Airway Management

Recognition of Airway ObstructionSystematic method of detecting airway obstruction :Look, listen and feelLook for chest and abdominal movementListen and feel for airflow at the mouth and nose.

Recognition of Airway ObstructionCharacteristic sounds in airway obstruction :Gurgling : liquid or semisolid foreign material in the main airway.Snoring : pharyng is partially occluded by soft palate or epiglottis.Crowing : sound of laryngeal spasm.Inspiratory stridor : obsruction at laryngeal level or above.Expiratory wheeze : obstruction of the lower airway.

Patient AssessmentLevel of consciousnessSpontaneous efforts vs. apneaAirway and cervical spine injuryChest expansionSigns of airway obstructionSigns of respiratory distressProtective airway reflexes

Opening the Airway the Triple Airway ManeuverSlightly extend neck (when cervical spine injury not suspected)Elevate mandibleOpen mouth

Hand Positioning the Triple Airway Maneuver

Reassess Spontaneous Breathing (Ventilation) When Airway OpenAdequate oxygen supplementationInadequate manual assisted ventilation

Manual Assisted VentilationApply face maskOro-/nasopharyngeal airway adjunctsMouth opening Hand positioningElevate mandible and chin Resuscitation bag compression volume and frequency

Single-Hand Method of Facemask ApplicationBase of mask placed over chin and mouth openedApex of mask over noseMandible elevated, neck hyperextended (no cervical spine injury), and downward pressure by mask hand

Two-Hand Method of Facemask ApplicationIndicationsDemonstration

Inadequate Mask-to-Face Seal

Identify leakReposition face maskImprove seal along cheek(s)Slightly increase downward pressure over face or neck extension (if no cervical spine injury)Use two-hand technique

Preparation for Endotracheal IntubationContinue adequate ventilation and hyperoxygenationDecompress stomach Assess degree of difficulty for intubationAnalgesia, sedation, amnesia, neuromuscular blockade as needed

Degree of DifficultyMicrognathiaCervical spine statusFacial injury, surgery, scarringThyromental distance (short neck)Mouth opening and Mallampati classification

Mallampati Classification

Analgesia, Sedation, Amnesia, Neuromuscular BlockadeAnalgesia topical, nerve blocks, sedationSedation/amnesia rapid acting, short duration, reversibleFentanyl: 25100 g iv, titrated to effectMidazolam: 12 mg iv, titrated to effectEtomidate: 0.30.4 mg/kg iv, titrated to effect

Analgesia, Sedation, Amnesia, Neuromuscular BlockadeNeuromuscular blockers assess needSuccinylcholine: 11.5 mg/kg iv bolus; depolarizing agent Vecuronium: 0.10.3 mg/kg iv bolus; nondepolarizing agent

Orotracheal Intubation Preparation

Appropriate monitoring oximetry, ECG, BPAssemble equipmentLaryngoscope test light, select bladeEndotracheal tube test cuff, lubricateStylet insert, angulateSuction testMagill forceps

Orotracheal Intubation PreparationDon protective garbElevate occiput with pad if no cervical spine injury suspectedProvide anesthesia, sedation, amnesia, and neuromuscular blockade as required

Orotracheal Intubation TechniqueProper operator position Holding the laryngoscope handleApplication of cricoid pressureMouth opening methods

Orotracheal Intubation TechniqueInsertion of laryngoscope blade tongue controlTongue displacement medially visualize epiglottis

Orotracheal Intubation TechniqueAdvance laryngoscope into position (vallecula for curved blade; under epiglottis for straight blade)Elevate base of tongue and expose glottic opening

Orotracheal Intubation TechniqueElevate base of tongue further to fully expose glottic opening and surrounding anatomy

Orotracheal Intubation TechniqueInsert endotracheal tube under direct vision to 2325 cm at lipRemove stylet and laryngoscope, inflate tube cuffConfirm tube position breath sounds, CO2 detectorSecure endotracheal tubeObtain chest radiograph

Orotracheal Intubation TechniqueStraight blade position, elevating the epiglottisBe aware of laryngospasm when epiglottis is touched

Pediatric ConsiderationsInfections commonly cause airway obstruction in young childrenBecause infants are obligate nose breathers until ~ age 6 months, suctioning nares may establish an open airwayWhen possible, allow child to assume position of comfort in early respiratory compromise

Pediatric ConsiderationsFace mask may agitate child several delivery devices should be availableIf obtunded or unable to assume a comfortable position, sniffing position is preferred in infants and young children to minimize airway obstruction from soft tissues (when no cervical spine injury is suspected)Overextension of neck may cause airway obstruction

Pediatric ConsiderationsPositive pressure during bag-mask ventilation may cause gastric distention; a nasogastric tube may be needed Tongue in infants and children up to ~ age 2 yrs occupies relatively large portion of oral cavity and is likely to cause obstruction during spontaneous breathing and manually assisted ventilation

Pediatric Considerations for Orotracheal Intubation

Secure patient for procedurePad or towel under shoulders of infant may be better than elevation of occiputEndotracheal tube size approximates size of patients small fingerUncuffed endotracheal tubes usually used when patient < 8 yrs old Straight laryngoscope blade usually used

Pediatric Considerations for Orotracheal IntubationObserve cervical spine precautions as neededRelatively larger tongue, angle of attachment of epiglottis, anterior and more cephalad position of larynx make exposure of glottic opening more difficult

Pediatric Considerations for Orotracheal IntubationCricoid pressure may improve visualization of glottisTrachea relatively short so mainstem intubation may occur more easilyDepth of insertion estimated by multiplying internal diameter of endotracheal tube by 3 (e.g., 4.0 tube 3 = 12 cm insertion depth)

Key Points