Embed Size (px)
Citation preview
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
ح ر ن ال حم ر م الل ه ال س يمب
Airway Management
and Ventilation
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Airway Management
Air reaches the lungs only
through the trachea.
In a compromised airway,
clearing the airway and
maintaining patency are
vital.
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Positioning the Patient
Move unresponsive patients found in a prone position to a supine
position.
If the patient is breathing adequately and is not injured, move to recovery position.
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Manual Airway Maneuvers
If an unresponsive patient has a pulse
but is not breathing, you must open the
airway.
Maneuver patient’s head to propel the
tongue forward and open the airway.
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
OPEN AIRWAY
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
OPEN AIRWAY
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
OPEN AIRWAY
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
OPEN AIRWAY
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Head Tilt-Chin Lift Maneuver
Indications:
Unresponsive
No spinal injury
Unable to protect
airway
Contraindications:
Responsive
Possible spinal injury
Advantages
No equipment
Noninvasive
Disadvantages
Hazardous to spinal injury
No protection from
aspiration
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
OPEN AIRWAY
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
OPEN AIRWAY
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Jaw-Thrust Maneuver
Indications
Unresponsive
Possible spine injury
Unable to protect
airway
Contraindications
Resistance to opening
the mouth
Advantages
Used with spine injury
or cervical collar
No special equipment
required
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Jaw-Thrust Maneuver
Disadvantages
Cannot maintain if
patient becomes
responsive or
combative
Difficult to maintain for an extended time
Difficult to use with
bag-mask ventilation
Thumb must remain in
place
Requires second
rescuer
No protection against aspiration
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Suctioning
Removes material from the mouth or throat quickly and efficiently
Ventilating with secretions in the mouth will result in upper airway
obstruction or aspiration.
Next priority after opening airway manually
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Suctioning Equipment
Fixed or portable
Hand-operated suctioning
units with disposable
canisters
Mechanical or vacuum-
powered suction units
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Suctioning Equipment
The following should be readily accessible:
Wide-bore, thick-walled, nonkinking tubing
Soft and rigid suction catheters
Nonbreakable, disposable collection bottle
Supply of water for rinsing the catheters
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Suctioning Equipment
Yankauer catheter
Use with adults (pharynx),
infants, children
French catheter
Can be placed in ET tube
Use for nose, back of mouth,
when a rigid catheter cannot
be used
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Suctioning Techniques
Suctioning removes oxygen.
Preoxygenate before suctioning.
Maximum suctioning time
Adult: 15 seconds
Child: 10 seconds
Infant: 5 seconds
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Suction
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Suctioning Techniques
Do not stimulate back of throat.
After suctioning, continue ventilation
and oxygenation.
Soft-tip catheters
Must lubricate when suctioning the
nasopharynx
Best when passed through an ET tube
Suction during extraction of catheter
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Suctioning
Techniques
Measure
Before inserting, measure for proper size.
• Corner of the mouth to the earlobe
Insert
Never insert a catheter past the base of the tongue.
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Simple airway adjuncts
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Airway Adjuncts
May be needed to help maintain patency in an unresponsive
patient after manually opening and suctioning
Not a substitute for proper head positioning
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
History
Oral Airway
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Oropharyngeal (Oral) Airway
Curved, hard plastic device
Fits over back of the tongue
Should be inserted in unresponsive patients who have no gag reflex
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Oro-pharyngeal, (Guedel) Airways
• open airway during sedation.
• Prevent the tongue from slipping
into the back.
• Color-coded, variable sizes
• Have smooth, polished surfaces
for increased patient comfort.
• lightweight.
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Oro-pharyngeal (Guedal) airways
Range of sizes: 8 000 - neonatal
00 - infant
0 - small child
1 - child
2 - small adult
3 - medium adult
4 - large adult
5 - outsize adult
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Sizing an oropharyngeal
airway
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Insert oropharyngeal airway
with tip facing palate.
