Airway Management (videos) - Mayur

Airway Management

Presented By: Mayur Jain

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 Management Maxillofacial trauma Aspiration of foreign body Vasodepressor syncope Asthma Heart failure Hypoglycemia Overdose reaction Anaphylaxis Epilepsy

Diagnosis

Diagnosis of Airway Obstruction LOOK

: Respiratory movements, gasping , suprasternal retraction LISTEN: Breath sounds FEEL : Expired air

Diagnosis 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 management

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

Purpose

Purpose Deprived

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 System

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

The Upper Airway A B C D E F G H

Epiglottis Mandible Frontal Sinus Soft Palate Trachea Glottis Esophagus Vocal Cords

The Upper Airway  Other

◦ ◦ ◦ ◦

Structures

Nasopharynx Oropharynx Laryngopharynx Larynx

The Upper Airway

Functions of the Upper Airway  Passageway

air  Warm  Filter  Humidify  Protection ◦ Gag Reflex ◦ Cough  Speech

for

The Lower Airway A B C D E F G H I J

Primary Bronchi Hyoid Bone Right Lung Secondary Bronchi Tracheal Ligament Trachea Larynx Esophagus Left Lung Trachea

Difference Between Adult And Infant Airway

Adult

Infant

Alveoli  Gas

Exchange

Lungs  Structure  Lobes  Pleura

Mallampati Grades

Class I

Class II

Class III

⇑ Difficulty

Class IV



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

Airway management procedures

Airway management procedures  A.

Noninvasive procedures

1. Back Blows 2. Head Tilt Chin lift procedure 3. Heimlich maneuver (Abdominal thrust) 4. Chest thrust 5. Finger sweep 6. Ambu -Bag

 B.

Invasive procedures

1. Oropharangeal airway 2. Nasopharangeal airway 3. Cricothyroidectomy 4. Tracheotomy 5. Endotracheal tube 6. Laryngeal Mask Airway

Non Invasive Procedures

Back Blows

Back Blows ◦ Indications:

Infants ◦ Contraindications:

Not recommended for Children and adults ◦ Advantages

Ease

Back Blows ◦ Disadvantages 1.Not as effective as Heimlich

Maneuver ◦ Procedure 1.Hold the infant in one hand 2.Head lower than trunk 3.Support jaws 4.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 ◦ Indications:

To remove foreign body. ◦ Advantages

Effective procedure ◦ Disadvantages

Injury to intra-abdominal organs may occur

Heimlich maneuver ◦ Procedure

Conscious patient : 2.Position behind patient and wrap arms around waist 3.Grasp one fist with other hand and position it slightly above umbilicus; caution- xiphoid process 4. Inward and upward thrusts until foreign body is out.

Heimlich Manuever : Conscious Patient Video

Heimlich manuever Procedure ◦ Unconscious patient : Patient positioned supine Open airway by “head tilt technique” Place heel of one hand on abdomen just above the umbilicus and second hand on top of that 4. Provide 6-10 thrusts.

Chest Thrust

Chest Thrust ◦ Indications: 1. Infant and child upto 8 years old 2. Pregnant female 3. Extreme obesity

◦ Contraindications: 1. Geriatric patients ◦ Advantages 1. Alternative to Heimlich Maneuver

Chest Thrust ◦ Procedure

Conscious victim :

2.Stand behind patient encircling victim’s chest 3.Place same grip on middle of sternum 4.Perform until foreign body is out

Chest Thrust ◦ Procedure

Unconscious victim :

2.Supine position 3.“Head tilt technique” 4.Same hand position on lower half of sternum 5.6-10 downward thrusts

Jaw Thrust

Jaw Thrust Indication

:

◦ 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 sweep

Finger sweep

◦ Indications:

1. Removal of foreign body in

unconscious patients ◦ Contraindications: 1. Conscious patient

Finger sweep ◦ Procedure

1.Supine position 2.Grasp tongue and anterio portion of mandible, pull the tongue 3.Use index finger to dislodge the foreign body 4.CAUTION: Don’t force the object deep into airway

Ambu Bag

Ambu Bag Indications:

◦ Unconscious patients ◦ Supplemental oxygen Source Advantages

:

◦ Can be used directly with Endotracheal tube Supplemental O2

◦ Allows spontaneous ventilation

Ambu Bag Diasdvantages:

