Air way mana ص

CPR consists of:

1. Airway Management2. Basic Life Support (BLS)3. Advanced Cardiac Life Support (ACLS)4. Advanced Trauma Life Support (ATLS)5. CPR in special situations6. Ethical Issues

,

AIRWAY MANAGEMENT

REVIEW & UPDATEDr. Salah Kamel ashourAlbada General Hospital

Tabuk [email protected]

0502617860

mailto:[email protected]

AIRWAY MANAGEMENT Basic & Advanced

ObjectivesReview airway anatomyIdentify important anatomical structures related to the intubation of a patientReview basic airway maneuversReview blind insertion airwaysReview advanced airway techniquesDescribe the process of opening the airway and maintaining itDescribe the indications, limitations, proper sizing, and contraindications of airway adjuncts

OBJECTIVESIdentify indications for intubation and prepare the necessary equipment.Identify the advantages and disadvantages of various devices for airway management. Refresh working knowledge of intubation equipment and airway support adjunctsDiscusse supraglottic and infraglottic a\w device ( LMA& COMBTUBE)Identify difficult airway. Identify equipment for difficult airway and know their use.

Objectives:

Discuss the ten commandments of airway management Review and demonstrate pediatric and adult basic/advanced airway techniquesReview techniques for confirmation of tube placement and ongoing monitoring Describe the indications, contraindications, advantages, disadvantages, complications and equipment for sedation procedures during intubation Perform needle and surgical cricothyroidotomy procedures

CONTENTS Introduction. Facts about A/W. Procedures of A/W management. Initial management of A/W.

Without Tracheal intubation. Advanced a/w management with tracheal

intubation. Management and protection of A/W. in patient with

head trauma. A/W. Management & chest trauma. Summary.

Regardless of certification level, to

Manage a patient's airway in the most effective way possible

It is the responsibility of every HEALTH CARE PROVIDER

Airway anatomy and function.Evaluation of airway.Maintenance and ventilation.Clinical management of the airway.How to open the A/W.

What should we know about“airway management?”

♥ A/W control is vital to improve pulmonary exchange , as well as , to protect patient's from aspiration .

♥ The most vital element in providing functional respiration is the AIRWAY .

INTRODUCTION

The A/W is the conduit through which air & o2 must pass before reaching the lungs .It include the anatomic structures extending from the nose and mouth to the larynx and trachea.

WHAT IS THE A / W?

Successful airway management requires

detailed understanding of upper and lower

airway structure (ANATOMY) and

function (PHYSIOLOGY)

Review of Upper and Lower

Airway ANATOMY

Upper and lower airway

ANATOMY

AnatomyUpper airway

The upper airway consists of the structures above the vocal cords. It is divided into the following regions:

Nose and oral cavity.. The nose, which is composed of bone cartilage, is the primary pathway for normal breathing. The oral cavity consists of the upper and lower teeth, the tongue and floor of the mouth, the hard palate and the openings of the major salivary glands. The floor of the mouth is supported by the mylohyoid muscles.

Pharynx. In normal size adult males, an approximately 13-cm long muscular tube located behind the oral and nasal cavities. It conducts food to the esophagus and air to the larynx, trachea and lungs. The pharynx is divided into three sections: Nasopharynx: extends from the back of the internal

nasal cavity to the soft palate. Contains the adenoids. Oropharynx: Begins at the soft palate and continues to

the level of hyoid bone. Serves as both respiratory and food passage. Contains the tonsils. The tongue is the principal source of obstruction, usually because of decreased muscle tone related to sedation drugs such that the tongue falls backward in a supine patient.

Laryngopharynx: Begins at the level of the hyoid bone and extends downward where it branches into two passages: the larynx at the front which leads to the lungs; the esophagus at the back which leads to the stomach.

Pharynx Divided into Three Segments:

Nasopharynx, Oropharynx, and Hypopharynx

Innervation and blood supply

The motor and most of the sensory supply to the pharynx is by the pharyngeal plexus, is formed by the pharyngeal branches of the vagus and glossopharyngeal nerves

. The pharynx is supplied by branches of the external carotid (ascending pharyngeal) and subclavian (inferior thyroid) arteries

Upper Airway: From Pharynx to Larynx

Uvula

Epiglottis

Larynx

Midline guidance: “The uvula points to the epiglottis, the epiglottis leads into the

larynx”.

Lingual Tonsil

Lower airway The lower airway encompasses the structures of the respiratory system below the larynx.

Trachea. Rigid tube approximately 10-15 cm length in the midline of the neck that provides a passage for air into the lungs.

Bronchial tree. Branched tree-like tube system leading from the trachea that conducts air into the lungs. It is made up of increasingly smaller tubes terminating in the alveoli.

Lungs. Paired organs consisting of millions of small sacs (alveoli) gas exchange occurs. The lungs occupy most of the space of the thoracic cavity.

The Larynx

The Larynx• The larynx is a 5-7

cm long structure. • Its upper boundary

starts at the tip of the epiglottis, opposite the 3rd to 4th, cervical vertebra.

• Its lower end is at the lower border of the cricoid cartilage.• This lies opposite the 6th

cervical vertebra. www.phon.ox.ac.uk

The Larynx

Superior surface anatomy :

Major Landmarks to look for - VII

Cartilaginous

Rings ofTrachea

TrueVocal Cords

Vocal Cord Sulcus (onTrue Vocal

Cords)

CricoidRing

FalseVocalCords

Larynx . Enlargement at the top of the

trachea which houses the vocal cords.

The structure contains muscles, ligaments, and cartilages.

The epiglottis is a fibrous leaf-like cartilage that hangs over the laryngeal inlet that closes during swallowing to prevent aspiration of gastric contents into the trachea.

.

Larynx The triangular opening between the

vocal cords is called the glottic opening and is the entry point to the larynx, It is the adult airway’s narrowest point. Patency of the glottic opening is dependent upon muscle tone

The glottis: open for inspiration and closed for

swallowing

Open Closed

Larynx The vocal cords of

the larynx as seen by a doctor using a laryngeal mirror. Note that the inside of the trachea can be seen through the open vocal cords and the opening to the esophagus can be seen lying behind the larynx. ©

http://yoursurgery.com/ProcedureDetails.cfm?BR=3&Proc=21

The Larynx: Critical Structures The Larynx neighbors

major critical structures:

Carotid arteries and jugular veins, and the vagus nerve

Superior and inferior thyroid arteries

Superior and recurrent laryngeal nerves

www.yoursurgery.com

Nerve SupplyVagus (X)

Superior Laryngeal

Recurrent Laryngeal

Continues in Thorax/Abdo to supply Heart, Trachea,

Lungs, GI Tract (to midgut)

Internal

BranchExterna

l Branch

Meningeal BranchAuricular Branch

Pharyngeal Branch


Superior Laryngeal

Recurrent Laryngeal



Cricothyroid

Internal

BranchExterna

l Branch

All other Intrinsic Muscles

MotorMeningeal BranchAuricular Branch

Pharyngeal Branch


Superior Laryngeal

Recurrent Laryngeal



Above cords

Below cords

Cricothyroid

Internal

BranchExterna

l Branch

All other Intrinsic Muscles

Sensory

MotorMeningeal BranchAuricular Branch

Pharyngeal Branch

Larynx Unilateral damage of a recurrent

laryngeal nerve results in paralysis of all the intrinsic muscles of the larynx except the cricothyroid, which will tend to adduct the vocal cord

