Airway adjuncts and management in ACLS

ADJUNCTS FOR AIRWAY CONTROL, VENTILATION

AND SUPPLEMENTAL OXYGEN

Objectives

1. To control the airway properly during cardiac arrest

2. To optimize ventilation3. To use airway adjuncts properly and effectively4. To provide supplemental oxygen properly and

effectively

1

Open airway by

OPEN AIRWAY( Head - tilt / chin - lift / jaw - thrust )

No respirations

present

Spontaneous respirations present

VENTILATE WITH SUPPLEMENTAL OXYGENMouth-to-Mask, B-V-M

KEEP AIRWAY OPEN AND MONITOR PATIENT

INSERT PHARYNGEAL AIRWAY (oral or nasal)

VENTILATE

ENDOTRACHEAL INTUBATION(as soon as possible)

No chest expansio

n

Foreign body

obstruction

AIRWAY CONTROLAirway Obstruction

•Tongue and/or

•Epiglottis

AIRWAY CONTROLOpening the Airway

Jaw thrust Head tilt–chin lift

AIRWAY CONTROLOropharyngeal Airway

AIRWAY CONTROLOropharyngeal Airway (cont.)

AIRWAY CONTROLOropharyngeal Airway (cont.)

AIRWAY CONTROLOropharyngeal Airway (cont.)

AIRWAY CONTROLOropharyngeal Airway (cont.)

AIRWAY CONTROLNasopharyngeal Airway

AIRWAY CONTROLNasopharyngeal Airway (cont.)

AIRWAY CONTROLNasopharyngeal Airway (cont.)

ENDOTRACHEAL INTUBATION

• Protection of the airway from aspiration of foreign material

• Facilitates ventilation and oxygenation• Facilitates suctioning of trachea and

bronchi• Provides route for drug administration• Prevents gastric insufflation• Allows faster rate of chest compression

Advantages

ENDOTRACHEAL INTUBATION

• Inability to ventilate the unconscious patient

• After insertion of pharyngeal airway• Inability of patient to protect own

airway (coma, areflexia, or cardiac arrest)

• Need for prolonged artificial ventilation

Indications

ENDOTRACHEAL INTUBATION

• Laryngoscope with several blades

• Endotracheal tubes• Malleable stylet• 10-ml syringe• Magill forceps• Water soluble lubricant• Functional suction unit

Equipment

ENDOTRACHEAL INTUBATIONLaryngoscope & Blades

ENDOTRACHEAL INTUBATIONLaryngoscope (cont.)

Connection of blade to handle

ENDOTRACHEAL INTUBATIONEndotracheal tube

ENDOTRACHEAL INTUBATIONEndotracheal tube (cont.)

Stylet

Aligning Axes of Upper Airway

Extend-the-head-on-neck (“look up”): aligns axis A relative to B

Flex-the-neck-on-shoulders (“look down”): aligns axis B relative to C

C

ABA

B

C

TracheaPharynx

Mouth

ENDOTRACHEAL INTUBATION

ENDOTRACHEAL INTUBATION

ENDOTRACHEAL INTUBATION

ENDOTRACHEAL INTUBATION

ENDOTRACHEAL INTUBATION

ENDOTRACHEAL INTUBATION

• Intubate as soon as possible after ventilation and oxygenation, in cardiac arrest

• Intubation should be done by most experienced person

• Do not take longer than 30 seconds• Auscultate the thorax and

epigastrium after intubation

Recommendations

ENDOTRACHEAL INTUBATION

• Trauma-teeth, lips, tongue, mucosa, vocal cords, trachea

• Esophageal intubation• Vomiting and aspiration• Hypertension and

arrhythmias

Complications

OXYGENATION AND VENTILATION

• Elimination of direct contact• Adequate lung ventilation• Enriched oxygen mixture• Easier than bag-valve-mask

Mouth-to-mask

Advantages

OXYGENATION AND VENTILATIONMouth-to-mask (cont.)

Mouth-to-mask device

OXYGENATION AND VENTILATIONMouth-to-mask (cont.)

Technique

OXYGENATION AND VENTILATION

• Provides immediate ventilation and oxygenation

• Sense of compliance and airway resistance conveyed to operator

• Ideal method of ventilation after intubation• High oxygen concentrations are possible• Can be used with spontaneous respirations

Bag-Valve-Mask

Advantages

OXYGENATION AND VENTILATIONBag-Valve-Mask (cont.)

With oxygen reservoir

Bag-Mask Ventilation• Key—ventilation volume: “enough to produce

obvious chest rise”

1-Person: difficult, less effective

2-Person:easier, more effective

OXYGENATION AND VENTILATION

OXYGENATION AND VENTILATIONBag-Valve-Mask (cont.)

Complications

• Inadequate tidal volumes leading to hypoventilation

• Gastric distension

OXYGENATION AND VENTILATIONManually Triggered Oxygen Powered

Breathing Device

• Allow for positive pressure ventilation• Deliver 100% oxygen concentration• Should provide a constant flow at 40

L/min• Should have a relief valve that opens at

60 cmH2O

SUCTION DEVICES

TRACHEOBRONCHIAL SUCTIONING

Techniques

• Check equipment• Set pressure between –80 to –120

mmHg• Pre-oxygenate with 100% O2 for

five minutes• Use sterile technique• Insert suction catheter through the tube• Apply suction and remove the catheter

with a rotation motion• Suction no longer than 10 seconds

OTHER ADJUNCTS & TECHNIQUES

Cricoid Pressure

Esophageal-Tracheal Combitube

A = esophageal obturator; ventilation into trachea through side openings = B

C = tracheal tube; ventilation through open end if proximal end inserted in trachea

D = pharyngeal cuff; inflated through catheter = E

F = esophageal cuff; inflated through catheter = G

H = teeth marker; blindly insert Combitube until marker is at level of teeth

Distal End

Proximal End

B

C

D

E

F

G

H

A

Esophageal-Tracheal Combitube Inserted in Esophagus

A = esophageal obturator; ventilation into trachea through side openings = B

D = pharyngeal cuff (inflated)

F = inflated esophageal/tracheal cuff

H = teeth markers; insert until marker lines at level of teeth

D

A

DB F

H

Laryngeal Mask Airway (LMA)

The LMA is an adjunctive airway that consists of a tube with a cuffed mask-like projection at distal end.

LMA Introduced Through Mouth Into Pharynx

LMA in Position

Once the LMA is in position, a clear, secure airway is present.

Anatomic Detail

Esophageal Detector Device (Bulb-Type)

Confirmation: Tracheal Tube Placement

End-tidal colorimetric CO2 indicators

Tracheal Tube Holders:Adult and Infant

Colorimetric End-Tidal CO2 Detector

End-Tidal CO2 Detectorconnected to Bag-valve-mask