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Management of the Airway SAUSHEC Medical Student Lecture Series

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Management of the Airway SAUSHEC Medical Student Lecture Series Powered By Docstoc
					             Management of the
                  Airway

             SAUSHEC Medical
              Student Lecture
                  Series
10/26/2011
        Introduction to Airway
             Management
• The first priority in patient care; the “A” of
  the ABC’s
• Rapid airway intervention is critical to
  prevent CNS injury and death
• Knowledge and skill in airway
  management techniques are vital for
  successful outcome
    Pathophysiology of Airway
          Compromise
• Etiologies
  – Trauma – neck, CNS, multi-trauma
  – Infection – pneumonia, epiglottitis
  – Edema – Anaphylaxis, angioedema
  – Tumor – Head and Neck CA
  – Foreign body
  – Anatomic anomalies
      Pathophysiology (Cont)
• Complete obstruction- physiologic
  response
   – cyanosis
   – patient distressed; unable to cough,
     speak, or breathe
   – unconsciousness, apnea
   – increased HR and BP
   – bradycardia, asystole
         Basic Maneuvers
• Supplemental oxygen
• Opening the airway
• Airway adjuncts
       Supplemental Oxygen
• Indicated for any seriously ill or injured
  patient
• May vary oxygen concentration delivered
  by using various devices
• Use 100% O2 for any critical patient
• Provides oxygen reserve prior to
  intubation
          Opening the Airway
•   Head and jaw positioning
•   Abdominal thrust
•   Laryngoscopy with forcep extraction
•   Suction
     Head and Jaw Positioning
• Head tilt
   – do not use if possible
     c-spine injury
   – combine with chin
     lift/jaw thrust to
     maximize airway
     patency
• Chin lift / jaw thrust
10/26/2011
            Abdominal Thrust

• Indicated in a conscious patient with:
  – total airway obstruction
  – partial obstruction with poor air exchange
• avoid use in:
  – infants <1 yr
  – pregnant or obese patients
          Forcep Extraction
• Preferred method in unconscious patient
• Direct visualization of foreign object with
  laryngoscope
• Removal of foreign body with Kelly or
  Magill forceps
                 Suction
• Used to clear blood, secretions, and
  particulate matter from the airway
• Most effectively and safely used under
  direct visualization
             Airway Adjuncts
• Oropharyngeal airway
  – prevents tongue from
    falling onto pharynx
    and occluding airway
  – use only in the
    unconscious patient
  – can obstruct airway if
    improperly placed
                Airway Adjuncts
• Nasopharyngeal
  airway
     – may use in semi-
       conscious or
       unconscious patient




10/26/2011
      Endotracheal Intubation
• Basic Orotracheal
  intubation
• Rapid sequence
  intubation
• Nasotracheal
       Orotracheal Intubation
• Indications “VSOP”
  – Ventilation – apnea, hypercapnia
  – Secretion control
  – Obstruction – tumor, FB
  – Protection – head injury, edema, etc.

  – Also: Drug admin in ACLS
  Orotracheal Intubation (cont)
• Contraindications
  – No absolute contraindications
  – Use caution and immobilization in patients
    with potential cervical spine injury
      Orotracheal Intubation
• Technique
  – Equipment preparation
  – Pre-oxygenation
  – Laryngoscopy
  – Tube insertion
  – Confirm tube placement
  – Anchor tube
             Orotracheal Intubation
• Preparation “SOAP ME”
     – Suction
     – Oxygen
     – Airways
     – Pre-medication
     – Monitors
     – Equipment for failure


10/26/2011
             Orotracheal Intubation
• Preoxygenation
     – Denitrogenation of FRC
     – 100% O2 for 5 minutes provides up to 5
       minutes of complete apnea before
       desaturation < 90%
     – 4 breaths at full vital capacity provide 60-80%
       of same effect
     – Essential to eliminate bag valve mask
       ventilation of patient
10/26/2011
        Orotracheal Intubation
• Technique:
  laryngoscopy
     • insert blade into right
       side of mouth,
       sweeping tongue to left
     • lift laryngoscope along
       line of handle, do not
       leverage teeth
     • cricoid pressure,
       suction as needed,
       visualize cords
                Orotracheal Intubation
• Technique: Tube
  Placement
     – tube insertion
             • insert tube into right
               side of mouth and
               watch it go through
               cords
             • inflate balloon