The larynx has arterial supply by

(1) the superior laryngeal artery (from the superior thyroid), which accompanies the internal laryngeal nerve,

(2) the inferior laryngeal artery (from the inferior thyroid), which accompanies the recurrent laryngeal nerve

Cricoids cartilage 1

Lungs 2

Trachea 3

Epiglottis 4

Nasopharynx 5

Thyroid cartilage

6

Alveolus 7

Larynx 8

Right main bronchus

9

Left main bronchus 10

Bronchiole 11

Oropharynx 12

Diaphragm 13

B Cricoids cartilage 1

E Lungs 2

C Trachea 3

H Epiglottis 4

F Nasopharynx 5

A Thyroid cartilage

6

M Alveolus 7

I Larynx 8

D Right main bronchus

9

J Left main bronchus

10

L Bronchiole 11

G Oropharynx 12

K Diaphragm 13

Pediatric Airway Infant and Child Considerations

Pediatric Airway Pediatric vs Adult Upper

Airway Larger tongue in comparison to

size of mouth Floppy epiglottis Delicate teeth and gums Larynx is more superior Funnel shaped larynx due to

undeveloped cricoid cartilage Narrowest point at cricoid ring

before 10 yoa

Pediatric Airway Pediatric vs Adult Upper

Airway Trachea -

Infants and children have narrower tracheas that are obstructed more easily by swelling.

Trachea is softer and more flexible in infants and children.

Diaphragm - chest wall is softer, infants and children tend to depend more heavily on the diaphragm for breathing

Pediatric Airway The Cricoid cartilage

like other cartilage in the infant and child, the cricoid cartilage is less developed and less rigid. It is the narrowest part of the infant’s or child’s airway.

Cricothyroid membrane

Thyroid glandThyroid

cartilageCricoid cartilage

Blood Supply of The lungs

Blood Supply The lungs are very vascular organs, meaning they

receive a very large blood supply. This is because the pulmonary arteries, which

supply the lungs, come directly from the right side of the heart.

They carry blood which is low in oxygen and high in carbon dioxide into the lungs so that the carbon dioxide can be blown off, and more oxygen can be absorbed into the bloodstream.

The newly oxygen-rich blood then travels back through the paired pulmonary veins into the left side of the heart. From there, it is pumped all around the body to supply oxygen to cells and organs.

Basic Physiology

http://www.biology.eku.edu/RITCHISO/301notes6.htm

Airway FunctionsPassage that allows air to move from atmosphere to alveoliMust remain patent (open) at all timesAnything that blocks airway will cause decrease in oxygen available to bodySize of obstruction affects available air exchange

Respiratory Physiology The physiology of respiration is a complex

process of gas exchange at the cellular level (CO2 and O2). When air loaded with oxygen reaches the alveoli, cellular respiration occurs. Oxygen inhaled into the lungs is moved into the alveoli through diffusion at the capillary level. This oxygen diffuses from areas of higher concentration to areas of lower concentration across the cell wall.

Respiratory Physiology Oxygenation - blood and the cells become

saturated with oxygen Hypoxia - inadequate oxygen being delivered to

the cells Signs of Hypoxia

Increased or decreased heart rate Altered mental status (early sign) Agitation Initial elevation of B.P. followed by a decrease Cyanosis (often a late sign)

Alveolar/Capillary Exchange

Oxygen-rich air enters the alveoli during each inspiration.

Oxygen-poor blood in the capillaries passes into the alveoli.

Oxygen enters the capillaries as carbon dioxide enters the alveoli.

Capillary/Cellular Exchange

Cells give up carbon dioxide to the capillaries.

Capillaries give up oxygen to the cells.

Airway managementdoes

not mean intubation

SO WHAT DOES

IT MEAN?

It means to ensure patency, provide adequate ventilation and maintain appropriate oxygenation.

Many times we forget the basics. Merely providing a chin lift or jaw thrust

can open and/or salvage many airways.

The proper use of adjuncts (oral/nasal airways), can convert a difficult-to-ventilate patient into a stable, well-ventilated one.

The appropriate administration of high-flow oxygen, with properly fitted masks, is enormously beneficial.

We must never forget that airway management is a collection of skills and techniques, not just an attempt to place a tube or device into the patient’s mouth or trachea

Remembering that: oxygenation is more important than tracheal Intubation .This can be done by: administering O2 via mask& bag to improve oxygenation prior to intubation

IF vomitus or F.B. is visible in the mouth of unconscious patient , it should be swept with a hooked index finger .

Placement of oral or nasal A/W. may help to maintain a patent A/W.

1. Relieve airway obstruction (e.g. head tilt-jaw thrust, finger sweep, suctioning)

2. Prevent aspiration (e.g. blood, foreign materials, stomach contents > leads to pneumonitis > 50% mortality rate

3. Maintain adequate ventilation/gas exchange

Goals of Airway Management

The Ten Commandments of Airway Management

1) Oxygenation and ventilation are the top priorities 2) Airway management does not mean intubation :-It means

to ensure patency, provide adequate ventilation and maintain appropriate oxygenation. Many times we forget the basics.

3) Be an expert at bag-valve-mask (BVM) ventilation . 4) Know your equipment

1) That daily check sheet is there for a reason. Airway equipment is one of the most important items you carry. Having backups (laryngoscope blades, bulbs, handles, adjuncts) and the ability to troubleshoot equipment are also important. Assume personal responsibility for all airway equipment and its proper functioning.

5) Know at least one rescue ventilation technique and use it Rescue ventilation can best be described as a ventilation attempt to

use in the face of a failed airway (can’t intubate/can’t ventilate) scenario. The most basic rescue technique is two-person BVM ventilation Next, the use of the CombiTube® and LMSis recommended. It is easy to use, can be inserted quickly and safely, and can accomplish ventilation when previous airway attempts fail. It allows for blind insertion in the most difficult of patients and situations and provides some protection against aspiration and higher airway pressures.

6) Develop a personal airway algorithm Each provider should have an algorithm specific to their skill level and approved scope

of practice. Not all patients and situations you encounter are going to be the same. Having only one or two airway skills in your repertoire can lead to a potentially dangerous approach to airway management. Everyone’s algorithm should begin with the basics. For example, start with BVM ventilation, advance to ET intubation, then place a Combitube®, and finally perform a surgical cricothyrotomy. This plan should be calmly practiced and mastered.

7) Don’t let your ego get in the way This can be dangerous for your patient, your partner or colleagues, and your career.

Remember, your goal is excellent patient care and a positive outcome, not skill accumulation or personal success. . Don’t ever forget to ask for assistance when you need it.

8) Invest time in learning airway skills Regularly devote training and practice time to airway management.

Try not to limit yourself to manikin airway trainers if possible. Work on gaining access to the simulator lab, operating room or emergency department. Also, read about the latest techniques and advances in airway management. Attend conferences and

airway obstacle courses for more hands-on training. : 9) Use CAPNOGRAPH & an end tidal CO2 detector and/or

esophageal detector device to assist you in confirming every intubation .

