Dr Baharulhakim Said b Daliman

Dato Dr Subrahmanyam Balan

Outline

Upper airway

Lower airway

Basic airway management

Assess for Airway Obstruction!
Difficulty breathing
Patient conduct (anxious, combative)
Abnormal sounds

Improve/Establish Airway Through Maneuvers

Chin lift
Jaw thrust

Remove Debris/Suction
Airway Adjuncts:

Nasal airway
Oral airway
Others

Opening the Airway

Head tilt-chin lift
Nontrauma

patients, medical
patients

Jaw-thrust
Suspected spinal

injury

Airway instruments
Face mask

Face mask
Appropriate size: cover from the bridge

of the nose to the cleft of the chin

To get a tight seal: EC-clamp technique
The thumb and index finger hold the mask

firmly over the nose and chin (forming a C)

The third through fifth fingers firmly grasp
the bony mandible (forming an E)
sniffing position

Sniffing position

Laryngoscope

Oral airway
Keep the tongue

from falling back

Unresponsive
patient with no
gag reflex
Corner of patients
mouth to the angle
of jaw

Oral airway; importance of

proper size

Nasopharyngeal airway
Inserted into

patient's nostrils
Tip of patients
nose to the
earlobe

Nasopharyngeal airway
Avoided in patients with:
evidence of fracture of middle third of

face.
cerebro-spinal fluid leaks.
vascular abnormalities of nose.
bleeding disorders.
sepsis in the nose.
trauma to the nose.

Endotracheal tube
PVC
Choose appropriate size
Male : 7.5 8.0 (ID)
Female : 7.0 7.5
Pediatric : age/4 + 4

Intubating Stylet

Indications for intubation

Failure to oxygenate
Failure to remove CO2
Neuromuscular weakness
CNS failure
Cardiovascular failure

Steps to control airway

Pre-Intubation

-Prepare Equipment
-Hyper-oxygenate

Steps to control airway

Orotracheal Intubation Procedure

Sweep
Left and
Look

Steps to control airway

Find Your Landmarks

Backward, Upward, Right Pressure (B.U.R.P.)

Steps to control airway

Find Your Landmarks

Steps to control airway

Find Your Landmarks

It may not be perfect!

Steps to control airway

Find Your Landmarks

Steps to control airway

Readjusting with Cricoid Pressure

Confirm the airway

Intubation Confirmation
Good, Better, Best
Traditional

Technology Based

Direct
Visualization

ETCO2 (monitor)

EDD (bulb)

Lung Sounds

Colormetric (cap)

Tube
Condensation

Pulse Ox change

Secure the airway

Secure Your Tube
Good, Better, Best
Tape
Improvised devices
Commercial devices
Immobilization

Steps to control airway

Common Mistakes
Making a difficult intubation more difficult
Rushing
Poor equipment preparation
Suction (lack there of)

Other options
Blind nasal
Fibreoptic intubation

Retrograde intubation
Trachlite
Cook airway / Bougie
LMA / Combitube / Laryngeal tube
Tracheostomy

Helpful adjuncts

Gum
Elastic
Bougie

Helpful adjuncts
Laryngeal Mask Airway

Developed in 1981 at the Royal London Hospital

By Dr Archie Brain

Helpful adjuncts
Laryngeal Mask Airway

Indications:
-When definitive airway management
cannot be obtained. (ETT)
Not a substitute for definitive airway
management

Helpful adjuncts
Laryngeal Mask Airway

Contraindication/Limitations:
-Obesity
-Non-secure
-Size based
-Not a med route

Helpful adjuncts
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

Helpful adjuncts
Laryngeal Mask Airway

Average Adult Woman = 4

Average Adult Male = 5
*If in doubt, check the LMA

Helpful adjuncts
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
-Let go and inflate cuff (visualize pop)
-Confirm and secure

Helpful adjuncts
Laryngeal Mask Airway
Air volume is variable depending on cuff size
and individual patient anatomy
General Guideline:
Size 1 = 4 ml
Size 2 = 10 ml
Size 2.5 = 14 ml
Size 3 = 20 ml
Size 4 = 30 ml
Size 5 = 40 ml

Helpful adjuncts
Laryngeal Mask Airway
Common Problems:
-Failure to seat properly
-Sizing difficulties
-Aspiration

Helpful adjuncts
Dual Lumen Airway

(Combitube)

Helpful adjuncts
Dual Lumen Airway

Indications:
-When definitive airway management
cannot be obtained. (ETT)
Not a substitute for definitive airway
management

Helpful adjuncts
Dual Lumen Airway
Contraindications/Limitations:
-No pediatrics
-57-7 tall (SA 4-56)
-Pathological esophageal disease
-Non-secure airway
-Latex sensitivity
-Toxic or Caustic Ingestions

Helpful adjuncts
Dual Lumen Airway
Procedure:
-Hyper oxygenate
-Check equip.
-Head in neutral position
-Insert until to guide lines

Helpful adjuncts
Dual Lumen Airway
Procedure:
Inflate Pharyngeal cuff
(blue) with 85-100cc of
air
Inflate tracheal cuff
(white) with 10-15cc of
air

Helpful adjuncts
Dual Lumen Airway
-Ventilate port 1 (longer, blue tube, #1).
If no lung sounds, switch ports
-Ventilate port 2 (shorter, white tube, #2)
*You will be either in the esophagus or the trachea

42

Helpful adjuncts
Lighted Stylette

AIRWAY

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 spo2 readings.
Always reconfirm tube placement
from time to time.

akimnh@yahoo.com