DR (MAJ) PANKAJ N SURANGE DR (MAJ) PANKAJ N SURANGE MBBS,MD,FICMRMBBS,MD,FICMR

GRADED SPECIALIST ANAESTHESIAGRADED SPECIALIST ANAESTHESIA

ARTEMIS HEALTH INSTITUTEARTEMIS HEALTH INSTITUTE

AIRWAY MANAGEMENTAIRWAY MANAGEMENT

Holds The Top Priority In The Practice Of MedicineHolds The Top Priority In The Practice Of Medicine

No Organ System Can Be Resuscited Without Securing No Organ System Can Be Resuscited Without Securing The AirwayThe Airway

Failure To Open Airway And To Ventilate Can Be Failure To Open Airway And To Ventilate Can Be CatastrophicCatastrophic

““Practice Makes A Man Perfect”Practice Makes A Man Perfect”

Make A Primary Plan Before Hand And Have A Back Up Make A Primary Plan Before Hand And Have A Back Up PlanPlan

““Call For Help”Call For Help”

The Goal Is To Ventilate Adequately Enough To Meet The The Goal Is To Ventilate Adequately Enough To Meet The

Patient's Oxygen Demands And Eliminate Carbon Dioxide.Patient's Oxygen Demands And Eliminate Carbon Dioxide.

ANATOMY OF AIRWAYANATOMY OF AIRWAY

SURFACE ANATOMYSURFACE ANATOMY

INLET OF LARYNXINLET OF LARYNX

Reasons To Manage an Airway:--

Obstruction None present Decompensating Breathing too fast or too slow

AIRWAY ALGORITHMAIRWAY ALGORITHM

Step 1: Open And Clear Step 2: Keep It Open Step 3: Ventilate (BLS) Step 4: Control The Airway Step 5: Confirm The Airway Step 6: Secure The Airway Step 7: Alternatives To ETI Step 8: Surgical Airways

TechniquesTechniques Head-tilt/Chin-liftHead-tilt/Chin-lift Jaw ThrustJaw Thrust SuctioningSuctioning Nasopharyngeal airwayNasopharyngeal airway Oropharyngeal airwayOropharyngeal airway

Opening the AirwayOpening the Airway

Head-Tilt/Chin-LiftHead-Tilt/Chin-Lift

Used when Used when nono neck injury is suspected neck injury is suspected Temporary procedureTemporary procedure Must be replaced with an airway adjunct unless Must be replaced with an airway adjunct unless

patient begins adequate spontaneous ventilationpatient begins adequate spontaneous ventilation

TechniqueTechnique Place one hand on patient’s foreheadPlace one hand on patient’s forehead Apply firm, backward pressure with palmApply firm, backward pressure with palm causing head to tilt backwardcausing head to tilt backward Place fingers of other hand under bony Place fingers of other hand under bony

part of patient’s lower jaw near chinpart of patient’s lower jaw near chin Lift jaw upward to bring chin forwardLift jaw upward to bring chin forward

Jaw ThrustJaw Thrust

Used when Used when spinal injury suspectedspinal injury suspected Temporary procedureTemporary procedure Must be replaced with airway adjunct unless Must be replaced with airway adjunct unless

patient begins adequate spontaneous patient begins adequate spontaneous ventilationventilation

TechniqueTechnique Place one hand on either side of patient’s head, Place one hand on either side of patient’s head,

resting elbows on surface on which victim is lyingresting elbows on surface on which victim is lying Grasp angles of patient’s lower jaw, lift with both Grasp angles of patient’s lower jaw, lift with both

handshands If patient’s lips close, retract lower lips with thumbs If patient’s lips close, retract lower lips with thumbs

SuctioningSuctioning

PurposePurpose Remove blood, vomit, other liquids, food particles from airwayRemove blood, vomit, other liquids, food particles from airway May May notnot be adequate for removing large, solid objects (teeth, be adequate for removing large, solid objects (teeth,

foreign bodies, food)foreign bodies, food) Should be performed immediately when Should be performed immediately when gurglinggurgling is heard is heard

with spontaneous or artificial ventilationwith spontaneous or artificial ventilation TechniquesTechniques

Insert catheter into oral cavity without suctionInsert catheter into oral cavity without suction Insert only to base of tongue.Insert only to base of tongue. Apply suction, move catheter from side to sideApply suction, move catheter from side to side Suction no longer than 15 seconds in adults, 10 seconds in Suction no longer than 15 seconds in adults, 10 seconds in

children, 5 seconds in infantschildren, 5 seconds in infants Rinse catheter with saline or water to prevent obstructionRinse catheter with saline or water to prevent obstruction ADVANCED AIRWAYADVANCED AIRWAY

PreoxygenatePreoxygenate Pass beyond distal tipPass beyond distal tip ½ of ID½ of ID Limit to 10-15 secLimit to 10-15 sec

Nasal AirwaysNasal Airways

Used on responsive patients who need help Used on responsive patients who need help keeping tongue out of airwaykeeping tongue out of airway Pt with gag reflexPt with gag reflex Maxillofacial injuryMaxillofacial injury