10)When seconds count, don’t count on seconds Each airway maneuver or intubation attempt should be your best

effort. Often, our best chance at getting a decent airway is the first attempt. Maximize your chances by leaving nothing to chance. Being prepared often means the difference between success and failure.

Airway anatomy and function.Evaluation of airway.Maintenance and ventilation.Clinical management of the airway.How to open the A/W.Basic & Advanced

What should we know about“airway management?”

Procedures of A/W

managementA/W Cane be managed

With(Advanced) or without

Basic))tracheal Intubation

ALWAYS REMEMBER THE BASICS

These skills should be used prior to initiating any

advanced airway techniqueHead-tilt/chin liftJaw thrustModified jaw thrust (for trauma patients)Sellick’s maneuver

Basic Airway Maneuvers

[

to open the A/W

Use head tilt & chin left or jaw

thrust

Techniques of Basic Airway Management

Non-invasive-Head positioning

-Removal of foreign body-Suctioning

-Mask ventilation

Opening and head positioning

• Jaw thrust

• Head Tilt Chin lift

• Combined

•Remember : C-spine stabilization

Airway managementManual methods:

Head tilt & Chin liftJaw Thrust ( Trauma)

Head-tilt/chin-liftHead-Tilt/Chin-Lift

Head-Tilt/Chin-Lift

TechniquePlace one hand on patient’s foreheadApply firm, backward pressure with palm causing head to tilt backward Place fingers of other hand under bony part of patient’s lower jaw near chinLift jaw upward to bring chin forward

Head-Tilt/Chin-Lift

♥Loss of consciousness is often accompanied by loss of submandibular muscle tone .

♥Occlusion of the A/W. by tongue can be relived by a head- tilt chin lift ( if no evidence of c.spine injury,

Head-Tilt/Chin-Lift

Falling of tongue backward ( during loss of consciousness) is the most common cause of U/A/W/ obstruction. which can be relieved by a head-tilt /chin lift or jaw- thrust.

Head-Tilt/Chin-Lift

Airway adjuncts

Oropharyngeal airwayNasopharyngeal airway

Airway adjunctsOropharyngeal airwayNasopharyngeal airway

Airway Adjuncts

• Oropharyngeal Airway (OP)– Helps prevent tongue from obstructing

posterior pharynx – Potential use in unconscious patient– Cannot use in patients with intact gag reflex– SIZING: measure from corner of mouth to

angle of jaw– PLACEMENT: direct method vs rotation

method.

Airway Adjuncts

• Nasopharyngeal Airway (NP)– Unconscious or depressed mental status– SIZING: Measure from the tip of the nares to

the tragus of ear– CONTRAINDICATIONS: basilar skull fracture,

midface fractures, bleeding disorders– Relative contraindication: children < 1 year

old

Oropharyngeal Airways

•Features: -single use

-rounded edges -bite block

-colour coding -airway path in centre

How do you size oral

airways?:

The correct size will vary Oral Airways with each patient.

To size the OPA, it is measured against the distance from the corner of the patient's mouth to the patient's earlobe.

SIZING THE OPA:

correct size :

• it is measured against the distance from the corner of the patient's mouth to the patient's earlobe.

incorrect size :

• If an airway

is too small ,it may obstruct the airway.

incorrect size :

• If an airway is too large ,it may obstruct the airway.

Incorrect insertion of an OPA

can displace the tongue into hypopharynx ,

causing air-way obstruction

OPAImproper placement of oropharyngeal airway

INSERTION OF THE OPA :

• It is the responsibility of every provider, regardless of certification level, to manage a patient's airway in the most effective way possible

• Position the casualty on his back.• Place your thumb and index finger of one hand on the

casualty's upper and lower teeth near a corner of his mouth so the thumb and finger will cross when the casualty's mouth is opened.

• Push your thumb and index finger against the casualty's upper and lower teeth in a scissors-like motion until his teeth separate and his mouth opens.

• If the teeth do not separate, wedge your index finger behind the casualty's back molars and force the teeth apart.

INSERT THE OROPHARYNGEAL AIRWAY :

Place the tip end of the airway into the casualty's mouth. Make sure the tip is on top of the tongue. Point the tip of the airway up toward the roof of the casualty's mouth.

Slide the airway along the roof of the casualty's mouth, following the natural curvature of the tongue.

When the tip of the airway reaches the back of the tongue past the soft palate, rotate the airway 180 degrees so the tip of the airway points toward the casualty's throat.


Advance the airway until the flange rests against the casualty's lips.

The airway should now be positioned so the tongue is held in place and will not slide to the back of the casualty's throat.


INSERTION OF THE OPA• 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


• 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 .


Blindly inserting the O/A/W upside down and turning it 180 ْonce it is in the mouth may push the tongue against the post. Pharynx which help to open A/W.

Check the casualty's respirations to make sure he is still breathing adequately and the oropharyngeal airway is not blocking his airway.Adjust the position of the oropharyngeal airway, if needed

MONITOR A CASUALTY WITH ANOROPHARYNGEAL AIRWAY IN PLACE

:

♥ The position of the airway in the patient’s mouth and breath sounds should be assessed frequently

♥ The oral cavity should be suctioned as needed. ♥ Mouth care should be done every two to four

hours and as needed. ♥ Mouth care can be done with a moistened

swab.

some tips to care for a patientwith an oropharyngeal airway

If the airway is coated with secretions, it can be removed and insert a clean airwayIf the patient has the oropharyngeal airway as a long-term measure, the airway should be cleaned and replaced at least once every eight hours.

some tips to care for a patientwith an oropharyngeal airway

Oropharyngeal airwayContraindicated in patients with

gag reflex.

Oropharyngeal Airway

SIZEPROPER

POSITION

Image from: http://www.hadassah.org.il/NR/rdonlyres/59B531BD-EECC-4FOE-9E81-14B9B29D139B1945/AirwayManagement.ppt

Question:Should you tie or tape the airway in place?

Response:No.

Question:What should you do if the casualty begins

to regain consciousness?

Response:Remove the airway .

2.Nasopharyngeal AirwaySoft plastic or rubber tube that is designed to pass just inferior to the base of the tonguePassed through one of the nares and can be used in patients with an intact gag reflexCONTRAINDICATED in cases of suspected or possible basilar skull fractureSizes range from 17-26 cm in length and 6-9 mm internal diameterMeasured from tip of the nose to the corner of the patients ear

Nasal Airway continuedThe nasal airway is lubricated with a water soluble lubricantThe beveled tip is inserted directed towards the septum, with the airway directed perpendicular to the faceIf resistance is met, rotating the airway may help or the other nare may be used

Nasopharyngeal airway

Contraindicated in patients with

basal skull#

Naso-pharyngeal A/W

Nasal A/W ( Naso-pharyngeal A/W)

The length is 2 – 4 cm longer than oral A/W Used to relieve upper A/W obstruction caused by

tongue or soft palate falling against posterior wall of the pharynx .

Suction via this A/W less traumatic than oral A/W.

