Introduction to airway management
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Introduction to Airway Management. Deepi G. Goyal, M.D. Mayo Clinic Department of Emergency Medicine. Who Needs to be Intubated?. Airway Management. Which of the following is most important when evaluating a 29 y/o pt with polypharmacy OD with respect to need for intubation?.

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Introduction to Airway Management

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Introduction to airway management

Introduction to Airway Management

Deepi G. Goyal, M.D.

Mayo Clinic

Department of

Emergency Medicine


Who needs to be intubated

Who Needs to be Intubated?


Airway management

Airway Management

  • Which of the following is most important when evaluating a 29 y/o pt with polypharmacy OD with respect to need for intubation?

  • Arterial Blood Gas Results

  • Hemodynamic instability

  • Pulse Oximetry

  • Clinical Evaluation of pt’s ability to maintain & protect airway and exchange gases

  • Gag reflex, chest auscultation, CXR


Indications for intubation

Indications for Intubation

  • Is there a failure of oxygenation or ventilation?

  • Is there a failure of airway protection?

  • What is the anticipated clinical course?


Oxygenation ventilation

Oxygenation/Ventilation

  • Which of the following is TRUE regarding arterial blood gases?

  • A low pO2 should drive the decision to intubate

  • A high pCO2 should drive the decision to intubate

  • Neither A nor B

  • Both A and B


Indications for intubation1

Indications for Intubation

  • Failure of Oxygenation/Ventilation

    • A Clinical Decision

      • Do NOT rely on ABGs

      • Mentation

      • Fatigue

      • Concomitant Injuries


Indications for intubation2

Indications for Intubation

  • Failure of Airway Protection

    • Loss of upper airway musculature

    • Loss of protective reflexes


Airway adequacy

Airway adequacy

  • Which of the following is LEAST helpful in terms of determining airway adequacy?

  • Absence of a gag reflex

  • Pooling of secretions

  • Ability of the patient to phonate

  • Anatomic features such as infections and trauma


Indications for intubation3

Indications for Intubation

  • Gag


Indications for intubation4

Indications for Intubation

  • Failure of Airway Protection

    • Gag reflex unreliable in predicting aspiration risk

    • Swallowing

      • Complex reflex

      • Better tool than gag


Indications for intubation5

Indications for Intubation

  • Anticipated Clinical Course

    • Currently acceptable anatomy and physiology may deteriorate

      • Expanding neck hematoma

    • Work of breathing may be overwhelming in light of multiple major injuries

    • Patient cooperation required for diagnostic/therapeutic interventions


Airway management1

Airway Management

  • Which of the following is the MOST IMPORTANT skill for airway management

  • Knowledge of proper blade and tube selection for intubation

  • Familiarity with proper direct laryngoscopy techniques

  • Ability to manually ventilate using bag-valve-mask

  • Both A and B


Airway management2

Airway Management

  • Manual ventilation

  • Direct laryngoscopy and intubation

  • Techniques for difficult airways

  • Confirmation of ETT placement


Airway management3

Airway Management

  • Which of the following is NOT a patient factor that would negatively impact the ability to ventilate a patient ?

  • Presence of a beard

  • Obesity

  • Endentulous patient

  • Large tongue

  • All of the above would negatively impact ventilation


Manual ventilation

Manual Ventilation

  • Cornerstone for airway management

    • Allows for decreased urgency when intubating and options for failed attempts

  • Components

    • Head positioning

    • Maintaining airway patency

    • Mask seal


Manual ventilation1

Manual Ventilation

  • Head Positioning

    • The tongue is your “Enemy”!!

    • Position head to prevent tongue from obstructing airway

      • Chin lift

      • Jaw Thrust


Manual ventilation2

Manual Ventilation

  • Maintaining airway patency

    • Use Adjuncts!!!

      • Nasal airway

      • Oral Airway


Manual ventilation3

Manual Ventilation

  • Mask Seal

    • Start with mask on nasal bridge and lever it onto malar eminences and alveolar ridge

    • Apply pressure with thumb and index finger to assure adequate seal

    • Use digits 3,4,5 to hold mandible and thrust it forward


Manual ventilation4

Manual Ventilation

  • Pearls

    • Use K-Y jelly on beards

    • For pts with sallow cheeks, fold and place 4x4’s in cheeks

    • Reinsert false teeth if necessary


Airway management4

Airway Management

  • Barriers

    • Patient Cooperation

    • Anatomy

    • Time


Airway management5

Airway Management

  • Barriers

    • Patient cooperation

    • Anatomy

      • Distortion (Trauma, infection, neoplasm, hemorrhage, vomitus)

