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Airway ManagementPart I
RET 2275
Respiratory Care Theory 2
Manual Resuscitators
Manual resuscitator Portable, hand-held device that allows for the delivery of positive
pressure and supplemental oxygen to the airway AKA: resuscitator bag, Ambu bag, bag-valve-mask (BMV)
Generic parts: Self-inflating bag Air intake valve Nonrebreathing valve Exhalation valve Oxygen reservoir
Manual Resuscitators
Nonrebreathing Valve Types Spring-loaded ball
Manual Resuscitators
Nonrebreathing Valve Types Duckbill
Manual Resuscitators
Nonrebreathing Valve Types Leaf
O2 Powered Resuscitators Pressure limited devices that
work similarly to reducing valves
Demand valve that can be manually operated or patient triggered
Can deliver 100% O2 at flows <40 L/min
Inspiratory pressures are limited to 60 cm H2O
Manual Resuscitators
Ambu SPUR
Manual Resuscitators
Device/Patient interface Mask
Manual Resuscitators
Device/Patient interface Directly connected to
endotracheal tube
Manual Resuscitators
Uses Ventilation during a resuscitation effort Transport of a ventilator-dependant patient Hyperinflation and delivery of enriched oxygen
mixtures before and after a suctioning procedure To generate airway pressures and large tidal volume
to expand atelectatic lung segments Adjunct in directed coughing
Upper Airway Obstruction
Causes of Upper Airway Obstruction Soft tissue obstruction
Loss of muscle tone resulting in the tongue falling back against the soft palate CNS depression – drug overdose, anesthesia Cardiac arrest Loss of consciousness
Upper Airway Obstruction
Causes Laryngeal obstruction more commonly the result of:
Muscle spasm (laryngospasm) Edema
Croup Epiglottitis
Foreign material Aspirate Vomitus Blood Space-occupying lesions, e.g., tumors
Upper Airway Obstruction
Causes Laryngeal obstruction more commonly the result of:
Muscle spasm (laryngospasm) Edema
Croup Epiglottitis
Foreign material Aspirate Vomitus Blood Space-occupying lesions, e.g., tumors
Upper Airway Obstruction
Clinical Findings Noisy inspiratory efforts, e.g., snoring Silence – complete obstruction Retractions
Intercostal Sternal Clavicular
Upper Airway Obstruction
Clinical Findings Prolonged, partial upper airway obstruction
Hypoxemia and hypercapnia
Total airway obstruction Death in 5 – 10 minutes
Upper Airway Obstruction
Positional Maneuvers to Open the Airway Head Tilt
Tilting the head back to relieve soft tissue obstruction
Upper Airway Obstruction
Positional Maneuvers to Open the Airway Anterior Mandibular Displacement (jaw thrust)
Grasping the jaw at the ramus on each side and lifting the jaw forward Treatment of choice for suspected vertebral column trauma
Manual Resuscitators
Ventilatory assistance may be administered with a manual resuscitator
Manual Resuscitators
Standards Have standard 15:20 mm (ID:OD) adaptors Deliver > 85% oxygen at 15 L/min. Volume of bag
Adult: 1600 ml Child: 500 ml Infant: 240 ml
Allow for delivery of PEEP
Manual Resuscitators
Standards Allow for attachment of volume and pressure
monitoring devices Child resuscitators should be pressure limited at 40
(± 10 cm H2O) Infant resuscitators should be pressure limit at 40
(± 5 cm H2O) No pressure limiting system for adult resuscitators
Hazards of Manual Resuscitation
Gastric distention Aspiration Diminished cardiac output
May be avoided by ventilating the patient using an inspiratory to expiratory (I:E) ration of 1:2, which allows the heart to fill during the expiratory phase when there is no pressure in the thoracic cavity
Airways in Manual Resuscitation
Pharyngeal Airways Specialized devices employed to maintain a patent
airway
Oropharyngeal Airways
Oropharyngeal Airways
Function Restores airway patency by separating the tongue from the posterior
wall of the pharynx Insertion
Orally Use jaw lift or tongue displacement
Correct sizing Measure from the corner of the patient’s mouth to angle of the jaw
Incorrect placement can worsen obstruction! Used in comatose patients
Oropharyngeal Airways
Correct Sizing
Oropharyngeal Airways
Correct Sizing
Oropharyngeal Airways
Insertion Using a head-tilt-chin-lift, a modified jaw-thrust, or by grasping the
tongue and jaw by placing your thumb in the patient's mouth, move the tongue forward. Position the OPA as shown with the tip in the patient's mouth and slowly insert the OPA. As the OPA is being inserted, slight resistance will be felt.
