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Airway Management

Airway Management. Objectives. Discuss Oxygen Delivery Systems Discuss Intubation Equipment & Procedures. Oygen Delivery Devises. Nasal Bi-Prong (NBP) Simple Face Mask Venturi Mask Non-Rebreather Ambu-Mask Laryngeal mask airway (LMA) Continous Positive Airway Pressure (CPAP)

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Airway Management

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  1. Airway Management

  2. Objectives • Discuss Oxygen Delivery Systems • Discuss Intubation Equipment & Procedures

  3. Oygen Delivery Devises • Nasal Bi-Prong (NBP) • Simple Face Mask • Venturi Mask • Non-Rebreather • Ambu-Mask • Laryngeal mask airway (LMA) • Continous Positive Airway Pressure (CPAP) • Bilevel Positive Airway Pressure (BiPAP) • Endotrachel tube • Tracheostomy

  4. FiO2 Available By Delivery Device • NBP 1 – 6 l/m @3 % for 1st liter and 4% for each additional liter • Venturi Mask 24%- 50 % • Nonrebreather 80-90% • CPAP 3-15cm H2O + O2 • BiPAP 3-15cmH2O + pressure support + O2 • Ambu-Bag 98% • Mechanical Ventilation 30-100%

  5. Anatomy: The Upper Airway Pharynx Laryngopharynx

  6. Anatomy: The Lower Airway Larynx Vocal Cords

  7. Anatomy: The Lower Airway Larynx Epiglottis Vestibule of Larynx Ventricle of Larynx Trachea Laryngopharynx

  8. Intubation Positioning (B is the correct method)

  9. Placement of Laryngoscope

  10. Curved Blade (Mac)

  11. Straight Blade (Miller)

  12. What you hope to see.

  13. Basic RSI Protocol • Preparation and Preoxygenation • Midazolam (Versed) 0.1 mg/kg IVP (5-6 mg) • Apply cricoid pressure • Succinylcholine 1 mg/kg IV (100 mg) Intubate

  14. RSI protocol for high ICP or penetrating Eye Injuries • Preparation and Preoxygenation • Prevent ICP rise • Lidocaine 1.5-2 mg/kg IV • Vecuronium .01 mg/kg IV (defasciculating dose) • Consider Fentanyl 3 ug/kg IVP • Prevent Vagally stimulated Bradycardia • Atropine 0.01 mg/kg IV (Minimum dose: 0.1 mg) • Sedation • Etomidate 0.3 mg/kg IVP OR • Thiopental (Pentothal) 4 mg/kg IVP (IF BP stable) • Apply cricoid pressure • Muscle relaxants/Paralytic Agents • Succinylcholine 1.5 mg/kg IV (2 mg/kg if <10 yo) OR • Vecuronium 0.2 mg/kg IV • Intubate

  15. General RSI Protocol (All Options) • Atropine 0.01 mg/kg IV (Minimum dose: 0.1 mg) • Prevents vagally stimulated Bradycardia • Consider Increased Intracranial pressure management • Lidocaine 1 mg/kg IV (Prevents ICP rise) • Fentanyl 3 ug/kg IVP • Consider Vecuronium 1 mg (defasciculating dose) • Sedation • Preferred medications • Etomidate 0.2-0.3 mg/kg IVP • Midazolam (Versed) 0.1 mg/kg IVP • Other options • Thiopental (Pentothal) 3-5 mg/kg IVP • Ketamine 1-2 mg/kg IV • Muscle relaxants/Paralytic Agents • Succinylcholine 1-1.5 mg/kg IV, 2-4 mg/kg IM • Vecuronium (Norcuron) 0.1 mg/kg IV • Pancuronium (Pavulon) 0.1 mg/kg IV

  16. Intubation Indications • Respiratory arrest • Respiratory failure • Hypoventilation/Hypercarbia • paCO2 >55 mmHg • Arterial Hypoxemia refractory to oxygen • paO2 <55 RA, • Respiratory Acidosis • Airway obstruction • Glasgow Coma Scale <=8 • Need for prolonged Ventilatory support • Class III or IV hemorrhage with poor perfusion • Severe flail chest or pulmonary Contusion • Multiple trauma, Head Injury and abnormal mental status • Inhalation Injury with erythema/edema at cords • Protection from aspiration

  17. Preparation • Monitoring Pulse Oximetry (Hypoxemia, Bradycardia) • May pretreat with Atropine 0.02 mg/kg prior to ET • Check laryngoscope for light and blade size • Estimated blade size selection • With laryngoscope blade held next to patient's face • Blade should reach between lips and larynx • Better to choose a blade too long than too short • Adult: #3 to #4 Macintosh Blade (curved) • Child <8 yo: #2 Macintosh Blade (curved) • Term Infant: #1 Miller Blade (straight) • Premature Infant: #0 Miller Blade (straight) • Check suction • Select ET size and length (See Endotracheal Tube) • Stylet should NOT extend beyond distal ET • Intubation attempts should not last >30 seconds • Limit intubation attempt to 20 seconds in newborns • Preoxygenate with 100% Oxygen • Consider Rapid Sequence Intubation if conscious

  18. Endotracheal Tube Insertion • Insert laryngoscope into the right mouth • At the tonsillar pillars sweep Tongue to midline • Extend blade over base of Tongue and • Curved blade: tip into vallecula • Straight Blade: tip over the epiglottis • Avoid entering esophagus first • Risk of laryngeal trauma • Exert traction upward along axis of handle • Do not use teeth or gums as a fulcrum • Results in significant oral/dental trauma • Insert ET Tube from the right corner of mouth • Avoids obstructing view • Cricoid pressure may facilitate glottis viewing • Position ET Tube • Black marker on ET Tube at level of cords • Cuffs should be placed just below cords

  19. Assess Tube Position • Symmetrical Chest Movement • Auscultate for equal breath sounds • Document absent breath sounds over stomach • Vapor condenses on inside of tube with exhalation • End-tidal carbon dioxide (required by new guidelines)

  20. Secure the ET Tube • Confirm tube position again by auscultation • Tape ET Tube in place and fix to cheek with benzoin • Note the distance marker at lips in chart • Commercial tube holder highly recommended

  21. Tube Changers

  22. Rigid Fiberoptic Bronchoscopy

  23. Retrograde Intubation

  24. Oral & Nasal Airways

  25. Flexible Bronchoscopy

  26. Laryngeal Mask Airway

  27. Cricothryriodotomy Kit

  28. Jet Ventilation

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