Advanced airway management. Advanced Airway Management One of the most common mistakes with...
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Advanced airway management
Advanced airway management. Advanced Airway Management One of the most common mistakes with respiratory or cardiac arrest is to use advanced techniques
Advanced Airway Management One of the most common mistakes with
respiratory or cardiac arrest is to use advanced techniques too
early. Establish and maintain a patent airway with basic techniques
first.
Slide 3
Advanced Airway Management Primary reasons: Failure to maintain
a patent airway and/or Failure to adequately oxygenate and
ventilate Involves insertion of advanced airway devices
LEMON Look externally. The following can make intubation
difficult: Short, thick necks Morbid obesity Dental conditions
Slide 6
LEMON Evaluate 3-3-2. 3 mouth width of more than 3 fingers is
best 3 mandible length of 3 fingers is best 2 distance from hyoid
bone to thyroid notch of 2 fingers wide is best
Slide 7
LEMON Mallampati Note oropharyngeal structures visible in an
upright, seated patient.
Slide 8
LEMON Obstruction Note anything that might interfere with
visualization or ET tube placement. Foreign body Obesity Hematoma
Masses
Slide 9
LEMON Neck mobility Sniffing position is ideal Neck mobility
problems most common with: Trauma patients Elderly patients
Slide 10
Endotracheal Intubation ET tube passes through glottic opening
and is sealed with a cuff inflated against the tracheal wall
Orotracheal intubation: through the mouth Nasotracheal intubation:
through the nose
Slide 11
Endotracheal Intubation Advantages Secure airway Protection
against aspiration Alternative to IV or IO route Disadvantages
Special equipment Physiologic functions bypassed Complications
Bleeding Hypoxia Laryngeal swelling Laryngospasm Vocal cord damage
Mucosal necrosis Barotrauma
Slide 12
Endotracheal Tubes Basic structure includes: Proximal end Tube
Cuff and pilot balloon Distal tip
Slide 13
Endotracheal Tubes Sizes range 2.5 to 9.0 mm in inside diameter
12 to 32 cm in length
Slide 14
Endotracheal Tubes Pediatric patients 2.5 to 4.5 mm tubes used
Funnel-shaped cricoid ring forms an anatomic seal with ET tube No
need for distal cuff in most cases.
Slide 15
Endotracheal Tubes Anatomic clues can help determine tube size
Internal diameter of the nostril approximates diameter of glottic
opening Diameter of the little finger or size of thumbnail
approximates airway size. Always have three sizes ready!
Slide 16
Laryngoscopes and Blades A laryngoscope is required to perform
orotracheal intubation by direct laryngoscopy. Consists of a handle
and interchangeable blades
Slide 17
Laryngoscopes and Blades Straight (Miller and Wisconsin) blades
Tip extends beneath epiglottis and lifts it up Useful with infants
and small children More likely to damage teeth in adults
Slide 18
Laryngoscopes and Blades Curved (Macintosh) blades Curve
conforms to tongue and pharynx Tip is placed in the vallecula
Indirectly lifts epiglottis to expose vocal cords
Slide 19
Laryngoscopes and Blades Blade sizes range from 0 to 4 0, 1,
and 2 appropriate for infants and children 3 and 4 considered adult
sizes Pediatric patients: based on age or height Adults: based on
experience, size of patient
Slide 20
Laryngoscopes and Blades Stylet: semirigid wire inserted into
ET tube Molds and maintains shape of tube Should be lubricated for
removal End should be bent to form a gentle curve End should rest
at least 1/2 from end of ET tube
Slide 21
Laryngoscopes and Blades Magill forceps Remove airway
obstructions under direct visualization. Guide tip of ET tube
through glottic opening if the proper angle cannot be achieved by
manipulating the tube
Slide 22
Orotracheal Intubation by Direct Laryngoscopy ET tube inserted
through mouth and into trachea while visualizing the glottic
opening with a laryngoscope
Slide 23
Orotracheal Intubation by Direct Laryngoscopy Indications
Airway control needed due to coma, respiratory arrest, and/or
cardiac arrest Ventilatory support before impending respiratory
failure Prolonged ventilatory support Absence of gag reflex
Traumatic brain injury Unresponsiveness Impending airway compromise
Medication administration
Slide 24
Orotracheal Intubation by Direct Laryngoscopy Contraindications
Intact gag reflex Inability to open mouth because of trauma,
dislocation of the jaw, or a pathologic condition Inability to see
the glottic opening Copious secretions, vomitus, or blood in
airway
Slide 25
Standard Precautions Intubation can expose you to bodily
fluids. Take proper precautions. Gloves Mask that covers your
entire face
Slide 26
Preoxygenation Critical before intubating 23 minutes for apneic
or hypoventilating patient Prevents hypoxia from occurring Monitor
SpO 2 and achieve as close to 100% saturation as possible.
