intubation

GOOD MORNING

Saturday, April 8, 2023

AIR WAY MANAGEMENT

CH.VENKATESWARARAO

2nd MDS

Anatomy of Respiratory System

Upper Respiratory Tract • Composed of the nose and nasal cavity,

paranasal sinuses, pharynx (throat), larynx. • All part of the conducting portion of the

respiratory system.

Pharynx • Common pathway for both air and

food. Partitioned into three adjoining regions: naso pharynx oropharynx laryngopharynx

Lower Respiratory Tract

• Conducting airways (trachea, bronchi, up to terminal bronchioles).

• Respiratory portion of the respiratory system (respiratory bronchioles, alveolar ducts, and alveoli).

Larynx

• Voice box is a short, somewhat cylindrical airway ends in the trachea.

• Supported by a framework of nine pieces of cartilage (three individual pieces and three cartilage pairs) that are held in place by ligaments and muscles.

Patient assessment and preparations

•1. History•2. Physical examination

• “The Ritual of the Seven “Ps of RSI” • 1. PREPARATION • 2. PRE-OXYGENTATION • 3. PRE-TREATMENT • 4. PARALYSIS with Induction • 5. POSITIONING • 6. PROVE PLACEMENT • 7. POST-INTUBATION MANAGEMENT

In assessing patient 4 areas should be evaluated for signs that may suggest difficulty.

1.Limited volume or displacement of tongue during laryngoscopy.

2.Limitation to inserting laryngoscope or obtaining straight line of sight to the glottis.

3. Limitation of mouth opening:

Anesthesiology, V 98, No 5, May 2003

AIRWAY ASSESSMENT:Mallampati classification

In Samsoon and Young’s modification (1987) 3 of the Mallampati classification, a IV class was added.

AIRWAY ASSESSMENT:

Patil testIt involves measuring the distance between the thyroid notch and tip of the jaw – The thyromental gap

Thyromental gap < 6cm – Difficult airway

6-6.5 – Might be less difficult

>6cm – Normal airwaySaturday, April 8, 2023

Grade I: most of glottis is seen

Grade II: only posterior portion of glottis can be seen.

Grade III: only epiglottis may be seen (none of glottis seen

Grade IV: neither epiglottis nor glottis can be seen

Cormack and Lehane

grade 3,4 - ↑ risk for difficult intubationSaturday, April 8, 2023

SAVVA, Sterno-mental distance,

• The distance from the suprasternal notch to the mentum and investigated

• Mallampati class, • Jaw protrusion, • Interincisor gap and• Thyromental distance. • It was measured with the head

fully extended on the neck with the mouth closed. A value of less than 12 cm is found to predict a difficult intubation

LEMON airway assessment method

INDIAN J. Anaesth. 2003 476 ; 47 (6) : 476-478

• Prayer sign

Wilson and colleagues• Developed another scoring system in which they took 5

variables –

• Weight,• Head,

• Neck and • Jaw movements,

• Mandibular recession,• Presence or absence of buck teeth.

Risk score was developed between 0 to 10. Saturday, April 8, 2023

INDIVIDUAL INDICES: DIFFICULT MASK VENTILATION

• Beard • Obesity: BMI > 30 kg/m²- ↑risk of DMV.• Abnormality of teeth –

• artificial dentures or edentulous.• Snorers• Elderly

Anesthesiology, V 98, No 5, May 2003Saturday, April 8, 202

Techniques of Airway Management

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

MANAGEMENT OF AIRWAYAirway

Predicted Normal

Predicted Abnormal Unexpectedly difficult

• Masks

• LMA

• Oropharyngeal airway

• Nasopharyngeal airway

• Blind Nasal Intubation

• Oral Intubation

1. Methods above the cords

• Blind Nasal intubation

• Oral Intubation

• Intubating LMA

• Fiberoptic

2. Methods below the cords

• Retrograde methods

• Tracheostomy

• Cricothyroidoctomy

• Failed intubation Drill

• Failed ventilation drill

NONINVASIVE PROCEDURES FOR OBSTRUCTED AIRWAY

Back blow

Manual thrusts

1. Heimlich maneuver(Abdominal thrust)

2. Chest thrust

Head tilt chin lift & Head tilt jaw trust

Head tilt, jaw trust

ENDOTRACHEAL INTUBA ENDOTRACHEAL INTUBATIONTION

Translaryngeal placement of endotracheal tube is called as endotracheal Intubation

History :•M. Gracia (1805-1906), a singing teacher in London, pioneered indirect laryngoscopy with a mirror.

•1895: Alfred Kierstein, 1912: Gustav Killian pioneered direct laryngoscopy

•1899: Chevalier Jackson: did his first bronchoscopy and popularized direct laryngoscopy.

•Edgar Stanley Rowbotham (1890-1979) and Ivan Whiteside Magill (1888-1986) passed tracheal tube via laryngoscope.

