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M ANAGEMENT OF O BSTRUCTED A IRWAY

IMPORTANT STRUCTURE OF THE AIRWAY

A NATOMY OF THE A IRWAY

UPPER AIRWAY

LOWER AIRWAY

SENSORY INNERVATIONS OF THE AIRWAY


Upper airway: 1. Trigeminal nerve (V) 2. Facial nerve (VII) 3. Glossopharyngeal nerve (IX).

LARYNX
The anatomical
division of the lower airway

starts from the


larynx and extends into the alveoli.

SENSORY INNERVATIONS OF THE LARYNX


Superior Laryngeal Nerve (Vagus nerve)

Internal -glottis and supraglottis, which includes the pharynx, underside of the epiglottis and the larynx above the cords. Remember: SIS-superior internal sensory. External -It supplies motor function to the crycothyroid muscle which tenses the vocal cords and could cause laryngopasm.

Recurrent Laryngeal Nerve

It provides sensation to the subglottic (ie. vocal cords, esophagus)

LOCATION OF LARYNGEAL NERVES

LARYNGEAL PROTECTION SYSTEM

The three basic functions of the larynx in order of importance are: protection of the airway, respiration, and phonation

The primary function of the larynx is its use as a sphincter protecting the lower airway from the entrance of liquid and food during swallowing, vomiting, and coughing.

T RI -S PHINCTER M ECHANISM

Aryepiglottic fold: : closes

during swallowing, diverting liquid and food away guarding against the entrance of ingested foreign bodies and vomitus during retching and gagging

False Vocal Cord (ventricular fold): function as exit valves to prevent the egress of air from the trachea (expectorative function). True Vocal Cords: Primary role is protection of the airway (most significant of the tiers against aspiration).

G LOTTIC C LOSURE R EFLEX

Produced by rapid contraction of the thyroarytenoid muscle in response to superior laryngeal nerve stimulation. Sensory stimuli other than those classically elicited by direct SLN stimulation are also capable of eliciting this reflex.

Examples of these include stimulation of all major cranial afferent nerves and other special sensory and spinal somatic nerves.

L ARYNGOSPASM

Physiologic exaggeration of the glottic closure reflex- but it is more forceful and prolonged closure of the larynx. Maintained well beyond the cessation of mucosal irritation. The most common causes are inhaled irritants, manipulation of the upper aerodigestive tract, foreign bodies, mucus, or blood in the glottic chink.

Most likely to occur when the patient is in the OR undergoing endotracheal intubation
Produced obstructive apnea and death by asphyxia

Laryngospasm is inhibited by: increased arterial pCO2, decreased arterial pO2, positive intrathoracic pressure, and the inspiratory phase of respiration.

C OUGH R EFLEX

May be voluntary, but more often in response to stimulation of receptors in the larynx or lower respiratory tract. It consists of three phases:

inspiratory- larynx opens wide to permit rapid and deep inspiration; compressive- tight closure of the glottis and strong activation of expiratory muscles; expulsive- larynx opens widely and a sudden outflow of air in the range of 6-10 liters/sec.

C IRCULATORY R EFLEXES

Stimulation of the larynx can produce changes in heart rate and blood pressure.
Direct result of laryngeal stimulation on blood pressure is hypertension, but if laryngeal stimulation produces significant bradycardia by vagal stimulation, hypotension can indirectly occur. This effect is most evident during induction of anesthesia and can occur in natural circumstances such as obstructive sleep apnea. Afferent (Superior Laryngeal Nerve) is responsible for this reflex, transection of this nerve abolishes cardiovascular responses to laryngeal stimulation and elective SLN stimulation affects BP and HR.

OBSTRUCTION IN AIRWAY

M ANEUVER FOR UNBLOCKING URT


Heimleich maneuver Suction Finger sweep technique

H EIMLEICH MANEUVER ADULT


From behind, wrap arms around the victim's waist. Make a fist and place the thumb side of fist against the victim's upper abdomen, below the ribcage and above the navel. Grasp fist with your other hand and press into their upper abdomen with a quick upward thrust. Do not squeeze the ribcage; confine the force of the thrust to hands. Repeat until object is expelled. If unable to reach around victim, place the victim on back. Facing the victim, kneel astride the victim's hips. With one hand on top of the other, place the heel of bottom hand on the upper abdomen below the rib cage and above the navel. Use body weight to press into the victim's upper abdomen with a quick upward thrust. Repeat until object is expelled. If the Victim has not recovered, proceed with CPR. Don't slap the victim's back.

