AIRWAY
MANAGEMENT
(ADVANCED)
OVERVIEW
• INDICATIONS FOR INTUBATION
• ASSESSMENT OF THE AIRWAY FOR ADVANCED
AIRWAY MANAGEMENT
• IDENTIFYING DIFFICULT AIRWAYS
• TECHNIQUE OF INTUBATION
• FAILED INTUBATION
Failure to Failure of
maintain or ventilation or
INDICATION protect airway
• Comatose (GCS <8/15)
(prevents aspiration)
oxygenation
• SaO2 <90% on high
flow oxygen
Expected decline/
decompensation in (Cardiac arrest)
S • Airway trauma (eg
facial fractures)
• or PaO2 <7.9kPa on
FiO2 >40%
• Ventilation failure
Clinical Status
(rising CO2)
IDENTIFICATION OF A
POTENTIALLY DIFFICULT AIRWAY
• TWO KINDS OF DIFFICULTIES YOU MAY ENCOUNTER:
• ANATOMICALLY DIFFICULT INTUBATIONS
• PHYSIOLOGICALLY DIFFICULT INTUBATIONS
MOANS - Difficult Bag-Valve-
Mask ventilation
ANATOMICALLY LEMON - Difficult laryngoscopy
DIFFICULT and intubation
AIRWAY RODS - Difficult extraglottic
MANAGEMENT device placement (LMA)
PREDICTORS
SHORT - Difficult
cricothyroidotomy
mask seal problems (beards)
M
obstruction/obesity
O
DIFFICULT A age >55 (poor muscle and tissue tone)
BVM
no teeth (face caves in)
N
stiff lungs (high pressures to BVM
S
Look externally
L
Evaluate the 3-3-2 rule
E
DIFFICULT
SURGICAL M Mallampati
AIRWAY O
Obstruction/Obesity
Neck mobility - limited
N
surgery or disrupted airway
S
hematoma (infection/abscess)
DIFFICULT H
obesity
SURGICAL O
AIRWAY R radiation therapy - previous
tumor
T
R Restricted Mouth Opening
DIFFICULT O Obstruction
EXTRAGLOTTI
C DEVICE D Disrupted or Distorted Airway
Stiff neck
S
WHAT TO DO IF AN ANATOMICALLY DIFFICULT
AIRWAY IS PREDICTED
ONCE YOU ARE AWARE THAT THERE MAY BE A PROBLEM YOU CAN
MAKE SURE:
• YOU HAVE BACK-UP DEVICES THAT WILL SUIT THE
CONDITION
• YOU HAVE A PLAN FOR INTERVENTION SHOULD THERE BE A
PROBLEM
PHYSIOLOGICALLY DIFFICULT AIRWAYS
Metabolically
Hypoxic patients deranged (severely
acidotic patients)
ESTABLISHING A
DEFINITIVE AIRWAY
WHAT IS RSI?
• RAPID SEQUENCE INTUBATION
• RSI IS THE ADMINISTRATION, AFTER PRE OXYGENATION, OF
A POTENT INDUCTION AGENT FOLLOWED IMMEDIATELY BY
A RAPIDLY ACTING NEUROMUSCULAR BLOCKING AGENT TO
INDUCE UNCONSCIOUSNESS AND MOTOR PARALYSIS FOR
TRACHEAL INTUBATION
• MOST COMMONLY USED METHOD OF INTUBATION IN THE EC
• (PATIENTS WHO ARE INTUBATED DURING CARDIAC ARREST
ARE THE ONLY PATIENTS WHO DO NOT REQUIRE INDUCTION
OR NEUROMUSCULAR BLOCKING AGENTS)
WHY RSI?
01 02 03 04
Emergency Patients Preoxygenation allows Sedation and paralysis Use of short acting
have full stomachs for safe apnea period together allow for drugs allows for rapid
without bag valve optimal intubating return of spontaneous
mask ventilation and conditions. (Get the ventilation
the associated risk of tube in first time!)
