Airway Management

Objectives• Recognize signs of a threatened airway

• Manual techniques for establishing an airway

• Manual techniques of mask ventilation without or with suspected cervical spine injuryinjury

• Preparation and perform endotracheal intubation and phramacologic therapy

• Be familiar with airway adjuncts (laryngeal mask airway, combitube)

Introduction• ABC of resuscitation

• Focus is to ensure the airway is open, assess patient breathing and support gas exchange

• Secondary goal is preservation of cardiovascular stability and the prevention of cardiovascular stability and the prevention of aspiration

• Healthcare providers must be skilled in manually supporting the airway and providing the essential process of oxygenation and ventilation

Assessment• First step : Assess airway patency and

spontaneous breathing. Look, listen and feelfor air movement.

• Observe the level of consciousness and determine if respiratory efforts are absent determine if respiratory efforts are absent proceed to manual support and assist ventilation while preparing to establish the airway

• Identify injury (e.g possible cervical spine fracture)

• Observe chest expansion, to assess respiratory muscle activity and adequate ventilation

Assessment• Observe for suprasternal, supraclavicular or

intercostal retraction, tracheal tug or nasal flaring that represent respiratory distress

• Auscultate over the neck and chest for breath sounds. Complete airway obstruction if there sounds. Complete airway obstruction if there is chest movement but breath sound are absent. Incomplete obstruction if we hear snoring, stridor, gurgling or noisy breathing.

• Assess the protective airway reflexes (cough and gag). Absence of protective reflexes need for airway support.

Oxygen supplementation• Nasal cannula O2 100% 0,5-5 lt/m (FiO2 0,40-

0,50)

• Venturi mask O2 100% 6lt/m

• Aerosol face mask

• Reservoar face mask (rebreathing or non rebreathing

Airway obstruction :

The majority of preventable deaths

following trauma occur as a result of airway

Airway obstruction

following trauma occur as a result of airway

obstruction.

Obstruction may occur at any point within

the airway, from the upper airways to the

bronchi deep within the chest.

Common causes of airway obstruction

Upper Airway

- tongue (due to unconsciousness)

- soft tissue swelling

- blood, vomit

- direct injury

Larynx (voice box) Larynx (voice box)

- foreign material, direct injury, soft tissue swelling

Lower Airway

- secretions, oedema, blood

- bronchospasm

- aspiration of gastric contents

LOOK for chest/abdominal movement

LISTEN at mouth and nose for breath sounds and

abnormal noises

FEEL at mouth and nose for expired air

Recognition of airway obstruction

FEEL at mouth and nose for expired air

Abnormal sounds in airway obstruction

Snoring - due to obstruction of upper airway by

the tongue

Gurgling - due to obstruction of upper airway by

liquids (blood, vomit)

Wheezing - due to narrowing of the lower airways

Complete airway obstruction is silent.

For pediatric patients• Common causes of airway obstruction is

upper airway infection (e.g viral croup, bacterial tracheitis, epiglottitis)

• Airway obstruction in semiconscious child is posterior displacement of tongue and collapse posterior displacement of tongue and collapse of hypopharynx

• Infant until 6 month age is obligate nose-breather, suctioning the nares can be useful in cleaning the airway.

Manual methods to establish an airway• Initial step to assure a patent airway in a

spontaneously breathing patient without possible injury to the cervical spine is Triple airway maneuver : neck extension, elevation of mandible (jaw thrust), mouth openingof mandible (jaw thrust), mouth opening

Manual in-line stabilisation of the c-spine

Head tilt (NOT if c-spine injury)

Chin lift with manual in-line stabilisation of the c-

spine

Opening the airway

spine

Jaw thrust with manual in-line stabilisation of the

c-spine

Suction with manual in-line stabilisation of the c-

spine

Mouth to mouth ventilation

Oral airways

Will stimulate vomiting and movement in

conscious or semi-conscious casualties

This may result in;

worsening airway problems

cervical spine compromise

Nasal airways

Will cause bleeding from the nose in a large

number of cases.

This will result in worsening airway problems so use

only as a last resort.

Manual Mask Ventilation• Indication :

- Patient is apneic

- Spontaneous tidal volume is inadequate

- Reduce the work of breating- Reduce the work of breating

- Hypoxemia due to poor spontaneous

ventilation

Manual Mask Ventilation

• Single handed method, left hand hold the mask placement, bag reservoir compressed by right hand

• Observe the chest expansion and auscultation• Observe the chest expansion and auscultation

• Listen for any gas leaks around the mask

• If patient apneic ventilation is performed 12-16 times per minute. If spontaneous breathing ventilation synchronized with patient inspiratory efforts

• Oxygen 100% at flow rate 15 l/minute

Cricoid pressure

Manual Mask Ventilation• If no cervical spine injury, the operator can do

slight neck extension, mandibular elevation and gentle downward pressure the mask on the face

• If cervical spine injury is suspected the • If cervical spine injury is suspected the operator should not do neck extension, may choose two handed for mask placement but assure no neck movement

Endotracheal intubation• Indication :

- airway protection

- relief of obstruction

- mechanical ventilation & oxygen - mechanical ventilation & oxygen

therapy

- respiratory failure

- shock

- hyperventilation for intracranial

hypertension

- reducing work of breathing

- facilitation of suctioning/pulmonary toilet

Laryngeal Mask

Combitube

Thank you