Slide 27
Positioning the Patient Airway has three axes: mouth, pharynx,
and larynx At acute angles in neutral position Place patient in
sniffing position to facilitate visualization of the airway.
Slide 28
Positioning the Patient Sniffing position 20 extension of the
atlanto-occipital joint 30 flexion at C6 and C7 with short neck
and/or no chin Elevate head and/or neck until ear is at the level
of the sternum
Slide 29
Blade Insertion Position yourself at the patients head. Grasp
laryngoscope. If mouth is not open: Place thumb below bottom lip
and push open. Scissor thumb and index finger between molars Open
with tongue-jaw lift
Slide 30
Blade Insertion Insert blade into right side of mouth Sweep
tongue to the left while moving blade into midline Slowly advance
the blade. Jones & Bartlett Learning. Courtesy of MIEMSS.
Specimens provided by the Maryland State Anatomy Board, Department
of Health and Mental Hygiene at the Anatomical Services Division,
University of Maryland School of Medicine
Slide 31
Blade Insertion Exert gentle traction at a 45 angle as you lift
the patients jaw. Keep your back and arm straight as you pull
upward. Jones & Bartlett Learning. Courtesy of MIEMSS.
Specimens provided by the Maryland State Anatomy Board, Department
of Health and Mental Hygiene at the Anatomical Services Division,
University of Maryland School of Medicine
Slide 32
Visualization of the Glottic Opening Continue lifting the
laryngoscope as you look down the blade. Work the tip of the blade
into position. The glottic opening should come into view. The vocal
cords lie within. Courtesy of James P. Thomas, M.D.
www.voicedoctor.net
Slide 33
Visualization of the Glottic Opening Gum elastic bougie
Flexible device Approximately 1 cm in diameter, 60 cm long Used in
epiglottis-only views to facilitate intubation
Slide 34
Visualization of the Glottic Opening Gum elastic bougie (contd)
Insert through the glottic opening under direct laryngoscopy. Once
placed, it becomes a guide for the ET tube.
Slide 35
Tube Insertion Pick up preselected ET tube. Hold it near
connector as you would a pencil. Insert tube from the right corner
of mouth through the vocal cords. Continue until the proximal end
of the cuff is 1 to 2 cm past the vocal cords.
Slide 36
Tube Insertion Do not pass the tube down the barrel of the
laryngoscope blade. Will obscure your view of the glottic
opening
Slide 37
Ventilation After you have seen the ET tube cuff pass roughly
1/2 beyond the vocal cords Gently remove the blade. Secure tube
with right hand Remove stylet from tube
Slide 38
Ventilation Inflate the distal cuff with 5 to 10 mL of air,
then detach the syringe from the inflation port. Have your
assistant attach the bag-mask device to the ET tube; continue
ventilation. Ensure that the patients chest rises with each
ventilation.
