Airway Management

Objectives of the Lecture

• Review of anatomy and physiology of airways
• Patient assessment and O2 therapy
• Indications and contraindications of artificial airways
• Artificial airways
• Manual ventilation techniques
• Intubation procedure
• Cricoid pressure
• Suctioning and cuff pressures and their significance
Anatomy of Airways
•Mouth, nose

•Larynx, trachea

•Primary bronchi and all branches of

bronchioles up to terminal bronchioles
Patient Assessment
• Airway-Airway patency –Obstruction of the upper airway is a
medical emergency! Most common cause is the tongue.
• Breathing-Look, Listen, Feel!
• Circulation-If untreated, airway obstruction leads to a
lowered blood oxygen tension and risks hypoxic damage to
the heart, brain and kidneys, cardiac arrest or even death.
• Remember: A normal verbal response from a patient
immediately informs you that the patient has a patent
airway, is breathing and is perfusing his/her brain.
Patient Assessment
•Patient History-underlying condition
•Neuro- level of consciousness
•Vital signs
•Respiratory-Inspection, Auscultation, Palpation,
Percussion.
•ABGs and SaO2
Provide Supplemental O2
therapy!!
•Nasal cannula- Starting device, provides up to 44%
Oxygen, Increasing the O2 flow by 1 litre will
increase the Fio2 by approx 4%.
•Face Mask- Provides up to 60% oxygen.
•Venturi Mask- accurately control the proportions of
inspired O2.
•Non rebreather mask- provides 100% oxygen. Each
litre per min increase in flow over 6 litre/min will
increase the fio2 by approx 10%.
Open The Airway!!
•Head tilt-chin lift
•Trauma patient-Jaw thrust manoeuvre
without head tilt.
•Manage foreign body airway obstruction
with the BLS technique of sub diaphragmatic
abdominal thrusts (Heimlich manoeuvre)
 Maintain the airway-Indications
for Artificial Airways
•To establish and maintain a patent airway

•To protect the airway from aspiration

•To provide access to the bronchial tree

•To provide a route for continuous or

intermittent ventilatory support
Artificial Airway
•Temporary measures : oropharyngeal airway,
nasopharyngeal airway, LMA (laryngeal mask
airway) Combitube (oesophageal-tracheal
tube)

•Definitive airway : ETT (endotracheal or

nasotracheal), tracheostomy,cricothyrotomy
Oropharyngeal Airways
•S shaped devices that hold the tongue away
from the posterior wall of pharynx
•Used in :
* Spontaneously breathing patients
* Patients who are unconscious/semi
conscious with no cough or gag reflex
Important to size correctly
Oropharyngeal Hazards
•A long oropharyngeal airway may press the
epiglottis against the larynx and occlude the airway.
•If not inserted properly, it may push the tongue
posteriorly and aggravate an upper airway
obstruction.
•May stimulate vomiting and laryngospasm in the
patient with a cough/gag reflex.
•Trauma to the lips and tongue.
Nasopharyngeal Airway
•Uncuffed tubes made of soft rubber or
plastic.
•Used in semi conscious patients.
•Used when insertion of an oropharyngeal
airway is technically difficult.
Nasopharyngeal Hazards
•A long airway can enter the oesophagus
•Can precipitate vomiting and laryngospasm
•Insertion can injure nasal mucosa and cause
bleeding with possible aspiration of clots into
trachea
Laryngeal Mask Airway
•The LMA provides an airway adjunct with a cuffed,
mask like projection at the distal end that is
introduced into the hyopopharynx until resistance is
felt.
•The resistance indicates that the distal end has
reached the hypo pharynx.
•When the cuff is inflated ,the mask is pushed up
against the trachea opening ,providing an effective
seal and a clear airway into the trachea.
LMA Indications
•Small surgical procedures involving a general
anaesthetic.
•Blind insertion means the operator does not have to
use a laryngoscope or learn to visualise the tracheal
opening.
•The possibility of fatal errors with the LMA is much
lower than that associated with tracheal tubes.
•The LMA may also prove superior to the tracheal
tube for the difficult airway.
LMA Contraindications
•The LMA provides less airway protection from
regurgitation than the tracheal tube.
•Contraindications in patients with
*reflux disease
*non fasting patients
*pharyngeal disease
*operations with single lung ventilation
*pregnancy
*morbid obesity
Oesophageal- Tracheal
Combitube
• The combitube is another invasive airway adjunct with many of the
advantages of the LMA.
• It is a tracheal tube bonded side by side with an oesophageal obturator.
• Ventilation can be given through either lumen, depending on where the
end inserted in the patient rests.
• More than 80% of the time the combitube ends up in the oesophagus.
After the 2 cuffs are inflated, ventilation should proceed through the side
vents on the obturator.
• If initial ventilations through the oesophageal obturator do not produce
chest rise, then the combitube is probably in the trachea. Switch the
ventilation bag to the other tube and provide several inflations. Chest
expansion should be noticeable.
Combitube
•It is a blind insertion device and thus eliminates the
need for training in laryngoscopy.
•Studies confirm superior ventilation and
oxygenation compared with the face mask and
equivalent performance compared with the tracheal
tube.
•However most experts consider tracheal intubation
to be the gold standard of airway management.
Manual Ventilation Techniques
•Mouth to mouth and mouth to nose ventilation by
pocket face mask.

