Advanced Airway Management

1. Advanced Airway Management University of Colorado Medical School Rural Health Track 2013

2. Advanced Airway Management • Basic Airway Management • Airway Suctioning • Oxygen Delivery Methods • Laryngeal Mask Airway • ET Intubation • Oropharyngeal Airway • Nasopharyngeal Airway • Cricothyrotomy

3. Basic Airway Management • For patients unable to protect their own airway • Jaw thrust/head tilt technique • This technique itself can open the airway • If concern for c-spine injury, use jaw thrust without head tilt • Excessive head tilt can occlude trachea in infants, consider padding under shoulders

4. Basic Airway Management

5. Basic Airway Management • Padding under shoulders for infant

6. Airway Suctioning • Obstruction of airway by secretions, blood, vomitus can lead to aspiration • Rigid catheters (Yankeur), soft catheters (Y suction) • Complications include airway trauma, coughing or gagging, delay in ventilation, vagal stimulation bradycardia, hypotension

7. Airway Suctioning Yankeur Rigid Catheter Y Suction Catheter

8. Oropharyngeal Suctioning- Procedure • Adults • Preoxygenate • Check connection to tubing • Occlude side port to test for adequate suction • Insert catheter into oropharynx under direct visualization • Neonates • Insert y-suction catheter into nasopharynx • Occlude sideport while withdrawing catheter • Repeat for oropharynx

9. Oxygen Delivery Methods • Nasal Cannula: flow rate 1-6 LPM (FiO2 24-40%) • Simple face mask: flow rate 5-10 LPM (FiO2 40-60%) • Non-rebreather mask: flow rate 10-15 LPM (FiO2 60-90%) • BiPAP/CPAP

10. Oxygen Delivery Methods • Bag Valve Mask- flow rate >15 LPM (FiO22 >90%)

11. Laryngeal Mask Airway • Supraglottic airway • Doesn’t require laryngeal visualization • Can precipitate vomiting or aspiration

12. Laryngeal Mask Airway • Prepare LMA: ensure patent cuff, apply water-based lubricant • Place patient in sniffing position • Insert tip of LMA into mouth • Advance into laryngopharynx until resistance is met • Ensure black line on tubing in line with upper lip • Inflate cuff • Confirm tube misting, auscultation, EtCO2 • Consider placement of bite block

13. Other Airways • King Tube • Combitube

14. Endotracheal Intubation • Placing orotracheal tube under direct vision through larynx into trachea • Protects airway, enables ventillation • Complications of laryngoscopy • direct trauma to mucous membranes, teeth, larynx • bradycardia from vagal stimulation • Raised intracranial pressure

15. Endotracheal Intubation • Complications of Intubation • Prolonged apnea  hypoxia • Esophageal or right mainstem bronchus intubation • Inadequate tube size  excessive leak, high pressures • Aspiration • Complications of Ventilation • Barotraumapneumothorax • Hypoventilation  hypoxia, hypercarbia • Hyperventilation hypocarbia, cerebral hypoxia • Reduction in preload  hypotension

16. Endotracheal Intubation • Preparation • Pre-oxygenation • Ensure IV access and patency, cardiac monitoring • Assess for predictors of technical difficulty (LEMON) • Look (obesity, pregnancy, airway, facial, neck trauma) • Evaluate 3-3-2 rule (small mouth, receding jaw, short neck) • Manual inline stabilization/Mallampati score • Obstruction (airway burn, protruding teeth, foreign body) • Neck mobility

17. Endotracheal Intubation • Preparation of equipment • Suction • Oxygen • BVM device • Airway adjuncts: OP airways, LMA • Laryngoscope with appropriate blade, check light source • ETT: right size • Bougie • Monitoring and EtCO2

18. Endotracheal Intubation • Tools: Laryngoscope • Macintosh blade- curved blade, rests on epiglotticvallecula • Miller blade- straight blade, lifts epiglottis directly

19. Endotracheal Intubation • Tools: ET tube

20. Endotracheal Intubation • Place head in sniffing position (MILS if c-spine injury) • Open mouth, inspect oral cavity • Remove dentures or debris • Place laryngoscope with left hand into the right side of patient’s mouth, sweeping tongue to left • Lift mandible without levering on teeth until direct visualization of the larynx

21. Endotracheal Intubation

22. Endotracheal Intubation • Introduce bougie through cords • Advance ET tube over bougie until cuff passes through cords • ETT length at lips for women 20-21, men 22-24 • Remove bougie • Connect BVM, commence ventilation • Inflate cuff • Confirm placement • EtCO2 capnography, attach detector proximal to filter • Auscultation in axillae and over stomach

23. Glidescope

24. Post-intubation management • Secure ETT with a cloth tie • Manually ventilate for EtCO2 35-40 mmHg • Post-intubation sedation as needed • Continue comprehensive monitoring and ETCO2

25. Oropharyngeal Airway • Prevents the tongue from occluding the airway, bite block • Should reach from the mouth to the angle of the jaw • Insertion (Adults) • Ensure concavity facing roof of the mouth • Insert 1/3, rotate 180 degrees over the tongue • Advance until flange against lips • Insertion (Pediatrics) • Concavity follows the curve of the tongue to avoid hard and soft palate trauma

26. Oropharyngeal Airway

27. Nasopharyngeal Airway • Useful in patients with airway obstruction, especially if oropharyngeal airway is inappropriate • Correct size reaches from tip of patient’s nose to ear lobe • Sizes 6,7 & 8 mm • Lubricate end of tube with lubricating jelly • Insert into nostril (usually right) with bevel facing nasal septum • Advance device along floor of nasopharynx, following curvature until flange rests against the nostril

28. Nasopharyngeal Airway

30. Cases

31. References • Queensland EMS Clinical Practice Procedures: https://ambulance.qld.gov.au/medical/pdf/02_cpp_airway.pdf • http://www.thoracic.org/clinical/copd-guidelines/for-health-professionals/exacerbation/inpatient-oxygen-therapy/oxygen-delivery-methods.php