      • Disproportion (tongue/pharynx, thyromental distance)

      • Dysmobility (Neck mobility, TMJ)

      • Dentition (prominent incisors)

    • Time


Manual ventilation5

Manual Ventilation

  • Head positioning

    • “Sniffing” position optimizes alignment of oral, pharyngeal, and laryngeal axes


Laryngoscopy

Laryngoscopy

  • Goal

    • Use laryngoscope blade to lift epiglottis anteriorly to visualize vocal cords

    • Insert endotracheal tube through vocal cords


Placement of et tube

Placement of ET Tube


Airway management6

Airway Management

  • Barriers

    • Patient cooperation

    • Anatomy

      • Distortion (Trauma, infection, neoplasm, hemorrhage, vomitus)

      • Disproportion (tongue/pharynx, thyromental distance)

      • Dysmobility (Neck mobility, TMJ)

      • Dentition (prominent incisors)

    • Time


Rapid sequence intubation

Rapid Sequence Intubation

  • Tube Confirmation

    • Listen to both lungfields

    • Listen again

    • Pulse Oximetry

    • End-Tidal CO2

    • Aspiration Devices


Laryngeal mask airway

Laryngeal Mask Airway

  • Laryngeal Mask Airway

    • Inserted blindly and forms seal around laryngeal inlet

    • Insertion no more difficult in class III or IV airways or in those with grade III or IV view

    • As stimulating as oropharyngeal airway

    • Does not protect against aspiration


Intubating lma

Intubating LMA

  • Intubating Laryngeal Mask Airway


Combitube

Combitube

  • Double lumen tube inserted blindly

  • Distal lumen usually inserted into esophagus

  • Shown to be effective, esp. in prehospital settings


Combitube1

Combitube

  • Insert Combitube gently in a curved downward movement

  • Insert until printed ringmarks lie between teeth or alveolar ridges.

  • Do not use force !


Combitube2

Combitube

  • Inflate the oropharyngeal balloon with the syringe with the blue dot

  • Inflate the distal cuff with the syringe with the white dot


Combitube3

Combitube

  • Test ventilation via the longer blue tube (#1)

  • Air cannot escape at the distal end of the blocked "esophageal" lumen and enters the pharynx via the perforations

  • Since mouth, nose, and esophagus are sealed by the balloon and the cuff, air is forced into the trachea


Combitube4

Combitube

  • 10% inserted into the trachea

  • If auscultation through the blue port is negative, switch to the shorter port and ventilate trachea directly


Nasal intubation

Nasal intubation

  • Should be a skill learned by every MD who may intubate on a regular basis


Nasal intubation1

Nasal Intubation

  • Requires spontaneous respiration

  • Requires skill and experience

  • Can be done in ~ 90% of ED intubations

  • Can be done in sitting position

  • No sedation/paralytics needed

  • Very Rapid


Nasal intubation2

Nasal intubation

  • Prep nostril with Lidocaine spray and phenylephrine

  • Use smaller ET tube

  • Use plenty of lubrication


Nasal intubation3

Nasal intubation

  • Insert in larger nostril

  • Insert straight back

  • Insert until passed upper pharyngs

  • Watch for fogging of tube


Nasal intubation4

Nasal intubation

  • Insert during inspiration

  • or coughing

  • or gagging


Nasal intubation5

Nasal intubation

  • Check placement…..

  • Remember an intubated pt can NOT talk

  • Double check placement….

    • Listen to breathsounds

    • use CO2 device if available


Nasal intubation6

Nasal intubation

  • If not sure properly intubated pull back and re-try

  • Re-position head

  • Apply cricoid pressure

  • Try again


Nasal intubation7

Nasal intubation

  • Avoid in:

    • suspect basal skull fracture

    • suspect hemophilia or thrombocytophilia

    • Prohibiting facial trauma

    • Epiglottitis etc.


Summary

Summary

  • Know the indications for intubation

  • Be comfortable with BVM

    • Understand anatomy

    • Use adjuncts

  • Nasally intubate if breathing

  • Use optimal technique and equipment for laryngoscopy


Summary1

Summary

  • Final tips

    • Recognize structures

    • Use a properly styletted endotracheal tube

    • Control the tongue

    • Use all available help

    • Use external laryngeal manipulation

    • Know your options if you are unable to intubate (cricothyrotomy)


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