Airway Management (Videos) - Mayur

Airway ManagementAirway Management

Presented By:

Mayur Jain

Introduction Introduction Difficulty in breathing is one of

the most disconcerting problems for the patient who is conscious yet unable to breath properly. One needs to be aware of the psychological aspect of the patient while management of airway obstruction.

Indications

Indications of Airway ManagementIndications of Airway Management

Maxillofacial traumaAspiration of foreign bodyVasodepressor syncopeAsthmaHeart failureHypoglycemiaOverdose reactionAnaphylaxisEpilepsy

Diagnosis

Diagnosis of Airway Diagnosis of Airway ObstructionObstruction

LOOK : Respiratory movements, gasping , suprasternal retraction

LISTEN: Breath sounds

FEEL : Expired air

DiagnosisDiagnosis of Airway Obstruction of Airway Obstruction

Abnormal sounds in airway obstruction◦Snoring - due to obstruction of upper

airway by the tongue ◦Gurgling - due to obstruction of upper

airway by liquids (blood, vomit) ◦Wheezing - due to narrowing of the

lower airways ◦Complete airway obstruction is silent.

Definition of Airway Definition of Airway managementmanagement

Definition of Airway Definition of Airway managementmanagement

“Airway management involves ensuring that the patient has a patent airway through which effective ventilation can take place.”

PurposePurpose

PurposePurposeDeprived of oxygen; brain death will

occur within minutes. To provide an artificial airway that is

as close to the patient's natural airway as possible along with a continuous source of oxygen.

Anatomy of Respiratory Anatomy of Respiratory SystemSystem

Anatomy of Respiratory Anatomy of Respiratory SystemSystemThe airways can be divided in to parts namely: The upper airway. The lower airway

The Upper Airway

EpiglottisMandibleFrontal SinusSoft PalateTracheaGlottisEsophagusVocal Cords

ABCDEFGH

The Upper Airway Other Structures

◦ Nasopharynx◦ Oropharynx◦ Laryngopharynx◦ Larynx

The Upper AirwayThe Upper Airway

Functions of the Upper Airway

Passageway for air

Warm Filter Humidify Protection

◦ Gag Reflex◦ Cough

Speech

The Lower AirwayPrimary Bronchi

Hyoid Bone

Right Lung

Secondary Bronchi

Tracheal Ligament

Trachea

Larynx

Esophagus

Left Lung

Trachea

A

B

C

D

E

F

G

H

I

J

Difference Between Adult And Infant Airway

Adult Infant

Alveoli Gas Exchange

Lungs Structure Lobes Pleura

Mallampati GradesMallampati Grades

Difficulty

Class I Class II Class III Class IV

Class I: Uvula/tonsillar pillars visibleClass II: Tip of uvula/pillars hidden by tongueClass III: Only soft palate visibleClass IV: Only hard palate visible

Airway management Airway management proceduresprocedures

Airway management Airway management proceduresproceduresA. Noninvasive procedures

1. Back Blows2. Head Tilt Chin lift procedure3. Heimlich maneuver (Abdominal thrust)4. Chest thrust5. Finger sweep6. Ambu -Bag

B. Invasive procedures1. Oropharangeal airway 2. Nasopharangeal airway3. Cricothyroidectomy4. Tracheotomy5. Endotracheal tube6. Laryngeal Mask Airway

Non Invasive ProceduresNon Invasive Procedures

Back BlowsBack Blows


◦ Indications: Infants

◦ Contraindications:Not recommended for Children and

adults◦ Advantages

Ease


◦Disadvantages1.Not as effective as Heimlich

Maneuver◦Procedure

1.Hold the infant in one hand2.Head lower than trunk3.Support jaws4.Blow with heel of hands between

shoulder blades

Back Blow Video

Heads Tilt Chin lift procedure

Head Tilt Chin lift procedure

Indications :◦To open the airway

Caution with :◦Suspected Neck injury

Procedure :◦One hand on forehead to tilt head

back ◦With fingers of other hand Lift

mandible upward and outward

Heads Tilt Chin lift procedure: Video

Heimlich maneuver Heimlich maneuver

Heimlich maneuver Heimlich maneuver ◦ Indications:

