Airway management

A. Cortegiani

“The most common… is the obstruction of the oropharynx by the relaxed tongue which is pushed against the posterior pharingeal wall… “ Safar P et al. J App Physiol. 1959

“The result is that the epiglottis and not the tongue is the main cause of obstruction of the upper airways.” Boidin MP et al Brit Journal Anest 1985

Signs of complete airways obstruction with respiratory efforts

• See-saw respirations

• Diaphragm flattens

• Abdo contents pushed down

• Abdo rises

• Chest “sucked in”

• Paradoxical

Diaphragm Lung

Air

Normal inspiration

Lung Diaphragm

Air

See-saw respirations

Signs of partial airways obstruction with respiratory efforts

Snoring: Pharynx is partially ocluded by soft palate or

epiglottis

Gurgling: caused by liquid or semisolid foreign material

in the large airways

Inspiratory stridor: Obstruction at laryngeal level

Crowing: sound of the laryngeal spasm

Expiratory wheeze: obstruction of the lower airways

Open the airways: head tilt & chin lift

Open the airways: Jaw thrust

Guedel cannula

Airway obstruction associated with the use of the guedel

airway. Marsh AM et al Br. J. Anaesth. (1991) 67 (5): 517-523.

It may cause vomiting or laringospam if glossopharyngeal and

laryngeal reflexes are present

Part of the tongue can occlude the end of the airway

the airway can lodge in the vallecula

the airway can be obstructed by the epiglottis

Nasopharyngeal airway

• It is tolerated better

• Usefull in clenched jaw, trismus

and maxillofacial injury

• Be careful if a skull base

fracture is suspected

Ventilation

“…Provide artificial ventilation as soon as possible for any patient in whom spontaneous ventilation is inadequate or absent…”

Pocket mask

Bag – mask ventilation

FiO2 21%

10 L/min O2

FiO2 85%

Bag – mask ventilation

1° & 2°: “C” on the mask

3°: “Thrust the chin up”

4°: On the ascending mandibular ramus

5°: On the mandibular

angle

How to squeeze the bag?

“Give a volume that corresponds to normal chest movement

“…Approximately 500 – 600 ml…” “2 breaths after 30 compression” “…Each breath over 1 second….”

Not exceed 5 seconds Avoid rapid or forceful breaths”

• Laringeal Mask (LMA)

LMA Supreme • High pressure supported

(37 cmH2o ?) • Enables passive and active removal of gastric content through dedicated channel

• More rapid insertion • Bite block

LMA PRO

Quicker and easier to insert than a tracheal tube

More efficient and easier ventilation than with a bag – mask

ventilation

High successful ventilation rates during CPR in in-hospital

studies (86 – 100%)

Not so high in out-of-hospital cardiac arrest (71 – 90%)

When inserted, ventilate at 10 BPM (as via tracheal tube)

LMA CONS

Increased risk of aspiration in

comparison to tracheal intubation

Inability to provide adequate

ventilation in patients with low lung

and/or lung compliance

Blue cuff: 50-100 ml air White cuff: 5 – 15 ml air

Tracheal intubation: who should be intubated?

Is there a failure of airway maintenance or protection?

Is there a failure of ventilation or oxygenation?

What is the anticipated clinical course?

R. Walls 2000

?

“…A recent systematic review: There was no overall benefit for tracheal intubation…”

Is about PREHOSPITAL!!!

AND…

Lecky et al: Emergency intubation for acutely ill and injured patients. Cochrane Database syst Rev 2008

“…A recent systematic review: There was no overall benefit for tracheal intubation…”

Is about paramedics!

Positioning

Back – Up- Right – Pressure:

BURP

Take it easy and…

Always let him….