Airway management

L.Dadak ARK FNUSA

Maintaining airway


Noninvasive •airway •laryngeal mask •combitube invasive •OTI, NTI •coniotomy •tracheotomy



vocal cords

Routine Airway Management
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Mask LM OTI

Keep airway open
haed tilt, chin lift Esmarch man.

Guedel airway Oro-Pharyngeal Airway
I: unconsciousness + airway obstruction with tongue Correct size OPA:  distance angle of mouth --- ear Risk in mild unconsciousness:  vomitus + aspiration

Naso-Pharyngeal Airway (trumpet)
Correct size of NPA:  distance nostril --- ear Risk:  bleeding from nasal cavity


Use of lubricant is essential

Face mask ventilation
Positive pressure ventilation by bag-valve mask
  

correct volume = movement of chest f 10/min 100% O2 1 hand hold:
− −





2 hands

inch + index f. 3 ff. - chin

(Bag) Mask Ventilation
Improved by ● OPA

LM Classic, ProSeal

Components of LM

LM placed against glottis (radix of tongue, recessus piriformis, esophageal superior sphincter) I: instead face mask, OTI, difficult airway CI: ● full stomach ● gastro-esophageal reflux, ● high inspiratory pressure ● longer operation

Combitube
● ● ●

emergency situations instead OTI I: difficult airway CI: stenosing process in pharynx / trachea

Tracheal intubation Def: Placing tube to trachea through mouth/nose and larynx. I: ● maintain open airway (GCS < 8) ● toilet (no cough) ● maintain ventilation (shock, hypoventilation) narrowest place in airway – vocal cords – subglotic space (<8years)

OTI, NTI - aids:
● ● ● ● ●

laryngoscope Magill tongs tracheal tubes syringe lead

How to:
● ● ● ● ● ● ●

prepare all aids, (ventilate) position of p. LA, GA, coma direct laryngoscopy placing tube inflate cuff ensure position

Head position

Laryngoscope:
 

crooked spoon - Macintosh straight spoon - Miller

Laryngoscopic view

Laryngoscopic view: radix of tongue epiglottis vocal cords trachea

Always easy? (Cormac & Lehane)

Improvement of View
●

pressure over larynx - right and down

Verify placing of the tube
  

auscultation End tidal CO2 fibroskopic view

Complications of TI - early:




 

 

trauma of teeth, soft tissue placed to esophagus / endobronchialy aspiration cardiovascular ↑ΒP, ↑f, arrhythmia ↑ ICP laryngospasmus, bronchospasmus

Complication of TI - later:
   

damage of vocal cords, trachea sinusitis, otitis, decubitus – lip, nose obturation of tracheal tube by secret, blood

How to do NTI: LA anemisation of nose ● tube through nose ● placing tube under visual control CAVE: deviation of septum nasi
●

Check your neck
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Mallanpati

●

3-3-2

RSI
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Rapid Sequence of Intubation Rapid Sequence of Induction

RSI indication
● ● ● ● ●

full stomach unknown time of starving GE reflux gastroparesis analgetics

RSI - sequence
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Preox + i.v. line, working suction induction = propofol, SchJ Sellick maneuver + OTI confirmation fixation by tape be ready for 2 l of gastric content

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Tracheotomy
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surgical access to trachea punction TS I: maintain AW long time
– –

●

artificial ventilation limitation of dead space

Difficult Airway
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Anticipated
– –

awake intubation – bronchoscope (TS)

●

Unanticipated
–

spont. vent. / paralyzed

Alternative Equipment
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VideoLaryngoskop C-trach fibroscope

Coniotomy
● ●

urgent access to airway lig. cricothyreoideum (lig. conicum)

Coniotomy
  

First try OTI find the ligament DO it.

Time of Airway Events

Cannot ventilate

Cannot intubate, can ventilate
● ●

keep ventilation call for help

Can not ventilate, can not intubate

Cannot ventilate, can not intubate + full stomach

Summary
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Preop exam – allways History ready to awake intubation sooner fibroscopic OTI Have a plan Surgical access takes max 90 s

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Extubation:
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contact clear orofarynx (sekretions, stoped bleeding) keeps haed 5s above bed / hand grip good pain controle minimal ET concentration of inhal. anesthetics

Fastrach

C-trach