Slide 39
Ventilation Listen to both lungs and to the stomach. You should
hear equal breath sounds and a quiet epigastrium. Ventilation
should be dictated by age. Adult with a pulse: 10 to 12 breaths/min
Infant/child with a pulse: 12 to 20 breaths/min Patient in cardiac
arrest: 8 to 10 breaths/min
Slide 40
Confirmation of Tube Placement Visualize the ET tube passing
between the vocal cords. Auscultate. Unequal or absent breath
sounds suggest: Esophageal placement Right mainstem bronchus
placement Pneumothorax Bronchial obstruction
Slide 41
Confirmation of Tube Placement Auscultate (contd). Bilaterally
absent breath sounds or gurgling over the epigastrium: esophagus
was intubated Immediately remove ET tube. Be prepared to suction
the airway.
Slide 42
Confirmation of Tube Placement Auscultate (contd). Breath
sounds only on right: tube has been advanced too far. Reposition
the tube.
Slide 43
Confirmation of Tube Placement With proper tube position:
Bag-mask device should be easy to compress. You should see
corresponding chest expansion. Increased resistance may indicate:
Gastric distention Esophageal intubation Tension pneumothorax
Slide 44
Confirmation of Tube Placement Continuous waveform capnography
plus clinical assessment Most reliable method of confirming
placement Attach capnography T-piece when bag-mask device is
attached to the ET tube.
Slide 45
Confirmation of Tube Placement Esophageal detector device
Syringe model: plunger is withdrawn Tube in the trachea: plunger
does not move Tube in the esophagus: plunger moves back Courtesy of
Marianne Gausche-Hill, MD, FACEP, FAAP
Slide 46
Confirmation of Tube Placement Esophageal detector device
(contd) Bulb model: bulb is squeezed Tube in the esophagus: bulb
remains collapsed Tube in the trachea: bulb briskly expands
Courtesy of Marianne Gausche-Hill, MD, FACEP, FAAP
Slide 47
Confirmation of Tube Placement After confirming proper
placement, mark ET tube where it emerges from the mouth Shows
others whether tube has slipped in or out
Slide 48
Securing the Tube Never take your hand off the ET tube before
securing with an appropriate device. Support the tube manually
while you ventilate to avoid a sudden jolt from the bag-mask
device.
Slide 49
Securing the Tube Steps: Note the centimeter marking on the ET
tube. Remove the bag-mask device. Position the tube in the center
of the mouth. Place the securing device over the tube. Reattach the
bag-mask device, auscultate, and note the capnography reading and
waveform.
Slide 50
Securing the Tube Many devices feature a built-in bite block.
Alternative: Secure tube with tape and insert a bite block or oral
airway. Minimize head movement in patient.
Slide 51
Nasotracheal Intubation Insertion of tube into trachea through
nose Indicated: Breathing spontaneously but requires definitive
airway management
Slide 52
Nasotracheal Intubation Advantages Can be performed on
responsive patients No need for laryngoscope Mouth does not need to
be opened Does not require sniffing position Patient cannot bite
the tube. Can be secured more easily Disadvantage Blind technique
Complications Bleeding Contraindicated: Apnea Head trauma and
midface fractures Anatomic abnormalities; frequent cocaine use
Slide 53
Nasotracheal Intubation Equipment Same as for orotracheal
intubation Minus laryngoscope and stylet Some tubes are designed
for blind method Some devices allow confirmation of intubation
without placing face next to tube
Slide 54
Technique for Nasotracheal Intubation Patients spontaneous
respirations guide the tube and confirm proper placement. Tube is
advanced as patient inhales
Slide 55
Technique for Nasotracheal Intubation Insert tube into nostril,
bevel facing toward the nasal septum Aim tip straight back toward
ear Position just above the glottic opening Jones & Bartlett
Learning. Courtesy of MIEMSS.
Slide 56
Technique for Nasotracheal Intubation Manipulate head to
control tube tip position and to maximize air movement. Instruct
patient to take a deep breath, and gently advance tube. Placement
will be evidenced by an increase in air movement through the
tube.