10/26/2011
  Orotracheal Intubation (cont)
• Technique problems
  – Improper position of
    patient’s head/neck
  – Not clearing tongue
    from line of sight
  – Leveraging
    laryngoscope against
    teeth
  Orotracheal Intubation (cont)
• Complications
  – Right mainstem intubation
  – Esophogeal intubation
  – Aspiration
  – Dental trauma
  – Vocal cord spasm/injury
   Rapid Sequence Intubation
• Use of pharmacologic adjuncts to
  intubation to induce rapid sedation and
  paralysis
• Allows immediate control of the airway
• Minimizes the risk of aspiration
• Optimizes conditions for successful
  intubation
   Rapid Sequence Intubation
• Indications
  – Facilitate emergent intubation
  – Evidence of increased intracranial pressure
   Rapid Sequence Intubation
• Contraindications
  – Inability to perform orotracheal intubation
  – Not prepared to obtain surgical control of the
    airway
  – Unresponsive patient/Cardiac arrest
    (unnecessary delay to intubation)
   Rapid Sequence Intubation
• Technique
  – Preparation and preoxygenation as per
    general OT intubation
  – Premedication
  – Sedation
  – Paralysis
  – Intubation
            Premedication
• Defasiculation
  – Pancuronium or vecuronium 0.01 mg/kg rapid
    IV push
  – May prevent succinylcholine associated
    fasciculations
  – May prevent increased intragastric,
    intracranial, and intraocular pressure
              Premedication
• Lidocaine
  – Used to suppress cough reflex and increased
    intracranial pressure response in patients with
    head injury
  – Dose: 1.5 mg/kg IV over 30-60 seconds
             Premedication
• Atropine
  – Prevent succinylcholine induced bradycardia
  – Pre-treat children < 8; adults if given repeat
    dose of succinylcholine
  – Dose: 0.01 mg/kg IV push (min 0.2 mg)
                     Sedation
• Etomidate
     – Ideal agent for ED RSI: Few hemodynamic
       effects, positive cerebro-protective effects
     – Non-barbituate sedative
     – Rapid onset and offset
     – Dose of 0.3 mg/kg IVP




10/26/2011
                  Sedation
• Thiopental
  – Barbiturate- rapid acting, brief sedation
  – Alternative in adult patients with head trauma
    who are hemodynamically stable
  – Adverse effects: hypotension, respiratory
    depression
  – Dose: 3-5 mg/kg IV push
                  Sedation
• Fentanyl
  – Potent narcotic analgesic with rapid onset and
    short duration
  – Adverse effects- respiratory depression, chest
    wall rigidity if >10 ug/kg given rapidly
  – Dose: 2-3 ug/kg at rate 1-2 ug/min; titrating to
    effect
                 Sedation
• Midazolam
  – Rapidly acting benzodiazepine with short
    duration of action and an amnestic effect
  – Adverse effects: respiratory depression,
    hypotension
  – Dose: 0.02-0.04 mg/kg
                 Paralysis
• Succinylcholine
  – Drug of choice for ED RSI
  – Depolarizing paralytic agent, onset of
    paralysis in 1 minute, offset < 5 mins
  – Adverse effects: muscle fasciculations,
    hyperkalemia, vagal stimulation, and
    malignant hyperthermia
  – Dose: 1.5 mg/kg IV push
                  Paralysis
• Always administer
  cricoid pressure prior
  to paralysis and
  continue until cuffed
  ET tube is in place
  and confirmed!
               Intubation
• Always confirm ETT placement
• Auscultate over all lung fields and
  epigastrium
• Confirm CO2 return by colorimetry
• Post-intubation CXR




