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Basic AirwayBasic Airway

ManagementManagement

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AnatomyAnatomy

Upper airwayUpper airway-- begins with the face and skeletalbegins with the face and skeletalstructures. The nasopharynx, tongue and oropharynxstructures. The nasopharynx, tongue and oropharynxhelp with air transfer to the lower airways humidifyinghelp with air transfer to the lower airways humidifyinggases and clearing debris.gases and clearing debris.

Middle airwayMiddle airway-- composed of the larynx soft tissue,composed of the larynx soft tissue,cartilage, thyroid and cricoid membrane. In the larynxcartilage, thyroid and cricoid membrane. In the larynxlies the vocal cords. Easily obstructed by secretionslies the vocal cords. Easily obstructed by secretionsedema and foreign bodies.edema and foreign bodies.

Lower airwayLower airway-- the trachea is made up of incompletethe trachea is made up of incompletecartilaginous rings held together by elastic musculaturecartilaginous rings held together by elastic musculatureposteriorly. The trachea travels down the anterior chestposteriorly. The trachea travels down the anterior chestbifurcating into the right and left bronchi.bifurcating into the right and left bronchi.

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When to Manage the AirwayWhen to Manage the Airway

Always in a code or critical situationAlways in a code or critical situation Agonal breathing can be confused with normalAgonal breathing can be confused with normal

breathingbreathing

Hypoxemia (not oxygenating)Hypoxemia (not oxygenating) Hypoventilation (not ventilating)Hypoventilation (not ventilating) Tissue hypoperfusion (not perfusing)Tissue hypoperfusion (not perfusing) Failure to protect the airway (I.e. severeFailure to protect the airway (I.e. severe

intoxication, CNS injury, GCSintoxication, CNS injury, GCS

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Basic Principles of AirwayBasic Principles of Airway

ManagementManagementAlways optimize oxygenationAlways optimize oxygenationAssess the airwayAssess the airway Prepare your equipmentPrepare your equipment Position the patient appropriatelyPosition the patient appropriately

Use airway adjunctsUse airway adjuncts Be good at bagBe good at bag--valvevalve--mask ventilationmask ventilation Have a backup planHave a backup plan

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Airway AssessmentAirway Assessment HistoryHistory--based assessment (difficult baseline anatomy,based assessment (difficult baseline anatomy,

distorted anatomy, previous difficult intubations)distorted anatomy, previous difficult intubations)

Mallampati scoringMallampati scoring Thyromental distanceThyromental distance Relevant injuries/acute medical problems (facialRelevant injuries/acute medical problems (facial

fractures, edema, bleeding, emesis)fractures, edema, bleeding, emesis)

Facial hairFacial hair ObesityObesity

Limited neck mobilityLimited neck mobility No teeth/false teethNo teeth/false teeth Stiff lungs/ difficult ventilationStiff lungs/ difficult ventilation

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Basic EquipmentBasic Equipment

Oxygen sourceOxygen source SuctionSuction BVM (appropriate size and fit)BVM (appropriate size and fit) Oropharyngeal airway (OPA) and/or nasopharyngealOropharyngeal airway (OPA) and/or nasopharyngeal

airway (NPA)airway (NPA)

Laryngoscopy equipment (handle, straight or curvedLaryngoscopy equipment (handle, straight or curvedblade, bulb, magills)blade, bulb, magills)

ETT appropriate size with styletETT appropriate size with stylet ETT confirmation methods (endtidal CO2, stethoscope,ETT confirmation methods (endtidal CO2, stethoscope,

spo2 monitor)spo2 monitor)

Backup/rescue devices (LMA, combitube, bougie, etc.)Backup/rescue devices (LMA, combitube, bougie, etc.)

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PreoxygenationPreoxygenation

Optimize SaO2 prior toOptimize SaO2 prior tointubation wheneverintubation wheneverpossiblepossible

May deliver supplementalMay deliver supplementaloxygen via nonoxygen via non--rebreather mask or BVMrebreather mask or BVM

Aggressive ventilationAggressive ventilationshould be discouraged forshould be discouraged forpatients with suspectedpatients with suspectedfull stomachfull stomach

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BVMBVM

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Oropharyngeal AirwayOropharyngeal Airway

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Nasopharyngeal AirwayNasopharyngeal Airway

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Laryngeal Mask Airway (LMA)Laryngeal Mask Airway (LMA)

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CombitubeCombitube

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Endotracheal intubationEndotracheal intubation

Remove dentures. Suction and clear oropharynxRemove dentures. Suction and clear oropharynxof blood vomit and secretions.of blood vomit and secretions.

