Advanced Airway Management
AIRWAY MANAGEMENT
Airway can be managed:
• By airway opening manoeuvres or artificial airway
adjuncts with or without mask ventilation
• By a tube from environment to below vocal cords
• By a tube connected to a mask that seals glottic
opening, air is delivered to laryngeal inlet
• By a tube that isolates oesophagus from airway
Airway opening techniques
- Head tilt
- Head tilt + chin lift
- Head tilt + neck lift + jaw thrust (Triple airway
manoeuvre)
- Thumb jaw lift
- Modified jaw thrust
Artificial adjuncts / pharyngeal intubation
Oropharyngeal airway:
- Unconscious patients
- As bite block in semi conscious patients
Nasopharyngeal airway:
- Trismus, IMF, coma
- Contraindicated in bleeding disorders, nasal
infections, injury to cribriform plate
Artificial adjuncts / pharyngeal intubation
• Suctioning
• Mask ventilation:
- Beard, snoring, edentulous patients, facial
deformities, external facial burns, tumours,
infections
- In adult with a possible full stomach - X
- Paediatric airway
- Problems: Pulmonary aspiration
Translaryngeal tracheal intubation
• Oral or nasal route
• Under direct or indirect vision (flexible fibreoptic
laryngoscope or rigid laryngoscope)
• In awake or anaesthetised / unconscious state
• Awake intubations if maintenance of airway not
possible after induction, hemodynamic instability,
intestinal obstruction
Orotracheal intubation under direct vision
• Indications:
- Maintenance of patent airway
- Pulmonary toilet
- Positive pressure ventilation, oxygenation
• Contraindications:
- Cervical spine injury
- Fracture anterior cranial fossa
- Retropharyngeal swelling
- Fractured larynx
Nasotracheal intubation
Advantages over oral intubation:
– less chances of dislodgement
– better tolerated in awake patient
– no risk of biting over tube
– easy insertion in neck movement impairment
– may produce bacteremia
Retrograde catheter guided translaryngeal blind intubation
Confirmation of placement of ETT
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Intubation under direct vision
Inspection of chest expansion, Auscultation
Capnometry
Fibreoptic bronchoscopy through ETT
Negative pressure devices
Pulse oximetry, Condensation in
tube,
movements in reservoir bag, CXR, Cuff
palpation, Vital signs, Tube markings
Transtracheal intubation
• Needle/Catheter cricothyroidotomy for
transtracheal jet ventilation
• Emergency cricothyroidotomy
• Minitracheostomy, percutaneous dilational
cricothyroidotomy, rapid percutaneous
tracheostomy
Laryngeal mask airway
• Intermediate in design and function between face
mask and ETT
• Applications:
– Primarily meant for awake intubation
– For emergency airway management after failed
intubation
– Children with congenital anomalies
– Beard, facial deformities, burns, submandibular
soft tissue non compliance
Patients more at risk for aspiration
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Full stomach (<8 hours fasting)
Trauma
Intra abdominal pathology
Oesophageal disease
Pregnancy
Obesity
Oesophageal airways
• Indications:
– Medical personnel not trained in ETT insertion
– ETT intubation equipment not available
– Attempts at ETT insertion unsuccessful
– Contraindicated in gag reflex, oesophageal injury,
caustic ingestion.