10/26/2011
      Nasotracheal Intubation
• Indications
  – Difficult/impossible direct laryngoscopy
  – Alternative to orotracheal intubation in: awake
    patients requiring intubation with spontaneous
    respirations
     Nasotracheal Intubation
• Contraindications
  – Apnea
  – Basilar skull fracture
  – Anticoagulant use or coagulopathy
  – Airway foreign body, abcess, or tumor
  – Severe midface trauma
     Nasotracheal Intubation
• Technique
  – Equipment preparation
  – Patient positioning
  – Tube insertion
  – Confirm placement
  – Anchor tube
      Nasotracheal Intubation
• Helpful hints
  – Occlude opposite nostril
  – “whistling” cap for ET tube
  – Cricoid pressure when passing tube
  – If breath sounds decrease, pull back
  – Direct visualization technique using Magill
    forceps
     Nasotracheal Intubation
• Complications
  – Esophogeal intubation
  – Aspiration
  – Nasal trauma / epistaxis
  – Posterior pharyngeal wall perforation
  – Vocal cord injury
          Surgical Airways
• Cricothyrotomy
• Percutaneous Transtracheal Ventilation
  (needle cricothyrotomy)
            Cricothyrotomy
• Indications
  – Failure of oral or nasal intubation
  – Upper airway obstruction unrelieved with
    other measures
  – Injuries making oral or nasal intubation
    difficult or dangerous, especially to the
    midface
             Cricothyrotomy
• Contraindications
  – Patients without contraindications to oral or
    nasal intubation who can be successfully
    intubated
  – Severe trauma to larynx, cricoid cartilage, or a
    transected trachea
  – Children under 10-12 years old
             Cricothyrotomy
• Technique
  – Locate membrane
  – Sterile skin prep and anesthesia
  – Incise skin with vertical incision
  – Incise membrane with horizontal stab
  – Dilate incision
  – Insert dilator and place tube – Shiley or 6.0
    ETT tube
10/26/2011
10/26/2011
             Cricothyrotomy
• Complications
  – Bleeding – cricothyroid artery runs superiorly
  – Injury to adjacent structures
  – Incorrect tube placement
  – Infection
  – Subglottic stenosis
     Transtracheal Ventilation
• Indications
  – Same as surgical
    cricothyrotomy
  – Surgical airway of
    choice for children
    under 12 years old
  – Contraindications as
    for surgical
    cricothyrotomy
    Transtracheal Ventilation
• Technique
  – Locate membrane
  – Anesthesia and sterile skin prep
  – Using 14 G catheter over needle, puncture
    skin and then membrane
  – Advance catheter and withdraw needle
  – 3.0 ETT connector fits
  – Attach to oxygen/ventilation device
  – 50 PSI minimum, 1s on, 2-3 off
    Transtracheal Ventilation
• complications
  – Subcutaneous emphysema
  – Kinking or blockage of catheter
  – Bleeding
  – Infection
  – Incorrect placement
  – Damage to surrounding structures
 Pediatric Airway Management
• Anatomic differences
• Basic maneuvers
• Orotracheal intubation
    Pediatric Anatomic Differences
•   Head and occiput relatively larger
•   Airway smaller
•   Larger tongue/oropharynx ratio
•   Larynx higher and more anterior
•   Narrowest portion of airway is at cricoid
   Pediatric Basic Maneuvers
• Opening the airway
  – “Sniffing” position ideal
  – Avoid hyperextension-may occlude airway
  – Avoid hyperflexion-may make visualizing the
    glottis difficult
  – Chin lift/jaw thrust indications as in adult
   Pediatric Basic Maneuvers
• Bag-valve-mask
  – Often can ventilate despite significant upper
    airway obstruction
  – Tidal volume 10-12 cc/kg
  – Use with 100% oxygen
  – Use cricoid pressure to avoid gastric
    distention
Pediatric Orotracheal Intubation
• Technique similar to adult intubation
• Equipment different
  – straight blades in up to age 4-5 years
  – uncuffed tubes in patients <8 years old
  – estimate tube size by size of little finger, or
    age formula or tables
  – (16 + Age)/4
• Be familiar with equipment and anatomy
                                    Equipment Guidelines
                                 According to Age and Weight

                 Premie         Neonate        6 months       1-2 years      5 years         8-10 years
Equipment        (1-2.5 kg)     (2-4.0 kg)     (7.0 kg)       (10-12 kg)     (16-18 kg)      (24-30 kg)
Airway              Infant          Small         Small           Small          Small           Small
Oral                  00              0             1               2              3              4.5
Breathing           Infant         Infant         Child           Child          Child       Child/Adult
Self-inflating
bag

O2                Premature       Newborn      Infant/Child       Child          Child       Small Adult
ventilation
masks

Endotracheal        2.5-3.0        3.0-3.5        3.5-4.0        4.0-4.5        5.0-5.5         5.5-6.5
Tube               uncuffed       uncuffed       uncuffed       uncuffed       uncuffed        uncuffed
Laryngoscop            0              1              1              1-2             2              2-3
e                  (straight)     (straight)     (straight)     (straight)    (straight or    (straight or
                                                                                curved)         curved)
Suction                6             6-8             8            8-10            10             10-12
Circulation        Newborn        Newborn         Infant          Child          Child           Adult
BP cuff
Venous               22-24          22-24          22-24          20-22          18-20           16-20
Access
Angiocath
                       Difficult Airway
• Predicting the difficult airway
     – Rule of 3s
             • 3 fingers between upper/lower teeth
             • 3 between mandible and hyoid
             • 3 between thyroid and sternal notch
     – Predicts success
             • Deficit in 2 or more predicts 3x difficulty
• Approximately 1 in 500 fails

10/26/2011
               Difficult Airway
• Predicting difficult BVM
     – High BMI
     – Advanced age
     – Beards
     – Lack of teeth




10/26/2011
             Difficult Airway
• Awake Fiberoptic
  intubation




10/26/2011
             Difficult Airway
• LMA




10/26/2011
             LMA Insertion




10/26/2011
              Difficult Airway
• Lighted Stylet




10/26/2011
             Difficult Airway
• Gum Elastic Bougie




10/26/2011
             Difficult Airway
• Retrograde Intubation




10/26/2011
             Difficult Airway
• Digital Intubation




10/26/2011

				
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