Airway ManagementPart I

RET 2275

Respiratory Care Theory 2

Manual Resuscitators

Manual resuscitator Portable, hand-held device that allows for the delivery of positive

pressure and supplemental oxygen to the airway AKA: resuscitator bag, Ambu bag, bag-valve-mask (BMV)

Generic parts: Self-inflating bag Air intake valve Nonrebreathing valve Exhalation valve Oxygen reservoir

Manual Resuscitators

Nonrebreathing Valve Types Spring-loaded ball

Manual Resuscitators

Nonrebreathing Valve Types Duckbill

Manual Resuscitators

Nonrebreathing Valve Types Leaf

O2 Powered Resuscitators Pressure limited devices that

work similarly to reducing valves

Demand valve that can be manually operated or patient triggered

Can deliver 100% O2 at flows <40 L/min

Inspiratory pressures are limited to 60 cm H2O

Manual Resuscitators

Ambu SPUR

Manual Resuscitators

Device/Patient interface Mask

Manual Resuscitators

Device/Patient interface Directly connected to

endotracheal tube

Manual Resuscitators

Uses Ventilation during a resuscitation effort Transport of a ventilator-dependant patient Hyperinflation and delivery of enriched oxygen

mixtures before and after a suctioning procedure To generate airway pressures and large tidal volume

to expand atelectatic lung segments Adjunct in directed coughing

Upper Airway Obstruction

Causes of Upper Airway Obstruction Soft tissue obstruction

Loss of muscle tone resulting in the tongue falling back against the soft palate CNS depression – drug overdose, anesthesia Cardiac arrest Loss of consciousness

Upper Airway Obstruction

Causes Laryngeal obstruction more commonly the result of:

Muscle spasm (laryngospasm) Edema

Croup Epiglottitis

Foreign material Aspirate Vomitus Blood Space-occupying lesions, e.g., tumors

Upper Airway Obstruction

Causes Laryngeal obstruction more commonly the result of:

Muscle spasm (laryngospasm) Edema

Croup Epiglottitis

Foreign material Aspirate Vomitus Blood Space-occupying lesions, e.g., tumors

Upper Airway Obstruction

Clinical Findings Noisy inspiratory efforts, e.g., snoring Silence – complete obstruction Retractions

Intercostal Sternal Clavicular

Upper Airway Obstruction

Clinical Findings Prolonged, partial upper airway obstruction

Hypoxemia and hypercapnia

Total airway obstruction Death in 5 – 10 minutes

Upper Airway Obstruction

Positional Maneuvers to Open the Airway Head Tilt

Tilting the head back to relieve soft tissue obstruction

Upper Airway Obstruction

Positional Maneuvers to Open the Airway Anterior Mandibular Displacement (jaw thrust)

Grasping the jaw at the ramus on each side and lifting the jaw forward Treatment of choice for suspected vertebral column trauma

Manual Resuscitators

Ventilatory assistance may be administered with a manual resuscitator

Manual Resuscitators

Standards Have standard 15:20 mm (ID:OD) adaptors Deliver > 85% oxygen at 15 L/min. Volume of bag

Adult: 1600 ml Child: 500 ml Infant: 240 ml

Allow for delivery of PEEP

Manual Resuscitators

Standards Allow for attachment of volume and pressure

monitoring devices Child resuscitators should be pressure limited at 40

(± 10 cm H2O) Infant resuscitators should be pressure limit at 40

(± 5 cm H2O) No pressure limiting system for adult resuscitators

Hazards of Manual Resuscitation

Gastric distention Aspiration Diminished cardiac output

May be avoided by ventilating the patient using an inspiratory to expiratory (I:E) ration of 1:2, which allows the heart to fill during the expiratory phase when there is no pressure in the thoracic cavity

Airways in Manual Resuscitation

Pharyngeal Airways Specialized devices employed to maintain a patent

airway

Oropharyngeal Airways

Oropharyngeal Airways

Function Restores airway patency by separating the tongue from the posterior

wall of the pharynx Insertion

Orally Use jaw lift or tongue displacement

Correct sizing Measure from the corner of the patient’s mouth to angle of the jaw

Incorrect placement can worsen obstruction! Used in comatose patients

Oropharyngeal Airways

Correct Sizing

Oropharyngeal Airways

Correct Sizing

Oropharyngeal Airways

Insertion Using a head-tilt-chin-lift, a modified jaw-thrust, or by grasping the

tongue and jaw by placing your thumb in the patient's mouth, move the tongue forward. Position the OPA as shown with the tip in the patient's mouth and slowly insert the OPA. As the OPA is being inserted, slight resistance will be felt.