H EIMLEICH MANEUVER CHILD

Lay the child down, face up, on a firm surface and kneel or stand at the victim's feet, or hold infant on lap facing away. Place the middle and index fingers of both hands below rib cage and above navel. Press into the victim's upper abdomen with a quick upward thrust; do not squeeze the rib cage. Repeat until object is expelled. If victim not recovered, proceed with CPR. Don't slap the victim's back.

H EIMLEICH MANEUVER SELF

Make a fist and place the thumb side of fist against your abdomen, below the ribcage and above the navel. Grasp fist with other hand and press into upper abdomen with a quick upward thrust. Repeat until object is expelled. Alternatively, lean over a fixed horizontal object (table edge, chair, railing) and press upper abdomen against the edge to produce a quick upward thrust. Repeat until object is expelled.

T RIPLE AIRWAY MANEUVER


Head tilt Chin lift Jaw thrust

T RIPLE AIRWAY MANEUVER

O ROPHARYNGEAL AIRWAY

OPA

Measure for correct size by measuring from the center of the mouth to the angle of the jaw, or from the corner of the mouth to the earlobe. Mouth is opened using the crossed finger technique. OPA is inserted in the patients mouth upside down so the tip of the OPA is facing the roof of the patients mouth. As the airway is inserted it is rotated 180 degrees until the flange comes to rest on the patients lips and/or teeth. The OPA may be inserted with the pharyngeal curvature if a tongue blade is used to depress the tongue. If patient begins to retch/gag, remove the OPA.

N ASOPHARYNGEAL
AIRWAY

NPA

Select the proper size airway by measuring from the tip of the patients earlobe to the tip of the patients nose. The diameter of the airway should be the largest that will fit by selecting the size that approximates the diameter of the patients little finger. Lubricate the airway with a water-soluble lubricant. With the patients head in a neutral position, gently pull back the tip of the patients nose. Insert the airway; bevel toward the nasal septum, into the right nostril following the natural curvature of the nasal passage. The flange should rest against the nasal opening.

B AG

VALVE MASK

BMV

While positioned at the top of the patients head, open the airway using the head-tilt/chin-lift maneuver or the jaw-thrust maneuver. Insert the appropriate sized airway adjunct. Choose the appropriate size mask for the patient. Mask should be transparent with an air cushion that rests against the patients face. Hold mask position and place mask over patients face assuring the top of the mask is over the bridge of the nose and the bottom is in the groove between the lower lip and the chin. Using the OK hand position, with both hands, manually open the airway and maintain the mask seal. Connect the bag-valve unit to the mask. Ventilate the patient by squeezing the entire bag over 1-2 seconds and then release the bag. Each ventilation must be a minimum of 800cc. Assure appropriate chest rise during ventilations. Continue to ventilate the patient for 30 seconds prior to attaching the oxygen. Next, assemble the oxygen tank and regulator. Attach oxygen tubing to the regulator and to the BVMs reservoir. Turn on the oxygen and adjust the regulator to 15 liters per minute. Allow the reservoir to fill with oxygen prior to the first ventilation. Reposition patient and begin artificial ventilations. As completed earlier, open the airway, place mask over the patients face, continue with proper mask/face seal, and begin venitlations. If two rescuers present, one will maintain a mask seal using both hands while maintaining an open airway while the other will ventilate the patient by collapsing the bag on the BVM fully with both hands.

L ARYNGEAL M ASK A IRWAY

Completely deflate the cuff of the mask. Place Introducer tip into strap at the junction of the cuff and two tubes (Fig. 1). Fold the tubes around the Introducer (Fig. 2) and fit the proximal end of the airway tube in the matching slot (Fig. 3). Apply a water-soluble lubricant on the posterior surface of the cuff. With the head extended and the neck flexed, carefully flatten the mask tip against the hard palate (Fig. 4 and Fig. 5).