Oropharyngeal Airways
Insertion At the point resistance is met, insertion should continue while
simultaneously rotating the OPA 180°. Advance the OPA until the flange is resting on or just above the patient's teeth.
Nasopharyngeal Airways
Nasopharyngeal Airways
Function Restores airway patency by separating the
tongue from the posterior wall of the pharynx
Used when oral placement is not possible Insertion
Nasally Necessary to check placement Correct sizing
Measure from the patient’s earlobe to the tip of the nose
Incorrect placement can worsen obstruction!
Used in awake patients
Nasopharyngeal Airways
Correct Sizing of NPA
Nasopharyngeal Airways
Correct Sizing of NPA
Nasopharyngeal Airways
Insertion of NPA First check the nostril
for signs of fracture or obstruction then apply generous amounts of a water-based lubricant to the NPA taking care not to fill the tip with the lubricant
Orient the bevel end so that it will pass along the inside of the nasal cavity with minimal effort
Nasopharyngeal Airways
Insertion of NPA Insert the NPA until the flange (the large end of the tube) is
seated on the patient's nose
Nasopharyngeal Airways
Proper placement of the nasopharyngeal airway
Ventilation with Manual Resuscitator
Ventilation with Manual Resuscitator
Place the patient supine Open the airway – manual maneuver Insert pharyngeal airway Place the mask on the patient’s face
Bridge of the nose first Securing a tight seal below the lower lip Maintain the mask position with thumb and index finger of one
hand, use the third, forth and fifth fingers to hook under the mandible, displacing it anteriorly to maintain a patent airway
Ventilation with Manual Resuscitator
Ventilation with Manual Resuscitator
Two-man ventilation with manual resuscitator
Ventilation with Manual Resuscitator
Ventilate the patient at a rate of 8 – 16 breaths/min.
Watch for chest expansion to ensure adequate volume
I:E ration of 1:2 or better
If the patient has spontaneous respiratory efforts, match your ventilation efforts with the patient’s efforts
Endotracheal Tubes
Function Relieve airway obstruction Facilitate secretion removal Protect against aspiration Provide positive pressure ventilation
Insertion Site Nasally Orally
Placement In the trachea 3 – 5 cm above the carina
Endotracheal Tubes
Placement of the ET Tube
Endotracheal Tubes
Standard adapter with a 15 mm external diameter
BodyPilot tube
Pilot balloon
Cuff
Beveled distal tip
Radiopaque Strip
(visible on x-ray)
Endotracheal Tubes
Inner diameter
Length makings
(distance in cm from beveled tube tip)
“Z-79” or “IT”
(Tissue toxicity testing)
Endotracheal Tubes
Murphy’s eye Provides an alternate pathway
for gas to flow in the event the distal tip become obstructed
Beveled distal tip
Reinforced Wire-Wrapped ET Tube Helical reinforcing wire imbedded into
the PVC material helps prevent kinking when used in a tortuous airway
Endotracheal Tubes
Hi-Lo EVAC Endotracheal Tube
Indwelling Hi-Lo EVAC Tube
Double Lumen ET Tube
Function Independent lung ventilation
Unilateral lung disease
Properties 2 proximal 15 mm ventilator connections 2 inner lumens for gas flow 2 cuffs
Larger cuff seal trachea Smaller cuff seals bronchial lumen
2 distal openings Fiberoptic bronchoscopy needed to
verify placement
Double Lumen ET Tube
Proper placement
Indications for Endotracheal Intubation
Relieve airway obstruction Facilitate secretion clearance Facilitate mechanical ventilation Protect lower airway
Orotracheal Intubation
Safely performed by: Physicians Respiratory Therapists Nurses Paramedics
Orotracheal Intubation
Step 1: Assemble and Check Equipment Suction Equipment
Suction regulator, canister, tubing, catheters, Yankauer (tonsil tip)
Manual resuscitator bag and mask O2 flowmeter and tubing
Orotracheal Intubation
Step 1: Assemble and Check Equipment Laryngoscope with assorted blades
Ensure light on blade is functioning Endotracheal tubes
