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Rapid Sequence Intubation. A patient who needs intubation may be awake. Need for airway control may necessitate intubation. RSI paralyzes the patient to facilitate endotracheal intubation. Rapid Sequence Intubation. Pediatric Orotracheal Intubation. The Pediatric Airway.

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rapid sequence intubation
Rapid Sequence Intubation
  • A patient who needs intubation may be awake.
    • Need for airway control may necessitate intubation.
  • RSI paralyzes the patient to facilitate endotracheal intubation.
the pediatric airway
The Pediatric Airway
  • Anatomical Differences
    • Smaller and more flexible than an adult
    • Tongue proportionately larger
    • Epiglottis floppy and round
    • Glottic opening higher and more anterior
    • Vocal cords slant upward, and arecloser to the base of the tongue
    • Narrowest part is the cricoid cartilage
pediatric intubation
Pediatric Intubation
  • A straight laryngoscope blade is preferred for most pediatric patients.
  • Selecting the appropriate tube diameter for children is critical.
    • ETT size (mm) = (Age in years + 16) ÷ 4
    • Matching it to the diameter of the child’s smallest finger
  • Use non-cuffed endotracheal tubes with infants and children under the age of 8 years.
ventilate the child
Ventilate the child

© Scott Metcalfe

prepare the equipment
Prepare the equipment

© Scott Metcalfe

insert the laryngoscope
Insert the laryngoscope

© Scott Metcalfe

secure the tube
Secure the tube

© Scott Metcalfe

ventilation of pediatric patients
Ventilation of Pediatric Patients
  • Mask seal can be more difficult
  • Bag size depends on age of child
  • Ventilate according to current standards
  • Obtain chest rise and fall with each breath
  • Assess adequacy of ventilations by observing chest rise, listening to lung sounds, and assessing clinical improvement
nasotracheal intubation17
Nasotracheal Intubation
  • “Blind” procedure without direct visualization of the vocal cords
  • Indications include:
    • Possible spinal injury
    • Clenched teeth
    • Fractured jaw, oral injuries, or recent oral surgery
    • Facial or airway swelling
    • Obesity
    • Arthritis preventing sniffing position
nasotracheal intubation18
Nasotracheal Intubation
  • Contraindications
    • Suspected nasal fractures
    • Suspected basilar skull fractures
    • Significantly deviated nasal septum or other nasal obstruction
    • Cardiac or respiratory arrest
nasotracheal intubation19
Nasotracheal Intubation
  • Advantages
    • The head and neck can remain in neutral position
    • It does not produce as much gag response and is better tolerated by the awake patient
    • It can be secured more easily than an orotracheal tube
    • The patient cannot bite the ETT
nasotracheal intubation20
Nasotracheal Intubation
  • Disadvantages
    • More difficult and time consuming
    • Potentially more traumatic for patients
    • Tube may kink or clog more easily
    • Greater risk of infection
    • Improper placement more likely
    • Requires that patient be breathing
field extubation
Field Extubation
  • Field extubation may be indicated when:
    • The patient is clearly able to maintain and protect his airway.
    • The patient is not under the influence of sedatives.
    • Reassessment indicates the problem that led to endotracheal intubation is resolved.
  • Consider the high risk of laryngospasm
esophageal tracheal combitube
Esophageal Tracheal Combitube
  • A dual-lumen airway
    • The longer, blue port (#1) is the proximal port
    • The shorter, clear port (#2) is the distal port, which opens at the distal end of the tube
  • Two inflatable cuffs
    • 100-mL cuff just proximal to the distal port
    • 15-mL cuff just distal to the proximal port
esophageal tracheal combitube26
Esophageal Tracheal Combitube
  • Advantages
    • Provides alternate airway control
    • Insertion is rapid and easy
    • Does not require visualization of the larynx
    • Pharyngeal balloon anchors the airway
    • Patient may be ventilated regardless of tube placement
    • Significantly diminishes gastric distention
    • Can be used on trauma patients
    • Gastric contents can be suctioned
esophageal tracheal combitube27
Esophageal Tracheal Combitube
  • Disadvantages
    • Suctioning tracheal secretions is impossible when the airway is in the esophagus.
    • Placing an endotracheal tube is very difficult with the ETC in place.
    • It cannot be used in conscious patients or in those with a gag reflex.
esophageal tracheal combitube28
Esophageal Tracheal Combitube
  • Disadvantages
    • The cuffs can cause esophageal, tracheal, and hypopharyngeal ischemia.
    • It does not isolate and completely protect the trachea.
    • It cannot be used in patients with esophageal disease or caustic ingestions.
    • It cannot be used with pediatric patients.
esophageal tracheal combitube29
Esophageal Tracheal Combitube

Click here to view a video on ETC.

pharyngo tracheal lumen airway
Pharyngo-Tracheal Lumen Airway
  • Two-tube system:
    • Proximal cuff seals oropharynx
    • Distal cuff seals either the esophagus or the trachea
  • Advantages
  • Disadvantages
laryngeal mask airway
Laryngeal Mask Airway
  • Has an inflatable distal end that is placed in the hypopharynx and then inflated
  • Blind insertion
  • Disadvantage:
    • Does not isolate trachea
intubating laryngeal mask airway
Intubating Laryngeal Mask Airway
  • It is designed to facilitate endotracheal intubation.
  • An epiglottic elevating bar in the mask aperture elevates the epiglottis.
  • Tube is directed centrally and anteriorly.

