1. به نام خدا

2. اداره راه هوای در بیماران خاص ولوله گذاری تراشه
اداره راه هوای در بیماران خاص ولوله گذاری تراشه

3. هـدف :
مهمترين هدف احياء مغزوبازگرداندن بيماربه بهترين وضع عصبي ممكن مي باشد .
C P R ~ C P C R
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4. کمک جهت برقراری تهویه باید سریع شروع شود
شانس بیشتر بقا
در عرض 4-6 دقیقه آسیب مغزی شروع میشود
بعد از 10 دقیقه حتما مغز آسیب میبیند

5. Airway management

6. Airway Anatomy Upper Airway Lower Airway Pharynx Epiglottis Glottis
Vocal cords
Larynx
Lower Airway
Trachea
Bronchi
Alveoli
Lung tissue, consisting of lobes and lobules (3 on the right and 2 on the left)
Pleura

8. R - Responsiveness
شانه بیمار را تکان داده بپرسید خوبی؟

9. Check For Breathing تنفس را بانگاه , شنیدن واحساس بررسی کنید
تنفس را بانگاه , شنیدن واحساس بررسی کنید
بیشتتر از 10 ثانیه طول نکشد

10. تشخیص سریع انسداد راه هوایی
نگاه: حرکت قفسه سینه وشکم
گوش دادن: صداهای تنفسی
احساس : جریان هوا در بینی ودهان

11. P - Position on back
همیشه احتمال آسیب سر , گردن وستون فقرات را به یاد داشته باشید.

14. Basic Airway Maneuvers
ALWAYS REMEMBER THE BASICS
These skills should be used prior to initiating any advanced airway technique
Head-tilt/chin lift
Jaw thrust
Sellick’s maneuver

15. A – Airway
راه هوایی را باز کنید
Head tilt chin lift

22. انواع Airway:
درصورت عدم ونتیلاسیون با وجود مانورهای داده شده می توان از Airway استفاده کرد.
نازوفارنژیال
اروفارنژیال

27. Breathing
اگر مصدوم تنفس ندارد 2 تنفس به او بدهید (1 ثانیه یا کمی بیشتر)
بینی را ببندید
دهان راکامل روی دهان قرار دهید
اگر 2نفس اول منتقل نشد مجددا re tilt کرده 2نفس دیگر بدهید (وگرنه به chockingباید شک کرد)

30. BVM Ventilation The most important airway skill
Always the first response to inadequate oxygenation and ventilation
The first “bail-out” maneuver to a failed intubation attempt
Attenuates the urgency to intubate

31. Golden Rules of Bagging
“ Anybody ( almost ) can be oxygenated and ventilated with a bag and a mask “
The art of bagging should be mastered before the art of intubation
Manual ventilation skill with proper equipment is a fundamental premise of advanced airway

37. BVM Ventilation: Assessment of Efficacy
Observe the chest rise and fall
Good bilateral air entry
Lack of air entering the stomach
Feeling the bag
Pulse oximetry

38. Predictors of difficult face mask ventilation
1- age>55 years 2-body mass index>26 Kg/m2 3-a beard 4-lack of teeth 4-a history of snoring

40. لوله گذاری تراشه

41. Anatomy

43. Methods:
Endotracheal intubation
Orotracheal
Nasotracheal

44. Endotracheal Intubation
Placement of a flexible plastic tube into the trachea to:
maintain an open airway,
serve as a conduit through which to administer certain drugs.
Is performed in critically injured, ill or anesthetized patients:
to facilitate ventilation of the
lungs, including mechanical ventilation,
to prevent the possibility of
asphyxiation or airway obstruction.

45. Indications:
For supporting ventilation in patient with pathologic disease:
Upper airway obstruction,
Respiratory failure,
Loss of consciousness
For supporting ventilation during general anaesthesia:
Type of surgery:
Operative site near the airway,
Thoracic or abdominal surgery,
Prone or lateral surgery,
Long period of surgery
Patient has risk of pulmonary aspiration
Difficult mask ventilation

46. BASIC AIRWAY EVALUATION
Previous anaesthetic problems and general appearance of the patient.
Neck, face, maxilla and mandible with jaw movements.
Head extension and movements, teeth, oropharanx and soft tissue of the neck .

