Headline Text
Welcome message from author
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Headline Text
Airway management in ER settings ldquoBasic amp Advancedrdquo
Updated with recent advances
DrVenugopalan PP DADNBMNAMSMEM-GWU Director Emergency Medicine
Aster DM Healthcare PG teacher NBE
Lecture NBE E learning program July 2017
Why airway management in Emergency Room
bull Airway management is the cornerstone of resuscitation
bull A defining skill for the specialty of emergency medicine bull The emergency physician has primary responsibility for
management of the airway bull All airway management techniques lie within the domain of
emergency medicine
When to intubate bull 1Failure to maintain
or protect the airway bull 2Failure of ventilation
or oxygenation bull 3Anticipated clinical
course and likelihood of deterioration
Clinical Decision
How do you know airway is patent
bull Level of consciousness bull Ability to phonate in response to voice command
or query (Integrity of the upper airway and the level of consciousness)
bull Ability to manage his or her own secretions ( pooling of secretions in the oropharynx absence of swallowing spontaneously or on command)
IntubationA patient who requires a manoeuver to establish a patent airway or who easily tolerates an oral airway probably requires intubation for protection of that airway unless temporary or readily reversible condition such as opioid overdose is present
Ventilatory failure or Oxygenation failure
bull Clinical assessment bull Pulse oximetry with or without
capnography bull Observation of improvement or
deterioration in the patientrsquos clinical condition
The decision to intubate
Intubate early especially in dynamic airways Bullets - neck trauma
Bites- anaphylaxis angioedema
Burns -caustic airway injuries Thermal injuries
Three B rsquos
Airway - mouth and neck infections tumors foreign bodies bleeds
stridor phonation swallowing secretions dyspnea
Breathing - failure of oxygenation or ventilation
often amenable to medical and non-invasive therapies ndash think NIV
Circulation supporting tissue oxygen delivery by unloading the muscles of respiration
sepsis
A-B-C-D-E-F
A-B-C-D-E-F
Disability CNS catastrophes and CNS depression ongoing seizures weakness
Avoid gag ndash assess ability to swallow and handle secretions (pooling drooling gurgling) for neuromuscular weakness FVC lt 12 mlkg and NIF
lt 20 cm H20
vomiting in the obtunded patient is a particular concern
Expected course anticipated decline transfer to radiology or another institution
Feral -need for prompt aggressive sedation to protect patientothers
especially with potential or undiagnosed medical instability
Arterial blood gases (ABGs) generally are not required to determine the patientrsquos need for intubation
Anticipated clinical deteriorationbull Certain overdoses bull Significant multiple trauma with or without head injury bull Multiple trauma with hypotension an open femur fracture and
diffuse abdominal tenderness bull Aggressive resuscitation pain control invasive procedures and
imaging outside of the emergency department inevitable operative management
bull Evidence of vascular or direct airway injury in the neck
Obstructed airway
Tongue and Epiglottis Any Foreign materials
Clear it
Noisy breathing
Tongue obstructing Airway
Head tilt ampChin lift
Jaw thrust
Trauma
Airway
Not ndash Maintainable
Adjuncts
Choice ndashOPA
bull Airway Reflexes hellipNo
O P A
Sizing - oropharyngeal airway
Oropharyngeal airway Insertion
Best method
OPA Insertion
N P A
bull OPA is not tolerating bull Airway reflexes retained bull Inability to open mouth
N P A
Airway
Still not ndash Maintainable
Advanced Airway
No Breathing
E ndash C Clamp
Place and hold mask properly
Two hand technique
Non-maintainable Airway
R S I
Conscious patient Semiconscious with retained reflexes
RSI Defined
ldquoVirtually simultaneous administration of a potent sedative agent and a neuromuscular blocking agent to induce unconsciousness and motor paralysis for tracheal intubationrdquo
What are The Problems Inherent to Intubation
bull Laryngoscopy and Intubation ndash Increased bronchospasm ndash Increased ICP ndash Increased catecholamine release
Beneficial Effects of RSI
bull ldquoTight Headsrdquo ndash Intracranial pathology
bull ldquoTight Heartsrdquo or ldquoTight Vesselsrdquo ndash Cardiovascular disease
bull ldquoTight Lungsrdquo ndash Reactive airway disease
Conventional With LMA
Pre Oxygenationhellip
RSI TimelineT ndash 10 minutes Prepare T ndash 5 minutes Preoxygenate T ndash 3 minutes Pretreat T = 0 Paralysis with
induction T + 30 seconds Protection T + 45 seconds Placement T + 90 seconds Post-Intubation
management
Problem Airway
epiglottis Vocal cords
Airway Evaluation
Double set up bull Neuromuscular paralysis generally
should be avoided in patients for whom a high degree of intubation difficulty is predicted unless the administration of the neuromuscular blocking agent (NMBA) is part of a planned approach to the difficult airway
Look Externally bull Severely bruised
bull Bloodied face of a combative trauma patient bull Immobilised in a cervical collar on a spine board bull Anatomical deformities
bull Subjective clinical judgment can be highly specific (90) but insensitive and so should be augmented by other evaluations
Obstruction or obesitybull Visualization of the glottis or intubation
itself mechanically impossible bull Epiglottis head and neck cancer Ludwigrsquos
angina neck hematoma or glottic polyps bull Examine the patient for airway obstruction
and assess the patientrsquos voice to satisfy this evaluation step
Neck mobility
bull Neck mobility is desirable for any intubation technique and is essential for positioning the patient for optimal direct laryngoscopy Neck mobility is assessed with the patientrsquos flexion and extension of the head and neck through a full range of motion
Lemon in ER setting
bull Unresponsive patient - Mallampatti is not practical - LEON
bull Unresponsive plus Trauma - Mallampatti and Neck mobility are not practical - LEO
Cormack and Lehane[CL]
bull The most widely used system for grading laryngoscopic view of the glottis is that of Cormack and Lehane (CL)
bull Grades laryngoscopy according to the extent to which laryngeal and glottic structures can be seen
CL grading bull Grade 1 laryngoscopy all or nearly all of the glottic aperture is seen bull Grade 2 laryngoscopy visualizes only a portion of the glottis
(arytenoid cartilages alone or arytenoid cartilages plus part of the vocal cords)
bull Grade 3 laryngoscopy visualizes only the epiglottis bull Grade 4 laryngoscopy not even the epiglottis is visible
Percentage Of Glottic Opening (POGO) score
Confirmation of Endotracheal Tube Placement
bull Direct visualisation bull Chest auscultation bull Gastric auscultation bull Bag resistance bull Exhaled volume bull Visualization of condensation within the ETT bull Chest radiography bull All are prone to failure as means of confirming tracheal intubation
ETCO2bull End-tidal carbon dioxide (ETCO2) detection
device to the ETT and assess it through six manual ventilations
bull Disposable colorimetric ETCO2 detectors are highly reliable convenient and easy to interpret indicating adequate CO2 detection by color change
End tidal CO2 detection
USG- EDDbull When ETCO2 detection
is not possible tracheal tube position can be confirmed with other techniques
bull One novel approach Bedside ultrasound
USG guided Intubation and placement confirmation
Esophageal Detector Devices (EDD)
EDD - how to work
Recognize Adequacy of Ventilations
Pulse oximeter
Approximate Blood oxygen level
SpO2 100 = PaO2 100mm of Hg SpO2 90= PaO2 60mm of Hg SpO2 60= PaO2 30mm of Hg SpO2 50= PaO2 27mm of Hg
Chest X raybull Although chest
radiography is universally recommended after ETT placement its primary purpose is to ensure that the tube is well positioned below the cords and above the carina
Other methods Gold standard
bull Fiberoptic confirmation
Difficult Airway Assessment
bull 4 Drsquos ndash Distortion Disproportion Dysmobility Dentition
bull BONES ndash Beard Obese No teeth Elderly Snores (sleep apnea)
bull SHORT ndash Surgery (headneckjaw) Hematoma Obese Radiation Tumor
bull LEMON bull MALLAMPATI bull Always have a ldquoRescue Airwayrdquo technique ready
McI
ntyr
e T
he d
iffic
ult t
rach
eal i
ntub
atio
n
Rescue Airways
bull Gum Elastic Bougie (GEB) bull Laryngeal Mask Airway (LMAILMA) bull Combitube bull Surgical Cricothyrotomy
Gum elastic bougie
Gum elastic bouge bull Useful only when
larynges is visualise at least partially
bull Difficulty intubation bull Tube changing bull Provision to
supplement oxygen
Advanced airway ndashBest choice Intubation
Equipments Needed
Laryngoscope with different types of blade
ET tube with proper size and type Average adult male 85 mm Average adult female 75 mm Low pressure cuff tubes above 5 years Uncuffed tubes below 5 years
lt 4 Age + 35
3
gt 4 Age + 45
4
Laryngoscope
Macoy Laryngoscope
Align the airway axis by proper positions
Intubation Axis
ET Tube insertion
Reverse Ramp Position
Cricoid pressure
Pressure on Cricoid cartilage Compress oesophagus between Cricoid ring and Vertebral column Prevent Regurgitation and Aspiration Make cord visualisation difficult Not recommended in Crash airway
External Laryngeal manipulation
BURP - Backward - Upward - Right- Posterior Pressure over thyroid cartilage Better vocal cord visualisation A grade 3 larynx become grade 2 with ELM It is not Cricoid pressure
Blind insertion devices
LMA Combitube Kingrsquos airway
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
Airway management in ER settings ldquoBasic amp Advancedrdquo
Updated with recent advances
DrVenugopalan PP DADNBMNAMSMEM-GWU Director Emergency Medicine
Aster DM Healthcare PG teacher NBE
Lecture NBE E learning program July 2017
Why airway management in Emergency Room
bull Airway management is the cornerstone of resuscitation
bull A defining skill for the specialty of emergency medicine bull The emergency physician has primary responsibility for
management of the airway bull All airway management techniques lie within the domain of
emergency medicine
When to intubate bull 1Failure to maintain
or protect the airway bull 2Failure of ventilation
or oxygenation bull 3Anticipated clinical
course and likelihood of deterioration
Clinical Decision
How do you know airway is patent
bull Level of consciousness bull Ability to phonate in response to voice command
or query (Integrity of the upper airway and the level of consciousness)
bull Ability to manage his or her own secretions ( pooling of secretions in the oropharynx absence of swallowing spontaneously or on command)
IntubationA patient who requires a manoeuver to establish a patent airway or who easily tolerates an oral airway probably requires intubation for protection of that airway unless temporary or readily reversible condition such as opioid overdose is present
Ventilatory failure or Oxygenation failure
bull Clinical assessment bull Pulse oximetry with or without
capnography bull Observation of improvement or
deterioration in the patientrsquos clinical condition
The decision to intubate
Intubate early especially in dynamic airways Bullets - neck trauma
Bites- anaphylaxis angioedema
Burns -caustic airway injuries Thermal injuries
Three B rsquos
Airway - mouth and neck infections tumors foreign bodies bleeds
stridor phonation swallowing secretions dyspnea
Breathing - failure of oxygenation or ventilation
often amenable to medical and non-invasive therapies ndash think NIV
Circulation supporting tissue oxygen delivery by unloading the muscles of respiration
sepsis
A-B-C-D-E-F
A-B-C-D-E-F
Disability CNS catastrophes and CNS depression ongoing seizures weakness
Avoid gag ndash assess ability to swallow and handle secretions (pooling drooling gurgling) for neuromuscular weakness FVC lt 12 mlkg and NIF
lt 20 cm H20
vomiting in the obtunded patient is a particular concern
Expected course anticipated decline transfer to radiology or another institution
Feral -need for prompt aggressive sedation to protect patientothers
especially with potential or undiagnosed medical instability
Arterial blood gases (ABGs) generally are not required to determine the patientrsquos need for intubation
Anticipated clinical deteriorationbull Certain overdoses bull Significant multiple trauma with or without head injury bull Multiple trauma with hypotension an open femur fracture and
diffuse abdominal tenderness bull Aggressive resuscitation pain control invasive procedures and
imaging outside of the emergency department inevitable operative management
bull Evidence of vascular or direct airway injury in the neck
Obstructed airway
Tongue and Epiglottis Any Foreign materials
Clear it
Noisy breathing
Tongue obstructing Airway
Head tilt ampChin lift
Jaw thrust
Trauma
Airway
Not ndash Maintainable
Adjuncts
Choice ndashOPA
bull Airway Reflexes hellipNo
O P A
Sizing - oropharyngeal airway
Oropharyngeal airway Insertion
Best method
OPA Insertion
N P A
bull OPA is not tolerating bull Airway reflexes retained bull Inability to open mouth
N P A
Airway
Still not ndash Maintainable
Advanced Airway
No Breathing
E ndash C Clamp
Place and hold mask properly
Two hand technique
Non-maintainable Airway
R S I
Conscious patient Semiconscious with retained reflexes
RSI Defined
ldquoVirtually simultaneous administration of a potent sedative agent and a neuromuscular blocking agent to induce unconsciousness and motor paralysis for tracheal intubationrdquo
What are The Problems Inherent to Intubation
bull Laryngoscopy and Intubation ndash Increased bronchospasm ndash Increased ICP ndash Increased catecholamine release
Beneficial Effects of RSI
bull ldquoTight Headsrdquo ndash Intracranial pathology
bull ldquoTight Heartsrdquo or ldquoTight Vesselsrdquo ndash Cardiovascular disease
bull ldquoTight Lungsrdquo ndash Reactive airway disease
Conventional With LMA
Pre Oxygenationhellip
RSI TimelineT ndash 10 minutes Prepare T ndash 5 minutes Preoxygenate T ndash 3 minutes Pretreat T = 0 Paralysis with
induction T + 30 seconds Protection T + 45 seconds Placement T + 90 seconds Post-Intubation
management
Problem Airway
epiglottis Vocal cords
Airway Evaluation
Double set up bull Neuromuscular paralysis generally
should be avoided in patients for whom a high degree of intubation difficulty is predicted unless the administration of the neuromuscular blocking agent (NMBA) is part of a planned approach to the difficult airway
Look Externally bull Severely bruised
bull Bloodied face of a combative trauma patient bull Immobilised in a cervical collar on a spine board bull Anatomical deformities
bull Subjective clinical judgment can be highly specific (90) but insensitive and so should be augmented by other evaluations
Obstruction or obesitybull Visualization of the glottis or intubation
itself mechanically impossible bull Epiglottis head and neck cancer Ludwigrsquos
angina neck hematoma or glottic polyps bull Examine the patient for airway obstruction
and assess the patientrsquos voice to satisfy this evaluation step
Neck mobility
bull Neck mobility is desirable for any intubation technique and is essential for positioning the patient for optimal direct laryngoscopy Neck mobility is assessed with the patientrsquos flexion and extension of the head and neck through a full range of motion
Lemon in ER setting
bull Unresponsive patient - Mallampatti is not practical - LEON
bull Unresponsive plus Trauma - Mallampatti and Neck mobility are not practical - LEO
Cormack and Lehane[CL]
bull The most widely used system for grading laryngoscopic view of the glottis is that of Cormack and Lehane (CL)
bull Grades laryngoscopy according to the extent to which laryngeal and glottic structures can be seen
CL grading bull Grade 1 laryngoscopy all or nearly all of the glottic aperture is seen bull Grade 2 laryngoscopy visualizes only a portion of the glottis
(arytenoid cartilages alone or arytenoid cartilages plus part of the vocal cords)
bull Grade 3 laryngoscopy visualizes only the epiglottis bull Grade 4 laryngoscopy not even the epiglottis is visible
Percentage Of Glottic Opening (POGO) score
Confirmation of Endotracheal Tube Placement
bull Direct visualisation bull Chest auscultation bull Gastric auscultation bull Bag resistance bull Exhaled volume bull Visualization of condensation within the ETT bull Chest radiography bull All are prone to failure as means of confirming tracheal intubation
ETCO2bull End-tidal carbon dioxide (ETCO2) detection
device to the ETT and assess it through six manual ventilations
bull Disposable colorimetric ETCO2 detectors are highly reliable convenient and easy to interpret indicating adequate CO2 detection by color change
End tidal CO2 detection
USG- EDDbull When ETCO2 detection
is not possible tracheal tube position can be confirmed with other techniques
bull One novel approach Bedside ultrasound
USG guided Intubation and placement confirmation
Esophageal Detector Devices (EDD)
EDD - how to work
Recognize Adequacy of Ventilations
Pulse oximeter
Approximate Blood oxygen level
SpO2 100 = PaO2 100mm of Hg SpO2 90= PaO2 60mm of Hg SpO2 60= PaO2 30mm of Hg SpO2 50= PaO2 27mm of Hg
Chest X raybull Although chest
radiography is universally recommended after ETT placement its primary purpose is to ensure that the tube is well positioned below the cords and above the carina
Other methods Gold standard
bull Fiberoptic confirmation
Difficult Airway Assessment
bull 4 Drsquos ndash Distortion Disproportion Dysmobility Dentition
bull BONES ndash Beard Obese No teeth Elderly Snores (sleep apnea)
bull SHORT ndash Surgery (headneckjaw) Hematoma Obese Radiation Tumor
bull LEMON bull MALLAMPATI bull Always have a ldquoRescue Airwayrdquo technique ready
McI
ntyr
e T
he d
iffic
ult t
rach
eal i
ntub
atio
n
Rescue Airways
bull Gum Elastic Bougie (GEB) bull Laryngeal Mask Airway (LMAILMA) bull Combitube bull Surgical Cricothyrotomy
Gum elastic bougie
Gum elastic bouge bull Useful only when
larynges is visualise at least partially
bull Difficulty intubation bull Tube changing bull Provision to
supplement oxygen
Advanced airway ndashBest choice Intubation
Equipments Needed
Laryngoscope with different types of blade
ET tube with proper size and type Average adult male 85 mm Average adult female 75 mm Low pressure cuff tubes above 5 years Uncuffed tubes below 5 years
lt 4 Age + 35
3
gt 4 Age + 45
4
Laryngoscope
Macoy Laryngoscope
Align the airway axis by proper positions
Intubation Axis
ET Tube insertion
Reverse Ramp Position
Cricoid pressure
Pressure on Cricoid cartilage Compress oesophagus between Cricoid ring and Vertebral column Prevent Regurgitation and Aspiration Make cord visualisation difficult Not recommended in Crash airway
External Laryngeal manipulation
BURP - Backward - Upward - Right- Posterior Pressure over thyroid cartilage Better vocal cord visualisation A grade 3 larynx become grade 2 with ELM It is not Cricoid pressure
Blind insertion devices
LMA Combitube Kingrsquos airway
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
Why airway management in Emergency Room
bull Airway management is the cornerstone of resuscitation
bull A defining skill for the specialty of emergency medicine bull The emergency physician has primary responsibility for
management of the airway bull All airway management techniques lie within the domain of
emergency medicine
When to intubate bull 1Failure to maintain
or protect the airway bull 2Failure of ventilation
or oxygenation bull 3Anticipated clinical
course and likelihood of deterioration
Clinical Decision
How do you know airway is patent
bull Level of consciousness bull Ability to phonate in response to voice command
or query (Integrity of the upper airway and the level of consciousness)
bull Ability to manage his or her own secretions ( pooling of secretions in the oropharynx absence of swallowing spontaneously or on command)
IntubationA patient who requires a manoeuver to establish a patent airway or who easily tolerates an oral airway probably requires intubation for protection of that airway unless temporary or readily reversible condition such as opioid overdose is present
Ventilatory failure or Oxygenation failure
bull Clinical assessment bull Pulse oximetry with or without
capnography bull Observation of improvement or
deterioration in the patientrsquos clinical condition
The decision to intubate
Intubate early especially in dynamic airways Bullets - neck trauma
Bites- anaphylaxis angioedema
Burns -caustic airway injuries Thermal injuries
Three B rsquos
Airway - mouth and neck infections tumors foreign bodies bleeds
stridor phonation swallowing secretions dyspnea
Breathing - failure of oxygenation or ventilation
often amenable to medical and non-invasive therapies ndash think NIV
Circulation supporting tissue oxygen delivery by unloading the muscles of respiration
sepsis
A-B-C-D-E-F
A-B-C-D-E-F
Disability CNS catastrophes and CNS depression ongoing seizures weakness
Avoid gag ndash assess ability to swallow and handle secretions (pooling drooling gurgling) for neuromuscular weakness FVC lt 12 mlkg and NIF
lt 20 cm H20
vomiting in the obtunded patient is a particular concern
Expected course anticipated decline transfer to radiology or another institution
Feral -need for prompt aggressive sedation to protect patientothers
especially with potential or undiagnosed medical instability
Arterial blood gases (ABGs) generally are not required to determine the patientrsquos need for intubation
Anticipated clinical deteriorationbull Certain overdoses bull Significant multiple trauma with or without head injury bull Multiple trauma with hypotension an open femur fracture and
diffuse abdominal tenderness bull Aggressive resuscitation pain control invasive procedures and
imaging outside of the emergency department inevitable operative management
bull Evidence of vascular or direct airway injury in the neck
Obstructed airway
Tongue and Epiglottis Any Foreign materials
Clear it
Noisy breathing
Tongue obstructing Airway
Head tilt ampChin lift
Jaw thrust
Trauma
Airway
Not ndash Maintainable
Adjuncts
Choice ndashOPA
bull Airway Reflexes hellipNo
O P A
Sizing - oropharyngeal airway
Oropharyngeal airway Insertion
Best method
OPA Insertion
N P A
bull OPA is not tolerating bull Airway reflexes retained bull Inability to open mouth
N P A
Airway
Still not ndash Maintainable
Advanced Airway
No Breathing
E ndash C Clamp
Place and hold mask properly
Two hand technique
Non-maintainable Airway
R S I
Conscious patient Semiconscious with retained reflexes
RSI Defined
ldquoVirtually simultaneous administration of a potent sedative agent and a neuromuscular blocking agent to induce unconsciousness and motor paralysis for tracheal intubationrdquo
What are The Problems Inherent to Intubation
bull Laryngoscopy and Intubation ndash Increased bronchospasm ndash Increased ICP ndash Increased catecholamine release
Beneficial Effects of RSI
bull ldquoTight Headsrdquo ndash Intracranial pathology
bull ldquoTight Heartsrdquo or ldquoTight Vesselsrdquo ndash Cardiovascular disease
bull ldquoTight Lungsrdquo ndash Reactive airway disease
Conventional With LMA
Pre Oxygenationhellip
RSI TimelineT ndash 10 minutes Prepare T ndash 5 minutes Preoxygenate T ndash 3 minutes Pretreat T = 0 Paralysis with
induction T + 30 seconds Protection T + 45 seconds Placement T + 90 seconds Post-Intubation
management
Problem Airway
epiglottis Vocal cords
Airway Evaluation
Double set up bull Neuromuscular paralysis generally
should be avoided in patients for whom a high degree of intubation difficulty is predicted unless the administration of the neuromuscular blocking agent (NMBA) is part of a planned approach to the difficult airway
Look Externally bull Severely bruised
bull Bloodied face of a combative trauma patient bull Immobilised in a cervical collar on a spine board bull Anatomical deformities
bull Subjective clinical judgment can be highly specific (90) but insensitive and so should be augmented by other evaluations
Obstruction or obesitybull Visualization of the glottis or intubation
itself mechanically impossible bull Epiglottis head and neck cancer Ludwigrsquos
angina neck hematoma or glottic polyps bull Examine the patient for airway obstruction
and assess the patientrsquos voice to satisfy this evaluation step
Neck mobility
bull Neck mobility is desirable for any intubation technique and is essential for positioning the patient for optimal direct laryngoscopy Neck mobility is assessed with the patientrsquos flexion and extension of the head and neck through a full range of motion
Lemon in ER setting
bull Unresponsive patient - Mallampatti is not practical - LEON
bull Unresponsive plus Trauma - Mallampatti and Neck mobility are not practical - LEO
Cormack and Lehane[CL]
bull The most widely used system for grading laryngoscopic view of the glottis is that of Cormack and Lehane (CL)
bull Grades laryngoscopy according to the extent to which laryngeal and glottic structures can be seen
CL grading bull Grade 1 laryngoscopy all or nearly all of the glottic aperture is seen bull Grade 2 laryngoscopy visualizes only a portion of the glottis
(arytenoid cartilages alone or arytenoid cartilages plus part of the vocal cords)
bull Grade 3 laryngoscopy visualizes only the epiglottis bull Grade 4 laryngoscopy not even the epiglottis is visible
Percentage Of Glottic Opening (POGO) score
Confirmation of Endotracheal Tube Placement
bull Direct visualisation bull Chest auscultation bull Gastric auscultation bull Bag resistance bull Exhaled volume bull Visualization of condensation within the ETT bull Chest radiography bull All are prone to failure as means of confirming tracheal intubation
ETCO2bull End-tidal carbon dioxide (ETCO2) detection
device to the ETT and assess it through six manual ventilations
bull Disposable colorimetric ETCO2 detectors are highly reliable convenient and easy to interpret indicating adequate CO2 detection by color change
End tidal CO2 detection
USG- EDDbull When ETCO2 detection
is not possible tracheal tube position can be confirmed with other techniques
bull One novel approach Bedside ultrasound
USG guided Intubation and placement confirmation
Esophageal Detector Devices (EDD)
EDD - how to work
Recognize Adequacy of Ventilations
Pulse oximeter
Approximate Blood oxygen level
SpO2 100 = PaO2 100mm of Hg SpO2 90= PaO2 60mm of Hg SpO2 60= PaO2 30mm of Hg SpO2 50= PaO2 27mm of Hg
Chest X raybull Although chest
radiography is universally recommended after ETT placement its primary purpose is to ensure that the tube is well positioned below the cords and above the carina
Other methods Gold standard
bull Fiberoptic confirmation
Difficult Airway Assessment
bull 4 Drsquos ndash Distortion Disproportion Dysmobility Dentition
bull BONES ndash Beard Obese No teeth Elderly Snores (sleep apnea)
bull SHORT ndash Surgery (headneckjaw) Hematoma Obese Radiation Tumor
bull LEMON bull MALLAMPATI bull Always have a ldquoRescue Airwayrdquo technique ready
McI
ntyr
e T
he d
iffic
ult t
rach
eal i
ntub
atio
n
Rescue Airways
bull Gum Elastic Bougie (GEB) bull Laryngeal Mask Airway (LMAILMA) bull Combitube bull Surgical Cricothyrotomy
Gum elastic bougie
Gum elastic bouge bull Useful only when
larynges is visualise at least partially
bull Difficulty intubation bull Tube changing bull Provision to
supplement oxygen
Advanced airway ndashBest choice Intubation
Equipments Needed
Laryngoscope with different types of blade
ET tube with proper size and type Average adult male 85 mm Average adult female 75 mm Low pressure cuff tubes above 5 years Uncuffed tubes below 5 years
lt 4 Age + 35
3
gt 4 Age + 45
4
Laryngoscope
Macoy Laryngoscope
Align the airway axis by proper positions
Intubation Axis
ET Tube insertion
Reverse Ramp Position
Cricoid pressure
Pressure on Cricoid cartilage Compress oesophagus between Cricoid ring and Vertebral column Prevent Regurgitation and Aspiration Make cord visualisation difficult Not recommended in Crash airway
External Laryngeal manipulation
BURP - Backward - Upward - Right- Posterior Pressure over thyroid cartilage Better vocal cord visualisation A grade 3 larynx become grade 2 with ELM It is not Cricoid pressure
Blind insertion devices
LMA Combitube Kingrsquos airway
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
When to intubate bull 1Failure to maintain
or protect the airway bull 2Failure of ventilation
or oxygenation bull 3Anticipated clinical
course and likelihood of deterioration
Clinical Decision
How do you know airway is patent
bull Level of consciousness bull Ability to phonate in response to voice command
or query (Integrity of the upper airway and the level of consciousness)
bull Ability to manage his or her own secretions ( pooling of secretions in the oropharynx absence of swallowing spontaneously or on command)
IntubationA patient who requires a manoeuver to establish a patent airway or who easily tolerates an oral airway probably requires intubation for protection of that airway unless temporary or readily reversible condition such as opioid overdose is present
Ventilatory failure or Oxygenation failure
bull Clinical assessment bull Pulse oximetry with or without
capnography bull Observation of improvement or
deterioration in the patientrsquos clinical condition
The decision to intubate
Intubate early especially in dynamic airways Bullets - neck trauma
Bites- anaphylaxis angioedema
Burns -caustic airway injuries Thermal injuries
Three B rsquos
Airway - mouth and neck infections tumors foreign bodies bleeds
stridor phonation swallowing secretions dyspnea
Breathing - failure of oxygenation or ventilation
often amenable to medical and non-invasive therapies ndash think NIV
Circulation supporting tissue oxygen delivery by unloading the muscles of respiration
sepsis
A-B-C-D-E-F
A-B-C-D-E-F
Disability CNS catastrophes and CNS depression ongoing seizures weakness
Avoid gag ndash assess ability to swallow and handle secretions (pooling drooling gurgling) for neuromuscular weakness FVC lt 12 mlkg and NIF
lt 20 cm H20
vomiting in the obtunded patient is a particular concern
Expected course anticipated decline transfer to radiology or another institution
Feral -need for prompt aggressive sedation to protect patientothers
especially with potential or undiagnosed medical instability
Arterial blood gases (ABGs) generally are not required to determine the patientrsquos need for intubation
Anticipated clinical deteriorationbull Certain overdoses bull Significant multiple trauma with or without head injury bull Multiple trauma with hypotension an open femur fracture and
diffuse abdominal tenderness bull Aggressive resuscitation pain control invasive procedures and
imaging outside of the emergency department inevitable operative management
bull Evidence of vascular or direct airway injury in the neck
Obstructed airway
Tongue and Epiglottis Any Foreign materials
Clear it
Noisy breathing
Tongue obstructing Airway
Head tilt ampChin lift
Jaw thrust
Trauma
Airway
Not ndash Maintainable
Adjuncts
Choice ndashOPA
bull Airway Reflexes hellipNo
O P A
Sizing - oropharyngeal airway
Oropharyngeal airway Insertion
Best method
OPA Insertion
N P A
bull OPA is not tolerating bull Airway reflexes retained bull Inability to open mouth
N P A
Airway
Still not ndash Maintainable
Advanced Airway
No Breathing
E ndash C Clamp
Place and hold mask properly
Two hand technique
Non-maintainable Airway
R S I
Conscious patient Semiconscious with retained reflexes
RSI Defined
ldquoVirtually simultaneous administration of a potent sedative agent and a neuromuscular blocking agent to induce unconsciousness and motor paralysis for tracheal intubationrdquo
What are The Problems Inherent to Intubation
bull Laryngoscopy and Intubation ndash Increased bronchospasm ndash Increased ICP ndash Increased catecholamine release
Beneficial Effects of RSI
bull ldquoTight Headsrdquo ndash Intracranial pathology
bull ldquoTight Heartsrdquo or ldquoTight Vesselsrdquo ndash Cardiovascular disease
bull ldquoTight Lungsrdquo ndash Reactive airway disease
Conventional With LMA
Pre Oxygenationhellip