•Edgar Stanley Rowbotham: did first blind nasal intubationSaturday, April 8, 2023

INDICATIONS:INDICATIONS:

• Respiratory Failure: • Hypoxia, Hypercapnia, tachypnea, or

apnea ; ie. ARDS, asthma, pulmonary edema, infection, COPD exacerbation

• Inability to ventilate unconscious patient• Maintenance or protection of an intact

airway• Cardiac Arrest

FONSECA VOL 1Saturday, April 8, 2023

INDICATIONS:INDICATIONS:• For supporting ventilation during gen

eral anesthesia• Type of surgery

• Operative site near the airway• Abdominal or thoracic surgery• Prone or lateral position• Long period of surgery

• Patient has risk of pulmonary aspiration

EQUIPMENT PREPARA EQUIPMENT PREPARATIONTION

ANAESTHESIA AND INTENSIVE CARE MEDICINE 7:10Equipment for airway managementKathryn Jackson ,Tim Cook

1) LARYNGOSCOPE : handle & blade

LARYNGOSCOPIC BLADE:

Macintosh (curved) and Miller (straight) blade Adult : Macintosh bladesmall children : Miller blade

Mc coy blade Miller blade

Macintosh bladeSaturday, April 8, 2023

2 ) ENDOTRACHEAL TUBE:

TYPES OF ETTs:1) Portex tubes:

• Semi rigid, with little tendency to kink. Most commonly used.

2) Rubber tubes:

• Soft, easily kinked.

3) Reinforced tubes:

• - Cuffed or non cuffed. Reinforced with wire to prevent kinking.

4) Special tubes:

• Double lumen (Robertshaw)Saturday, April 8, 2023

ENDOTRACHEAL TUBE: (ETT)

• Male : ID 8.0 mms • Female : ID 7.5 mms• New born - 3 mths : ID 3.0 mms• 3-9 months : ID 3.5 mms• 9-18 months : ID 4.0 mms• 2- 6 yrs : ID = (Age/3) + 3.5• > 6 yrs : ID = (Age/4) + 4.5

1) Size of ETT : internal diameter (ID)

3) ETT CUFF

High volume Low pressure cuff

Low volume High pressure cuff

2) MATERIAL : Red rubber or PVC

4) BEVEL 5) ’MURPHYSEYE

6) Depth of insertion:

Midtrachea or below vocal cord~2 cm

• Adult • Male ~23 cm

• Female ~21 cm

• Children• Oral ETT = (Age/2) + 12 (cm)

• Nasal ETT= (Age/2) + 15 (cm)

OTHER EQUIPMENTS:

STYLET(malleabl

OROPHARYNGEAL OR NASOPHARYNGEAL AIRWAY

Oral airway Nasal airway

FFFF FFFF & SELF INFLATING BAF

MAGI LL FORCEPS

LOCAL ANAESTHETIC SPRAY

PREOXYGENATION:

• ventilate with 100 % oxygen for approximately 3 min

Preoxygenation and Prevention of Desaturation During Emergency Airway Management, .2011.10.002

Sniffing position

Extension -at atlanto

occipital joint

Flexion at l ower cervi

cal spine

FFFF F F F F F F FF F F FF F F F FFF FF FF F FFFF F

BAG MASK VENTILATIONC

HOLDING A LARYNGOSCOPE

Hold the handle ofthe laryngoscope with your left hand

OPEN MOUTH TECHNIQUES

Hyper-extension technique ,Cross fingers techniques

INTUBATION TECHNIQUEINTUBATION TECHNIQUE

• Introduce the blade into the right side of the patient's mouth

• move the blade posteriorly and toward the midline, sweeping the tongue to the left and keeping it away from the visual path with the flange of the blade

• ensure the lower lip is not being pinched by the lower incisors and laryngoscope blade

• advance the laryngoscope until the epiglottis is in view

INSERTING THE BLADE

INTUBATION TECHNIQUE

• lift the laryngoscope upward and forward• insert the ETT from the right angle of mouth

with its concave curve facing downward and to the right side of the patient

• maneuver the endotracheal tube into the larynx, midway between the cricoid cartilage and the sternal angle

LIFTING UP A LARYNGOSCOPE:

•Pull the blade forward and upward using firm but Steady pressure without rotating the wrist•Avoid leaning on the upper teeth with the blade

BURP Maneuver:

ON THYROID CARTILAGE

•Backward:•against the cervical Vertebrae

•Upward

•Right: lateral pressure to the right

ROLE OF AN ASSISTANT

• To provide the endotracheal tube to the operator’s right hand

• To apply circoid pressure

• Facilitates intubation using BURP maneuver

INTUBATION TECHNIQUE• inflate the cuff and apply positive pressure

ventilation while the assistant auscultates• secure the endotracheal tube in position

after b/l equal air entry is confirmed

CONFIRMATION :By Physical Exam

• Confirm tube placement immediately• Listen over the epigastrium and observe

the chest wall for movement• If stomach gurgling and no chest wall

expansion – • esophagus intubated: deflate the cuff

and remove ET tube• Reattempt intubation after re -oxygenation

CONFIRMATION: CONTD.

• If chest wall rises and stomach not gurgling,

perform 5-point auscultation

• If still doubt, use laryngoscope to see the tube passing through the vocal cords (best)

• Secure the tube

• Look for moisture condensation on the inside of the tracheal tube

• (not 100%: false +ve with esophageal intubations)

intubation

edgar stanley

endotracheal

airway assessment

respiratory

burp maneuver

miller blade

blade

management

Documents

INTUBATION DIFFICILE: NOUVEL ALGORITHME -...

Intubation Crush

ET Intubation

Endotracheal Intubation

Post-Intubation Sedation

Rapid Sequence Intubation

ENDOTRACHEAL INTUBATION -...

Intubation difficile

Nasogastric intubation

Elective Intubation - Respiratory...

Post Intubation Care

Challenges and Advances in Intubation: Rapid Sequence...

Intubation 101

Intubation - cahs.health.wa.gov.au

Delayed sequence intubation

Newborn intubation