To remove foreign body.◦ Advantages

Effective procedure◦ Disadvantages

Injury to intra-abdominal organs may occur

Heimlich maneuverHeimlich maneuver

◦Procedure Conscious patient :1.Position behind patient and wrap

arms around waist2.Grasp one fist with other hand and

position it slightly above umbilicus; caution- xiphoid process

3. Inward and upward thrusts until foreign body is out.

Heimlich Manuever : Conscious Patient Video

Heimlich manueverHeimlich manuever

Procedure◦Unconscious patient :

1. Patient positioned supine

2. Open airway by “head tilt technique”3. Place heel of one hand on abdomen just above the umbilicus and second hand on top of that4. Provide 6-10 thrusts.

Chest ThrustChest Thrust

Chest ThrustChest Thrust◦ Indications:

1. Infant and child upto 8 years old2. Pregnant female3. Extreme obesity

◦ Contraindications:1. Geriatric patients

◦ Advantages1. Alternative to Heimlich Maneuver

Chest ThrustChest Thrust◦ Procedure

Conscious victim :

1.Stand behind patient encircling victim’s chest

2.Place same grip on middle of sternum

3.Perform until foreign body is out

Chest ThrustChest Thrust◦ Procedure

Unconscious victim :

1.Supine position2.“Head tilt technique”3.Same hand position on lower half

of sternum4.6-10 downward thrusts

Jaw Thrust

Jaw ThrustIndication :

◦To open the airway blocked due to tongue prolapse

Procedure :◦Grasp the angles of the lower jaw,

one hand on each side, and displacing the mandible forward.

◦Thumbs opening the mouth

Jaw Thrust Video

Finger sweepFinger sweep

Finger sweepFinger sweep◦ Indications:

1.Removal of foreign body in unconscious patients

◦ Contraindications:1.Conscious patient

Finger sweepFinger sweep

◦ Procedure

1.Supine position2.Grasp tongue and anterio portion

of mandible, pull the tongue3.Use index finger to dislodge the

foreign body4.CAUTION: Don’t force the object

deep into airway

Ambu BagAmbu Bag

Ambu BagAmbu BagIndications:

◦Unconscious patients◦Supplemental oxygen Source

Advantages :◦Can be used directly with

Endotracheal tube Supplemental O2

◦Allows spontaneous ventilation

Ambu BagAmbu BagDiasdvantages:

◦Require special training◦Does not ensure adequate airway

Ambu BagAmbu Bag

Ambu BagAmbu BagTechnique:

◦Attach appropriate mask◦Ensure good seal◦Hold mask with one hand and

squeeze bag intermittently with other hand

Ambu BagAmbu Bag

Recovery Position Video

Invasive TechniquesInvasive Techniques

Invasive techniquesInvasive techniques Indications:

1.Failure of noninvasive techniques2.Obstruction due to swelling;

laryngeal edema, epiglottitis Contraindications:

1. Inadequate training2.Lack of proper equipments

Invasive TechniquesInvasive Techniques Advantages

1.Higher success rate Disadvantages:

1. Need for expertise2. Equipments3. Cost

Risks/Protective MeasuresRisks/Protective Measures

Be prepared for:◦Coughing◦Spitting◦Vomiting◦Biting

Body Substance Isolation◦Gloves◦Face masks◦Eye shields

Oropharyngeal AirwayOropharyngeal Airway

Oropharyngeal AirwayOropharyngeal AirwayIndications :

◦Unconscious but spontaneously breathing patients due to tongue positions

Advantages :◦Seperates tongue from posterior

pharyngeal wallDisadvantages :

◦Activates gag reflex in conscious patients

Oropharyngeal AirwayOropharyngeal AirwaySize :

◦Adult : 100 mm◦Small adult : 80 – 90 mm

Technique :◦Position◦Use tongue blade◦Insert inverted and later rotate

Oropharyngeal AirwayOropharyngeal AirwayVarious Sizes

Nasopharyngeal AirwayNasopharyngeal Airway

Nasopharyngeal AirwayNasopharyngeal AirwayIndications:

