Transcript Airway Management Part I RET 2275 Respiratory Care Theory 2

Airway Management
Part I
RET 2275
Respiratory Care Theory 2
Manual Resuscitators
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Manual resuscitator
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Portable, hand-held device that allows for the delivery of positive
pressure and supplemental oxygen to the airway
AKA: resuscitator bag, Ambu bag, bag-valve-mask (BMV)
Generic parts:
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Self-inflating bag
Air intake valve
Nonrebreathing valve
Exhalation valve
Oxygen reservoir
Manual Resuscitators
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Nonrebreathing Valve Types
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Spring-loaded ball
Manual Resuscitators
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Nonrebreathing Valve Types
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Duckbill
Manual Resuscitators
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Nonrebreathing Valve Types
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Leaf
Manual Resuscitators
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O2 Powered Resuscitators
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Pressure limited devices that
work similarly to reducing
valves
Demand valve that can be
manually operated or patient
triggered
Can deliver 100% O2 at flows
<40 L/min
Inspiratory pressures are
limited to 60 cm H2O
Ambu SPUR
Manual Resuscitators
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Device/Patient interface
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Mask
Manual Resuscitators
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Device/Patient interface
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Directly connected to
endotracheal tube
Manual Resuscitators
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Uses
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Ventilation during a resuscitation effort
Transport of a ventilator-dependant patient
Hyperinflation and delivery of enriched oxygen
mixtures before and after a suctioning procedure
To generate airway pressures and large tidal volume
to expand atelectatic lung segments
Adjunct in directed coughing
Upper Airway Obstruction
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Causes of Upper Airway Obstruction
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Soft tissue obstruction
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Loss of muscle tone resulting in the tongue falling back against
the soft palate
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CNS depression – drug overdose, anesthesia
Cardiac arrest
Loss of consciousness
Upper Airway Obstruction
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Causes
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Laryngeal obstruction more commonly the result of:
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Muscle spasm (laryngospasm)
Edema
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Croup
Epiglottitis
Foreign material
Aspirate
Vomitus
Blood
Space-occupying lesions, e.g., tumors
Upper Airway Obstruction
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Causes
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Laryngeal obstruction more commonly the result of:
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Muscle spasm (laryngospasm)
Edema
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Croup
Epiglottitis
Foreign material
Aspirate
Vomitus
Blood
Space-occupying lesions, e.g., tumors
Upper Airway Obstruction
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Clinical Findings
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Noisy inspiratory efforts, e.g., snoring
Silence – complete obstruction
Retractions
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Intercostal
Sternal
Clavicular
Upper Airway Obstruction
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Clinical Findings
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Prolonged, partial upper airway obstruction
 Hypoxemia and hypercapnia
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Total airway obstruction
 Death in 5 – 10 minutes
Upper Airway Obstruction
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Positional Maneuvers to Open the Airway
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Head Tilt
 Tilting the head back to relieve soft tissue obstruction
Upper Airway Obstruction
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Positional Maneuvers to Open the Airway
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Anterior Mandibular Displacement (jaw thrust)
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Grasping the jaw at the ramus on each side and lifting the
jaw forward
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Treatment of choice for suspected vertebral column trauma
Manual Resuscitators
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Ventilatory assistance may be administered with a manual
resuscitator
Manual Resuscitators
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Standards
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Have standard 15:20 mm (ID:OD) adaptors
Deliver > 85% oxygen at 15 L/min.
Volume of bag
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Adult: 1600 ml
Child: 500 ml
Infant: 240 ml
Allow for delivery of PEEP
Manual Resuscitators
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Standards
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Allow for attachment of volume and pressure
monitoring devices
Child resuscitators should be pressure limited at 40
(± 10 cm H2O)
Infant resuscitators should be pressure limit at 40
(± 5 cm H2O)
No pressure limiting system for adult resuscitators
Hazards of Manual Resuscitation
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Gastric distention
Aspiration
Diminished cardiac output
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May be avoided by ventilating the patient using an
inspiratory to expiratory (I:E) ration of 1:2, which
allows the heart to fill during the expiratory phase
when there is no pressure in the thoracic cavity
Airways in Manual Resuscitation
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Pharyngeal Airways
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Specialized devices employed to maintain a patent
airway
Oropharyngeal Airways
Oropharyngeal Airways
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Function
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Insertion
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Orally
Use jaw lift or tongue displacement
Correct sizing
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Restores airway patency by separating the tongue from the posterior
wall of the pharynx
Measure from the corner of the patient’s mouth to angle of the jaw
Incorrect placement can worsen obstruction!
