upper airway management dr k s hettiarachchi consultant anaesthetist sbsch peradeniya
TRANSCRIPT
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Upper Airway management
Dr K S HettiarachchiConsultant anaesthetistSBSCHPeradeniya
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options to manage
the airway
Simple airway adjuncts– Oropharyngeal
airway – Nasopharyngeal
airways
Bag-valve-mask(BVM) – ventilation
Laryngeal Mask Airway (LMA)
ET tube
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Simple airway
adjuncts
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Rusch Color Coded Guedel Airways
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Airway obstruction
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Sizing an oropharyngeal airway
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Oropharyngeal airway insertion
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Airway Management
Mouth to Mask
BVM (Bag-valve-mask)Ventilation
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The most important
airway skill
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Mask Ventilation
The most important airway skill
Always the first response to inadequate oxygenation and ventilation
The first “bail-out” maneuver to a failed intubation attempt
Attenuates the urgency to intubate
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BVM Ventilation
Requires practice to master
One hand to– maintain face seal– position head– maintain patency
Other hand ventilates
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Bag-valve-mask, 2-person ventilation
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Sniffing the morning air!!
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Sniffing PositionAlign oral, pharyngeal, and laryngeal axes tobring epiglottis and vocal cords into view
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BVM Ventilation:
Assessment of Efficacy
How do I know I am ventilating?
• Observe the chest rise and fall
• Good bilateral air entry
• Lack of air entering the stomach
• Feeling the bag• ETco2• Pulse oximetry
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Laryngeal Mask Airway
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LMA Insertion
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Laryngeal Mask Airway
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LMA Size
Patient Size
1 Neonate / Infants < 5 kg
1 ½ Infants 5-10 kg
2 Infants / Children 10-20 kg
2 ½ Children 20-30 kg
3 Children/Small adults 30-50 kg
4 Adults 50-70 kg
5 Large adult >70 kg
LMA Sizing
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Advantages of Using LMA
1. Leaves provider’s hands free
2. Patient can produce effective cough
3. Allows spontaneous ventilation
4. Malposition even can adequately ventilate
5. Sore Throat- less than ETT
6. Better tolerated than ETT
7. Better than Face Mask
8. Minimal CV Response
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Disadvantages of LMA over ETT 1. Lower seal pressure
2. Higher frequency of gastric insufflation
3. Increased Aspiration risk
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Endotracheal
intubation
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Equipment
LaryngoscopeTubesOxygen sourceBag & MaskSuction
LubricantForceps (Magill)Adhesive tapeStyletSyringe
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Stainless Laryngoscope Blades
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Tracheal Tube
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ETT : sizes (Pediartics)
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Anticipate the difficulties
– Identify in advance the patient with anatomical difficulty
– Have sufficient skill and training
– Have a preformulated plan for potential disaster
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What do we do when we have
a difficult
airway ?
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Be prepared
• Do we have all the help we need, all Airway equipment with us? (Suction?)
Competence with all equipment Working equipment Be prepared for surgical management Master the art of bagging Have at least one, if not two, working
IV lines
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Equipment
– Suction, Oxygen– Laryngoscope, ET Tubes, Stylet– BVM– Monitoring equipment
• Continuous cardiac monitoring• Pulse oximeter (continuous)• Auto BP (ideal)• CO2 device (ET confirmation device)
– Pharmacologic agents, mixed and ready
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Airway Differences
Nose
Tongue
TracheaCricoidAirway
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Adapted from Walls et al. anual of Emergency Airway Management. 2nd Ed. 2004.
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Airway Shape
Adapted from Walls et al. Manual of Emergency Airway Management. 2nd Ed. 2004.
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Effect Of Edema
Poiseuille’s law
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Technique of Laryngoscopy
• “Sniffing” position to align oral-pharyngeal-laryngeal axis
• Flex neck by placing pillow beneath occiput (raise 10 cm)
• Extend head maximally• With laryngoscope
– open mouth fully– push tongue to left out of view– pull upward at 45 degrees
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Correct Placement for intubation (b)
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Insertion of tracheal tube
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Airway Management
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Airway Management
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Airway Management
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Confirmation of ETT Placement:Clinical Evaluation
• Observation of ETT pacing through cords• Clear, equal breath sounds bilaterally• Absence of breath sounds over
epigastrium• Symmetrical rising of chest• Condensation or “fogging” of ETT• ET co2
ALL SUBJECT TO FAILURE• Pulse oximetry is LATE indicator
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Confirmation of ETT Placement
• Placement of ETT in the esophagus is an accepted complication of intubation
• However, failure to recognize and correct esophageal intubation immediately IS NOT ACCEPTABLE
• ETCO2 detection should be used on every emergency intubation
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Summery
Options to manage the airway
• Simple airway adjuncts• oropharyngeal airway • Nasopharyngeal airways
• Mouth to mask ventilation• Bag-valve-mask – ventilation (BVM)• Laryngeal Mask Airway (LMA)• ET tube