Oropharyngeal Airways

Insertion At the point resistance is met, insertion should continue while

simultaneously rotating the OPA 180°. Advance the OPA until the flange is resting on or just above the patient's teeth.

Nasopharyngeal Airways

Nasopharyngeal Airways

Function Restores airway patency by separating the

tongue from the posterior wall of the pharynx

Used when oral placement is not possible Insertion

Nasally Necessary to check placement Correct sizing

Measure from the patient’s earlobe to the tip of the nose

Incorrect placement can worsen obstruction!

Used in awake patients

Nasopharyngeal Airways

Correct Sizing of NPA

Nasopharyngeal Airways

Correct Sizing of NPA

Nasopharyngeal Airways

Insertion of NPA First check the nostril

for signs of fracture or obstruction then apply generous amounts of a water-based lubricant to the NPA taking care not to fill the tip with the lubricant

Orient the bevel end so that it will pass along the inside of the nasal cavity with minimal effort

Nasopharyngeal Airways

Insertion of NPA Insert the NPA until the flange (the large end of the tube) is

seated on the patient's nose

Nasopharyngeal Airways

Proper placement of the nasopharyngeal airway

Ventilation with Manual Resuscitator

Ventilation with Manual Resuscitator

Place the patient supine Open the airway – manual maneuver Insert pharyngeal airway Place the mask on the patient’s face

Bridge of the nose first Securing a tight seal below the lower lip Maintain the mask position with thumb and index finger of one

hand, use the third, forth and fifth fingers to hook under the mandible, displacing it anteriorly to maintain a patent airway

Ventilation with Manual Resuscitator

Ventilation with Manual Resuscitator

Two-man ventilation with manual resuscitator

Ventilation with Manual Resuscitator

Ventilate the patient at a rate of 8 – 16 breaths/min.

Watch for chest expansion to ensure adequate volume

I:E ration of 1:2 or better

If the patient has spontaneous respiratory efforts, match your ventilation efforts with the patient’s efforts

Endotracheal Tubes

Function Relieve airway obstruction Facilitate secretion removal Protect against aspiration Provide positive pressure ventilation

Insertion Site Nasally Orally

Placement In the trachea 3 – 5 cm above the carina

Endotracheal Tubes

Placement of the ET Tube

Endotracheal Tubes

Standard adapter with a 15 mm external diameter

BodyPilot tube

Pilot balloon

Cuff

Beveled distal tip

Radiopaque Strip

(visible on x-ray)

Endotracheal Tubes

Inner diameter

Length makings

(distance in cm from beveled tube tip)

“Z-79” or “IT”

(Tissue toxicity testing)

Endotracheal Tubes

Murphy’s eye Provides an alternate pathway

for gas to flow in the event the distal tip become obstructed

Beveled distal tip

Reinforced Wire-Wrapped ET Tube Helical reinforcing wire imbedded into

the PVC material helps prevent kinking when used in a tortuous airway

Endotracheal Tubes

Hi-Lo EVAC Endotracheal Tube

Indwelling Hi-Lo EVAC Tube

Double Lumen ET Tube

Function Independent lung ventilation

Unilateral lung disease

Properties 2 proximal 15 mm ventilator connections 2 inner lumens for gas flow 2 cuffs

Larger cuff seal trachea Smaller cuff seals bronchial lumen

2 distal openings Fiberoptic bronchoscopy needed to

verify placement

Double Lumen ET Tube

Proper placement

Indications for Endotracheal Intubation

Relieve airway obstruction Facilitate secretion clearance Facilitate mechanical ventilation Protect lower airway

Orotracheal Intubation

Safely performed by: Physicians Respiratory Therapists Nurses Paramedics

Orotracheal Intubation

Step 1: Assemble and Check Equipment Suction Equipment

Suction regulator, canister, tubing, catheters, Yankauer (tonsil tip)