© LMA North America

cobra perilaryngeal airway
Cobra Perilaryngeal Airway
  • Similar to the laryngeal mask
    • Supraglottic airway
  • “Cobra head” of the airway holds both the soft tissue and the epiglottis out of the way

© Engineered Medical Systems, Inc. Indianapolis, IN

ambu laryngeal mask
Ambu Laryngeal Mask
  • Supraglottic, single-use, disposable airway
  • Features a special curve that replicates the natural human airway anatomy

© Ambu Inc. Baltimore, MD

king lt airway
King LT Airway
  • Alternative airway
    • Large silicone cuff that disperses pressure over a large mucosal surface area
  • Stabilizes the airway at the base of the tongue

©Tracey Lemons/King Systems Corporation, Indianapolis, Indiana

foreign body removal under direct laryngoscopy
Foreign Body Removal Under Direct Laryngoscopy
  • Removing an obstructing foreign body using Magill forceps or a suction device
  • You should carry out basic life support maneuvers first.
    • If these fail to alleviate the obstruction, direct visualization of the airway for foreign body removal is indicated.
surgical airways
Surgical Airways
  • You should use surgical airway procedures only after you have exhausted your other airway skills:
    • Needle cricothyrotomy
    • Surgical cricothyrotomy
surgical airways39
Surgical Airways
  • Indications
    • Massive facial or neck trauma
    • Total upper airway obstruction
  • Contraindications
    • Inability to identify anatomical landmarks
    • Crush injury to the larynx
    • Tracheal transection
    • Underlying anatomical abnormalities
needle cricothyrotomy
Needle Cricothyrotomy
  • Transtracheal jet insufflation is required
  • Complications:
    • Barotrauma from overinflation
    • Excessive bleeding due to improper catheter placement
    • Subcutaneous emphysema
    • Airway obstruction
    • Hypoventilation
open cricothyrotomy
Open Cricothyrotomy
  • It is preferred to needle cricothyrotomy when a complete obstruction prevents a glottic route for expiration.
  • Its greater potential complications mandate even more training and skills monitoring.
  • Contraindications:
    • Includes children under 12
open cricothyrotomy48
Open Cricothyrotomy
  • Cricothyrotomy Complications:
    • Incorrect tube placement into a false passage
    • Cricoid and/or thyroid cartilage damage
    • Thyroid gland damage
    • Severe bleeding
    • Laryngeal nerve damage
    • Subcutaneous emphysema
    • Vocal cord damage
    • Infection
the difficult airway
The Difficult Airway
  • Terms
    • Difficult airway
      • A conventionally trained paramedic experiences difficulty with mask ventilation, endotracheal intubation, or both
    • Difficult mask ventilation
      • Inability of unassisted paramedic to maintain an SpO2 > 90% using 100% oxygen and positive pressure mask ventilation
      • Inability of the unassisted paramedic to prevent or reverse signs of inadequate ventilation during positive pressure mask ventilation
the difficult airway59
The Difficult Airway
  • Terms (cont.)
    • Difficult laryngoscopy
      • Not being able to see any part of the vocal cords with conventional laryngoscopy
    • Difficult intubation
      • Conventional laryngoscopy requires either (1) more than three attempts, or (2) more than ten minutes
  • Factors related to difficult airway are related to historical information, anatomical, and poor technique
the difficult airway60
The Difficult Airway
  • Historical Factors:
    • Patient has had a history of problems with airway management or anesthesia.
    • If time and patient condition allows, obtain a brief airway history.
the difficult airway61
The Difficult Airway
  • Anatomical Considerations
    • Anatomy of the upper airway varies significantly across the human species.
    • The most frequently used system of pre-intubation airway assessment is the Mallampati Classification system.
      • The tonsillar pillars and the uvula are assessed.
mallampati classification system
Mallampati Classification System
  • Class 1
    • Entire tonsil clearly visible
  • Class 2
    • Upper half of tonsil fossa visible
  • Class 3
    • Soft and hard palate clearly visible
  • Class 4
    • Only hard palate visible

The Mallampati classification system is at top.

the difficult airway63
The Difficult Airway
  • Other rating systems
    • Revised Cormack and LeHane classifications
      • Similar to Mallampati
      • Assigns 4 classes
    • POGO
      • The percentage of the glottis that can be visualized is scored
        • From 0 to 100%
the difficult airway other considerations
The Difficult AirwayOther Considerations
  • Short neck
  • Thick neck
  • Restricted range of motion
  • Dentition
  • Small mouth
  • Short mandible
  • Anterior larynx
  • Obesity
  • Anatomical distortion
managing patients with stoma sites67
Managing Patients with Stoma Sites
  • Patients who have had a laryngectomy or tracheostomy breathe through a stoma.
  • There are often problems with excess secretions, and a stoma may become plugged.
    • Use extreme caution with any suctioning.
  • Anticipating complications when managing an airway
    • Be prepared to suction all airways to remove blood or other secretions and forthe patient to vomit.