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Rotate airway 180º into position.
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Oropharyngeal airway
insertion
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Oropharyngeal (Oral) Airway
Indications
Unresponsive patients
who have no gag
reflex
Contraindications
Responsive patients
Patients with a gag
reflex
Advantages
Noninvasive and easily
placed
Prevents blockage by
the tongue
Disadvantages
No prevention of
aspiration
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Copa airways
Select The Proper Size
Inspect Before using
Lubricate The Cuff
Pre-oxygenate & Achieve Proper Depth Of Anesthesia
Position The Patient’s Head
Insert The COPA™ Airway
Position The COPA™ Airway
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Copa airway, cont.
Secure The COPA™ Airway
With Strap
Inflate The Cuff
Approximate
Inflation
Volume(ml(
COPA Size
(cm)
258
309
3510
4011
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
COPA
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
COPA
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Nasopharyngeal Airway
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Nasopharyngeal airway insertion
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Nasopharyngeal airway insertion
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Nasopharyngeal Airways
Nasal Airways
Length: From the tip of the nose to the meatus of the ear
Relative contraindications
Coagulopathy
Basilar skull fracture
Nasal infections or deformities
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Nasopharyngeal (Nasal) Airway
Soft, rubber tube
Insert through nose
Better tolerated
Do not use with trauma to
the nose or skull fracture.
Lubricate the airway and insert gently.
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Nasopharyngeal (Nasal) Airway
Indications
Unresponsive
Altered mental status
with an intact gag
reflex
Contraindications
Patient intolerance
Facial fracture or skull
fracture
Advantages
Suctioned through
Patent airway
Tolerated by
responsive patients
Can be placed “blindly”
No requirement for the
mouth to be open
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Nasopharyngeal Airway
Disadvantages
Improper technique may result in severe bleeding.
Does not protect from aspiration
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Advanced
Airway
Management
One of the most common mistakes with
respiratory or cardiac arrest is to use advanced
techniques too early.
Establish and maintain a patent airway with
basic techniques first.
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Advanced Airway Management
Primary reasons:
• Failure to maintain a patent airway
• and/or
• Failure to adequately oxygenate and ventilate
Involves insertion of advanced
airway devices
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Predicting the Difficult Airway
•Congenital abnormalities
•Recent surgery
•Trauma
• Infection
•Neoplastic diseases
Anatomic findings:
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Predicting the Difficult Airway
• Look externally
• Evaluate 3-3-2
• Mallampati
• Obstruction
• Neck mobility
LEMON
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
LEMON
Look externally.
The following can make intubation difficult:
Short, thick necks
Morbid obesity
Dental conditions
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
LEMON
Evaluate 3-3-2.
3 — mouth width of more than 3 fingers is best
3 — mandible length of 3 fingers is best (from the tip of the chin to the
hyoid bone).
2 — distance from hyoid bone to thyroid notch of 2 fingers wide is best
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
LEMON
Mallampati
Note oropharyngeal structures visible in an upright, seated patient.
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
LEMON
Obstruction
Note anything that might interfere with visualization or ET tube placement.
Foreign body
Obesity
Hematoma
Masses
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
LEMON
Neck mobility
•Neck mobility problems most common with:
•Trauma patients
•Elderly patients
•Sniffing position is ideal
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Endotracheal Intubation
ET tube passes through glottic opening and is sealed with a cuff
inflated against the tracheal wall
Orotracheal intubation: through the mouth
Nasotracheal intubation: through the nose
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Endotracheal Intubation
AdvantagesSecure airway
Protection against aspiration
Alternative to IV or IO route
DisadvantagesSpecial equipment
Physiologic functions bypassed
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Endotracheal Intubation Complications
Bleeding HypoxiaLaryngeal swelling
Laryngospasm
Vocal cord damage
Mucosal necrosis
Barotrauma
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Endotracheal
Tubes
Basic structure includes:
Proximal end
Tube
Cuff and pilot balloon
Distal tip
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Endotracheal
Tubes
Sizes range
2.5 to 9.0 mm in inside
diameter
12 to 32 cm in length
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Endotracheal Tubes
Pediatric patients
2.5 to 4.5 mm tubes used
Funnel-shaped cricoid ring forms an
anatomic seal with ET tube
No need for distal cuff in most cases.