Technique•Measure from tip of nose to tragus of ear•Ensure airway will fit through nostril•Lubricate with water-soluble lubricant or anesthetic jelly•Insert with bevel toward base of nostril or septum•If resistance is met, try other nostril•Do not use in patients with mid-face trauma or possible basilar skull fractures

Oral AirwaysOral Airways

Used on Used on unresponsiveunresponsive patients patients without without gag reflexgag reflex

Helps hold tongue away from back of Helps hold tongue away from back of throatthroat

Technique•Measure from corner of mouth to earlobe or angle of jaw•In adults insert with tip facing roof of patient’s mouth, advance until resistance encountered, turn 180o until flange comes to rest on patient’s teeth•In infants and children use tongue depressor to lift tongue, insert oral airway right side up•Too long –press epiglottis•Too short-force tongue back

Adequate BreathingAdequate Breathing

Normal RateNormal Rate Adult: 12 to 20/minuteAdult: 12 to 20/minute Child: 15 to 30/minuteChild: 15 to 30/minute Infant: 25 to 50/minuteInfant: 25 to 50/minute

Regular RhythmRegular Rhythm Adequate QualityAdequate Quality

Movement of air at mouth, noseMovement of air at mouth, nose Chest expansion adequate, symmetrical Chest expansion adequate, symmetrical

(equal)(equal) Breath sounds present, equalBreath sounds present, equal Minimum effort of breathingMinimum effort of breathing Adequate tidal volume (depth)Adequate tidal volume (depth)

VENTILATION TECHNIQUES

Ventilation TechniquesVentilation Techniques

Mouth-to-MaskMouth-to-Mask Connect mask to oxygen at 15 liters per Connect mask to oxygen at 15 liters per

minuteminute Kneel directly above patient’s headKneel directly above patient’s head Apply mask to patient’s faceApply mask to patient’s face Place thumbs along sides of mask, index Place thumbs along sides of mask, index

fingers of both hands under patient’s fingers of both hands under patient’s mandiblemandible

Lift jaw into mask, tilt head if neck injury Lift jaw into mask, tilt head if neck injury notnot suspectedsuspected

Blow into one-way valve slowly over 2 Blow into one-way valve slowly over 2 seconds until patient’s chest risesseconds until patient’s chest rises

Ventilation TechniquesVentilation Techniques

Bag-valve maskBag-valve mask Self-inflating bagSelf-inflating bag One-way valveOne-way valve Face maskFace mask Oxygen reservoirOxygen reservoir

BVM Issues•Single rescuer may have difficulty maintaining air-tight seal•Two rescuers using device are more effective•Provides less volume than mouth-to-mask•Position yourself at top of patient’s head for best performance•Oral or nasal airway should be inserted

Ventilation TechniquesVentilation Techniques

BVM Technique (Two Rescuer)BVM Technique (Two Rescuer) Open airway, insert oral or nasal airwayOpen airway, insert oral or nasal airway Position thumbs over top half of mask, index and Position thumbs over top half of mask, index and

middle fingers over bottom halfmiddle fingers over bottom half Place apex of mask over bridge of nose, lower Place apex of mask over bridge of nose, lower

mask over mouth/upper chinmask over mouth/upper chin Use ring and little fingers to bring jaw up to maskUse ring and little fingers to bring jaw up to mask Have assistant squeeze bag with two hands until Have assistant squeeze bag with two hands until

chest riseschest rises Ventilate every 5 seconds for adults, every 3 Ventilate every 5 seconds for adults, every 3

seconds for infants and childrenseconds for infants and children

Ventilation TechniquesVentilation Techniques

BVM Technique (One Rescuer)BVM Technique (One Rescuer) Open airway, insert oral or nasal airwayOpen airway, insert oral or nasal airway Form a “C” around ventilation port with Form a “C” around ventilation port with

thumb, index fingerthumb, index finger Use middle, ring, little fingers under jaw Use middle, ring, little fingers under jaw

to maintain chin lift, complete sealto maintain chin lift, complete seal Squeeze bag with other hand until chest Squeeze bag with other hand until chest

risesrises Ventilate every 5 seconds for adults, Ventilate every 5 seconds for adults,

every 3 seconds for infants and childrenevery 3 seconds for infants and children

Ventilation TechniquesVentilation Techniques

If chest does not rise, reevaluateIf chest does not rise, reevaluate If abdomen rises, reposition head or jawIf abdomen rises, reposition head or jaw If air escapes under mask, reposition If air escapes under mask, reposition

fingers and maskfingers and mask Check for obstructionCheck for obstruction If chest still does not rise and fall use If chest still does not rise and fall use

another method of ventilationanother method of ventilation

LARYNGOSCOPY AND LARYNGOSCOPY AND INTUBATIONINTUBATION

EQUIPMENTSEQUIPMENTS

LARYNGOSCOPELARYNGOSCOPE Blade Size-1 To 4Blade Size-1 To 4

ETTETT 2.5mm-9mm2.5mm-9mm 7-7.5mm-women, 8.0-8.5mm –men7-7.5mm-women, 8.0-8.5mm –men LENGTH: 20-21cm-women, 22-23cm -men LENGTH: 20-21cm-women, 22-23cm -men Children's- 4+Age/4Children's- 4+Age/4 IMPORTANT ACCESSORIESIMPORTANT ACCESSORIES