Better tolerated than orally A/W. in awake or lightly anaesthetized patient.

After it is lubricated it can be gently inserted down at an angle to the face to avoid traumatizing the turbinate or the roof of the nose

Nasal Airways• Patients needing nasal airway

–Unresponsive patients who are snoring

–Unresponsive patients with gag reflex

It should be alternated every 24 h. between R& L. nares to minimize complication .

Should not be used in : *Anticoagulant patient . * Children with prominent adenoids

Absolute contraindication in skull fracture base

Sinusitis , otitis media , nasal necrosis , are possible complication of its use

SIZING THE NPA• The correct size will vary with

each patient. To size the NPA, it is measured against the distance from the patient's nose to the patient's earlobe

CORRECT SIZE INCORRECT SIZE

INSERTION OF AN NPAFirst, 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 and insert the NPA until

the flange (the large end of the tube) is seated on the patient's nose as shown below

Two NPA's can be inserted to provide even better ventilation. Placing the second is similar in fashion with one difference: The bevel of the second

NPA must be oriented to the nasal septum as was the first but the curvature of the NPA itself indicates that while being inserted, it must be

turned 180° when about 1/2 way into the nasal cavity

SPECIAL CONSIDERATIONS Another acceptable sizing technique is

to match the diameter of the NPA to that of the patient's little finger

If significant resistance is felt upon insertion of the NPA, remove it and attempt placement in the opposite nostril

Be prepared for bleeding that may occur with the placement of the NPA

Always make efforts to be prepared with suction devices at the ready with all airway procedures in the event the patient should vomit

Potential Hazards Involved in the Use of Nasopharyngeal airways airways• Using an airway that is too long; this

may cause the tip to enter the esophagus.

• Injuring the nasal mucosa causing bleeding. This can lead to aspiration of blood or clots.

• If nasal airway doesn’t have flange at the nasal end can lose airway in nose and the airway.

Bag-valve-mask

ventilation(BVM)

Be an expert at bag-valve-mask (BVM) ventilation

INDICATIONS: The BVM is a device used to

deliver positive pressure ventilations to patients :-who are breathing ineffectively or not breathing at all.

Bag-mask ventilation is a basic but critical airway management skill. It enables clinicians to provide adequate ventilation for patients requiring airway support and allows enough time to establish a more controlled approach to airway management,.Because the technique can be difficult to perform correctly, clinicians performing the procedure should continually practice and monitor their technique

Bag-valve-maskComponents of BVM VentilationSelf-inflating bagOne-way valveFace maskOxygen reservoirMust be connected to oxygen to perform

most effectively

Bag-valve-maskBy adding oxygen and a reservoir close to 100% oxygen can be delivered to the patientWhen using a BVM an OPA/NPA should be used if possibleVolume of approximately 1,600 millilitersProvides less volume than mouth-to-maskSingle Rescuer may have trouble maintaining seal Two Rescuer more effectiveAvailable in infant, child, and adult sizes

Bag and mask ventilation is an important clinical skill to

masterIn most resuscitation settings a self-reinflating bagwith nonrebreathing valves (such as that shown) isused to provide positive pressure ventilation, usually using100% oxygen. This bag fills spontaneously after being squeezed and can be used even when oxygen is unavailable.

Strategies for

Successful BVM

Ventilation

APPLYING THE BVM:

The mask of the BVM should be placed over the patient's nose and mouth to ensure an adequate seal between the patient's face and the mask itself. OPA/NPA's can be used in conjunction with the BVM to ensure adequate passage for each ventilation

Basics skill of BVM

Paying attention to the basics of this skill will make it maximally effective

Single person BVM

Two person BVM

Bag-mask ventilation

All healthcare providers should be familiar with the use of the bag- mask device for support of oxygenation and ventilation.

Successful bag-mask ventilation depends on three things:

Patent airway :Airway patency can be established using basic airway maneuvers Adequate mask seal :In order to secure a good seal, the mask must be placed and held correctly Proper ventilation (ie, proper volume, rate )

In order to secure a good seal, the mask must be placed and held correctly Excessive tidal volumes: A volume just large enough to cause chest rise (no more than 8 to 10 cc/kg) should be used. During cardiopulmonary resuscitation (CPR), even smaller tidal volumes are adequate (5 to 6 cc/kg) due to the reduced cardiac output of such patients. Forcing air too quickly: The bag should not be squeezed explosively. It should be squeezed steadily over approximately one full second. Ventilating too rapidly. The ventilatory rate should not exceed 10 to 12 breaths per minute.

Ventilation TechniquesBVM Issues

Single rescuer may have difficulty maintaining air-tight seal

Two rescuers using device are more effective

Position yourself at top of patient’s head for best performance

Oral or nasal airway should be inserted

Ventilation Techniques

BVM Technique (Two Rescuer)Open airway, insert oral or nasal airwayPosition thumbs over top half of mask, index and middle fingers over bottom halfPlace apex of mask over bridge of nose, lower mask over mouth/upper chinUse ring and little fingers to bring jaw up to maskHave assistant squeeze bag with two hands until chest risesVentilate every 5 seconds for adults, every 3 seconds for infants and children

Bag-mask ventilation

two-person fitting technique; are more effective

one person secures the mask to the face while an assistant delivers breaths

Two hands method with one rescuer using two hands to hold the mask in place while another

rescuer applies PPV.with the BVMThe rescuer uses his/her thumb and index finger to hold the mask while the middle, ring, and pinky fingers are used to grasp the soft tissue under the patient's jaw. forming a seal as the patient's face is pulled up and into the mask.

)B (ADVANCED A/W

MANAGEMENT

Advanced airway devices

Endotracheal IntubationSupraglottic ( LMA) Infraglottic )Combitube)Fibreoptic Video laryngoscope

Advanced airway

UPDATEAHA2010

Surgical AirwayCricothyroidotomyTracheostomy

INTUBATIONWhen does the patient need it?

• Unconscious/semiconscious patient with GCS <9• Respiratory failure (snake bite, drug overdose)• All gasping patients• Cardiac arrest• Anaphylaxis • Pulmonary edema/ARDS for Positive pressure

ventilation• Before gastric lavage, in poisoning patients with low

GCS

Purpose of intubation•To maintain a patent airway•To maintain adequate oxygenation

•Protect from aspiration•For positive pressure ventilation

Note: It is the most definitive means of achieving complete control of the airway

Airway assessment before intubating (elective)

• Look for size of teeth• Size & mobility of the jaw• Mobility of C-spine (avoid in trauma)• Short neck• Obesity / pregnancy• Mallampati class

Mallampati Airway Classification System.

This system is a method for quantifying the degree of difficulty of endotracheal

intubation based on amount of posterior pharynx that can be visualized. The exam is performed with the patient sitting with

the head in a neutral position and the mouth open as wide as possible

• Class I: soft palate, fauces, uvula, pillars visible. No difficulty.

Class II: soft palate, fauces, portion of the uvula visible. Mild difficulty.Class III: soft palate, base of uvula visible. Moderate difficulty.Class IV: hard palate only. Severe difficulty.

