Airway Managment 2

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In The Name Of GodIn The Name Of God

Airway Airway ManagementManagement

IntroductionIntroduction

Directed ByDirected By::Behdad Bazargani Behdad Bazargani

M.DM.D..AnesthesiologistAnesthesiologist

Ali Shah Abbasi M.DAli Shah Abbasi M.D..AnesthesiologistAnesthesiologist

CPR consists of:CPR consists of:

1. Airway Management

2. Basic Life Support (BLS)

3. Advanced Cardiac Life Support (ACLS)

4. Advanced Trauma Life Support (ATLS)

5. CPR in special situations

6. Ethical Issues

HistoryHistory

1966 :

National research council conference (generated standards).

2005 :

American Heart Association (AHA).

IntroductionIntroduction

Systematic efforts for relief patient from situation which threatened the life.

Effective CPR:

Artificial delivery of oxygenated blood to systemic circulatory beds at rates sufficient for preserving vital organ function and physiologic substrates.

SurvivalSurvival

Highest survival rates and quality of survival are attained when:

- BLS is initiated within 4 min

- ACLS is initiated within 8 min

Management of CPRManagement of CPR

It is a team effort.Coordination of the team is the responsibility of the team leader (Ideally Anesthesiologist).Responsibilities of the team leader:

1- Ensure the quality of BLS.2- Facilitate early use of electrical defibrillation.3- Direct and monitor the adequacy of drug

therapy.4- Ultimately, the team leader decide when

CPR should cease.

IndicationsIndications

1. Unconscious (unresponsive)

2. Abnormal breathing, although there may be brief irregular, gasping breaths

3. Pulselessness or non effective circulation

4. Traumatic patient (electrical, drawing, crash, car accident, …)

To handle a CPRTo handle a CPR

1. Avoid agitation

2. Have a good knowledge

3. Have a good physical ability

What to What to do First?do First?

New DevelopmentsNew Developments

Elimination of lay rescuer assessment of signs of circulation before beginning chest compressions. Simplification of instructions for rescue

breaths should be given over 1second with sufficient volume to achieve visible chest rise. Elimination of lay rescuer training in rescue

breathing without chest compressions.

New DevelopmentsNew Developments……

Recommendation of a (universal) compression-to- ventilation ratio of 30:2 for single rescuers of victims of all ages (except newborn infants).

Increased emphasis on the importance of chest compressions: rescuers will be taught to “push hard, push fast” (at a rate of 100 compressions per minute), allow complete chest recoil, and minimize interruptions in chest compressions.

New DevelopmentsNew Developments……

Recommendation for provision of about 5 cycles (or about 2 minutes) of CPR between rhythm checks during treatment of pulseless arrest. Rescuers should not check the rhythm or a pulse immediately after shock delivery—they should immediately resume CPR, beginning with chest compressions, and should check the rhythm after 5 cycles (or about 2 minutes) of CPR.

New DevelopmentsNew Developments……Recommendation that all rescue efforts, including insertion of an advanced airway (eg, endotracheal tube, esophagealtracheal combitube [Combitube], or laryngeal mask airway [LMA]), administration of medications, and reassessment of the patient be performed in a way that minimizes interruption of chest compressions.

Recommendation of only 1 shock followed immediately by CPR (beginning with chest compressions) instead of 3 stacked shocks for treatment of ventricular fibrillation/ pulseless ventricular tachycardia.

Thanks Thanks For Your For Your AttentioAttentio

Airway Airway ManagementManagement

Directed ByDirected By::

Behdad Bazargani M.DBehdad Bazargani M.D..AnesthesiologistAnesthesiologist

Conditions need Airway management

General anesthesia

Respiratory failure

Airway obstruction

Airway AnatomyAirway Anatomy

Pharynx

Larynx

Trachea

1.Nasopharynx

2.Oropharynx

Emergency Airway Management Evaluation

Level of consciousness-Alert-Responds to verbal stimuli-Responds to painfull stimuli-Unresponsive

Airway-Patent-Clear

Trauma to cervical spine

Techniques of Airway Management

Non-invasive-Head positioning-Removal of foreign body-Suctioning-Mask ventilation

Invasive-ETT-LMA-Combitube

Airway obstruction

Head tilt chin lift & Head tilt jaw trust

Mask ventilation

One hand mask holding

Two hand mask holding

Oral AirwaysOral Airways

Disposable Berman Airways

Hudson Cath-Guide Airways

Rusch Berman Airways

Rusch Color Coded Guedel Airways

Oral AirwayOral Airway

Nasopharyngeal Airway

Rusch Latex Free Nasopharyngeal Airway

Nasopharyngeal Airway

Endotracheal Endotracheal IntubationIntubation

Indications for Indications for endotracheal intubationendotracheal intubation

1. Provides relative protection against pulmonary aspiration.

2. Maintains a patent conduit for respiratory gas exchange.

3. Provides a means for coupling the lungs to mechanical ventilators.

4. Establishes a route for clearance of secretions.

5. Provides a route for drug administration.

Equipments

LaryngoscopeTubesOxygen sourceBag & MaskSuction

Lubricant

Forceps (Magill)

Adhesive tape

Stylet

Syringe

Stainless Laryngoscope Blades

Laryngoscope Blades

Tracheal Tube

Uncuffed Tracheal Tube

Endotrol Tracheal Tube with Controllable Tip

EMT Emergency Medicine Cuffed Tube with Injection Port

ETT sizesETT sizes

Male: No. 8 + 0.5

Female: No. 7 + 0.5

Children: No = + 4 (or 3, for cuffed)Age 4

ETT : sizes (pediartics)ETT : sizes (pediartics)

