1. AIRWAY MANAGEMENT Purwoko Sugeng H

2.  Anatomy of the airway  How to recognize an adequate or an inadequate airway  How to open an airway  How to use airway adjuncts  Rapid Sequence Intubation TOPIC

3. Upper Airway  Begins at mouth and nose  Air is warmed and humidified in nasal turbinates  Pharynx  Oropharynx, nasopharynx, and laryngopharynx  Ends at glottic opening continued

4. Upper Airway

5. Lower Airway Anatomy  Function  Exchange of O 2 and CO 2  Location  Trachea  Bronchi and bronchioles  Alveoli  Lungs Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

6. Lower Airway

7. Airway Obstructions  Variety of obstructions interfere with air flow  Foreign bodies: food, small toys  Liquids: blood, vomit  Obstruction may result from poor muscle tone caused by altered mental status continued

8. Airway Obstructions  Acute  Foreign bodies  Vomit  Blood  Occurring over time  Edema from burns, trauma, or infection  Decreasing mental status continued

9. Airway Obstructions  Bronchoconstriction  Disorder of lower airway  Smooth muscle constricts internal diameter of airway

10. Airway Assessment  Addressed in primary assessment  Two questions must be answered  Is airway open?  Airway assessment is not just a moment in time  Must give constant consideration  Will airway stay open?

11. Findings Indicating Airway Problems  Inability to speak  Unusual raspy quality to voice  Stridor  Snoring  Gurgling

12. Signs of Inadequate Airway  Foreign bodies in airway  No air felt or heard (air exchange below normal)  Absent or minimal chest movements  Abdominal breathing

13. Patient Care: Airway Management  When primary assessment indicates inadequate airway, a life-threatening condition exists  Take prompt action to open and the maintain airway

14. Open Airway  If airway is not open, use position to open it  Head-tilt, chin-lift maneuver and jaw-thrust maneuver move airway structures into position allowing air movement

15. Head-Tilt Chin-Lift Maneuver

16. Performing Head-Tilt Chin-Lift Maneuver 1. Place one hand on forehead and fingertips of other hand under patient’s lower jaw 2. Tilt head 3. Lift chin 4. Do not allow mouth to close

17. Jaw-Thrust Maneuver

18. Performing Jaw-Thrust Maneuver 1. Place one hand on each side of patient’s lower jaw at angles of jaw below ears 2. Using index fingers, push angles of patient’s lower jaw forward 3. Do not tilt or rotate patient’s head

19. Patient Care: Airway Adjuncts  Airway position and maneuvers are short- term solutions  Airway adjunct provides longer term air channel  Two most common airway adjuncts:  Oropharyngeal airway (OPA)  Nasopharyngeal airway (NPA)

20. Oropharyngeal Airway  Device used to move tongue forward as it curves back to pharynx  Sizes: infant to large adult

21. Sizing Oropharyngeal Airways

22. Inserting OPA  Open mouth with crossed-finger technique  Position airway with tip pointing toward roof of mouth continued

23. Inserting OPA 1. Insert until you meet resistance 2. Gently rotate airway 180° so tip is pointing down into pharynx 3. Check that flange of airway is against lips 4. Monitor patient closely

24. Oropharyngeal Airway—Insertion Method 1 Method 2

25. Nasopharyngeal Airway  Soft, flexible tube inserted through nostril and into hypopharynx  Moves tongue and soft tissue forward to provide a channel for air continued

26. Nasopharyngeal Airway  Come in various sizes  Must be measured  Typical adult sizes: 34, 32, 30, and 28 French

27. Inserting NPA 1. Lubricate outside of tube with water-based lubricant before insertion 2. Push tip of nose upward; keep head in neutral position 3. Insert into nostril; advance until flange rests firmly against nostril continued

28. Rapid Sequence Intubation a process that involves pharmacologically inducing unconsciousness and paralyzing the patient in a manner that facilitates tracheal intubation, while minimizing the risk of aspiration using application of cricoid pressure. a process that involves pharmacologically inducing unconsciousness and paralyzing the patient in a manner that facilitates tracheal intubation, while minimizing the risk of aspiration using application of cricoid pressure.