RSI TimelineT ndash 10 minutes Prepare T ndash 5 minutes Preoxygenate T ndash 3 minutes Pretreat T = 0 Paralysis with
induction T + 30 seconds Protection T + 45 seconds Placement T + 90 seconds Post-Intubation
management
Problem Airway
epiglottis Vocal cords
Airway Evaluation
Double set up bull Neuromuscular paralysis generally
should be avoided in patients for whom a high degree of intubation difficulty is predicted unless the administration of the neuromuscular blocking agent (NMBA) is part of a planned approach to the difficult airway
Look Externally bull Severely bruised
bull Bloodied face of a combative trauma patient bull Immobilised in a cervical collar on a spine board bull Anatomical deformities
bull Subjective clinical judgment can be highly specific (90) but insensitive and so should be augmented by other evaluations
Obstruction or obesitybull Visualization of the glottis or intubation
itself mechanically impossible bull Epiglottis head and neck cancer Ludwigrsquos
angina neck hematoma or glottic polyps bull Examine the patient for airway obstruction
and assess the patientrsquos voice to satisfy this evaluation step
Neck mobility
bull Neck mobility is desirable for any intubation technique and is essential for positioning the patient for optimal direct laryngoscopy Neck mobility is assessed with the patientrsquos flexion and extension of the head and neck through a full range of motion
Lemon in ER setting
bull Unresponsive patient - Mallampatti is not practical - LEON
bull Unresponsive plus Trauma - Mallampatti and Neck mobility are not practical - LEO
Cormack and Lehane[CL]
bull The most widely used system for grading laryngoscopic view of the glottis is that of Cormack and Lehane (CL)
bull Grades laryngoscopy according to the extent to which laryngeal and glottic structures can be seen
CL grading bull Grade 1 laryngoscopy all or nearly all of the glottic aperture is seen bull Grade 2 laryngoscopy visualizes only a portion of the glottis
(arytenoid cartilages alone or arytenoid cartilages plus part of the vocal cords)
bull Grade 3 laryngoscopy visualizes only the epiglottis bull Grade 4 laryngoscopy not even the epiglottis is visible
Percentage Of Glottic Opening (POGO) score
Confirmation of Endotracheal Tube Placement
bull Direct visualisation bull Chest auscultation bull Gastric auscultation bull Bag resistance bull Exhaled volume bull Visualization of condensation within the ETT bull Chest radiography bull All are prone to failure as means of confirming tracheal intubation
ETCO2bull End-tidal carbon dioxide (ETCO2) detection
device to the ETT and assess it through six manual ventilations
bull Disposable colorimetric ETCO2 detectors are highly reliable convenient and easy to interpret indicating adequate CO2 detection by color change
End tidal CO2 detection
USG- EDDbull When ETCO2 detection
is not possible tracheal tube position can be confirmed with other techniques
bull One novel approach Bedside ultrasound
USG guided Intubation and placement confirmation
Esophageal Detector Devices (EDD)
EDD - how to work
Recognize Adequacy of Ventilations
Pulse oximeter
Approximate Blood oxygen level
SpO2 100 = PaO2 100mm of Hg SpO2 90= PaO2 60mm of Hg SpO2 60= PaO2 30mm of Hg SpO2 50= PaO2 27mm of Hg
Chest X raybull Although chest
radiography is universally recommended after ETT placement its primary purpose is to ensure that the tube is well positioned below the cords and above the carina
Other methods Gold standard
bull Fiberoptic confirmation
Difficult Airway Assessment
bull 4 Drsquos ndash Distortion Disproportion Dysmobility Dentition
bull BONES ndash Beard Obese No teeth Elderly Snores (sleep apnea)
bull SHORT ndash Surgery (headneckjaw) Hematoma Obese Radiation Tumor
bull LEMON bull MALLAMPATI bull Always have a ldquoRescue Airwayrdquo technique ready
McI
ntyr
e T
he d
iffic
ult t
rach
eal i
ntub
atio
n
Rescue Airways
bull Gum Elastic Bougie (GEB) bull Laryngeal Mask Airway (LMAILMA) bull Combitube bull Surgical Cricothyrotomy
Gum elastic bougie
Gum elastic bouge bull Useful only when
larynges is visualise at least partially
bull Difficulty intubation bull Tube changing bull Provision to
supplement oxygen
Advanced airway ndashBest choice Intubation
Equipments Needed
Laryngoscope with different types of blade
ET tube with proper size and type Average adult male 85 mm Average adult female 75 mm Low pressure cuff tubes above 5 years Uncuffed tubes below 5 years
lt 4 Age + 35
3
gt 4 Age + 45
4
Laryngoscope
Macoy Laryngoscope
Align the airway axis by proper positions
Intubation Axis
ET Tube insertion
Reverse Ramp Position
Cricoid pressure
Pressure on Cricoid cartilage Compress oesophagus between Cricoid ring and Vertebral column Prevent Regurgitation and Aspiration Make cord visualisation difficult Not recommended in Crash airway
External Laryngeal manipulation
BURP - Backward - Upward - Right- Posterior Pressure over thyroid cartilage Better vocal cord visualisation A grade 3 larynx become grade 2 with ELM It is not Cricoid pressure
Blind insertion devices
LMA Combitube Kingrsquos airway
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
How do you know airway is patent
bull Level of consciousness bull Ability to phonate in response to voice command
or query (Integrity of the upper airway and the level of consciousness)
bull Ability to manage his or her own secretions ( pooling of secretions in the oropharynx absence of swallowing spontaneously or on command)
IntubationA patient who requires a manoeuver to establish a patent airway or who easily tolerates an oral airway probably requires intubation for protection of that airway unless temporary or readily reversible condition such as opioid overdose is present
Ventilatory failure or Oxygenation failure
bull Clinical assessment bull Pulse oximetry with or without
capnography bull Observation of improvement or
deterioration in the patientrsquos clinical condition
The decision to intubate
Intubate early especially in dynamic airways Bullets - neck trauma
Bites- anaphylaxis angioedema
Burns -caustic airway injuries Thermal injuries
Three B rsquos
Airway - mouth and neck infections tumors foreign bodies bleeds
stridor phonation swallowing secretions dyspnea
Breathing - failure of oxygenation or ventilation
often amenable to medical and non-invasive therapies ndash think NIV
Circulation supporting tissue oxygen delivery by unloading the muscles of respiration
sepsis
A-B-C-D-E-F
A-B-C-D-E-F
Disability CNS catastrophes and CNS depression ongoing seizures weakness
Avoid gag ndash assess ability to swallow and handle secretions (pooling drooling gurgling) for neuromuscular weakness FVC lt 12 mlkg and NIF
lt 20 cm H20
vomiting in the obtunded patient is a particular concern
Expected course anticipated decline transfer to radiology or another institution
Feral -need for prompt aggressive sedation to protect patientothers
especially with potential or undiagnosed medical instability
Arterial blood gases (ABGs) generally are not required to determine the patientrsquos need for intubation
Anticipated clinical deteriorationbull Certain overdoses bull Significant multiple trauma with or without head injury bull Multiple trauma with hypotension an open femur fracture and
diffuse abdominal tenderness bull Aggressive resuscitation pain control invasive procedures and
imaging outside of the emergency department inevitable operative management
bull Evidence of vascular or direct airway injury in the neck
Obstructed airway
Tongue and Epiglottis Any Foreign materials
Clear it
Noisy breathing
Tongue obstructing Airway
Head tilt ampChin lift
Jaw thrust
Trauma
Airway
Not ndash Maintainable
Adjuncts
Choice ndashOPA
bull Airway Reflexes hellipNo
O P A
Sizing - oropharyngeal airway
Oropharyngeal airway Insertion
Best method
OPA Insertion
N P A
bull OPA is not tolerating bull Airway reflexes retained bull Inability to open mouth
N P A
Airway
Still not ndash Maintainable
Advanced Airway
No Breathing
E ndash C Clamp
Place and hold mask properly
Two hand technique
Non-maintainable Airway
R S I
Conscious patient Semiconscious with retained reflexes
RSI Defined
ldquoVirtually simultaneous administration of a potent sedative agent and a neuromuscular blocking agent to induce unconsciousness and motor paralysis for tracheal intubationrdquo
What are The Problems Inherent to Intubation
bull Laryngoscopy and Intubation ndash Increased bronchospasm ndash Increased ICP ndash Increased catecholamine release
Beneficial Effects of RSI
bull ldquoTight Headsrdquo ndash Intracranial pathology
bull ldquoTight Heartsrdquo or ldquoTight Vesselsrdquo ndash Cardiovascular disease
bull ldquoTight Lungsrdquo ndash Reactive airway disease
Conventional With LMA
Pre Oxygenationhellip
RSI TimelineT ndash 10 minutes Prepare T ndash 5 minutes Preoxygenate T ndash 3 minutes Pretreat T = 0 Paralysis with
induction T + 30 seconds Protection T + 45 seconds Placement T + 90 seconds Post-Intubation
management
Problem Airway
epiglottis Vocal cords
Airway Evaluation
Double set up bull Neuromuscular paralysis generally
should be avoided in patients for whom a high degree of intubation difficulty is predicted unless the administration of the neuromuscular blocking agent (NMBA) is part of a planned approach to the difficult airway
Look Externally bull Severely bruised
bull Bloodied face of a combative trauma patient bull Immobilised in a cervical collar on a spine board bull Anatomical deformities
bull Subjective clinical judgment can be highly specific (90) but insensitive and so should be augmented by other evaluations
Obstruction or obesitybull Visualization of the glottis or intubation
itself mechanically impossible bull Epiglottis head and neck cancer Ludwigrsquos
angina neck hematoma or glottic polyps bull Examine the patient for airway obstruction
and assess the patientrsquos voice to satisfy this evaluation step
Neck mobility
bull Neck mobility is desirable for any intubation technique and is essential for positioning the patient for optimal direct laryngoscopy Neck mobility is assessed with the patientrsquos flexion and extension of the head and neck through a full range of motion
Lemon in ER setting
bull Unresponsive patient - Mallampatti is not practical - LEON
bull Unresponsive plus Trauma - Mallampatti and Neck mobility are not practical - LEO
Cormack and Lehane[CL]
bull The most widely used system for grading laryngoscopic view of the glottis is that of Cormack and Lehane (CL)
bull Grades laryngoscopy according to the extent to which laryngeal and glottic structures can be seen
CL grading bull Grade 1 laryngoscopy all or nearly all of the glottic aperture is seen bull Grade 2 laryngoscopy visualizes only a portion of the glottis
(arytenoid cartilages alone or arytenoid cartilages plus part of the vocal cords)
bull Grade 3 laryngoscopy visualizes only the epiglottis bull Grade 4 laryngoscopy not even the epiglottis is visible
Percentage Of Glottic Opening (POGO) score
Confirmation of Endotracheal Tube Placement
bull Direct visualisation bull Chest auscultation bull Gastric auscultation bull Bag resistance bull Exhaled volume bull Visualization of condensation within the ETT bull Chest radiography bull All are prone to failure as means of confirming tracheal intubation
ETCO2bull End-tidal carbon dioxide (ETCO2) detection
device to the ETT and assess it through six manual ventilations
bull Disposable colorimetric ETCO2 detectors are highly reliable convenient and easy to interpret indicating adequate CO2 detection by color change
End tidal CO2 detection
USG- EDDbull When ETCO2 detection
is not possible tracheal tube position can be confirmed with other techniques
bull One novel approach Bedside ultrasound
USG guided Intubation and placement confirmation
Esophageal Detector Devices (EDD)
EDD - how to work
Recognize Adequacy of Ventilations
Pulse oximeter
Approximate Blood oxygen level
SpO2 100 = PaO2 100mm of Hg SpO2 90= PaO2 60mm of Hg SpO2 60= PaO2 30mm of Hg SpO2 50= PaO2 27mm of Hg
Chest X raybull Although chest
radiography is universally recommended after ETT placement its primary purpose is to ensure that the tube is well positioned below the cords and above the carina
Other methods Gold standard
bull Fiberoptic confirmation
Difficult Airway Assessment
bull 4 Drsquos ndash Distortion Disproportion Dysmobility Dentition
bull BONES ndash Beard Obese No teeth Elderly Snores (sleep apnea)
bull SHORT ndash Surgery (headneckjaw) Hematoma Obese Radiation Tumor
bull LEMON bull MALLAMPATI bull Always have a ldquoRescue Airwayrdquo technique ready
McI
ntyr
e T
he d
iffic
ult t
rach
eal i
ntub
atio
n
Rescue Airways
bull Gum Elastic Bougie (GEB) bull Laryngeal Mask Airway (LMAILMA) bull Combitube bull Surgical Cricothyrotomy
Gum elastic bougie
Gum elastic bouge bull Useful only when
larynges is visualise at least partially
bull Difficulty intubation bull Tube changing bull Provision to
supplement oxygen
Advanced airway ndashBest choice Intubation
Equipments Needed
Laryngoscope with different types of blade
ET tube with proper size and type Average adult male 85 mm Average adult female 75 mm Low pressure cuff tubes above 5 years Uncuffed tubes below 5 years
lt 4 Age + 35
3
gt 4 Age + 45
4
Laryngoscope
Macoy Laryngoscope
Align the airway axis by proper positions
Intubation Axis
ET Tube insertion
Reverse Ramp Position
Cricoid pressure
Pressure on Cricoid cartilage Compress oesophagus between Cricoid ring and Vertebral column Prevent Regurgitation and Aspiration Make cord visualisation difficult Not recommended in Crash airway
External Laryngeal manipulation
BURP - Backward - Upward - Right- Posterior Pressure over thyroid cartilage Better vocal cord visualisation A grade 3 larynx become grade 2 with ELM It is not Cricoid pressure
Blind insertion devices
LMA Combitube Kingrsquos airway
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
IntubationA patient who requires a manoeuver to establish a patent airway or who easily tolerates an oral airway probably requires intubation for protection of that airway unless temporary or readily reversible condition such as opioid overdose is present
Ventilatory failure or Oxygenation failure
bull Clinical assessment bull Pulse oximetry with or without
capnography bull Observation of improvement or
deterioration in the patientrsquos clinical condition
The decision to intubate
Intubate early especially in dynamic airways Bullets - neck trauma
Bites- anaphylaxis angioedema
Burns -caustic airway injuries Thermal injuries
Three B rsquos
Airway - mouth and neck infections tumors foreign bodies bleeds
stridor phonation swallowing secretions dyspnea
Breathing - failure of oxygenation or ventilation
often amenable to medical and non-invasive therapies ndash think NIV
Circulation supporting tissue oxygen delivery by unloading the muscles of respiration
sepsis
A-B-C-D-E-F
A-B-C-D-E-F
Disability CNS catastrophes and CNS depression ongoing seizures weakness
Avoid gag ndash assess ability to swallow and handle secretions (pooling drooling gurgling) for neuromuscular weakness FVC lt 12 mlkg and NIF
lt 20 cm H20
vomiting in the obtunded patient is a particular concern
Expected course anticipated decline transfer to radiology or another institution
Feral -need for prompt aggressive sedation to protect patientothers
especially with potential or undiagnosed medical instability
Arterial blood gases (ABGs) generally are not required to determine the patientrsquos need for intubation
Anticipated clinical deteriorationbull Certain overdoses bull Significant multiple trauma with or without head injury bull Multiple trauma with hypotension an open femur fracture and
diffuse abdominal tenderness bull Aggressive resuscitation pain control invasive procedures and
imaging outside of the emergency department inevitable operative management
bull Evidence of vascular or direct airway injury in the neck
Obstructed airway
Tongue and Epiglottis Any Foreign materials
Clear it
Noisy breathing
Tongue obstructing Airway
Head tilt ampChin lift
Jaw thrust
Trauma
Airway
Not ndash Maintainable
Adjuncts
Choice ndashOPA
bull Airway Reflexes hellipNo
O P A
Sizing - oropharyngeal airway
Oropharyngeal airway Insertion
Best method
OPA Insertion
N P A
bull OPA is not tolerating bull Airway reflexes retained bull Inability to open mouth
N P A
Airway
Still not ndash Maintainable
Advanced Airway
No Breathing
E ndash C Clamp
Place and hold mask properly
Two hand technique
Non-maintainable Airway
R S I
Conscious patient Semiconscious with retained reflexes
RSI Defined
ldquoVirtually simultaneous administration of a potent sedative agent and a neuromuscular blocking agent to induce unconsciousness and motor paralysis for tracheal intubationrdquo
What are The Problems Inherent to Intubation
bull Laryngoscopy and Intubation ndash Increased bronchospasm ndash Increased ICP ndash Increased catecholamine release
Beneficial Effects of RSI
bull ldquoTight Headsrdquo ndash Intracranial pathology
bull ldquoTight Heartsrdquo or ldquoTight Vesselsrdquo ndash Cardiovascular disease
bull ldquoTight Lungsrdquo ndash Reactive airway disease
Conventional With LMA
Pre Oxygenationhellip
RSI TimelineT ndash 10 minutes Prepare T ndash 5 minutes Preoxygenate T ndash 3 minutes Pretreat T = 0 Paralysis with
induction T + 30 seconds Protection T + 45 seconds Placement T + 90 seconds Post-Intubation
management
Problem Airway
epiglottis Vocal cords
Airway Evaluation
Double set up bull Neuromuscular paralysis generally
should be avoided in patients for whom a high degree of intubation difficulty is predicted unless the administration of the neuromuscular blocking agent (NMBA) is part of a planned approach to the difficult airway
Look Externally bull Severely bruised
bull Bloodied face of a combative trauma patient bull Immobilised in a cervical collar on a spine board bull Anatomical deformities
bull Subjective clinical judgment can be highly specific (90) but insensitive and so should be augmented by other evaluations
Obstruction or obesitybull Visualization of the glottis or intubation
itself mechanically impossible bull Epiglottis head and neck cancer Ludwigrsquos
angina neck hematoma or glottic polyps bull Examine the patient for airway obstruction
and assess the patientrsquos voice to satisfy this evaluation step
Neck mobility
bull Neck mobility is desirable for any intubation technique and is essential for positioning the patient for optimal direct laryngoscopy Neck mobility is assessed with the patientrsquos flexion and extension of the head and neck through a full range of motion
Lemon in ER setting
bull Unresponsive patient - Mallampatti is not practical - LEON
bull Unresponsive plus Trauma - Mallampatti and Neck mobility are not practical - LEO
Cormack and Lehane[CL]
bull The most widely used system for grading laryngoscopic view of the glottis is that of Cormack and Lehane (CL)
bull Grades laryngoscopy according to the extent to which laryngeal and glottic structures can be seen
CL grading bull Grade 1 laryngoscopy all or nearly all of the glottic aperture is seen bull Grade 2 laryngoscopy visualizes only a portion of the glottis
(arytenoid cartilages alone or arytenoid cartilages plus part of the vocal cords)
bull Grade 3 laryngoscopy visualizes only the epiglottis bull Grade 4 laryngoscopy not even the epiglottis is visible
Percentage Of Glottic Opening (POGO) score
Confirmation of Endotracheal Tube Placement
bull Direct visualisation bull Chest auscultation bull Gastric auscultation bull Bag resistance bull Exhaled volume bull Visualization of condensation within the ETT bull Chest radiography bull All are prone to failure as means of confirming tracheal intubation
ETCO2bull End-tidal carbon dioxide (ETCO2) detection
device to the ETT and assess it through six manual ventilations
bull Disposable colorimetric ETCO2 detectors are highly reliable convenient and easy to interpret indicating adequate CO2 detection by color change
End tidal CO2 detection
USG- EDDbull When ETCO2 detection
is not possible tracheal tube position can be confirmed with other techniques
bull One novel approach Bedside ultrasound
USG guided Intubation and placement confirmation
Esophageal Detector Devices (EDD)
EDD - how to work
Recognize Adequacy of Ventilations
Pulse oximeter
Approximate Blood oxygen level
SpO2 100 = PaO2 100mm of Hg SpO2 90= PaO2 60mm of Hg SpO2 60= PaO2 30mm of Hg SpO2 50= PaO2 27mm of Hg
Chest X raybull Although chest
radiography is universally recommended after ETT placement its primary purpose is to ensure that the tube is well positioned below the cords and above the carina
Other methods Gold standard
bull Fiberoptic confirmation
Difficult Airway Assessment
bull 4 Drsquos ndash Distortion Disproportion Dysmobility Dentition
bull BONES ndash Beard Obese No teeth Elderly Snores (sleep apnea)
bull SHORT ndash Surgery (headneckjaw) Hematoma Obese Radiation Tumor
bull LEMON bull MALLAMPATI bull Always have a ldquoRescue Airwayrdquo technique ready
McI
ntyr
e T
he d
iffic
ult t
rach
eal i
ntub
atio
n
Rescue Airways
bull Gum Elastic Bougie (GEB) bull Laryngeal Mask Airway (LMAILMA) bull Combitube bull Surgical Cricothyrotomy
Gum elastic bougie
Gum elastic bouge bull Useful only when
larynges is visualise at least partially
bull Difficulty intubation bull Tube changing bull Provision to
supplement oxygen
Advanced airway ndashBest choice Intubation
Equipments Needed
Laryngoscope with different types of blade
ET tube with proper size and type Average adult male 85 mm Average adult female 75 mm Low pressure cuff tubes above 5 years Uncuffed tubes below 5 years
lt 4 Age + 35
3
gt 4 Age + 45
4
Laryngoscope
Macoy Laryngoscope
Align the airway axis by proper positions
Intubation Axis
ET Tube insertion
Reverse Ramp Position
Cricoid pressure
Pressure on Cricoid cartilage Compress oesophagus between Cricoid ring and Vertebral column Prevent Regurgitation and Aspiration Make cord visualisation difficult Not recommended in Crash airway
External Laryngeal manipulation
BURP - Backward - Upward - Right- Posterior Pressure over thyroid cartilage Better vocal cord visualisation A grade 3 larynx become grade 2 with ELM It is not Cricoid pressure
Blind insertion devices
LMA Combitube Kingrsquos airway
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
Ventilatory failure or Oxygenation failure
bull Clinical assessment bull Pulse oximetry with or without
capnography bull Observation of improvement or
deterioration in the patientrsquos clinical condition
The decision to intubate
Intubate early especially in dynamic airways Bullets - neck trauma
Bites- anaphylaxis angioedema
Burns -caustic airway injuries Thermal injuries
Three B rsquos
Airway - mouth and neck infections tumors foreign bodies bleeds
stridor phonation swallowing secretions dyspnea
Breathing - failure of oxygenation or ventilation
often amenable to medical and non-invasive therapies ndash think NIV
Circulation supporting tissue oxygen delivery by unloading the muscles of respiration
sepsis
A-B-C-D-E-F
A-B-C-D-E-F
Disability CNS catastrophes and CNS depression ongoing seizures weakness
Avoid gag ndash assess ability to swallow and handle secretions (pooling drooling gurgling) for neuromuscular weakness FVC lt 12 mlkg and NIF
lt 20 cm H20
vomiting in the obtunded patient is a particular concern
Expected course anticipated decline transfer to radiology or another institution
Feral -need for prompt aggressive sedation to protect patientothers
especially with potential or undiagnosed medical instability
Arterial blood gases (ABGs) generally are not required to determine the patientrsquos need for intubation
Anticipated clinical deteriorationbull Certain overdoses bull Significant multiple trauma with or without head injury bull Multiple trauma with hypotension an open femur fracture and
diffuse abdominal tenderness bull Aggressive resuscitation pain control invasive procedures and
imaging outside of the emergency department inevitable operative management
bull Evidence of vascular or direct airway injury in the neck
Obstructed airway
Tongue and Epiglottis Any Foreign materials
Clear it
Noisy breathing
Tongue obstructing Airway
Head tilt ampChin lift
Jaw thrust
Trauma
Airway
Not ndash Maintainable
Adjuncts
Choice ndashOPA
bull Airway Reflexes hellipNo
O P A
Sizing - oropharyngeal airway
Oropharyngeal airway Insertion
Best method
OPA Insertion
N P A
bull OPA is not tolerating bull Airway reflexes retained bull Inability to open mouth
N P A
Airway
Still not ndash Maintainable
Advanced Airway
No Breathing
E ndash C Clamp
Place and hold mask properly
Two hand technique
Non-maintainable Airway
R S I
Conscious patient Semiconscious with retained reflexes
RSI Defined
ldquoVirtually simultaneous administration of a potent sedative agent and a neuromuscular blocking agent to induce unconsciousness and motor paralysis for tracheal intubationrdquo
What are The Problems Inherent to Intubation
bull Laryngoscopy and Intubation ndash Increased bronchospasm ndash Increased ICP ndash Increased catecholamine release
Beneficial Effects of RSI
bull ldquoTight Headsrdquo ndash Intracranial pathology
bull ldquoTight Heartsrdquo or ldquoTight Vesselsrdquo ndash Cardiovascular disease
bull ldquoTight Lungsrdquo ndash Reactive airway disease
Conventional With LMA
Pre Oxygenationhellip
RSI TimelineT ndash 10 minutes Prepare T ndash 5 minutes Preoxygenate T ndash 3 minutes Pretreat T = 0 Paralysis with
induction T + 30 seconds Protection T + 45 seconds Placement T + 90 seconds Post-Intubation
management
Problem Airway
epiglottis Vocal cords
Airway Evaluation
Double set up bull Neuromuscular paralysis generally
should be avoided in patients for whom a high degree of intubation difficulty is predicted unless the administration of the neuromuscular blocking agent (NMBA) is part of a planned approach to the difficult airway
Look Externally bull Severely bruised
bull Bloodied face of a combative trauma patient bull Immobilised in a cervical collar on a spine board bull Anatomical deformities
bull Subjective clinical judgment can be highly specific (90) but insensitive and so should be augmented by other evaluations
Obstruction or obesitybull Visualization of the glottis or intubation
itself mechanically impossible bull Epiglottis head and neck cancer Ludwigrsquos
angina neck hematoma or glottic polyps bull Examine the patient for airway obstruction
and assess the patientrsquos voice to satisfy this evaluation step
Neck mobility
bull Neck mobility is desirable for any intubation technique and is essential for positioning the patient for optimal direct laryngoscopy Neck mobility is assessed with the patientrsquos flexion and extension of the head and neck through a full range of motion
Lemon in ER setting
bull Unresponsive patient - Mallampatti is not practical - LEON
bull Unresponsive plus Trauma - Mallampatti and Neck mobility are not practical - LEO
Cormack and Lehane[CL]
bull The most widely used system for grading laryngoscopic view of the glottis is that of Cormack and Lehane (CL)
bull Grades laryngoscopy according to the extent to which laryngeal and glottic structures can be seen
CL grading bull Grade 1 laryngoscopy all or nearly all of the glottic aperture is seen bull Grade 2 laryngoscopy visualizes only a portion of the glottis
(arytenoid cartilages alone or arytenoid cartilages plus part of the vocal cords)
bull Grade 3 laryngoscopy visualizes only the epiglottis bull Grade 4 laryngoscopy not even the epiglottis is visible
Percentage Of Glottic Opening (POGO) score
Confirmation of Endotracheal Tube Placement
bull Direct visualisation bull Chest auscultation bull Gastric auscultation bull Bag resistance bull Exhaled volume bull Visualization of condensation within the ETT bull Chest radiography bull All are prone to failure as means of confirming tracheal intubation
ETCO2bull End-tidal carbon dioxide (ETCO2) detection
device to the ETT and assess it through six manual ventilations
bull Disposable colorimetric ETCO2 detectors are highly reliable convenient and easy to interpret indicating adequate CO2 detection by color change
End tidal CO2 detection
USG- EDDbull When ETCO2 detection
is not possible tracheal tube position can be confirmed with other techniques
bull One novel approach Bedside ultrasound
USG guided Intubation and placement confirmation
Esophageal Detector Devices (EDD)
EDD - how to work
Recognize Adequacy of Ventilations
Pulse oximeter
Approximate Blood oxygen level
SpO2 100 = PaO2 100mm of Hg SpO2 90= PaO2 60mm of Hg SpO2 60= PaO2 30mm of Hg SpO2 50= PaO2 27mm of Hg
Chest X raybull Although chest
radiography is universally recommended after ETT placement its primary purpose is to ensure that the tube is well positioned below the cords and above the carina
Other methods Gold standard
bull Fiberoptic confirmation
Difficult Airway Assessment
bull 4 Drsquos ndash Distortion Disproportion Dysmobility Dentition
bull BONES ndash Beard Obese No teeth Elderly Snores (sleep apnea)
bull SHORT ndash Surgery (headneckjaw) Hematoma Obese Radiation Tumor
bull LEMON bull MALLAMPATI bull Always have a ldquoRescue Airwayrdquo technique ready
McI
ntyr
e T
he d
iffic
ult t
rach
eal i
ntub
atio
n
Rescue Airways
bull Gum Elastic Bougie (GEB) bull Laryngeal Mask Airway (LMAILMA) bull Combitube bull Surgical Cricothyrotomy
Gum elastic bougie
Gum elastic bouge bull Useful only when
larynges is visualise at least partially
bull Difficulty intubation bull Tube changing bull Provision to
supplement oxygen
Advanced airway ndashBest choice Intubation
Equipments Needed
Laryngoscope with different types of blade
ET tube with proper size and type Average adult male 85 mm Average adult female 75 mm Low pressure cuff tubes above 5 years Uncuffed tubes below 5 years
lt 4 Age + 35
3
gt 4 Age + 45
4
Laryngoscope
Macoy Laryngoscope
Align the airway axis by proper positions
Intubation Axis
ET Tube insertion
Reverse Ramp Position
Cricoid pressure
Pressure on Cricoid cartilage Compress oesophagus between Cricoid ring and Vertebral column Prevent Regurgitation and Aspiration Make cord visualisation difficult Not recommended in Crash airway
External Laryngeal manipulation
BURP - Backward - Upward - Right- Posterior Pressure over thyroid cartilage Better vocal cord visualisation A grade 3 larynx become grade 2 with ELM It is not Cricoid pressure
Blind insertion devices
LMA Combitube Kingrsquos airway
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
The decision to intubate
Intubate early especially in dynamic airways Bullets - neck trauma
Bites- anaphylaxis angioedema
Burns -caustic airway injuries Thermal injuries
Three B rsquos
Airway - mouth and neck infections tumors foreign bodies bleeds
stridor phonation swallowing secretions dyspnea
Breathing - failure of oxygenation or ventilation
often amenable to medical and non-invasive therapies ndash think NIV
Circulation supporting tissue oxygen delivery by unloading the muscles of respiration
sepsis
A-B-C-D-E-F
A-B-C-D-E-F
Disability CNS catastrophes and CNS depression ongoing seizures weakness
Avoid gag ndash assess ability to swallow and handle secretions (pooling drooling gurgling) for neuromuscular weakness FVC lt 12 mlkg and NIF
lt 20 cm H20
vomiting in the obtunded patient is a particular concern
Expected course anticipated decline transfer to radiology or another institution
Feral -need for prompt aggressive sedation to protect patientothers
especially with potential or undiagnosed medical instability
Arterial blood gases (ABGs) generally are not required to determine the patientrsquos need for intubation
Anticipated clinical deteriorationbull Certain overdoses bull Significant multiple trauma with or without head injury bull Multiple trauma with hypotension an open femur fracture and
diffuse abdominal tenderness bull Aggressive resuscitation pain control invasive procedures and
imaging outside of the emergency department inevitable operative management
bull Evidence of vascular or direct airway injury in the neck
Obstructed airway
Tongue and Epiglottis Any Foreign materials
Clear it
Noisy breathing
Tongue obstructing Airway
Head tilt ampChin lift
Jaw thrust
Trauma
Airway
Not ndash Maintainable