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Endotracheal Tubes
Anatomic clues can help determine tube size
Internal diameter of the nostril approximates diameter of glottic opening
Diameter of the little finger or size of thumbnail approximates airway
size.
Always have three sizes ready!
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Laryngoscopes
and Blades
A laryngoscope is required to
perform orotracheal
intubation by direct
laryngoscopy.
Consists of a handle and
interchangeable blades
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Laryngoscopes
and Blades
Straight (Miller and Wisconsin)
blades
Tip extends beneath epiglottis and
lifts it up
Useful with infants and small
children
More likely to damage teeth in
adults
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Laryngoscopes and Blades
Curved (Macintosh)
blades
Curve conforms to
tongue and pharynx
Tip is placed in the
vallecula
Indirectly lifts
epiglottis to expose
vocal cords
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Laryngoscopes and Blades
Blade sizes range from
0 to 4
• 0, 1, and 2 appropriate for infants and children
• 3 and 4 considered adult sizes
• Pediatric patients: based on age or height
• Adults: based on experience, size of patient
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
21
0ctober 2018
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Laryngoscopes and Blades
Stylet: semirigid wire inserted
into ET tube
Molds and maintains shape of
tube
Should be lubricated for
removal
End should be bent to form a
gentle curve
End should rest at least 1/2″
from end of ET tube
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Laryngoscopes and Blades
Magill forceps
Remove airway obstructions
under direct visualization.
Guide tip of ET tube through
glottic opening if the proper
angle cannot be achieved by
manipulating the tube
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Orotracheal Intubation by Direct
Laryngoscopy
ET tube inserted through
mouth and into trachea
while visualizing the glottic
opening with a
laryngoscope
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Orotracheal Intubation : Indications
Airway control needed
due to coma,
respiratory arrest,
and/or cardiac arrest
Ventilatory support
before impending
respiratory failure
Prolonged ventilatory
support
Absence of gag reflex
Traumatic brain injury
Unresponsiveness
Impending airway
compromise
Medication
administration
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Orotracheal Intubation :Contraindications
Intact gag reflex
Inability to open mouth because of trauma, dislocation of the jaw, or a pathologic condition
Inability to see the glottic opening
Copious secretions, vomitus, or blood in airway
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Standard Precautions
Intubation can expose you to bodily fluids.
Take proper precautions
Gloves
Mask that covers your entire face
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Preoxygenation
Critical before intubating
2–3 minutes for apneic or
hypoventilating patient
Prevents hypoxia from
occurring
Monitor SpO2 and achieve
as close to 100% saturation
as possible.
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Positioning the
Patient
Airway has three axes:
mouth, pharynx, and larynx
At acute angles in neutral
position
Place patient in “sniffing”
position to facilitate
visualization of the airway.
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Positioning
the Patient
Sniffing position
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Blade Insertion
Position yourself at the
patient’s head.
Grasp laryngoscope.
If mouth is not open:
Place thumb below bottom
lip and push open.
“Scissor” thumb and index
finger between molars
Open with tongue-jaw lift
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Blade Insertion
Insert blade into right side of
mouth
Sweep tongue to the left
while moving blade into midline
Slowly advance the blade.
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Blade Insertion
Exert gentle traction at a 45°
angle as you lift the patient’s
jaw.
Keep your back and arm
straight as you pull upward.
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Visualization of the Glottic Opening
Continue lifting the
laryngoscope as you look
down the blade.
Work the tip of the blade into position.
The glottic opening should
come into view.