◦ Require special training ◦ Does not ensure adequate airway

Ambu Bag

Ambu Bag Technique:

◦ Attach appropriate mask ◦ Ensure good seal ◦ Hold mask with one hand and squeeze bag intermittently with other hand

Ambu Bag

Recovery Position Video

Invasive Techniques

Invasive techniques 

Indications:

1. Failure of noninvasive techniques 2. Obstruction due to swelling; laryngeal edema, epiglottitis 

Contraindications:

1. Inadequate training 2. Lack of proper equipments

Invasive Techniques 

Advantages

1. Higher success rate 

Disadvantages:

1. Need for expertise 2. Equipments 3. Cost

Risks/Protective Measures Be

◦ ◦ ◦ ◦

prepared for:

Coughing Spitting Vomiting Biting

Body

Substance Isolation

◦ Gloves ◦ Face masks ◦ Eye shields

Oropharyngeal Airway

Oropharyngeal Airway Indications

:

◦ Unconscious but spontaneously breathing patients due to tongue positions Advantages

:

◦ Seperates tongue from posterior pharyngeal wall Disadvantages

:

◦ Activates gag reflex in conscious patients

Oropharyngeal Airway Size

:

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

:

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

Oropharyngeal Airway

Oropharyngeal Airway

Oropharyngeal Airway Various Sizes

Oropharyngeal Airway

Nasopharyngeal Airway

Nasopharyngeal Airway Indications:

◦ Tongue obstruction ◦ Inadequate oral opening ◦ Oral Surgery Advantages

:

◦ Well tolerated even in conscious patient Sizes

: (Internal Diameter)

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

Nasopharyngeal Airway

Nasopharyngeal Airway Various Sizes

Nasopharyngeal Airway Position Determine

the size of tubes Local Anesthesia Lubricate

Nasopharyngeal Airway

Nasopharyngeal Airway

Tracheotomy

Tracheostomy Definition

:

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

Tracheostomy Classification:

◦ 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

Tracheotomy ◦ Indications: 1. Long term airway maintenance 2. Glottic edema 3. Laryngeal nerve palsy 4. Head injury 5. Tetanus 6. Coma 7. Chest injury 8. Laryngeal infections

Tracheotomy  Contraindications:

◦ Cervical Spine fracture ◦ Tracheomalecia ◦ Carcinoma of trachea  Advantages ◦ Bypass upper airway obstruction ◦ Reduces the dead space ◦ Attachment to vetilator is possible

Tracheotomy ◦ Equipments :

2.Blade 3.Tracheal dilator 4.Cats paw retractor 5.Tracheostomy tube

Tracheotomy  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

Tracheotomy Completed

tracheotomy: 1 - Vocal cords 2 - Thyroid cartilage 3 - Cricoid cartilage 4 - Tracheal cartilages 5 - Balloon cuff

Tracheotomy ◦

Possible Complications 1. Perforation of esophagus 2. Hemorrhage 3. Pnemothorax 4. Tracheal stenosis 5. Loss of speech 6. Chances of infection

Percutaneous Tracheotomy Procedure

◦ skin incision along relaxed skin tension lines ◦ Insert of 14-gauge needle ◦ Tracheal dilatation ◦ Insert tracheostomy tube ◦ Connect ventilator tubing

Percutaneous Tracheotomy

Cricothyrotomy

Cricothyrotomy 

◦

◦

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

Cricothyrotomy Contraindications

(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

Anatomy Thyroid

and cricoid cartilages Cricothyroid membrane

Anatomy

Cricothyrotomy 

Equipments :

1. Scalpel No. 11 Blade 2. Or 13 gauge half inch long needle

Cricothyrotomy Video

Cricothyrotomy 

Technique:

1. Supine position 2. Hyperextension of neck 3. Locate cricothyroid membrane 4. Vertical skin incision 5. Retract with thumb and index finger 6. Horizontal incision as close to cricoid cartilage as possible 7. Rotate the blade at 90 degrees 8. If available, insert tubes

Cricothyrotomy Video

Endotracheal intubation

Endotracheal Intubation Introduction

◦ Tube into trachea to provide ventilations using ventilator

Endotracheal Intubation Definition

:

