Airway Management

2. DEFINITION
• Airway management is the evaluation, planning and
use of medical procedures and devices for the purpose
of maintaining or restoring ventilation of a patient

3. AIRWAY MANAGEMENT
• Optimal strategies aid in airway patency, oxygen delivery and
carbon dioxide excretion
• Can be classified into two : non invasive and invasive
• Non-invasive includes passive oxygenation, bag valve mask
ventilation, non-invasive positive pressure ventilation
• Invasive includes supraglottic airways, endotracheal intubation and
cricothyroidotomy

4. AIRWAY OBSTRUCTION
• Obstruction of airway is medical emergency
• If untreated it may leads to a lower blood oxygen tension and
risks hypoxic damage to brain, kidneys, liver or could be fatal.

7. SIGNS OF AIRWAY OBSTRUCTION
• Snoring
• Gurgling sounds
• Stridor
• Pooling of secretions
• Inability to swallow ~ loss of gag reflex
• Skin colour - cyanosis
• Breathing effort - use of accessory muscles
• Respiratory rate - tachypnea
• Altered mental status - anxiety, confusion, coma

8. OPEN AIRWAY
• Head tilt-chin lift
• Jaw thrust

11. Blood/secretion – suction/remove debris
Floppy tongue – oropharyngeal airway
Maxilo-facial injury – attempt reduction/
intubation/ cricothyrotomy
Mechanical blockade – finger sweap and
removal of object
Partially obstructed airway – jaw trust/ chin-
lift
Perform a rapid clinical airway assessment which
includes - the patient’s level of responsiveness, skin
color, respiratory rate, and depth of respirations.
Obtain oxygen saturation.

12. NON-INVASIVE AIRWAY DEVICES
1. Oropharyngeal airway
2. Nasopharyngeal airway
3. Bag-valve mask

13. 1. Oropharyngeal airway
• A curved, rigid instrument used to prevent the base of
tongue from occluding the hypopharynx
• Indicatiosn for pstients without gag reflex
• Appropriate size is measured from the tip of the mouth to
the angle of mandible
• To insert, place with the concave portion cephalad and
rotate 180 degree once passing tongue
• However the contraindications for this device is for the
responsive patient/ has gag reflex.
2. Nasopharyngeal airway
• A pliable device that is inserted into the nostril
• Particularly useful in patients with an intact gag
reflex/maxillofacial trauma
• Measured from tip of nose to tragus of ear
• To insert, lubricate, then place into the most patent nostril
• For the contraindicatiosn is for the responsive patient,
alleged MVA patient (suspected frature to the base of
skull/ midface, and infant which is less than 1 y/o.

14. BAG-VALVE MASK
• Consist of a self-inflating bag coupled with a
facemask and a valve to prevent inhalation
• Typically used with supplemental oxygen, however
can be used with room air
• Adequate oxygenation and ventilation required
airway patency and a good mask seal
• Seal; can be a one or two person technique
(subsequent slide)

15. Allows
room air to
enter if
fresh gas
flow is
inadequate
and an
outlet valve
that allows
O2 to flow
out if
pressure is
excessive
Prevents
air from
returning
to
reservoir
bag
Prevent
too much
pressure
Prevent
expired
air from
going
back
into the
system
When inadequate flow
is given, acts as a
source of air; from
room O2

16. 3 WAYS OF HOLDING BVM
1. 1 hand E-C
clamp
technique
2. 2 hands E-C
clamp
technique
3. 2 thumbs
down
technique

17. DIFFICULT BVM
• M – mask seal – trauma, beard
• O – obesity
• A – age >55
• N – no teeth
• S – stiff lungs

18. SUPRAGLOTTIC AIRWAY DEVICES
• Consist of a single cuff inflated with 20-
30 cc of air
• Technically easier to insert, minimal
interruption in chest compression,
useful when the vocal cord are not
visualized during intubation
• Complications included aspiration of
gastric contents
Device that is placed in the oropharynx allowing for oxygenation and
ventilation without the visualized or surgical insertion of a tube into
the trachea
Examples : Laryngeal mask airway

21. DIFFICULT LMA
• R – restricted
mouth opening
• O – obesity,
obstruction
• D – distorted
anatomy
• S – stiff lungs or
C-spine

22. ENDOTRACHEAL TUBE
• Maintain airway patency
• Permits suctioning of
airway secretions
• Enables delivery of high
concentration of oxygen
• May protect the airway
from aspiration

24. OXYGEN THERAPY
• Process of administration of O2 at concentrations greater than
room air to prevent HYPOXIA / HYPOXEMIA ( low concentration
oxygen in the blood).
• O2 therapy may help you to get enough O2 supply. It’s use
when low blood O2 is present and helps you to get enough O2
supply.
• It can be administered in various way from a nasal cannula
(nasal prong) to hyperbaric oxygen inside a close chamber.

