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ALS Subcommittee 2010
AIRWAY MANAGEMENT
ALS Subcommittee 2010ALS Subcommittee 2010
Learning and Skills Objectives
• Describe the “airway hierarchy”• Be able to use airway devices• Understand the complications of these airway
devices
ALS Subcommittee 2010ALS Subcommittee 2010
“Airway hierarchy”
– Oxygen delivering devices:• Nasal cannula• Face mask
– Non-invasive airway devices:• Oropharyngeal airway• Nasopharyngeal airway• Pocket-mask device• Bag-mask device
– Invasive airway devices:• Laryngeal mask airway (LMA)• Endotracheal tube (ETT)
ALS Subcommittee 2010ALS Subcommittee 2010
“Airway hierarchy”
– Oxygen delivering devices:• Nasal cannula• Face mask
– Non-invasive airway devices:• Oropharyngeal airway• Nasopharyngeal airway• Pocket-mask device• Bag-mask device
– Invasive airway devices:• Laryngeal mask airway (LMA)• Endotracheal tube (ETT)
ALS Subcommittee 2010ALS Subcommittee 2010
Oxygen Delivering Devices
In breathing patients who can protect his airway, conscious or unconscious
Nasal cannula Simple face mask
Venturi mask Mask with O2 reservoir
ALS Subcommittee 2010ALS Subcommittee 2010
“Airway hierarchy”
– Oxygen delivering devices:• Nasal cannulae• Face masks
– Non-invasive airway devices:• Oropharyngeal airway• Nasopharyngeal airway• Pocket-mask device• Bag-mask device
– Invasive airway devices:• Laryngeal mask airway (LMA)• Endotracheal tube (ETT)
ALS Subcommittee 2010ALS Subcommittee 2010
Oropharyngeal or Nasopharyngeal Airway
Only in unconscious patient to prevent the tongue from falling back
Oropharyngeal airway Nasopharyngeal airway
ALS Subcommittee 2010ALS Subcommittee 2010
Oropharyngeal and Nasopharyngeal Airway
in Correct Position
Oropharyngeal airway in place in the mouth
Nasopharyngeal airway in place in the nose
ALS Subcommittee 2010ALS Subcommittee 2010
“Airway hierarchy”
– Oxygen delivering devices:• Nasal cannulae• Face masks
– Non-invasive airway devices:• Oropharyngeal airway• Nasopharyngeal airway• Pocket-mask device• Bag-mask device
– Invasive airway devices:• Laryngeal mask airway (LMA)• Endotracheal tube (ETT)
ALS Subcommittee 2010ALS Subcommittee 2010
Pocket-mask and Bag-mask
1-way valve
To ventilate patients non-invasively
ALS Subcommittee 2010ALS Subcommittee 2010
Bag-mask Ventilation
1-hand technique for BVM 2-hand technique for BVM
ALS Subcommittee 2010ALS Subcommittee 2010
“Airway hierarchy”
– Oxygen delivering devices:• Nasal cannula• Face mask
– Noninvasive airway devices:• Oropharyngeal airway• Nasopharyngeal airway• Pocket-mask device• Bag-mask device
– Invasive airway devices:• Laryngeal mask airway (LMA)• Endotracheal tube (ETT)
ALS Subcommittee 2010ALS Subcommittee 2010
Laryngeal Mask Airway (LMA)
The LMA - a SUPRAGLOTTIC airway that consists of a tube with a cuffed mask-like projection at distal end
ALS Subcommittee 2010ALS Subcommittee 2010
LMA - Indications
• When mask ventilation fails to achieve adequate oxygenation
• As an adjunct to airway management by personnel not skilled in tracheal intubation
• As an adjunct to airway management by personnel skilled in tracheal intubation when endotracheal intubation is difficult or not successful
ALS Subcommittee 2010ALS Subcommittee 2010
Insertion: Preparation
• Choose the appropriate size• Recommended size guidelines:
– Size 1: < 5 kg– Size 1.5: 5 - 10 kg– Size 2: 10 - 20 kg
– Size 2.5: 20 - 30 kg– Size 3: 30 - 50 kg
– Size 4: 50 – 70 kg– Size 5: >70 kg
ALS Subcommittee 2010ALS Subcommittee 2010
LMA in place in the Mouth
ALS Subcommittee 2010ALS Subcommittee 2010
Complications of LMA
Sore throat
Dysphagia
Dryness of the throat and/or mucosa
Tongue cyanosis
Vocal cord paralysis
Major: Aspiration
ALS Subcommittee 2010ALS Subcommittee 2010
“Airway hierarchy”
– Oxygen delivering devices:• Nasal cannula• Face mask
– Noninvasive airway devices:• Oropharyngeal airway• Nasopharyngeal airway• Pocket-mask device• Bag-mask device
– Invasive airway devices:• Laryngeal mask airway (LMA)• Endotracheal tube (ETT)
ALS Subcommittee 2010
CONTROL OF THE AIRWAY WITH
ENDOTRACHEAL TUBEIS USUALLY REGARDED AS THE
“GOLD STANDARD”
limited to trained and skilled personnel
ALS Subcommittee 2010ALS Subcommittee 2010
Endotracheal Intubation
Weigh benefit of intubation VS adverse effect of interrupting chest compressions during intubation
Intubation should be done by most experienced person
Do not take longer than 30 seconds per attempt
ALS Subcommittee 2010ALS Subcommittee 2010
Curved Blade Attached to Laryngoscope Handle
ALS Subcommittee 2010ALS Subcommittee 2010
Aligning Axes of Upper Airway
A
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
BAB
C
TracheaPharynx
Mouth
ALS Subcommittee 2010
Cricoid Pressure
ThyroidCartilage
Cricoid
ALS Subcommittee 2010
Visualization of Vocal Cords
Glotticopening
Arytenoidcartilage
Tongue
EpiglottisVallecula
Vocalcord
Anatomy
ALS Subcommittee 2010ALS Subcommittee 2010
Endotracheal Intubation
Complications
• Hypoxia – the act of intubation is an hypoxic event
• Trauma—teeth, lips, tongue, mucosa, vocal cords, trachea
• Vomiting and aspiration
• Hypertension/hypotension and arrhythmias
ALS Subcommittee 2010ALS Subcommittee 2010
Confirmation of advanced airway placement
• Colour
• Visible chest rise
• Vapour in ETT
• 5 points auscultation
• Capnography / CO2 detector devices
ALS Subcommittee 2010ALS Subcommittee 2010
THANK YOUNATIONAL COMMITTEE ON RESUSCITATION TRAINING
SUBCOMMITEE FOR ADVANCED LIFE SUPPORT
Dr Tan Cheng Cheng Dr Luah Lean Wah Dr Ismail Tan bin Mohd Ali Tan Dr Wan Nasrudin bin Wan Ismail Dr Chong Yoon Sin Dr Priya Gill Dr Ridzuan bin Dato’ Mohd Isa Dr Thohiroh binti Abdul Razak Dr Adi bin Osman