47. Mallampati classification larangoscopic view.
ASSESSMENT OF AIRWAY
Mallampati classification larangoscopic view.

48. Laryngoscopic view
Grade 3,4  risk for difficult intubation!

49. Airway Assessment
Interincisor gap : normal  more than 3 cms

50. Movement of temperomandibular joint (TMJ)
Grinding

51. Airway Assessment
1) Condition that associated with difficult intubation:
Congenital anomalies  Pierre Robin syndrome , Down’s syndrome
Infection in airway  Retropharyngeal abscess, Epiglottitis
Tumor in oral cavity or larynx
Enlarge thyroid gland trachea shift to lateral or compressed tracheal lumen

52. Continuation... Maxillofacial ,cervical or laryngeal trauma
Temperomandibular joint dysfunction
Burn scar at face and neck
Morbidly obese or pregnancy

53. Anatomical factors affecting Larangoscopy
Short Neck.
Protruding incisor teeth.
Long high arched palate.
Poor mobility of neck.
Increase in either anterior depth or Posterior depth of the mandible decrease in Atlanto Occipital distance that's why role of Radiology has increased in our specialty

55. Instruments used...
Self-refilling bag-valve combination (eg, Ambu bag) or bag-valve unit (Ayres bag), connector, tubing, and oxygen source. Assemble all items before attempting intubation.
2. Tincture of benzoin and precut tape.
3. Introducer (stylets or Magill forceps).
4. Suction apparatus (tonsil tip and catheter
suction).
5. Syringe, 10-mL, to inflate the cuff.
6. Mucosal anesthetics (eg, 2% lidocaine)
7. Water-soluble sterile lubricant.
8. Gloves.

56. 1) Laryngoscope : handle and blade

57. LARYNGOSCOPIC BLADE Macintosh (curved) and Miller (straight) blade
Adult : Macintosh blade, small children : Miller blade
Miller blade
Macintosh blade

58. 2) Endotracheal tube

59. Curved blade technique
Open the patient's mouth with the right hand, and remove any dentures.
Grasp the laryngoscope in the left hand
Spread the patient's lips, and insert the blade between the teeth, being careful not to break a tooth.
Pass the blade to the right of the tongue, and advance the blade into the hypopharynx, pushing the tongue to the left.
Lift the laryngoscope upward and forward, without changing the angle of the blade, to expose the vocal cords.

61. تایید لوله کذاری داخل تراشه
نگاه به قفسه سینه وشکم
سمع کردن ریه ها و شکم
جریان هوا در لوله
کاپنوگرافی
برونکوسکوپی فیبراپتیک

62. Nasoendotracheal intubation
Advantages:
1) Comfortable for prolong intubation in postoperative period
2) Suitable for oral surgery : tonsillectomy , mandible surgery
3) For blind nasal intubation
4) Can take oral feeding
5) Resist for kinking and difficult to accidental extubation
Disadvantages:
1) Trauma to nasal mucosa
2) Risk for sinusitis in prolong intubation
3) Risk for bacteremia
4) Smaller diameter than oral route  difficult for suction

64. Contraindication for nasoendotracheal intubation
1) Fracture base of skull
2) Coagulopathy
3) Nasal cavity obstruction
4) Retropharyngeal abscess

65. Complication of endotracheal intubation
1) During intubation
2) During remained intubation
3) During extubation
4) After extubation

66. 1) During intubation Trauma to lip, tongue or teeth
Hypertension and tachycardia or arrhythmia
Pulmonary aspiration
Laryngospasm
Bronchospasm
Laryngeal edema
Arytenoid dislocation  hoarseness
Increased intracranial pressure
Spinal cord trauma in cervical spine injury
Esophageal intubation

67. 3) During Extubation 2) During remained intubation
Obstruction from klinking , secretion or overinflation of cuff
Accidental extubation or endobronchial intubation
Disconnection from breathing circuit
Pulmonary aspiration
Lib or nasal ulcer in case with prolong period of intubation
Sinusitis or otitis in case with prolong nasoendotracheal intubation
3) During Extubation
Laryngospasm
Pulmonary aspiration
Edema of upper airway

68. 4) After Extubation Sore throat Hoarseness
Tracheal stenosis (Prolong intubation)
Laryngeal granuloma

69. Thanks for your attention!