• Types: Oesophageal obturator airway, tracheo oesophageal airway, Oesophageal tracheal combitube
Difficult airway algorithm
1. Assess basic management problems:
• Difficult intubation
• Difficult ventilation
• Difficulty with patient co operation
2. Consider basic management choices:
• Non surgical technique vs surgical technique
• Awake vs Anaesthetized Intubation
• Preservation vs ablation of sp. ventilation
3. Develop primary and alternative strategies:
– Awake intubation:
- Non surgical intervention
- Airway secured by surgical access
– Intubation under anaesthesia:
- If unsuccessful, return to spontaneous or
mask ventilation or awaken patient or
emergency surgical access
Complications of laryngoscopy and intubation
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Tooth dislodgement, Soft tissue injury
Coughing, laryngospasm, vomitting, aspiration
Injury: trachea, spinal cord, Oesophageal intubation
Hypoxemia, hypercarbia
Hypertension, tachycardia, arrhythmia, bradycardia
Myocardial ischaemia, Brain stem herniation
Complications of nasal intubation
Airway maintenance in maxillofacial injuries
• Obstruction by blood clot, vomit, saliva, bone,
teeth dentures
• Inhalation of any of the above
• Relationship of head injury to hypoxia, with blood
loss resulting in hypovolemia
• Fractures of mandible & maxilla (fig)
Mnemonic in ATLS
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Airway maintenance with cervical spine control
Breathing
Circulation with haemorrhage control
Discerning the neurological status
Complete physical evaluation
Recognition of acute respiratory failure
Examinations should include:
– Mandibular mobility
– Size and mobility of tongue
– State and fragility of dentition
– Amount and viscosity of secretions
– Presence of haemorrhage or masses
– Auscultation and percussion of lung fields
Systematic approach to airway management
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Recognize airway obstruction
Clear airway (manual & suction)
Reposition patient
Artificial airway
Perform ET intubation
Cricothyroidotomy
Tracheostomy
Tracheostomy
• Semiconscious after head injury
• To facilitate adequate tarcheo bronchial toilet
• Management of concomitant problems
• Need for prolonged positive pressure ventilation:
• when injuries are severe enough to cause
hypercarbia or hypoxia
• for control of cerebral oedema
Tracheostomy
• Landmarks
• Complications:
– Tracheal stenosis, bleeding, obstruction of tube,
mucosal ulceration, cartilaginous necrosis
– Haemorrhage,
hypoxia,
pneumothorax,
subcutaneous emphysema, tracheo oesophageal
fistula, damage to recurrent laryngeal nerves
– Haemorrhage, infection, aspiration
Cricothyroidotomy
• Advantages:
– More rapid
– Less complications
– Improved cosmetic result
– Less soft tissue thickness to pass through
• Contraindicated in children, laryngeal infection
Modified Forms of Respiration
• Reflexes which act to protect the respiratory
system:
– Cough- forceful, spasmodic exhalation of a large
volume of air
– Sneeze- sudden forceful exhalation from the nose
– Hiccough- sudden inspiration caused by spasmodic
contraction of the diaphragm & glottic closure
– Gag reflex- spastic pharyngeal & esophageal reflex
caused by stimulation of posterior pharynx
– Sighing- hyperinflation of lungs, opens atelectic
alveoli
The ability to breathe and
the ability to protect the
airway are not always the
same.
ASSESSMENT
• BSI/ scene safety
• General impression
• Identify and correct any life threatening
conditions:
• Responsiveness/ c-spine
• Airway
• Breathing
• Circulation
GENERAL IMPRESSION
• POSITION
– Tripod
– Bolt upright
• COPD
• CHF
• Able to speak in sentences
AIRWAY
• Is it patent?
– Snoring, gurgling or stridor may indicate
potential problems
– Secretions, objects, blood, vomitus present
• Neck
– JVD (jugular vein distention)
– TD (tracheal deviation, tugging)
BREATHING
• Adequacy?
– Rate and quality?
• Spontaneous & regular
• effortless
• Chest rise
– Equal and present: excursion
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Deformity/ crepitus
Ecchymosis
Subcutaneous emphysema
Paradoxical (asymmetric)
– Flail chest
BREATHING EFFORT
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Normal
Labored/ dyspnic
Tachypnic/ bradypnea
Accessory muscle use
– Intercostal retractions
– Suprasternal
– Abdominal muscle use
• Pediatrics
– Grunting
– Nostril flaring
BREATH SOUNDS
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CTA bilat
Diminished
Rhonci
Rales
Wheezing
RESPIRATORY PATTERNS
• Cheyne –Stokes
– Regular pattern of increasing rate & volume
followed by gradual decrease and a short period
of apnea
– Brain stem insult
• Kussmaul’s
– Deep, gasping regular respirations
– Diabetic coma
• Biot’s
– Irregular rate & volume with intermittent periods of
apnea
– Increased ICP
• Central Neurogenic Hyperventilation
– Regular, deep and rapid
– Increased ICP
• Agonal
– Slow, shallow, irregular
– Brain hypoxia
PULSUS PARADOXUS
• Decrease in systolic BP > 10 mm HG during
inspiration
• Caused by increase in intrathoracic pressure
– COPD
• Interference with ventricular filling
• Results in decreased BP
DEFINITIONS
• Hypoxemia
– Reduction of O2 in arterial blood
• Hypoxia
– Insufficient O2 available to meet O2 requirements
• Hypercarbia
– Increased level of CO@ in blood
Monitoring
• Pulse oximetry
• End tidal CO2
– Quantitative
• capnography
– Qualitative
• Colormetric
– Purple to yellow
CAPNOGRAPHY- EtCO2
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Standard of care in hospital
Immediate response to extubation
Stand up in court to prove intubation
Waveform indicative:
– Normal
– Obstructed airway- do you NEED a B-2
agonist?