Adjuncts
Choice ndashOPA
bull Airway Reflexes hellipNo
O P A
Sizing - oropharyngeal airway
Oropharyngeal airway Insertion
Best method
OPA Insertion
N P A
bull OPA is not tolerating bull Airway reflexes retained bull Inability to open mouth
N P A
Airway
Still not ndash Maintainable
Advanced Airway
No Breathing
E ndash C Clamp
Place and hold mask properly
Two hand technique
Non-maintainable Airway
R S I
Conscious patient Semiconscious with retained reflexes
RSI Defined
ldquoVirtually simultaneous administration of a potent sedative agent and a neuromuscular blocking agent to induce unconsciousness and motor paralysis for tracheal intubationrdquo
What are The Problems Inherent to Intubation
bull Laryngoscopy and Intubation ndash Increased bronchospasm ndash Increased ICP ndash Increased catecholamine release
Beneficial Effects of RSI
bull ldquoTight Headsrdquo ndash Intracranial pathology
bull ldquoTight Heartsrdquo or ldquoTight Vesselsrdquo ndash Cardiovascular disease
bull ldquoTight Lungsrdquo ndash Reactive airway disease
Conventional With LMA
Pre Oxygenationhellip
RSI TimelineT ndash 10 minutes Prepare T ndash 5 minutes Preoxygenate T ndash 3 minutes Pretreat T = 0 Paralysis with
induction T + 30 seconds Protection T + 45 seconds Placement T + 90 seconds Post-Intubation
management
Problem Airway
epiglottis Vocal cords
Airway Evaluation
Double set up bull Neuromuscular paralysis generally
should be avoided in patients for whom a high degree of intubation difficulty is predicted unless the administration of the neuromuscular blocking agent (NMBA) is part of a planned approach to the difficult airway
Look Externally bull Severely bruised
bull Bloodied face of a combative trauma patient bull Immobilised in a cervical collar on a spine board bull Anatomical deformities
bull Subjective clinical judgment can be highly specific (90) but insensitive and so should be augmented by other evaluations
Obstruction or obesitybull Visualization of the glottis or intubation
itself mechanically impossible bull Epiglottis head and neck cancer Ludwigrsquos
angina neck hematoma or glottic polyps bull Examine the patient for airway obstruction
and assess the patientrsquos voice to satisfy this evaluation step
Neck mobility
bull Neck mobility is desirable for any intubation technique and is essential for positioning the patient for optimal direct laryngoscopy Neck mobility is assessed with the patientrsquos flexion and extension of the head and neck through a full range of motion
Lemon in ER setting
bull Unresponsive patient - Mallampatti is not practical - LEON
bull Unresponsive plus Trauma - Mallampatti and Neck mobility are not practical - LEO
Cormack and Lehane[CL]
bull The most widely used system for grading laryngoscopic view of the glottis is that of Cormack and Lehane (CL)
bull Grades laryngoscopy according to the extent to which laryngeal and glottic structures can be seen
CL grading bull Grade 1 laryngoscopy all or nearly all of the glottic aperture is seen bull Grade 2 laryngoscopy visualizes only a portion of the glottis
(arytenoid cartilages alone or arytenoid cartilages plus part of the vocal cords)
bull Grade 3 laryngoscopy visualizes only the epiglottis bull Grade 4 laryngoscopy not even the epiglottis is visible
Percentage Of Glottic Opening (POGO) score
Confirmation of Endotracheal Tube Placement
bull Direct visualisation bull Chest auscultation bull Gastric auscultation bull Bag resistance bull Exhaled volume bull Visualization of condensation within the ETT bull Chest radiography bull All are prone to failure as means of confirming tracheal intubation
ETCO2bull End-tidal carbon dioxide (ETCO2) detection
device to the ETT and assess it through six manual ventilations
bull Disposable colorimetric ETCO2 detectors are highly reliable convenient and easy to interpret indicating adequate CO2 detection by color change
End tidal CO2 detection
USG- EDDbull When ETCO2 detection
is not possible tracheal tube position can be confirmed with other techniques
bull One novel approach Bedside ultrasound
USG guided Intubation and placement confirmation
Esophageal Detector Devices (EDD)
EDD - how to work
Recognize Adequacy of Ventilations
Pulse oximeter
Approximate Blood oxygen level
SpO2 100 = PaO2 100mm of Hg SpO2 90= PaO2 60mm of Hg SpO2 60= PaO2 30mm of Hg SpO2 50= PaO2 27mm of Hg
Chest X raybull Although chest
radiography is universally recommended after ETT placement its primary purpose is to ensure that the tube is well positioned below the cords and above the carina
Other methods Gold standard
bull Fiberoptic confirmation
Difficult Airway Assessment
bull 4 Drsquos ndash Distortion Disproportion Dysmobility Dentition
bull BONES ndash Beard Obese No teeth Elderly Snores (sleep apnea)
bull SHORT ndash Surgery (headneckjaw) Hematoma Obese Radiation Tumor
bull LEMON bull MALLAMPATI bull Always have a ldquoRescue Airwayrdquo technique ready
McI
ntyr
e T
he d
iffic
ult t
rach
eal i
ntub
atio
n
Rescue Airways
bull Gum Elastic Bougie (GEB) bull Laryngeal Mask Airway (LMAILMA) bull Combitube bull Surgical Cricothyrotomy
Gum elastic bougie
Gum elastic bouge bull Useful only when
larynges is visualise at least partially
bull Difficulty intubation bull Tube changing bull Provision to
supplement oxygen
Advanced airway ndashBest choice Intubation
Equipments Needed
Laryngoscope with different types of blade
ET tube with proper size and type Average adult male 85 mm Average adult female 75 mm Low pressure cuff tubes above 5 years Uncuffed tubes below 5 years
lt 4 Age + 35
3
gt 4 Age + 45
4
Laryngoscope
Macoy Laryngoscope
Align the airway axis by proper positions
Intubation Axis
ET Tube insertion
Reverse Ramp Position
Cricoid pressure
Pressure on Cricoid cartilage Compress oesophagus between Cricoid ring and Vertebral column Prevent Regurgitation and Aspiration Make cord visualisation difficult Not recommended in Crash airway
External Laryngeal manipulation
BURP - Backward - Upward - Right- Posterior Pressure over thyroid cartilage Better vocal cord visualisation A grade 3 larynx become grade 2 with ELM It is not Cricoid pressure
Blind insertion devices
LMA Combitube Kingrsquos airway
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
Airway - mouth and neck infections tumors foreign bodies bleeds
stridor phonation swallowing secretions dyspnea
Breathing - failure of oxygenation or ventilation
often amenable to medical and non-invasive therapies ndash think NIV
Circulation supporting tissue oxygen delivery by unloading the muscles of respiration
sepsis
A-B-C-D-E-F
A-B-C-D-E-F
Disability CNS catastrophes and CNS depression ongoing seizures weakness
Avoid gag ndash assess ability to swallow and handle secretions (pooling drooling gurgling) for neuromuscular weakness FVC lt 12 mlkg and NIF
lt 20 cm H20
vomiting in the obtunded patient is a particular concern
Expected course anticipated decline transfer to radiology or another institution
Feral -need for prompt aggressive sedation to protect patientothers
especially with potential or undiagnosed medical instability
Arterial blood gases (ABGs) generally are not required to determine the patientrsquos need for intubation
Anticipated clinical deteriorationbull Certain overdoses bull Significant multiple trauma with or without head injury bull Multiple trauma with hypotension an open femur fracture and
diffuse abdominal tenderness bull Aggressive resuscitation pain control invasive procedures and
imaging outside of the emergency department inevitable operative management
bull Evidence of vascular or direct airway injury in the neck
Obstructed airway
Tongue and Epiglottis Any Foreign materials
Clear it
Noisy breathing
Tongue obstructing Airway
Head tilt ampChin lift
Jaw thrust
Trauma
Airway
Not ndash Maintainable
Adjuncts
Choice ndashOPA
bull Airway Reflexes hellipNo
O P A
Sizing - oropharyngeal airway
Oropharyngeal airway Insertion
Best method
OPA Insertion
N P A
bull OPA is not tolerating bull Airway reflexes retained bull Inability to open mouth
N P A
Airway
Still not ndash Maintainable
Advanced Airway
No Breathing
E ndash C Clamp
Place and hold mask properly
Two hand technique
Non-maintainable Airway
R S I
Conscious patient Semiconscious with retained reflexes
RSI Defined
ldquoVirtually simultaneous administration of a potent sedative agent and a neuromuscular blocking agent to induce unconsciousness and motor paralysis for tracheal intubationrdquo
What are The Problems Inherent to Intubation
bull Laryngoscopy and Intubation ndash Increased bronchospasm ndash Increased ICP ndash Increased catecholamine release
Beneficial Effects of RSI
bull ldquoTight Headsrdquo ndash Intracranial pathology
bull ldquoTight Heartsrdquo or ldquoTight Vesselsrdquo ndash Cardiovascular disease
bull ldquoTight Lungsrdquo ndash Reactive airway disease
Conventional With LMA
Pre Oxygenationhellip
RSI TimelineT ndash 10 minutes Prepare T ndash 5 minutes Preoxygenate T ndash 3 minutes Pretreat T = 0 Paralysis with
induction T + 30 seconds Protection T + 45 seconds Placement T + 90 seconds Post-Intubation
management
Problem Airway
epiglottis Vocal cords
Airway Evaluation
Double set up bull Neuromuscular paralysis generally
should be avoided in patients for whom a high degree of intubation difficulty is predicted unless the administration of the neuromuscular blocking agent (NMBA) is part of a planned approach to the difficult airway
Look Externally bull Severely bruised
bull Bloodied face of a combative trauma patient bull Immobilised in a cervical collar on a spine board bull Anatomical deformities
bull Subjective clinical judgment can be highly specific (90) but insensitive and so should be augmented by other evaluations
Obstruction or obesitybull Visualization of the glottis or intubation
itself mechanically impossible bull Epiglottis head and neck cancer Ludwigrsquos
angina neck hematoma or glottic polyps bull Examine the patient for airway obstruction
and assess the patientrsquos voice to satisfy this evaluation step
Neck mobility
bull Neck mobility is desirable for any intubation technique and is essential for positioning the patient for optimal direct laryngoscopy Neck mobility is assessed with the patientrsquos flexion and extension of the head and neck through a full range of motion
Lemon in ER setting
bull Unresponsive patient - Mallampatti is not practical - LEON
bull Unresponsive plus Trauma - Mallampatti and Neck mobility are not practical - LEO
Cormack and Lehane[CL]
bull The most widely used system for grading laryngoscopic view of the glottis is that of Cormack and Lehane (CL)
bull Grades laryngoscopy according to the extent to which laryngeal and glottic structures can be seen
CL grading bull Grade 1 laryngoscopy all or nearly all of the glottic aperture is seen bull Grade 2 laryngoscopy visualizes only a portion of the glottis
(arytenoid cartilages alone or arytenoid cartilages plus part of the vocal cords)
bull Grade 3 laryngoscopy visualizes only the epiglottis bull Grade 4 laryngoscopy not even the epiglottis is visible
Percentage Of Glottic Opening (POGO) score
Confirmation of Endotracheal Tube Placement
bull Direct visualisation bull Chest auscultation bull Gastric auscultation bull Bag resistance bull Exhaled volume bull Visualization of condensation within the ETT bull Chest radiography bull All are prone to failure as means of confirming tracheal intubation
ETCO2bull End-tidal carbon dioxide (ETCO2) detection
device to the ETT and assess it through six manual ventilations
bull Disposable colorimetric ETCO2 detectors are highly reliable convenient and easy to interpret indicating adequate CO2 detection by color change
End tidal CO2 detection
USG- EDDbull When ETCO2 detection
is not possible tracheal tube position can be confirmed with other techniques
bull One novel approach Bedside ultrasound
USG guided Intubation and placement confirmation
Esophageal Detector Devices (EDD)
EDD - how to work
Recognize Adequacy of Ventilations
Pulse oximeter
Approximate Blood oxygen level
SpO2 100 = PaO2 100mm of Hg SpO2 90= PaO2 60mm of Hg SpO2 60= PaO2 30mm of Hg SpO2 50= PaO2 27mm of Hg
Chest X raybull Although chest
radiography is universally recommended after ETT placement its primary purpose is to ensure that the tube is well positioned below the cords and above the carina
Other methods Gold standard
bull Fiberoptic confirmation
Difficult Airway Assessment
bull 4 Drsquos ndash Distortion Disproportion Dysmobility Dentition
bull BONES ndash Beard Obese No teeth Elderly Snores (sleep apnea)
bull SHORT ndash Surgery (headneckjaw) Hematoma Obese Radiation Tumor
bull LEMON bull MALLAMPATI bull Always have a ldquoRescue Airwayrdquo technique ready
McI
ntyr
e T
he d
iffic
ult t
rach
eal i
ntub
atio
n
Rescue Airways
bull Gum Elastic Bougie (GEB) bull Laryngeal Mask Airway (LMAILMA) bull Combitube bull Surgical Cricothyrotomy
Gum elastic bougie
Gum elastic bouge bull Useful only when
larynges is visualise at least partially
bull Difficulty intubation bull Tube changing bull Provision to
supplement oxygen
Advanced airway ndashBest choice Intubation
Equipments Needed
Laryngoscope with different types of blade
ET tube with proper size and type Average adult male 85 mm Average adult female 75 mm Low pressure cuff tubes above 5 years Uncuffed tubes below 5 years
lt 4 Age + 35
3
gt 4 Age + 45
4
Laryngoscope
Macoy Laryngoscope
Align the airway axis by proper positions
Intubation Axis
ET Tube insertion
Reverse Ramp Position
Cricoid pressure
Pressure on Cricoid cartilage Compress oesophagus between Cricoid ring and Vertebral column Prevent Regurgitation and Aspiration Make cord visualisation difficult Not recommended in Crash airway
External Laryngeal manipulation
BURP - Backward - Upward - Right- Posterior Pressure over thyroid cartilage Better vocal cord visualisation A grade 3 larynx become grade 2 with ELM It is not Cricoid pressure
Blind insertion devices
LMA Combitube Kingrsquos airway
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
A-B-C-D-E-F
Disability CNS catastrophes and CNS depression ongoing seizures weakness
Avoid gag ndash assess ability to swallow and handle secretions (pooling drooling gurgling) for neuromuscular weakness FVC lt 12 mlkg and NIF
lt 20 cm H20
vomiting in the obtunded patient is a particular concern
Expected course anticipated decline transfer to radiology or another institution
Feral -need for prompt aggressive sedation to protect patientothers
especially with potential or undiagnosed medical instability
Arterial blood gases (ABGs) generally are not required to determine the patientrsquos need for intubation
Anticipated clinical deteriorationbull Certain overdoses bull Significant multiple trauma with or without head injury bull Multiple trauma with hypotension an open femur fracture and
diffuse abdominal tenderness bull Aggressive resuscitation pain control invasive procedures and
imaging outside of the emergency department inevitable operative management
bull Evidence of vascular or direct airway injury in the neck
Obstructed airway
Tongue and Epiglottis Any Foreign materials
Clear it
Noisy breathing
Tongue obstructing Airway
Head tilt ampChin lift
Jaw thrust
Trauma
Airway
Not ndash Maintainable
Adjuncts
Choice ndashOPA
bull Airway Reflexes hellipNo
O P A
Sizing - oropharyngeal airway
Oropharyngeal airway Insertion
Best method
OPA Insertion
N P A
bull OPA is not tolerating bull Airway reflexes retained bull Inability to open mouth
N P A
Airway
Still not ndash Maintainable
Advanced Airway
No Breathing
E ndash C Clamp
Place and hold mask properly
Two hand technique
Non-maintainable Airway
R S I
Conscious patient Semiconscious with retained reflexes
RSI Defined
ldquoVirtually simultaneous administration of a potent sedative agent and a neuromuscular blocking agent to induce unconsciousness and motor paralysis for tracheal intubationrdquo
What are The Problems Inherent to Intubation
bull Laryngoscopy and Intubation ndash Increased bronchospasm ndash Increased ICP ndash Increased catecholamine release
Beneficial Effects of RSI
bull ldquoTight Headsrdquo ndash Intracranial pathology
bull ldquoTight Heartsrdquo or ldquoTight Vesselsrdquo ndash Cardiovascular disease
bull ldquoTight Lungsrdquo ndash Reactive airway disease
Conventional With LMA
Pre Oxygenationhellip
RSI TimelineT ndash 10 minutes Prepare T ndash 5 minutes Preoxygenate T ndash 3 minutes Pretreat T = 0 Paralysis with
induction T + 30 seconds Protection T + 45 seconds Placement T + 90 seconds Post-Intubation
management
Problem Airway
epiglottis Vocal cords
Airway Evaluation
Double set up bull Neuromuscular paralysis generally
should be avoided in patients for whom a high degree of intubation difficulty is predicted unless the administration of the neuromuscular blocking agent (NMBA) is part of a planned approach to the difficult airway
Look Externally bull Severely bruised
bull Bloodied face of a combative trauma patient bull Immobilised in a cervical collar on a spine board bull Anatomical deformities
bull Subjective clinical judgment can be highly specific (90) but insensitive and so should be augmented by other evaluations
Obstruction or obesitybull Visualization of the glottis or intubation
itself mechanically impossible bull Epiglottis head and neck cancer Ludwigrsquos
angina neck hematoma or glottic polyps bull Examine the patient for airway obstruction
and assess the patientrsquos voice to satisfy this evaluation step
Neck mobility
bull Neck mobility is desirable for any intubation technique and is essential for positioning the patient for optimal direct laryngoscopy Neck mobility is assessed with the patientrsquos flexion and extension of the head and neck through a full range of motion
Lemon in ER setting
bull Unresponsive patient - Mallampatti is not practical - LEON
bull Unresponsive plus Trauma - Mallampatti and Neck mobility are not practical - LEO
Cormack and Lehane[CL]
bull The most widely used system for grading laryngoscopic view of the glottis is that of Cormack and Lehane (CL)
bull Grades laryngoscopy according to the extent to which laryngeal and glottic structures can be seen
CL grading bull Grade 1 laryngoscopy all or nearly all of the glottic aperture is seen bull Grade 2 laryngoscopy visualizes only a portion of the glottis
(arytenoid cartilages alone or arytenoid cartilages plus part of the vocal cords)
bull Grade 3 laryngoscopy visualizes only the epiglottis bull Grade 4 laryngoscopy not even the epiglottis is visible
Percentage Of Glottic Opening (POGO) score
Confirmation of Endotracheal Tube Placement
bull Direct visualisation bull Chest auscultation bull Gastric auscultation bull Bag resistance bull Exhaled volume bull Visualization of condensation within the ETT bull Chest radiography bull All are prone to failure as means of confirming tracheal intubation
ETCO2bull End-tidal carbon dioxide (ETCO2) detection
device to the ETT and assess it through six manual ventilations
bull Disposable colorimetric ETCO2 detectors are highly reliable convenient and easy to interpret indicating adequate CO2 detection by color change
End tidal CO2 detection
USG- EDDbull When ETCO2 detection
is not possible tracheal tube position can be confirmed with other techniques
bull One novel approach Bedside ultrasound
USG guided Intubation and placement confirmation
Esophageal Detector Devices (EDD)
EDD - how to work
Recognize Adequacy of Ventilations
Pulse oximeter
Approximate Blood oxygen level
SpO2 100 = PaO2 100mm of Hg SpO2 90= PaO2 60mm of Hg SpO2 60= PaO2 30mm of Hg SpO2 50= PaO2 27mm of Hg
Chest X raybull Although chest
radiography is universally recommended after ETT placement its primary purpose is to ensure that the tube is well positioned below the cords and above the carina
Other methods Gold standard
bull Fiberoptic confirmation
Difficult Airway Assessment
bull 4 Drsquos ndash Distortion Disproportion Dysmobility Dentition
bull BONES ndash Beard Obese No teeth Elderly Snores (sleep apnea)
bull SHORT ndash Surgery (headneckjaw) Hematoma Obese Radiation Tumor
bull LEMON bull MALLAMPATI bull Always have a ldquoRescue Airwayrdquo technique ready
McI
ntyr
e T
he d
iffic
ult t
rach
eal i
ntub
atio
n
Rescue Airways
bull Gum Elastic Bougie (GEB) bull Laryngeal Mask Airway (LMAILMA) bull Combitube bull Surgical Cricothyrotomy
Gum elastic bougie
Gum elastic bouge bull Useful only when
larynges is visualise at least partially
bull Difficulty intubation bull Tube changing bull Provision to
supplement oxygen
Advanced airway ndashBest choice Intubation
Equipments Needed
Laryngoscope with different types of blade
ET tube with proper size and type Average adult male 85 mm Average adult female 75 mm Low pressure cuff tubes above 5 years Uncuffed tubes below 5 years
lt 4 Age + 35
3
gt 4 Age + 45
4
Laryngoscope
Macoy Laryngoscope
Align the airway axis by proper positions
Intubation Axis
ET Tube insertion
Reverse Ramp Position
Cricoid pressure
Pressure on Cricoid cartilage Compress oesophagus between Cricoid ring and Vertebral column Prevent Regurgitation and Aspiration Make cord visualisation difficult Not recommended in Crash airway
External Laryngeal manipulation
BURP - Backward - Upward - Right- Posterior Pressure over thyroid cartilage Better vocal cord visualisation A grade 3 larynx become grade 2 with ELM It is not Cricoid pressure
Blind insertion devices
LMA Combitube Kingrsquos airway
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
Arterial blood gases (ABGs) generally are not required to determine the patientrsquos need for intubation
Anticipated clinical deteriorationbull Certain overdoses bull Significant multiple trauma with or without head injury bull Multiple trauma with hypotension an open femur fracture and
diffuse abdominal tenderness bull Aggressive resuscitation pain control invasive procedures and
imaging outside of the emergency department inevitable operative management
bull Evidence of vascular or direct airway injury in the neck
Obstructed airway
Tongue and Epiglottis Any Foreign materials
Clear it
Noisy breathing
Tongue obstructing Airway
Head tilt ampChin lift
Jaw thrust
Trauma
Airway
Not ndash Maintainable
Adjuncts
Choice ndashOPA
bull Airway Reflexes hellipNo
O P A
Sizing - oropharyngeal airway
Oropharyngeal airway Insertion
Best method
OPA Insertion
N P A
bull OPA is not tolerating bull Airway reflexes retained bull Inability to open mouth
N P A
Airway
Still not ndash Maintainable
Advanced Airway
No Breathing
E ndash C Clamp
Place and hold mask properly
Two hand technique
Non-maintainable Airway
R S I
Conscious patient Semiconscious with retained reflexes
RSI Defined
ldquoVirtually simultaneous administration of a potent sedative agent and a neuromuscular blocking agent to induce unconsciousness and motor paralysis for tracheal intubationrdquo
What are The Problems Inherent to Intubation
bull Laryngoscopy and Intubation ndash Increased bronchospasm ndash Increased ICP ndash Increased catecholamine release
Beneficial Effects of RSI
bull ldquoTight Headsrdquo ndash Intracranial pathology
bull ldquoTight Heartsrdquo or ldquoTight Vesselsrdquo ndash Cardiovascular disease
bull ldquoTight Lungsrdquo ndash Reactive airway disease
Conventional With LMA
Pre Oxygenationhellip
RSI TimelineT ndash 10 minutes Prepare T ndash 5 minutes Preoxygenate T ndash 3 minutes Pretreat T = 0 Paralysis with
induction T + 30 seconds Protection T + 45 seconds Placement T + 90 seconds Post-Intubation
management
Problem Airway
epiglottis Vocal cords
Airway Evaluation
Double set up bull Neuromuscular paralysis generally
should be avoided in patients for whom a high degree of intubation difficulty is predicted unless the administration of the neuromuscular blocking agent (NMBA) is part of a planned approach to the difficult airway
Look Externally bull Severely bruised
bull Bloodied face of a combative trauma patient bull Immobilised in a cervical collar on a spine board bull Anatomical deformities
bull Subjective clinical judgment can be highly specific (90) but insensitive and so should be augmented by other evaluations
Obstruction or obesitybull Visualization of the glottis or intubation
itself mechanically impossible bull Epiglottis head and neck cancer Ludwigrsquos
angina neck hematoma or glottic polyps bull Examine the patient for airway obstruction
and assess the patientrsquos voice to satisfy this evaluation step
Neck mobility
bull Neck mobility is desirable for any intubation technique and is essential for positioning the patient for optimal direct laryngoscopy Neck mobility is assessed with the patientrsquos flexion and extension of the head and neck through a full range of motion
Lemon in ER setting
bull Unresponsive patient - Mallampatti is not practical - LEON
bull Unresponsive plus Trauma - Mallampatti and Neck mobility are not practical - LEO
Cormack and Lehane[CL]
bull The most widely used system for grading laryngoscopic view of the glottis is that of Cormack and Lehane (CL)
bull Grades laryngoscopy according to the extent to which laryngeal and glottic structures can be seen
CL grading bull Grade 1 laryngoscopy all or nearly all of the glottic aperture is seen bull Grade 2 laryngoscopy visualizes only a portion of the glottis
(arytenoid cartilages alone or arytenoid cartilages plus part of the vocal cords)
bull Grade 3 laryngoscopy visualizes only the epiglottis bull Grade 4 laryngoscopy not even the epiglottis is visible
Percentage Of Glottic Opening (POGO) score
Confirmation of Endotracheal Tube Placement
bull Direct visualisation bull Chest auscultation bull Gastric auscultation bull Bag resistance bull Exhaled volume bull Visualization of condensation within the ETT bull Chest radiography bull All are prone to failure as means of confirming tracheal intubation
ETCO2bull End-tidal carbon dioxide (ETCO2) detection
device to the ETT and assess it through six manual ventilations
bull Disposable colorimetric ETCO2 detectors are highly reliable convenient and easy to interpret indicating adequate CO2 detection by color change
End tidal CO2 detection
USG- EDDbull When ETCO2 detection
is not possible tracheal tube position can be confirmed with other techniques
bull One novel approach Bedside ultrasound
USG guided Intubation and placement confirmation
Esophageal Detector Devices (EDD)
EDD - how to work
Recognize Adequacy of Ventilations
Pulse oximeter
Approximate Blood oxygen level
SpO2 100 = PaO2 100mm of Hg SpO2 90= PaO2 60mm of Hg SpO2 60= PaO2 30mm of Hg SpO2 50= PaO2 27mm of Hg
Chest X raybull Although chest
radiography is universally recommended after ETT placement its primary purpose is to ensure that the tube is well positioned below the cords and above the carina
Other methods Gold standard
bull Fiberoptic confirmation
Difficult Airway Assessment
bull 4 Drsquos ndash Distortion Disproportion Dysmobility Dentition
bull BONES ndash Beard Obese No teeth Elderly Snores (sleep apnea)
bull SHORT ndash Surgery (headneckjaw) Hematoma Obese Radiation Tumor
bull LEMON bull MALLAMPATI bull Always have a ldquoRescue Airwayrdquo technique ready
McI
ntyr
e T
he d
iffic
ult t
rach
eal i
ntub
atio
n
Rescue Airways
bull Gum Elastic Bougie (GEB) bull Laryngeal Mask Airway (LMAILMA) bull Combitube bull Surgical Cricothyrotomy
Gum elastic bougie
Gum elastic bouge bull Useful only when
larynges is visualise at least partially
bull Difficulty intubation bull Tube changing bull Provision to
supplement oxygen
Advanced airway ndashBest choice Intubation
Equipments Needed
Laryngoscope with different types of blade
ET tube with proper size and type Average adult male 85 mm Average adult female 75 mm Low pressure cuff tubes above 5 years Uncuffed tubes below 5 years
lt 4 Age + 35
3
gt 4 Age + 45
4
Laryngoscope
Macoy Laryngoscope
Align the airway axis by proper positions
Intubation Axis
ET Tube insertion
Reverse Ramp Position
Cricoid pressure
Pressure on Cricoid cartilage Compress oesophagus between Cricoid ring and Vertebral column Prevent Regurgitation and Aspiration Make cord visualisation difficult Not recommended in Crash airway
External Laryngeal manipulation
BURP - Backward - Upward - Right- Posterior Pressure over thyroid cartilage Better vocal cord visualisation A grade 3 larynx become grade 2 with ELM It is not Cricoid pressure
Blind insertion devices
LMA Combitube Kingrsquos airway
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
Anticipated clinical deteriorationbull Certain overdoses bull Significant multiple trauma with or without head injury bull Multiple trauma with hypotension an open femur fracture and
diffuse abdominal tenderness bull Aggressive resuscitation pain control invasive procedures and
imaging outside of the emergency department inevitable operative management
bull Evidence of vascular or direct airway injury in the neck
Obstructed airway
Tongue and Epiglottis Any Foreign materials
Clear it
Noisy breathing
Tongue obstructing Airway
Head tilt ampChin lift
Jaw thrust
Trauma
Airway
Not ndash Maintainable
Adjuncts
Choice ndashOPA
bull Airway Reflexes hellipNo
O P A
Sizing - oropharyngeal airway
Oropharyngeal airway Insertion
Best method
OPA Insertion
N P A
bull OPA is not tolerating bull Airway reflexes retained bull Inability to open mouth
N P A
Airway
Still not ndash Maintainable
Advanced Airway
No Breathing
E ndash C Clamp
Place and hold mask properly
Two hand technique
Non-maintainable Airway
R S I
Conscious patient Semiconscious with retained reflexes
RSI Defined
ldquoVirtually simultaneous administration of a potent sedative agent and a neuromuscular blocking agent to induce unconsciousness and motor paralysis for tracheal intubationrdquo
What are The Problems Inherent to Intubation
bull Laryngoscopy and Intubation ndash Increased bronchospasm ndash Increased ICP ndash Increased catecholamine release
Beneficial Effects of RSI
bull ldquoTight Headsrdquo ndash Intracranial pathology
bull ldquoTight Heartsrdquo or ldquoTight Vesselsrdquo ndash Cardiovascular disease
bull ldquoTight Lungsrdquo ndash Reactive airway disease
Conventional With LMA
Pre Oxygenationhellip
RSI TimelineT ndash 10 minutes Prepare T ndash 5 minutes Preoxygenate T ndash 3 minutes Pretreat T = 0 Paralysis with
induction T + 30 seconds Protection T + 45 seconds Placement T + 90 seconds Post-Intubation
management
Problem Airway
epiglottis Vocal cords
Airway Evaluation
Double set up bull Neuromuscular paralysis generally
should be avoided in patients for whom a high degree of intubation difficulty is predicted unless the administration of the neuromuscular blocking agent (NMBA) is part of a planned approach to the difficult airway
Look Externally bull Severely bruised
bull Bloodied face of a combative trauma patient bull Immobilised in a cervical collar on a spine board bull Anatomical deformities
bull Subjective clinical judgment can be highly specific (90) but insensitive and so should be augmented by other evaluations
Obstruction or obesitybull Visualization of the glottis or intubation
itself mechanically impossible bull Epiglottis head and neck cancer Ludwigrsquos
angina neck hematoma or glottic polyps bull Examine the patient for airway obstruction
and assess the patientrsquos voice to satisfy this evaluation step
Neck mobility
bull Neck mobility is desirable for any intubation technique and is essential for positioning the patient for optimal direct laryngoscopy Neck mobility is assessed with the patientrsquos flexion and extension of the head and neck through a full range of motion
Lemon in ER setting
bull Unresponsive patient - Mallampatti is not practical - LEON
bull Unresponsive plus Trauma - Mallampatti and Neck mobility are not practical - LEO
Cormack and Lehane[CL]
bull The most widely used system for grading laryngoscopic view of the glottis is that of Cormack and Lehane (CL)
bull Grades laryngoscopy according to the extent to which laryngeal and glottic structures can be seen
CL grading bull Grade 1 laryngoscopy all or nearly all of the glottic aperture is seen bull Grade 2 laryngoscopy visualizes only a portion of the glottis
(arytenoid cartilages alone or arytenoid cartilages plus part of the vocal cords)
