Introduction to Airway Management

1. Introduction to Airway Management Deepi G. Goyal, M.D. Mayo Clinic Department of Emergency Medicine

2. Who Needs to be Intubated?

3. Airway Management • Which of the following is most important when evaluating a 29 y/o pt with polypharmacy OD with respect to need for intubation? • Arterial Blood Gas Results • Hemodynamic instability • Pulse Oximetry • Clinical Evaluation of pt’s ability to maintain & protect airway and exchange gases • Gag reflex, chest auscultation, CXR

4. Indications for Intubation • Is there a failure of oxygenation or ventilation? • Is there a failure of airway protection? • What is the anticipated clinical course?

5. Oxygenation/Ventilation • Which of the following is TRUE regarding arterial blood gases? • A low pO2 should drive the decision to intubate • A high pCO2 should drive the decision to intubate • Neither A nor B • Both A and B

6. Indications for Intubation • Failure of Oxygenation/Ventilation • A Clinical Decision • Do NOT rely on ABGs • Mentation • Fatigue • Concomitant Injuries

7. Indications for Intubation • Failure of Airway Protection • Loss of upper airway musculature • Loss of protective reflexes

8. Airway adequacy • Which of the following is LEAST helpful in terms of determining airway adequacy? • Absence of a gag reflex • Pooling of secretions • Ability of the patient to phonate • Anatomic features such as infections and trauma

9. Indications for Intubation • Gag

10. Indications for Intubation • Failure of Airway Protection • Gag reflex unreliable in predicting aspiration risk • Swallowing • Complex reflex • Better tool than gag

11. Indications for Intubation • Anticipated Clinical Course • Currently acceptable anatomy and physiology may deteriorate • Expanding neck hematoma • Work of breathing may be overwhelming in light of multiple major injuries • Patient cooperation required for diagnostic/therapeutic interventions

12. Airway Management • Which of the following is the MOST IMPORTANT skill for airway management • Knowledge of proper blade and tube selection for intubation • Familiarity with proper direct laryngoscopy techniques • Ability to manually ventilate using bag-valve-mask • Both A and B

13. Airway Management • Manual ventilation • Direct laryngoscopy and intubation • Techniques for difficult airways • Confirmation of ETT placement

14. Airway Management • Which of the following is NOT a patient factor that would negatively impact the ability to ventilate a patient ? • Presence of a beard • Obesity • Endentulous patient • Large tongue • All of the above would negatively impact ventilation

15. Manual Ventilation • Cornerstone for airway management • Allows for decreased urgency when intubating and options for failed attempts • Components • Head positioning • Maintaining airway patency • Mask seal

16. Manual Ventilation • Head Positioning • The tongue is your “Enemy”!! • Position head to prevent tongue from obstructing airway • Chin lift • Jaw Thrust

17. Manual Ventilation • Maintaining airway patency • Use Adjuncts!!! • Nasal airway • Oral Airway

18. Manual Ventilation • Mask Seal • Start with mask on nasal bridge and lever it onto malar eminences and alveolar ridge • Apply pressure with thumb and index finger to assure adequate seal • Use digits 3,4,5 to hold mandible and thrust it forward

19. Manual Ventilation • Pearls • Use K-Y jelly on beards • For pts with sallow cheeks, fold and place 4x4’s in cheeks • Reinsert false teeth if necessary

20. Airway Management • Barriers • Patient Cooperation • Anatomy • Time

21. Airway Management • Barriers • Patient cooperation • Anatomy • Distortion (Trauma, infection, neoplasm, hemorrhage, vomitus) • Disproportion (tongue/pharynx, thyromental distance) • Dysmobility (Neck mobility, TMJ) • Dentition (prominent incisors) • Time

22. Manual Ventilation • Head positioning • “Sniffing” position optimizes alignment of oral, pharyngeal, and laryngeal axes

23. Laryngoscopy • Goal • Use laryngoscope blade to lift epiglottis anteriorly to visualize vocal cords • Insert endotracheal tube through vocal cords

24. Placement of ET Tube

25. Airway Management • Barriers • Patient cooperation • Anatomy • Distortion (Trauma, infection, neoplasm, hemorrhage, vomitus) • Disproportion (tongue/pharynx, thyromental distance) • Dysmobility (Neck mobility, TMJ) • Dentition (prominent incisors) • Time

26. Rapid Sequence Intubation • Tube Confirmation • Listen to both lungfields • Listen again • Pulse Oximetry • End-Tidal CO2 • Aspiration Devices

27. Laryngeal Mask Airway • Laryngeal Mask Airway • Inserted blindly and forms seal around laryngeal inlet • Insertion no more difficult in class III or IV airways or in those with grade III or IV view • As stimulating as oropharyngeal airway • Does not protect against aspiration

28. Intubating LMA • Intubating Laryngeal Mask Airway

29. Combitube • Double lumen tube inserted blindly • Distal lumen usually inserted into esophagus • Shown to be effective, esp. in prehospital settings

30. Combitube • Insert Combitube gently in a curved downward movement • Insert until printed ringmarks lie between teeth or alveolar ridges. • Do not use force !

31. Combitube • Inflate the oropharyngeal balloon with the syringe with the blue dot • Inflate the distal cuff with the syringe with the white dot

32. Combitube • Test ventilation via the longer blue tube (#1) • Air cannot escape at the distal end of the blocked "esophageal" lumen and enters the pharynx via the perforations • Since mouth, nose, and esophagus are sealed by the balloon and the cuff, air is forced into the trachea

33. Combitube • 10% inserted into the trachea • If auscultation through the blue port is negative, switch to the shorter port and ventilate trachea directly

34. Nasal intubation • Should be a skill learned by every MD who may intubate on a regular basis

35. Nasal Intubation • Requires spontaneous respiration • Requires skill and experience • Can be done in ~ 90% of ED intubations • Can be done in sitting position • No sedation/paralytics needed • Very Rapid

36. Nasal intubation • Prep nostril with Lidocaine spray and phenylephrine • Use smaller ET tube • Use plenty of lubrication

37. Nasal intubation • Insert in larger nostril • Insert straight back • Insert until passed upper pharyngs • Watch for fogging of tube

38. Nasal intubation • Insert during inspiration • or coughing • or gagging

39. Nasal intubation • Check placement….. • Remember an intubated pt can NOT talk • Double check placement…. • Listen to breathsounds • use CO2 device if available

40. Nasal intubation • If not sure properly intubated pull back and re-try • Re-position head • Apply cricoid pressure • Try again

41. Nasal intubation • Avoid in: • suspect basal skull fracture • suspect hemophilia or thrombocytophilia • Prohibiting facial trauma • Epiglottitis etc.

42. Summary • Know the indications for intubation • Be comfortable with BVM • Understand anatomy • Use adjuncts • Nasally intubate if breathing • Use optimal technique and equipment for laryngoscopy

43. Summary • Final tips • Recognize structures • Use a properly styletted endotracheal tube • Control the tongue • Use all available help • Use external laryngeal manipulation • Know your options if you are unable to intubate (cricothyrotomy)