WAVEFORM
• Normal
– Acute upstroke- exhalation
– Acute down stroke- inhalation
– Straight across
– Shark fin- lower airway obstruction
Advanced Airway Management
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Manual airway control
Ventilation
Oxygenation
…Proceed to advanced management
Allows for correction of:
– Profound hypoxia
– hypercarbia
• Followed by advanced adjunct
placement ASAP
– Prevent gastric inflation
– Prevent aspiration
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Endotracheal tube
Combitube
PtL
LMA
Endotracheal Intubation
• When ventilating an unresponsive patient
through conventional methods cannot be
achieved
• Protect the airway
• Prolonged artificial respiration required
• Patients with or likely to experience upper
airway compromise
• Decreased tidal volume- bradypnea
• Airway obstruction
Advantages
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Controls the airway
Facilitates ventilation/ O2
Prevents gastric inflation
Allows for direct suctioning
Medication administration
Disadvantages
• Requires extensive and ongoing training for
proficiency
• Requires specialized equipment
• Bypasses physiological function of upper
airway
– Warm
– Filter
– Humidify
Complications with Intubated
Patients
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Displacement
Obstruction
Pneumothorax
Equipment failure
• Contraindicated in epiglottitis
Possible Occurring
Complications
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Bleeding
Laryngeal swelling
Laryngospasm
Vocal cord damage
Mucosal necrosis
Barotrauma
Dental trauma
Laryngeal trauma
Esophageal placement
Laryngoscope
• Move tongue and epiglottis
• Allows visualization of cords and glottis
• Miller- straight
– Lift epiglottis
– pediatrics
• Macintosh- curved
– Fits in valeculla
– More room for visualization
– Reduced trauma/ gag reflex
ETT
• 15mm universal adapter
• 2.5-9.0mm diameter
• 12-32cm length
– Male- 23cm 8.0-8.5mm
– Female- 21cm 7.5-8.0mm
• Balloon cuff
– Occludes tracheal lumen
– Pilot balloon
• magill forceps
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Direct observation
Breathing & apneic
BSI- goggles & gloves
Position- sniffing
Preoxygenate
– Replace nitrogen stores with O2
• Assemble & check equipment
Verify Placement
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Esophageal intubation detector
CO2 detector
Auscultation
EtCO2 Capnography
– 35-45mm Hg
– Hyperventilation in head injury with herniation 3035mm HG
ASPIRATION
• Partially dissolved food
• Protein dissolving enzymes
• Hydrochloric acid
Pathophysiology
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Increased interstitial fluid due to injury
Pulmonary edema
Destruction of alveoli
ARDS
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Impaired gas exchange
Hypoxemia
Hypercarbia
Increased mortality
Prevention
• Cricoid pressure
• Suctioning
– Tonsil tip
– Whistle tip
• Positioning
Hazards of Suctioning
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Cardiac dysrhythmias
Increased BP/ HR
Decreased BP/ HR
Gag reflex
– Cough
– Increased ICP
– Decreased CBF
Multilumen Airways
• Combitube
• Pharyngotracheal Lumen Airway
Advantages
• Blind insertion
• Facial seal is not necessary
• Can be placed in esophagus or trachea
Contraindications
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< 16 years old
< 5 feet tall or > 6 ft 7 in tall (4 ft combi)
Ingestion of caustic substances
Esophageal disease
Presence of gag reflex