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Anything new in Airway Management?

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?

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  1. Anything new in Airway Management? Dr Adrian Burger Emergency Medicine Senior Registrar UCT/US

  2. 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!

  3. Opening • Jaw thrust • Head Tilt Chin lift • Combined • Remember : C-spine stabilization

  4. Opening or securing the Airway • BMV • OPA/NPA • LMA • Combitube® • ETT

  5. Mask • 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

  6. Mask

  7. Positive Pressure Ventilation • Rescuer’s breathing efforts and one-way valve • Bag Mask Ventilation (BMV)

  8. Mask with one-way valve

  9. Oropharyngeal Airway/Guedel • Different colours = different sizes • Neonate to large adult

  10. Oropharyngeal Airways

  11. Oropharyngeal Airway/Guedel • Features: - single use - rounded edges - bite block - colour coding - airway path in centre

  12. 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!)

  13. Oropharyngeal Airway/Guedel • How to put it in: Depress tongue Slip over spatula with curve caudal direction Place bite block between teeth • NO TWISTING MOVEMENT

  14. Oropharyngeal Airway/Guedel • Indications: To open and maintain an airway in a patient with a depressed level of consciousness With FMO2 or BMV

  15. Oropharyngeal Airway/Guedel • Contra indications: Patient won’t accept it LOC Risk of vomiting & aspiration

  16. Nasopharyngeal Airway • For maintaining airway in “more awake” patients • Sits in nasopharynx and opens airway • Does NOT protect against aspiration

  17. Nasopharyngeal Airway

  18. Nasopharyngeal Airway • How to size it? Estimate by comparing to patients little finger • How to insert it? Lubricate Gently push posteriorly towards ear on same side Fix with a safety pin

  19. Nasopharyngeal Airway • Contra-indications: Base of skull fracture Serious midline facial fractures When definitive airway needed

  20. LMA • Advanced airway • Useful alternative for “difficult intubation” • Easy to use • Sits on larynx - Protects lungs?

  21. LMA

  22. LMA • 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

  23. 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?

  24. LMA in Emergency Medicine • Aspiration? Less than with BMV Supraglottic device Aspirated from CPR or post LMA? Cricoid pressure during CPR

  25. 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”

  26. 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

  27. LMA in Emergency Medicine • Disadvantages: Needs adequate training Risk of aspiration Limited Paediatric use Not always successful

  28. LMA Insertion

  29. LMA Insertion

  30. Combitube®

  31. Combitube® • Advantages: Protect airway from aspiration Easy to use AHA: alternative to ETT for CPR • Disadvantages: Trauma to soft tissues Not available here in SA

  32. Combitube® • 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

  33. Combitube® Insertion

  34. ETT

  35. 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

  36. ETT • Advantages: Airway patent and protected Secretions suction O2 Medication Known tidal volume

  37. ETT • Disadvantages: Training Skill lost Interrupted CPR

  38. Why ETT? • For above benefits • Inability to BMV or ineffective BMV • Secure threatened airway • Certain thoracic injuries

  39. Anatomy

  40. endotracheal tubes • cuffed tubes • uncuffed tubes

  41. placement of ETT • length of tube at the larynx (cm) = internal diameter of correct ETT for size

  42. railroad techniques for changing tubes • getting the curves right

  43. Tube Placement Confirmation • Clinical - visual - auscultation - laryngoscopy • Detection devices - CO2 (2a) - EDD

  44. 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

  45. Secure the ETT • Record depth at front teeth • Evidence is commercial=tape • Re-evaluate • 3 Rules - verify placement - asynchronous CPR - avoid excessive ventilation

  46. BMV • Best for last! • Easy to master • First line in CPR • Every unit has one • Effective

  47. BMV

  48. BMV • OLD: ETT ventilation adjunct of choice for CPR • ETT complications - misplaced - displaced - interrupted CPR • AHA: BMV or advanced airway for CPR • Prehospital: BMV=LMA & Combitube®

  49. Failed Intubation • Can’t intubate, Can Ventilate Don’t panic, call for help Reassess need to intubate Reposition patient, airway Cricoid pressure Bougie Consider other advanced airways Call for help

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