gastric distention and
aspiration
STAGES OF RSI
-10 MIN PREPARATION
-5 MIN PREOXYGENATION
-2 MIN PRETREATMENT
0 MIN PARALYSIS WITH INDUCTION
+30S PLACEMENT OF TUBE
+45S PROOF OF TUBE POSITION
+ 90S POST INTUBATION MONITORING
PREPARATION (SOAP ME)
Suction (yankauer/ suction
Position patient correctly,
devices) Personnel
Oxygen, pre-oxygenation Monitors to use during
and delivery device (BVM) procedure (BP/ 3-lead/ Sats) and
Medication for intubation
Airway
E
devices
(laryngoscope/ ETT/ OPA) and quipment to confirm
Alternative Airways (LMA) (stethoscope, ETCO2, EDD)
PREOXYGENATION
• AIM TO INCREASE OXYGENATION AND REMOVE
NITROGEN FROM LUNGS
• GIVE 100% OXYGEN FOR 3-5 MIN OR 8 VITAL
CAPACITY BREATHS
PRETREATMENT/PRELOAD
• CRYSTALLOID FLUID BOLUS 10ML/KG
• FENTANYL 1-3MCG/KG OR
• LIGNOCAINE 1.5MG/KG
PARALYSIS WITH INDUCTION
INDUCTION AGENTS
• KETAMINE 1.5-2 MG/KG IBW
• ETOMIDATE 0.3-0.4 MG/KG TBW
• FENTANYL 2-10 MCG/KG TBW
• MIDAZOLAM 0.1-0.3 MG/KG TBW
• PROPOFOL 1-2.5 MG/KG IBW + (0.4 X TBW) (OTHERS SIMPLY USE 1.5 MG/KG X TBW AS
THE GENERAL GUIDE)
• THIOPENTAL 3-5 MG/KG TBW
KNOW THE DOSE, SIDE-EFFECTS AND CONTRAINDICATIONS OF YOUR FAVORED AGENTS
HTTPS://LIFEINTHEFASTLANE.COM/CCC/RAPID-SEQUENCE-INTUBATION/
Suxamethonium 1-2 mg/kg
TBW
PARALYSIS
Rocuronium 0.6-1.2 mg/kg
WITH IBW
INDUCTION
Vecuronium 0.15-0.25 mg/kg
IBW
PLACEMENT OF TUBE
• LARYNGOSCOPE ALWAYS HELD IN LEFT HAND AND INTRODUCED INTO
RIGHT SIDE OF MOUTH
• TONGUE SWEPT TO LEFT
• TIP OF BLADE ADVANCED UNTIL EPIGLOTTIS SEEN
PLACEMENT OF TUBE
• TIP OF BLADE INTO
VALLECULA
• ENTIRE LARYNGOSCOPE
LIFTED IN DIRECTION OF
THE HANDLE. (DON’T
PIVOT)
PLACEMENT OF
TUBE
• TIP OF ETT ADVANCED THROUGH
THE CORDS
• DEPTH:
• BLACK LINE AT CORDS/
CUFF THROUGH CORDS
• ETT SIZEX3
• NOTE MARKING AT LIP
• CONFIRM WITH EDD
• THEN INFLATE BALLOON
• CHECK PLACEMENT
• SECURE ETT
Capnography (End tidal
CO2) = Gold standard
Direct Visualisation of ETT
through cords
PROOF OF Oesophageal detector
device (EDD)
TUBE epigastrium = absent sounds
POSITION 5 point auscultation
Axilla and bases both sides
have good air entry
Misting of ETT
Equal rise and fall of chest
OESOPHAGEAL
DETECTOR DEVICE
(EDD)
• SQUEEZE THEN ATTACH TO ETT AND
RELEASE, ALLOW TO RE-EXPAND
• IF IN OESOPHAGUS WILL NOT RE-
EXPAND AS OESOPHAGUS WILL
COLLAPSE ROUND EDD
• (BEFORE ANY BAGGING)
• FALSELY RE-EXPANDS IF STOMACH
EXPANDED WITH AIR DUE TO
VENTILATION
• FALSELY DOESN’T RE-EXPAND
IF SMALL CHILD (<20KG)
OR OBESITY
END TIDAL CO2
MONITORING
• WANT TO LOOK AT END TIDAL CO2
TO ASSESS IF IN TRACHEA
• QUALITATIVE YELLOW = YES
• PH SENSITIVE FILTER PAPER
• TURNS YELLOW IF >2-5KPA PCO2
• ONLY QUALITATIVE
• QUANTITATIVE = CAPNOGRAPHY
• INFRARED DETECTION
• WAVEFORM ANALYSIS
END TIDAL CO2 MONITORING
• PROBLEMS WITH QUALITATIVE:
• FALSE POSITIVES
• GAS COOLDRINKS
• GASTRIC DISTENSION FROM BVM
• FALSE NEGATIVES
• CARDIAC ARREST
• MASSIVE PE
• MASSIVE OBESITY
SATURATION MONITOR
• PULSE OXIMETER DETECTS HAEMOGLOBIN OXYGEN
SATURATION PERIPHERALLY
• IS A DELAYED RESPONSE
• REMEMBER TO BE CAREFUL IF:
• NAILPOLISH
• HIGH AMBIENT LIGHT
• CARBON MONOXIDE POISONING
• NO PULSE IN PATIENT
• HYPOTENSIVE
• HYPOTHERMIC
3 lead ECG monitoring for rhythms
Sat monitoring
POST ABGs (PaO2 and PaCO2)
INTUBATION BP (non-invasive or invasive)
MONITORING
Capnograhy if available
CXR for ETT placement
D Displacement of ETT (bronchi
RMB/oesophagus)
WHAT O Obstruction of ETT/ Circuit
HAPPENS IF
SATS P Pneumothorax
DROPS
E Equipment Failure
S Stomach full of air (especially
children)
COMPLICATIONS OF INTUBATION
Trauma • Lips/ Teeth/ Airway/ Vocal cords
Infection - pneumonia
Laryngospasm/Bronchospasm
Oesophageal intubation
Right Main Bronchus intubation
Tension Pneumothorax
Go back to basics and Ventilate
If cannot intubate, but can ventilate then
• Ventilate
• Stay calm, call for help
• Try to intubate later
• If still cannot then rescue device:
CANNOT
• LMA
• Combitube INTUBATE
If cannot intubate, cannot ventilate
• Rescue device
• if fails →Surgical airway (cricothyroidotomy)
LMA =
LARYNGEAL MASK
AIRWAY
COMBITUBE