Keep the Introducer blade close to the chin and rotate the LMA ProSeal inward in one smooth circular movement following the curve of the Introducer (Fig. 6). Advance into the hypopharynx until a definite resistance is felt (Fig. 7). Before removing the Introducer, hold the LMA ProSeal tube with the non-dominant hand to stabilize the tube. At this point, the LMA ProSeal should be correctly placed with its tip firmly pressed against the upper esophageal sphincter (Fig. 8). Remove the Introducer. Inflate the cuff with just enough air to obtain a seal (an intracuff pressure of ~ 60 cm H2O). Never overinflate the cuff.

ENDOTRACHEAL INTUBATION PROCEDURE

ASSESSING THE PATIENT


Physical examination
I. II.

Vital signs and oxygen saturation Examine the mouth and oral cavity (the best combination for east airway management is a large oral cavity with a small mobile tongue) Evaluate the extent and symmetry of mouth opening (three finger breadths is optimal) Check for loose, missing or cracked teeth Note any prominent buck teeth or particularly large incisors that may interfere with laryngoscopy (dental and oral injuries are common complications of laryngoscopy) Note the size of the tongue (large tongues may interfere with use of the laryngoscope) Note the arch of the palate (high arched palates have been known to hamper visualization of the larynx)

III.

IV. V.

VI.

VII.

Examine the pharynx. The appearance of the posterior PHARYNX may predict ease of laryngoscopy and visualization of the LARYNX. Malampatti has classified patients in classes I-IV based on visualization of structures during pre-operative evaluation.

If the whole of the tonsillar pillars are visualized, the airway is rated Class I and intubation is likely to be uncomplicated. If the uvula, but not the tonsillar pillars can be visualized, the airway is rated as Class II. Class III is characterized by visualization of part of the uvula and soft palate.

REQUIRED EQUIPMENTS

Endotracheal tube
I. II. III.

7.5 mm is the Universally Accepted size for an unknown victim Men are usually larger, therefore an 8.0 mm tube may be appropriate Females are usually smaller, therefore a 7.0 mm tube may be appropriate

10 cc Syringe used to fill the cuff at the end of the endotracheal tube Stylet a wire inserted into the endotracheal tube in order to stiffen it during passage Water soluble lubrication KY Jelly or Surgilube Stethoscope to check for proper placement of the endotracheal tube

Magill forceps May be used to help guide an endotracheal tube from the pharynx into the larynx Laryngoscope handle Laryngoscope blade

Oropharyngeal airway (bite block) to prevent the patient from biting down on the endotracheal tube
Tape to secure the endotracheal tube in place Gloves

Ambu-bag to facilitate positive pressure ventilations


Suction Device to clear the airway of debris (blood, mucous, saliva)

I NTUBATION P ROCEDURE

Position of the patient: Supine Pillow under head Open airway: suction or manually extract foreign material. Chin lift, jaw thrust. Preoxygenate with 100% non-rebreather or bag-valve-mask. Keep pulse ox greater than 95% at all times.

Flexion of the neck.


Extension of the atlanto-occipital joint. (This is the position sometimes called "sniffing the morning air")

Open the mouth by separating the lips and pulling on the upper jaw with the index finger. Hold the laryngoscope in the left hand. Insert the laryngoscope into the mouth with the blade directed to the right tonsil. Once the right tonsil is reached, sweep the blade to the midline keeping the tongue on the left.

This brings the epiglottis into view. DO NOT LOSE SIGHT OF IT. Advance the laryngoscope blade till it reaches the angle between the base of the tongue and the epiglottis. Lift the laryngoscope upwards and away from the nose towards the chest. This manoeuvre should bring the vocal cords into view, but it may be necessary for an assistant to press on the trachea to improve the direct view of the larynx.

Take the endotracheal tube in the right hand. Keep the concavity of the tube facing the right side of the mouth. This causes least interruption to the view of the vocal cords. Watch the tube entering the larynx and insert it through the cords only till the cuff is just below the cords. Inflate the cuff to provide a minimal leak when the bag is squeezed. Listen for air entry at both apices and both axillae to ensure correct placement, using a stethoscope and look at the chest for expansion with each breath.