Preparation for intubation

• BSI precaution• Suction• Airway adjuncts• Laryngoscope• ETT• Stylet• Bougie

• BVM• Anesthetic gel• Magill forceps• Pulseoxymetry & ECG Monitor • Emergency drugs• Cricothyroidotomy equipments

Magill forceps

Bougie

Endo tracheal tube

Suggested Tracheal Tube Sizes and Depth

centimeters at lips

tracheal tube size

Laryngoscope blade

Approx weight (kg)

10 – 10.5 3.0 – 3.5 1 ,straight

3 – 5 0 Newborn (0-3

months)

10 – 10.5 3.5 – 4.0 1 ,straight

6 – 9 Infant (3-12 months)

11 – 13 4.5 – 5 2 ,straight

10 – 14 Small child (1-4 years

14 – 16 5 –5.5 2 ,straight

or curved

15 – 22 Child )5-8 years (

17 – 18 6 / cuffed

2 or 3 , straight or curved

24 – 30 child >)8 years

Choose the appropriate ETT size

• Adult males 7.5 - 8.5• Adult females 7 – 8• For pediatric patients (2- 8 years)

ETT size= 4 + (age in years) 4• Use uncuffed tubes in patients <8 years • Subtract 0.5 for the appropriate size

cuffed ETT

Tube PlacementETT depth –(tip to lip)Adult

Adult males 20-21 cmAdult females 19- 20 cm

For pediatric patients (Age in years/2) + 12ETT internal diameter x 3

Endotracheal Tube

New AHA Formulas:Uncuffed ETT: (age in years/4) + 4

Cuffed ETT: (age in years/4) +3ETT depth (lip): ETT size x 3

Age Wt ETT(mm ID) Length(cm) Preterm 1 kg 2.5 6 1-2.5 kg 3.0 7-9Neonate-6mo 3.0-3.5 106 mo-1 3.5-4.0 111-2 yrs 4.0-5.0 12

Positioning the patient

Intubation procedure

• Position : (sniffing position)• Flexion at lower neck• Extension at atlanto-occipital joint,

if there is no C- spine injury.

• Suspected C- spine injury:• Manual in line stabilization should be

done

Procedure

• Pre oxygenate the patient adequately, with 100% oxygen using BVM

• Hold laryngoscope in left hand and insert laryngoscope blade into the right side of mouth and sweep the tongue to left

• Lift the handle tangentially at 90 to the blade

• Visualize vocal cords (BURP technique)

o

BURP technique

• Applying Backward, Upward and Rightward Pressure over the lower third of thyroid cartilage for proper visualization of the vocal cords during intubation

Technique of Endotracheal Intubation

♥ Conventional technique. ♥ Rapid Sequence induction”RSI”♥ Awake patient under local anesthesia using a

flexible endoscope or by other means (e.g., using a video laryngoscope). This technique is preferred if difficulties are anticipated, as it allows the patient to breathe spontaneously throughout the procedure, thus ensuring ventilation and oxygenation even in the event of a failed intubation

http://en.wikipedia.org/wiki/Local_anesthesia

http://en.wikipedia.org/wiki/Endoscopy

Technique of ET Intubation

Intubation is typically performed under direct visualization. That is, by looking through the mouth directly at the vocal cords (direct laryngoscopy), and watching the endotracheal tube pass through the cords and into the trachea

Technique of Endotracheal Intubation Route of intubation

The usual routes of intubation are

♥Oro-tracheal ♥Naso-tracheal.

.

Route of intubation

Some alternatives to intubation are

Tracheostomy - a surgical technique, typically for patients who require long-term respiratory support

Cricothyroidotomy - an emergency technique used when intubation is unsuccessful and tracheostomy is not an option

.

http://en.wikipedia.org/wiki/Tracheostomy

http://en.wikipedia.org/wiki/Cricothyroidotomy

The process of intubation Technique of Endotracheal

Intubation Assure an adequate BLS airway If the clinical situation allows, pre-

oxygenate the patient by having the patient breathe 100% oxygen through a bag-valve mask for at least 3 minutes before intubation

The process of intubation Select appropriate ET tube

If appropriate tube has a cuff, check cuff to ensure that it does not leak; note the amount of air needed to inflate.

Deflate tube cuff. Leave syringe attached.

Insert appropriate stylet, making sure that it is recessed at least one cm. from the distal.

Opening of the ET tube. Lubricate the tip of the tube.

The process of intubation If the patient’s mental status is

diminished or if the patient is pharmacologically sedated, an assistant should apply firm pressure to the cricoid cartilage.

This maneuver (the Sellick maneuver) compresses the soft-walled esophagus between

the cricoid cartilage and the cervical vertebrae, theoretically preventing passive regurgitation of gastric contents

Steps of oroendotracheal intubation

Vareculla

The process of intubation Head positioning : this is the single most important

aspect from a nursing point of view. Do not remove the pillow. The correct position for the head is "sniffing the morning air", with the neck slightly flexed and the head extended. One places a pillow under the head and neck but NOT under the shoulders. This allows a straight line of vision from the mouth to the vocal cords

Intubation -Positioning

Goal is to align three axesOA/PA/LA

Medical positioningHead tilt chin liftTowels (older = head, younger = shoulders)

Trauma positioningManual in-line stabilization

The process of intubation When intubating an infant, you

typically do not need to provide additional head support, because the infant’s large occiput naturally

causes the head to assume the

sniffing position

What is the sniffing position? How is it created. Describe differences in the sniffing position

between children and adults.

The “sniffing” position

sniffing position In children

Children’s heads are bigger than their chests, so to achieve the sniffing position their chests need support.

In children less than five years old the upper cervical spine is more flexible and can bow upward, forcing the posterior pharyngeal wall upward against the tongue and epiglottis, thereby creating more obstruction.

So that a child’s airway is usually best maintained by leaving the head in a more neutral position

Sniffing position

Sniffing position There are two components :-

First, the neck should be flexed on the chest. :Flexion at lower cervical spine “

Second, the head should be extended on the neck. “Extension at atlanto-occipital joint”

The sniffing position will align three planes or axes: mouth (oropharynx), pharynx and hypopharynx (larynx, trachea

Positioning-Medical

vs.Trauma

Adapted from Walls et al .Manual of

Emergency Airway Management .

2nd Ed. 2004.

Positioning



2nd Ed. 2004.

Intubation -Approach

Remember, much different than adultsExternally

Larger head/occiputHead flexes forward and can obstruct

InternallyLarger tongueFriable tissuesDifferent angles and shapes

Airway DifferencesNose

Tongue

TracheaCricoidAirway



2nd Ed. 2004.

Airway Shape



2nd Ed. 2004.

Intubation -Approach

Further differences“Pinker” vocal cords worsen visualizationDifferent location of narrowest point

More precise ETT choiceAir leak vs. trauma/stenosisPeds cuffed tubes?

Smaller cricothyroid membraneNo surgical crics in childrenNeedle crics difficult

Other ConsiderationsMore gastric insufflation with BVMDifferent oxygenation abilities

Higher basal usageLess residual lung capacityQuicker desats during intubation

10 kg to 90% in >4 minutes (vs. 8 for adult)More likely to have vagal response

Intubation -Techniques

Always enter from the right cornerTongue control is criticalLift the epiglottis with the MillerSlide the Mac into the vallecula

Can lift the epiglottis if needed



2nd Ed. 2004.