Hold cricoid pressure.Hold cricoid pressure.

Position patients head to sniffing position.Position patients head to sniffing position.Patients with suspected cPatients with suspected c--spine injuries will havespine injuries will haveinin--line stabilization through all events.line stabilization through all events.

Laryngoscope blade is chosen by the intubator.Laryngoscope blade is chosen by the intubator.Curved (Macintosh) blade is better used toCurved (Macintosh) blade is better used tomobilize the tongue. The straight (Miller) blademobilize the tongue. The straight (Miller) bladeis used to lift the epiglottis.is used to lift the epiglottis.

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Endotracheal intubationEndotracheal intubation

Place laryngoscope blade in the right side of thePlace laryngoscope blade in the right side of thepatients mouth and sweep the tongue away to the leftpatients mouth and sweep the tongue away to the leftas you advance.as you advance.

Identify the vocal cords.Identify the vocal cords. Place the ETT through the cords. Stop advancing oncePlace the ETT through the cords. Stop advancing once

the balloon has passed completely through the cords.the balloon has passed completely through the cords.

All intubations should initially be performed with a stylet.All intubations should initially be performed with a stylet. Inflate the ETT cuff.Inflate the ETT cuff.

Confirm tube position.Confirm tube position. Release of cricoid pressure.Release of cricoid pressure. Secure the ETT, noting position of the tube at the teeth.Secure the ETT, noting position of the tube at the teeth.

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LaryngoscopyLaryngoscopy

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LaryngoscopyLaryngoscopy

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The CordsThe Cords

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PostPost--Intubation ManagementIntubation Management

Confirm tube placementConfirm tube placement Ventilate via bag valve deviceVentilate via bag valve device

Monitor respiratory dynamicsMonitor respiratory dynamics Orogastric tube placementOrogastric tube placement Long acting NMB and sedationLong acting NMB and sedation

Monitor for signs of inadequate ventilationMonitor for signs of inadequate ventilation Monitor lipline/position at teeth to guard againstMonitor lipline/position at teeth to guard against

ETT dislodgementETT dislodgement

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EndEnd--Tidal CO2 DetectorsTidal CO2 Detectors

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Other Methods of ConfirmingOther Methods of Confirming

Tube PlacementTube Placement Equal breath sounds bilaterallyEqual breath sounds bilaterally Absence of gastric soundsAbsence of gastric sounds

SaO2SaO2 Condensation in the ETTCondensation in the ETT Balloon detection devicesBalloon detection devices

Quantitative EtCO2Quantitative EtCO2 Direct visualizationDirect visualization Chest XChest X--rayray

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Securing the ETTSecuring the ETT

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Advanced Airway ManagementAdvanced Airway Management Advanced techniquesAdvanced techniques

Nasal intubationNasal intubation

Fiberoptic intubationFiberoptic intubation

Retrograde intubationRetrograde intubation CricothyroidotomyCricothyroidotomy

Light wandLight wand

MedicationsMedications

SedativesSedatives ParalyticsParalytics

Adjuncts (Increased ICP, bronchospasm, pediatrics)Adjuncts (Increased ICP, bronchospasm, pediatrics)

Rapid Sequence Intubation (RSI)Rapid Sequence Intubation (RSI)

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ConclusionConclusion

Always manage the airway in a critical situationAlways manage the airway in a critical situation HighHigh--flow oxygen via nonrebreather facemaskflow oxygen via nonrebreather facemask Position patient to open airwayPosition patient to open airway

Use airway adjunctsUse airway adjuncts Be good at BVM ventilationBe good at BVM ventilation Dont spend a lot of time trying to intubateDont spend a lot of time trying to intubate Be familiar with advanced airway devicesBe familiar with advanced airway devices

LMA & combitubeLMA & combitube

If intubating, confirm placement & abort ifIf intubating, confirm placement & abort ifunsureunsure

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Questions?Questions?

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