◦ 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

Endotracheal Intubation 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 Intubation  Equipment: 2. Endotracheal

tube Adult female= 7- 8 mm Adult Male = 8 – 9 mm child = diameter of little finger

Endotracheal tube

Endotracheal Tube

Endotracheal Tubes

Endotracheal Tubes

Endotracheal Intubation 

Equipments Laryngoscope blade

1. Stright Adult : size 3 to 4 Child : Size 2-3 Baby : size 1- 2

2. Curved 1. 2. 3.

Adult : size 3 to 4 Child : Size 2-3 Baby : size 1- 2

Laryngoscope

Curved Laryngoscope

Straight Laryngoscope

Curved Blade (Macintosh) Insert

from right to

left Visualize anatomy Blade in vallecula Lift up and away DO NOT PRY ON TEETH Lift epiglottis indirectly

Straight Blade (Miller) Insert

from right to

left Visualize anatomy Blade past vallecula and over epiglottis Lift up and away DO NOT PRY ON TEETH Lift epiglottis directly

Intubation Technique

Vocal Cords

Laryngoscopy

Endotracheal Intubation Procedure: 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 Intubation Position

patient into “sniffing position” if possible; restrain as necessary. Standing at the supine patient’s head, gentle insert laryngoscope blade with left hand. 

Positioning

Positioning Patient

Positioning

◦ Goal Align 3 planes of view, so Vocal cords are most visible ◦ T - trachea ◦ P - Pharynx ◦ O - Oropharynx

Endotracheal Intubation

Endotracheal Intubation Visualize

glottic opening/vocal

cords. Insert the tubes

Endotracheal Intubation

Endotracheal Intubation

Tip of blade is placed in vallecula, and laryngoscope is lifted further to expose glottis. The tube is inserted through the right side of the mouth.

Endotracheal Intubation

Tube is advanced through vocal cords into trachea.

Tube Placement

Endotracheal Intubation Inflate

ETT cuff with 5 – 10 cc air via syringe. Ventilate with bag and oxygen.

Endotracheal Intubation

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

Endotracheal Intubation

Methods for securing adhesive tape.

Endotracheal Intubation Confirm

tube placement

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

Endotracheal Intubation Complication:

Prevention:

Missing/broken teeth:

Remove loose teeth Check chest x-ray to prior; avoid using rule out aspiration. upper teeth as fulcrum for laryngoscope blade.

Clenched teeth: Air leak:

Management:

Paralytic medication. Check cuff prior to beginning procedure.

Inject more air or change tube over guide wire.

Endotracheal Intubation

Inability to visualize Proper patient vocal cords: positioning, proper laryngoscope blade size, proper suctioning.

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

Esophageal intubation:

Visualize cords.

Remove tube, reoxygenate 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 Airway Indications:

◦ ◦ ◦ ◦

General Anesthesia Emergency In patients trapped in sitting position Unsuccessful intubation

Disadvantages

:

◦ Does not protect lung from aspiration

Laryngeal Mask Airway

Laryngeal Mask Airway

Laryngeal Mask Airway Procedure:

◦ ◦ ◦ ◦ ◦

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

LMA Placement

Pharmacology

Pharmacologic Assisted Intubation Sedation

◦ Reduce anxiety ◦ Induce amnesia ◦ Depress gag reflex, spontaneous breathing ◦ Used for induction anxious, agitated patient ◦ Contraindications hypersensitivity hypotension

Pharmacologic Assisted Intubation Common

Medications for

Sedation ◦ Benzodiazepines (diazepam, midazolam) ◦ Narcotics (fentanyl) ◦ Anesthesia Induction Agents Etomidate Ketamine Propofol (Diprivan®)

Pharmacologic Assisted Intubation  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

Pharmacologic Assisted Intubation  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

Pharmacologic Assisted Intubation 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

Pharmacologic Assisted Intubation 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

Pharmacologic Assisted Intubation ◦ 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

Conclusion The

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 ???

References

 Textbook of Medical Emergencies, Malamed.  Clinician’s Manual of Oral and Maxillofacial Su  Performing endotracheal intubation, Cindy Go  Tracheostomy and its variants, Dr.Praveen Ku  www.wikipedia.com  www.medicinenet.org  www.anesthesiology.org  www.emtb.com  www.clarus-medical.com  www.fotosearch.com

Thank You!