The process of intubation

To begin the procedure, The physician opens the patient's mouth by separating the lips and pulling on the upper jaw with the index finger

The process of intubation cont..

Remove the patient’s upper and lower dentures, if present, immediately before laryngoscopy


The laryngoscope is introduced into the right hand side of the mouth (it is held by the left hand).

The process of intubation cont.. The tongue is

swept to the left and the tip of the blade is advanced until a fold of skin / cartilage is visualised at twelve o’ clock. This is the epiglottis, and this sits over the glottis (the opening of the larynx) during swallowing

Uvula

Epiglottis

Larynx

The glottis: open for inspiration and closed for

swallowing

Open Closed

The process of intubation cont.. The tip of the blade is advanced to

the base of the epiglottis, known as the vallecula, and the entire laryngoscope is lifted upwards and outwards. This flips the epiglottis upwards and exposes the glottis below. An opening is seen with two white vocal cords forming a triangle on each side


Standard Macintosh laryngoscopy

Short curved blade to rest in vallecula and lift epiglottis

The process of intubation cont.. Often an assistant has

to press on the trachea to provide a direct view of the larynx. The physician then takes the endotracheal tube,, in the right hand and starts inserting it through the mouth opening. The tube is inserted through the cords to the point that the cuff rests just below the cords


advance the tube until the balloon is 3 to 4 cm beyond the vocal cords.

Inflate the endotracheal balloon with air to the minimum pressure required to prevent air leakage during ventilation with a bag. This usually requires less than 10 ml of air to provide a minimal leak when the bag is squeezed

The process of intubation cont.. There are two types of cuff: high

pressure-low volume (which takes 2-3ml of air) and high volume-low pressure (10 – 15ml of air). The principle with both is the same: the cuff is inflated until the leak is abolished; no more, no less. Too high a cuff pressure will necrose the tracheal mucosa (by cutting off it’s circulation) and cause a tracheal stricture.

The process of intubation cont.. The tube may be

secured in a variety of ways, all that is important is that it is held tightly, and can not slide up and down the trachea. It is preferable to secure the tube to the upper jaw (the maxilla) than to the lower one (the mandible) as this moves up and down

Movement of tip of ETT with flexion and extension Neck flexion may cause 2 cm of descent

of tip of tube Neck extension from neutral may cause

2 cm of ascent of tip With head in neutral position , tip

of ETT should be 5-7 cm from carina Position of carina

Follow right or left main stem bronchus backwards until it meets opposite main stem bronchus

Projects over T5, T6 or T7 in 95% of cases

Hyperventilate patient and apply c-spine stabilization.

القلب جمعيةالسعودية

SAUDI HEART ASSOCIATION

Apply Sellick’s Maneuver and intubate.

القلب جمعيةالسعوديةSAUDI HEART ASSOCIATION

Ventilate patient and confirm placement.



Manually stabilizing the head and neck to maintain

cervical spine The assistant

places his hands on either side of the head (by holding a hand over each ear ) keeping the patient's shoulders and occipit firmly placed on the board preventing any head rotation

Visualize the tube going through this structure

Glottis

Procedure• After inserting the tube• Take out the stylet, inflate cuff• Ventilate patient through tube and confirm

breath sounds over epigastrium and 4 lung fields. (5 point auscultation)

• If tube is placed properly, secure the tube in place.

Rapid Sequence Intubation

Combined administration of sedative & neuromuscular blocking agent to facilitate

tracheal intubation.


• RSI should not be used in patients who do not need pharmacological adjuvants for intubation such as those with agonal respirations or cardiac arrest

• Do not give RSI medication in whom laryngoscopy is likely impossible

(Ex: Angioedema, Mallampati class 3 and 4)


Preoxygenation:• Hyperventilate at 20-24 breaths per minute with

100% O2, using BVM with a reservoir bag.

• Attain a saturation of over 95% before administering any drugs.

• Perform Sellick’s maneuver before administering the first RSI agent, and should be maintained until tube is passed and cuff inflated

Pharmacological Aids in Emergency Intubation

Inducing agent• Sedation – Institutional choice

•Fentanyl •Midazolam 0.01 – 0.03 mg/kg •Thiopental 3 mg - 5 mg/kg•Ketamine 1mg - 2mg/kg•Propofol 0.5 to 1mg/kg

Paralyzing agent

• Immediately after the induction dose

•Succinylcholine 1 mg to 1.5 mg/kg

•Rocuronium o.2 - 0.6 mg/kg

Succinylcholine

Advantages:Rapid onset (45-60 sec)Short duration (5-9min)Watch for: Brady arrhythmias, malignant hyperthermia,

hyperkalemia, cardiac arrest, increased ICP, IOP, intra gastric pressure

Special considerations

• Give Atropine 0.02 mg/kg IV for pediatric patients to prevent bradycardia & asystole

• Give Lidocaine 1.5mg/kg IV, if raised ICP is anticipated (head injury, meningitis, SOL in brain)

Confirming the tube placement

• Five point auscultation• Look for equal chest rise• End tidal CO2 detectors• Esophageal detector devices

Note: Visualizing the tube going through the cords is the best method of confirmation

Five point auscultation

Visualization

Correct ET Tube Placement

Secure ET tube in place, note the numberSedate patient with appropriate MAAS

Avoid accidental, or self extubation

Misplaced ETT• Right main stem intubation: - Breath Sounds more on right side - Deflate cuff, pull back about 1 inch, reinflate, ventilate and reconfirm• Esophageal intubation: - Sounds primarily over epigastium - Deflate cuff, remove tube - Hyperventilate patient for another 1-2 minutes, - Reintubate

• No single method for confirming tube placement has been shown to be 100% reliable. Accordingly, the use of multiple methods to confirm correct tube placement.

Confirmation of correct tube placement and maintenance

of the tube once it is in place

A.Observational methods to confirm correct tube placement.

B.Instruments to confirm correct tube placement.

Confirmation of correct tube placement and maintenance

of the tube once it is in place

confirmation of correct tube placement and maintenance of the

tube once it is in place • No single method for confirming tube

placement has been shown to be 100% reliable. Accordingly, the use of multiple methods to confirm correct tube placement

Observational methods to confirm correct tube placement

• Direct visualization of the tube passing through the vocal cords .

• Clear and equal bilateral breath sounde on auscultation of the chest

• Absent sounds on auscultation of epigastrum. • Equal bilateral chest rise with ventilation.• Condensation (fogging) of water vapor in the tube

during exhalation • Refilling of reservoir bag during exhalation

Instruments to confirm correct tube placement

• Waveform capnography. :AHA2010?

UPDATE • Pulse oximetry. • Chest x-ray: the tip of ET tube should be

between the carina and thoracic inlet or approximately at the level of the aortic notch or at the level of T5.