bull Grade 3 laryngoscopy visualizes only the epiglottis bull Grade 4 laryngoscopy not even the epiglottis is visible
Percentage Of Glottic Opening (POGO) score
Confirmation of Endotracheal Tube Placement
bull Direct visualisation bull Chest auscultation bull Gastric auscultation bull Bag resistance bull Exhaled volume bull Visualization of condensation within the ETT bull Chest radiography bull All are prone to failure as means of confirming tracheal intubation
ETCO2bull End-tidal carbon dioxide (ETCO2) detection
device to the ETT and assess it through six manual ventilations
bull Disposable colorimetric ETCO2 detectors are highly reliable convenient and easy to interpret indicating adequate CO2 detection by color change
End tidal CO2 detection
USG- EDDbull When ETCO2 detection
is not possible tracheal tube position can be confirmed with other techniques
bull One novel approach Bedside ultrasound
USG guided Intubation and placement confirmation
Esophageal Detector Devices (EDD)
EDD - how to work
Recognize Adequacy of Ventilations
Pulse oximeter
Approximate Blood oxygen level
SpO2 100 = PaO2 100mm of Hg SpO2 90= PaO2 60mm of Hg SpO2 60= PaO2 30mm of Hg SpO2 50= PaO2 27mm of Hg
Chest X raybull Although chest
radiography is universally recommended after ETT placement its primary purpose is to ensure that the tube is well positioned below the cords and above the carina
Other methods Gold standard
bull Fiberoptic confirmation
Difficult Airway Assessment
bull 4 Drsquos ndash Distortion Disproportion Dysmobility Dentition
bull BONES ndash Beard Obese No teeth Elderly Snores (sleep apnea)
bull SHORT ndash Surgery (headneckjaw) Hematoma Obese Radiation Tumor
bull LEMON bull MALLAMPATI bull Always have a ldquoRescue Airwayrdquo technique ready
McI
ntyr
e T
he d
iffic
ult t
rach
eal i
ntub
atio
n
Rescue Airways
bull Gum Elastic Bougie (GEB) bull Laryngeal Mask Airway (LMAILMA) bull Combitube bull Surgical Cricothyrotomy
Gum elastic bougie
Gum elastic bouge bull Useful only when
larynges is visualise at least partially
bull Difficulty intubation bull Tube changing bull Provision to
supplement oxygen
Advanced airway ndashBest choice Intubation
Equipments Needed
Laryngoscope with different types of blade
ET tube with proper size and type Average adult male 85 mm Average adult female 75 mm Low pressure cuff tubes above 5 years Uncuffed tubes below 5 years
lt 4 Age + 35
3
gt 4 Age + 45
4
Laryngoscope
Macoy Laryngoscope
Align the airway axis by proper positions
Intubation Axis
ET Tube insertion
Reverse Ramp Position
Cricoid pressure
Pressure on Cricoid cartilage Compress oesophagus between Cricoid ring and Vertebral column Prevent Regurgitation and Aspiration Make cord visualisation difficult Not recommended in Crash airway
External Laryngeal manipulation
BURP - Backward - Upward - Right- Posterior Pressure over thyroid cartilage Better vocal cord visualisation A grade 3 larynx become grade 2 with ELM It is not Cricoid pressure
Blind insertion devices
LMA Combitube Kingrsquos airway
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
Obstructed airway
Tongue and Epiglottis Any Foreign materials
Clear it
Noisy breathing
Tongue obstructing Airway
Head tilt ampChin lift
Jaw thrust
Trauma
Airway
Not ndash Maintainable
Adjuncts
Choice ndashOPA
bull Airway Reflexes hellipNo
O P A
Sizing - oropharyngeal airway
Oropharyngeal airway Insertion
Best method
OPA Insertion
N P A
bull OPA is not tolerating bull Airway reflexes retained bull Inability to open mouth
N P A
Airway
Still not ndash Maintainable
Advanced Airway
No Breathing
E ndash C Clamp
Place and hold mask properly
Two hand technique
Non-maintainable Airway
R S I
Conscious patient Semiconscious with retained reflexes
RSI Defined
ldquoVirtually simultaneous administration of a potent sedative agent and a neuromuscular blocking agent to induce unconsciousness and motor paralysis for tracheal intubationrdquo
What are The Problems Inherent to Intubation
bull Laryngoscopy and Intubation ndash Increased bronchospasm ndash Increased ICP ndash Increased catecholamine release
Beneficial Effects of RSI
bull ldquoTight Headsrdquo ndash Intracranial pathology
bull ldquoTight Heartsrdquo or ldquoTight Vesselsrdquo ndash Cardiovascular disease
bull ldquoTight Lungsrdquo ndash Reactive airway disease
Conventional With LMA
Pre Oxygenationhellip
RSI TimelineT ndash 10 minutes Prepare T ndash 5 minutes Preoxygenate T ndash 3 minutes Pretreat T = 0 Paralysis with
induction T + 30 seconds Protection T + 45 seconds Placement T + 90 seconds Post-Intubation
management
Problem Airway
epiglottis Vocal cords
Airway Evaluation
Double set up bull Neuromuscular paralysis generally
should be avoided in patients for whom a high degree of intubation difficulty is predicted unless the administration of the neuromuscular blocking agent (NMBA) is part of a planned approach to the difficult airway
Look Externally bull Severely bruised
bull Bloodied face of a combative trauma patient bull Immobilised in a cervical collar on a spine board bull Anatomical deformities
bull Subjective clinical judgment can be highly specific (90) but insensitive and so should be augmented by other evaluations
Obstruction or obesitybull Visualization of the glottis or intubation
itself mechanically impossible bull Epiglottis head and neck cancer Ludwigrsquos
angina neck hematoma or glottic polyps bull Examine the patient for airway obstruction
and assess the patientrsquos voice to satisfy this evaluation step
Neck mobility
bull Neck mobility is desirable for any intubation technique and is essential for positioning the patient for optimal direct laryngoscopy Neck mobility is assessed with the patientrsquos flexion and extension of the head and neck through a full range of motion
Lemon in ER setting
bull Unresponsive patient - Mallampatti is not practical - LEON
bull Unresponsive plus Trauma - Mallampatti and Neck mobility are not practical - LEO
Cormack and Lehane[CL]
bull The most widely used system for grading laryngoscopic view of the glottis is that of Cormack and Lehane (CL)
bull Grades laryngoscopy according to the extent to which laryngeal and glottic structures can be seen
CL grading bull Grade 1 laryngoscopy all or nearly all of the glottic aperture is seen bull Grade 2 laryngoscopy visualizes only a portion of the glottis
(arytenoid cartilages alone or arytenoid cartilages plus part of the vocal cords)
bull Grade 3 laryngoscopy visualizes only the epiglottis bull Grade 4 laryngoscopy not even the epiglottis is visible
Percentage Of Glottic Opening (POGO) score
Confirmation of Endotracheal Tube Placement
bull Direct visualisation bull Chest auscultation bull Gastric auscultation bull Bag resistance bull Exhaled volume bull Visualization of condensation within the ETT bull Chest radiography bull All are prone to failure as means of confirming tracheal intubation
ETCO2bull End-tidal carbon dioxide (ETCO2) detection
device to the ETT and assess it through six manual ventilations
bull Disposable colorimetric ETCO2 detectors are highly reliable convenient and easy to interpret indicating adequate CO2 detection by color change
End tidal CO2 detection
USG- EDDbull When ETCO2 detection
is not possible tracheal tube position can be confirmed with other techniques
bull One novel approach Bedside ultrasound
USG guided Intubation and placement confirmation
Esophageal Detector Devices (EDD)
EDD - how to work
Recognize Adequacy of Ventilations
Pulse oximeter
Approximate Blood oxygen level
SpO2 100 = PaO2 100mm of Hg SpO2 90= PaO2 60mm of Hg SpO2 60= PaO2 30mm of Hg SpO2 50= PaO2 27mm of Hg
Chest X raybull Although chest
radiography is universally recommended after ETT placement its primary purpose is to ensure that the tube is well positioned below the cords and above the carina
Other methods Gold standard
bull Fiberoptic confirmation
Difficult Airway Assessment
bull 4 Drsquos ndash Distortion Disproportion Dysmobility Dentition
bull BONES ndash Beard Obese No teeth Elderly Snores (sleep apnea)
bull SHORT ndash Surgery (headneckjaw) Hematoma Obese Radiation Tumor
bull LEMON bull MALLAMPATI bull Always have a ldquoRescue Airwayrdquo technique ready
McI
ntyr
e T
he d
iffic
ult t
rach
eal i
ntub
atio
n
Rescue Airways
bull Gum Elastic Bougie (GEB) bull Laryngeal Mask Airway (LMAILMA) bull Combitube bull Surgical Cricothyrotomy
Gum elastic bougie
Gum elastic bouge bull Useful only when
larynges is visualise at least partially
bull Difficulty intubation bull Tube changing bull Provision to
supplement oxygen
Advanced airway ndashBest choice Intubation
Equipments Needed
Laryngoscope with different types of blade
ET tube with proper size and type Average adult male 85 mm Average adult female 75 mm Low pressure cuff tubes above 5 years Uncuffed tubes below 5 years
lt 4 Age + 35
3
gt 4 Age + 45
4
Laryngoscope
Macoy Laryngoscope
Align the airway axis by proper positions
Intubation Axis
ET Tube insertion
Reverse Ramp Position
Cricoid pressure
Pressure on Cricoid cartilage Compress oesophagus between Cricoid ring and Vertebral column Prevent Regurgitation and Aspiration Make cord visualisation difficult Not recommended in Crash airway
External Laryngeal manipulation
BURP - Backward - Upward - Right- Posterior Pressure over thyroid cartilage Better vocal cord visualisation A grade 3 larynx become grade 2 with ELM It is not Cricoid pressure
Blind insertion devices
LMA Combitube Kingrsquos airway
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
Tongue obstructing Airway
Head tilt ampChin lift
Jaw thrust
Trauma
Airway
Not ndash Maintainable
Adjuncts
Choice ndashOPA
bull Airway Reflexes hellipNo
O P A
Sizing - oropharyngeal airway
Oropharyngeal airway Insertion
Best method
OPA Insertion
N P A
bull OPA is not tolerating bull Airway reflexes retained bull Inability to open mouth
N P A
Airway
Still not ndash Maintainable
Advanced Airway
No Breathing
E ndash C Clamp
Place and hold mask properly
Two hand technique
Non-maintainable Airway
R S I
Conscious patient Semiconscious with retained reflexes
RSI Defined
ldquoVirtually simultaneous administration of a potent sedative agent and a neuromuscular blocking agent to induce unconsciousness and motor paralysis for tracheal intubationrdquo
What are The Problems Inherent to Intubation
bull Laryngoscopy and Intubation ndash Increased bronchospasm ndash Increased ICP ndash Increased catecholamine release
Beneficial Effects of RSI
bull ldquoTight Headsrdquo ndash Intracranial pathology
bull ldquoTight Heartsrdquo or ldquoTight Vesselsrdquo ndash Cardiovascular disease
bull ldquoTight Lungsrdquo ndash Reactive airway disease
Conventional With LMA
Pre Oxygenationhellip
RSI TimelineT ndash 10 minutes Prepare T ndash 5 minutes Preoxygenate T ndash 3 minutes Pretreat T = 0 Paralysis with
induction T + 30 seconds Protection T + 45 seconds Placement T + 90 seconds Post-Intubation
management
Problem Airway
epiglottis Vocal cords
Airway Evaluation
Double set up bull Neuromuscular paralysis generally
should be avoided in patients for whom a high degree of intubation difficulty is predicted unless the administration of the neuromuscular blocking agent (NMBA) is part of a planned approach to the difficult airway
Look Externally bull Severely bruised
bull Bloodied face of a combative trauma patient bull Immobilised in a cervical collar on a spine board bull Anatomical deformities
bull Subjective clinical judgment can be highly specific (90) but insensitive and so should be augmented by other evaluations
Obstruction or obesitybull Visualization of the glottis or intubation
itself mechanically impossible bull Epiglottis head and neck cancer Ludwigrsquos
angina neck hematoma or glottic polyps bull Examine the patient for airway obstruction
and assess the patientrsquos voice to satisfy this evaluation step
Neck mobility
bull Neck mobility is desirable for any intubation technique and is essential for positioning the patient for optimal direct laryngoscopy Neck mobility is assessed with the patientrsquos flexion and extension of the head and neck through a full range of motion
Lemon in ER setting
bull Unresponsive patient - Mallampatti is not practical - LEON
bull Unresponsive plus Trauma - Mallampatti and Neck mobility are not practical - LEO
Cormack and Lehane[CL]
bull The most widely used system for grading laryngoscopic view of the glottis is that of Cormack and Lehane (CL)
bull Grades laryngoscopy according to the extent to which laryngeal and glottic structures can be seen
CL grading bull Grade 1 laryngoscopy all or nearly all of the glottic aperture is seen bull Grade 2 laryngoscopy visualizes only a portion of the glottis
(arytenoid cartilages alone or arytenoid cartilages plus part of the vocal cords)
bull Grade 3 laryngoscopy visualizes only the epiglottis bull Grade 4 laryngoscopy not even the epiglottis is visible
Percentage Of Glottic Opening (POGO) score
Confirmation of Endotracheal Tube Placement
bull Direct visualisation bull Chest auscultation bull Gastric auscultation bull Bag resistance bull Exhaled volume bull Visualization of condensation within the ETT bull Chest radiography bull All are prone to failure as means of confirming tracheal intubation
ETCO2bull End-tidal carbon dioxide (ETCO2) detection
device to the ETT and assess it through six manual ventilations
bull Disposable colorimetric ETCO2 detectors are highly reliable convenient and easy to interpret indicating adequate CO2 detection by color change
End tidal CO2 detection
USG- EDDbull When ETCO2 detection
is not possible tracheal tube position can be confirmed with other techniques
bull One novel approach Bedside ultrasound
USG guided Intubation and placement confirmation
Esophageal Detector Devices (EDD)
EDD - how to work
Recognize Adequacy of Ventilations
Pulse oximeter
Approximate Blood oxygen level
SpO2 100 = PaO2 100mm of Hg SpO2 90= PaO2 60mm of Hg SpO2 60= PaO2 30mm of Hg SpO2 50= PaO2 27mm of Hg
Chest X raybull Although chest
radiography is universally recommended after ETT placement its primary purpose is to ensure that the tube is well positioned below the cords and above the carina
Other methods Gold standard
bull Fiberoptic confirmation
Difficult Airway Assessment
bull 4 Drsquos ndash Distortion Disproportion Dysmobility Dentition
bull BONES ndash Beard Obese No teeth Elderly Snores (sleep apnea)
bull SHORT ndash Surgery (headneckjaw) Hematoma Obese Radiation Tumor
bull LEMON bull MALLAMPATI bull Always have a ldquoRescue Airwayrdquo technique ready
McI
ntyr
e T
he d
iffic
ult t
rach
eal i
ntub
atio
n
Rescue Airways
bull Gum Elastic Bougie (GEB) bull Laryngeal Mask Airway (LMAILMA) bull Combitube bull Surgical Cricothyrotomy
Gum elastic bougie
Gum elastic bouge bull Useful only when
larynges is visualise at least partially
bull Difficulty intubation bull Tube changing bull Provision to
supplement oxygen
Advanced airway ndashBest choice Intubation
Equipments Needed
Laryngoscope with different types of blade
ET tube with proper size and type Average adult male 85 mm Average adult female 75 mm Low pressure cuff tubes above 5 years Uncuffed tubes below 5 years
lt 4 Age + 35
3
gt 4 Age + 45
4
Laryngoscope
Macoy Laryngoscope
Align the airway axis by proper positions
Intubation Axis
ET Tube insertion
Reverse Ramp Position
Cricoid pressure
Pressure on Cricoid cartilage Compress oesophagus between Cricoid ring and Vertebral column Prevent Regurgitation and Aspiration Make cord visualisation difficult Not recommended in Crash airway
External Laryngeal manipulation
BURP - Backward - Upward - Right- Posterior Pressure over thyroid cartilage Better vocal cord visualisation A grade 3 larynx become grade 2 with ELM It is not Cricoid pressure
Blind insertion devices
LMA Combitube Kingrsquos airway
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
Head tilt ampChin lift
Jaw thrust
Trauma
Airway
Not ndash Maintainable
Adjuncts
Choice ndashOPA
bull Airway Reflexes hellipNo
O P A
Sizing - oropharyngeal airway
Oropharyngeal airway Insertion
Best method
OPA Insertion
N P A
bull OPA is not tolerating bull Airway reflexes retained bull Inability to open mouth
N P A
Airway
Still not ndash Maintainable
Advanced Airway
No Breathing
E ndash C Clamp
Place and hold mask properly
Two hand technique
Non-maintainable Airway
R S I
Conscious patient Semiconscious with retained reflexes
RSI Defined
ldquoVirtually simultaneous administration of a potent sedative agent and a neuromuscular blocking agent to induce unconsciousness and motor paralysis for tracheal intubationrdquo
What are The Problems Inherent to Intubation
bull Laryngoscopy and Intubation ndash Increased bronchospasm ndash Increased ICP ndash Increased catecholamine release
Beneficial Effects of RSI
bull ldquoTight Headsrdquo ndash Intracranial pathology
bull ldquoTight Heartsrdquo or ldquoTight Vesselsrdquo ndash Cardiovascular disease
bull ldquoTight Lungsrdquo ndash Reactive airway disease
Conventional With LMA
Pre Oxygenationhellip
RSI TimelineT ndash 10 minutes Prepare T ndash 5 minutes Preoxygenate T ndash 3 minutes Pretreat T = 0 Paralysis with
induction T + 30 seconds Protection T + 45 seconds Placement T + 90 seconds Post-Intubation
management
Problem Airway
epiglottis Vocal cords
Airway Evaluation
Double set up bull Neuromuscular paralysis generally
should be avoided in patients for whom a high degree of intubation difficulty is predicted unless the administration of the neuromuscular blocking agent (NMBA) is part of a planned approach to the difficult airway
Look Externally bull Severely bruised
bull Bloodied face of a combative trauma patient bull Immobilised in a cervical collar on a spine board bull Anatomical deformities
bull Subjective clinical judgment can be highly specific (90) but insensitive and so should be augmented by other evaluations
Obstruction or obesitybull Visualization of the glottis or intubation
itself mechanically impossible bull Epiglottis head and neck cancer Ludwigrsquos
angina neck hematoma or glottic polyps bull Examine the patient for airway obstruction
and assess the patientrsquos voice to satisfy this evaluation step
Neck mobility
bull Neck mobility is desirable for any intubation technique and is essential for positioning the patient for optimal direct laryngoscopy Neck mobility is assessed with the patientrsquos flexion and extension of the head and neck through a full range of motion
Lemon in ER setting
bull Unresponsive patient - Mallampatti is not practical - LEON
bull Unresponsive plus Trauma - Mallampatti and Neck mobility are not practical - LEO
Cormack and Lehane[CL]
bull The most widely used system for grading laryngoscopic view of the glottis is that of Cormack and Lehane (CL)
bull Grades laryngoscopy according to the extent to which laryngeal and glottic structures can be seen
CL grading bull Grade 1 laryngoscopy all or nearly all of the glottic aperture is seen bull Grade 2 laryngoscopy visualizes only a portion of the glottis
(arytenoid cartilages alone or arytenoid cartilages plus part of the vocal cords)
bull Grade 3 laryngoscopy visualizes only the epiglottis bull Grade 4 laryngoscopy not even the epiglottis is visible
Percentage Of Glottic Opening (POGO) score
Confirmation of Endotracheal Tube Placement
bull Direct visualisation bull Chest auscultation bull Gastric auscultation bull Bag resistance bull Exhaled volume bull Visualization of condensation within the ETT bull Chest radiography bull All are prone to failure as means of confirming tracheal intubation
ETCO2bull End-tidal carbon dioxide (ETCO2) detection
device to the ETT and assess it through six manual ventilations
bull Disposable colorimetric ETCO2 detectors are highly reliable convenient and easy to interpret indicating adequate CO2 detection by color change
End tidal CO2 detection
USG- EDDbull When ETCO2 detection
is not possible tracheal tube position can be confirmed with other techniques
bull One novel approach Bedside ultrasound
USG guided Intubation and placement confirmation
Esophageal Detector Devices (EDD)
EDD - how to work
Recognize Adequacy of Ventilations
Pulse oximeter
Approximate Blood oxygen level
SpO2 100 = PaO2 100mm of Hg SpO2 90= PaO2 60mm of Hg SpO2 60= PaO2 30mm of Hg SpO2 50= PaO2 27mm of Hg
Chest X raybull Although chest
radiography is universally recommended after ETT placement its primary purpose is to ensure that the tube is well positioned below the cords and above the carina
Other methods Gold standard
bull Fiberoptic confirmation
Difficult Airway Assessment
bull 4 Drsquos ndash Distortion Disproportion Dysmobility Dentition
bull BONES ndash Beard Obese No teeth Elderly Snores (sleep apnea)
bull SHORT ndash Surgery (headneckjaw) Hematoma Obese Radiation Tumor
bull LEMON bull MALLAMPATI bull Always have a ldquoRescue Airwayrdquo technique ready
McI
ntyr
e T
he d
iffic
ult t
rach
eal i
ntub
atio
n
Rescue Airways
bull Gum Elastic Bougie (GEB) bull Laryngeal Mask Airway (LMAILMA) bull Combitube bull Surgical Cricothyrotomy
Gum elastic bougie
Gum elastic bouge bull Useful only when
larynges is visualise at least partially
bull Difficulty intubation bull Tube changing bull Provision to
supplement oxygen
Advanced airway ndashBest choice Intubation
Equipments Needed
Laryngoscope with different types of blade
ET tube with proper size and type Average adult male 85 mm Average adult female 75 mm Low pressure cuff tubes above 5 years Uncuffed tubes below 5 years
lt 4 Age + 35
3
gt 4 Age + 45
4
Laryngoscope
Macoy Laryngoscope
Align the airway axis by proper positions
Intubation Axis
ET Tube insertion
Reverse Ramp Position
Cricoid pressure
Pressure on Cricoid cartilage Compress oesophagus between Cricoid ring and Vertebral column Prevent Regurgitation and Aspiration Make cord visualisation difficult Not recommended in Crash airway
External Laryngeal manipulation
BURP - Backward - Upward - Right- Posterior Pressure over thyroid cartilage Better vocal cord visualisation A grade 3 larynx become grade 2 with ELM It is not Cricoid pressure
Blind insertion devices
LMA Combitube Kingrsquos airway
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
Jaw thrust
Trauma
Airway
Not ndash Maintainable
Adjuncts
Choice ndashOPA
bull Airway Reflexes hellipNo
O P A
Sizing - oropharyngeal airway
Oropharyngeal airway Insertion
Best method
OPA Insertion
N P A
bull OPA is not tolerating bull Airway reflexes retained bull Inability to open mouth
N P A
Airway
Still not ndash Maintainable
Advanced Airway
No Breathing
E ndash C Clamp
Place and hold mask properly
Two hand technique
Non-maintainable Airway
R S I
Conscious patient Semiconscious with retained reflexes
RSI Defined
ldquoVirtually simultaneous administration of a potent sedative agent and a neuromuscular blocking agent to induce unconsciousness and motor paralysis for tracheal intubationrdquo
What are The Problems Inherent to Intubation
bull Laryngoscopy and Intubation ndash Increased bronchospasm ndash Increased ICP ndash Increased catecholamine release
Beneficial Effects of RSI
bull ldquoTight Headsrdquo ndash Intracranial pathology
bull ldquoTight Heartsrdquo or ldquoTight Vesselsrdquo ndash Cardiovascular disease
bull ldquoTight Lungsrdquo ndash Reactive airway disease
Conventional With LMA
Pre Oxygenationhellip
RSI TimelineT ndash 10 minutes Prepare T ndash 5 minutes Preoxygenate T ndash 3 minutes Pretreat T = 0 Paralysis with
induction T + 30 seconds Protection T + 45 seconds Placement T + 90 seconds Post-Intubation
management
Problem Airway
epiglottis Vocal cords
Airway Evaluation
Double set up bull Neuromuscular paralysis generally
should be avoided in patients for whom a high degree of intubation difficulty is predicted unless the administration of the neuromuscular blocking agent (NMBA) is part of a planned approach to the difficult airway
Look Externally bull Severely bruised
bull Bloodied face of a combative trauma patient bull Immobilised in a cervical collar on a spine board bull Anatomical deformities
bull Subjective clinical judgment can be highly specific (90) but insensitive and so should be augmented by other evaluations
Obstruction or obesitybull Visualization of the glottis or intubation
itself mechanically impossible bull Epiglottis head and neck cancer Ludwigrsquos
angina neck hematoma or glottic polyps bull Examine the patient for airway obstruction
and assess the patientrsquos voice to satisfy this evaluation step
Neck mobility
bull Neck mobility is desirable for any intubation technique and is essential for positioning the patient for optimal direct laryngoscopy Neck mobility is assessed with the patientrsquos flexion and extension of the head and neck through a full range of motion
Lemon in ER setting
bull Unresponsive patient - Mallampatti is not practical - LEON
bull Unresponsive plus Trauma - Mallampatti and Neck mobility are not practical - LEO
Cormack and Lehane[CL]
bull The most widely used system for grading laryngoscopic view of the glottis is that of Cormack and Lehane (CL)
bull Grades laryngoscopy according to the extent to which laryngeal and glottic structures can be seen
CL grading bull Grade 1 laryngoscopy all or nearly all of the glottic aperture is seen bull Grade 2 laryngoscopy visualizes only a portion of the glottis
(arytenoid cartilages alone or arytenoid cartilages plus part of the vocal cords)
bull Grade 3 laryngoscopy visualizes only the epiglottis bull Grade 4 laryngoscopy not even the epiglottis is visible
Percentage Of Glottic Opening (POGO) score
Confirmation of Endotracheal Tube Placement
bull Direct visualisation bull Chest auscultation bull Gastric auscultation bull Bag resistance bull Exhaled volume bull Visualization of condensation within the ETT bull Chest radiography bull All are prone to failure as means of confirming tracheal intubation
ETCO2bull End-tidal carbon dioxide (ETCO2) detection
device to the ETT and assess it through six manual ventilations
bull Disposable colorimetric ETCO2 detectors are highly reliable convenient and easy to interpret indicating adequate CO2 detection by color change
End tidal CO2 detection
USG- EDDbull When ETCO2 detection
is not possible tracheal tube position can be confirmed with other techniques
bull One novel approach Bedside ultrasound
USG guided Intubation and placement confirmation
Esophageal Detector Devices (EDD)
EDD - how to work
Recognize Adequacy of Ventilations
Pulse oximeter
Approximate Blood oxygen level
SpO2 100 = PaO2 100mm of Hg SpO2 90= PaO2 60mm of Hg SpO2 60= PaO2 30mm of Hg SpO2 50= PaO2 27mm of Hg
Chest X raybull Although chest
radiography is universally recommended after ETT placement its primary purpose is to ensure that the tube is well positioned below the cords and above the carina
Other methods Gold standard
bull Fiberoptic confirmation
Difficult Airway Assessment
bull 4 Drsquos ndash Distortion Disproportion Dysmobility Dentition
bull BONES ndash Beard Obese No teeth Elderly Snores (sleep apnea)
bull SHORT ndash Surgery (headneckjaw) Hematoma Obese Radiation Tumor
bull LEMON bull MALLAMPATI bull Always have a ldquoRescue Airwayrdquo technique ready
McI
ntyr
e T
he d
iffic
ult t
rach
eal i
ntub
atio
n
Rescue Airways
bull Gum Elastic Bougie (GEB) bull Laryngeal Mask Airway (LMAILMA) bull Combitube bull Surgical Cricothyrotomy
Gum elastic bougie
Gum elastic bouge bull Useful only when
larynges is visualise at least partially
bull Difficulty intubation bull Tube changing bull Provision to
supplement oxygen
Advanced airway ndashBest choice Intubation
Equipments Needed
Laryngoscope with different types of blade
ET tube with proper size and type Average adult male 85 mm Average adult female 75 mm Low pressure cuff tubes above 5 years Uncuffed tubes below 5 years
lt 4 Age + 35
3
gt 4 Age + 45
4
Laryngoscope
Macoy Laryngoscope
Align the airway axis by proper positions
Intubation Axis
ET Tube insertion
Reverse Ramp Position
Cricoid pressure
Pressure on Cricoid cartilage Compress oesophagus between Cricoid ring and Vertebral column Prevent Regurgitation and Aspiration Make cord visualisation difficult Not recommended in Crash airway
External Laryngeal manipulation
BURP - Backward - Upward - Right- Posterior Pressure over thyroid cartilage Better vocal cord visualisation A grade 3 larynx become grade 2 with ELM It is not Cricoid pressure
Blind insertion devices
LMA Combitube Kingrsquos airway
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
Trauma
Airway
Not ndash Maintainable
Adjuncts
Choice ndashOPA
bull Airway Reflexes hellipNo
O P A
Sizing - oropharyngeal airway
Oropharyngeal airway Insertion
Best method
OPA Insertion
N P A
bull OPA is not tolerating bull Airway reflexes retained bull Inability to open mouth
N P A
Airway
Still not ndash Maintainable
Advanced Airway
No Breathing
E ndash C Clamp
Place and hold mask properly
Two hand technique
Non-maintainable Airway
R S I
Conscious patient Semiconscious with retained reflexes
RSI Defined
ldquoVirtually simultaneous administration of a potent sedative agent and a neuromuscular blocking agent to induce unconsciousness and motor paralysis for tracheal intubationrdquo
What are The Problems Inherent to Intubation
bull Laryngoscopy and Intubation ndash Increased bronchospasm ndash Increased ICP ndash Increased catecholamine release
Beneficial Effects of RSI
bull ldquoTight Headsrdquo ndash Intracranial pathology
bull ldquoTight Heartsrdquo or ldquoTight Vesselsrdquo ndash Cardiovascular disease
bull ldquoTight Lungsrdquo ndash Reactive airway disease
Conventional With LMA
Pre Oxygenationhellip
RSI TimelineT ndash 10 minutes Prepare T ndash 5 minutes Preoxygenate T ndash 3 minutes Pretreat T = 0 Paralysis with
induction T + 30 seconds Protection T + 45 seconds Placement T + 90 seconds Post-Intubation
management
Problem Airway
epiglottis Vocal cords
Airway Evaluation
Double set up bull Neuromuscular paralysis generally
should be avoided in patients for whom a high degree of intubation difficulty is predicted unless the administration of the neuromuscular blocking agent (NMBA) is part of a planned approach to the difficult airway
Look Externally bull Severely bruised
bull Bloodied face of a combative trauma patient bull Immobilised in a cervical collar on a spine board bull Anatomical deformities
bull Subjective clinical judgment can be highly specific (90) but insensitive and so should be augmented by other evaluations
Obstruction or obesitybull Visualization of the glottis or intubation
itself mechanically impossible bull Epiglottis head and neck cancer Ludwigrsquos
angina neck hematoma or glottic polyps bull Examine the patient for airway obstruction
and assess the patientrsquos voice to satisfy this evaluation step
Neck mobility
bull Neck mobility is desirable for any intubation technique and is essential for positioning the patient for optimal direct laryngoscopy Neck mobility is assessed with the patientrsquos flexion and extension of the head and neck through a full range of motion
Lemon in ER setting
bull Unresponsive patient - Mallampatti is not practical - LEON
bull Unresponsive plus Trauma - Mallampatti and Neck mobility are not practical - LEO
Cormack and Lehane[CL]
bull The most widely used system for grading laryngoscopic view of the glottis is that of Cormack and Lehane (CL)
bull Grades laryngoscopy according to the extent to which laryngeal and glottic structures can be seen
CL grading bull Grade 1 laryngoscopy all or nearly all of the glottic aperture is seen bull Grade 2 laryngoscopy visualizes only a portion of the glottis
(arytenoid cartilages alone or arytenoid cartilages plus part of the vocal cords)
bull Grade 3 laryngoscopy visualizes only the epiglottis bull Grade 4 laryngoscopy not even the epiglottis is visible
Percentage Of Glottic Opening (POGO) score
Confirmation of Endotracheal Tube Placement
bull Direct visualisation bull Chest auscultation bull Gastric auscultation bull Bag resistance bull Exhaled volume bull Visualization of condensation within the ETT bull Chest radiography bull All are prone to failure as means of confirming tracheal intubation
ETCO2bull End-tidal carbon dioxide (ETCO2) detection
device to the ETT and assess it through six manual ventilations
bull Disposable colorimetric ETCO2 detectors are highly reliable convenient and easy to interpret indicating adequate CO2 detection by color change