The vocal cords lie within.
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Visualization of the Glottic Opening
Gum elastic bougie
Flexible device
Approximately 1 cm in
diameter, 60 cm long
Used in epiglottis-only views
to facilitate intubation
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Visualization of the Glottic Opening
Gum elastic bougie (cont’d)
Insert through the glottic
opening under direct
laryngoscopy.
Once placed, it becomes a
guide for the ET tube.
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Tube Insertion
Pick up preselected ET tube.
•Hold it near connector as you would a pencil.Pick up
Insert tube from the right corner of mouth through the vocal cords.
•Continue until the proximal end of the cuff is 1 to 2 cm past the vocal cords.
Insert
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Tube
Insertion
Do not pass the tube
down the barrel of the
laryngoscope blade.
Will obscure your
view of the glottic
opening
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
28 October
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Ventilation
After you have seen the ET tube cuff pass roughly 1/2″
beyond the vocal cords
Gently remove the blade.
Secure tube with right hand
Remove stylet from tube
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Ventilation
Inflate the distal cuff with 5 to 10 mL of
air, then detach the syringe from the
inflation port.
Have your assistant attach the bag-
mask device to the ET tube; continue
ventilation.
Ensure that the patient’s chest rises
with each ventilation.
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Ventilation
Listen to both lungs and to the
stomach.
You should hear equal breath
sounds and a quiet epigastrium.
Ventilation should be dictated by
age.
Adult with a pulse: 10 to 12
breaths/min
Infant/child with a pulse: 12 to 20
breaths/min
Patient in cardiac arrest: 8 to 10
breaths/min
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Confirmation of Tube Placement
Visualize the ET tube passing between the vocal cords.
Auscultate.
Unequal or absent breath sounds suggest:
Esophageal placement
Right mainstem bronchus placement
Pneumothorax
Bronchial obstruction
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Confirmation of Tube Placement
Auscultate (cont’d).
Bilaterally absent breath sounds or gurgling over the epigastrium:
esophagus was intubated
Immediately remove ET tube.
Be prepared to suction the airway.
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Confirmation of Tube Placement
Auscultate (cont’d).
Breath sounds only on right: tube has been advanced too far.
Reposition the tube.
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Confirmation of Tube Placement
With proper tube position:
Bag-mask device should be easy to compress.
You should see corresponding chest expansion.
Increased resistance may indicate:
Gastric distention
Esophageal intubation
Tension pneumothorax
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Confirmation of Tube Placement
Continuous waveform capnography
plus clinical assessment
Most reliable method of confirming
placement
Attach capnography T-piece when
bag-mask device is attached to the ET
tube.
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Confirmation of Tube Placement
Esophageal detector
device
Syringe model: plunger is
withdrawn
Tube in the trachea:
plunger does not move
Tube in the esophagus:
plunger moves back
Courtesy of Marianne Gausche-Hill, MD, FACEP, FAAP
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Confirmation of Tube Placement
Esophageal detector
device (cont’d)
Bulb model: bulb is
squeezed
Tube in the esophagus:
bulb remains collapsed
Tube in the trachea: bulb
briskly expands
Courtesy of Marianne Gausche-Hill, MD, FACEP, FAAP
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Confirmation of Tube Placement
After confirming proper placement, mark ET tube where it emerges
from the mouth
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Securing the Tube
Never take your hand off the ET tube before securing with an
appropriate device.
Support the tube manually while you ventilate to avoid a sudden jolt
from the bag-mask device.
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Securing the Tube
Many devices feature a built-in bite block.
Alternative: Secure tube with tape and insert a bite block or oral airway.
Minimize head movement in patient.
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Nasotracheal Intubation
Insertion of tube into
trachea through nose
Indicated:
Breathing
spontaneously but
requires definitive airway management
Contraindicated:
Head trauma and
midface fractures
Anatomic
abnormalities; frequent cocaine use
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Nasotracheal Intubation
Advantages
Can be performed on
responsive patients
No need for
laryngoscope
Mouth does not need to be opened
Does not require
sniffing position
Patient cannot bite the
tube.
