Advanced Airway
Management
University of Colorado Medical School
Rural Track
2013
Advanced Airway Management
 Basic Airway Management
 Airway Suctioning
 Oxygen Delivery Methods
 Laryngeal Mask Airway
 ET Intubation
 Oropharyngeal Airway
 Nasopharyngeal Airway
 Cricothyrotomy
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
Basic Airway Management
Basic Airway Management
 Padding under shoulders for infant
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
Airway Suctioning
Yankeur Rigid Catheter
Y Suction Catheter
Oropharyngeal SuctioningProcedure
 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
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
Oxygen Delivery Methods
 Bag Valve Mask- flow rate >15 LPM (FiO22 >90%)
Laryngeal Mask Airway
 Supraglottic airway
 Doesn’t require laryngeal visualization
 Can precipitate vomiting or aspiration
Size
Weight guide
Population
1
<5 kg
Infant
2
10-20 kg
Small Child
3
30-50 kg
Small Adult
4
50-70 kg
Average Adult
5
70-100 kg
Large Adult
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
Other Airways
 King Tube
 Combitube
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
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
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
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
Endotracheal Intubation
 Tools: Laryngoscope
 Macintosh blade- curved blade, rests on epiglottic vallecula
 Miller blade- straight blade, lifts epiglottis directly
Blade
Size
Patient
Miller
0
Infant
Miller
1
Small child
Macintosh
2
Large child
Macintosh
3
Small adult
Macintosh
4
Large adult
Endotracheal Intubation
 Tools: ET tube
Age
Uncuffed
ETT (mm)
Cuffed
Depth at lips
ETT (mm) (cm)
Newborn
3.0-3.5
3.0
9-10
1-5 mths
3.5
3.0-3.5
10
6-11 mths
3.5-4
3.5
11
1 yr
4.0-4.5
4.0
12
2-3 yrs
4.5-5.0
4.0-4.5
12-13
4-5 yrs
5.0-5.5
4.5-5.0
13-15
6-9 yrs
5.5-6.0
5.0-5.5
15
10-12 yrs
6.5-7.0
6.0-6.5
17
13+
7.0-7.5
6.5-7.0
19
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
Endotracheal Intubation
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
Glidescope
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
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
Oropharyngeal Airway
Size
Color
Suggested
Population
000
Clear
Neonate (under 6
wks)
00
Blue
Infant (1-6
months)
0
Black
Older
infants/toddlers
1
White
Small child (3-10
years)
2
Green
Adolescent/adult
female
3
Yellow
Adult male
4
Red
Large adult male
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
Nasopharyngeal Airway
Cases
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-oxygentherapy/oxygen-delivery-methods.php