◦Tongue obstruction◦Inadequate oral opening◦Oral Surgery

Advantages :◦Well tolerated even in conscious

patientSizes : (Internal Diameter)

◦Large adult :8-9 mm◦Small adult : 6-8 mm


Various Sizes

Nasopharyngeal AirwayNasopharyngeal AirwayPositionDetermine the size of tubesLocal AnesthesiaLubricate

TracheotomyTracheotomy

TracheostomyTracheostomyDefinition :

“Formation of a fistulas hole between the skin and trachea”

TracheostomyTracheostomyClassification:

◦Emergency Tracheostomy◦Semi-emergency Tracheostomy◦Planned Tracheostomy

◦High Level : 1, 2, 3 tracheal rings ◦Low Level : 2,3,4 tracheal rings

◦Temporary : for respiratory distress◦Permanent :Laryngopharyngectomy

TracheotomyTracheotomy◦ Indications:

1. Long term airway maintenance2. Glottic edema3. Laryngeal nerve palsy4. Head injury5. Tetanus6. Coma7. Chest injury8. Laryngeal infections

TracheotomyTracheotomyContraindications:

◦ Cervical Spine fracture◦ Tracheomalecia◦ Carcinoma of trachea

Advantages◦ Bypass upper airway obstruction◦ Reduces the dead space◦ Attachment to vetilator is possible

TracheotomyTracheotomy

◦Equipments :

1.Blade2.Tracheal dilator3.Cats paw retractor4.Tracheostomy tube

TracheotomyTracheotomy Technique :

◦Patient position◦Hyperextension of neck◦Locate the cricoid cartilage◦Vertical incision of 2-3 cm◦Retract skin using Cat paw retractor◦Incise the trachea and dilate it using

tracheal dilator◦Apply 2% lignocain gauze ( Reflex)◦Insert the tracheotomy tubes

TracheotomyTracheotomyCompleted

tracheotomy:1 - Vocal cords2 - Thyroid cartilage3 - Cricoid cartilage4 - Tracheal cartilages5 - Balloon cuff

TracheotomyTracheotomy◦ Possible Complications

1. Perforation of esophagus2. Hemorrhage3. Pnemothorax4. Tracheal stenosis5. Loss of speech6. Chances of infection

Percutaneous TracheotomyProcedure

◦skin incision along relaxed skin tension lines

◦Insert of 14-gauge needle◦Tracheal dilatation◦Insert tracheostomy tube◦Connect ventilator tubing

Percutaneous Tracheotomy

CricothyrotomyCricothyrotomy

CricothyrotomyCricothyrotomy

Indications◦ Absolute need for definitive airway, AND

unable to perform ETI due to structural or anatomic reasons, AND

risk of not securing airway is > than surgical airway risk

OR◦ Absolute need for definitive airway AND

unable to clear an upper airway obstruction, AND

multiple unsuccessful attempts at ETT, AND other methods of ventilation do not allow for

effective ventilation, respiration

CricothyrotomyCricothyrotomyContraindications (relative)

No real demonstrated indication Risks > Benefits Age < 8 years (some say 10, some say

12) Evidence of fractured larynx or cricoid

cartilage Evidence of tracheal transection

Advantages: Less complications Less bleeding Heals within a few days

AnatomyAnatomy

Thyroid and cricoid cartilages

Cricothyroid membrane

AnatomyAnatomy

CricothyrotomyCricothyrotomy Equipments :

1. Scalpel No. 11 Blade2. Or 13 gauge half inch long needle

Cricothyrotomy VideoCricothyrotomy Video

CricothyrotomyCricothyrotomy Technique:

1. Supine position2. Hyperextension of neck3. Locate cricothyroid membrane4. Vertical skin incision5. Retract with thumb and index finger6. Horizontal incision as close to cricoid

cartilage as possible7. Rotate the blade at 90 degrees8. If available, insert tubes

Cricothyrotomy VideoCricothyrotomy Video

Endotracheal intubationEndotracheal intubation

Endotracheal IntubationEndotracheal Intubation

Introduction ◦Tube into trachea to provide

ventilations using ventilator

Endotracheal IntubationEndotracheal IntubationDefinition :

◦ Endotracheal intubation is the placement of a tube into the trachea (windpipe) in order to maintain an open airway in patients who are unconscious or unable to breathe on their own. Oxygen, anesthetics, or other gaseous medications can be delivered through the tube.