End tidal CO2 detection
USG- EDDbull When ETCO2 detection
is not possible tracheal tube position can be confirmed with other techniques
bull One novel approach Bedside ultrasound
USG guided Intubation and placement confirmation
Esophageal Detector Devices (EDD)
EDD - how to work
Recognize Adequacy of Ventilations
Pulse oximeter
Approximate Blood oxygen level
SpO2 100 = PaO2 100mm of Hg SpO2 90= PaO2 60mm of Hg SpO2 60= PaO2 30mm of Hg SpO2 50= PaO2 27mm of Hg
Chest X raybull Although chest
radiography is universally recommended after ETT placement its primary purpose is to ensure that the tube is well positioned below the cords and above the carina
Other methods Gold standard
bull Fiberoptic confirmation
Difficult Airway Assessment
bull 4 Drsquos ndash Distortion Disproportion Dysmobility Dentition
bull BONES ndash Beard Obese No teeth Elderly Snores (sleep apnea)
bull SHORT ndash Surgery (headneckjaw) Hematoma Obese Radiation Tumor
bull LEMON bull MALLAMPATI bull Always have a ldquoRescue Airwayrdquo technique ready
McI
ntyr
e T
he d
iffic
ult t
rach
eal i
ntub
atio
n
Rescue Airways
bull Gum Elastic Bougie (GEB) bull Laryngeal Mask Airway (LMAILMA) bull Combitube bull Surgical Cricothyrotomy
Gum elastic bougie
Gum elastic bouge bull Useful only when
larynges is visualise at least partially
bull Difficulty intubation bull Tube changing bull Provision to
supplement oxygen
Advanced airway ndashBest choice Intubation
Equipments Needed
Laryngoscope with different types of blade
ET tube with proper size and type Average adult male 85 mm Average adult female 75 mm Low pressure cuff tubes above 5 years Uncuffed tubes below 5 years
lt 4 Age + 35
3
gt 4 Age + 45
4
Laryngoscope
Macoy Laryngoscope
Align the airway axis by proper positions
Intubation Axis
ET Tube insertion
Reverse Ramp Position
Cricoid pressure
Pressure on Cricoid cartilage Compress oesophagus between Cricoid ring and Vertebral column Prevent Regurgitation and Aspiration Make cord visualisation difficult Not recommended in Crash airway
External Laryngeal manipulation
BURP - Backward - Upward - Right- Posterior Pressure over thyroid cartilage Better vocal cord visualisation A grade 3 larynx become grade 2 with ELM It is not Cricoid pressure
Blind insertion devices
LMA Combitube Kingrsquos airway
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
Airway
Not ndash Maintainable
Adjuncts
Choice ndashOPA
bull Airway Reflexes hellipNo
O P A
Sizing - oropharyngeal airway
Oropharyngeal airway Insertion
Best method
OPA Insertion
N P A
bull OPA is not tolerating bull Airway reflexes retained bull Inability to open mouth
N P A
Airway
Still not ndash Maintainable
Advanced Airway
No Breathing
E ndash C Clamp
Place and hold mask properly
Two hand technique
Non-maintainable Airway
R S I
Conscious patient Semiconscious with retained reflexes
RSI Defined
ldquoVirtually simultaneous administration of a potent sedative agent and a neuromuscular blocking agent to induce unconsciousness and motor paralysis for tracheal intubationrdquo
What are The Problems Inherent to Intubation
bull Laryngoscopy and Intubation ndash Increased bronchospasm ndash Increased ICP ndash Increased catecholamine release
Beneficial Effects of RSI
bull ldquoTight Headsrdquo ndash Intracranial pathology
bull ldquoTight Heartsrdquo or ldquoTight Vesselsrdquo ndash Cardiovascular disease
bull ldquoTight Lungsrdquo ndash Reactive airway disease
Conventional With LMA
Pre Oxygenationhellip
RSI TimelineT ndash 10 minutes Prepare T ndash 5 minutes Preoxygenate T ndash 3 minutes Pretreat T = 0 Paralysis with
induction T + 30 seconds Protection T + 45 seconds Placement T + 90 seconds Post-Intubation
management
Problem Airway
epiglottis Vocal cords
Airway Evaluation
Double set up bull Neuromuscular paralysis generally
should be avoided in patients for whom a high degree of intubation difficulty is predicted unless the administration of the neuromuscular blocking agent (NMBA) is part of a planned approach to the difficult airway
Look Externally bull Severely bruised
bull Bloodied face of a combative trauma patient bull Immobilised in a cervical collar on a spine board bull Anatomical deformities
bull Subjective clinical judgment can be highly specific (90) but insensitive and so should be augmented by other evaluations
Obstruction or obesitybull Visualization of the glottis or intubation
itself mechanically impossible bull Epiglottis head and neck cancer Ludwigrsquos
angina neck hematoma or glottic polyps bull Examine the patient for airway obstruction
and assess the patientrsquos voice to satisfy this evaluation step
Neck mobility
bull Neck mobility is desirable for any intubation technique and is essential for positioning the patient for optimal direct laryngoscopy Neck mobility is assessed with the patientrsquos flexion and extension of the head and neck through a full range of motion
Lemon in ER setting
bull Unresponsive patient - Mallampatti is not practical - LEON
bull Unresponsive plus Trauma - Mallampatti and Neck mobility are not practical - LEO
Cormack and Lehane[CL]
bull The most widely used system for grading laryngoscopic view of the glottis is that of Cormack and Lehane (CL)
bull Grades laryngoscopy according to the extent to which laryngeal and glottic structures can be seen
CL grading bull Grade 1 laryngoscopy all or nearly all of the glottic aperture is seen bull Grade 2 laryngoscopy visualizes only a portion of the glottis
(arytenoid cartilages alone or arytenoid cartilages plus part of the vocal cords)
bull Grade 3 laryngoscopy visualizes only the epiglottis bull Grade 4 laryngoscopy not even the epiglottis is visible
Percentage Of Glottic Opening (POGO) score
Confirmation of Endotracheal Tube Placement
bull Direct visualisation bull Chest auscultation bull Gastric auscultation bull Bag resistance bull Exhaled volume bull Visualization of condensation within the ETT bull Chest radiography bull All are prone to failure as means of confirming tracheal intubation
ETCO2bull End-tidal carbon dioxide (ETCO2) detection
device to the ETT and assess it through six manual ventilations
bull Disposable colorimetric ETCO2 detectors are highly reliable convenient and easy to interpret indicating adequate CO2 detection by color change
End tidal CO2 detection
USG- EDDbull When ETCO2 detection
is not possible tracheal tube position can be confirmed with other techniques
bull One novel approach Bedside ultrasound
USG guided Intubation and placement confirmation
Esophageal Detector Devices (EDD)
EDD - how to work
Recognize Adequacy of Ventilations
Pulse oximeter
Approximate Blood oxygen level
SpO2 100 = PaO2 100mm of Hg SpO2 90= PaO2 60mm of Hg SpO2 60= PaO2 30mm of Hg SpO2 50= PaO2 27mm of Hg
Chest X raybull Although chest
radiography is universally recommended after ETT placement its primary purpose is to ensure that the tube is well positioned below the cords and above the carina
Other methods Gold standard
bull Fiberoptic confirmation
Difficult Airway Assessment
bull 4 Drsquos ndash Distortion Disproportion Dysmobility Dentition
bull BONES ndash Beard Obese No teeth Elderly Snores (sleep apnea)
bull SHORT ndash Surgery (headneckjaw) Hematoma Obese Radiation Tumor
bull LEMON bull MALLAMPATI bull Always have a ldquoRescue Airwayrdquo technique ready
McI
ntyr
e T
he d
iffic
ult t
rach
eal i
ntub
atio
n
Rescue Airways
bull Gum Elastic Bougie (GEB) bull Laryngeal Mask Airway (LMAILMA) bull Combitube bull Surgical Cricothyrotomy
Gum elastic bougie
Gum elastic bouge bull Useful only when
larynges is visualise at least partially
bull Difficulty intubation bull Tube changing bull Provision to
supplement oxygen
Advanced airway ndashBest choice Intubation
Equipments Needed
Laryngoscope with different types of blade
ET tube with proper size and type Average adult male 85 mm Average adult female 75 mm Low pressure cuff tubes above 5 years Uncuffed tubes below 5 years
lt 4 Age + 35
3
gt 4 Age + 45
4
Laryngoscope
Macoy Laryngoscope
Align the airway axis by proper positions
Intubation Axis
ET Tube insertion
Reverse Ramp Position
Cricoid pressure
Pressure on Cricoid cartilage Compress oesophagus between Cricoid ring and Vertebral column Prevent Regurgitation and Aspiration Make cord visualisation difficult Not recommended in Crash airway
External Laryngeal manipulation
BURP - Backward - Upward - Right- Posterior Pressure over thyroid cartilage Better vocal cord visualisation A grade 3 larynx become grade 2 with ELM It is not Cricoid pressure
Blind insertion devices
LMA Combitube Kingrsquos airway
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
Choice ndashOPA
bull Airway Reflexes hellipNo
O P A
Sizing - oropharyngeal airway
Oropharyngeal airway Insertion
Best method
OPA Insertion
N P A
bull OPA is not tolerating bull Airway reflexes retained bull Inability to open mouth
N P A
Airway
Still not ndash Maintainable
Advanced Airway
No Breathing
E ndash C Clamp
Place and hold mask properly
Two hand technique
Non-maintainable Airway
R S I
Conscious patient Semiconscious with retained reflexes
RSI Defined
ldquoVirtually simultaneous administration of a potent sedative agent and a neuromuscular blocking agent to induce unconsciousness and motor paralysis for tracheal intubationrdquo
What are The Problems Inherent to Intubation
bull Laryngoscopy and Intubation ndash Increased bronchospasm ndash Increased ICP ndash Increased catecholamine release
Beneficial Effects of RSI
bull ldquoTight Headsrdquo ndash Intracranial pathology
bull ldquoTight Heartsrdquo or ldquoTight Vesselsrdquo ndash Cardiovascular disease
bull ldquoTight Lungsrdquo ndash Reactive airway disease
Conventional With LMA
Pre Oxygenationhellip
RSI TimelineT ndash 10 minutes Prepare T ndash 5 minutes Preoxygenate T ndash 3 minutes Pretreat T = 0 Paralysis with
induction T + 30 seconds Protection T + 45 seconds Placement T + 90 seconds Post-Intubation
management
Problem Airway
epiglottis Vocal cords
Airway Evaluation
Double set up bull Neuromuscular paralysis generally
should be avoided in patients for whom a high degree of intubation difficulty is predicted unless the administration of the neuromuscular blocking agent (NMBA) is part of a planned approach to the difficult airway
Look Externally bull Severely bruised
bull Bloodied face of a combative trauma patient bull Immobilised in a cervical collar on a spine board bull Anatomical deformities
bull Subjective clinical judgment can be highly specific (90) but insensitive and so should be augmented by other evaluations
Obstruction or obesitybull Visualization of the glottis or intubation
itself mechanically impossible bull Epiglottis head and neck cancer Ludwigrsquos
angina neck hematoma or glottic polyps bull Examine the patient for airway obstruction
and assess the patientrsquos voice to satisfy this evaluation step
Neck mobility
bull Neck mobility is desirable for any intubation technique and is essential for positioning the patient for optimal direct laryngoscopy Neck mobility is assessed with the patientrsquos flexion and extension of the head and neck through a full range of motion
Lemon in ER setting
bull Unresponsive patient - Mallampatti is not practical - LEON
bull Unresponsive plus Trauma - Mallampatti and Neck mobility are not practical - LEO
Cormack and Lehane[CL]
bull The most widely used system for grading laryngoscopic view of the glottis is that of Cormack and Lehane (CL)
bull Grades laryngoscopy according to the extent to which laryngeal and glottic structures can be seen
CL grading bull Grade 1 laryngoscopy all or nearly all of the glottic aperture is seen bull Grade 2 laryngoscopy visualizes only a portion of the glottis
(arytenoid cartilages alone or arytenoid cartilages plus part of the vocal cords)
bull Grade 3 laryngoscopy visualizes only the epiglottis bull Grade 4 laryngoscopy not even the epiglottis is visible
Percentage Of Glottic Opening (POGO) score
Confirmation of Endotracheal Tube Placement
bull Direct visualisation bull Chest auscultation bull Gastric auscultation bull Bag resistance bull Exhaled volume bull Visualization of condensation within the ETT bull Chest radiography bull All are prone to failure as means of confirming tracheal intubation
ETCO2bull End-tidal carbon dioxide (ETCO2) detection
device to the ETT and assess it through six manual ventilations
bull Disposable colorimetric ETCO2 detectors are highly reliable convenient and easy to interpret indicating adequate CO2 detection by color change
End tidal CO2 detection
USG- EDDbull When ETCO2 detection
is not possible tracheal tube position can be confirmed with other techniques
bull One novel approach Bedside ultrasound
USG guided Intubation and placement confirmation
Esophageal Detector Devices (EDD)
EDD - how to work
Recognize Adequacy of Ventilations
Pulse oximeter
Approximate Blood oxygen level
SpO2 100 = PaO2 100mm of Hg SpO2 90= PaO2 60mm of Hg SpO2 60= PaO2 30mm of Hg SpO2 50= PaO2 27mm of Hg
Chest X raybull Although chest
radiography is universally recommended after ETT placement its primary purpose is to ensure that the tube is well positioned below the cords and above the carina
Other methods Gold standard
bull Fiberoptic confirmation
Difficult Airway Assessment
bull 4 Drsquos ndash Distortion Disproportion Dysmobility Dentition
bull BONES ndash Beard Obese No teeth Elderly Snores (sleep apnea)
bull SHORT ndash Surgery (headneckjaw) Hematoma Obese Radiation Tumor
bull LEMON bull MALLAMPATI bull Always have a ldquoRescue Airwayrdquo technique ready
McI
ntyr
e T
he d
iffic
ult t
rach
eal i
ntub
atio
n
Rescue Airways
bull Gum Elastic Bougie (GEB) bull Laryngeal Mask Airway (LMAILMA) bull Combitube bull Surgical Cricothyrotomy
Gum elastic bougie
Gum elastic bouge bull Useful only when
larynges is visualise at least partially
bull Difficulty intubation bull Tube changing bull Provision to
supplement oxygen
Advanced airway ndashBest choice Intubation
Equipments Needed
Laryngoscope with different types of blade
ET tube with proper size and type Average adult male 85 mm Average adult female 75 mm Low pressure cuff tubes above 5 years Uncuffed tubes below 5 years
lt 4 Age + 35
3
gt 4 Age + 45
4
Laryngoscope
Macoy Laryngoscope
Align the airway axis by proper positions
Intubation Axis
ET Tube insertion
Reverse Ramp Position
Cricoid pressure
Pressure on Cricoid cartilage Compress oesophagus between Cricoid ring and Vertebral column Prevent Regurgitation and Aspiration Make cord visualisation difficult Not recommended in Crash airway
External Laryngeal manipulation
BURP - Backward - Upward - Right- Posterior Pressure over thyroid cartilage Better vocal cord visualisation A grade 3 larynx become grade 2 with ELM It is not Cricoid pressure
Blind insertion devices
LMA Combitube Kingrsquos airway
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
O P A
Sizing - oropharyngeal airway
Oropharyngeal airway Insertion
Best method
OPA Insertion
N P A
bull OPA is not tolerating bull Airway reflexes retained bull Inability to open mouth
N P A
Airway
Still not ndash Maintainable
Advanced Airway
No Breathing
E ndash C Clamp
Place and hold mask properly
Two hand technique
Non-maintainable Airway
R S I
Conscious patient Semiconscious with retained reflexes
RSI Defined
ldquoVirtually simultaneous administration of a potent sedative agent and a neuromuscular blocking agent to induce unconsciousness and motor paralysis for tracheal intubationrdquo
What are The Problems Inherent to Intubation
bull Laryngoscopy and Intubation ndash Increased bronchospasm ndash Increased ICP ndash Increased catecholamine release
Beneficial Effects of RSI
bull ldquoTight Headsrdquo ndash Intracranial pathology
bull ldquoTight Heartsrdquo or ldquoTight Vesselsrdquo ndash Cardiovascular disease
bull ldquoTight Lungsrdquo ndash Reactive airway disease
Conventional With LMA
Pre Oxygenationhellip
RSI TimelineT ndash 10 minutes Prepare T ndash 5 minutes Preoxygenate T ndash 3 minutes Pretreat T = 0 Paralysis with
induction T + 30 seconds Protection T + 45 seconds Placement T + 90 seconds Post-Intubation
management
Problem Airway
epiglottis Vocal cords
Airway Evaluation
Double set up bull Neuromuscular paralysis generally
should be avoided in patients for whom a high degree of intubation difficulty is predicted unless the administration of the neuromuscular blocking agent (NMBA) is part of a planned approach to the difficult airway
Look Externally bull Severely bruised
bull Bloodied face of a combative trauma patient bull Immobilised in a cervical collar on a spine board bull Anatomical deformities
bull Subjective clinical judgment can be highly specific (90) but insensitive and so should be augmented by other evaluations
Obstruction or obesitybull Visualization of the glottis or intubation
itself mechanically impossible bull Epiglottis head and neck cancer Ludwigrsquos
angina neck hematoma or glottic polyps bull Examine the patient for airway obstruction
and assess the patientrsquos voice to satisfy this evaluation step
Neck mobility
bull Neck mobility is desirable for any intubation technique and is essential for positioning the patient for optimal direct laryngoscopy Neck mobility is assessed with the patientrsquos flexion and extension of the head and neck through a full range of motion
Lemon in ER setting
bull Unresponsive patient - Mallampatti is not practical - LEON
bull Unresponsive plus Trauma - Mallampatti and Neck mobility are not practical - LEO
Cormack and Lehane[CL]
bull The most widely used system for grading laryngoscopic view of the glottis is that of Cormack and Lehane (CL)
bull Grades laryngoscopy according to the extent to which laryngeal and glottic structures can be seen
CL grading bull Grade 1 laryngoscopy all or nearly all of the glottic aperture is seen bull Grade 2 laryngoscopy visualizes only a portion of the glottis
(arytenoid cartilages alone or arytenoid cartilages plus part of the vocal cords)
bull Grade 3 laryngoscopy visualizes only the epiglottis bull Grade 4 laryngoscopy not even the epiglottis is visible
Percentage Of Glottic Opening (POGO) score
Confirmation of Endotracheal Tube Placement
bull Direct visualisation bull Chest auscultation bull Gastric auscultation bull Bag resistance bull Exhaled volume bull Visualization of condensation within the ETT bull Chest radiography bull All are prone to failure as means of confirming tracheal intubation
ETCO2bull End-tidal carbon dioxide (ETCO2) detection
device to the ETT and assess it through six manual ventilations
bull Disposable colorimetric ETCO2 detectors are highly reliable convenient and easy to interpret indicating adequate CO2 detection by color change
End tidal CO2 detection
USG- EDDbull When ETCO2 detection
is not possible tracheal tube position can be confirmed with other techniques
bull One novel approach Bedside ultrasound
USG guided Intubation and placement confirmation
Esophageal Detector Devices (EDD)
EDD - how to work
Recognize Adequacy of Ventilations
Pulse oximeter
Approximate Blood oxygen level
SpO2 100 = PaO2 100mm of Hg SpO2 90= PaO2 60mm of Hg SpO2 60= PaO2 30mm of Hg SpO2 50= PaO2 27mm of Hg
Chest X raybull Although chest
radiography is universally recommended after ETT placement its primary purpose is to ensure that the tube is well positioned below the cords and above the carina
Other methods Gold standard
bull Fiberoptic confirmation
Difficult Airway Assessment
bull 4 Drsquos ndash Distortion Disproportion Dysmobility Dentition
bull BONES ndash Beard Obese No teeth Elderly Snores (sleep apnea)
bull SHORT ndash Surgery (headneckjaw) Hematoma Obese Radiation Tumor
bull LEMON bull MALLAMPATI bull Always have a ldquoRescue Airwayrdquo technique ready
McI
ntyr
e T
he d
iffic
ult t
rach
eal i
ntub
atio
n
Rescue Airways
bull Gum Elastic Bougie (GEB) bull Laryngeal Mask Airway (LMAILMA) bull Combitube bull Surgical Cricothyrotomy
Gum elastic bougie
Gum elastic bouge bull Useful only when
larynges is visualise at least partially
bull Difficulty intubation bull Tube changing bull Provision to
supplement oxygen
Advanced airway ndashBest choice Intubation
Equipments Needed
Laryngoscope with different types of blade
ET tube with proper size and type Average adult male 85 mm Average adult female 75 mm Low pressure cuff tubes above 5 years Uncuffed tubes below 5 years
lt 4 Age + 35
3
gt 4 Age + 45
4
Laryngoscope
Macoy Laryngoscope
Align the airway axis by proper positions
Intubation Axis
ET Tube insertion
Reverse Ramp Position
Cricoid pressure
Pressure on Cricoid cartilage Compress oesophagus between Cricoid ring and Vertebral column Prevent Regurgitation and Aspiration Make cord visualisation difficult Not recommended in Crash airway
External Laryngeal manipulation
BURP - Backward - Upward - Right- Posterior Pressure over thyroid cartilage Better vocal cord visualisation A grade 3 larynx become grade 2 with ELM It is not Cricoid pressure
Blind insertion devices
LMA Combitube Kingrsquos airway
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
Sizing - oropharyngeal airway
Oropharyngeal airway Insertion
Best method
OPA Insertion
N P A
bull OPA is not tolerating bull Airway reflexes retained bull Inability to open mouth
N P A
Airway
Still not ndash Maintainable
Advanced Airway
No Breathing
E ndash C Clamp
Place and hold mask properly
Two hand technique
Non-maintainable Airway
R S I
Conscious patient Semiconscious with retained reflexes
RSI Defined
ldquoVirtually simultaneous administration of a potent sedative agent and a neuromuscular blocking agent to induce unconsciousness and motor paralysis for tracheal intubationrdquo
What are The Problems Inherent to Intubation
bull Laryngoscopy and Intubation ndash Increased bronchospasm ndash Increased ICP ndash Increased catecholamine release
Beneficial Effects of RSI
bull ldquoTight Headsrdquo ndash Intracranial pathology
bull ldquoTight Heartsrdquo or ldquoTight Vesselsrdquo ndash Cardiovascular disease
bull ldquoTight Lungsrdquo ndash Reactive airway disease
Conventional With LMA
Pre Oxygenationhellip
RSI TimelineT ndash 10 minutes Prepare T ndash 5 minutes Preoxygenate T ndash 3 minutes Pretreat T = 0 Paralysis with
induction T + 30 seconds Protection T + 45 seconds Placement T + 90 seconds Post-Intubation
management
Problem Airway
epiglottis Vocal cords
Airway Evaluation
Double set up bull Neuromuscular paralysis generally
should be avoided in patients for whom a high degree of intubation difficulty is predicted unless the administration of the neuromuscular blocking agent (NMBA) is part of a planned approach to the difficult airway
Look Externally bull Severely bruised
bull Bloodied face of a combative trauma patient bull Immobilised in a cervical collar on a spine board bull Anatomical deformities
bull Subjective clinical judgment can be highly specific (90) but insensitive and so should be augmented by other evaluations
Obstruction or obesitybull Visualization of the glottis or intubation
itself mechanically impossible bull Epiglottis head and neck cancer Ludwigrsquos
angina neck hematoma or glottic polyps bull Examine the patient for airway obstruction
and assess the patientrsquos voice to satisfy this evaluation step
Neck mobility
bull Neck mobility is desirable for any intubation technique and is essential for positioning the patient for optimal direct laryngoscopy Neck mobility is assessed with the patientrsquos flexion and extension of the head and neck through a full range of motion
Lemon in ER setting
bull Unresponsive patient - Mallampatti is not practical - LEON
bull Unresponsive plus Trauma - Mallampatti and Neck mobility are not practical - LEO
Cormack and Lehane[CL]
bull The most widely used system for grading laryngoscopic view of the glottis is that of Cormack and Lehane (CL)
bull Grades laryngoscopy according to the extent to which laryngeal and glottic structures can be seen
CL grading bull Grade 1 laryngoscopy all or nearly all of the glottic aperture is seen bull Grade 2 laryngoscopy visualizes only a portion of the glottis
(arytenoid cartilages alone or arytenoid cartilages plus part of the vocal cords)
bull Grade 3 laryngoscopy visualizes only the epiglottis bull Grade 4 laryngoscopy not even the epiglottis is visible
Percentage Of Glottic Opening (POGO) score
Confirmation of Endotracheal Tube Placement
bull Direct visualisation bull Chest auscultation bull Gastric auscultation bull Bag resistance bull Exhaled volume bull Visualization of condensation within the ETT bull Chest radiography bull All are prone to failure as means of confirming tracheal intubation
ETCO2bull End-tidal carbon dioxide (ETCO2) detection
device to the ETT and assess it through six manual ventilations
bull Disposable colorimetric ETCO2 detectors are highly reliable convenient and easy to interpret indicating adequate CO2 detection by color change
End tidal CO2 detection
USG- EDDbull When ETCO2 detection
is not possible tracheal tube position can be confirmed with other techniques
bull One novel approach Bedside ultrasound
USG guided Intubation and placement confirmation
Esophageal Detector Devices (EDD)
EDD - how to work
Recognize Adequacy of Ventilations
Pulse oximeter
Approximate Blood oxygen level
SpO2 100 = PaO2 100mm of Hg SpO2 90= PaO2 60mm of Hg SpO2 60= PaO2 30mm of Hg SpO2 50= PaO2 27mm of Hg
Chest X raybull Although chest
radiography is universally recommended after ETT placement its primary purpose is to ensure that the tube is well positioned below the cords and above the carina
Other methods Gold standard
bull Fiberoptic confirmation
Difficult Airway Assessment
bull 4 Drsquos ndash Distortion Disproportion Dysmobility Dentition
bull BONES ndash Beard Obese No teeth Elderly Snores (sleep apnea)
bull SHORT ndash Surgery (headneckjaw) Hematoma Obese Radiation Tumor
bull LEMON bull MALLAMPATI bull Always have a ldquoRescue Airwayrdquo technique ready
McI
ntyr
e T
he d
iffic
ult t
rach
eal i
ntub
atio
n
Rescue Airways
bull Gum Elastic Bougie (GEB) bull Laryngeal Mask Airway (LMAILMA) bull Combitube bull Surgical Cricothyrotomy
Gum elastic bougie
Gum elastic bouge bull Useful only when
larynges is visualise at least partially
bull Difficulty intubation bull Tube changing bull Provision to
supplement oxygen
Advanced airway ndashBest choice Intubation
Equipments Needed
Laryngoscope with different types of blade
ET tube with proper size and type Average adult male 85 mm Average adult female 75 mm Low pressure cuff tubes above 5 years Uncuffed tubes below 5 years
lt 4 Age + 35
3
gt 4 Age + 45
4
Laryngoscope
Macoy Laryngoscope
Align the airway axis by proper positions
Intubation Axis
ET Tube insertion
Reverse Ramp Position
Cricoid pressure
Pressure on Cricoid cartilage Compress oesophagus between Cricoid ring and Vertebral column Prevent Regurgitation and Aspiration Make cord visualisation difficult Not recommended in Crash airway
External Laryngeal manipulation
BURP - Backward - Upward - Right- Posterior Pressure over thyroid cartilage Better vocal cord visualisation A grade 3 larynx become grade 2 with ELM It is not Cricoid pressure
Blind insertion devices
LMA Combitube Kingrsquos airway
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
Oropharyngeal airway Insertion
Best method
OPA Insertion
N P A
bull OPA is not tolerating bull Airway reflexes retained bull Inability to open mouth
N P A
Airway
Still not ndash Maintainable
Advanced Airway
No Breathing
E ndash C Clamp
Place and hold mask properly
Two hand technique
Non-maintainable Airway
R S I
Conscious patient Semiconscious with retained reflexes
RSI Defined
ldquoVirtually simultaneous administration of a potent sedative agent and a neuromuscular blocking agent to induce unconsciousness and motor paralysis for tracheal intubationrdquo
What are The Problems Inherent to Intubation
bull Laryngoscopy and Intubation ndash Increased bronchospasm ndash Increased ICP ndash Increased catecholamine release
Beneficial Effects of RSI
bull ldquoTight Headsrdquo ndash Intracranial pathology
bull ldquoTight Heartsrdquo or ldquoTight Vesselsrdquo ndash Cardiovascular disease
bull ldquoTight Lungsrdquo ndash Reactive airway disease
Conventional With LMA
Pre Oxygenationhellip
RSI TimelineT ndash 10 minutes Prepare T ndash 5 minutes Preoxygenate T ndash 3 minutes Pretreat T = 0 Paralysis with
induction T + 30 seconds Protection T + 45 seconds Placement T + 90 seconds Post-Intubation
management
Problem Airway
epiglottis Vocal cords
Airway Evaluation
Double set up bull Neuromuscular paralysis generally
should be avoided in patients for whom a high degree of intubation difficulty is predicted unless the administration of the neuromuscular blocking agent (NMBA) is part of a planned approach to the difficult airway
Look Externally bull Severely bruised
bull Bloodied face of a combative trauma patient bull Immobilised in a cervical collar on a spine board bull Anatomical deformities
bull Subjective clinical judgment can be highly specific (90) but insensitive and so should be augmented by other evaluations
Obstruction or obesitybull Visualization of the glottis or intubation
itself mechanically impossible bull Epiglottis head and neck cancer Ludwigrsquos
angina neck hematoma or glottic polyps bull Examine the patient for airway obstruction
and assess the patientrsquos voice to satisfy this evaluation step
Neck mobility
bull Neck mobility is desirable for any intubation technique and is essential for positioning the patient for optimal direct laryngoscopy Neck mobility is assessed with the patientrsquos flexion and extension of the head and neck through a full range of motion
Lemon in ER setting
bull Unresponsive patient - Mallampatti is not practical - LEON
bull Unresponsive plus Trauma - Mallampatti and Neck mobility are not practical - LEO
Cormack and Lehane[CL]
bull The most widely used system for grading laryngoscopic view of the glottis is that of Cormack and Lehane (CL)
bull Grades laryngoscopy according to the extent to which laryngeal and glottic structures can be seen
CL grading bull Grade 1 laryngoscopy all or nearly all of the glottic aperture is seen bull Grade 2 laryngoscopy visualizes only a portion of the glottis
(arytenoid cartilages alone or arytenoid cartilages plus part of the vocal cords)
bull Grade 3 laryngoscopy visualizes only the epiglottis bull Grade 4 laryngoscopy not even the epiglottis is visible
Percentage Of Glottic Opening (POGO) score
Confirmation of Endotracheal Tube Placement
bull Direct visualisation bull Chest auscultation bull Gastric auscultation bull Bag resistance bull Exhaled volume bull Visualization of condensation within the ETT bull Chest radiography bull All are prone to failure as means of confirming tracheal intubation
ETCO2bull End-tidal carbon dioxide (ETCO2) detection
device to the ETT and assess it through six manual ventilations
bull Disposable colorimetric ETCO2 detectors are highly reliable convenient and easy to interpret indicating adequate CO2 detection by color change
End tidal CO2 detection
USG- EDDbull When ETCO2 detection
is not possible tracheal tube position can be confirmed with other techniques
bull One novel approach Bedside ultrasound
USG guided Intubation and placement confirmation
Esophageal Detector Devices (EDD)
EDD - how to work
Recognize Adequacy of Ventilations
Pulse oximeter
Approximate Blood oxygen level
SpO2 100 = PaO2 100mm of Hg SpO2 90= PaO2 60mm of Hg SpO2 60= PaO2 30mm of Hg SpO2 50= PaO2 27mm of Hg
Chest X raybull Although chest
radiography is universally recommended after ETT placement its primary purpose is to ensure that the tube is well positioned below the cords and above the carina
Other methods Gold standard
bull Fiberoptic confirmation
Difficult Airway Assessment
bull 4 Drsquos ndash Distortion Disproportion Dysmobility Dentition
bull BONES ndash Beard Obese No teeth Elderly Snores (sleep apnea)
bull SHORT ndash Surgery (headneckjaw) Hematoma Obese Radiation Tumor
bull LEMON bull MALLAMPATI bull Always have a ldquoRescue Airwayrdquo technique ready
McI
ntyr
e T
he d
iffic
ult t
rach
eal i
ntub
atio
n
Rescue Airways
bull Gum Elastic Bougie (GEB) bull Laryngeal Mask Airway (LMAILMA) bull Combitube bull Surgical Cricothyrotomy