•Self – inflating ventilation bags (attached to masks

and other airway adjuncts).

•Purpose:
• To provide ventilation and oxygenation before advanced
airway is in place in emergency situation
• Pre-oxygenation during endotracheal intubation
Pocket Mask Ventilation
•Barrier device to provide effective ventilation and
oxygenation in emergency situation.
•Administration of supplemental oxygen possible.
•Eliminates exposure to exhaled air.
•It’s transparent to check if victim is vomiting.
•Easy to use.
•Superior to bag-mask ventilation mainly when only
1 rescuer available.
Face Pocket Mask Ventilation
Technique
•1 person – position at the side of pt. to facilitate
combination with chest compressions. If 2 people,
the person who is ventilating positions her/himself
at the top of the head and second person by the
side to provide chest compressions.

•Ventilation is slow, over 1 second, in ratio for 30

compressions to 2 breaths for health care providers,
until an advanced airway is in situ. (ACLS guidelines
2005).
Face Pocket Mask Ventilation
Technique
•Watch for chest rising ( only evidence of
ventilation the patient)
•Perform 5 cycles of CPR ( 2min) before
rhythm check
Self Inflating Ventilation Bags
•Main device for emergency ventilation.
•Universal connectors (15mm,22mm) allow
different airways adjuncts to be used.
•Oxygen port for supplemental oxygen
•Medication ports
•True non-rebreathing valve
•Reservoir
Bag-valve Masks Ventilation
Technique
• Oropharyngeal airway to be inserted to help to maintain patent airway
and facilitate suctioning

• Most commercially available adult sized bag mask units will have a 1600-
2000 ml bag

• 1 rescuer with 1 hand squeeze can empty only 50% of volume

• Seal has to be ensured-2 person technique

• Prepare for intubation

 Equipment for Endotracheal
Intubation
•Laryngoscope blades and handle
•Selection of Et tubes, selection of Guedel
airways
•10ml syringe
•Lubricant
•Local anaesthetic – spray
•Tongue depressor
•Magill’s forceps
Equipment for Endotracheal
Intubation
•Bougie
•Experienced Practitioner
•Suction equipment ready and checked
•Tape to secure the tube and scissors
•Manual bag with 100% O2 and face mask
•Emergency drugs at hand
•Catheter mount
•Difficult intubation trolley
 Technique of Endotracheal
Intubation
•Pt’s preparation (information, position).
•Preparation of equipment.
•Preparation of i.v. drugs and i.v. access.
•Pre-oxygenate/cricoid pressure (RSI).
•Intubation procedure-Attempt limited to 30 secs, any
longer need to re-oxygenate.
•Position checks-5 point auscultation.
•Capnography - Gold is good.
•Fixation of Et tube and chest xray.
•Post intubation care.
 Complications of Endotracheal
Intubation
•Injury to mucosa of oral cavity and oropharynx
( bleed, chipped teeth, lacerations)
•Injury to vocal cords
•Laryngeal oedema
•Tracheal stenosis and tracheoesophageal fistula
•Aspiration pneumonia and Ventilator associated
pneumonia
•Accidental displacement of tube
•Transient hypoxia
 Cricoid Pressure

•Definition: application of sufficient pressure to the

cricoid cartilage that will displace this ring backwards
against the cervical vertebrae and effectively occlude
oesophagus
•Why ?
• To prevent aspiration of gastric content into the airways
secondary to regurgitation during endotracheal intubation
 Indications for Use of Cricoid
Pressure
•Emergency intubation ( rapid sequence
induction)
•No time to empty stomach contents
•Delayed gastric emptying secondary to pain,
shock, pregnancy, obesity, abdominal
distention of different reasons
•Hiatus hernia
•No pharyngeal reflex secondary to neurological
disorder
Contraindications
•Active vomiting