Pillow 6-8 CmPillow 6-8 Cm Sticking PlasterSticking Plaster Bag & MaskBag & Mask O2 O2 StyletStylet Suction Suction

PREREQUISITESPREREQUISITES

Patient PositioninPatient Positionin Neck Flexion-Neck Flexion- 35°35° Head Extension- 15°Head Extension- 15°

Preoxygenate Preoxygenate SuctionSuction MonitorsMonitors I.V AccessI.V Access Drugs-inducing Agents, Ms Relaxants &Emergency DrugsDrugs-inducing Agents, Ms Relaxants &Emergency Drugs Ensure Ventilation Before Giving Muscle RelaxantEnsure Ventilation Before Giving Muscle Relaxant

Direct Laryngoscopy:Direct Laryngoscopy:1.1. Place the patient in the sniffing position. Place the patient in the sniffing position.

2.2. Check the laryngoscope and blade for proper fit, and make sure that the Check the laryngoscope and blade for proper fit, and make sure that the light works. light works.

3.3. Make sure that all materials are assembled and close at hand. Make sure that all materials are assembled and close at hand.

4. 4. Curved blade technique: Curved blade technique:

a.a. Open the patient's mouth with the right hand, and remove any dentures. Open the patient's mouth with the right hand, and remove any dentures.

b.b. Grasp the laryngoscope in the left hand Grasp the laryngoscope in the left hand

c.c. Spread the patient's lips, and insert the blade between the teeth, being Spread the patient's lips, and insert the blade between the teeth, being careful not to break a tooth. careful not to break a tooth.

d.d. Pass the blade to the right of the tongue, and advance the blade into the Pass the blade to the right of the tongue, and advance the blade into the hypopharynx, pushing the tongue to the left hypopharynx, pushing the tongue to the left

and advanced the tip towards vallecula. and advanced the tip towards vallecula.

e.e. Lift the laryngoscope upward and forward, Lift the laryngoscope upward and forward,

without changing the angle of the blade, without changing the angle of the blade,

to expose the vocal cords.to expose the vocal cords.

INTUBATION:INTUBATION: Lubricate the end of the tube (optional). Lubricate the end of the tube (optional).

Insert the stylet, and bend the tube and stylet gently into a crescent Insert the stylet, and bend the tube and stylet gently into a crescent

shape shape

Tip of the stylet at least 1 cm proximal to the end of the tube. Tip of the stylet at least 1 cm proximal to the end of the tube.

When visualizing the glottis and vocal cords, gently pass the tube next When visualizing the glottis and vocal cords, gently pass the tube next

the laryngoscope blade through the vocal cords into trachea, far enough the laryngoscope blade through the vocal cords into trachea, far enough

so that the balloon is just beyond the cords. BURP maneuverso that the balloon is just beyond the cords. BURP maneuver

Withdraw the stylet. Withdraw the stylet.

Connect the bag-valve combination, and begin ventilation with 100% Connect the bag-valve combination, and begin ventilation with 100%

oxygen. oxygen.

Confirm position Confirm position StomachStomach B/L chestB/L chest

Inflate the cuff with the 10-ml syringe until there is Inflate the cuff with the 10-ml syringe until there is

no air leak around the tube when positive pressure no air leak around the tube when positive pressure

Is applied. Is applied.

Wrap adhesive tape around the tubeWrap adhesive tape around the tube

CANNOT INTUBATE

CANNOT INTUBATE

STEP 7. ALTERNATIVES TO ETI

Developed in 1981 at the Royal London Hospital By Dr Archie Brain

When definitive airway management cannot be obtained. (ETT)

Laryngeal Mask Airway (LMA)Laryngeal Mask Airway (LMA)

Laryngeal Mask Airway

Weight Based Sizing <5kg = Size 1 5--10 kg = Size 2 20--30 kg = Size 2.5 Small Adult= Size 3 Average Adult = Size 4 Large Adult = Size 5

Laryngeal Mask Airway

Procedure: Hyper oxygenate Check cuff Lubricate posterior cuff Head in neutral or slightly flexed position Insert following hard palate (use index finger to guide) Stop when met with resistance Inflate cuff Confirm and secure

CANNOT INTUBATE –CANNOT VENTILATE

STEP 8. SURGICAL AIRWAY

CRICOTHYROTOMYCRICOTHYROTOMY

•Cannot intubate, cannot ventilate: needle cricothroidotomy for ventilation•Difficult intubation: needle cricothroidotomy for reterograde intubation

CRICOTHYROTOMYCRICOTHYROTOMY

-Identify Cricothyroid membrane -Pierce at 45 Pierce angle -Place catheter or stylletteAdvance dilator

14 /16G 3.0mm

Needle Cricothyrotomy

LAST RESORT!

ARE YOU PREPARED