Dr Baharulhakim Said b Daliman Dato Dr Subrahmanyam Balan

Outline

Airway anatomy

Positioning

Airway adjuncts

Indication for intubation

Difficult airway management

Conclusion

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 Direct Visualization Lung Sounds Technology Based ETCO2 (monitor) EDD (bulb) Colormetric (cap) Pulse Ox change

Tube Condensation

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

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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-valvemask ventilation. Always monitor the spo2 readings. Always reconfirm tube placement from time to time.

akimnh@yahoo.com