•Laryngeal trauma

•Cervical spine injury

•Immobile neck
 Technique of Applying Cricoid
Pressure
•Assess anatomy of the neck of patient

•Find thyroid cartilage ( Adams apple)

•Find soft depression below the thyroid cartilage

(cricothyroid membrane)

•Find the hard prominence just below membrane –

cricoid cartilage
 Technique of Applying Cricoid
Pressure
•Apply firm pressure (100cm H2O)while pinching
the thumb and index finger toward the
patient’s back and somewhat toward the head

•Remember: light c. pressure applied at the

beginning of intubation, firm c. pressure
applied after muscle relaxant is administered
When to Release Cricoid
Pressure
•Only when ET tube is secured in trachea by inflating
cuff, anaesthetist confirms position of Et tube by 5-
point auscultation, bilateral chest wall rising and
satisfactory oxygenation

•Only Anaesthetist orders to release cricoid pressure

•Complications: oesophageal rupture

Cricothyrotomy
•Rapid entrance into the airway for temporary
ventilation and oxygenation of patients for
whom airway control is not possible by other
methods.
•Performed under emergency conditions
Tracheostomy
•A surgical opening into the trachea performed
under controlled conditions.
•Performed only after the airway has first been
secured by other means.
•Incision made below the cricoid cartilage through
the 2nd-4th tracheal rings.
•Preferred method for long term ventilation.
 Suctioning
•Definition: involves mechanical aspiration of
secretions from oropharyngeal space, nose or Et tube

•Vital component of effective airway care

•Indications:
• to maintain the patency and integrity of natural
and artificial airways
• audible and visible secretions in oral cavity,
oropharynx or airway device
 Suctioning
•Indications cont.:
• patient’s signs and symptoms of respiratory distress (attempt
to cough, increased resp. rate or heart rate, increased BP,
absence of breath sounds, pt. restless…)

• deteriorating ABG

• during bronchoscopy and to obtainspecimen

 Significance of ETT Cuff
Pressures
• Provides an airtight seal, so prevents air leaking in and out of
lungs. It prevents aspiration of material from digestive tract.
• Despite adequate ( 20 – 30 cm H2O) inflation of Et tube cuff the
micro aspiration of pooled secretions above the cuff occurs
( Young J. et al,1997,1999)
• Leakage occurs in 100% of intubated patients
• Leakage of secretions occurs down longitudinal folds within the
cuff walls and these folds develop in each high pressure low
volume cuffs ( standard cuffs )
• Rate of leakage was 0.27ml/sec
• This process is main cause of VAP
• In ICU normal cuff pressure we use is 22-32 cms H2O
 Prevention of VAP Associated
With Airway Management
• Maintain clean oropharyngeal space by frequent checks and if
necessary by suctioning
• Mouth care with tooth brush is essential
• Check cuff pressures at the beginning of each shift and if Et
tube was repositioned
• Do not reposition Et tube if not required
• Position patient at 30 – 45 deg. (Hixson et al, 1998)
• Prevent GI regurgitation ( aspirate Ng tubes regularly, if
vomiting occurs –position on side and suction quickly, ensure
that pt. on Omeprazol or other Proton pump inhibitor
•Thank you for your attention

•Questions?
 References

Thelan A. Lynne, Critical Care Nursing,Diagnosis and

Management,1998
AHA, ACLS Provider Manual, Care of the Airway,
updated version of 2004
AHA, Currents in Emergency Cardiovascular Care, Vol.
16, winter 2005-2006
Stuart I. Fox et al., Human Physiology , 2002
Drakulovic, et al,(1999) Supine body position as a risk
factor for nosocomial pneumonia in mechanically
ventilated patients: a randomised trial. THE LANCET.
354 (9193): 1851-1858
References
Young,P. J., Rollinson,M., Downward, G., Henderson, S.(1997)
Leakage of fluid past the tracheal tube cuff in a benchtop
model. British Journal of Anaesthesia . 78 (5): 557-562

Young, P. J., Basson, C., Hamilton, D., Ridley, S. A. (1999a)

Prevention of tracheal aspiration using the pressure-limited
tracheal tube cuff. Anaesthesia. 54 (6): 559-563

Tablan, O. C. et al., (1994) Guideline for Prevention of

Nosocomial Pneumonia. Centre for Diesease Control and
Prevention.
http://www.cdc.gov/ncidod/hip/pneumonia/pneu_mmw.ht
m
(2003, February 28)