Can be secured more
easily
Disadvantage
Blind technique
Complications
Bleeding
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Nasotracheal Intubation
Equipment
Same as for orotracheal intubation
Minus laryngoscope and stylet
Some tubes are designed for blind method
Some devices allow confirmation of intubation without placing face
next to tube
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Technique for Nasotracheal
Intubation
Patient’s spontaneous respirations guide the tube and confirm
proper placement.
Tube is advanced as patient inhales
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Technique for Nasotracheal
Intubation
Insert tube into nostril,
bevel facing toward the
nasal septum
Aim tip straight back
toward ear
Position just above the
glottic opening © Jones & Bartlett Learning. Courtesy of MIEMSS.
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Technique for Nasotracheal
Intubation
Manipulate head to control
tube tip position and to
maximize air movement.
Instruct patient to take a deep
breath, and gently advance
tube.
Placement will be evidenced by
an increase in air movement
through the tube.
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Technique for Nasotracheal
Intubation
Soft-tissue bulge on either side of the airway
Tube is probably in the piriform fossa
Hold head still, slightly withdraw the tube
Once maximum airflow is detected, advance tube
No soft-tissue bulge
Tube has entered the esophagus.
Withdraw until you detect airflow; extend head.
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Technique for Nasotracheal
Intubation
Once tube is in place, inflate the distal cuff
Attach bag-mask device and ventilate.
Clean up any secretions or excess lubricant.
Secure the tube with tape.
Document depth of insertion at the nostril.
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Digital Intubation
Directly palpate the glottic structures and elevate the epiglottis with
your finger while guiding the ET tube into the trachea.
Option in extreme circumstances
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Digital Intubation
Indications (exceptional circumstances)
Laryngoscope, or other techniques, have failed
Patient in confined space
Patient is obese or has a short neck
Copious secretions
Head cannot be moved
Cannot visualize intubation landmarks
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Digital Intubation
Can be performed in pediatric patients, but usually impossible due
to finger size
Absolutely contraindicated if patient is:
Breathing
Not deeply unresponsive
Has intact gag reflex
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Digital Intubation
Advantages
Does not require a
laryngoscope
Ideal if vocal cords are
obscured by secretions
Does not require sniffing position
Disadvantages
Risk of being bitten
Risk of exposure to
infectious disease
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Digital Intubation
Complications
Misplacement of the ET tube
Bite block can cause lip and tooth damage
Vigorous or improper attempts can cause airway trauma or swelling.
Can result in hypoxia
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Digital Intubation Equipment
Same as for orotracheal
intubation (minus laryngoscope),
plus fingers
Stylet
ETCO2 detector or esophageal
detector device
Appropriate device to secure the
tube
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Technique for Digital Intubation
Prepare equipment as assistant ventilates
Select tube: one half to a full size smaller than
with direct laryngoscopy
Tip of the tube is guided into the trachea
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Technique for Digital Intubation
Two configurations are recommended.
“Open J” configuration
“U-handle” configuration
© Jones & Bartlett Learning. Courtesy of MIEMSS.
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Technique for Digital Intubation
Sniffing position is not
required
Insert bite block between
molars.
Insert index and
middle fingers into
right side of the
mouth.
Press against tongue.
Pull epiglottis forward.
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Technique for Digital Intubation
Hold ET tube in right hand; insert it into the left side of the mouth
Advance tube toward the glottis
Once you feel the cuff pass 2″ beyond your fingertip, stabilize the tube
and withdraw fingers
Remove the stylet and inflate the cuff.
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Technique for Digital Intubation
Attach bag-mask device and ventilate.
Confirm placement.
Auscultate lungs and epigastrium.
Monitor ETCO2.
Properly secure the tube in place.
