Intubation-Workshop1
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Transcript Intubation-Workshop1
Advanced Airway
Management
University of Colorado Medical School
Rural Track
2013
Advanced Airway Management
Basic Airway Management
Airway Suctioning
Oxygen Delivery Methods
Laryngeal Mask Airway
ET Intubation
Oropharyngeal Airway
Nasopharyngeal Airway
Cricothyrotomy
Basic Airway Management
For patients unable to protect their own airway
Jaw thrust/head tilt technique
This technique itself can open the airway
If concern for c-spine injury, use jaw thrust without head tilt
Excessive head tilt can occlude trachea in infants, consider
padding under shoulders
Basic Airway Management
Basic Airway Management
Padding under shoulders for infant
Airway Suctioning
Obstruction of airway by secretions, blood, vomitus
can lead to aspiration
Rigid catheters (Yankeur), soft catheters (Y suction)
Complications include airway trauma, coughing or
gagging, delay in ventilation, vagal stimulation
bradycardia, hypotension
Airway Suctioning
Yankeur Rigid Catheter
Y Suction Catheter
Oropharyngeal SuctioningProcedure
Adults
Preoxygenate
Check connection to tubing
Occlude side port to test for adequate suction
Insert catheter into oropharynx under direct visualization
Neonates
Insert y-suction catheter into nasopharynx
Occlude sideport while withdrawing catheter
Repeat for oropharynx
Oxygen Delivery Methods
Nasal Cannula: flow rate 1-6 LPM (FiO2 24-40%)
Simple face mask: flow rate 5-10 LPM (FiO2 40-60%)
Non-rebreather mask: flow rate 10-15 LPM (FiO2 60-90%)
BiPAP/CPAP
Oxygen Delivery Methods
Bag Valve Mask- flow rate >15 LPM (FiO22 >90%)
Laryngeal Mask Airway
Supraglottic airway
Doesn’t require laryngeal visualization
Can precipitate vomiting or aspiration
Size
Weight guide
Population
1
<5 kg
Infant
2
10-20 kg
Small Child
3
30-50 kg
Small Adult
4
50-70 kg
Average Adult
5
70-100 kg
Large Adult
Laryngeal Mask Airway
Prepare LMA: ensure patent cuff, apply water-based lubricant
Place patient in sniffing position
Insert tip of LMA into mouth
Advance into laryngopharynx until
resistance is met
Ensure black line on tubing in line with upper lip
Inflate cuff
Confirm tube misting, auscultation, EtCO2
Consider placement of bite block
Other Airways
King Tube
Combitube
Endotracheal Intubation
Placing orotracheal tube under direct vision through larynx
into trachea
Protects airway, enables ventillation
Complications of laryngoscopy
direct trauma to mucous membranes, teeth, larynx
bradycardia from vagal stimulation
Raised intracranial pressure
Endotracheal Intubation
Complications of Intubation
Prolonged apnea hypoxia
Esophageal or right mainstem bronchus intubation
Inadequate tube size excessive leak, high pressures
Aspiration
Complications of Ventilation
Barotrauma pneumothorax
Hypoventilation hypoxia, hypercarbia
Hyperventilation hypocarbia, cerebral hypoxia
Reduction in preload hypotension
Endotracheal Intubation
Preparation
Pre-oxygenation
Ensure IV access and patency, cardiac monitoring
Assess for predictors of technical difficulty (LEMON)
Look (obesity, pregnancy, airway, facial, neck trauma)
Evaluate 3-3-2 rule (small mouth, receding jaw, short neck)
Manual inline stabilization/Mallampati score
Obstruction (airway burn, protruding teeth, foreign body)
Neck mobility
Endotracheal Intubation
Preparation of equipment
Suction
Oxygen
BVM device
Airway adjuncts: OP airways, LMA
Laryngoscope with appropriate blade, check light
source
ETT: right size
Bougie
Monitoring and EtCO2
Endotracheal Intubation
Tools: Laryngoscope
Macintosh blade- curved blade, rests on epiglottic vallecula
Miller blade- straight blade, lifts epiglottis directly
Blade
Size
Patient
Miller
0
Infant
Miller
1
Small child
Macintosh
2
Large child
Macintosh
3
Small adult
Macintosh
4
Large adult
Endotracheal Intubation
Tools: ET tube
Age
Uncuffed
ETT (mm)
Cuffed
Depth at lips
ETT (mm) (cm)
Newborn
3.0-3.5
3.0
9-10
1-5 mths
3.5
3.0-3.5
10
6-11 mths
3.5-4
3.5
11
1 yr
4.0-4.5
4.0
12
2-3 yrs
4.5-5.0
4.0-4.5
12-13
4-5 yrs
5.0-5.5
4.5-5.0
13-15
6-9 yrs
5.5-6.0
5.0-5.5
15
10-12 yrs
6.5-7.0
6.0-6.5
17
13+
7.0-7.5
6.5-7.0
19
Endotracheal Intubation
Place head in sniffing position (MILS if c-spine injury)
Open mouth, inspect oral cavity
Remove dentures or debris
Place laryngoscope with left hand into the right side
of patient’s mouth, sweeping tongue to left
Lift mandible without levering on teeth until direct
visualization of the larynx
Endotracheal Intubation
Endotracheal Intubation
Introduce bougie through cords
Advance ET tube over bougie until cuff passes through cords
ETT length at lips for women 20-21, men 22-24
Remove bougie
Connect BVM, commence ventilation
Inflate cuff
Confirm placement
EtCO2 capnography, attach detector proximal to filter
Auscultation in axillae and over stomach
Glidescope
Post-intubation management
Secure ETT with a cloth tie
Manually ventilate for EtCO2 35-40 mmHg
Post-intubation sedation as needed
Continue comprehensive monitoring and ETCO2
Oropharyngeal Airway
Prevents the tongue from occluding the airway, bite block
Should reach from the mouth to the angle of the jaw
Insertion (Adults)
Ensure concavity facing roof of the mouth
Insert 1/3, rotate 180 degrees over the tongue
Advance until flange against lips
Insertion (Pediatrics)
Concavity follows the curve of the tongue to avoid hard and
soft palate trauma
Oropharyngeal Airway
Size
Color
Suggested
Population
000
Clear
Neonate (under 6
wks)
00
Blue
Infant (1-6
months)
0
Black
Older
infants/toddlers
1
White
Small child (3-10
years)
2
Green
Adolescent/adult
female
3
Yellow
Adult male
4
Red
Large adult male
Nasopharyngeal Airway
Useful in patients with airway obstruction, especially if
oropharyngeal airway is inappropriate
Correct size reaches from tip of patient’s nose to ear lobe
Sizes 6,7 & 8 mm
Lubricate end of tube with lubricating jelly
Insert into nostril (usually right) with bevel facing nasal septum
Advance device along floor of nasopharynx, following curvature
until flange rests against the nostril
Nasopharyngeal Airway
Cases
References
Queensland EMS Clinical Practice Procedures:
https://ambulance.qld.gov.au/medical/pdf/02_cpp_airway.
pdf
http://www.thoracic.org/clinical/copd-guidelines/for-
health-professionals/exacerbation/inpatient-oxygentherapy/oxygen-delivery-methods.php