Endotracheal Intubation

Indications: ◦ Treatment of symptomatic hypercapnia.◦ Treatment of symptomatic hypoxemia.◦ Airway protection against aspiration.◦ Pulmonary toilet◦ Present or impending respiratory failure◦ Apnea◦ Unable to protect own airway

Contraindications: ◦ Awake patient.◦ Airway can be managed less invasively


Advantages◦Secures airway◦Route for a few medications ◦Optimizes ventilation, oxygenation◦Allows suctioning of lower airway

Hazards:◦Esophageal intubation◦Damage to vocal cords◦Damage to teeth (Laryngoscope)◦Endobroncheal intubation

Endotracheal IntubationEndotracheal Intubation Equipment:

1. Endotracheal tube

Adult female= 7- 8 mm

Adult Male = 8 – 9 mm

child = diameter of little finger

Endotracheal tubeEndotracheal tube

Endotracheal TubeEndotracheal Tube

Endotracheal TubesEndotracheal Tubes

Endotracheal IntubationEndotracheal Intubation Equipments1. Laryngoscope blade

1. Stright1. Adult : size 3 to 42. Child : Size 2-33. Baby : size 1- 2

2. Curved1. Adult : size 3 to 42. Child : Size 2-33. Baby : size 1- 2

Laryngoscope

Straight Laryngoscope

Curved Laryngoscope

Curved Blade (Macintosh)Curved Blade (Macintosh)

Insert from right to left

Visualize anatomy Blade in valleculaLift up and away

DO NOT PRY ON TEETH

Lift epiglottis indirectly

Straight Blade (Miller)Straight Blade (Miller)

Insert from right to left

Visualize anatomyBlade past vallecula

and over epiglottisLift up and away

DO NOT PRY ON TEETH

Lift epiglottis directly

Intubation Technique

Vocal Cords

LaryngoscopyLaryngoscopy

Endotracheal IntubationEndotracheal IntubationProcedure: Assess

◦ airway – note landmarks, swelling, deformities.

◦ Remove dentures. – Assess tongue size, dental obstruction, visibility of oropharynx,

◦ degree of neck mobility. - Maintain cervical spine stability as necessary.

Open airway: suction or manually extract foreign material. – Chin lift, jaw thrust.

Heimlich maneuver as needed.

Endotracheal IntubationEndotracheal IntubationPosition patient into “sniffing

position” if possible; restrain as necessary.

Standing at the supine patient’s head, gentle insert laryngoscope blade with left hand.

PositioningPositioning

PositioningPositioning

Patient Positioning◦ Goal

Align 3 planes of view, so

Vocal cords are most visible

◦ T - trachea◦ P - Pharynx◦ O - Oropharynx

Endotracheal Endotracheal IntubationIntubationVisualize glottic opening/vocal

cords.Insert the tubes

Endotracheal Endotracheal IntubationIntubation


Tip of blade is placed in vallecula, and laryngoscopeis lifted further to expose glottis. The tube is inserted

through the right side of the mouth.


Tube is advanced through vocal cords into trachea.

Tube PlacementTube Placement

Endotracheal Endotracheal IntubationIntubationInflate ETT cuff with 5 – 10 cc air

via syringe. Ventilate with bag and oxygen.


Tube is positioned so that cuff is below vocalcords, and laryngoscope is removed.


Methods for securing adhesive tape.

Endotracheal IntubationEndotracheal IntubationConfirm tube placement

◦ chest auscultation, ◦ CO2 monitor ◦ chest x-ray.


Complication: Prevention: Management:

Missing/broken teeth:

Remove loose teeth prior; avoid using upper teeth as fulcrum for laryngoscope blade.