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Transillumination Techniques for
Intubation
Bright light source placed
inside the trachea emits a
bright, well-circumscribed
light
© Jones & Bartlett Learning. Courtesy of MIEMSS.
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Transillumination Techniques for
Intubation
Indicated
Other techniques have failed.
Contraindicated
Intact gag reflex
Airway obstruction
May be difficult in obese or short neck patients
Pediatric patients: stylet must fit inside tube
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Transillumination Techniques for
Intubation Advantages
No laryngoscope
Visual parameter
Does not require
visualization of the
glottic opening
Safe with possible
spinal injuries
Disadvantages
Special equipment
Proficiency with
equipment
Can be difficult in
brightly lit areas
Complications
Misplacement
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Technique for Transillumination-Guided
Intubation
Preoxygenate for at least 2 to 3 minutes.
Choose ET tube and check the cuff
Lubricate and insert the lighted stylet.
Ensure it is firmly seated into the tube.
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Technique for Transillumination-Guided
Intubation
Bend tube into the proper shape
Head in neutral or slightly extended position
While holding the stylet, displace the jaw forwardly.
Turn on the lighted stylet, and insert it in the midline of the mouth.
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Technique for Transillumination-Guided
Intubation
Continue insertion; draw wrist toward you .
Tightly circumscribed light slightly below the thyroid cartilage: tube has
entered trachea
Faintly glowing light and bulging of the soft tissue: tube is in the
vallecular space.
Dim, diffuse light at the anterior part of the neck: esophageal
placement
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Technique for Transillumination-Guided
Intubation
Once light is visible at the midline, hold the stylet
in place and advance the tube.
When the tube is in the trachea, stabilize it and withdraw the stylet.
Inflate the distal cuff, detach the syringe, and
attach the bag-mask device.
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Technique for Transillumination-Guided Intubation
Ventilate the patient while auscultating both lungs and the
epigastrium.
Secure the tube and continue ventilations.
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Retrograde Intubation
Needle: placed percutaneously within
the trachea via the cricothyroid
membrane
Wire: placed through the needle,
through the trachea, into the mouth
Wire is visualized, secured
ET tube is placed over wire and guided
into trachea
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Retrograde Intubation
Indications
Upper airway
obstruction
Copious secretions in
the airway
Failure to intubate by less invasive methods
Contraindications
Lack of familiarity with
the procedure
Laryngeal trauma
Unrecognizable or
distorted landmarks
Coagulopathy
Severe hypoxia
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Retrograde Intubation
Complications
Hypoxia
Cardiac dysrhythmia
Mechanical trauma
Infection
Increased intracranial pressure
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Failed Intubation
Definition:
Failure to maintain oxygen saturation during or after one or more failed
intubation attempts
Total of three failed intubation attempts
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Failed Intubation
Many rescue airway techniques
Simple BLS airway maneuvers with oral airway and/or nasal airway and
bag-mask device
Rescue airway device
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Tracheobronchial Suctioning
Involves passing a suction catheter into the ET tube to remove
pulmonary secretions
Do not do it if you do not have to!
If it must be performed:
Use sterile technique.
Monitor cardiac rhythm and oxygen saturation.
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Tracheobronchial Suctioning
Preoxygenate for at least 2 to 3 minutes.
Insert suction catheter until resisted.
Apply suction as the catheter is extracted
Reattach bag-mask device, continue ventilations, and reassess.
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Field Extubation
Extubation: process of removing tube from an intubated patient
Before performing, contact medical control or follow local protocols.
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Field Extubation
Risks
Over-estimating patient’s ability to protect airway
Laryngospasm
Upper airway swelling
Do not remove tube unless you can reintubate!
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Field Extubation
Contraindicated with any risk of recurrent respiratory failure or
uncertainty about a patient’s ability to maintain airway
If indicated, ensure adequate oxygenation.
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Field Extubation
Explain procedure to patient
Have patient sit up or lean slightly forward.