• Colorimetric end tidal CO2 detector • Oesophageal Detection Device (ODD) -

Confirmation ETT Position Continuous CO2 monitoring or

capnometry Gold standard

Must have at least 3 continuous readings without declining CO2

Update AHAS2010

Update AHAS2010

Radiographs are obtained routinely after intubation

Endotracheal tube• (ETT) is

recognized by thin white opaque line usually running the length of the tube

• A correctly positioned ETT lies in the mid trachea and its tip is approximately 4-5 cm above the carina

3-4 cm

• the tip of the ETT is low lying and is at the origin of the right main bronchus. Further migration of the ETT will result in right sided endobronchial intubation and collapse of the left lung

Radiographs are obtained routinely after intubation

Endotracheal tube (ETT) is recognized by thin white opaque line usually

running the length of the tube Tip of endotracheal tube (red arrow) projects below the carina (blue arrow) into the bronchus intermediacy on the right

Continuously recheck and reconfirm the placement of the endotracheal tube.



Reconfirm ETT placement.

Conclusion• Always oxygenate patient before and

after intubation.• Do not attempt intubation unless you are

totally skilled, rather perform bag-valve-mask ventilation.

• Always monitor the CO2 & spo2 readings.

• Always reconfirm tube placement from time to time.

Some factors that may increase the risk of complications include: Neck or cervical spine injury Pre-existing lung disease Poor condition of teeth Recent meal Dehydration

Complications Associated With Intubation

Complications Associated With Intubation

1)Trauma of the teeth, cords, arytenoid cartilages, larynx and related structures.

2)Nasotracheal tubes can damage the turbinates, cause epistaxis, and even perforate the nasopharyngeal mucosa.

3)Hypertension and tachycardia can occur from the intense stimulation of intubation; This is potentially dangerous in the patient with coronary heart disease.

4)Transient cardiac arrhythmias related to vagal stimulation or sympathetic nerve traffic may occur .

Complications Continued…

4)The most serious complication of endotracheal intubation is unrecognized esophageal intubation, which may lead to hypoxemia, hypercapnia, and death

5)Baro-trauma resulting from over ventilating with a bag without a pressure release valve( phneumothorax).

6)Damage to the endotracheal tube cuff, resulting in a cuff leak and poor seal


7)Over stimulation of the larynx resulting in laryngospasm, causing a complete airway obstruction.

8)Inserting the tube to deep resulting in unilateral intubation (right bronchus).

9)Tube obstruction due to foreign material, dried respiratory secretion and/or blood.


10)Additional complications include bradycardia, laryngospasm, bronchospasm, and apnea owing to pharyngeal stimulation.

11) Trauma to teeth, lips, and vocal cords and exacerbation of cervical spine injuries can also occur

Management : Prevention: Complication: Check chest x-ray to rule out aspiration. Remove loose teeth prior; avoid

using upper teeth as fulcrum for laryngoscope blade.

Missing/broken teeth:

Paralytic medication.

Clenched teeth:Inject more air or change tube over guide wire.

Check cuff prior to beginning procedure.

Air leak:Reposition, choose a different blade, adequate suction, cricoid pressure by assistant.

Proper patient positioning, proper laryngoscope blade size, proper suctioning.

Inability to visualize vocal cords:

Remove tube, re-oxygenate and reinsert. Visualize cords. Esophageal intubation:

Deflate cuff, re-position and re-inflate. Avoid excessive tube advancement.

Right lung intubation:

Benzodiazepine or paralytic medication. Spray vocal cords with 2% Lidocaine.

Laryngospasm:

Have alternative plan prepared: e.g., BVM, another type of tube, cricothyrotomy.

None. Failure to intubate:

Prevention and Management

http://apps.med.buffalo.edu/procedures/basicairway.asp?p=4

http://apps.med.buffalo.edu/procedures/basicairway.asp?p=4

ADVANCED AIRWAY DEVICES.:-

# Supraglottic (lAM) # Infraglottic (COMBITUBE)

UPDATE AHA2010

251

Laryngeal Mask Airway (LMA)

The LMA is an adjunctive airway that consists of a tube with a cuffed mask-like projection at distal end.

LMA

Used in any age Easy to place Few complications Contraindications:

Gag reflex FBs Airway obstruction High ventilation pressure

LMA Sizing

LMA Size Patient Size1 Neonate / Infants > 5 kg

1 ½ Infants 5-10 kg2 Infants / Children 10-20 kg

2 ½ Children 20-30 kg3 Children/Small adults 30-50 kg4 Adults 50-70 kg5 Large adult >70 kg

I-LMA Only sizes 3, 4, 5 Same rules and sizing

as LMA Need special armored

tube for intubation New similar devices

exist Leave LMA portion in

place in field

Laryngeal Mask Airways LMA

The Laryngeal Mask Airway is an alternative airway device used for anesthesia and airway support. It consists of an inflatable silicone mask and rubber connecting tube. It is inserted blindly into the pharynx, forming a low-pressure seal around the laryngeal inlet and permitting gentle positive pressure ventilation. All parts are latex-free.

LARYNGEAL MASK AIRWAY

LMA INDICATIONS The Laryngeal Mask Airway is an

appropriate airway for short procedures and in emergency situations.

Can be used as rescue airway and fiberoptic conduit when intubation is difficult.

Can be used for bronchoscopy in awake patients.

LMA CONTRAINDICATIONS

Non-fasted patients Morbidly obese patients Pregnancy Obstructive or abnormal lesions of the

oropharynx Increased Airway resistance and decreased

lung compliance

LMA Tips for Success:

Begin with ASA I & II patients Learn and use standard insertion technique Use appropriate size and do NOT overinflate Maintain adequate anesthetic depth Remove when the patient opens mouth to

command

Signs of correct LMA placement

a. Slight outward movement of the tube upon LMAinflation.

b. Presence of a small oval swelling in the neck around the thyroid and cricoid area.c. No cuff visible in the oral cavity.

d. Expansion of chest wall on bag compressionBefore taping the LMA in place, a bite block isinserted to stabilize the LMA and prevent tube occlusion

Objectives:• Identify the indications, contraindications and

side effects of LMA use.• Identify the equipment necessary for the

placement of an LMA.• Discuss the steps necessary to prepare for

LMA placement.• Discuss the methods of LMA placement.• Identify and discuss problems associated with

LMA placement.

Introduction• The LMA was invented by Dr.

Archie Brain at the London Hospital, Whitechapel in 1981

• The LMA consists of two parts:– The mask– The tube

• The LMA has proven to be very effective in the management of airway crisis

Introduction continued

• The LMA design: – Provides an “oval seal

around the laryngeal inlet” once the LMA is inserted and the cuff inflated.

– Once inserted, it lies at the crossroads of the digestive and respiratory tracts.

Indications for theuse of the LMA

• Situations involving a difficult mask (BVM) fit.

• May be used as a back-up device where endotracheal intubation is not successful.

• May be used as a “second-last-ditch” airway where a surgical airway is the only remaining option.