Manual resuscitator bag and mask O2 flowmeter and tubing

Orotracheal Intubation

Step 1: Assemble and Check Equipment Laryngoscope with assorted blades

Ensure light on blade is functioning Endotracheal tubes

Inflate cuff and check for leaks

Orotracheal Intubation

Step 1: Assemble and Check Equipment Stylet Magil forceps (nasal intubation)

Orotracheal Intubation

Step 1: Assemble and Check Equipment Tongue depressor Tape Syringe Lubricating jelly Local anesthetic (spray)

Orotracheal Intubation

Step 1: Assemble and Check Equipment Towels (for positioning) Stethoscope CDC barrier precaution

Gloves, gowns, masks, eyewear

Orotracheal Intubation

Step 2: Position the Patient Must align the mouth,

pharynx and larynx Place one or more rolled

towels under the patient’s head

Orotracheal Intubation

Step 3: Preoxygenate the Patient with Resuscitator / Mask Provides a reserve of oxygen during intubation

attempts Intubation attempts should not last greater than 30

seconds If attempt fails, ventilate and oxygenate for 3-5

minutes before reattempting to intubate

Orotracheal Intubation

Step 4: Insert the Laryngoscope Laryngoscope in left hand while

right hand opens the mouth Insert the laryngoscope into the

right side of the mouth and move it toward the center, displacing the tongue to the left

Advance the tip of the blade along the curve of the tongue until you visualize the epiglottis

Orotracheal Intubation

Step 5: Visualize the Glottis

Orotracheal Intubation

Step 6: Displace the Epiglottis MacIntosh Blade – displaces

the epiglottis indirectly by advancing the tip of the blade into the vallecula

Miller Blade – displaces the epiglottis directly by advancing the tip of the blade over the its posterior surface and lifting the laryngoscope up and forward

Orotracheal Intubation

Step 7: Insert the Tube Insert the tube from the

right side of the mouth Advance tube through

the glottis until the cuff passes the vocal cords

Inflate the cuff to seal the airway

Ventilate and oxygenate

Orotracheal Intubation

Step 8: Assess Tube Position (3 - 5 cm above carina) Auscultation – bilateral breath sounds Observation of chest movement Tube length ( approximately 22 cm to teeth for adults) Colorimetry

Colorimetry - CO2 Detector

Positive for CO2

Negative for CO2

Orotracheal Intubation

Step 8: Assess Tube Position (3 - 5 cm above carina) Capnometry (End-Tidal CO2) Light wand Fiberoptic laryngoscope Esophogeal detection device Chest x-ray

Orotracheal Intubation

Step 9: Secure the Endotracheal Tube

Intubation Videos

Oral Intubation Procedure – Routine

Points to Remember

Hazards of Endotracheal Intubation

Post-extubation mucosal edema Trauma Aspiration Bleeding Infection Tube problems (pilot balloon, kinking etc.)

Cuff Pressure Monitoring Techniques

Auscultate over trachea Minimal Occluding Volume – inflate cuff until cuff air

leak stops Minimal Leak Technique – inflate cuff until cuff air leak

stops, then withdraw enough air to allow a small air leak at peak inspiration

Cuff Pressure Monitoring Techniques

Cuff Pressure Measurement Cufflator Checked once per shift Pressures not to exceed:

27 – 34 cm H2O (20 – 25 mm Hg)

Excessive pressures my cause tracheal damage if cuff pressures are greater than tracheal perfusion pressures

Combitube Airway

Double lumen airway Esophageal gastric airway Endotracheal tube Effective whether in the esophagus or the trachea

Designed to be inserted blindly Used for difficult intubation Short-term

Combitube Airway

Correct insertion and placement

Laryngeal Mask Airway (LMA)

Designed to form a low-pressure seal in the laryngeal inlet by means of an inflated cuff Maintains a patent upper airway and

facilitates ventilation Designed to be inserter blindly

Used for difficult intubation Short-term

Laryngeal Mask Airway (LMA)

Correct insertion and placement

Laryngeal Mask Airway (LMA)

Correct insertion and placement

Laryngeal Mask Airway (LMA)

This tube, when inserted into the larynx and the laryngeal cuff inflated, provides a closed seal system to ventilate the lower airway and protect against aspiration.

Insertion video