Airway Management

Airway management

Why do we breathe?

To support life Disruption of airway and breathing is the most common cause of death

Airway management  Airway

management consists of clearing the upper airway, maintaining an open air passage with a mechanical device, and/or assisting respirations.  Prevent hypoxic damage to the brain and other vital organs.

Respiratory System

The Airways are Protected by Reflexes   

Cough Reflex “Batuk” Gag Reflex Swallowing Reflex “Telan”

These reflexes are lost in patients with HEAD / SPINAL INJURY or who are UNCONSCIOUS

Disruptions to the airway Tongue Blood

Bleeding from mouth and nose

Vomitu s Secreti ons Supine Position Posisi Baring

Upright Position Posisi Tegak

Foreign Bodies Swellin g

Vomitus blocking airways

Oxygen therapy The prime goal of airway management is to prevent hypoxic damage to the brain and other vital organs. Therefore if available, oxygen should be administered Below is a graph which reflects the % oxygen administered with various methods of airway management.

FUNDAMENTAL AIM: To restore the tissue oxygen tension towards normal. Increase [O2] in inspired air (FiO2) Improve gaseous exchange Increase O2 carriage to the tissues Improve tissue oxygenation.

Who needs O2? All of us !!! Who needs more O2? Patients with any sign of breathing difficulty  Unconscious / unresponsive patients  During CPR*  All major trauma victims  Risk of impaired airway  Heart attacks, strokes, seizures  History suggestive of drug overdoses**  Provide oxygen if considered, even if unsure  Any patient who may benefit from it 

21%

Oxygen Delivery Devices Nasal Cannulae  Most

comfortable for patients  Max 2 – 4 L/min providing 28 – 35 % O2 

Higher flow rate uncomfortable / useless

Simple Face Mask 5 – 10 L/min providing 40 – 60 % O2 < 5 L/min: re-breathing occurs 10 L/min: irritation to eyes, nose

Venturi masks

35% FR 6L

50% FR 12L

31% FL 6L 28% FR 4L

Color

% of O2

Blue Yellow White Red Orange

24% 28% 31% 40% 50%

O2 flow Rate 2L 4L 6L 8-10 L 12 L

Oxygen Delivery Devices  Non    

re-breather mask (“High Flow Mask”)

High oxygen concentration delivered (80% O2 with 15 L/min) Flow rate at least 10 L/min (** very dangerous if less than 10 L/min) One-way valves prevent re-breathing Used for critically-ill patients (who need high oxygen levels)

Initial Assessment Look, Listen, Feel

Check for at least five seconds before deciding whether it is absent.

OPEN AIRWAY Place your right hand on the victim's forehead, displacing it downwards, and with your left hand hold the victim's chin; tilting it up.

a) Head tilt chin lift

b) Jaw Thrust

Maintaining the Open Airway 

Oropharyngeal airway (Guedal’s airway)  Size  Insertion  Indications  Contra-indications

Oropharyngeal airway The oropharyngeal airway is a specially curved, rigid, hollow plastic tube. It is available in various sizes (i.e. from neonate - adult sizes). They should only be used in unconscious patients

Oropharyngeal airway Estimate the correct size required by selecting the airway that approximates most closely to the vertical distance between the patients incisor teeth and mandibular angle.

Nasopharyngeal airway Never attempt to insert a nasopharyngeal airway in a patient who you suspect of having a basal skull fracture

Nasopharyngeal airway Lubricate the airway Carefully with a slight twisting action, insert the nasopharygeal airway, bevelled edge first. Try to point the curve of the airway to the patient's feet.

Nasal airways Will cause bleeding from the nose in a large number of cases. This will result in worsening airway problems so use only as a last resort.

Facial mask and self inflating bag By connecting a reservoir system to the self-inflating bag - can increase the inspired oxygen concentration to approx 85%.

Mouth to mask Blow through the inspiratory valve. Remember to observe the patient to see if this has caused a chest rise.

Facial mask and self inflating bag Place the face mask to the patients face making a tight seal. The other person can then compress the bag sufficiently enough to allow a chest rise. If in an arrest situation 2 ventilations per 30 chest compressions. If the patient has a circulation try to achieve a rate of 12 ventilations per minute.

Initial Assessment  Breathing  This

adequacy or inadequacy:

determination is probably the most important one you will make for this patient.  Assess rate and quality  An inadequate rate (too fast or too slow), OR an inadequate depth (minimal air exchange) means you must provide PPV immediately.

Endo-tracheal Intubation Tracheal intubation is the placement of a flexible plastic tube into the trachea to protect the patient's airway and provide a means of mechanical ventilation.

Tracheal intubation is the "gold standard" of advanced airway maintenance was downplayed (in favour of more basic techniques like bag-valve-mask ventilation) by the American Heart Association's Guidelines for Cardiopulmonary Resuscitation in 2000 and again in 2005. Tracheal intubation is a potentially very dangerous invasive procedure that requires a lot of clinical experience to master. the associated complications may rapidly lead to the patient's death.

Indications Inability to oxygenate patient (SpO2 < 90%, PaO2 < 55) Inability to ventilate patient (rising PaCO2, respiratory acidosis, mental status change or other symptoms) Patient unable to protect the airway

PREPARATION: 1.

Laryngoscope with blades and bright light source.

2.

Bag-valve-mask connected to functioning oxygen delivery system.

3.

Working suction with Yankauer / catheters

4.

Endotracheal tube(s)

5.

Oral pharyngeal airway

6.

Syringe to inflate ETT cuff.

7.

Introducer Bougie / Flexiguide Stylet.

8.

Magill forceps

9.

K-Y Jelly

10. Plaster 11. Stethoscope 12. Alternative airway (example: LMA ,Proseal, Combitube), 13. Manpower 14. Vital signs monitor ( Capnometer). 15. IV is in place 16. Anticipated pharmacological agents

Observational methods to confirm correct tube placement 1. Direct visualization of the tube passing through the vocal cords 2. Clear and equal bilateral breath sounds on auscultation of the chest 3. Absent sounds on auscultation of the epigastrium 4. Equal bilateral chest rise with ventilation 5. Fogging of the tube 6. An absence of stomach contents in the tube

Instruments to confirm correct tube placement 1. Calorimetric end tidal CO2 detector 2. Waveform capnography 3. Pulse oximetry (patients with a pulse)

Complications 1. Can't intubate, 2. Esophageal intubation 3. Aspiration 4. Trauma from laryngoscope -Teeth, lips, soft tissues 5. Edema 6. Equipment failure 7. Cardiac arrest.