Equipment forLMA Insertion

• Body Substance Isolation equipment• Appropriate size LMA • Syringe with appropriate volume for

LMA cuff inflation• Water soluble lubricant• Ventilation equipment• Stethoscope• Tape or other device(s) to secure LMA

Preparation of theLMA for Insertion

• Step 1: Size selection• Step 2: Examination of the LMA• Step 3: Check deflation and

inflation of the cuff• Step 4: Lubrication of the LMA• Step 5: Position the Airway

Step 1: Size Selection• Verify that the size of the LMA

is correct for the patient• Recommended Size

guidelines:– Size 1: under 5 kg– Size 1.5: 5 to 10 kg– Size 2: 10 to 20 kg– Size 2.5: 20 to 30 kg– Size 3: 30 kg to

small adult– Size 4: adult– Size 5: Large

adult/poor seal with size 4

Step 2: Examinationof the LMA• Visually inspect the LMA cuff for tears or

other abnormalities• Inspect the tube to ensure that it is free

of blockage or loose particles• Deflate the cuff to ensure that it will

maintain a vacuum• Inflate the cuff to ensure that it does

not leak

Step 3: Deflation and Inflation of the LMA

• Slowly deflate the cuff to form a smooth flat wedge shape which will pass easily around the back of the tongue and behind the epiglottis.

• During inflation the maximum air in cuff should not exceed:

– Size 1: 4 ml– Size 1.5: 7 ml– Size 2: 10 ml– Size 2.5: 14 ml– Size 3: 20 ml– Size 4: 30 ml– Size 5: 40 ml

Step 4: Lubricationof the LMA

• Use a water soluble lubricant to lubricate the LMA

• Only lubricate the LMA just prior to insertion

• Lubricate the back of the mask thoroughly Important Notice: • Avoid excessive amounts of lubricant

– on the anterior surface of the cuff or – in the bowl of the mask.

• Inhalation of the lubricant following placement may result in coughing or obstruction.

Step 5: Positioningof the Airway• Extend the head and

flex the neck• Avoid LMA fold over:

– Assistant pulls the lower jaw downwards.

– Visualize the posterior oral airway.

– Ensure that the LMA is not folding over in the oral cavity as it is inserted.

LMAInsertionTechnique

LMA Insertion Step 1• Grasp the LMA by

the tube, holding it like a pen as near as possible to the mask end.

• Place the tip of the LMA against the inner surface of the patient’s upper teeth

LMA Insertion Step 2• Under direct vision:

– Press the mask tip upwards against the hard palate to flatten it out.

– Using the index finger, keep pressing upwards as you advance the mask into the pharynx to ensure the tip remains flattened and avoids the tongue.

LMA Insertion Step 3

• Keep the neck flexed and head extended:

– Press the mask into the posterior pharyngeal wall using the index finger.

LMA Insertion Step 4• Continue pushing

with your index finger.

– Guide the mask downward into position.

LMA Insertion Step 5

• Grasp the tube firmly with the other hand

– then withdraw your index finger from the pharynx.

– Press gently downward with your other hand to ensure the mask is fully inserted.

LMA Insertion Step 6• Inflate the mask with the

recommended volume of air.

• Do not over-inflate the LMA.

• Do not touch the LMA tube while it is being inflated unless the position is obviously unstable.

– Normally the mask should be allowed to rise up slightly out of the hypopharynx as it is inflated to find its correct position.

Verify Placement of the LMA

• Connect the LMA to a Bag-Valve Mask device or low pressure ventilator

• Ventilate the patient while confirming equal breath sounds over both lungs in all fields and the absence of ventilatory sounds over the epigastrium

Securing the LMA

• Insert a bite-block or roll of gauze to prevent occlusion of the tube should the patient bite down.

• Now the LMA can be secured utilizing the same techniques as those employed in the securing of an endotracheal tube.

Problems withLMA Insertion

• Failure to press the deflated mask up against the hard palate or inadequate lubrication or deflation can cause the mask tip to fold back on itself.

Problems withLMA Insertion

• Once the mask tip has started to fold over, this may progress, pushing the epiglottis into its down-folded position causing mechanical obstruction

Problems withLMA Insertion• If the mask tip is deflated

forward it can push down the epiglottis causing obstruction

• If the mask is inadequately deflated it may either

– push down the epiglottis– penetrate the glottis.

Summary• Recent studies suggest that the LMA is

an airway device that paramedics “adapt to rapidly”.

• Paramedics have proven themselves very successful in the placement of the LMA.

• Though endotracheal intubation remains the definitive technique for securing an airway in the prehospital setting, it is believed that the LMA may help in a small percentage of patients who prove to be difficult to intubate endotracheally.

References:• Dr. A.I.J. Brain LMSSA, FFARCSI. “The Intavent Laryngeal

Mask Instruction Manual.” 1992.• William Windham M.D. “the LMA Alternative. 1998.

JEMS.• Chad Brocato, EMT-P. “The LMA Unmasked.” 1998.

JEMS.

Esophageal Tracheal CombitubeThe esophageal tracheal combitube (Combitube™) is a two-barreled tube that functions well when placed in either the trachea or the esophagus. Insertion does not require neck movement. Note: The short white tube is connected to the end of the tube; the long blue tube is connected to the side holes located between the two balloons Esophageal Tracheal CombitubeThe esophageal tracheal combitube (Combitube™) is a two-barreled tube that functions well when placed in either the trachea or the esophagus. Insertion does not require neck movement. Note: The short white tube is connected to the end of the tube; the long blue tube is connected to the side holes located between the two balloons

Combitube

291

Esophageal-Tracheal Combitube

A = esophageal obturator; ventilation into trachea through side openings = B

C = tracheal tube; ventilation through open end if proximal end inserted in trachea

D = pharyngeal cuff; inflated through catheter = E

F = esophageal cuff; inflated through catheter = G

H = teeth marker; blindly insert Combitube until marker is at level of teeth

Distal End

Proximal End

B

C

D

E

F

G

H

A

292

Esophageal-Tracheal Combitube Inserted in Esophagus

A = esophageal obturator; ventilation into trachea through side openings = B

D =pharyngeal cuff (inflated)

F =inflated esophageal/tracheal cuff

H =teeth markers; insert until marker lines at level of teeth

D

A

DB F

H

Esophageal Tracheal Combitube

combitube (Combitube™) is a two-barreled tube that functions well when placed in either the trachea or the esophagus. Insertion does not require neck movement. Note: The short white tube is connected to the end of the tube; the long blue tube is connected to the side holes located between the two balloons

Combitube©

When to Use the Combitube CPR

Remember to do CPR! Attach AED!

Respiratory Arrest Agonal Respirations without intact gag reflex Respiratory Arrest leads to Cardiac Arrest

Contraindications for Combitube©

Gag Reflex Conscious Breathing Adequately Caustic Ingestion Known esophageal disease or varices Under 16 y/o Under 5 feet or over 6 feet 8inches

Advantages for Combitube©

Rapid Insertion Limits regurgitation, aspiration &

distention Blind insertion High oxygen delivery Less training required Inserted in neutral position

Disadvantages for Combitube©

Patient must be unresponsive without gag reflex

Some are difficult to obtain adequate seal

Some do not totally protect against aspiration

Most responsive patients will vomit when removed

May damage esophagus

When Can I Remove the Combitube?

Patient returns to full consciousness Patient able to maintain own airway Orders from OLMC

Procedure for Removing

SUCTION READY! Deflate Tube #2 Deflate Tube #1 Tell patient to exhale Pull out quickly and in-line SUCTION

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