Slide 57
Technique for Nasotracheal Intubation Soft-tissue bulge on
either side of the airway Tube is probably in the piriform fossa
Hold head still, slightly withdraw the tube Once maximum airflow is
detected, advance tube No soft-tissue bulge Tube has entered the
esophagus. Withdraw until you detect airflow; extend head.
Slide 58
Technique for Nasotracheal Intubation Once tube is in place,
inflate the distal cuff Attach bag-mask device and ventilate. Clean
up any secretions or excess lubricant. Secure the tube with tape.
Document depth of insertion at the nostril.
Slide 59
Digital Intubation Directly palpate the glottic structures and
elevate the epiglottis with your finger while guiding the ET tube
into the trachea. Option in extreme circumstances
Slide 60
Digital Intubation Indications (exceptional circumstances)
Laryngoscope, or other techniques, have failed Patient in confined
space Patient is obese or has a short neck Copious secretions Head
cannot be moved Cannot visualize intubation landmarks
Slide 61
Digital Intubation Can be performed in pediatric patients, but
usually impossible due to finger size Absolutely contraindicated if
patient is: Breathing Not deeply unresponsive Has intact gag
reflex
Slide 62
Digital Intubation Advantages Does not require a laryngoscope
Ideal if vocal cords are obscured by secretions Does not require
sniffing position Disadvantages Risk of being bitten Risk of
exposure to infectious disease
Slide 63
Digital Intubation Complications Misplacement of the ET tube
Bite block can cause lip and tooth damage Vigorous or improper
attempts can cause airway trauma or swelling. Can result in
hypoxia
Slide 64
Digital Intubation Equipment Same as for orotracheal intubation
(minus laryngoscope), plus fingers Stylet ETCO 2 detector or
esophageal detector device Appropriate device to secure the
tube
Slide 65
Technique for Digital Intubation Prepare equipment as assistant
ventilates Select tube: one half to a full size smaller than with
direct laryngoscopy Tip of the tube is guided into the trachea
Slide 66
Technique for Digital Intubation Two configurations are
recommended. Open J configuration U-handle configuration Jones
& Bartlett Learning. Courtesy of MIEMSS.
Slide 67
Technique for Digital Intubation Sniffing position is not
required Insert bite block between molars. Insert index and middle
fingers into right side of the mouth. Press against tongue. Pull
epiglottis forward.
Slide 68
Technique for Digital Intubation Hold ET tube in right hand;
insert it into the left side of the mouth Advance tube toward the
glottis Once you feel the cuff pass 2 beyond your fingertip,
stabilize the tube and withdraw fingers Remove the stylet and
inflate the cuff.
Slide 69
Technique for Digital Intubation Attach bag-mask device and
ventilate. Confirm placement. Auscultate lungs and epigastrium.
Monitor ETCO 2. Properly secure the tube in place.
Slide 70
Transillumination Techniques for Intubation
Slide 71
Bright light source placed inside the trachea emits a bright,
well- circumscribed light Jones & Bartlett Learning. Courtesy
of MIEMSS.
Slide 72
Transillumination Techniques for Intubation Indicated Other
techniques have failed. Contraindicated Intact gag reflex Airway
obstruction May be difficult in obese or short neck patients
Pediatric patients: stylet must fit inside tube
Slide 73
Transillumination Techniques for Intubation Advantages No
laryngoscope Visual parameter Does not require visualization of the
glottic opening Safe with possible spinal injuries Disadvantages
Special equipment Proficiency with equipment Can be difficult in
brightly lit areas Complications Misplacement
Slide 74
Transillumination Equipment Device with a rigid stylet and a
bright light source at the end Light should shine laterally and
forward. Stylet must be long enough to accommodate a
standard-length ET tube Stylet must be secured within the tube
Slide 75
Technique for Transillumination-Guided Intubation Preoxygenate
for at least 2 to 3 minutes. Choose ET tube and check the cuff
Lubricate and insert the lighted stylet. Ensure it is firmly seated
into the tube.