Inflate cuff and check for leaks
Orotracheal Intubation
Step 1: Assemble and Check Equipment Stylet Magil forceps (nasal intubation)
Orotracheal Intubation
Step 1: Assemble and Check Equipment Tongue depressor Tape Syringe Lubricating jelly Local anesthetic (spray)
Orotracheal Intubation
Step 1: Assemble and Check Equipment Towels (for positioning) Stethoscope CDC barrier precaution
Gloves, gowns, masks, eyewear
Orotracheal Intubation
Step 2: Position the Patient Must align the mouth,
pharynx and larynx Place one or more rolled
towels under the patient’s head
Orotracheal Intubation
Step 3: Preoxygenate the Patient with Resuscitator / Mask Provides a reserve of oxygen during intubation
attempts Intubation attempts should not last greater than 30
seconds If attempt fails, ventilate and oxygenate for 3-5
minutes before reattempting to intubate
Orotracheal Intubation
Step 4: Insert the Laryngoscope Laryngoscope in left hand while
right hand opens the mouth Insert the laryngoscope into the
right side of the mouth and move it toward the center, displacing the tongue to the left
Advance the tip of the blade along the curve of the tongue until you visualize the epiglottis
Orotracheal Intubation
Step 5: Visualize the Glottis
Orotracheal Intubation
Step 6: Displace the Epiglottis MacIntosh Blade – displaces
the epiglottis indirectly by advancing the tip of the blade into the vallecula
Miller Blade – displaces the epiglottis directly by advancing the tip of the blade over the its posterior surface and lifting the laryngoscope up and forward
Orotracheal Intubation
Step 7: Insert the Tube Insert the tube from the
right side of the mouth Advance tube through
the glottis until the cuff passes the vocal cords
Inflate the cuff to seal the airway
Ventilate and oxygenate
Orotracheal Intubation
Step 8: Assess Tube Position (3 - 5 cm above carina) Auscultation – bilateral breath sounds Observation of chest movement Tube length ( approximately 22 cm to teeth for adults) Colorimetry
Colorimetry - CO2 Detector
Positive for CO2
Negative for CO2
Orotracheal Intubation
Step 8: Assess Tube Position (3 - 5 cm above carina) Capnometry (End-Tidal CO2) Light wand Fiberoptic laryngoscope Esophogeal detection device Chest x-ray
Orotracheal Intubation
Step 9: Secure the Endotracheal Tube
Intubation Videos
Oral Intubation Procedure – Routine
Points to Remember
Hazards of Endotracheal Intubation
Post-extubation mucosal edema Trauma Aspiration Bleeding Infection Tube problems (pilot balloon, kinking etc.)
Cuff Pressure Monitoring Techniques
Auscultate over trachea Minimal Occluding Volume – inflate cuff until cuff air
leak stops Minimal Leak Technique – inflate cuff until cuff air leak
stops, then withdraw enough air to allow a small air leak at peak inspiration
Cuff Pressure Monitoring Techniques
Cuff Pressure Measurement Cufflator Checked once per shift Pressures not to exceed:
27 – 34 cm H2O (20 – 25 mm Hg)
Excessive pressures my cause tracheal damage if cuff pressures are greater than tracheal perfusion pressures
Combitube Airway
Double lumen airway Esophageal gastric airway Endotracheal tube Effective whether in the esophagus or the trachea
Designed to be inserted blindly Used for difficult intubation Short-term
Combitube Airway
Correct insertion and placement
Laryngeal Mask Airway (LMA)
Designed to form a low-pressure seal in the laryngeal inlet by means of an inflated cuff Maintains a patent upper airway and
facilitates ventilation Designed to be inserter blindly
Used for difficult intubation Short-term
Laryngeal Mask Airway (LMA)
Correct insertion and placement
Laryngeal Mask Airway (LMA)
Correct insertion and placement
Laryngeal Mask Airway (LMA)
This tube, when inserted into the larynx and the laryngeal cuff inflated, provides a closed seal system to ventilate the lower airway and protect against aspiration.
Insertion video