29. Rapid Sequence Intubation  Indications  Failure of airway maintenance/protection lost or diminished gag reflex lost or diminished gag reflex  Failure of oxygenation/ventilation pulmonary edema, COPD pulmonary edema, COPD  Anticipated clinical course multiple trauma, head injured multiple trauma, head injured intoxication, air transport intoxication, air transport

30. Six “Ps” of RSI  Preparation  Preoxygenation  Pretreatment/Premedication  Paralysis (with induction)  Placement of the tube  Postintubation management

31. Preparation  Personnel : not a one person job  Equipment :  Medications  Evaluate  LEMON  Positioning

32. Difficult Intubation  LEMONS  Look Externally  Evaluate 3-3-2  Mallampati Score  Obstruction  Neck Mobility  Scene and Situation

33. LOOK Externally  Beards or facial hair  Short, fat neck  Morbidly obese patients  Facial or neck trauma  Broken teeth (can lacerate balloons)  Dentures (should be removed)  Large teeth  Protruding tongue  A narrow or abnormally shaped face LEMONS

34. EVALUATE 3-3-2  Mouth Opens at least 3 finger widths.  Three finger widths thyromental distance.  Two finger widths mandibulohyoid distance. LEMONS

35. Thyromental Distance  Distance from the mentum to the thyroid notch.  Ideally done with the neck fully extended. Can be done in-line  Helps determine how readily the laryngeal axis will fall in line with the pharyngeal axis.

36. Thyromental Distance-3 fingers?

37. Mandibulohyoid Distance- 2 fingers?  Measured from the mentum to the top of the hyoid bone.  The epiglottis arises from the thyroid and remains dorsal to the hyoid bone.  Therefore, the position of the hyoid bone marks the entrance to the larynx.

38. LEMONS

39.  Laryngoscopy or intubation may be more difficult in the presence of an obstruction  Anatomy  Trauma  Foreign body obstruction  Edema (burns) LEMONS Obstruction

40. Obstructions Laryngoscopic View Grades Grade 1:Full aperture visible Grade 2:Lower part of cords visible Grade 3:Only epiglottis visible Grade 4:Epiglottis not visible

41. Neck Mobility  Ideally the neck should be able to extend back approximately 35°  Problems:  Cervical Spine Immobilization  Ankylosing Spondylitis  Rheumatoid Arthritis LEMONS

42. Scene and Situation  Scene safety  Environment  Do you have a reasonable chance to get the tube?  Space, positioning, access

43. Preoxygenation 100% O2 for 5 minutes of 5 vital capacity breaths can theoretically permit 3-5 minutes of apnea before desaturation to less than 90% occurs

44. Premedication  Goal is to blunt the patient’s physiologic responses to intubation  Minimizes bradycardia, hypoxemia, cough/gag reflex, increases in intracranial, intraocular, and intragastric pressures

45. Premedication  Lidocaine  Opioid  Atropine  Defasciculating doses “priming”

46.  Sedation  Barbiturates/hypnotics  Non-barbiturate  Neuroleptics  Opiates  Benzodiazepines

47. Paralysis  Paralytic agents used for intubation  Depolarizing agents Can lead to fasciculations Can lead to fasciculations Succinylcholine (Anectine) Succinylcholine (Anectine)  Nondepolarizing agents Vecuronium (Norcuron) Vecuronium (Norcuron) Pancuronium (Pavulon) Pancuronium (Pavulon)

48. Placement of Tube  Allow medications to work and assure complete neuromuscular blockade of the patient  Maintain Sellick maneuver until cuff inflated  Ventilate with bag-valve mask if unsuccessful  Additional doses of sedatives/NMB may be necessary  Confirm tube placement

49. Post Intubation Management  Secure tube  Continuous pulse oximetry  Reassess vital signs frequently  Obtain chest x-ray, ABG  Restrain patient  Consider long term sedation