edema Vocal Cord ParalysisVocal Cord Paralysis Arytenoid Cartilage DislocationArytenoid Cartilage Dislocation Department of Anesthesiology Uniformed Services University of the Health Sciences

31. Alternatives To Orotracheal Intubation Under Anesthesia Awake Orotracheal IntubationAwake Orotracheal Intubation Nasotracheal IntubationNasotracheal Intubation - Awake Blind Nasal - Nasotracheal Intubation After Induction Intubation With Fiberoptic BronchoscopeIntubation With Fiberoptic Bronchoscope - Awake versus Under Anesthesia - Orotracheal versus Nasotracheal Retrograde IntubationRetrograde Intubation Department of Anesthesiology Uniformed Services University of the Health Sciences

32. Verification Of Correct Tube Placement Symmetric Chest MovementSymmetric Chest Movement Symmetric Breath SoundsSymmetric Breath Sounds End tidal Carbon DioxideEnd tidal Carbon Dioxide - Greater Than 30 For 3-5 Breaths Condensation Of Water In The tubeCondensation Of Water In The tube Palpation Of Cuff In Suprasternal NotchPalpation Of Cuff In Suprasternal Notch Fiberoptic BronchoscopyFiberoptic Bronchoscopy Department of Anesthesiology Uniformed Services University of the Health Sciences