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

Introduction to Airway Management

Deepi G. Goyal, M.D.

Mayo Clinic

Department of

Emergency Medicine

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

  • 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 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


  • Goal

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

    • Insert endotracheal tube through vocal cords

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


  • Double lumen tube inserted blindly

  • Distal lumen usually inserted into esophagus

  • Shown to be effective, esp. in prehospital settings


  • Insert Combitube gently in a curved downward movement

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

  • Do not use force !


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

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


  • 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


  • 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.


  • Know the indications for intubation

  • Be comfortable with BVM

    • Understand anatomy

    • Use adjuncts

  • Nasally intubate if breathing

  • Use optimal technique and equipment for laryngoscopy


  • 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)