Gum elastic bougie
Gum elastic bouge bull Useful only when
larynges is visualise at least partially
bull Difficulty intubation bull Tube changing bull Provision to
supplement oxygen
Advanced airway ndashBest choice Intubation
Equipments Needed
Laryngoscope with different types of blade
ET tube with proper size and type Average adult male 85 mm Average adult female 75 mm Low pressure cuff tubes above 5 years Uncuffed tubes below 5 years
lt 4 Age + 35
3
gt 4 Age + 45
4
Laryngoscope
Macoy Laryngoscope
Align the airway axis by proper positions
Intubation Axis
ET Tube insertion
Reverse Ramp Position
Cricoid pressure
Pressure on Cricoid cartilage Compress oesophagus between Cricoid ring and Vertebral column Prevent Regurgitation and Aspiration Make cord visualisation difficult Not recommended in Crash airway
External Laryngeal manipulation
BURP - Backward - Upward - Right- Posterior Pressure over thyroid cartilage Better vocal cord visualisation A grade 3 larynx become grade 2 with ELM It is not Cricoid pressure
Blind insertion devices
LMA Combitube Kingrsquos airway
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
Best method
OPA Insertion
N P A
bull OPA is not tolerating bull Airway reflexes retained bull Inability to open mouth
N P A
Airway
Still not ndash Maintainable
Advanced Airway
No Breathing
E ndash C Clamp
Place and hold mask properly
Two hand technique
Non-maintainable Airway
R S I
Conscious patient Semiconscious with retained reflexes
RSI Defined
ldquoVirtually simultaneous administration of a potent sedative agent and a neuromuscular blocking agent to induce unconsciousness and motor paralysis for tracheal intubationrdquo
What are The Problems Inherent to Intubation
bull Laryngoscopy and Intubation ndash Increased bronchospasm ndash Increased ICP ndash Increased catecholamine release
Beneficial Effects of RSI
bull ldquoTight Headsrdquo ndash Intracranial pathology
bull ldquoTight Heartsrdquo or ldquoTight Vesselsrdquo ndash Cardiovascular disease
bull ldquoTight Lungsrdquo ndash Reactive airway disease
Conventional With LMA
Pre Oxygenationhellip
RSI TimelineT ndash 10 minutes Prepare T ndash 5 minutes Preoxygenate T ndash 3 minutes Pretreat T = 0 Paralysis with
induction T + 30 seconds Protection T + 45 seconds Placement T + 90 seconds Post-Intubation
management
Problem Airway
epiglottis Vocal cords
Airway Evaluation
Double set up bull Neuromuscular paralysis generally
should be avoided in patients for whom a high degree of intubation difficulty is predicted unless the administration of the neuromuscular blocking agent (NMBA) is part of a planned approach to the difficult airway
Look Externally bull Severely bruised
bull Bloodied face of a combative trauma patient bull Immobilised in a cervical collar on a spine board bull Anatomical deformities
bull Subjective clinical judgment can be highly specific (90) but insensitive and so should be augmented by other evaluations
Obstruction or obesitybull Visualization of the glottis or intubation
itself mechanically impossible bull Epiglottis head and neck cancer Ludwigrsquos
angina neck hematoma or glottic polyps bull Examine the patient for airway obstruction
and assess the patientrsquos voice to satisfy this evaluation step
Neck mobility
bull Neck mobility is desirable for any intubation technique and is essential for positioning the patient for optimal direct laryngoscopy Neck mobility is assessed with the patientrsquos flexion and extension of the head and neck through a full range of motion
Lemon in ER setting
bull Unresponsive patient - Mallampatti is not practical - LEON
bull Unresponsive plus Trauma - Mallampatti and Neck mobility are not practical - LEO
Cormack and Lehane[CL]
bull The most widely used system for grading laryngoscopic view of the glottis is that of Cormack and Lehane (CL)
bull Grades laryngoscopy according to the extent to which laryngeal and glottic structures can be seen
CL grading bull Grade 1 laryngoscopy all or nearly all of the glottic aperture is seen bull Grade 2 laryngoscopy visualizes only a portion of the glottis
(arytenoid cartilages alone or arytenoid cartilages plus part of the vocal cords)
bull Grade 3 laryngoscopy visualizes only the epiglottis bull Grade 4 laryngoscopy not even the epiglottis is visible
Percentage Of Glottic Opening (POGO) score
Confirmation of Endotracheal Tube Placement
bull Direct visualisation bull Chest auscultation bull Gastric auscultation bull Bag resistance bull Exhaled volume bull Visualization of condensation within the ETT bull Chest radiography bull All are prone to failure as means of confirming tracheal intubation
ETCO2bull End-tidal carbon dioxide (ETCO2) detection
device to the ETT and assess it through six manual ventilations
bull Disposable colorimetric ETCO2 detectors are highly reliable convenient and easy to interpret indicating adequate CO2 detection by color change
End tidal CO2 detection
USG- EDDbull When ETCO2 detection
is not possible tracheal tube position can be confirmed with other techniques
bull One novel approach Bedside ultrasound
USG guided Intubation and placement confirmation
Esophageal Detector Devices (EDD)
EDD - how to work
Recognize Adequacy of Ventilations
Pulse oximeter
Approximate Blood oxygen level
SpO2 100 = PaO2 100mm of Hg SpO2 90= PaO2 60mm of Hg SpO2 60= PaO2 30mm of Hg SpO2 50= PaO2 27mm of Hg
Chest X raybull Although chest
radiography is universally recommended after ETT placement its primary purpose is to ensure that the tube is well positioned below the cords and above the carina
Other methods Gold standard
bull Fiberoptic confirmation
Difficult Airway Assessment
bull 4 Drsquos ndash Distortion Disproportion Dysmobility Dentition
bull BONES ndash Beard Obese No teeth Elderly Snores (sleep apnea)
bull SHORT ndash Surgery (headneckjaw) Hematoma Obese Radiation Tumor
bull LEMON bull MALLAMPATI bull Always have a ldquoRescue Airwayrdquo technique ready
McI
ntyr
e T
he d
iffic
ult t
rach
eal i
ntub
atio
n
Rescue Airways
bull Gum Elastic Bougie (GEB) bull Laryngeal Mask Airway (LMAILMA) bull Combitube bull Surgical Cricothyrotomy
Gum elastic bougie
Gum elastic bouge bull Useful only when
larynges is visualise at least partially
bull Difficulty intubation bull Tube changing bull Provision to
supplement oxygen
Advanced airway ndashBest choice Intubation
Equipments Needed
Laryngoscope with different types of blade
ET tube with proper size and type Average adult male 85 mm Average adult female 75 mm Low pressure cuff tubes above 5 years Uncuffed tubes below 5 years
lt 4 Age + 35
3
gt 4 Age + 45
4
Laryngoscope
Macoy Laryngoscope
Align the airway axis by proper positions
Intubation Axis
ET Tube insertion
Reverse Ramp Position
Cricoid pressure
Pressure on Cricoid cartilage Compress oesophagus between Cricoid ring and Vertebral column Prevent Regurgitation and Aspiration Make cord visualisation difficult Not recommended in Crash airway
External Laryngeal manipulation
BURP - Backward - Upward - Right- Posterior Pressure over thyroid cartilage Better vocal cord visualisation A grade 3 larynx become grade 2 with ELM It is not Cricoid pressure
Blind insertion devices
LMA Combitube Kingrsquos airway
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
N P A
bull OPA is not tolerating bull Airway reflexes retained bull Inability to open mouth
N P A
Airway
Still not ndash Maintainable
Advanced Airway
No Breathing
E ndash C Clamp
Place and hold mask properly
Two hand technique
Non-maintainable Airway
R S I
Conscious patient Semiconscious with retained reflexes
RSI Defined
ldquoVirtually simultaneous administration of a potent sedative agent and a neuromuscular blocking agent to induce unconsciousness and motor paralysis for tracheal intubationrdquo
What are The Problems Inherent to Intubation
bull Laryngoscopy and Intubation ndash Increased bronchospasm ndash Increased ICP ndash Increased catecholamine release
Beneficial Effects of RSI
bull ldquoTight Headsrdquo ndash Intracranial pathology
bull ldquoTight Heartsrdquo or ldquoTight Vesselsrdquo ndash Cardiovascular disease
bull ldquoTight Lungsrdquo ndash Reactive airway disease
Conventional With LMA
Pre Oxygenationhellip
RSI TimelineT ndash 10 minutes Prepare T ndash 5 minutes Preoxygenate T ndash 3 minutes Pretreat T = 0 Paralysis with
induction T + 30 seconds Protection T + 45 seconds Placement T + 90 seconds Post-Intubation
management
Problem Airway
epiglottis Vocal cords
Airway Evaluation
Double set up bull Neuromuscular paralysis generally
should be avoided in patients for whom a high degree of intubation difficulty is predicted unless the administration of the neuromuscular blocking agent (NMBA) is part of a planned approach to the difficult airway
Look Externally bull Severely bruised
bull Bloodied face of a combative trauma patient bull Immobilised in a cervical collar on a spine board bull Anatomical deformities
bull Subjective clinical judgment can be highly specific (90) but insensitive and so should be augmented by other evaluations
Obstruction or obesitybull Visualization of the glottis or intubation
itself mechanically impossible bull Epiglottis head and neck cancer Ludwigrsquos
angina neck hematoma or glottic polyps bull Examine the patient for airway obstruction
and assess the patientrsquos voice to satisfy this evaluation step
Neck mobility
bull Neck mobility is desirable for any intubation technique and is essential for positioning the patient for optimal direct laryngoscopy Neck mobility is assessed with the patientrsquos flexion and extension of the head and neck through a full range of motion
Lemon in ER setting
bull Unresponsive patient - Mallampatti is not practical - LEON
bull Unresponsive plus Trauma - Mallampatti and Neck mobility are not practical - LEO
Cormack and Lehane[CL]
bull The most widely used system for grading laryngoscopic view of the glottis is that of Cormack and Lehane (CL)
bull Grades laryngoscopy according to the extent to which laryngeal and glottic structures can be seen
CL grading bull Grade 1 laryngoscopy all or nearly all of the glottic aperture is seen bull Grade 2 laryngoscopy visualizes only a portion of the glottis
(arytenoid cartilages alone or arytenoid cartilages plus part of the vocal cords)
bull Grade 3 laryngoscopy visualizes only the epiglottis bull Grade 4 laryngoscopy not even the epiglottis is visible
Percentage Of Glottic Opening (POGO) score
Confirmation of Endotracheal Tube Placement
bull Direct visualisation bull Chest auscultation bull Gastric auscultation bull Bag resistance bull Exhaled volume bull Visualization of condensation within the ETT bull Chest radiography bull All are prone to failure as means of confirming tracheal intubation
ETCO2bull End-tidal carbon dioxide (ETCO2) detection
device to the ETT and assess it through six manual ventilations
bull Disposable colorimetric ETCO2 detectors are highly reliable convenient and easy to interpret indicating adequate CO2 detection by color change
End tidal CO2 detection
USG- EDDbull When ETCO2 detection
is not possible tracheal tube position can be confirmed with other techniques
bull One novel approach Bedside ultrasound
USG guided Intubation and placement confirmation
Esophageal Detector Devices (EDD)
EDD - how to work
Recognize Adequacy of Ventilations
Pulse oximeter
Approximate Blood oxygen level
SpO2 100 = PaO2 100mm of Hg SpO2 90= PaO2 60mm of Hg SpO2 60= PaO2 30mm of Hg SpO2 50= PaO2 27mm of Hg
Chest X raybull Although chest
radiography is universally recommended after ETT placement its primary purpose is to ensure that the tube is well positioned below the cords and above the carina
Other methods Gold standard
bull Fiberoptic confirmation
Difficult Airway Assessment
bull 4 Drsquos ndash Distortion Disproportion Dysmobility Dentition
bull BONES ndash Beard Obese No teeth Elderly Snores (sleep apnea)
bull SHORT ndash Surgery (headneckjaw) Hematoma Obese Radiation Tumor
bull LEMON bull MALLAMPATI bull Always have a ldquoRescue Airwayrdquo technique ready
McI
ntyr
e T
he d
iffic
ult t
rach
eal i
ntub
atio
n
Rescue Airways
bull Gum Elastic Bougie (GEB) bull Laryngeal Mask Airway (LMAILMA) bull Combitube bull Surgical Cricothyrotomy
Gum elastic bougie
Gum elastic bouge bull Useful only when
larynges is visualise at least partially
bull Difficulty intubation bull Tube changing bull Provision to
supplement oxygen
Advanced airway ndashBest choice Intubation
Equipments Needed
Laryngoscope with different types of blade
ET tube with proper size and type Average adult male 85 mm Average adult female 75 mm Low pressure cuff tubes above 5 years Uncuffed tubes below 5 years
lt 4 Age + 35
3
gt 4 Age + 45
4
Laryngoscope
Macoy Laryngoscope
Align the airway axis by proper positions
Intubation Axis
ET Tube insertion
Reverse Ramp Position
Cricoid pressure
Pressure on Cricoid cartilage Compress oesophagus between Cricoid ring and Vertebral column Prevent Regurgitation and Aspiration Make cord visualisation difficult Not recommended in Crash airway
External Laryngeal manipulation
BURP - Backward - Upward - Right- Posterior Pressure over thyroid cartilage Better vocal cord visualisation A grade 3 larynx become grade 2 with ELM It is not Cricoid pressure
Blind insertion devices
LMA Combitube Kingrsquos airway
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
N P A
Airway
Still not ndash Maintainable
Advanced Airway
No Breathing
E ndash C Clamp
Place and hold mask properly
Two hand technique
Non-maintainable Airway
R S I
Conscious patient Semiconscious with retained reflexes
RSI Defined
ldquoVirtually simultaneous administration of a potent sedative agent and a neuromuscular blocking agent to induce unconsciousness and motor paralysis for tracheal intubationrdquo
What are The Problems Inherent to Intubation
bull Laryngoscopy and Intubation ndash Increased bronchospasm ndash Increased ICP ndash Increased catecholamine release
Beneficial Effects of RSI
bull ldquoTight Headsrdquo ndash Intracranial pathology
bull ldquoTight Heartsrdquo or ldquoTight Vesselsrdquo ndash Cardiovascular disease
bull ldquoTight Lungsrdquo ndash Reactive airway disease
Conventional With LMA
Pre Oxygenationhellip
RSI TimelineT ndash 10 minutes Prepare T ndash 5 minutes Preoxygenate T ndash 3 minutes Pretreat T = 0 Paralysis with
induction T + 30 seconds Protection T + 45 seconds Placement T + 90 seconds Post-Intubation
management
Problem Airway
epiglottis Vocal cords
Airway Evaluation
Double set up bull Neuromuscular paralysis generally
should be avoided in patients for whom a high degree of intubation difficulty is predicted unless the administration of the neuromuscular blocking agent (NMBA) is part of a planned approach to the difficult airway
Look Externally bull Severely bruised
bull Bloodied face of a combative trauma patient bull Immobilised in a cervical collar on a spine board bull Anatomical deformities
bull Subjective clinical judgment can be highly specific (90) but insensitive and so should be augmented by other evaluations
Obstruction or obesitybull Visualization of the glottis or intubation
itself mechanically impossible bull Epiglottis head and neck cancer Ludwigrsquos
angina neck hematoma or glottic polyps bull Examine the patient for airway obstruction
and assess the patientrsquos voice to satisfy this evaluation step
Neck mobility
bull Neck mobility is desirable for any intubation technique and is essential for positioning the patient for optimal direct laryngoscopy Neck mobility is assessed with the patientrsquos flexion and extension of the head and neck through a full range of motion
Lemon in ER setting
bull Unresponsive patient - Mallampatti is not practical - LEON
bull Unresponsive plus Trauma - Mallampatti and Neck mobility are not practical - LEO
Cormack and Lehane[CL]
bull The most widely used system for grading laryngoscopic view of the glottis is that of Cormack and Lehane (CL)
bull Grades laryngoscopy according to the extent to which laryngeal and glottic structures can be seen
CL grading bull Grade 1 laryngoscopy all or nearly all of the glottic aperture is seen bull Grade 2 laryngoscopy visualizes only a portion of the glottis
(arytenoid cartilages alone or arytenoid cartilages plus part of the vocal cords)
bull Grade 3 laryngoscopy visualizes only the epiglottis bull Grade 4 laryngoscopy not even the epiglottis is visible
Percentage Of Glottic Opening (POGO) score
Confirmation of Endotracheal Tube Placement
bull Direct visualisation bull Chest auscultation bull Gastric auscultation bull Bag resistance bull Exhaled volume bull Visualization of condensation within the ETT bull Chest radiography bull All are prone to failure as means of confirming tracheal intubation
ETCO2bull End-tidal carbon dioxide (ETCO2) detection
device to the ETT and assess it through six manual ventilations
bull Disposable colorimetric ETCO2 detectors are highly reliable convenient and easy to interpret indicating adequate CO2 detection by color change
End tidal CO2 detection
USG- EDDbull When ETCO2 detection
is not possible tracheal tube position can be confirmed with other techniques
bull One novel approach Bedside ultrasound
USG guided Intubation and placement confirmation
Esophageal Detector Devices (EDD)
EDD - how to work
Recognize Adequacy of Ventilations
Pulse oximeter
Approximate Blood oxygen level
SpO2 100 = PaO2 100mm of Hg SpO2 90= PaO2 60mm of Hg SpO2 60= PaO2 30mm of Hg SpO2 50= PaO2 27mm of Hg
Chest X raybull Although chest
radiography is universally recommended after ETT placement its primary purpose is to ensure that the tube is well positioned below the cords and above the carina
Other methods Gold standard
bull Fiberoptic confirmation
Difficult Airway Assessment
bull 4 Drsquos ndash Distortion Disproportion Dysmobility Dentition
bull BONES ndash Beard Obese No teeth Elderly Snores (sleep apnea)
bull SHORT ndash Surgery (headneckjaw) Hematoma Obese Radiation Tumor
bull LEMON bull MALLAMPATI bull Always have a ldquoRescue Airwayrdquo technique ready
McI
ntyr
e T
he d
iffic
ult t
rach
eal i
ntub
atio
n
Rescue Airways
bull Gum Elastic Bougie (GEB) bull Laryngeal Mask Airway (LMAILMA) bull Combitube bull Surgical Cricothyrotomy
Gum elastic bougie
Gum elastic bouge bull Useful only when
larynges is visualise at least partially
bull Difficulty intubation bull Tube changing bull Provision to
supplement oxygen
Advanced airway ndashBest choice Intubation
Equipments Needed
Laryngoscope with different types of blade
ET tube with proper size and type Average adult male 85 mm Average adult female 75 mm Low pressure cuff tubes above 5 years Uncuffed tubes below 5 years
lt 4 Age + 35
3
gt 4 Age + 45
4
Laryngoscope
Macoy Laryngoscope
Align the airway axis by proper positions
Intubation Axis
ET Tube insertion
Reverse Ramp Position
Cricoid pressure
Pressure on Cricoid cartilage Compress oesophagus between Cricoid ring and Vertebral column Prevent Regurgitation and Aspiration Make cord visualisation difficult Not recommended in Crash airway
External Laryngeal manipulation
BURP - Backward - Upward - Right- Posterior Pressure over thyroid cartilage Better vocal cord visualisation A grade 3 larynx become grade 2 with ELM It is not Cricoid pressure
Blind insertion devices
LMA Combitube Kingrsquos airway
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
Airway
Still not ndash Maintainable
Advanced Airway
No Breathing
E ndash C Clamp
Place and hold mask properly
Two hand technique
Non-maintainable Airway
R S I
Conscious patient Semiconscious with retained reflexes
RSI Defined
ldquoVirtually simultaneous administration of a potent sedative agent and a neuromuscular blocking agent to induce unconsciousness and motor paralysis for tracheal intubationrdquo
What are The Problems Inherent to Intubation
bull Laryngoscopy and Intubation ndash Increased bronchospasm ndash Increased ICP ndash Increased catecholamine release
Beneficial Effects of RSI
bull ldquoTight Headsrdquo ndash Intracranial pathology
bull ldquoTight Heartsrdquo or ldquoTight Vesselsrdquo ndash Cardiovascular disease
bull ldquoTight Lungsrdquo ndash Reactive airway disease
Conventional With LMA
Pre Oxygenationhellip
RSI TimelineT ndash 10 minutes Prepare T ndash 5 minutes Preoxygenate T ndash 3 minutes Pretreat T = 0 Paralysis with
induction T + 30 seconds Protection T + 45 seconds Placement T + 90 seconds Post-Intubation
management
Problem Airway
epiglottis Vocal cords
Airway Evaluation
Double set up bull Neuromuscular paralysis generally
should be avoided in patients for whom a high degree of intubation difficulty is predicted unless the administration of the neuromuscular blocking agent (NMBA) is part of a planned approach to the difficult airway
Look Externally bull Severely bruised
bull Bloodied face of a combative trauma patient bull Immobilised in a cervical collar on a spine board bull Anatomical deformities
bull Subjective clinical judgment can be highly specific (90) but insensitive and so should be augmented by other evaluations
Obstruction or obesitybull Visualization of the glottis or intubation
itself mechanically impossible bull Epiglottis head and neck cancer Ludwigrsquos
angina neck hematoma or glottic polyps bull Examine the patient for airway obstruction
and assess the patientrsquos voice to satisfy this evaluation step
Neck mobility
bull Neck mobility is desirable for any intubation technique and is essential for positioning the patient for optimal direct laryngoscopy Neck mobility is assessed with the patientrsquos flexion and extension of the head and neck through a full range of motion
Lemon in ER setting
bull Unresponsive patient - Mallampatti is not practical - LEON
bull Unresponsive plus Trauma - Mallampatti and Neck mobility are not practical - LEO
Cormack and Lehane[CL]
bull The most widely used system for grading laryngoscopic view of the glottis is that of Cormack and Lehane (CL)
bull Grades laryngoscopy according to the extent to which laryngeal and glottic structures can be seen
CL grading bull Grade 1 laryngoscopy all or nearly all of the glottic aperture is seen bull Grade 2 laryngoscopy visualizes only a portion of the glottis
(arytenoid cartilages alone or arytenoid cartilages plus part of the vocal cords)
bull Grade 3 laryngoscopy visualizes only the epiglottis bull Grade 4 laryngoscopy not even the epiglottis is visible
Percentage Of Glottic Opening (POGO) score
Confirmation of Endotracheal Tube Placement
bull Direct visualisation bull Chest auscultation bull Gastric auscultation bull Bag resistance bull Exhaled volume bull Visualization of condensation within the ETT bull Chest radiography bull All are prone to failure as means of confirming tracheal intubation
ETCO2bull End-tidal carbon dioxide (ETCO2) detection
device to the ETT and assess it through six manual ventilations
bull Disposable colorimetric ETCO2 detectors are highly reliable convenient and easy to interpret indicating adequate CO2 detection by color change
End tidal CO2 detection
USG- EDDbull When ETCO2 detection
is not possible tracheal tube position can be confirmed with other techniques
bull One novel approach Bedside ultrasound
USG guided Intubation and placement confirmation
Esophageal Detector Devices (EDD)
EDD - how to work
Recognize Adequacy of Ventilations
Pulse oximeter
Approximate Blood oxygen level
SpO2 100 = PaO2 100mm of Hg SpO2 90= PaO2 60mm of Hg SpO2 60= PaO2 30mm of Hg SpO2 50= PaO2 27mm of Hg
Chest X raybull Although chest
radiography is universally recommended after ETT placement its primary purpose is to ensure that the tube is well positioned below the cords and above the carina
Other methods Gold standard
bull Fiberoptic confirmation
Difficult Airway Assessment
bull 4 Drsquos ndash Distortion Disproportion Dysmobility Dentition
bull BONES ndash Beard Obese No teeth Elderly Snores (sleep apnea)
bull SHORT ndash Surgery (headneckjaw) Hematoma Obese Radiation Tumor
bull LEMON bull MALLAMPATI bull Always have a ldquoRescue Airwayrdquo technique ready
McI
ntyr
e T
he d
iffic
ult t
rach
eal i
ntub
atio
n
Rescue Airways
bull Gum Elastic Bougie (GEB) bull Laryngeal Mask Airway (LMAILMA) bull Combitube bull Surgical Cricothyrotomy
Gum elastic bougie
Gum elastic bouge bull Useful only when
larynges is visualise at least partially
bull Difficulty intubation bull Tube changing bull Provision to
supplement oxygen
Advanced airway ndashBest choice Intubation
Equipments Needed
Laryngoscope with different types of blade
ET tube with proper size and type Average adult male 85 mm Average adult female 75 mm Low pressure cuff tubes above 5 years Uncuffed tubes below 5 years
lt 4 Age + 35
3
gt 4 Age + 45
4
Laryngoscope
Macoy Laryngoscope
Align the airway axis by proper positions
Intubation Axis
ET Tube insertion
Reverse Ramp Position
Cricoid pressure
Pressure on Cricoid cartilage Compress oesophagus between Cricoid ring and Vertebral column Prevent Regurgitation and Aspiration Make cord visualisation difficult Not recommended in Crash airway
External Laryngeal manipulation
BURP - Backward - Upward - Right- Posterior Pressure over thyroid cartilage Better vocal cord visualisation A grade 3 larynx become grade 2 with ELM It is not Cricoid pressure
Blind insertion devices
LMA Combitube Kingrsquos airway
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
No Breathing
E ndash C Clamp
Place and hold mask properly
Two hand technique
Non-maintainable Airway
R S I
Conscious patient Semiconscious with retained reflexes
RSI Defined
ldquoVirtually simultaneous administration of a potent sedative agent and a neuromuscular blocking agent to induce unconsciousness and motor paralysis for tracheal intubationrdquo
What are The Problems Inherent to Intubation
bull Laryngoscopy and Intubation ndash Increased bronchospasm ndash Increased ICP ndash Increased catecholamine release
Beneficial Effects of RSI
bull ldquoTight Headsrdquo ndash Intracranial pathology
bull ldquoTight Heartsrdquo or ldquoTight Vesselsrdquo ndash Cardiovascular disease
bull ldquoTight Lungsrdquo ndash Reactive airway disease
Conventional With LMA
Pre Oxygenationhellip
RSI TimelineT ndash 10 minutes Prepare T ndash 5 minutes Preoxygenate T ndash 3 minutes Pretreat T = 0 Paralysis with
induction T + 30 seconds Protection T + 45 seconds Placement T + 90 seconds Post-Intubation
management
Problem Airway
epiglottis Vocal cords
Airway Evaluation
Double set up bull Neuromuscular paralysis generally
should be avoided in patients for whom a high degree of intubation difficulty is predicted unless the administration of the neuromuscular blocking agent (NMBA) is part of a planned approach to the difficult airway
Look Externally bull Severely bruised
bull Bloodied face of a combative trauma patient bull Immobilised in a cervical collar on a spine board bull Anatomical deformities
bull Subjective clinical judgment can be highly specific (90) but insensitive and so should be augmented by other evaluations
Obstruction or obesitybull Visualization of the glottis or intubation
itself mechanically impossible bull Epiglottis head and neck cancer Ludwigrsquos
angina neck hematoma or glottic polyps bull Examine the patient for airway obstruction
and assess the patientrsquos voice to satisfy this evaluation step
Neck mobility
bull Neck mobility is desirable for any intubation technique and is essential for positioning the patient for optimal direct laryngoscopy Neck mobility is assessed with the patientrsquos flexion and extension of the head and neck through a full range of motion
Lemon in ER setting
bull Unresponsive patient - Mallampatti is not practical - LEON
bull Unresponsive plus Trauma - Mallampatti and Neck mobility are not practical - LEO
Cormack and Lehane[CL]
bull The most widely used system for grading laryngoscopic view of the glottis is that of Cormack and Lehane (CL)
bull Grades laryngoscopy according to the extent to which laryngeal and glottic structures can be seen
CL grading bull Grade 1 laryngoscopy all or nearly all of the glottic aperture is seen bull Grade 2 laryngoscopy visualizes only a portion of the glottis
(arytenoid cartilages alone or arytenoid cartilages plus part of the vocal cords)
bull Grade 3 laryngoscopy visualizes only the epiglottis bull Grade 4 laryngoscopy not even the epiglottis is visible
Percentage Of Glottic Opening (POGO) score
Confirmation of Endotracheal Tube Placement
bull Direct visualisation bull Chest auscultation bull Gastric auscultation bull Bag resistance bull Exhaled volume bull Visualization of condensation within the ETT bull Chest radiography bull All are prone to failure as means of confirming tracheal intubation
ETCO2bull End-tidal carbon dioxide (ETCO2) detection
device to the ETT and assess it through six manual ventilations
bull Disposable colorimetric ETCO2 detectors are highly reliable convenient and easy to interpret indicating adequate CO2 detection by color change
End tidal CO2 detection
USG- EDDbull When ETCO2 detection
is not possible tracheal tube position can be confirmed with other techniques
bull One novel approach Bedside ultrasound
USG guided Intubation and placement confirmation
Esophageal Detector Devices (EDD)
EDD - how to work
Recognize Adequacy of Ventilations
Pulse oximeter
Approximate Blood oxygen level
SpO2 100 = PaO2 100mm of Hg SpO2 90= PaO2 60mm of Hg SpO2 60= PaO2 30mm of Hg SpO2 50= PaO2 27mm of Hg
Chest X raybull Although chest
radiography is universally recommended after ETT placement its primary purpose is to ensure that the tube is well positioned below the cords and above the carina
Other methods Gold standard
bull Fiberoptic confirmation
Difficult Airway Assessment
bull 4 Drsquos ndash Distortion Disproportion Dysmobility Dentition
bull BONES ndash Beard Obese No teeth Elderly Snores (sleep apnea)
bull SHORT ndash Surgery (headneckjaw) Hematoma Obese Radiation Tumor
bull LEMON bull MALLAMPATI bull Always have a ldquoRescue Airwayrdquo technique ready
McI
ntyr
e T
he d
iffic
ult t
rach
eal i
ntub
atio
n
Rescue Airways
bull Gum Elastic Bougie (GEB) bull Laryngeal Mask Airway (LMAILMA) bull Combitube bull Surgical Cricothyrotomy
Gum elastic bougie
Gum elastic bouge bull Useful only when
larynges is visualise at least partially
bull Difficulty intubation bull Tube changing bull Provision to
supplement oxygen
Advanced airway ndashBest choice Intubation
Equipments Needed
Laryngoscope with different types of blade
ET tube with proper size and type Average adult male 85 mm Average adult female 75 mm Low pressure cuff tubes above 5 years Uncuffed tubes below 5 years
lt 4 Age + 35
3
gt 4 Age + 45
4
Laryngoscope
Macoy Laryngoscope
Align the airway axis by proper positions
Intubation Axis
ET Tube insertion
Reverse Ramp Position
Cricoid pressure
Pressure on Cricoid cartilage Compress oesophagus between Cricoid ring and Vertebral column Prevent Regurgitation and Aspiration Make cord visualisation difficult Not recommended in Crash airway
External Laryngeal manipulation
BURP - Backward - Upward - Right- Posterior Pressure over thyroid cartilage Better vocal cord visualisation A grade 3 larynx become grade 2 with ELM It is not Cricoid pressure
Blind insertion devices
LMA Combitube Kingrsquos airway
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
Two hand technique
Non-maintainable Airway
R S I
Conscious patient Semiconscious with retained reflexes
RSI Defined
ldquoVirtually simultaneous administration of a potent sedative agent and a neuromuscular blocking agent to induce unconsciousness and motor paralysis for tracheal intubationrdquo
What are The Problems Inherent to Intubation
bull Laryngoscopy and Intubation ndash Increased bronchospasm ndash Increased ICP ndash Increased catecholamine release
Beneficial Effects of RSI
bull ldquoTight Headsrdquo ndash Intracranial pathology
bull ldquoTight Heartsrdquo or ldquoTight Vesselsrdquo ndash Cardiovascular disease
bull ldquoTight Lungsrdquo ndash Reactive airway disease
Conventional With LMA
Pre Oxygenationhellip
RSI TimelineT ndash 10 minutes Prepare T ndash 5 minutes Preoxygenate T ndash 3 minutes Pretreat T = 0 Paralysis with
induction T + 30 seconds Protection T + 45 seconds Placement T + 90 seconds Post-Intubation
management
Problem Airway
