Airway management
and ventilation
Respiratory tract
CAUSES OF AIRWAY OBSTRUCTION
• Upper respiratory tract
• tongue
• tissue edema, foreign body
• blood, gastric contents
• Larynx
• laryngospasm, foreign body
• Lower respiratory tract
• secretions, edema, blood
• bronchospasm
• aspiration
RECOGNITION OF AIRWAY
OBSTRUCTION
LOOK
for chest movement
LISTEN
at the mouth for breath
sounds
FEEL
for air on your cheek
O2
A.
NON-INSTRUMENTAL AIRWAY
MANAGEMENT
The two most widely used manoeuvres
1)HEAD TILT
2)CHIN LIFT
3) JAW THRUST
Utilized whenever cervical spine injury is
suspected, if fails use head-tilt and chin lift
despite the risk
TRIPLE AIRWAY MANOEUVRE
3 Elements
•
Head tilt (neck extension), maintaining extension on
both sides of the mandible
•
Mandible elevation from the temporomandibular joint,
so that lower teeth are positioned above the upper teeth
•
Opening the mouth with both thumbs
Used in patients with short or thick neck, in the obese,
in patients with neck arthritis limiting neck movement
REDUCED TRIPLE MANOEUVRE
NO HEAD TILT!!!!
Utilized whenever cervical spine injury is
suspected, if fails perform full triple manoeuvre or
head tilt/chin lift
Suction
B. INSTRUMENTAL METHODS
1) FACE SHIELDS
2) POCKET MASKS
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Mouth-to-pocket mask ventilation
Advantages:
• Reduces direct contact with oral cavity
• Reduces the risk of infection
transmission
Disadvantages:
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Sealing the mask
Gastric inflation
-
Bag-valve mask ventilation (BVM):
recommended for two-rescuer CPR
BVM VENTILATION
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Advantages
Reduces contact
Enables oxygen delivery
in high concentrations–
up to 100%
Can be connected to
face mask, laryngeal
mask, Combitube,
endotracheal tube
Disadvantages
When used with face
mask:
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Risk of insufficient tidal
volumes
Risk of gastric inflation
Two rescuers are needed
for optimal ventilation
3) OROPHARYNGEAL AIRWAYS
(GUEDEL AIRWAYS)
SIZE SELECTION
Placement of oropharyngeal airways
Placing the airways may provoke vomiting or laryngospasm in
individuals with preserved reflexes from upper respiratory tract.
It should only be placed when the patient is unconscious.
5) LARYNGEAL MASK AIRWAY (LMA)
I-GEL
LMA
COBRA
Covers glottical opening with an elastic mask with
inflatable, sealing cuff
Does not protect from regurgitation
LARYNGEAL MASK AIRWAYS
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Advantages
Quick and easy to place
Different sizes selected
according to body
weight
More effective
ventilation than with
face mask
No need to use
laryngoscope
•
•
•
Disadvantages
Does not protect from
regurgitation of gastric
contents
Not appropriate for high
pressure ventilationgastric inflation
Does not enable airway
suctioning
LMA PLACEMENT
Thanks to the fact that it doesn’t require neck extension it
may be regarded as the device of choice for airway
management in patients with cervical spine injury
LMA
I-GEL
PRO-SEAL
ILMA
6) LARYNGEAL TUBE
LT - classic, silicone laryngeal tube
LTS - „rescue" laryngeal tube
silicone, two lumen tube with additional
lumen for gastric suction
Distal tip placed in the upper portion of the esophagus
Both cuffs inflated at once
7) TRACHEAL INTUBATION
The gold standard in airway management:
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Enables adequate ventilation with appropriate tidal volumes
even if chest compressions are continuously performed,
Protects the airways from foreign bodies which may be
present in the mouth
Enables adequate ventilation even when airway resistance
is high (e.g. in pulmonary edema, bronchospasm). May be
used with a respirator or BVM,
Enables upper airway suctioning to clear the lungs from
aspirated contents or pulmonary secretions,
Stomach, esophagus and oral cavity suctioning also possible
Enables drug administration.
LARYNGOSCOPE
McIntosh
Miller
TRACHEAL TUBES
ADDITIONAL EQUPIPMENT
MAGILL FORCEPS
STYLETS
STETHOSCOPE
FIBEROSCOPE
MANOMETER
DENTAL
SHIELDS
TRACHEAL INTUBATION
TECHNIQUE
- Preoxygenate the patient if possible
- Maximal time- 30 seconds
- Put ET in under visual control
- In case of any doubts or difficulties oxygenate the
patient again and try once more
Patients die as a result of hypoxia, i.e. lack of
ventilation not because they couldn’t be
intubated!!!!
ET placement confirmation
Visual control during intubation
• Auscultation:
• In the midaxillary line on both sides of the
chest
• In the epigastrium
• Symmetrical chest movement during ventilation
Capnography
• „Oesophageal detector device”
• Pressing on the chest to see if water vapour is
present in the tube
•
Tracheal intubation
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Advantages
Enables 100% oxygen
ventilation
Protects from aspiration
Enables airway
suctioning
Alternative route for drug
administration
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Disadvantages
Training and skills
needed
Esophageal placement
Complications possible if
patient suffered cervical
spine injury
SELLICK MANOEUVRE
cricoid cartilage pressure
•
Assistent applies pressure
to cricoid cartilage in
order to occlude the
esophagus between the
cartilage and the spine.
This is intended to
prevent regurgitation and
aspiration
POSSIBLE COMPLICATIONS OF INTUBATION
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Tracheal laryngeal stenosis,
Airway edema- particularly in children,
Airway infection,
Undected esophageal intubation,
Undetected bronchial intubation (usually right sided)
Dental injury- usually upper incisors,
Tongue injury,
Pneumothorax,
Nasal bleeding,
Esophageal or throat perforation following the use of a stylet
Aspiration of gastric contents,
Spinal cord injury,
Laryngeal rupture,
Vocal cords rupture with resulting dysphonia or aphonia
Tube obstruction,
Tracheal rupture,
Laryngospasm,
Laryngeal edema with dysphonia, stridor and dyspnoea.
CRICOID PRESSURE
•
Advantages
Lowers aspiration risk
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Disadvantages
Makes intubation more
difficult
May render ventilation
with an LMA
impossible
Contraindicated when
vomiting occursesophageal rupture
CRICOTHYROIDOTOMY/
NEEDLE CRICOTHYROIDOTOMY
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•
CRICOTHYROIDOTOMY– making an incision
in the cricothyroid membrane for airway
management
NEEDLE CRICOTHYROIDOTOMY- needle
insertion through cricothyroid membrane
followed by introducing an over-the-wire
catheter
CRICOTHYROIDOTOMY
•
Indications:
Inability to manage the airways non-invasively in any of the
possible ways
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Complications:
Pneumothorax, subcutaneous emphysema
Excessive bleeding
Esophageal perforation
Insufficient ventilation
Barotrauma (lung perforation)
THE VORTEX APPROACH
THE VORTEX APPROACH
THE VORTEX APPROACH