Advanced Airway

Advanced Airway
Supraglottic Endotracheal
Airways Intubation

Laryngeal
Mask Airway

Combitube

Laryngeal
Tube
 Supraglottic Airways
• Supraglottic airways are devices designed to
maintain an open airway and facilitate
ventilation.
• Insertion of a supraglottic airway does not
require visualization of vocal cord and so it is
possible to insert without interrupting chest
compression during resuscitation.
Laryngeal Mask Airway
 Indication of LMA
• Elective ventilation
 LMA is an acceptable alternative
to mask anesthesia in the
operating room.
It is often used for short
procedures when endotracheal
intubation is not necessary. [1]
• Difficult airway
After failed intubation, the LMA
can be used as a rescue device.
The LMA can easily be
attempted quickly, while an
assistant simultaneously prepares
for cricothyroidotomy in patient
who cannot be intubated.
• Cardiac arrest
 The LMA is an acceptable
alternative to intubation for airway
management in the cardiac arrest
patient (Class IIa).
• Conduit for intubation
The LMA can be used as a
conduit for intubation, particularly
when direct laryngoscopy is
unsuccessful.
• Prehospital airway management
The LMA is useful in the
prehospital setting not only for
patients in cardiac arrest but also
for managing a difficult airway.
• Pediatric use
Laryngeal mask airways are
available in a range of pediatric
sizes.
Contraindication of LMA
Relative contraindications Increased risk of
(in the elective
setting) are as follows: aspiration:
Prolonged bag-valve-
mask ventilation, morbid
obesity, second or third
trimester pregnancy,
Absolute patients who have not
contraindications (in all fasted before ventilation,
settings, including upper gastrointestinal
emergent) are as follows: bleed

Cannot open mouth

Suspected or known
abnormalities in
supraglottic anatomy

Complete upper
airway obstruction
Need for high airway
pressures
 Laryngeal Mask Airway
Before any attempt to insert an LMA, the following equipment
has to be prepared:

• Personal protective equipment - mask, eye shield/goggle,

gloves
• Appropriate size LMA
• Syringe with appropriate volume (10, 20 or 50 ml) for LMA
cuff inflation
• Water soluble lubricant
• Ventilation equipment
• Tape or other device(s) to secure LMA
• Stethoscope
Procedure
 Endotracheal Intubation
• An Endotracheal Tube is a device inserted into
the patient’s trachea through the mouth or
nose to maintain an open airway.
• It is used to assist the delivery of anaesthetic
gases or air to and from the patient.
• Control of the airway with Endotracheal tube
is usually regarded as the ‘Gold Standard’
 Indication of Endotracheal Intubation
• Cardiac arrest with ongoing chest compressions

• Inability of a conscious patient to adequately

ventilate/oxygenate

• Inability of the patient to protect their airway (coma

(GCS <9), areflexia, loss of gag reflex or cardiac arrest)

• Inability to ventilate the unconscious patient with

conventional methods
 Contraindication
• Any situation where the pharynx is obstructed
(pharyngeal foreign body, massive swelling of
the pharynx), or if there is serious
maxillofacial trauma
• Special care must be taken in any patient
where a C-spine injury is possible. DO NOT
LIFT THE CHIN!
 Equipment
MALES:
M - Mask (Bag-mask), Magill forceps
A - Airways (Oropharyngeal/Nasopharyngeal
Airway)
L - Laryngoscope, LMA, Lubricant gel
E - Endotracheal tubes + Stylet + tape for
securing ETT
S - Suction (Catheter/Yaunker), Syringe, Stylet
ETT
 Laryngoscope

Types of laryngoscopes:
 Macintosh  for adults  curved blade, end of blade should be
placed in front of epiglottis in valecula
 Miller or Magill  for children  straight blade, end of blade should
be under epiglottis
 Technique of ETT
Step 1: Position patient in the ‘sniffing the
morning air’ position
• Flexion at lower cervical spine
• Extension attlanto-occipital joint
 Cont’…
Step 2: Preoxygenation
• 100% O2 for 3 minutes or with 4 vital capacity
breaths

Step 3: Laryngoscopy and insertion of ETT

 3A: Laryngoscopy

•Use left hand to hold laryngoscope

• Enter at right side of mouth and push tongue towards left side
•Move the laryngoscope blade toward midline and advance to the base of
tongue. Advance the blade to the vallecula if the curved blade is used or to just
beyond tip of epiglottis if the straight blade is used
•Lift upward and forward to bring the larynx and vocal cords into view as
indicated by the arrow in the diagram above. The direction of force necessary
to lift the mandible and tongue is 45 degrees. Do not use the teeth as a
fulcrum or a lever
 Cont’…
3B: Insertion of ETT
• Insert the ETT through the vocal cords.
View the proximal end of the cuff at the level of the vocal cords and
advance it about 1 to 2.5cm further into the trachea
• Inflate the ETT with enough air to occlude the airway (usually 10 to 20ml)