Slide 76
Technique for Transillumination-Guided Intubation Bend tube
into the proper shape Head in neutral or slightly extended position
While holding the stylet, displace the jaw forwardly. Turn on the
lighted stylet, and insert it in the midline of the mouth.
Slide 77
Technique for Transillumination-Guided Intubation Continue
insertion; draw wrist toward you. Tightly circumscribed light
slightly below the thyroid cartilage: tube has entered trachea
Faintly glowing light and bulging of the soft tissue: tube is in
the vallecular space. Dim, diffuse light at the anterior part of
the neck: esophageal placement
Slide 78
Technique for Transillumination-Guided Intubation Once light is
visible at the midline, hold the stylet in place and advance the
tube. When the tube is in the trachea, stabilize it and withdraw
the stylet. Inflate the distal cuff, detach the syringe, and attach
the bag-mask device.
Slide 79
Technique for Transillumination-Guided Intubation Ventilate the
patient while auscultating both lungs and the epigastrium. Secure
the tube and continue ventilations.
Slide 80
Retrograde Intubation
Slide 81
Needle: placed percutaneously within the trachea via the
cricothyroid membrane Wire: placed through the needle, through the
trachea, into the mouth Wire is visualized, secured ET tube is
placed over wire and guided into trachea
Slide 82
Retrograde Intubation Indications Upper airway obstruction
Copious secretions in the airway Failure to intubate by less
invasive methods Contraindications Lack of familiarity with the
procedure Laryngeal trauma Unrecognizable or distorted landmarks
Coagulopathy Severe hypoxia
Failed Intubation Definition: Failure to maintain oxygen
saturation during or after one or more failed intubation attempts
Total of three failed intubation attempts
Slide 87
Failed Intubation Many rescue airway techniques Simple BLS
airway maneuvers with oral airway and/or nasal airway and bag-mask
device Rescue airway device
Slide 88
Tracheobronchial Suctioning Involves passing a suction catheter
into the ET tube to remove pulmonary secretions Do not do it if you
do not have to! If it must be performed: Use sterile technique.
Monitor cardiac rhythm and oxygen saturation.
Slide 89
Tracheobronchial Suctioning Preoxygenate for at least 2 to 3
minutes. Insert suction catheter until resisted. Apply suction as
the catheter is extracted Reattach bag-mask device, continue
ventilations, and reassess.
Slide 90
Field Extubation Extubation: process of removing tube from an
intubated patient Before performing, contact medical control or
follow local protocols.
Slide 91
Field Extubation Risks Over-estimating patients ability to
protect airway Laryngospasm Upper airway swelling Do not remove
tube unless you can reintubate!
Slide 92
Field Extubation Contraindicated with any risk of recurrent
respiratory failure or uncertainty about a patients ability to
maintain airway If indicated, ensure adequate oxygenation.
Slide 93
Field Extubation Explain procedure to patient Have patient sit
up or lean slightly forward. Assemble equipment to suction,
ventilate, and reintubate.
Slide 94
Field Extubation Confirm patient can protect airway Suction
oropharynx Deflate distal cuff as patient exhales On next
exhalation, remove tube
Slide 95
Pediatric Intubation Technique
Slide 96
Pediatric Endotracheal Intubation If bag-mask is not producing
adequate ventilation, patient should be intubated Indications are
the same as those in adults
Slide 97
Laryngoscope and Blades Thinner pediatric handles are
preferred. Straight blades facilitate lifting of epiglottis Blade
should extend from mouth to ear
Slide 98
Laryngoscope and Blades Use length-based resuscitation tape
measure or the following guidelines: Premature newborn: size 0
straight blade Newborn to 1 year: size 1 straight blade 2 years to
adolescent: size 2 straight blade Adolescent and older: size 3
straight or curved blade
Slide 99
Endotracheal Tubes To estimate the appropriate size:
Length-based resuscitation tape measure Formulas [Age (in years) +
16] 4 [Age (in years) 4] + 4 Anatomic clues General guidelines
Courtesy of Marianne Gausche-Hill, MD, FACEP, FAAP Jones &
Bartlett Learning. Courtesy of MIEMSS.