Tracheostomy cannulae

suctioning techniques
Suctioning Techniques
  • Wear protective eyewear, gloves, and face mask.
  • Preoxygenate the patient.
  • Determine depth of catheter insertion.
  • With suction off, insert catheter.
  • Suction while removing catheter .
  • Ventilate patient.
tracheobronchial suctioning
Tracheobronchial Suctioning
  • It is sometimes necessary to remove secretions or mucous plugs that can cause respiratory distress.
  • Hypoxia is a concern.
  • Use sterile technique.
  • It may be necessary to instill sterile water to thin secretions.
gastric distention and decompression76
Gastric Distention and Decompression
  • A common problem with ventilating a nonintubated patient is gastric distention.
  • You should place a tube in the stomach for gastric decompression.
    • Nasogastric tube
    • Orogastric tube
gastric distention and decompression77
Gastric Distention and Decompression
  • Indications:
    • The need for decompression because of the risk of aspiration or difficulty ventilating
    • Gastric lavage in hypothermia and some overdose emergencies
  • Complications:
    • Possibility of esophageal bleeding
    • Increased risk of esophageal perforation
gastric distention and decompression78
Gastric Distention and Decompression
  • Procedure
    • Place head in neutral position
    • Measure tube
    • Use topical anesthetic
    • Lubricate and insert tube
      • Encourage patient to swallow
    • Advance to pre-determined mark
    • Verify placement
    • Apply suction
    • Secure in place
oxygen delivery devices
Oxygen Delivery Devices


Oxygen Percentage

Nasal cannula


Venturi mask

24, 28, 35, or 40%

Simple face mask

40 – 60%

Nonrebreather mask

80 – 95%

oxygen delivery devices81
Oxygen Delivery Devices
  • Small Volume Nebulizer
    • Allows for delivery of medications in aerosol form (nebulization)
  • Oxygen Humidifier
    • Benefits patients with croup, epiglottitis, or bronchiolitis, as well as those patients receiving long-term oxygen therapy
  • Effective ventilatory support requires a tidal volume of at least 800 mL of oxygen at 10 to 12 breaths per minute.
  • Effective artificial ventilation requires:
    • A patent airway
    • An effective seal between the mask and the patient’s face
    • Delivery of adequate volumes
ventilation methods
Ventilation Methods
  • Mouth-to-mouth
  • Mouth-to-nose
  • Mouth-to-mask
  • Bag-valve device
  • Demand valve device
  • Automatic transport ventilator
mouth to mouth mouth to nose
  • Indicated in the presence of apnea when no other ventilation devices are available
    • Limited by the capacity of the person delivering the ventilations
    • Potential for exposing either the rescuer or the patient to communicable diseases
mouth to mask
  • Prevents direct contact between you and your patient’s mouth
  • Devices usually have a one-way valve that prevents you from contacting the patient’s expired air.
  • May also provide an inlet for supplemental oxygen
bag valve devices
Bag-Valve Devices
  • Prehospital and emergency department personnel most commonly use the bag-valve device.
  • One, two, or three rescuers may perform bag-valve-mask ventilation.

© Scott Metcalfe

bag valve devices88
Bag-Valve Devices
  • Observe the patient for chest rise, gastric distention, and changes in compliance of the bag with ventilation.
  • Complications:
    • Inadequate volume delivery
    • Barotrauma
    • Gastric distention
demand valve
Demand Valve
  • Flow-restricted, oxygen-powered ventilation device
  • Flow is restricted to 30 cm H2O or less to diminish gastric distention
  • Cannot measure delivered volumes or feel lung compliance
automatic transport ventilator
Automatic Transport Ventilator
  • Advantages:
    • Maintain minute volume
    • Mechanically simple and adapts to a portable oxygen supply
  • Typically comes with two or three controls
    • Rate
    • Volume
  • Contraindications
  • A significant percentage of claims and lawsuits involve inadequate patient ventilation.
  • Detailed documentation shown could go a long way toward warding off such a claim.
  • It is crucial to document in medically correct and legally sufficient terms exactly what was done in managing the airway.
  • Anatomy of the Respiratory System
  • Physiology of the Respiratory System
  • Respiratory Problems
  • Respiratory System Assessment
  • Basic Airway Management
  • Advanced Airway Management
  • Orotracheal Intubation
  • Pediatric Orotracheal Intubation
  • Nasotracheal Intubation
  • Managing Patients with Stoma Sites
  • Suctioning
  • Gastric Distention and Decompression
  • Oxygenation
  • Ventilation
  • Documentation