Used in comatose patients
Oropharyngeal Airways
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Correct Sizing
Oropharyngeal Airways
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Correct Sizing
Oropharyngeal Airways
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Insertion
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Using a head-tilt-chin-lift, a modified jaw-thrust, or by grasping the
tongue and jaw by placing your thumb in the patient's mouth, move the
tongue forward. Position the OPA as shown with the tip in the patient's
mouth and slowly insert the OPA. As the OPA is being inserted, slight
resistance will be felt.
Oropharyngeal Airways
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Insertion
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At the point resistance is met, insertion should continue while
simultaneously rotating the OPA 180°. Advance the OPA until the flange
is resting on or just above the patient's teeth.
Nasopharyngeal Airways
Nasopharyngeal Airways
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Function
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Insertion
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Nasally
Necessary to check placement
Correct sizing
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Restores airway patency by separating the
tongue from the posterior wall of the
pharynx
Used when oral placement is not possible
Measure from the patient’s earlobe to the
tip of the nose
Incorrect placement can worsen
obstruction!
Used in awake patients
Nasopharyngeal Airways
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Correct Sizing of NPA
Nasopharyngeal Airways
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Correct Sizing of NPA
Nasopharyngeal Airways
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Insertion of NPA
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First check the nostril
for signs of fracture or
obstruction then apply
generous amounts of a
water-based lubricant
to the NPA taking care
not to fill the tip with the
lubricant
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Orient the bevel end so
that it will pass along the
inside of the nasal cavity
with minimal effort
Nasopharyngeal Airways
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Insertion of NPA
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Insert the NPA until the flange (the large end of the tube) is
seated on the patient's nose
Nasopharyngeal Airways
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Proper placement of the nasopharyngeal airway
Ventilation with Manual Resuscitator
Ventilation with Manual Resuscitator
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Place the patient supine
Open the airway – manual maneuver
Insert pharyngeal airway
Place the mask on the patient’s face
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Bridge of the nose first
Securing a tight seal below the lower lip
Maintain the mask position with thumb and index finger of one
hand, use the third, forth and fifth fingers to hook under the
mandible, displacing it anteriorly to maintain a patent airway
Ventilation with Manual Resuscitator
Ventilation with Manual Resuscitator
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Two-man ventilation with manual resuscitator
Ventilation with Manual Resuscitator
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Ventilate the patient at a rate of 8 – 16 breaths/min.
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Watch for chest expansion to ensure adequate volume
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I:E ration of 1:2 or better
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If the patient has spontaneous respiratory efforts, match
your ventilation efforts with the patient’s efforts
Endotracheal Tubes
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Function
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Insertion Site
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Relieve airway obstruction
Facilitate secretion removal
Protect against aspiration
Provide positive pressure ventilation
Nasally
Orally
Placement
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In the trachea
3 – 5 cm above the carina
Endotracheal Tubes
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Placement of the ET Tube
Endotracheal Tubes
Standard adapter with
a 15 mm external
diameter
Pilot tube
Radiopaque Strip
(visible on x-ray)
Body
Pilot balloon
Cuff
Beveled distal tip
Endotracheal Tubes
Length makings
(distance in cm from beveled tube tip)
“Z-79” or “IT”
Inner diameter
(Tissue toxicity testing)
Endotracheal Tubes
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Murphy’s eye
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Provides an alternate pathway
for gas to flow in the event the
distal tip become obstructed
Beveled distal tip
Endotracheal Tubes
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Reinforced Wire-Wrapped ET Tube
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Helical reinforcing wire imbedded into
the PVC material helps prevent
kinking when used in a tortuous airway
Hi-Lo EVAC Endotracheal Tube
Indwelling Hi-Lo EVAC Tube
Double Lumen ET Tube
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Function
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Independent lung ventilation
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Properties
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2 proximal 15 mm ventilator connections
2 inner lumens for gas flow
2 cuffs
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Unilateral lung disease
Larger cuff seal trachea
Smaller cuff seals bronchial lumen
2 distal openings
Fiberoptic bronchoscopy needed to
verify placement
Double Lumen ET Tube
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Proper placement
Indications for Endotracheal Intubation
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Relieve airway obstruction
Facilitate secretion clearance
Facilitate mechanical ventilation
Protect lower airway
Orotracheal Intubation
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Safely performed by:
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Physicians
Respiratory Therapists
Nurses
Paramedics
Orotracheal Intubation