Slide 100
Endotracheal Tubes Cuffed ET tubes are generally not used in
the field until the child is 8 to 10 years old. Can cause ischemia
and damage the tracheal mucosa Have tubes one size smaller and one
size larger than expected
Slide 101
Endotracheal Tubes Appropriate depth of insertion is 2 to 3 cm
beyond the vocal cords Record depth at corner of mouth Uncuffed
tubes: stop when black band is at the vocal cords. Cuffed tubes:
stop when cuff is just below the vocal cords.
Slide 102
Pediatric Stylet Insert into tube, stop at least 1 cm from end
Fit tube sizes 3.0 to 6.0 mm After inserting into tube, bend tube
into a gentle upward curve
Slide 103
Preoxygenation Preoxygenate for at least 2 to 3 minutes. Ensure
that the childs head is in the sniffing position or the neutral
position. If needed, insert an airway adjunct.
Slide 104
Additional Preparation Monitor cardiac rhythm. Monitor pulse
rate and oxygen saturation. Have suction available. Atropine
sulfate may be administered.
Slide 105
Pediatric Intubation Technique With head in sniffing position,
apply thumb pressure on chin to open mouth. If an oral airway was
inserted, remove it. Suction if needed. Hold the laryngoscope in
trigger finger position.
Slide 106
Pediatric Intubation Technique Insert the blade in the right
side of the mouth. Sweep tongue to the left, keep under blade.
Advance the blade; apply traction upward. Never use teeth/gums as a
fulcrum for the blade
Slide 107
Pediatric Intubation Technique Straight blade: When the blade
passes the epiglottis, gently lift the epiglottis. Curved blade:
place blade tip in vallecula; lift jaw, tongue, and blade at a 45
angle. Identify vocal cords and other landmarks.
Slide 108
Pediatric Intubation Technique Hold tube in right hand; insert
from the right- side corner of the mouth. Guide tube through the
vocal cords, advancing until black band is just beyond Record the
depth, and remove the blade.
Slide 109
Pediatric Intubation Technique Remove stylet; hold tube in
place. Recheck tube depth. Cuffed tube: inflate to form seal Attach
tube to bag-mask device.
Slide 110
Pediatric Intubation Technique Confirm tube placement.
Bilateral chest rise during ventilation Auscultate lungs
bilaterally. If sounds are decreased on left, tube may be too deep.
To correct, withdraw tube until sounds are equal. Rerecord tube
depth.
Slide 111
Pediatric Intubation Technique Auscultate over epigastrium.
Bubbling sounds indicate esophageal intubation. Additional methods
to confirm placement: Improvement in skin color, pulse rate, and
oxygen saturation Waveform capnography
Slide 112
Pediatric Intubation Technique Colorimetric ETCO 2 detector or
EDD Cannot be used in children weighing < 15 kg Esophageal bulb
or syringe cannot be used in children weighing < 20 kg After
placement, secure tube Reconfirm placement following any
movement.
Slide 113
Pediatric Intubation Technique If tube is too large or you
cannot identify the vocal cords and glottic landmarks: Abort
intubation and ventilate. Modify equipment and start from the
beginning. If intubation cannot be accomplished after two attempts,
discontinue.
Slide 114
Pediatric Intubation Technique If childs condition
deteriorates, use DOPE for common causes. Displacement Obstruction
Pneumothorax Equipment failure
Slide 115
Complications of Endotracheal Intubation Essentially the same
as for adults Unrecognized esophageal intubation Induction of
emesis and aspiration Hypoxia Damage to teeth, soft tissues, and
intraoral structures