25. INDICATIONS FOR O2 THERAPY
• Anoxia: No O2 availability in tissues
• Hypoxia: Insufficient of O2 availability in tissue
• Hypoxemia: Insufficient O2 in the blood
• Severe trauma
• Severe respiratory distress ( Acute asthma/ pneumonia)

26. SIGNS & SYMPTOMS FOR O2 THERAPY
• Tachypnea
• Dyspnea
• Lethargy
• Cyanosis
• Disorientation

27. SUPPLEMENTAL OXYGEN DELIVERY DEVICES

28. NASAL CANNULA
• 2 prongs
• Flow rate 1-6L/min
• Supplies 21-44% O2
• Every 1L increase oxygen flow
will increase FiO2 by 4%
• Oxygen concentration depends
on oxygen flow rate, pattern of
ventilation, patient inspiratory
flow rate

29. SIMPLE FACE MASK
• Fits loosely on face which
allows room air to be
inhaled
• Flow rate 5-10L/min
• Supplies 35-60% O2

30. HIGH FLOW MASK
• Addition of reservoir bag
increase capacity of O2
reservoir by 600-1000ml
• Rebreathing mask: Provides
70-80% O2 with flow rate 10-
15L/min
• Non-rebreathing mask:
Provides 95-100% O2 with
flow rate 10-15L/min

31. VENTURI MASK
• Based on Bernoulli
principle: O2 is passed
through a narrow orifice
and creates a high velocity
stream of gas.
• Gives desired
concentration of O2 (24-
60%)
• Usually used for COPD
patient

33. RAPID SEQUENCED
INTUBATION ( RSI)

34. •An airway management technique that produces:
•Inducing immediate unresponsiveness (induction
agent)
• Muscular relaxation (neuromuscular blocking
agent)
•In a non fasting patient to prevent aspiration
•The fastest and most effective means of controlling
the emergency airway
Definition

35. Inability to maintain patent airway/tone
Upper airway swelling, facial/neck trauma, Poor GCS
Ventilatory compromise
Hypoventilation, large pneumothorax, flail chest, Severe COPD,
status asthmaticus
Failure to adequately oxygenate
Severe hypoxemia, APO, PE, ARDS
Anticipation of deteriorating course
Severe haemorrhagic shock, ICB with poor GCS, Septic shock

36. 7 P'S IN RSI
1. PREPARATION
2. PRE OXYGENATION
3. PRE TREATMENT
4.
PARALYSIS
5.PROTECTION +
POSITIONING
6. PLACEMENT
WITH PROOF
7. POST
INTUBATION
CARE

37. PREPARATION
• Preparing of medical staff available and the patient. Make sure
to inform the relatives about the procedure and get the
consent.
• Preparation of the equipment for intubation (MALES)
M- Mask (Beg valve mask, margills forceps)
A- Airway adjunct (Nasopharyngeal airway/ oropharyngeal
airway)
L- Laryngoscope set (Handle, blade size 2,3,4,5, lubricant
gel)
E- Endotracheal tubes (Sizes depend on patient)
S- Stethocopes, suction, syringe, spatula)

38. PRE- OXYGENATION
• Bag for 3-5 minutes to get enough O2 for lungs to stand for
intubation procedure using beg valve mask (BVM)
• To increase physiological stores of oxygen in order to prolong
the time to desaturation during a period of apnoea, usual
following induction of anaesthesia
Ideally 100% oxygen should be given at least
3mins before induction of anesthesia

39. PRE- MEDICATION
• Pre medication such as sedations, analgesics and muscle
relaxant will be served to the patient.
• Fentanyl 1.5- 3 mcg/kg iv to reduce symphathetic response of
increased BP and heart rate
• Lidocaine 1.5mg/kg iv to reduce bronchospasm and reduce
raised intracranial pressure

40. PARALYSIS WITH INDUCTION
• Induction agent :
• Midazolam : 0.1-0.3 mg/kg
• Etomidate: 0.3 mg/kg
• Ketamine: 1-2 mg/kg
• Propofol: 1-2mg/kg
• Paralytic drug
• Succinylcholine 1-2 mg/kg iv
• Rocuronium 0.6-1.2 mg/kg iv

41. POSITIONING
1)The head should be extended on the neck (Sniffing
position).
2)If cervical spine trauma is suspected, have an assistant
provide in-line immobilization.
3)Optional: Sellick manoeuvre (cricoid pressure) to
prevent passive regurgitation

42. CRICOID PRESSURE (SELLICK'S
MANEUVER)

44. CONFIRMATION OF ETT PLACEMENT
• Direct visualization
• Vapor in the ET tube
• Equal chest rise bilaterally
• 5 point auscultation
• Oxygen saturation improve
and maintain
• Capnography
• X-Ray post intubation

45. IDEAL POSITION OF ETT IS IN THE MIDDLE THIRD OF
TRACHEA AT T2 TO T4 LEVEL

46. POST INTUBATION MANAGEMENT
• Note depth of ETT
• 20-21 cm in women, 22-23 cm in men
• The teeth should be used as landmarks due to their fixed position
• Secure the ETT – tape or tie the tube
• Check cuff pressure (20-30 cm H2O)
• Leaking due to inadequate cuff pressure can cause aspiration pneumonia
• Too high a pressure can lead to necrosis, perforation and tracheomalacia
due to weakening of the tracheal cartilage
• Periodical check of cuff pressure because they tend to deflate within hours
or with change of position

47. • Cont
• Start sedation
• Midamorphine infusion
• Midazolam 30 mg + Morphine 30 mg diluted to a total 30 ml 0.9 % Normal Saline run 2-
5 ml/ hour.
• Propofol infusion 20-60 mcg/kg/minute.
• Insert ryles tube
• Head up 30 degrees
• Chest X-ray. (To confirm placement)

48. COMPLICATIONS OF
ENDOTRACHEAL INTUBATION

49. Q & A
• What is the definition of airway management?
• Name the maneuver that be use in for opening the airway.
• How to ensure that we use the correct size of oropharyngeal
airway and nasopharygeal airway?