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Step 1: Assemble and Check Equipment
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Suction Equipment
 Suction regulator, canister, tubing, catheters, Yankauer
(tonsil tip)
Manual resuscitator bag and mask
O2 flowmeter and tubing
Orotracheal Intubation
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Step 1: Assemble and Check Equipment
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Laryngoscope with assorted blades
 Ensure light on blade is functioning
Endotracheal tubes
 Inflate cuff and check for leaks
Orotracheal Intubation
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Step 1: Assemble and Check Equipment
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Stylet
Magil forceps (nasal intubation)
Orotracheal Intubation
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Step 1: Assemble and Check Equipment
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Tongue depressor
Tape
Syringe
Lubricating jelly
Local anesthetic (spray)
Orotracheal Intubation
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Step 1: Assemble and Check Equipment
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Towels (for positioning)
Stethoscope
CDC barrier precaution
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Gloves, gowns, masks, eyewear
Orotracheal Intubation
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Step 2: Position the Patient
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Must align the mouth,
pharynx and larynx
Place one or more rolled
towels under the patient’s
head
Orotracheal Intubation
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Step 3: Preoxygenate the Patient with
Resuscitator / Mask
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Provides a reserve of oxygen during intubation
attempts
Intubation attempts should not last greater than 30
seconds
If attempt fails, ventilate and oxygenate for 3-5
minutes before reattempting to intubate
Orotracheal Intubation
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Step 4: Insert the Laryngoscope
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Laryngoscope in left hand while
right hand opens the mouth
Insert the laryngoscope into the
right side of the mouth and move it
toward the center, displacing the
tongue to the left
Advance the tip of the blade along
the curve of the tongue until you
visualize the epiglottis
Orotracheal Intubation
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Step 5: Visualize the Glottis
Orotracheal Intubation
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Step 6: Displace the Epiglottis
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MacIntosh Blade – displaces
the epiglottis indirectly by
advancing the tip of the blade
into the vallecula
Miller Blade – displaces the
epiglottis directly by advancing
the tip of the blade over the its
posterior surface and lifting the
laryngoscope up and forward
Orotracheal Intubation
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Step 7: Insert the Tube
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Insert the tube from the
right side of the mouth
Advance tube through
the glottis until the cuff
passes the vocal cords
Inflate the cuff to seal the
airway
Ventilate and oxygenate
Orotracheal Intubation
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Step 8: Assess Tube Position (3 - 5 cm above carina)
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Auscultation – bilateral breath sounds
Observation of chest movement
Tube length ( approximately 22 cm to teeth for adults)
Colorimetry
Colorimetry - CO2 Detector
Negative for
CO2
Positive for
CO2
Orotracheal Intubation
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Step 8: Assess Tube Position (3 - 5 cm above carina)
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Capnometry (End-Tidal CO2)
Light wand
Fiberoptic laryngoscope
Esophogeal detection device
Chest x-ray
Orotracheal Intubation
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Step 9: Secure the Endotracheal Tube
Intubation Videos
Oral Intubation Procedure – Routine
Points to Remember
Hazards of Endotracheal Intubation
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Post-extubation mucosal edema
Trauma
Aspiration
Bleeding
Infection
Tube problems (pilot balloon, kinking etc.)
Cuff Pressure Monitoring Techniques
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Auscultate over trachea
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Minimal Occluding Volume – inflate cuff until cuff air
leak stops
Minimal Leak Technique – inflate cuff until cuff air leak
stops, then withdraw enough air to allow a small air
leak at peak inspiration
Cuff Pressure Monitoring Techniques
 Cuff Pressure Measurement
 Cufflator
 Checked once per shift
 Pressures not to exceed:
 27 – 34 cm H2O (20 – 25 mm
Hg)
 Excessive pressures my cause
tracheal damage if cuff
pressures are greater than
tracheal perfusion pressures
Combitube Airway
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Double lumen airway
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Esophageal gastric airway
Endotracheal tube
Effective whether in the esophagus or the trachea
Designed to be inserted blindly
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Used for difficult intubation
Short-term
Combitube Airway
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Correct insertion and placement
Laryngeal Mask Airway (LMA)
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Designed to form a low-pressure seal in
the laryngeal inlet by means of an
inflated cuff
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Maintains a patent upper airway and
facilitates ventilation
Designed to be inserter blindly
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Used for difficult intubation
Short-term
Laryngeal Mask Airway (LMA)
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Correct insertion and placement
Laryngeal Mask Airway (LMA)
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Correct insertion and placement
Laryngeal Mask Airway (LMA)
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Insertion video
This tube, when
inserted into the larynx
and the laryngeal cuff
inflated, provides a
closed seal system to
ventilate the lower
airway and protect
against aspiration.