C RICOTYROTOMY

INDICATIONS

Failure of oral or nasal intubation or adequate oxygenation and ventilation with airway adjuncts (laryngeal mask airway, etc.). Massive oral, nasal, or pharyngeal hemorrhage Masseter muscle spasm Clenched teeth Structural deformities of the oropharynx, whether congenital or acquired Stenosis of the upper airway (pharynx or larynx)

Laryngospasm Mass effect (cancer, tumor, polyp, web, or other mass) Airway obstruction (partial or complete) Oropharyngeal edema

Foreign body obstruction


Obstruction of the airway due to displacement of normal structures

CONTRAINDICATIONS

Age under 5 to 12 years, tracheal transection or low obstruction

Relative contraindications:

difficulty identifying anatomic structures due to swelling, trauma, previous radiation therapy, injury, etc.

TECHNIQUE

Prepare all necessary equipment and test the tracheostomy tube by inflating the tube with air from 10-cc syringe. Position the patient . He or she should be supine, with a rolled bath towel under the shoulders, and with the neck in hyperextension. Sterilize the skin from the sternal notch to chin and laterally to the base of the neck. Identify the cricothyroid membrane. Anesthetize the skin over the membrane using the 10-cc syringe with 25-gauge needle with the 1% lidocaine.

Make a transverse incision of the skin over the cricothyroid membrane.


Identify the membrane and then continue the incision through it approximately 1 cm on each side of the midline.

TECHNIQUE

With the mosquito or kelly clamp in the left hand, insert the clamp into the incision and spread it . This is sufficient to provide an airway for a patient with supraglotic airway obstruction. With the right hand insert the tracheostomy tube or the orotracheal tube through the incision into the trachea, directing it caudally. Connect the bag-valve unit to the tube and ventilate the patient the patient with 100% oxygen. Observe respiratory movements of the chest and breath sounds. Inflate the tube balloon

Fixate
Suction Obtain a chest x-ray to check the position of the tube.

POST-PROCEDURE CARE

Obtain a post-procedure chest radiograph.

COMPLICATIONS

Laryngotracheal injury Tension pneumothorax Clogging of the tracheostomy tube with blood or secretions

R EFERENCES

Danzl DF, Vissers RJ. Tracheal intubation and mechanical ventilation. In: Tintinalli JE, Kelen GD, Stapczynski JS, Ma OJ, Cline DM, eds. Emergency Medicine: A Comprehensive Study Guide. 6th ed. New York, NY: McGraw-Hill; 2004: chap 19. Barash, PG; Cullen, BF; Stoelting, RK, eds (2009). Clinical Anesthesia (6th ed.). Philadelphia: Lippincott Williams & Wilkins. Retrieved 2010-10-16. Bhishagratna, KL, ed (1907). Sushruta Samhita, Volume1: Sutrasthanam. Calcutta: Kaviraj Kunja Lal Bhishagratna. Retrieved 2010-10-16. Benumof, JL, ed (2007). Benumof's Airway Management: Principles and Practice (2nd ed.). Philadelphia: MosbyElsevier. Retrieved 2010-10-16

REFERENCES

Bailey, Byron J., ed. Head and Neck SurgeryOtolaryngology. Philadelphia, PA.: J.B. Lippincott Co., 1993. Bailey BJ, Biller HF, ed. Surgery of the Larynx. Philadelphia, PA.: WB Saunders Company, 1985. Cummings, Charles, ed. Otolaryngology- Head and Neck Surgery. St. Louis, Missouri: Mosby-Year Book, Inc., 1993.

Kassir R, Anatomy and Physiology of the Larynx. Grand Rounds Presentation, January 13, 1993. Lee KJ, ed. Essential Otolaryngology. New York, NY.: Elesvier Science Publishing Company, Inc., 1991. Paparella MM, Shumrick DA, ed. Otolaryngology. Philadelphia, PA.: WB Saunders Company, 1991.
G. Edward Morgan, Jr., Maged S. Mikhail, Michael J. Murray, Clinical Anesthesiology, 4th Edition

THANKS!!