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Introduction to Airway Management

Introduction to Airway Management. Deepi G. Goyal, M.D. Mayo Clinic Department of Emergency Medicine. Who Needs to be Intubated?. Airway Management. Which of the following is most important when evaluating a 29 y/o pt with polypharmacy OD with respect to need for intubation?.

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Introduction to Airway Management

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  1. Introduction to Airway Management Deepi G. Goyal, M.D. Mayo Clinic Department of Emergency Medicine

  2. Who Needs to be Intubated?

  3. Airway Management • Which of the following is most important when evaluating a 29 y/o pt with polypharmacy OD with respect to need for intubation? • Arterial Blood Gas Results • Hemodynamic instability • Pulse Oximetry • Clinical Evaluation of pt’s ability to maintain & protect airway and exchange gases • Gag reflex, chest auscultation, CXR

  4. Indications for Intubation • Is there a failure of oxygenation or ventilation? • Is there a failure of airway protection? • What is the anticipated clinical course?

  5. Oxygenation/Ventilation • Which of the following is TRUE regarding arterial blood gases? • A low pO2 should drive the decision to intubate • A high pCO2 should drive the decision to intubate • Neither A nor B • Both A and B

  6. Indications for Intubation • Failure of Oxygenation/Ventilation • A Clinical Decision • Do NOT rely on ABGs • Mentation • Fatigue • Concomitant Injuries

  7. Indications for Intubation • Failure of Airway Protection • Loss of upper airway musculature • Loss of protective reflexes

  8. Airway adequacy • Which of the following is LEAST helpful in terms of determining airway adequacy? • Absence of a gag reflex • Pooling of secretions • Ability of the patient to phonate • Anatomic features such as infections and trauma

  9. Indications for Intubation • Gag

  10. Indications for Intubation • Failure of Airway Protection • Gag reflex unreliable in predicting aspiration risk • Swallowing • Complex reflex • Better tool than gag

  11. Indications for Intubation • Anticipated Clinical Course • Currently acceptable anatomy and physiology may deteriorate • Expanding neck hematoma • Work of breathing may be overwhelming in light of multiple major injuries • Patient cooperation required for diagnostic/therapeutic interventions

  12. Airway Management • Which of the following is the MOST IMPORTANT skill for airway management • Knowledge of proper blade and tube selection for intubation • Familiarity with proper direct laryngoscopy techniques • Ability to manually ventilate using bag-valve-mask • Both A and B

  13. Airway Management • Manual ventilation • Direct laryngoscopy and intubation • Techniques for difficult airways • Confirmation of ETT placement

  14. Airway Management • Which of the following is NOT a patient factor that would negatively impact the ability to ventilate a patient ? • Presence of a beard • Obesity • Endentulous patient • Large tongue • All of the above would negatively impact ventilation

  15. Manual Ventilation • Cornerstone for airway management • Allows for decreased urgency when intubating and options for failed attempts • Components • Head positioning • Maintaining airway patency • Mask seal

  16. Manual Ventilation • Head Positioning • The tongue is your “Enemy”!! • Position head to prevent tongue from obstructing airway • Chin lift • Jaw Thrust

  17. Manual Ventilation • Maintaining airway patency • Use Adjuncts!!! • Nasal airway • Oral Airway

  18. Manual Ventilation • Mask Seal • Start with mask on nasal bridge and lever it onto malar eminences and alveolar ridge • Apply pressure with thumb and index finger to assure adequate seal • Use digits 3,4,5 to hold mandible and thrust it forward

  19. Manual Ventilation • Pearls • Use K-Y jelly on beards • For pts with sallow cheeks, fold and place 4x4’s in cheeks • Reinsert false teeth if necessary

  20. Airway Management • Barriers • Patient Cooperation • Anatomy • Time

  21. Airway Management • Barriers • Patient cooperation • Anatomy • Distortion (Trauma, infection, neoplasm, hemorrhage, vomitus) • Disproportion (tongue/pharynx, thyromental distance) • Dysmobility (Neck mobility, TMJ) • Dentition (prominent incisors) • Time

  22. Manual Ventilation • Head positioning • “Sniffing” position optimizes alignment of oral, pharyngeal, and laryngeal axes

  23. Laryngoscopy • Goal • Use laryngoscope blade to lift epiglottis anteriorly to visualize vocal cords • Insert endotracheal tube through vocal cords

  24. Placement of ET Tube

  25. Airway Management • Barriers • Patient cooperation • Anatomy • Distortion (Trauma, infection, neoplasm, hemorrhage, vomitus) • Disproportion (tongue/pharynx, thyromental distance) • Dysmobility (Neck mobility, TMJ) • Dentition (prominent incisors) • Time

  26. Rapid Sequence Intubation • Tube Confirmation • Listen to both lungfields • Listen again • Pulse Oximetry • End-Tidal CO2 • Aspiration Devices

  27. Laryngeal Mask Airway • Laryngeal Mask Airway • Inserted blindly and forms seal around laryngeal inlet • Insertion no more difficult in class III or IV airways or in those with grade III or IV view • As stimulating as oropharyngeal airway • Does not protect against aspiration

  28. Intubating LMA • Intubating Laryngeal Mask Airway

  29. Combitube • Double lumen tube inserted blindly • Distal lumen usually inserted into esophagus • Shown to be effective, esp. in prehospital settings

  30. Combitube • Insert Combitube gently in a curved downward movement • Insert until printed ringmarks lie between teeth or alveolar ridges. • Do not use force !

  31. Combitube • Inflate the oropharyngeal balloon with the syringe with the blue dot • Inflate the distal cuff with the syringe with the white dot

  32. Combitube • Test ventilation via the longer blue tube (#1) • Air cannot escape at the distal end of the blocked "esophageal" lumen and enters the pharynx via the perforations • Since mouth, nose, and esophagus are sealed by the balloon and the cuff, air is forced into the trachea

  33. Combitube • 10% inserted into the trachea • If auscultation through the blue port is negative, switch to the shorter port and ventilate trachea directly

  34. Nasal intubation • Should be a skill learned by every MD who may intubate on a regular basis

  35. Nasal Intubation • Requires spontaneous respiration • Requires skill and experience • Can be done in ~ 90% of ED intubations • Can be done in sitting position • No sedation/paralytics needed • Very Rapid

  36. Nasal intubation • Prep nostril with Lidocaine spray and phenylephrine • Use smaller ET tube • Use plenty of lubrication

  37. Nasal intubation • Insert in larger nostril • Insert straight back • Insert until passed upper pharyngs • Watch for fogging of tube

  38. Nasal intubation • Insert during inspiration • or coughing • or gagging

  39. Nasal intubation • Check placement….. • Remember an intubated pt can NOT talk • Double check placement…. • Listen to breathsounds • use CO2 device if available

  40. Nasal intubation • If not sure properly intubated pull back and re-try • Re-position head • Apply cricoid pressure • Try again

  41. Nasal intubation • Avoid in: • suspect basal skull fracture • suspect hemophilia or thrombocytophilia • Prohibiting facial trauma • Epiglottitis etc.

  42. Summary • Know the indications for intubation • Be comfortable with BVM • Understand anatomy • Use adjuncts • Nasally intubate if breathing • Use optimal technique and equipment for laryngoscopy

  43. Summary • Final tips • Recognize structures • Use a properly styletted endotracheal tube • Control the tongue • Use all available help • Use external laryngeal manipulation • Know your options if you are unable to intubate (cricothyrotomy)

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