Check chest x-ray to rule out aspiration.

Clenched teeth: Paralytic medication.

Air leak: Check cuff prior to beginning procedure.

Inject more air or change tube over guide wire.


Inability to visualize vocal cords:

Proper patient positioning, proper laryngoscope blade size, proper suctioning.

Reposition, choose a different blade, adequate suction, cricoid pressure by assistant.

Esophageal intubation:

Visualize cords. Remove tube, re-oxygenate and reinsert.

Laryngospasm: Spray vocal cords with 2% Lidocaine.

Benzodiazepine or paralytic medication.

Failure to intubate:

Have alternative plan prepared: cricothyrotomy.

Laryngeal Mask Airway

Laryngeal Mask AirwayIndications:

◦General Anesthesia◦Emergency◦In patients trapped in sitting position◦Unsuccessful intubation

Disadvantages :◦Does not protect lung from

aspiration

Laryngeal Mask Airway

Laryngeal Mask AirwayProcedure:

◦ Identify correct size◦ Lubricate◦ Anesthetize◦ Extend neck◦ Insert, follow the curvatures of oropharynx

and rest over pyriform fossa◦ Inflate cuff◦ Check position using sthethoscope◦ Attach to ventilator apparatus

LMA Placement

PharmacologyPharmacology

Pharmacologic Assisted IntubationPharmacologic Assisted Intubation

Sedation◦ Reduce anxiety◦ Induce amnesia◦ Depress gag reflex, spontaneous

breathing◦ Used for

induction anxious, agitated patient

◦ Contraindications hypersensitivity hypotension


Common Medications for Sedation◦Benzodiazepines (diazepam,

midazolam)◦Narcotics (fentanyl) ◦Anesthesia Induction Agents

Etomidate Ketamine Propofol (Diprivan®)


Indications When intubation required in patient

who: is awake, has gag reflex, or is agitated, combative

Contraindications Most are specific to medication Inability to ventilate once paralysis

induced


Advantages◦ Enables provider to intubate patients who

otherwise would be difficult, impossible to intubate

◦ Minimizes patient resistance to intubation◦ Reduces risk of laryngospasm

Disadvantages/Potential Complications◦ Does not provide sedation, amnesia◦ Provider unable to intubate, ventilate after

NMB◦ Aspiration during procedure◦ Difficult to detect motor seizure activity◦ Side effects, adverse effects of specific

drugs


Mechanism of Action◦ Acts at neuromuscular junction where

ACh normally allows nerve impulse transmission

◦ Binds to nicotinic receptor sites on skeletal muscle

◦ Blocks further action by ACh at receptor sites

◦ These drugs brings about the neuromuscular blockade


Common Used NMB Agents◦Depolarizing NMB agents

succinylcholine (Anectine®) : 2.0 mg/kg result within 60 sec.

◦Non-depolarizing NMB agents vecuronium (Norcuron®) : 0.08-0.12

mg/kg rocuronium (Zemuron®) : 1 mg/kg IV pancuronium (Pavulon®) : 0.15 to 0.2

mg/kg IV


◦Summarized Procedure Prepare all equipment, medications while

ventilating patient Hyperventilate Administer induction/sedation agents

and pretreatment meds (e.g. lidocaine or atropine)

Administer NMB agent Intubate as usual Continue NMB and sedation/analgesia

prn

ConclusionConclusionThe airway management

techniques may be very rarely required in the “Dental Practice”, but when required these techniques differentiate between the Life And Death of the patient.

Thus it is imperative for every dental surgeon to have atleast the basic knowledge of airway management techniques.

Questions ???Questions ???

ReferencesReferencesTextbook of Medical Emergencies, Malame

d.Clinician’s Manual of Oral and Maxillofacial

Surgery, Kwon and LaskinPerforming endotracheal intubation, Cindy

GoodrichTracheostomy and its variants, Dr.Praveen

Kumar www.wikipedia.comwww.medicinenet.orgwww.anesthesiology.orgwww.emtb.comwww.clarus-medical.comwww.fotosearch.com

Thank You!Thank You!

Airway Management (Videos) - Mayur

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