Anything new in Airway
Management?
Dr Adrian Burger
Emergency Medicine Senior Registrar
UCT/US
So what do we do?
• A,B,C’s……
• A is for clearing, opening and or securing
the airway
• Clearing - turn on side
- suction
- no more blind finger sweeps!
Opening
• Jaw thrust
• Head Tilt Chin lift
• Combined
• Remember : C-spine stabilization
Opening or securing the Airway
• BMV
• OPA/NPA
• LMA
• Combitube®
• ETT
Mask
• Most basic piece of “airway” kit
• Different types - clear, black
- cushion around edge
• Won’t maintain airway by self
• Needs head tilt/chin lift or jaw thrust
• Also needs Positive Pressure Ventilation
Mask
Positive Pressure Ventilation
• Rescuer’s breathing efforts and one-way
valve
• Bag Mask Ventilation (BMV)
Mask with one-way valve
Oropharyngeal Airway/Guedel
• Different colours =
SIZE
different sizes
• Neonate to large adult 000
OO
O
1
2
3
4
5
COLOUR
Violet
Blue
Black
White
Green
Orange
Red
Yellow
Oropharyngeal Airways
Oropharyngeal Airway/Guedel
• Features:
- single use
- rounded edges
- bite block
- colour coding
- airway path in centre
Oropharyngeal Airway/Guedel
• How to size it????
The size of the Guedel airway is the
distance
between the center of the incisors and the
angle of the jaw (on the same side!)
Oropharyngeal Airway/Guedel
• How to put it in:
Depress tongue
Slip over spatula with curve caudal direction
Place bite block between teeth
• NO TWISTING MOVEMENT
Oropharyngeal Airway/Guedel
• Indications:
To open and maintain an airway in a
patient with a depressed level of
consciousness
With FMO2 or BMV
Oropharyngeal Airway/Guedel
• Contra indications:
Patient won’t accept it
LOC
Risk of vomiting & aspiration
Nasopharyngeal Airway
• For maintaining airway in “more awake”
patients
• Sits in nasopharynx and opens airway
• Does NOT protect against aspiration
Nasopharyngeal Airway
Nasopharyngeal Airway
• How to size it?
Estimate by comparing to patients little
finger
• How to insert it?
Lubricate
Gently push posteriorly towards ear on same side
Fix with a safety pin
Nasopharyngeal Airway
• Contra-indications:
Base of skull fracture
Serious midline facial fractures
When definitive airway needed
LMA
• Advanced airway
• Useful alternative for “difficult intubation”
• Easy to use
• Sits on larynx - Protects lungs?
LMA
LMA
• Have a range in unit
• Re-use ?20 times
• Part of kit
• Formula for Children:
The combined widths of
the patient's index,
middle and ring fingers
SIZE
1
1.5
2
2.5
3
4
5
6
PATIENT
<5 kg
5-10kg
10-20kg
20-30kg
30-50kg
50-70kg
70-100kg
>100kg
LMA in Emergency Medicine
• Indications:
Unconscious or anaesthetized patients
AHA Guidelines for adults:
BLS: alternative to BMV
ACLS: Optional/alternative to BMV, failed ETT
• Aspiration?
• Paediatrics?
LMA in Emergency Medicine
• Aspiration?
Less than with BMV
Supraglottic device
Aspirated from CPR or post LMA?
Cricoid pressure during CPR
LMA Use in Emergency Paediatrics
• Little Data
“Despite widespread use LMA, there is little data
on its effectiveness during positive pressure
ventilation in infants and young children “
• Obstruction
The LMA appears more likely to cause partial
airway obstruction in infants ( < 10kg) than in
older children.
• PALS®: Class Indeterminate
• Neonates: “Can’t intubate can’t ventilate”
LMA in Emergency Medicine
• Benefits:
Ineffective BMV with failed ETT
AHA: Alternative to ETT or BMV in CPR
Blind ETT, by passing ETT through LMA
Drugs - 27% efficacy
LMA in Emergency Medicine
• Disadvantages:
Needs adequate training
Risk of aspiration
Limited Paediatric use
Not always successful
LMA Insertion
LMA Insertion
Combitube®
Combitube®
• Advantages:
Protect airway from aspiration
Easy to use
AHA: alternative to ETT for CPR
• Disadvantages:
Trauma to soft tissues
Not available here in SA
Combitube®
• Head neutral or slightly flexed
• Hold tongue and jaw between thumb &
forefinger and lift
• Gently insert Combitube® in a curved back and
downward movement until black markers
aligned with teeth
• Inflate (proximal) pharyngeal balloon
• Inflate (distal) tracheal balloon
• Confirm which one of #1 or #2 tube is in lungs
by using bag ventilator
Combitube® Insertion
ETT
Equipment for ETT
•
•
•
•
•
•
•
•
Mask and bag ventilator with O2
ETT - checked, lubricated, tape ready
Laryngoscope
Drugs: Induction agent & muscle relaxant
McGills forceps, Bougie
Primary detection tools
Other advanced airways
Surgical airway capability
ETT
• Advantages:
Airway patent and protected
Secretions suction
O2
Medication
Known tidal volume
ETT
• Disadvantages:
Training
Skill lost
Interrupted CPR
Why ETT?
• For above benefits
• Inability to BMV or ineffective BMV
• Secure threatened airway
• Certain thoracic injuries
Anatomy
endotracheal tubes
• cuffed tubes
• uncuffed tubes
placement of ETT
• length of tube at the larynx (cm) = internal
diameter of correct ETT for size
railroad techniques for changing
tubes
• getting the curves right
Tube Placement Confirmation
• Clinical - visual
- auscultation
- laryngoscopy
• Detection devices - CO2 (2a)
- EDD
Detection Devices
• Always clinical + device
• No single device specific or sensitive
• CO2 detector: 33%-100% sensitive
: 97%-100% specific
: only studied on ETT
• EDD: bulb compressed or syringe pulled
: High sensitivity
: Poor specificity
• CXR
Secure the ETT
•
•
•
•
Record depth at front teeth
Evidence is commercial=tape
Re-evaluate
3 Rules - verify placement
- asynchronous CPR
- avoid excessive ventilation
BMV
•
•
•
•
•
Best for last!
Easy to master
First line in CPR
Every unit has one
Effective
BMV
BMV
• OLD: ETT ventilation adjunct of choice for
CPR
• ETT complications - misplaced
- displaced
- interrupted CPR
• AHA: BMV or advanced airway for CPR
• Prehospital: BMV=LMA & Combitube®
Failed Intubation
• Can’t intubate, Can Ventilate
Don’t panic, call for help
Reassess need to intubate
Reposition patient, airway
Cricoid pressure
Bougie
Consider other advanced airways
Call for help
Failed Intubation
• Can’t intubate, Can’t Ventilate
Call for help, don’t panic
Reassess airway, positioning
Reassess equipment
Two person ventilation
Other advanced airway
Surgical airway
CALL FOR HELP
Remember
• Check your equipment before you need it
• Be prepared
• Don’t panic
Parting shot
“Patients do not die from lack of intubation
they die from lack of oxygenation”
References
• Currents, winter2005-2006
• JAMA, Feb 9, 2000-Vol 283, No6 p783-790
• www.aic.cuhk.edu.hk/web8/index
• www.healthsystem.virginia.edu/Internet/AnesthesiologyElective/airway/anatomy
• www.lmana.com/prod/components/products/lma_classic