1. Airway instruments Dr. Amr Marzouk Mohamed Assistant lecturer of anesthesia

2. Objectives Review airway anatomy Review basic airway maneuvers Review blind insertion airways Review advanced airway techniques

3. Upper and Lower Airways

4. Airway Anatomy Upper 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

5. 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 –Modified jaw thrust (for trauma patients) –Sellick’s maneuver

6. 1.Oropharyngeal Airway Size is measured from the corner of the mouth to the angle of the jaw Sizes range from 0-6 It holds the tongue away from the posterior pharynx, but does not isolate the trachea

7. Oral Airway continued The oral airway is inserted with the curve towards the side of the mouth Then rotated so that the curve of the airway matches the curve of the tongue

8. 2.Nasopharyngeal Airway Soft plastic or rubber tube that is designed to pass just inferior to the base of the tongue Passed through one of the nares and can be used in patients with an intact gag reflex CONTRAINDICATED in cases of suspected or possible basilar skull fracture Sizes range from 17-26 cm in length and 6-9 mm internal diameter Measured from tip of the nose to the corner of the patients ear

9. Nasal Airway continued The nasal airway is lubricated with a water soluble lubricant The beveled tip is inserted directed towards the septum, with the airway directed perpendicular to the face If resistance is met, rotating the airway may help or the other nare may be used

10. Blind Insertion Airways Combi-tube LMA (Laryngeal Mask Airway) King Airway Blind insertion airways considered an alternative airway control device to be used when intubation is unsuccessful They do not require visualization of the vocal cords

11. 3. Combitube®

12. Combi-tube This is a multi-lumen airway that works whether it is inserted into the esophagus or the trachea It either blocks the esophagus above and below the glottic opening or by directly ventilating the trachea Contraindicated in patients under 5 foot tall or those under 14 years old, in patients who have ingested caustic substances, patients with esophageal trauma or disease, and in patients with an intact gag reflex

13. Combi-tube continued

14. 4.Laryngeal Mask Airway Sits over the glottic opening Available in different sizes Has a drain tube to aid in gastric suctioning With some versions an endotracheal tube may be passed through to aid in intubation

15. LMA Positioning

16. Advanced Airways Orotracheal Intubation Nasotracheal Intubation Digital Intubation Surgical Airways

17. 5.Orotracheal Intubation Requires direct visualization of the vocal cords with the use of a laryngoscope Completely isolates the esophagus from the trachea At least two forms of placement verification are required –Physical assessment (color improvement, equal breath sounds, absence of gurgling over epigastrim, and direct visualization of tube passing through cords) –End-tidal CO2 detector –Esophageal detector device (EDD)

18. Orotracheal Intubation Procedure Assemble all needed equipment, while patient is being ventilated –Choose appropriate ET tube size –Check balloon with 10cc of air –OPTIONAL-Place stylet, stopping approximately ½ inch short of end of tube –Assemble laryngoscope and check light –Connect and check suction Position patient in “sniffing” postion, (neck flexed forward, head extended back, and back of head should be level with or above the shoulders). IMPORTANT- If C-spine injury is suspected have an assistant hold the patient’s head in a neutral position.

19. Intubation Continued Pre-oxygenate the patient with 100% oxygen Insert laryngoscope to right of midline. Move to midline, pushing the tongue to the left. Lift straight up on the blade to expose posterior pharynx. Identify the epiglottis; tip of curved (Macintosh) blade should sit in valeculla, (in front of epiglottis), straight blade should slip over the epiglottis. With further, gentle traction, identify trachea and arytenoid cartilages and vocal cords Insert ET tube along the blade, into the trachea and advance the tube 1-1.5 inches beyond the cords and inflate the cuff.

20. Intubation Continued Ventilate and watch for chest rise and fall. Listen for breath sounds, over stomach, four lung fields and axillae. (If breath sounds are diminished or absent on left side, indicating a right mainstem intubation, slightly pull tube back and reassess breath sounds). Note number on the side of the ET tube at the central incisor and secure the tube. Reassess breath sounds, now and any time the patient is moved.

21. Nasotracheal Intubation Can be done blind or with the aid of a laryngoscope. –If done blind, the patient must be breathing. Cannot be performed on patients with a suspected basilar skull fracture. Can be performed on patients with an intact gag reflex.

22. 6. Intubating LMA

24. LMA Take-Home Points Test cuff before use Don’t lubricate anterior mask Insert only in comatose patient Keep cuff inflated until patient awake Don’t throw out!! Used 40 – 50 times

25. 7.Digital Intubation Useful if unable to reach patient well. Head manipulation is minimal. Performed by physically finding the epiglottis with middle and index fingers, and then sliding the tube interiorly into the trachea.

26. A. Flexible Fiberoptic Scope

27. Flexible Fiberoptic Scope Advantages Allows direct airway visualization Causes little hemodynamic stress Nasotracheal or orotracheal route Can be done in all age groups Requires minimal neck movement

28. Flexible Fiberoptic Scope Disadvantages Expensive Expertise requires practice Delicate equipment needs careful maintenance Visual field easily impaired by blood and secretions

29. B. Rigid Fiberoptic Scope

30. Rigid Fiberoptic Scope BullardWu Scope

31. Rigid Fiberoptic Scope UpsherGlideScope

32. Levitan Scope Rigid Fiberoptic Scope

33. Advantages Direct airway visualization Minimal neck movement May overcome difficult view Useful in disrupted airway Durable, sturdy instruments

34. Rigid Fiberoptic Scope Disadvantages Expensive Expertise requires practice Visual field easily impaired by blood and secretions Not readily available

35. C. Lightwand (Trachlight)

36. Lightwand (Trachlight)

37. Disadvantages Blind technique May damage airway Usually requires darkened room Expertise requires practice

38. 8.Nu-Trake Surgical airways should only be used when all other methods have been exhausted It is not intended for children under the age of 5 years old.

39. Nu-Trake Procedure Hyperextend the patients neck, if c-spine injury is not possible, and identify the cricothyroid membrane Pinch 1 cm of skin and insert scapel blade through skin, cutting in an outward, upward motion. Use housing with stylet and puncture membrane at same angle as the lower edge of the housing. Aspirate. Easy movement of syringe plunger indicates proper entry into trachea. Twist Luer adapter counterclockwise and remove stylet and syringe.

40. Nu-Trake Procedures continued Advance split needles until the housing rests on the skin. Housing should rock freely to confirm proper insertion depth. Inset 4.5 mm airway/obturator assembly into housing. Use palm of hand to advance obturator. DO NOT USE HOUSING WINGS. Remove obturator and ventilate patient. Secure housing with twill ties. For larger airway, remove 4.5 mm airway and repeat last two steps with 6.0 mm and 7.2 mm airways.

41. Summary Always remember the ABCs, without an airway your patient will not survive. There are several ways to manage a patient’s airway. Don’t forget the basics, all your patient may need is for someone to open their airway, to start improving.