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Anything new in Airway Management?. Dr Adrian Burger Emergency Medicine Senior Registrar UCT/US. So what do we do? . A,B,C’s…… A is for clearing, opening and or securing the airway Clearing - turn on side - suction - no more blind finger sweeps!. Opening.

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anything new in airway management

Anything new in Airway Management?

Dr Adrian Burger

Emergency Medicine Senior Registrar


so what do we do
So what do we do?
  • A,B,C’s……
  • A is for clearing, opening and or securing the airway
  • Clearing - turn on side

- suction

- no more blind finger sweeps!

  • Jaw thrust
  • Head Tilt Chin lift
  • Combined
  • Remember : C-spine stabilization
opening or securing the airway
Opening or securing the Airway
  • BMV
  • LMA
  • Combitube®
  • ETT
  • Most basic piece of “airway” kit
  • Different types - clear, black

- cushion around edge

  • Won’t maintain airway by self
  • Needs head tilt/chin lift or jaw thrust
  • Also needs Positive Pressure Ventilation
positive pressure ventilation
Positive Pressure Ventilation
  • Rescuer’s breathing efforts and one-way valve
  • Bag Mask Ventilation (BMV)
oropharyngeal airway guedel
Oropharyngeal Airway/Guedel
  • Different colours = different sizes
  • Neonate to large adult
oropharyngeal airway guedel1
Oropharyngeal Airway/Guedel
  • Features:

- single use

- rounded edges

- bite block

- colour coding

- airway path in centre

oropharyngeal airway guedel2
Oropharyngeal Airway/Guedel
  • How to size it????

The size of the Guedel airway is the distance

between the center of the incisors and the angle of the jaw (on the same side!)

oropharyngeal airway guedel3
Oropharyngeal Airway/Guedel
  • How to put it in:

Depress tongue

Slip over spatula with curve caudal direction

Place bite block between teeth

oropharyngeal airway guedel4
Oropharyngeal Airway/Guedel
  • Indications:

To open and maintain an airway in a

patient with a depressed level of


With FMO2 or BMV

oropharyngeal airway guedel5
Oropharyngeal Airway/Guedel
  • Contra indications:

Patient won’t accept it


Risk of vomiting & aspiration

nasopharyngeal airway
Nasopharyngeal Airway
  • For maintaining airway in “more awake” patients
  • Sits in nasopharynx and opens airway
  • Does NOT protect against aspiration
nasopharyngeal airway2
Nasopharyngeal Airway
  • How to size it?

Estimate by comparing to patients little


  • How to insert it?


Gently push posteriorly towards ear on same side

Fix with a safety pin

nasopharyngeal airway3
Nasopharyngeal Airway
  • Contra-indications:

Base of skull fracture

Serious midline facial fractures

When definitive airway needed

  • Advanced airway
  • Useful alternative for “difficult intubation”
  • Easy to use
  • Sits on larynx - Protects lungs?
  • Have a range in unit
  • Re-use ?20 times
  • Part of kit
  • Formula for Children:

The combined widths of

the patient's index,

middle and ring fingers

lma in emergency medicine
LMA in Emergency Medicine
  • Indications:

Unconscious or anaesthetized patients

AHA Guidelines for adults:

BLS: alternative to BMV

ACLS: Optional/alternative to BMV, failed ETT

  • Aspiration?
  • Paediatrics?
lma in emergency medicine1
LMA in Emergency Medicine
  • Aspiration?

Less than with BMV

Supraglottic device

Aspirated from CPR or post LMA?

Cricoid pressure during CPR

lma use in emergency paediatrics
LMA Use in Emergency Paediatrics
  • Little Data

“Despite widespread use LMA, there is little data on its effectiveness during positive pressure ventilation in infants and young children “

  • Obstruction

The LMA appears more likely to cause partial airway obstruction in infants ( < 10kg) than in older children.

  • PALS®: Class Indeterminate
  • Neonates: “Can’t intubate can’t ventilate”
lma in emergency medicine2
LMA in Emergency Medicine
  • Benefits:

Ineffective BMV with failed ETT

AHA: Alternative to ETT or BMV in CPR

Blind ETT, by passing ETT through LMA

Drugs - 27% efficacy

lma in emergency medicine3
LMA in Emergency Medicine
  • Disadvantages:

Needs adequate training

Risk of aspiration

Limited Paediatric use

Not always successful

  • Advantages:

Protect airway from aspiration

Easy to use

AHA: alternative to ETT for CPR

  • Disadvantages:

Trauma to soft tissues

Not available here in SA

  • Head neutral or slightly flexed
  • Hold tongue and jaw between thumb & forefinger and lift
  • Gently insert Combitube® in a curved back and downward movement until black markers aligned with teeth
  • Inflate (proximal) pharyngeal balloon
  • Inflate (distal) tracheal balloon
  • Confirm which one of #1 or #2 tube is in lungs by using bag ventilator
equipment for ett
Equipment for ETT
  • Mask and bag ventilator with O2
  • ETT - checked, lubricated, tape ready
  • Laryngoscope
  • Drugs: Induction agent & muscle relaxant
  • McGills forceps, Bougie
  • Primary detection tools
  • Other advanced airways
  • Surgical airway capability
  • Advantages:

Airway patent and protected

Secretions suction



Known tidal volume

  • Disadvantages:


Skill lost

Interrupted CPR

why ett
Why ETT?
  • For above benefits
  • Inability to BMV or ineffective BMV
  • Secure threatened airway
  • Certain thoracic injuries
endotracheal tubes
endotracheal tubes
  • cuffed tubes
  • uncuffed tubes
placement of ett
placement of ETT
  • length of tube at the larynx (cm) = internal diameter of correct ETT for size
tube placement confirmation
Tube Placement Confirmation
  • Clinical - visual

- auscultation

- laryngoscopy

  • Detection devices - CO2 (2a)


detection devices
Detection Devices
  • Always clinical + device
  • No single device specific or sensitive
  • CO2 detector: 33%-100% sensitive

: 97%-100% specific

: only studied on ETT

  • EDD: bulb compressed or syringe pulled

: High sensitivity

: Poor specificity

  • CXR
secure the ett
Secure the ETT
  • Record depth at front teeth
  • Evidence is commercial=tape
  • Re-evaluate
  • 3 Rules - verify placement

- asynchronous CPR

- avoid excessive ventilation

  • Best for last!
  • Easy to master
  • First line in CPR
  • Every unit has one
  • Effective
  • OLD: ETT ventilation adjunct of choice for


  • ETT complications - misplaced

- displaced

- interrupted CPR

  • AHA: BMV or advanced airway for CPR
  • Prehospital: BMV=LMA & Combitube®
failed intubation
Failed Intubation
  • Can’t intubate, Can Ventilate

Don’t panic, call for help

Reassess need to intubate

Reposition patient, airway

Cricoid pressure


Consider other advanced airways

Call for help

failed intubation1
Failed Intubation
  • Can’t intubate, Can’t Ventilate

Call for help, don’t panic

Reassess airway, positioning

Reassess equipment

Two person ventilation

Other advanced airway

Surgical airway


  • Check your equipment before you need it
  • Be prepared
  • Don’t panic
parting shot
Parting shot

“Patients do not die from lack of intubation they die from lack of oxygenation”

  • Currents, winter2005-2006
  • JAMA, Feb 9, 2000-Vol 283, No6 p783-790