epiglottis Vocal cords
Airway Evaluation
Double set up bull Neuromuscular paralysis generally
should be avoided in patients for whom a high degree of intubation difficulty is predicted unless the administration of the neuromuscular blocking agent (NMBA) is part of a planned approach to the difficult airway
Look Externally bull Severely bruised
bull Bloodied face of a combative trauma patient bull Immobilised in a cervical collar on a spine board bull Anatomical deformities
bull Subjective clinical judgment can be highly specific (90) but insensitive and so should be augmented by other evaluations
Obstruction or obesitybull Visualization of the glottis or intubation
itself mechanically impossible bull Epiglottis head and neck cancer Ludwigrsquos
angina neck hematoma or glottic polyps bull Examine the patient for airway obstruction
and assess the patientrsquos voice to satisfy this evaluation step
Neck mobility
bull Neck mobility is desirable for any intubation technique and is essential for positioning the patient for optimal direct laryngoscopy Neck mobility is assessed with the patientrsquos flexion and extension of the head and neck through a full range of motion
Lemon in ER setting
bull Unresponsive patient - Mallampatti is not practical - LEON
bull Unresponsive plus Trauma - Mallampatti and Neck mobility are not practical - LEO
Cormack and Lehane[CL]
bull The most widely used system for grading laryngoscopic view of the glottis is that of Cormack and Lehane (CL)
bull Grades laryngoscopy according to the extent to which laryngeal and glottic structures can be seen
CL grading bull Grade 1 laryngoscopy all or nearly all of the glottic aperture is seen bull Grade 2 laryngoscopy visualizes only a portion of the glottis
(arytenoid cartilages alone or arytenoid cartilages plus part of the vocal cords)
bull Grade 3 laryngoscopy visualizes only the epiglottis bull Grade 4 laryngoscopy not even the epiglottis is visible
Percentage Of Glottic Opening (POGO) score
Confirmation of Endotracheal Tube Placement
bull Direct visualisation bull Chest auscultation bull Gastric auscultation bull Bag resistance bull Exhaled volume bull Visualization of condensation within the ETT bull Chest radiography bull All are prone to failure as means of confirming tracheal intubation
ETCO2bull End-tidal carbon dioxide (ETCO2) detection
device to the ETT and assess it through six manual ventilations
bull Disposable colorimetric ETCO2 detectors are highly reliable convenient and easy to interpret indicating adequate CO2 detection by color change
End tidal CO2 detection
USG- EDDbull When ETCO2 detection
is not possible tracheal tube position can be confirmed with other techniques
bull One novel approach Bedside ultrasound
USG guided Intubation and placement confirmation
Esophageal Detector Devices (EDD)
EDD - how to work
Recognize Adequacy of Ventilations
Pulse oximeter
Approximate Blood oxygen level
SpO2 100 = PaO2 100mm of Hg SpO2 90= PaO2 60mm of Hg SpO2 60= PaO2 30mm of Hg SpO2 50= PaO2 27mm of Hg
Chest X raybull Although chest
radiography is universally recommended after ETT placement its primary purpose is to ensure that the tube is well positioned below the cords and above the carina
Other methods Gold standard
bull Fiberoptic confirmation
Difficult Airway Assessment
bull 4 Drsquos ndash Distortion Disproportion Dysmobility Dentition
bull BONES ndash Beard Obese No teeth Elderly Snores (sleep apnea)
bull SHORT ndash Surgery (headneckjaw) Hematoma Obese Radiation Tumor
bull LEMON bull MALLAMPATI bull Always have a ldquoRescue Airwayrdquo technique ready
McI
ntyr
e T
he d
iffic
ult t
rach
eal i
ntub
atio
n
Rescue Airways
bull Gum Elastic Bougie (GEB) bull Laryngeal Mask Airway (LMAILMA) bull Combitube bull Surgical Cricothyrotomy
Gum elastic bougie
Gum elastic bouge bull Useful only when
larynges is visualise at least partially
bull Difficulty intubation bull Tube changing bull Provision to
supplement oxygen
Advanced airway ndashBest choice Intubation
Equipments Needed
Laryngoscope with different types of blade
ET tube with proper size and type Average adult male 85 mm Average adult female 75 mm Low pressure cuff tubes above 5 years Uncuffed tubes below 5 years
lt 4 Age + 35
3
gt 4 Age + 45
4
Laryngoscope
Macoy Laryngoscope
Align the airway axis by proper positions
Intubation Axis
ET Tube insertion
Reverse Ramp Position
Cricoid pressure
Pressure on Cricoid cartilage Compress oesophagus between Cricoid ring and Vertebral column Prevent Regurgitation and Aspiration Make cord visualisation difficult Not recommended in Crash airway
External Laryngeal manipulation
BURP - Backward - Upward - Right- Posterior Pressure over thyroid cartilage Better vocal cord visualisation A grade 3 larynx become grade 2 with ELM It is not Cricoid pressure
Blind insertion devices
LMA Combitube Kingrsquos airway
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
Non-maintainable Airway
R S I
Conscious patient Semiconscious with retained reflexes
RSI Defined
ldquoVirtually simultaneous administration of a potent sedative agent and a neuromuscular blocking agent to induce unconsciousness and motor paralysis for tracheal intubationrdquo
What are The Problems Inherent to Intubation
bull Laryngoscopy and Intubation ndash Increased bronchospasm ndash Increased ICP ndash Increased catecholamine release
Beneficial Effects of RSI
bull ldquoTight Headsrdquo ndash Intracranial pathology
bull ldquoTight Heartsrdquo or ldquoTight Vesselsrdquo ndash Cardiovascular disease
bull ldquoTight Lungsrdquo ndash Reactive airway disease
Conventional With LMA
Pre Oxygenationhellip
RSI TimelineT ndash 10 minutes Prepare T ndash 5 minutes Preoxygenate T ndash 3 minutes Pretreat T = 0 Paralysis with
induction T + 30 seconds Protection T + 45 seconds Placement T + 90 seconds Post-Intubation
management
Problem Airway
epiglottis Vocal cords
Airway Evaluation
Double set up bull Neuromuscular paralysis generally
should be avoided in patients for whom a high degree of intubation difficulty is predicted unless the administration of the neuromuscular blocking agent (NMBA) is part of a planned approach to the difficult airway
Look Externally bull Severely bruised
bull Bloodied face of a combative trauma patient bull Immobilised in a cervical collar on a spine board bull Anatomical deformities
bull Subjective clinical judgment can be highly specific (90) but insensitive and so should be augmented by other evaluations
Obstruction or obesitybull Visualization of the glottis or intubation
itself mechanically impossible bull Epiglottis head and neck cancer Ludwigrsquos
angina neck hematoma or glottic polyps bull Examine the patient for airway obstruction
and assess the patientrsquos voice to satisfy this evaluation step
Neck mobility
bull Neck mobility is desirable for any intubation technique and is essential for positioning the patient for optimal direct laryngoscopy Neck mobility is assessed with the patientrsquos flexion and extension of the head and neck through a full range of motion
Lemon in ER setting
bull Unresponsive patient - Mallampatti is not practical - LEON
bull Unresponsive plus Trauma - Mallampatti and Neck mobility are not practical - LEO
Cormack and Lehane[CL]
bull The most widely used system for grading laryngoscopic view of the glottis is that of Cormack and Lehane (CL)
bull Grades laryngoscopy according to the extent to which laryngeal and glottic structures can be seen
CL grading bull Grade 1 laryngoscopy all or nearly all of the glottic aperture is seen bull Grade 2 laryngoscopy visualizes only a portion of the glottis
(arytenoid cartilages alone or arytenoid cartilages plus part of the vocal cords)
bull Grade 3 laryngoscopy visualizes only the epiglottis bull Grade 4 laryngoscopy not even the epiglottis is visible
Percentage Of Glottic Opening (POGO) score
Confirmation of Endotracheal Tube Placement
bull Direct visualisation bull Chest auscultation bull Gastric auscultation bull Bag resistance bull Exhaled volume bull Visualization of condensation within the ETT bull Chest radiography bull All are prone to failure as means of confirming tracheal intubation
ETCO2bull End-tidal carbon dioxide (ETCO2) detection
device to the ETT and assess it through six manual ventilations
bull Disposable colorimetric ETCO2 detectors are highly reliable convenient and easy to interpret indicating adequate CO2 detection by color change
End tidal CO2 detection
USG- EDDbull When ETCO2 detection
is not possible tracheal tube position can be confirmed with other techniques
bull One novel approach Bedside ultrasound
USG guided Intubation and placement confirmation
Esophageal Detector Devices (EDD)
EDD - how to work
Recognize Adequacy of Ventilations
Pulse oximeter
Approximate Blood oxygen level
SpO2 100 = PaO2 100mm of Hg SpO2 90= PaO2 60mm of Hg SpO2 60= PaO2 30mm of Hg SpO2 50= PaO2 27mm of Hg
Chest X raybull Although chest
radiography is universally recommended after ETT placement its primary purpose is to ensure that the tube is well positioned below the cords and above the carina
Other methods Gold standard
bull Fiberoptic confirmation
Difficult Airway Assessment
bull 4 Drsquos ndash Distortion Disproportion Dysmobility Dentition
bull BONES ndash Beard Obese No teeth Elderly Snores (sleep apnea)
bull SHORT ndash Surgery (headneckjaw) Hematoma Obese Radiation Tumor
bull LEMON bull MALLAMPATI bull Always have a ldquoRescue Airwayrdquo technique ready
McI
ntyr
e T
he d
iffic
ult t
rach
eal i
ntub
atio
n
Rescue Airways
bull Gum Elastic Bougie (GEB) bull Laryngeal Mask Airway (LMAILMA) bull Combitube bull Surgical Cricothyrotomy
Gum elastic bougie
Gum elastic bouge bull Useful only when
larynges is visualise at least partially
bull Difficulty intubation bull Tube changing bull Provision to
supplement oxygen
Advanced airway ndashBest choice Intubation
Equipments Needed
Laryngoscope with different types of blade
ET tube with proper size and type Average adult male 85 mm Average adult female 75 mm Low pressure cuff tubes above 5 years Uncuffed tubes below 5 years
lt 4 Age + 35
3
gt 4 Age + 45
4
Laryngoscope
Macoy Laryngoscope
Align the airway axis by proper positions
Intubation Axis
ET Tube insertion
Reverse Ramp Position
Cricoid pressure
Pressure on Cricoid cartilage Compress oesophagus between Cricoid ring and Vertebral column Prevent Regurgitation and Aspiration Make cord visualisation difficult Not recommended in Crash airway
External Laryngeal manipulation
BURP - Backward - Upward - Right- Posterior Pressure over thyroid cartilage Better vocal cord visualisation A grade 3 larynx become grade 2 with ELM It is not Cricoid pressure
Blind insertion devices
LMA Combitube Kingrsquos airway
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
RSI Defined
ldquoVirtually simultaneous administration of a potent sedative agent and a neuromuscular blocking agent to induce unconsciousness and motor paralysis for tracheal intubationrdquo
What are The Problems Inherent to Intubation
bull Laryngoscopy and Intubation ndash Increased bronchospasm ndash Increased ICP ndash Increased catecholamine release
Beneficial Effects of RSI
bull ldquoTight Headsrdquo ndash Intracranial pathology
bull ldquoTight Heartsrdquo or ldquoTight Vesselsrdquo ndash Cardiovascular disease
bull ldquoTight Lungsrdquo ndash Reactive airway disease
Conventional With LMA
Pre Oxygenationhellip
RSI TimelineT ndash 10 minutes Prepare T ndash 5 minutes Preoxygenate T ndash 3 minutes Pretreat T = 0 Paralysis with
induction T + 30 seconds Protection T + 45 seconds Placement T + 90 seconds Post-Intubation
management
Problem Airway
epiglottis Vocal cords
Airway Evaluation
Double set up bull Neuromuscular paralysis generally
should be avoided in patients for whom a high degree of intubation difficulty is predicted unless the administration of the neuromuscular blocking agent (NMBA) is part of a planned approach to the difficult airway
Look Externally bull Severely bruised
bull Bloodied face of a combative trauma patient bull Immobilised in a cervical collar on a spine board bull Anatomical deformities
bull Subjective clinical judgment can be highly specific (90) but insensitive and so should be augmented by other evaluations
Obstruction or obesitybull Visualization of the glottis or intubation
itself mechanically impossible bull Epiglottis head and neck cancer Ludwigrsquos
angina neck hematoma or glottic polyps bull Examine the patient for airway obstruction
and assess the patientrsquos voice to satisfy this evaluation step
Neck mobility
bull Neck mobility is desirable for any intubation technique and is essential for positioning the patient for optimal direct laryngoscopy Neck mobility is assessed with the patientrsquos flexion and extension of the head and neck through a full range of motion
Lemon in ER setting
bull Unresponsive patient - Mallampatti is not practical - LEON
bull Unresponsive plus Trauma - Mallampatti and Neck mobility are not practical - LEO
Cormack and Lehane[CL]
bull The most widely used system for grading laryngoscopic view of the glottis is that of Cormack and Lehane (CL)
bull Grades laryngoscopy according to the extent to which laryngeal and glottic structures can be seen
CL grading bull Grade 1 laryngoscopy all or nearly all of the glottic aperture is seen bull Grade 2 laryngoscopy visualizes only a portion of the glottis
(arytenoid cartilages alone or arytenoid cartilages plus part of the vocal cords)
bull Grade 3 laryngoscopy visualizes only the epiglottis bull Grade 4 laryngoscopy not even the epiglottis is visible
Percentage Of Glottic Opening (POGO) score
Confirmation of Endotracheal Tube Placement
bull Direct visualisation bull Chest auscultation bull Gastric auscultation bull Bag resistance bull Exhaled volume bull Visualization of condensation within the ETT bull Chest radiography bull All are prone to failure as means of confirming tracheal intubation
ETCO2bull End-tidal carbon dioxide (ETCO2) detection
device to the ETT and assess it through six manual ventilations
bull Disposable colorimetric ETCO2 detectors are highly reliable convenient and easy to interpret indicating adequate CO2 detection by color change
End tidal CO2 detection
USG- EDDbull When ETCO2 detection
is not possible tracheal tube position can be confirmed with other techniques
bull One novel approach Bedside ultrasound
USG guided Intubation and placement confirmation
Esophageal Detector Devices (EDD)
EDD - how to work
Recognize Adequacy of Ventilations
Pulse oximeter
Approximate Blood oxygen level
SpO2 100 = PaO2 100mm of Hg SpO2 90= PaO2 60mm of Hg SpO2 60= PaO2 30mm of Hg SpO2 50= PaO2 27mm of Hg
Chest X raybull Although chest
radiography is universally recommended after ETT placement its primary purpose is to ensure that the tube is well positioned below the cords and above the carina
Other methods Gold standard
bull Fiberoptic confirmation
Difficult Airway Assessment
bull 4 Drsquos ndash Distortion Disproportion Dysmobility Dentition
bull BONES ndash Beard Obese No teeth Elderly Snores (sleep apnea)
bull SHORT ndash Surgery (headneckjaw) Hematoma Obese Radiation Tumor
bull LEMON bull MALLAMPATI bull Always have a ldquoRescue Airwayrdquo technique ready
McI
ntyr
e T
he d
iffic
ult t
rach
eal i
ntub
atio
n
Rescue Airways
bull Gum Elastic Bougie (GEB) bull Laryngeal Mask Airway (LMAILMA) bull Combitube bull Surgical Cricothyrotomy
Gum elastic bougie
Gum elastic bouge bull Useful only when
larynges is visualise at least partially
bull Difficulty intubation bull Tube changing bull Provision to
supplement oxygen
Advanced airway ndashBest choice Intubation
Equipments Needed
Laryngoscope with different types of blade
ET tube with proper size and type Average adult male 85 mm Average adult female 75 mm Low pressure cuff tubes above 5 years Uncuffed tubes below 5 years
lt 4 Age + 35
3
gt 4 Age + 45
4
Laryngoscope
Macoy Laryngoscope
Align the airway axis by proper positions
Intubation Axis
ET Tube insertion
Reverse Ramp Position
Cricoid pressure
Pressure on Cricoid cartilage Compress oesophagus between Cricoid ring and Vertebral column Prevent Regurgitation and Aspiration Make cord visualisation difficult Not recommended in Crash airway
External Laryngeal manipulation
BURP - Backward - Upward - Right- Posterior Pressure over thyroid cartilage Better vocal cord visualisation A grade 3 larynx become grade 2 with ELM It is not Cricoid pressure
Blind insertion devices
LMA Combitube Kingrsquos airway
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
What are The Problems Inherent to Intubation
bull Laryngoscopy and Intubation ndash Increased bronchospasm ndash Increased ICP ndash Increased catecholamine release
Beneficial Effects of RSI
bull ldquoTight Headsrdquo ndash Intracranial pathology
bull ldquoTight Heartsrdquo or ldquoTight Vesselsrdquo ndash Cardiovascular disease
bull ldquoTight Lungsrdquo ndash Reactive airway disease
Conventional With LMA
Pre Oxygenationhellip
RSI TimelineT ndash 10 minutes Prepare T ndash 5 minutes Preoxygenate T ndash 3 minutes Pretreat T = 0 Paralysis with
induction T + 30 seconds Protection T + 45 seconds Placement T + 90 seconds Post-Intubation
management
Problem Airway
epiglottis Vocal cords
Airway Evaluation
Double set up bull Neuromuscular paralysis generally
should be avoided in patients for whom a high degree of intubation difficulty is predicted unless the administration of the neuromuscular blocking agent (NMBA) is part of a planned approach to the difficult airway
Look Externally bull Severely bruised
bull Bloodied face of a combative trauma patient bull Immobilised in a cervical collar on a spine board bull Anatomical deformities
bull Subjective clinical judgment can be highly specific (90) but insensitive and so should be augmented by other evaluations
Obstruction or obesitybull Visualization of the glottis or intubation
itself mechanically impossible bull Epiglottis head and neck cancer Ludwigrsquos
angina neck hematoma or glottic polyps bull Examine the patient for airway obstruction
and assess the patientrsquos voice to satisfy this evaluation step
Neck mobility
bull Neck mobility is desirable for any intubation technique and is essential for positioning the patient for optimal direct laryngoscopy Neck mobility is assessed with the patientrsquos flexion and extension of the head and neck through a full range of motion
Lemon in ER setting
bull Unresponsive patient - Mallampatti is not practical - LEON
bull Unresponsive plus Trauma - Mallampatti and Neck mobility are not practical - LEO
Cormack and Lehane[CL]
bull The most widely used system for grading laryngoscopic view of the glottis is that of Cormack and Lehane (CL)
bull Grades laryngoscopy according to the extent to which laryngeal and glottic structures can be seen
CL grading bull Grade 1 laryngoscopy all or nearly all of the glottic aperture is seen bull Grade 2 laryngoscopy visualizes only a portion of the glottis
(arytenoid cartilages alone or arytenoid cartilages plus part of the vocal cords)
bull Grade 3 laryngoscopy visualizes only the epiglottis bull Grade 4 laryngoscopy not even the epiglottis is visible
Percentage Of Glottic Opening (POGO) score
Confirmation of Endotracheal Tube Placement
bull Direct visualisation bull Chest auscultation bull Gastric auscultation bull Bag resistance bull Exhaled volume bull Visualization of condensation within the ETT bull Chest radiography bull All are prone to failure as means of confirming tracheal intubation
ETCO2bull End-tidal carbon dioxide (ETCO2) detection
device to the ETT and assess it through six manual ventilations
bull Disposable colorimetric ETCO2 detectors are highly reliable convenient and easy to interpret indicating adequate CO2 detection by color change
End tidal CO2 detection
USG- EDDbull When ETCO2 detection
is not possible tracheal tube position can be confirmed with other techniques
bull One novel approach Bedside ultrasound
USG guided Intubation and placement confirmation
Esophageal Detector Devices (EDD)
EDD - how to work
Recognize Adequacy of Ventilations
Pulse oximeter
Approximate Blood oxygen level
SpO2 100 = PaO2 100mm of Hg SpO2 90= PaO2 60mm of Hg SpO2 60= PaO2 30mm of Hg SpO2 50= PaO2 27mm of Hg
Chest X raybull Although chest
radiography is universally recommended after ETT placement its primary purpose is to ensure that the tube is well positioned below the cords and above the carina
Other methods Gold standard
bull Fiberoptic confirmation
Difficult Airway Assessment
bull 4 Drsquos ndash Distortion Disproportion Dysmobility Dentition
bull BONES ndash Beard Obese No teeth Elderly Snores (sleep apnea)
bull SHORT ndash Surgery (headneckjaw) Hematoma Obese Radiation Tumor
bull LEMON bull MALLAMPATI bull Always have a ldquoRescue Airwayrdquo technique ready
McI
ntyr
e T
he d
iffic
ult t
rach
eal i
ntub
atio
n
Rescue Airways
bull Gum Elastic Bougie (GEB) bull Laryngeal Mask Airway (LMAILMA) bull Combitube bull Surgical Cricothyrotomy
Gum elastic bougie
Gum elastic bouge bull Useful only when
larynges is visualise at least partially
bull Difficulty intubation bull Tube changing bull Provision to
supplement oxygen
Advanced airway ndashBest choice Intubation
Equipments Needed
Laryngoscope with different types of blade
ET tube with proper size and type Average adult male 85 mm Average adult female 75 mm Low pressure cuff tubes above 5 years Uncuffed tubes below 5 years
lt 4 Age + 35
3
gt 4 Age + 45
4
Laryngoscope
Macoy Laryngoscope
Align the airway axis by proper positions
Intubation Axis
ET Tube insertion
Reverse Ramp Position
Cricoid pressure
Pressure on Cricoid cartilage Compress oesophagus between Cricoid ring and Vertebral column Prevent Regurgitation and Aspiration Make cord visualisation difficult Not recommended in Crash airway
External Laryngeal manipulation
BURP - Backward - Upward - Right- Posterior Pressure over thyroid cartilage Better vocal cord visualisation A grade 3 larynx become grade 2 with ELM It is not Cricoid pressure
Blind insertion devices
LMA Combitube Kingrsquos airway
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
Beneficial Effects of RSI
bull ldquoTight Headsrdquo ndash Intracranial pathology
bull ldquoTight Heartsrdquo or ldquoTight Vesselsrdquo ndash Cardiovascular disease
bull ldquoTight Lungsrdquo ndash Reactive airway disease
Conventional With LMA
Pre Oxygenationhellip
RSI TimelineT ndash 10 minutes Prepare T ndash 5 minutes Preoxygenate T ndash 3 minutes Pretreat T = 0 Paralysis with
induction T + 30 seconds Protection T + 45 seconds Placement T + 90 seconds Post-Intubation
management
Problem Airway
epiglottis Vocal cords
Airway Evaluation
Double set up bull Neuromuscular paralysis generally
should be avoided in patients for whom a high degree of intubation difficulty is predicted unless the administration of the neuromuscular blocking agent (NMBA) is part of a planned approach to the difficult airway
Look Externally bull Severely bruised
bull Bloodied face of a combative trauma patient bull Immobilised in a cervical collar on a spine board bull Anatomical deformities
bull Subjective clinical judgment can be highly specific (90) but insensitive and so should be augmented by other evaluations
Obstruction or obesitybull Visualization of the glottis or intubation
itself mechanically impossible bull Epiglottis head and neck cancer Ludwigrsquos
angina neck hematoma or glottic polyps bull Examine the patient for airway obstruction
and assess the patientrsquos voice to satisfy this evaluation step
Neck mobility
bull Neck mobility is desirable for any intubation technique and is essential for positioning the patient for optimal direct laryngoscopy Neck mobility is assessed with the patientrsquos flexion and extension of the head and neck through a full range of motion
Lemon in ER setting
bull Unresponsive patient - Mallampatti is not practical - LEON
bull Unresponsive plus Trauma - Mallampatti and Neck mobility are not practical - LEO
Cormack and Lehane[CL]
bull The most widely used system for grading laryngoscopic view of the glottis is that of Cormack and Lehane (CL)
bull Grades laryngoscopy according to the extent to which laryngeal and glottic structures can be seen
CL grading bull Grade 1 laryngoscopy all or nearly all of the glottic aperture is seen bull Grade 2 laryngoscopy visualizes only a portion of the glottis
(arytenoid cartilages alone or arytenoid cartilages plus part of the vocal cords)
bull Grade 3 laryngoscopy visualizes only the epiglottis bull Grade 4 laryngoscopy not even the epiglottis is visible
Percentage Of Glottic Opening (POGO) score
Confirmation of Endotracheal Tube Placement
bull Direct visualisation bull Chest auscultation bull Gastric auscultation bull Bag resistance bull Exhaled volume bull Visualization of condensation within the ETT bull Chest radiography bull All are prone to failure as means of confirming tracheal intubation
ETCO2bull End-tidal carbon dioxide (ETCO2) detection
device to the ETT and assess it through six manual ventilations
bull Disposable colorimetric ETCO2 detectors are highly reliable convenient and easy to interpret indicating adequate CO2 detection by color change
End tidal CO2 detection
USG- EDDbull When ETCO2 detection
is not possible tracheal tube position can be confirmed with other techniques
bull One novel approach Bedside ultrasound
USG guided Intubation and placement confirmation
Esophageal Detector Devices (EDD)
EDD - how to work
Recognize Adequacy of Ventilations
Pulse oximeter
Approximate Blood oxygen level
SpO2 100 = PaO2 100mm of Hg SpO2 90= PaO2 60mm of Hg SpO2 60= PaO2 30mm of Hg SpO2 50= PaO2 27mm of Hg
Chest X raybull Although chest
radiography is universally recommended after ETT placement its primary purpose is to ensure that the tube is well positioned below the cords and above the carina
Other methods Gold standard
bull Fiberoptic confirmation
Difficult Airway Assessment
bull 4 Drsquos ndash Distortion Disproportion Dysmobility Dentition
bull BONES ndash Beard Obese No teeth Elderly Snores (sleep apnea)
bull SHORT ndash Surgery (headneckjaw) Hematoma Obese Radiation Tumor
bull LEMON bull MALLAMPATI bull Always have a ldquoRescue Airwayrdquo technique ready
McI
ntyr
e T
he d
iffic
ult t
rach
eal i
ntub
atio
n
Rescue Airways
bull Gum Elastic Bougie (GEB) bull Laryngeal Mask Airway (LMAILMA) bull Combitube bull Surgical Cricothyrotomy
Gum elastic bougie
Gum elastic bouge bull Useful only when
larynges is visualise at least partially
bull Difficulty intubation bull Tube changing bull Provision to
supplement oxygen
Advanced airway ndashBest choice Intubation
Equipments Needed
Laryngoscope with different types of blade
ET tube with proper size and type Average adult male 85 mm Average adult female 75 mm Low pressure cuff tubes above 5 years Uncuffed tubes below 5 years
lt 4 Age + 35
3
gt 4 Age + 45
4
Laryngoscope
Macoy Laryngoscope
Align the airway axis by proper positions
Intubation Axis
ET Tube insertion
Reverse Ramp Position
Cricoid pressure
Pressure on Cricoid cartilage Compress oesophagus between Cricoid ring and Vertebral column Prevent Regurgitation and Aspiration Make cord visualisation difficult Not recommended in Crash airway
External Laryngeal manipulation
BURP - Backward - Upward - Right- Posterior Pressure over thyroid cartilage Better vocal cord visualisation A grade 3 larynx become grade 2 with ELM It is not Cricoid pressure
Blind insertion devices
LMA Combitube Kingrsquos airway
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
Conventional With LMA
Pre Oxygenationhellip
RSI TimelineT ndash 10 minutes Prepare T ndash 5 minutes Preoxygenate T ndash 3 minutes Pretreat T = 0 Paralysis with
induction T + 30 seconds Protection T + 45 seconds Placement T + 90 seconds Post-Intubation
management
Problem Airway
epiglottis Vocal cords
Airway Evaluation
Double set up bull Neuromuscular paralysis generally
should be avoided in patients for whom a high degree of intubation difficulty is predicted unless the administration of the neuromuscular blocking agent (NMBA) is part of a planned approach to the difficult airway
Look Externally bull Severely bruised
bull Bloodied face of a combative trauma patient bull Immobilised in a cervical collar on a spine board bull Anatomical deformities
bull Subjective clinical judgment can be highly specific (90) but insensitive and so should be augmented by other evaluations
Obstruction or obesitybull Visualization of the glottis or intubation
itself mechanically impossible bull Epiglottis head and neck cancer Ludwigrsquos
angina neck hematoma or glottic polyps bull Examine the patient for airway obstruction
and assess the patientrsquos voice to satisfy this evaluation step
Neck mobility
bull Neck mobility is desirable for any intubation technique and is essential for positioning the patient for optimal direct laryngoscopy Neck mobility is assessed with the patientrsquos flexion and extension of the head and neck through a full range of motion
Lemon in ER setting
bull Unresponsive patient - Mallampatti is not practical - LEON
bull Unresponsive plus Trauma - Mallampatti and Neck mobility are not practical - LEO
Cormack and Lehane[CL]
bull The most widely used system for grading laryngoscopic view of the glottis is that of Cormack and Lehane (CL)
bull Grades laryngoscopy according to the extent to which laryngeal and glottic structures can be seen
CL grading bull Grade 1 laryngoscopy all or nearly all of the glottic aperture is seen bull Grade 2 laryngoscopy visualizes only a portion of the glottis
(arytenoid cartilages alone or arytenoid cartilages plus part of the vocal cords)
bull Grade 3 laryngoscopy visualizes only the epiglottis bull Grade 4 laryngoscopy not even the epiglottis is visible
Percentage Of Glottic Opening (POGO) score
Confirmation of Endotracheal Tube Placement
bull Direct visualisation bull Chest auscultation bull Gastric auscultation bull Bag resistance bull Exhaled volume bull Visualization of condensation within the ETT bull Chest radiography bull All are prone to failure as means of confirming tracheal intubation
ETCO2bull End-tidal carbon dioxide (ETCO2) detection
device to the ETT and assess it through six manual ventilations
bull Disposable colorimetric ETCO2 detectors are highly reliable convenient and easy to interpret indicating adequate CO2 detection by color change
End tidal CO2 detection
USG- EDDbull When ETCO2 detection
is not possible tracheal tube position can be confirmed with other techniques
bull One novel approach Bedside ultrasound
USG guided Intubation and placement confirmation
Esophageal Detector Devices (EDD)
EDD - how to work
Recognize Adequacy of Ventilations
Pulse oximeter
Approximate Blood oxygen level
SpO2 100 = PaO2 100mm of Hg SpO2 90= PaO2 60mm of Hg SpO2 60= PaO2 30mm of Hg SpO2 50= PaO2 27mm of Hg
Chest X raybull Although chest
radiography is universally recommended after ETT placement its primary purpose is to ensure that the tube is well positioned below the cords and above the carina
Other methods Gold standard
bull Fiberoptic confirmation
Difficult Airway Assessment
bull 4 Drsquos ndash Distortion Disproportion Dysmobility Dentition
bull BONES ndash Beard Obese No teeth Elderly Snores (sleep apnea)
bull SHORT ndash Surgery (headneckjaw) Hematoma Obese Radiation Tumor
bull LEMON bull MALLAMPATI bull Always have a ldquoRescue Airwayrdquo technique ready
McI
ntyr
e T
he d
iffic
ult t
rach
eal i
ntub
atio
n
Rescue Airways
bull Gum Elastic Bougie (GEB) bull Laryngeal Mask Airway (LMAILMA) bull Combitube bull Surgical Cricothyrotomy
Gum elastic bougie
Gum elastic bouge bull Useful only when
larynges is visualise at least partially
bull Difficulty intubation bull Tube changing bull Provision to
supplement oxygen
Advanced airway ndashBest choice Intubation
Equipments Needed
Laryngoscope with different types of blade
ET tube with proper size and type Average adult male 85 mm Average adult female 75 mm Low pressure cuff tubes above 5 years Uncuffed tubes below 5 years
lt 4 Age + 35
3
gt 4 Age + 45
4
Laryngoscope
Macoy Laryngoscope
Align the airway axis by proper positions
Intubation Axis
ET Tube insertion
Reverse Ramp Position
Cricoid pressure