Assemble equipment to suction, ventilate, and reintubate.
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Field Extubation
Confirm patient can protect airway
Suction oropharynx
Deflate distal cuff as patient exhales
On next exhalation, remove tube
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Pediatric Endotracheal Intubation
If bag-mask is not
producing adequate
ventilation, patient
should be intubated
Indications are the
same as those in
adults
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Laryngoscope and Blades
Thinner pediatric handles are preferred.
Straight blades facilitate lifting of epiglottis
Blade should extend from mouth to ear
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Laryngoscope and Blades
Use length-based resuscitation tape measure or the following
guidelines:
Premature newborn: size 0 straight blade
Newborn to 1 year: size 1 straight blade
2 years to adolescent: size 2 straight blade
Adolescent and older: size 3 straight or curved blade
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Endotracheal Tubes
To estimate the appropriate
size:
Length-based resuscitation
tape measure
Formulas
[Age (in years) + 16] ÷ 4
[Age (in years) ÷ 4] + 4
Anatomic clues
General guidelines
Courtesy of Marianne Gausche-Hill, MD, FACEP, FAAP
© Jones & Bartlett Learning. Courtesy of MIEMSS.
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Endotracheal Tubes
Cuffed ET tubes are generally not used in the field until the child is 8
to 10 years old.
Can cause ischemia and damage the tracheal mucosa
Have tubes one size smaller and one size larger than expected
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Endotracheal Tubes
Appropriate depth of insertion is 2 to 3 cm beyond the vocal cords
Record depth at corner of mouth
Uncuffed tubes: stop when black band is at the vocal cords.
Cuffed tubes: stop when cuff is just below the vocal cords.
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Pediatric Stylet
Insert into tube, stop at least 1 cm from end
Fit tube sizes 3.0 to 6.0 mm
After inserting into tube, bend tube into a gentle upward curve
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Preoxygenation
Preoxygenate for at least 2 to 3 minutes.
Ensure that the child’s head is in the sniffing position or the neutral
position.
If needed, insert an airway adjunct.
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Additional Preparation
Monitor cardiac rhythm.
Monitor pulse rate and oxygen saturation.
Have suction available.
Atropine sulfate may be administered.
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Pediatric Intubation Technique
With head in sniffing position, apply thumb pressure on chin to open
mouth.
If an oral airway was inserted, remove it.
Suction if needed.
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Pediatric Intubation Technique
Straight blade: When the blade passes the epiglottis, gently lift the
epiglottis.
Curved blade: place blade tip in vallecula; lift jaw, tongue, and blade at a 45° angle.
Identify vocal cords and other landmarks.
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Pediatric Intubation Technique
Hold tube in right hand; insert from the right-side corner of the
mouth.
Guide tube through the vocal cords, advancing until black band is just beyond
Record the depth, and remove the blade.
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Pediatric Intubation Technique
Remove stylet; hold tube in place.
Recheck tube depth.
Cuffed tube: inflate to form seal
Attach tube to bag-mask device.
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Pediatric Intubation Technique
Confirm tube placement.
Bilateral chest rise during ventilation
Auscultate lungs bilaterally.
If sounds are decreased on left, tube may be too deep.
To correct, withdraw tube until sounds are equal.
Rerecord tube depth.
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Pediatric Intubation Technique
Auscultate over epigastrium.
Bubbling sounds indicate esophageal intubation.
Additional methods to confirm placement:
Improvement in skin color, pulse rate, and oxygen saturation
Waveform capnography
Air
wa
y M
an
ag
em
en
t
By
A
ssis
t P
rof. D
r. T
ari
k S
arh
an
Pediatric Intubation Technique
Colorimetric ETCO2 detector or EDD
Cannot be used in children weighing < 15 kg
Esophageal bulb or syringe cannot be used in children weighing < 20 kg
After placement, secure tube
Reconfirm placement following any movement.
