OBJECTIVES • Identify indications for intubation and prepare the necessary equipment. • Identify the advantages and disadvantages of various devices for airway management. • Identify difficult airway. • Identify equipment for difficult airway and know their use.
INDICATIONS OF INTUBATION • Cardiopulmonary Arrest • Patient in coma • Tachpnea/ Bradypnea • Progressive cyanosis • Surgical patients • Airway protection from any cause
ADVANTAGES • Provides an unobstructed airway • Prevents aspiration of secretions into the lungs • Facilitates positive pressure ventilation without gastric inflation • Facilitates body positioning and movement • May be utilized to deliver medication • Narcan • Atropine • Epinephrine • Lidocaine
DISADVANTAGES • Needs advanced training to properly perform the procedure • Bypasses function of the nose to warm and filter the inspired air • Increased incidence of trauma due to neck manipulation when spinal cord injury is suspected • May increase respiratory resistance • Improper placement
INTUBATION ROLL • Rigid Laryngoscopes • Laryngoscope blades different sizes and types • ETT of various sizes • Flexible Stylets • Oral airways • Exhaled CO2 detector • ETT fixation device • Lubricant gel • Syringe
ENDOTRACHEAL TUBES Types of endotracheal tube (ETT) include oral or nasal, cuffed or un-cuffed, preformed (eg RAE tube), reinforced tubes, double-lumen tubes and tracheostomy tubes. For human use, tubes range in size from 2-10.5 mm in internal diameter (ID).
Endotracheal tubes are made from red rubber and Polyvinylchloride. Those placed in a laser field may be flexometallic.
REINFORCED ETT Indications For Usage • Patient's head is in extended or flexed position • Patient will be turned over • Long-term cases • Neurosurgical procedures • Head and neck procedures
NASAL AND ORAL RAE • NASAL
RAE TUBES II • Preformed Endotracheal Tubes are designed to conveniently position the anesthesia circuit out of the surgical field for oral and maxillofacial procedures. • Oral Preformed shape directs tube downward, to rest on patients chin • Cuffed tubes available with Murphy Eye only • Uncuffed tubes have two Murphy Eyes for enhanced patient safety • Bold marks at the center of bend with distance to distal tip indicated
Indications for usage Thoracic surgery Broncho-spirometry Thoracoscopies Differential or selective lung ventilation Lung Lavage ENDOBRONCHIAL TUBE
ENDOBRONCHIAL TUBE WITH CPAP SYSTEM Indications For Usage • Thoracic surgery • Broncho-spirometry • Thoracoscopies • Differential or selective lung ventilation
ETCO2 DETECTORS • Single use to verify ETT placement • Reliable carbon dioxide detectors help verify ETT placement • Responds quickly to exhaled CO2 with a simple color change from purple to yellow • Breath-to-breath response • Constant visual feedback for up to 2 hours
Correct ET Tube Placement:Capnography Purpul Yellow
Correct ET Tube Placement • Secure ET tube in place, note the number • Sedate patient with appropriate MAAS • Avoid accidental, or self extubation
SECURING THE AIRWAY COMFIT™ ETT Holder • The tapeless way to secure an ETT • Completely adjustable • Wide cotton-lined neckband minimizes skin irritation, providing maximum patient comfort • Minimal plastic loop around the ET tube allows access to the oral cavity • Economical in two ways: low initial cost, no frequent changing • Latex-free product
Tracheal Tube Cuff Care • These include bedside sphygmomanometers, special aneroid cuff manometers, and electronic cuff pressure devices. • Ideally, most tubes seal at pressures between 14 and 20 mm Hg (19 to 27 cm H2O). • Tracheal capillary pressure lies between 20 and 30 mm Hg • Impairment in tracheal blood flow seen at 22 mm Hg and total obstruction seen at 37 mm Hg
Minimum Leak Volume Technique • Air inflation of the tube cuff until the airflow heard escaping around the cuff during positive pressure breath ceases. • Place a stethoscope over larynx. Indirectly assesses inflation of cuff. • Slowly withdraw air (in 0.1-mL increments) until a small leak is heard on inspiration. • Remove syringe tip, check inflation of pilot balloon
SECRETION CLEARANCE OPEN SUCTION SYSTEM • Made of non-toxic PVC • Available coded for size identification Closed suction systems CLOSED SUCTION SYSTEM • (CSS) are increasingly replacing open suction systems (OSS) to perform endotracheal toilet in mechanically ventilated intensive care unit patients.
