Airway Management for the Non-Anesthesiologist

Transcription

1 Airway Management for the Non-Anesthesiologist Rondall K. Lane, M.D., M.P.H. Department of Anesthesia and Perioperative Care University of California, San Francisco

2 Evaluating the Airway Predictors of Difficult Mask BMI of > 30 Presence of a beard Mallampati 3 or 4 Age of 57 or older limited jaw protrusion Snoring Edentulous Pregnant patient

3 Evaluating the Airway

4 Evaluating the Airway Airway Grade & Mallampati Class

5 Predictors of Difficult Airway For finding grade III or IV view on DL Sensitivity % Specificity % Positive Predictive Value Mouth Opening Thyromental distance Mallampati Class III Limited Neck movement Inability to prognath Increased body wt >110 History of difficult intubation

6 Evaluating the Airway Signs of airway obstruction A "see-saw" pattern of chest and abdominal breathing movements. Use of accessory muscles of inspiration Tracheal tug, supra-sternal and supraclavicular recessions and nasal flaring. Cyanosis, agitation, obtundation

7 Before the Mask Simple tips to improve the airway Chin Lift Jaw Thrust

8 Bag Mask Ventilation The most important piece of equipment!

9 Bag Mask Ventilation Positioning

10 Bag Mask Ventilation The most important piece of equipment

11 Bag Mask Ventilation

12 The Oral Airway

13 The Oral Airway Place OA on the patient's cheek with the flange parallel to patient s front teeth. Tip of the oropharyngeal airway should not pass the angle of the jaw. If the airway is too long, it could obstruct breathing by displacing the tongue against the oropharynx. Too short, the oral airway will not hold the tongue away from the pharynx, and patency won't be restored

14 The Oral Airway

15 The Nasal Airway Preferred in conscious patients better tolerated and less likely to induce a gag reflex. Length of the nasal airway is estimated as the distance from the nares to the meatus of the ears and is usually 2-4 cm longer than the oral airway. They are contraindicated in patients who are anti-coagulated patients with basilar skull fractures patients with nasal infections and deformities children (because of risk of epistaxis)

16 Troubleshooting the difficult Mask Review the key steps of BVM ventilation: EQUIPMENT, POSITION, SEAL, AND OXYGENATION/VENTILATION. Is your oxygen source on? Is your bag functioning? Do you have the appropriate airway adjunct? Evaluate patient positioning: is the ear-to-sternal notch position attained? Repeat your chin lift and jaw thrust. Evaluate your seal: change technique to a 1- or 2-person hold? Does mask fit properly? Consider other causes of poor oxygenation and ventilation, such as vomitus, secretions, or difficult anatomy.

17 The Esophageal-Tracheal Combitube

18 The Esophageal-Tracheal Combitube Key Points The available sizes are 41 Fr 5ft (152 cm) and 37 Fr (below 5 ft). Combitube can be introduced blindly without the use of a laryngoscope. Patient head position can be neutral. If the Combitube is positioned blindly, the left hand should lift the chin while the right hand maneuvers the Combitube.

19 The Esophageal-Tracheal Combitube

20 The Esophageal-Tracheal Combitube

21 The LMA

22 The LMA

23 The Fiber Optic Intubation

24 The Fiber Optic Intubation

25 The Fiber Optic Intubation

26 The Fiber Optic Intubation

27 Successful Fiber Optic Intubation Beware of ETT going through Murphy eye of an ET tube Becomes impossible to advance the tube into the trachea Deformity of the upper airway or distortion of the airway been reported to obstruct the passage of a tube over fiberscope Airway intubator may obstruct passage of ETT over a fiber at proximal edge catching the cuff of the tube causing obstruction Cricoid pressure Obstructed passage in two of 30 patients in one study Jaw thrusting Thrusting jaw forward shifts larynx anteriorly & widens the esophageal inlet. ETT is more likely to be inserted into the inlet

28 Successful Fiber Optic Intubation Solutions Place the FB between the arytenoids and rotate the ETT so the bevel faces posterior in the larynx Use of a thick fiberscope and a thin tracheal tube Use of a gap-filler Use of an ILMA flexible tube Warming of a tracheal tube Removal of an airway intubator Rotation of a tube Flexion of the neck

29 The Video Laryngoscope

30 Tube Exchangers and Pilot Balloon Repair Kits

31 10 Commandments Commandment #1 Oxygenation and ventilation are the top priorities. Commandment #2 Airway management does not mean intubation. Commandment #3 Be an expert at bag-valve-mask (BVM) ventilation. Commandment #4 Know your equipment. Commandment #5 Know at least one rescue ventilation technique.

32 10 Commandments Commandment #6 Develop a personal airway algorithm. Commandment #7 Don't let your ego get in the way. Commandment #8 Invest time in learning airway skills. Commandment #9 Use an end-tidal CO2 (EtCO2) detector to confirm every intubation. Commandment #10 When seconds count, don't count on seconds.