Step 4: Confirm correct position of ETT

• Observe colour of patient
• Visualise chest rise with delivery of first manual breath
• Detect vapour in ETT
• 5 points auscultation for breath sounds (auscultate epigastrium, anterior
chest at bilateral mid-clavicular lines and thorax at bilateral mid-axillary
lines)
• Detect end-tidal CO2 with capnography or CO2 detector device

Step 5: Secure ETT with tape

Step 6: Ventilate with a tidal volume of 6-8 ml/kg (visible chest rise) at a rate
of 8-10 breath per minute
 Complication (During Intubation)
• Hypoxia from the procedure itself, esophageal
intubation and/or laryngospasm and bronchospasm
• Hypertension/hypotension, tachycardia/bradycardia
and arrhythmias from/parasympathetic/sympathetic
response
• Trauma to teeth, lips, tongue, mucosa, vocal cords,
trachea
• Vomiting and aspiration
• Spinal cord trauma in cervical spine injury
• Arytenoid dislocation  hoarseness
 Complication
When ETT in situ : During extubation :
• Migration to • Laryngospasm
bronchus/esophagus • Edema of upper airway
• Obstruction from kinking, • Pulmonary aspiration
secretions or over-inflation of After Extubation :
cuff
• Sore throat
• Disconnection from breathing
circuit • Hoarseness
• Accidental extubation/ETT Long Term :
dislodgement • Subglottic stenosis
• Sinusitis or otitis or nasal ulcer • Vocal cord granuloma
in prolonged nasal intubation • Laryngeal granuloma
• Lip ulcer in prolonged oral
intubation
 Endotracheal Intubation

Advantages Disadvantages

• provides an unobstructed airway if • air goes directly through the

the tube is properly placed mouth without being warmed,
• Protects airway from aspiration of humidified, or filtered which
foreign material normally take place in the nasal
• Facilitates ventilation and passages
oxygenation
• Facilitates suctioning of trachea
and bronchi
• Provides route for drug
administration
• Prevents gastric inflation if used
with cuff
 Combitube
• Combitube is a two barreled tube that
functions well when placed in either the
trachea or oesophagus
• The shorter white port is for the distal lumen,
which opens just to the side of the atraumatic
bevelled tip of the tube.
• The longer blue port is for the proximal lumen,
which opens between the two cuff through
eight side holes.
 Surgical Airway Technique
Indication :
• When a patient’s airway cannot be secured
using nonsurgical method or when other
devices or rescue techniques have failed pr
not available
• Patient with severe facial trauma
 Contraindication
Absolute contraindications
• Pediatrics - Children younger than 12 years, unless of teenage or
adult size

Relative contraindications
• Airway obstruction distal enough to the cricoid membrane that a
cricothyrotomy would not provide a secure airway with which to
ventilate the patient
• Presence of a SHORT neck, which includes S urgery (history or prior
neck surgery), H ematoma, O besity, R adiation (evidence of
radiation therapy), or T rauma/burns, making it difficult to locate
the patient’s anatomical landmarks or producing an increased risk
of further complications
• Tumor, infection, or abscess at site of incision
• Lack of operator expertise
 Cricothyrotomy
• Assemble and prepare equipment.
• Position the patient supine, with the neck in a neutral position.
• Clean the patient’s neck in a sterile fashion using antiseptic swabs.
• Anesthetize the area locally, if time allows.
• Locate the cricothyroid membrane anteriorly between the thyroid and cricoid cartilage.
• Stabilize the trachea with the left hand until the trachea is intubated.
• Make a 2- to 3-cm midline vertical incision through the skin from the caudal end of the
thyroid cartilage to the cephalic end of the cricoid cartilage.
• Make a 1- to 2-cm transverse incision through the cricothyroid membrane.
• Insert the scalpel handle into the incision and rotate 90°. (A hemostat may also be used
to open the airway.)
• Insert a tracheal hook into the opening, hooking the caudal end of the opening, and lift,
allowing for passage of an appropriately sized cuffed endotracheal or tracheostomy
tube (usually No. 5 or No. 6), directing the tube distally.First alternative: Insert the tube
through the opening produced by the opened hemostat.
• Second alternative: Holding the handle of the scalpel straight down in the opening,
slide the handle cephalically and insert the tube straight down along the handle until it
hits the back of the trachea. Then, angle the tube caudally and advance the tube.
• Inflate the cuff; observe and check for chest rise.
• Secure the airway.
• Caution: Do not cut the thyroid or cricoid cartilage.
 Needle Cricothyrotomi

• Identify the cricothyroid membrane and the midline

• Insert 14-gauge intravenous cannula and syringe
through the skin and membrane
• Continuously apply negative pressure until air enters
the syringe
• Stop at this point and push the cannula off the needle
into the trachea
• The insertion of the cannula into the trachea allows
apneic (low pressure) ventilation or jet (high-pressure)
ventilation.
 Indication
• Inability to maintain a patent airway
• Suspected cervical spine instability (percutaneous
technique only)
• Prevention of damage to vocal cords and (possibly)
subglottic stenosis
• Abnormal anatomy (percutaneous only)
• Upper airway obstruction
• High ventilatory requirement (relative)
• Requirement for tracheobronchial toilet with
suctioning
• Part of larger surgical procedure (e.g., laryngectomy)