ETT Depth of insertionETT Depth of insertion

Depth(cm) = + 12

Male: 23 cm

Female: 21 cm

ETT : Depth of insertionETT : Depth of insertion

Sniffing Position

Incorrect position

Sniffing Position

Incorrect positionIncorrect position

Incorrect positionIncorrect position……

laryngoscopy

Sniffing Position

Laryngeal Mask Airway

Laryngeal Mask AirwayLaryngeal Mask Airway

LMA-Fastrach

LMA- Fastrach

LMA-Fastrach

Examples of clinical airway problems managed with the LMA

AcromegalyAnkilosing spondilitisRheumatoid arthritisFacial burnsFailed airway in obstetric patientsFailed rigid broncoscopyFractured jawTemporomandibular joint diseaseLimited mouth openingMicrognathiaNeck contractureFix immobile cervical spineOssification of posterior longitudinal ligamentCervical spinal tumorTreacher CollinsPierre RobinUnstable neck

Characteristics of the LMACharacteristics of the LMA

Sizes Weight (Kg) Cuff Vol.(ml)

#1 <5 4

#1.5 5-10 7

#2 10-20 10

#2.5 20-30 14

#3 30< 20

#4 normal 30

#5 large 40

THE LMA IS NOT DISPOSABLE

Advantages of Using the LMAAdvantages of Using the LMA

leaves provider’s hands freepatient can produce effective coughallows spontaneous ventilationeven malpositioned can adequately ventilate

Disadvantages of LMA over the ETT

Lower seal pressureHigher frequency of gastric insufflationIncreased Aspiration risk

LMA ComplicationsLMA Complications

Aspiration

Coughing

Sore Throat

Combitube

CombitubeCombitube……

Retrograde intubationRetrograde intubation

Retrograde Intubation…

CricothyrotomyCricothyrotomy

Cricothyrotomy Devices

CricothyrotomyCricothyrotomy

Cricothyrotomy…

Placement of Needle

Cricothyrotomy…

Wire Guide and Catheter In Place

Cricothyrotomy…

Catheter, Dilator and Wire Guide In Place

Cricothyrotomy…

Rusch QuickTrachRusch QuickTrach

Jet Ventilation

Jet ventilation CatheterJet ventilation Catheter

Thank youThank you

Awake IntubationAwake Intubation

Directed ByDirected By::

Behdad Bazargani Behdad Bazargani M.DM.D..

AnesthesiologistAnesthesiologist

IndicationsIndications

1. Respiratory failure

2. Decrease LOC

3. Difficult airway

Respiratory failure…

Status Asthmaticus

Status Epilepticus

Pulmonary Edema

Chest wall injuries

Motor:Category scoreObeys 6

Localizes 5

Withdraws 4

Flexion 3

Extension 2

None 1

GCSGCS

Verbal response:Category scoreOriented 5

Confused 4

Inappropriate words 3

Incomprehensible sounds 2

None 1

GCSGCS

Eye opening:Category scoreSpontaneously 4

To speech 3

To pain 2

None 1

GCS GCS ==oror<< 8 8

IntubationIntubation

EquipmentsEquipments

Ventilator

Laryngoscope

Oxygen source

Bag & Mask

Suction

Lubricant

Forceps (Magill)

Adhesive tape

Stylette

Syringe

DrugsDrugs

A- Neuromuscular blocking drugs (NMBDs):

1- Depolarizing NMBDs-

Succinylcholine (1 – 1.5 mg/Kg IV)

2- Non Depolarizing NMBDs-

Vecuronium (0.25 mg/Kg IV)

Cis-atracurium (0.2 mg/Kg IV)

All patients requiring airway management are probably at risk for aspiration of gastric contents (Sellick maneuver).

DrugsDrugs……

B- Sedative-hypnotics: Sodium Thiopental PropofolC- Benzodiazepines: Midazolam (0.5 – 1 mg IV) Diazepam (2 mg IV)D- Opioids: Morphine, Fentanyl, Remifentanil

DrugsDrugs……

E- Beta-adrenergic blocking drugs:

Esmolol (10 – 20 mg IV)

F- Local anesthetics agents:

Lidocaine ( 1 – 1.5 mg/Kg IV or aerosol anesthetic sprays)

G- Nerve blocks…

IV Drugs for Endotracheal IntubationCONDITIONHYPNOSISMUSCLE

RELAXAN

ANALGESIAAMNESIA

GCS=3NoneNoneNoneNone

Cardiacarrest

NoneNoneNoneNone

ShockSBP<80mmHg

NoneSCh1.5mg/kg

Fentanyl0.5-1μg/kg

HypotensionSBP

80-100mmHg

Thiopental0.3-1mg/kg

SCh1.5mg/kg

Fentanyl1-2μg/kg

Midazolam1-2mg

Head injuryGCS 4-9

Thiopental2-5mg/kg

SCh1.5mg/kg

Fentanyl1-2μg/kg

Midazolam1-2mg

CombativeNormal BP

Thiopental2-5mg/kg

SCh1.5mg/kg

Fentanyl1-2μg/kg

Midazolam1-2mg

Sellick’s maneuverSellick’s maneuver

ThenThen……

Ask for Ask for VentilatorVentilator

Thank YouThank You

Airway Managment 2

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