Closed Suctioning: Facilitate continuous mechanical ventilation and oxygenation during the suctioning. Indicated when PEEP level above 10cmH2O Endotracheal or Tracheostomy Tube Suctioning Open Suctioning Disconnection from the ventilator Not recommended when PEEP >10
ETT WITH EVACUATION LUMEN INDICATIONS For airway management by oral/nasal intubation of the trachea and for evacuation or drainage of secretion from the subglottic space
ADVANTAGES OF EVAC • Helps decrease the rate of ventilator-associated pneumonia (VAP) in the hospital and to reduce VAP related costs • Convenient and safe method for suctioning accumulated secretions in the subglottic space • Large elliptical evacuation port located on dorsal side proximal to cuff provides effective evacuation • Integral suction lumen allows continuous suctioning without risking trauma to the vocal cords as with manual catheter suctioning
ETT CARE • Use of Gause @ the angles of mouth to prevent damage to mucosa • Moving ETT Q NOC from one to the other side to avoid damage to mucosa • Monitoring the correct position of ETT@ the lip mark and positioning it properly • Monitoring the ETT position on CXR from time to time • Regular suctioning through ETT
DIFFICULT AIRWAY LET US SEE… • What is a difficult airway ? • The importance of difficult airway cart. • Different modalities to be used in difficult airways situations. • Anticipate Difficult Airway. • Be Prepared and have many back up plans.
WHAT IS A DIFFICULT AIRWAY • According to American Association of Anesthesiologist, it is a clinical situation in which a trained anesthesiologist experiences difficulty with mask ventilation, tracheal intubation or both. • Requires more than 3 attempts or 10 min. to intubate. • Grade lll to lV in both Cormack and Mallampadi Classifications.
PRE-INTUBATION EVALUATION Potentially difficult laryngoscopy includes: • Less than 35 degree neck extension. • Less than 7 cm distance between mandible and the hyoid bone. • Less than 12.5 cm sternomandibular distance with head fully extended. • Poorly visualized uvula. • Short, thick neck. • Receding mandible and protruding teeth.
MALLAMPADI CLASSIFICATION • Grade I: soft palate, uvula, tonsillar pillars visible. • Grade II: soft palate, uvula visible. • Grade III: soft palate, base of uvula visible. • Grade IV: soft palate not visible (100% Grade lll or Grade lV view).
DIFFICULT AIRWAY CART Necessary equipment needed for an anticipated or unexpected difficult airway • LMAs • Combitube • Bougie • Oral and nasopahryngeal airways • Fast Track • Cricothyrotomy kit • Tube Exchangers • Fiberoptic bronchoscope
INTUBATING STYLET • A stylet for intubating an endotracheal tube is like medico-surgical tube comprising of a bendable metal rod sealed in a tubular plastic sheath. The ends of the sheath are molded in a smoothly rounded closed shape. • Passed through an ETT, can be bend to give ETT the shape of a hockey stick. .
STYLET ADVANTAGES • Alow intubation of the trachea with minimal visualization of the vocal cords. • Easy to learn. • Helps in stablizing the ETT for intubation DISADVANTAGES • May be incorrectly inserted and can damage tracheal tissues.
VARIOUS STYLETS • Shikani seeing stylet • Bonfils fiberscope • Machida Portable Stylet Fibersopce • Video-Optical Intubation Stylet • Aeroview • Schroeder Stylet • Nanoscope • Many Others………..
LMA • The Laryngeal Mask Airway is an alternative airway device used for anesthesia and airway support. It consists of an inflatable silicone mask and rubber connecting tube. It is inserted blindly into the pharynx, forming a low-pressure seal around the laryngeal inlet and permitting gentle positive pressure ventilation. All parts are latex-free.
LMA INDICATIONS • The Laryngeal Mask Airway is an appropriate airway for short procedures and in emergency situations. • Can be used as rescue airway and fiberoptic conduit when intubation is difficult. • Can be used for bronchoscopy in awake patients.
LMA CONTRAINDICATIONS • Non-fasted patients • Morbidly obese patients • Pregnancy • Obstructive or abnormal lesions of the oropharynx • Increased Airway resistance and decreased lung compliance
LMA Tips for Success: • Begin with ASA I & II patients • Learn and use standard insertion technique • Use appropriate size and do NOT overinflate • Maintain adequate anesthetic depth • Remove when the patient opens mouth to command
COMBITUBE • Consists of two fused tubes with a 15 mm connector at proximal end. • Contains 2 cuffs, 100 cc proximal and 15 cc distal. • Distal lumen usually lies in esophagus so the gas through blue tube will ventilate Trachea. • If Combitube enters trachea, ventilation is through clear tube. Available in only one disposable size for age> 15 years , height >5ft.