Airway Management Part I RET 2275 Respiratory Care Theory 2

Manual Resuscitators Manual resuscitator Generic parts: 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

Manual Resuscitators 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

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 Insertion Site Placement 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 Radiopaque Strip (visible on x-ray) Pilot tube Body Pilot balloon Cuff Beveled distal tip

Endotracheal Tubes Length makings (distance in cm from beveled tube tip) “Z-79” or “IT” (Tissue toxicity testing) Inner diameter

Endotracheal Tubes Murphy’s eye Provides an alternate pathway for gas to flow in the event the distal tip become obstructed Beveled distal tip

Endotracheal Tubes Reinforced Wire-Wrapped ET Tube Helical reinforcing wire imbedded into the PVC material helps prevent kinking when used in a tortuous airway

Hi-Lo EVAC Endotracheal Tube

Indwelling Hi-Lo EVAC Tube

Double Lumen ET Tube Function Properties 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 Negative for CO2 Positive 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 Designed to be inserted blindly 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