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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 Deepi G. Goyal, M.D. Mayo Clinic Department of Emergency Medicine
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
Indications for Intubation • Is there a failure of oxygenation or ventilation? • Is there a failure of airway protection? • What is the anticipated clinical course?
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
Indications for Intubation • Failure of Oxygenation/Ventilation • A Clinical Decision • Do NOT rely on ABGs • Mentation • Fatigue • Concomitant Injuries
Indications for Intubation • Failure of Airway Protection • Loss of upper airway musculature • Loss of protective reflexes
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
Indications for Intubation • Failure of Airway Protection • Gag reflex unreliable in predicting aspiration risk • Swallowing • Complex reflex • Better tool than gag
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
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
Airway Management • Manual ventilation • Direct laryngoscopy and intubation • Techniques for difficult airways • Confirmation of ETT placement
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
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
Manual Ventilation • Head Positioning • The tongue is your “Enemy”!! • Position head to prevent tongue from obstructing airway • Chin lift • Jaw Thrust
Manual Ventilation • Maintaining airway patency • Use Adjuncts!!! • Nasal airway • Oral Airway
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
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
Airway Management • Barriers • Patient Cooperation • Anatomy • Time
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
Manual Ventilation • Head positioning • “Sniffing” position optimizes alignment of oral, pharyngeal, and laryngeal axes
Laryngoscopy • Goal • Use laryngoscope blade to lift epiglottis anteriorly to visualize vocal cords • Insert endotracheal tube through vocal cords
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
Rapid Sequence Intubation • Tube Confirmation • Listen to both lungfields • Listen again • Pulse Oximetry • End-Tidal CO2 • Aspiration Devices
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
Intubating LMA • Intubating Laryngeal Mask Airway
Combitube • Double lumen tube inserted blindly • Distal lumen usually inserted into esophagus • Shown to be effective, esp. in prehospital settings
Combitube • Insert Combitube gently in a curved downward movement • Insert until printed ringmarks lie between teeth or alveolar ridges. • Do not use force !
Combitube • Inflate the oropharyngeal balloon with the syringe with the blue dot • Inflate the distal cuff with the syringe with the white dot
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
Combitube • 10% inserted into the trachea • If auscultation through the blue port is negative, switch to the shorter port and ventilate trachea directly
Nasal intubation • Should be a skill learned by every MD who may intubate on a regular basis
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
Nasal intubation • Prep nostril with Lidocaine spray and phenylephrine • Use smaller ET tube • Use plenty of lubrication
Nasal intubation • Insert in larger nostril • Insert straight back • Insert until passed upper pharyngs • Watch for fogging of tube
Nasal intubation • Insert during inspiration • or coughing • or gagging
Nasal intubation • Check placement….. • Remember an intubated pt can NOT talk • Double check placement…. • Listen to breathsounds • use CO2 device if available
Nasal intubation • If not sure properly intubated pull back and re-try • Re-position head • Apply cricoid pressure • Try again
Nasal intubation • Avoid in: • suspect basal skull fracture • suspect hemophilia or thrombocytophilia • Prohibiting facial trauma • Epiglottitis etc.
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
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)