Pressure on Cricoid cartilage Compress oesophagus between Cricoid ring and Vertebral column Prevent Regurgitation and Aspiration Make cord visualisation difficult Not recommended in Crash airway
External Laryngeal manipulation
BURP - Backward - Upward - Right- Posterior Pressure over thyroid cartilage Better vocal cord visualisation A grade 3 larynx become grade 2 with ELM It is not Cricoid pressure
Blind insertion devices
LMA Combitube Kingrsquos airway
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
RSI TimelineT ndash 10 minutes Prepare T ndash 5 minutes Preoxygenate T ndash 3 minutes Pretreat T = 0 Paralysis with
induction T + 30 seconds Protection T + 45 seconds Placement T + 90 seconds Post-Intubation
management
Problem Airway
epiglottis Vocal cords
Airway Evaluation
Double set up bull Neuromuscular paralysis generally
should be avoided in patients for whom a high degree of intubation difficulty is predicted unless the administration of the neuromuscular blocking agent (NMBA) is part of a planned approach to the difficult airway
Look Externally bull Severely bruised
bull Bloodied face of a combative trauma patient bull Immobilised in a cervical collar on a spine board bull Anatomical deformities
bull Subjective clinical judgment can be highly specific (90) but insensitive and so should be augmented by other evaluations
Obstruction or obesitybull Visualization of the glottis or intubation
itself mechanically impossible bull Epiglottis head and neck cancer Ludwigrsquos
angina neck hematoma or glottic polyps bull Examine the patient for airway obstruction
and assess the patientrsquos voice to satisfy this evaluation step
Neck mobility
bull Neck mobility is desirable for any intubation technique and is essential for positioning the patient for optimal direct laryngoscopy Neck mobility is assessed with the patientrsquos flexion and extension of the head and neck through a full range of motion
Lemon in ER setting
bull Unresponsive patient - Mallampatti is not practical - LEON
bull Unresponsive plus Trauma - Mallampatti and Neck mobility are not practical - LEO
Cormack and Lehane[CL]
bull The most widely used system for grading laryngoscopic view of the glottis is that of Cormack and Lehane (CL)
bull Grades laryngoscopy according to the extent to which laryngeal and glottic structures can be seen
CL grading bull Grade 1 laryngoscopy all or nearly all of the glottic aperture is seen bull Grade 2 laryngoscopy visualizes only a portion of the glottis
(arytenoid cartilages alone or arytenoid cartilages plus part of the vocal cords)
bull Grade 3 laryngoscopy visualizes only the epiglottis bull Grade 4 laryngoscopy not even the epiglottis is visible
Percentage Of Glottic Opening (POGO) score
Confirmation of Endotracheal Tube Placement
bull Direct visualisation bull Chest auscultation bull Gastric auscultation bull Bag resistance bull Exhaled volume bull Visualization of condensation within the ETT bull Chest radiography bull All are prone to failure as means of confirming tracheal intubation
ETCO2bull End-tidal carbon dioxide (ETCO2) detection
device to the ETT and assess it through six manual ventilations
bull Disposable colorimetric ETCO2 detectors are highly reliable convenient and easy to interpret indicating adequate CO2 detection by color change
End tidal CO2 detection
USG- EDDbull When ETCO2 detection
is not possible tracheal tube position can be confirmed with other techniques
bull One novel approach Bedside ultrasound
USG guided Intubation and placement confirmation
Esophageal Detector Devices (EDD)
EDD - how to work
Recognize Adequacy of Ventilations
Pulse oximeter
Approximate Blood oxygen level
SpO2 100 = PaO2 100mm of Hg SpO2 90= PaO2 60mm of Hg SpO2 60= PaO2 30mm of Hg SpO2 50= PaO2 27mm of Hg
Chest X raybull Although chest
radiography is universally recommended after ETT placement its primary purpose is to ensure that the tube is well positioned below the cords and above the carina
Other methods Gold standard
bull Fiberoptic confirmation
Difficult Airway Assessment
bull 4 Drsquos ndash Distortion Disproportion Dysmobility Dentition
bull BONES ndash Beard Obese No teeth Elderly Snores (sleep apnea)
bull SHORT ndash Surgery (headneckjaw) Hematoma Obese Radiation Tumor
bull LEMON bull MALLAMPATI bull Always have a ldquoRescue Airwayrdquo technique ready
McI
ntyr
e T
he d
iffic
ult t
rach
eal i
ntub
atio
n
Rescue Airways
bull Gum Elastic Bougie (GEB) bull Laryngeal Mask Airway (LMAILMA) bull Combitube bull Surgical Cricothyrotomy
Gum elastic bougie
Gum elastic bouge bull Useful only when
larynges is visualise at least partially
bull Difficulty intubation bull Tube changing bull Provision to
supplement oxygen
Advanced airway ndashBest choice Intubation
Equipments Needed
Laryngoscope with different types of blade
ET tube with proper size and type Average adult male 85 mm Average adult female 75 mm Low pressure cuff tubes above 5 years Uncuffed tubes below 5 years
lt 4 Age + 35
3
gt 4 Age + 45
4
Laryngoscope
Macoy Laryngoscope
Align the airway axis by proper positions
Intubation Axis
ET Tube insertion
Reverse Ramp Position
Cricoid pressure
Pressure on Cricoid cartilage Compress oesophagus between Cricoid ring and Vertebral column Prevent Regurgitation and Aspiration Make cord visualisation difficult Not recommended in Crash airway
External Laryngeal manipulation
BURP - Backward - Upward - Right- Posterior Pressure over thyroid cartilage Better vocal cord visualisation A grade 3 larynx become grade 2 with ELM It is not Cricoid pressure
Blind insertion devices
LMA Combitube Kingrsquos airway
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
Problem Airway
epiglottis Vocal cords
Airway Evaluation
Double set up bull Neuromuscular paralysis generally
should be avoided in patients for whom a high degree of intubation difficulty is predicted unless the administration of the neuromuscular blocking agent (NMBA) is part of a planned approach to the difficult airway
Look Externally bull Severely bruised
bull Bloodied face of a combative trauma patient bull Immobilised in a cervical collar on a spine board bull Anatomical deformities
bull Subjective clinical judgment can be highly specific (90) but insensitive and so should be augmented by other evaluations
Obstruction or obesitybull Visualization of the glottis or intubation
itself mechanically impossible bull Epiglottis head and neck cancer Ludwigrsquos
angina neck hematoma or glottic polyps bull Examine the patient for airway obstruction
and assess the patientrsquos voice to satisfy this evaluation step
Neck mobility
bull Neck mobility is desirable for any intubation technique and is essential for positioning the patient for optimal direct laryngoscopy Neck mobility is assessed with the patientrsquos flexion and extension of the head and neck through a full range of motion
Lemon in ER setting
bull Unresponsive patient - Mallampatti is not practical - LEON
bull Unresponsive plus Trauma - Mallampatti and Neck mobility are not practical - LEO
Cormack and Lehane[CL]
bull The most widely used system for grading laryngoscopic view of the glottis is that of Cormack and Lehane (CL)
bull Grades laryngoscopy according to the extent to which laryngeal and glottic structures can be seen
CL grading bull Grade 1 laryngoscopy all or nearly all of the glottic aperture is seen bull Grade 2 laryngoscopy visualizes only a portion of the glottis
(arytenoid cartilages alone or arytenoid cartilages plus part of the vocal cords)
bull Grade 3 laryngoscopy visualizes only the epiglottis bull Grade 4 laryngoscopy not even the epiglottis is visible
Percentage Of Glottic Opening (POGO) score
Confirmation of Endotracheal Tube Placement
bull Direct visualisation bull Chest auscultation bull Gastric auscultation bull Bag resistance bull Exhaled volume bull Visualization of condensation within the ETT bull Chest radiography bull All are prone to failure as means of confirming tracheal intubation
ETCO2bull End-tidal carbon dioxide (ETCO2) detection
device to the ETT and assess it through six manual ventilations
bull Disposable colorimetric ETCO2 detectors are highly reliable convenient and easy to interpret indicating adequate CO2 detection by color change
End tidal CO2 detection
USG- EDDbull When ETCO2 detection
is not possible tracheal tube position can be confirmed with other techniques
bull One novel approach Bedside ultrasound
USG guided Intubation and placement confirmation
Esophageal Detector Devices (EDD)
EDD - how to work
Recognize Adequacy of Ventilations
Pulse oximeter
Approximate Blood oxygen level
SpO2 100 = PaO2 100mm of Hg SpO2 90= PaO2 60mm of Hg SpO2 60= PaO2 30mm of Hg SpO2 50= PaO2 27mm of Hg
Chest X raybull Although chest
radiography is universally recommended after ETT placement its primary purpose is to ensure that the tube is well positioned below the cords and above the carina
Other methods Gold standard
bull Fiberoptic confirmation
Difficult Airway Assessment
bull 4 Drsquos ndash Distortion Disproportion Dysmobility Dentition
bull BONES ndash Beard Obese No teeth Elderly Snores (sleep apnea)
bull SHORT ndash Surgery (headneckjaw) Hematoma Obese Radiation Tumor
bull LEMON bull MALLAMPATI bull Always have a ldquoRescue Airwayrdquo technique ready
McI
ntyr
e T
he d
iffic
ult t
rach
eal i
ntub
atio
n
Rescue Airways
bull Gum Elastic Bougie (GEB) bull Laryngeal Mask Airway (LMAILMA) bull Combitube bull Surgical Cricothyrotomy
Gum elastic bougie
Gum elastic bouge bull Useful only when
larynges is visualise at least partially
bull Difficulty intubation bull Tube changing bull Provision to
supplement oxygen
Advanced airway ndashBest choice Intubation
Equipments Needed
Laryngoscope with different types of blade
ET tube with proper size and type Average adult male 85 mm Average adult female 75 mm Low pressure cuff tubes above 5 years Uncuffed tubes below 5 years
lt 4 Age + 35
3
gt 4 Age + 45
4
Laryngoscope
Macoy Laryngoscope
Align the airway axis by proper positions
Intubation Axis
ET Tube insertion
Reverse Ramp Position
Cricoid pressure
Pressure on Cricoid cartilage Compress oesophagus between Cricoid ring and Vertebral column Prevent Regurgitation and Aspiration Make cord visualisation difficult Not recommended in Crash airway
External Laryngeal manipulation
BURP - Backward - Upward - Right- Posterior Pressure over thyroid cartilage Better vocal cord visualisation A grade 3 larynx become grade 2 with ELM It is not Cricoid pressure
Blind insertion devices
LMA Combitube Kingrsquos airway
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
Double set up bull Neuromuscular paralysis generally
should be avoided in patients for whom a high degree of intubation difficulty is predicted unless the administration of the neuromuscular blocking agent (NMBA) is part of a planned approach to the difficult airway
Look Externally bull Severely bruised
bull Bloodied face of a combative trauma patient bull Immobilised in a cervical collar on a spine board bull Anatomical deformities
bull Subjective clinical judgment can be highly specific (90) but insensitive and so should be augmented by other evaluations
Obstruction or obesitybull Visualization of the glottis or intubation
itself mechanically impossible bull Epiglottis head and neck cancer Ludwigrsquos
angina neck hematoma or glottic polyps bull Examine the patient for airway obstruction
and assess the patientrsquos voice to satisfy this evaluation step
Neck mobility
bull Neck mobility is desirable for any intubation technique and is essential for positioning the patient for optimal direct laryngoscopy Neck mobility is assessed with the patientrsquos flexion and extension of the head and neck through a full range of motion
Lemon in ER setting
bull Unresponsive patient - Mallampatti is not practical - LEON
bull Unresponsive plus Trauma - Mallampatti and Neck mobility are not practical - LEO
Cormack and Lehane[CL]
bull The most widely used system for grading laryngoscopic view of the glottis is that of Cormack and Lehane (CL)
bull Grades laryngoscopy according to the extent to which laryngeal and glottic structures can be seen
CL grading bull Grade 1 laryngoscopy all or nearly all of the glottic aperture is seen bull Grade 2 laryngoscopy visualizes only a portion of the glottis
(arytenoid cartilages alone or arytenoid cartilages plus part of the vocal cords)
bull Grade 3 laryngoscopy visualizes only the epiglottis bull Grade 4 laryngoscopy not even the epiglottis is visible
Percentage Of Glottic Opening (POGO) score
Confirmation of Endotracheal Tube Placement
bull Direct visualisation bull Chest auscultation bull Gastric auscultation bull Bag resistance bull Exhaled volume bull Visualization of condensation within the ETT bull Chest radiography bull All are prone to failure as means of confirming tracheal intubation
ETCO2bull End-tidal carbon dioxide (ETCO2) detection
device to the ETT and assess it through six manual ventilations
bull Disposable colorimetric ETCO2 detectors are highly reliable convenient and easy to interpret indicating adequate CO2 detection by color change
End tidal CO2 detection
USG- EDDbull When ETCO2 detection
is not possible tracheal tube position can be confirmed with other techniques
bull One novel approach Bedside ultrasound
USG guided Intubation and placement confirmation
Esophageal Detector Devices (EDD)
EDD - how to work
Recognize Adequacy of Ventilations
Pulse oximeter
Approximate Blood oxygen level
SpO2 100 = PaO2 100mm of Hg SpO2 90= PaO2 60mm of Hg SpO2 60= PaO2 30mm of Hg SpO2 50= PaO2 27mm of Hg
Chest X raybull Although chest
radiography is universally recommended after ETT placement its primary purpose is to ensure that the tube is well positioned below the cords and above the carina
Other methods Gold standard
bull Fiberoptic confirmation
Difficult Airway Assessment
bull 4 Drsquos ndash Distortion Disproportion Dysmobility Dentition
bull BONES ndash Beard Obese No teeth Elderly Snores (sleep apnea)
bull SHORT ndash Surgery (headneckjaw) Hematoma Obese Radiation Tumor
bull LEMON bull MALLAMPATI bull Always have a ldquoRescue Airwayrdquo technique ready
McI
ntyr
e T
he d
iffic
ult t
rach
eal i
ntub
atio
n
Rescue Airways
bull Gum Elastic Bougie (GEB) bull Laryngeal Mask Airway (LMAILMA) bull Combitube bull Surgical Cricothyrotomy
Gum elastic bougie
Gum elastic bouge bull Useful only when
larynges is visualise at least partially
bull Difficulty intubation bull Tube changing bull Provision to
supplement oxygen
Advanced airway ndashBest choice Intubation
Equipments Needed
Laryngoscope with different types of blade
ET tube with proper size and type Average adult male 85 mm Average adult female 75 mm Low pressure cuff tubes above 5 years Uncuffed tubes below 5 years
lt 4 Age + 35
3
gt 4 Age + 45
4
Laryngoscope
Macoy Laryngoscope
Align the airway axis by proper positions
Intubation Axis
ET Tube insertion
Reverse Ramp Position
Cricoid pressure
Pressure on Cricoid cartilage Compress oesophagus between Cricoid ring and Vertebral column Prevent Regurgitation and Aspiration Make cord visualisation difficult Not recommended in Crash airway
External Laryngeal manipulation
BURP - Backward - Upward - Right- Posterior Pressure over thyroid cartilage Better vocal cord visualisation A grade 3 larynx become grade 2 with ELM It is not Cricoid pressure
Blind insertion devices
LMA Combitube Kingrsquos airway
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
Look Externally bull Severely bruised
bull Bloodied face of a combative trauma patient bull Immobilised in a cervical collar on a spine board bull Anatomical deformities
bull Subjective clinical judgment can be highly specific (90) but insensitive and so should be augmented by other evaluations
Obstruction or obesitybull Visualization of the glottis or intubation
itself mechanically impossible bull Epiglottis head and neck cancer Ludwigrsquos
angina neck hematoma or glottic polyps bull Examine the patient for airway obstruction
and assess the patientrsquos voice to satisfy this evaluation step
Neck mobility
bull Neck mobility is desirable for any intubation technique and is essential for positioning the patient for optimal direct laryngoscopy Neck mobility is assessed with the patientrsquos flexion and extension of the head and neck through a full range of motion
Lemon in ER setting
bull Unresponsive patient - Mallampatti is not practical - LEON
bull Unresponsive plus Trauma - Mallampatti and Neck mobility are not practical - LEO
Cormack and Lehane[CL]
bull The most widely used system for grading laryngoscopic view of the glottis is that of Cormack and Lehane (CL)
bull Grades laryngoscopy according to the extent to which laryngeal and glottic structures can be seen
CL grading bull Grade 1 laryngoscopy all or nearly all of the glottic aperture is seen bull Grade 2 laryngoscopy visualizes only a portion of the glottis
(arytenoid cartilages alone or arytenoid cartilages plus part of the vocal cords)
bull Grade 3 laryngoscopy visualizes only the epiglottis bull Grade 4 laryngoscopy not even the epiglottis is visible
Percentage Of Glottic Opening (POGO) score
Confirmation of Endotracheal Tube Placement
bull Direct visualisation bull Chest auscultation bull Gastric auscultation bull Bag resistance bull Exhaled volume bull Visualization of condensation within the ETT bull Chest radiography bull All are prone to failure as means of confirming tracheal intubation
ETCO2bull End-tidal carbon dioxide (ETCO2) detection
device to the ETT and assess it through six manual ventilations
bull Disposable colorimetric ETCO2 detectors are highly reliable convenient and easy to interpret indicating adequate CO2 detection by color change
End tidal CO2 detection
USG- EDDbull When ETCO2 detection
is not possible tracheal tube position can be confirmed with other techniques
bull One novel approach Bedside ultrasound
USG guided Intubation and placement confirmation
Esophageal Detector Devices (EDD)
EDD - how to work
Recognize Adequacy of Ventilations
Pulse oximeter
Approximate Blood oxygen level
SpO2 100 = PaO2 100mm of Hg SpO2 90= PaO2 60mm of Hg SpO2 60= PaO2 30mm of Hg SpO2 50= PaO2 27mm of Hg
Chest X raybull Although chest
radiography is universally recommended after ETT placement its primary purpose is to ensure that the tube is well positioned below the cords and above the carina
Other methods Gold standard
bull Fiberoptic confirmation
Difficult Airway Assessment
bull 4 Drsquos ndash Distortion Disproportion Dysmobility Dentition
bull BONES ndash Beard Obese No teeth Elderly Snores (sleep apnea)
bull SHORT ndash Surgery (headneckjaw) Hematoma Obese Radiation Tumor
bull LEMON bull MALLAMPATI bull Always have a ldquoRescue Airwayrdquo technique ready
McI
ntyr
e T
he d
iffic
ult t
rach
eal i
ntub
atio
n
Rescue Airways
bull Gum Elastic Bougie (GEB) bull Laryngeal Mask Airway (LMAILMA) bull Combitube bull Surgical Cricothyrotomy
Gum elastic bougie
Gum elastic bouge bull Useful only when
larynges is visualise at least partially
bull Difficulty intubation bull Tube changing bull Provision to
supplement oxygen
Advanced airway ndashBest choice Intubation
Equipments Needed
Laryngoscope with different types of blade
ET tube with proper size and type Average adult male 85 mm Average adult female 75 mm Low pressure cuff tubes above 5 years Uncuffed tubes below 5 years
lt 4 Age + 35
3
gt 4 Age + 45
4
Laryngoscope
Macoy Laryngoscope
Align the airway axis by proper positions
Intubation Axis
ET Tube insertion
Reverse Ramp Position
Cricoid pressure
Pressure on Cricoid cartilage Compress oesophagus between Cricoid ring and Vertebral column Prevent Regurgitation and Aspiration Make cord visualisation difficult Not recommended in Crash airway
External Laryngeal manipulation
BURP - Backward - Upward - Right- Posterior Pressure over thyroid cartilage Better vocal cord visualisation A grade 3 larynx become grade 2 with ELM It is not Cricoid pressure
Blind insertion devices
LMA Combitube Kingrsquos airway
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
Obstruction or obesitybull Visualization of the glottis or intubation
itself mechanically impossible bull Epiglottis head and neck cancer Ludwigrsquos
angina neck hematoma or glottic polyps bull Examine the patient for airway obstruction
and assess the patientrsquos voice to satisfy this evaluation step
Neck mobility
bull Neck mobility is desirable for any intubation technique and is essential for positioning the patient for optimal direct laryngoscopy Neck mobility is assessed with the patientrsquos flexion and extension of the head and neck through a full range of motion
Lemon in ER setting
bull Unresponsive patient - Mallampatti is not practical - LEON
bull Unresponsive plus Trauma - Mallampatti and Neck mobility are not practical - LEO
Cormack and Lehane[CL]
bull The most widely used system for grading laryngoscopic view of the glottis is that of Cormack and Lehane (CL)
bull Grades laryngoscopy according to the extent to which laryngeal and glottic structures can be seen
CL grading bull Grade 1 laryngoscopy all or nearly all of the glottic aperture is seen bull Grade 2 laryngoscopy visualizes only a portion of the glottis
(arytenoid cartilages alone or arytenoid cartilages plus part of the vocal cords)
bull Grade 3 laryngoscopy visualizes only the epiglottis bull Grade 4 laryngoscopy not even the epiglottis is visible
Percentage Of Glottic Opening (POGO) score
Confirmation of Endotracheal Tube Placement
bull Direct visualisation bull Chest auscultation bull Gastric auscultation bull Bag resistance bull Exhaled volume bull Visualization of condensation within the ETT bull Chest radiography bull All are prone to failure as means of confirming tracheal intubation
ETCO2bull End-tidal carbon dioxide (ETCO2) detection
device to the ETT and assess it through six manual ventilations
bull Disposable colorimetric ETCO2 detectors are highly reliable convenient and easy to interpret indicating adequate CO2 detection by color change
End tidal CO2 detection
USG- EDDbull When ETCO2 detection
is not possible tracheal tube position can be confirmed with other techniques
bull One novel approach Bedside ultrasound
USG guided Intubation and placement confirmation
Esophageal Detector Devices (EDD)
EDD - how to work
Recognize Adequacy of Ventilations
Pulse oximeter
Approximate Blood oxygen level
SpO2 100 = PaO2 100mm of Hg SpO2 90= PaO2 60mm of Hg SpO2 60= PaO2 30mm of Hg SpO2 50= PaO2 27mm of Hg
Chest X raybull Although chest
radiography is universally recommended after ETT placement its primary purpose is to ensure that the tube is well positioned below the cords and above the carina
Other methods Gold standard
bull Fiberoptic confirmation
Difficult Airway Assessment
bull 4 Drsquos ndash Distortion Disproportion Dysmobility Dentition
bull BONES ndash Beard Obese No teeth Elderly Snores (sleep apnea)
bull SHORT ndash Surgery (headneckjaw) Hematoma Obese Radiation Tumor
bull LEMON bull MALLAMPATI bull Always have a ldquoRescue Airwayrdquo technique ready
McI
ntyr
e T
he d
iffic
ult t
rach
eal i
ntub
atio
n
Rescue Airways
bull Gum Elastic Bougie (GEB) bull Laryngeal Mask Airway (LMAILMA) bull Combitube bull Surgical Cricothyrotomy
Gum elastic bougie
Gum elastic bouge bull Useful only when
larynges is visualise at least partially
bull Difficulty intubation bull Tube changing bull Provision to
supplement oxygen
Advanced airway ndashBest choice Intubation
Equipments Needed
Laryngoscope with different types of blade
ET tube with proper size and type Average adult male 85 mm Average adult female 75 mm Low pressure cuff tubes above 5 years Uncuffed tubes below 5 years
lt 4 Age + 35
3
gt 4 Age + 45
4
Laryngoscope
Macoy Laryngoscope
Align the airway axis by proper positions
Intubation Axis
ET Tube insertion
Reverse Ramp Position
Cricoid pressure
Pressure on Cricoid cartilage Compress oesophagus between Cricoid ring and Vertebral column Prevent Regurgitation and Aspiration Make cord visualisation difficult Not recommended in Crash airway
External Laryngeal manipulation
BURP - Backward - Upward - Right- Posterior Pressure over thyroid cartilage Better vocal cord visualisation A grade 3 larynx become grade 2 with ELM It is not Cricoid pressure
Blind insertion devices
LMA Combitube Kingrsquos airway
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
Neck mobility
bull Neck mobility is desirable for any intubation technique and is essential for positioning the patient for optimal direct laryngoscopy Neck mobility is assessed with the patientrsquos flexion and extension of the head and neck through a full range of motion
Lemon in ER setting
bull Unresponsive patient - Mallampatti is not practical - LEON
bull Unresponsive plus Trauma - Mallampatti and Neck mobility are not practical - LEO
Cormack and Lehane[CL]
bull The most widely used system for grading laryngoscopic view of the glottis is that of Cormack and Lehane (CL)
bull Grades laryngoscopy according to the extent to which laryngeal and glottic structures can be seen
CL grading bull Grade 1 laryngoscopy all or nearly all of the glottic aperture is seen bull Grade 2 laryngoscopy visualizes only a portion of the glottis
(arytenoid cartilages alone or arytenoid cartilages plus part of the vocal cords)
bull Grade 3 laryngoscopy visualizes only the epiglottis bull Grade 4 laryngoscopy not even the epiglottis is visible
Percentage Of Glottic Opening (POGO) score
Confirmation of Endotracheal Tube Placement
bull Direct visualisation bull Chest auscultation bull Gastric auscultation bull Bag resistance bull Exhaled volume bull Visualization of condensation within the ETT bull Chest radiography bull All are prone to failure as means of confirming tracheal intubation
ETCO2bull End-tidal carbon dioxide (ETCO2) detection
device to the ETT and assess it through six manual ventilations
bull Disposable colorimetric ETCO2 detectors are highly reliable convenient and easy to interpret indicating adequate CO2 detection by color change
End tidal CO2 detection
USG- EDDbull When ETCO2 detection
is not possible tracheal tube position can be confirmed with other techniques
bull One novel approach Bedside ultrasound
USG guided Intubation and placement confirmation
Esophageal Detector Devices (EDD)
EDD - how to work
Recognize Adequacy of Ventilations
Pulse oximeter
Approximate Blood oxygen level
SpO2 100 = PaO2 100mm of Hg SpO2 90= PaO2 60mm of Hg SpO2 60= PaO2 30mm of Hg SpO2 50= PaO2 27mm of Hg
Chest X raybull Although chest
radiography is universally recommended after ETT placement its primary purpose is to ensure that the tube is well positioned below the cords and above the carina
Other methods Gold standard
bull Fiberoptic confirmation
Difficult Airway Assessment
bull 4 Drsquos ndash Distortion Disproportion Dysmobility Dentition
bull BONES ndash Beard Obese No teeth Elderly Snores (sleep apnea)
bull SHORT ndash Surgery (headneckjaw) Hematoma Obese Radiation Tumor
bull LEMON bull MALLAMPATI bull Always have a ldquoRescue Airwayrdquo technique ready
McI
ntyr
e T
he d
iffic
ult t
rach
eal i
ntub
atio
n
Rescue Airways
bull Gum Elastic Bougie (GEB) bull Laryngeal Mask Airway (LMAILMA) bull Combitube bull Surgical Cricothyrotomy
Gum elastic bougie
Gum elastic bouge bull Useful only when
larynges is visualise at least partially
bull Difficulty intubation bull Tube changing bull Provision to
supplement oxygen
Advanced airway ndashBest choice Intubation
Equipments Needed
Laryngoscope with different types of blade
ET tube with proper size and type Average adult male 85 mm Average adult female 75 mm Low pressure cuff tubes above 5 years Uncuffed tubes below 5 years
lt 4 Age + 35
3
gt 4 Age + 45
4
Laryngoscope
Macoy Laryngoscope
Align the airway axis by proper positions
Intubation Axis
ET Tube insertion
Reverse Ramp Position
Cricoid pressure
Pressure on Cricoid cartilage Compress oesophagus between Cricoid ring and Vertebral column Prevent Regurgitation and Aspiration Make cord visualisation difficult Not recommended in Crash airway
External Laryngeal manipulation
BURP - Backward - Upward - Right- Posterior Pressure over thyroid cartilage Better vocal cord visualisation A grade 3 larynx become grade 2 with ELM It is not Cricoid pressure
Blind insertion devices
LMA Combitube Kingrsquos airway
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
Lemon in ER setting
bull Unresponsive patient - Mallampatti is not practical - LEON
bull Unresponsive plus Trauma - Mallampatti and Neck mobility are not practical - LEO
Cormack and Lehane[CL]
bull The most widely used system for grading laryngoscopic view of the glottis is that of Cormack and Lehane (CL)
bull Grades laryngoscopy according to the extent to which laryngeal and glottic structures can be seen
CL grading bull Grade 1 laryngoscopy all or nearly all of the glottic aperture is seen bull Grade 2 laryngoscopy visualizes only a portion of the glottis
(arytenoid cartilages alone or arytenoid cartilages plus part of the vocal cords)
bull Grade 3 laryngoscopy visualizes only the epiglottis bull Grade 4 laryngoscopy not even the epiglottis is visible
Percentage Of Glottic Opening (POGO) score
Confirmation of Endotracheal Tube Placement
bull Direct visualisation bull Chest auscultation bull Gastric auscultation bull Bag resistance bull Exhaled volume bull Visualization of condensation within the ETT bull Chest radiography bull All are prone to failure as means of confirming tracheal intubation
ETCO2bull End-tidal carbon dioxide (ETCO2) detection
device to the ETT and assess it through six manual ventilations
bull Disposable colorimetric ETCO2 detectors are highly reliable convenient and easy to interpret indicating adequate CO2 detection by color change
End tidal CO2 detection
USG- EDDbull When ETCO2 detection
is not possible tracheal tube position can be confirmed with other techniques
bull One novel approach Bedside ultrasound
USG guided Intubation and placement confirmation
Esophageal Detector Devices (EDD)
EDD - how to work
Recognize Adequacy of Ventilations
Pulse oximeter
Approximate Blood oxygen level
SpO2 100 = PaO2 100mm of Hg SpO2 90= PaO2 60mm of Hg SpO2 60= PaO2 30mm of Hg SpO2 50= PaO2 27mm of Hg
Chest X raybull Although chest
radiography is universally recommended after ETT placement its primary purpose is to ensure that the tube is well positioned below the cords and above the carina
Other methods Gold standard
bull Fiberoptic confirmation
Difficult Airway Assessment
bull 4 Drsquos ndash Distortion Disproportion Dysmobility Dentition
bull BONES ndash Beard Obese No teeth Elderly Snores (sleep apnea)
bull SHORT ndash Surgery (headneckjaw) Hematoma Obese Radiation Tumor
bull LEMON bull MALLAMPATI bull Always have a ldquoRescue Airwayrdquo technique ready
McI
ntyr
e T
he d
iffic
ult t
rach
eal i
ntub
atio
n
Rescue Airways
bull Gum Elastic Bougie (GEB) bull Laryngeal Mask Airway (LMAILMA) bull Combitube bull Surgical Cricothyrotomy
Gum elastic bougie
Gum elastic bouge bull Useful only when
larynges is visualise at least partially
bull Difficulty intubation bull Tube changing bull Provision to
supplement oxygen
Advanced airway ndashBest choice Intubation
Equipments Needed
Laryngoscope with different types of blade
ET tube with proper size and type Average adult male 85 mm Average adult female 75 mm Low pressure cuff tubes above 5 years Uncuffed tubes below 5 years
lt 4 Age + 35
3
gt 4 Age + 45
4
Laryngoscope
Macoy Laryngoscope
Align the airway axis by proper positions
Intubation Axis
ET Tube insertion
Reverse Ramp Position
Cricoid pressure
Pressure on Cricoid cartilage Compress oesophagus between Cricoid ring and Vertebral column Prevent Regurgitation and Aspiration Make cord visualisation difficult Not recommended in Crash airway
External Laryngeal manipulation
BURP - Backward - Upward - Right- Posterior Pressure over thyroid cartilage Better vocal cord visualisation A grade 3 larynx become grade 2 with ELM It is not Cricoid pressure
Blind insertion devices
LMA Combitube Kingrsquos airway
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
Cormack and Lehane[CL]
bull The most widely used system for grading laryngoscopic view of the glottis is that of Cormack and Lehane (CL)
bull Grades laryngoscopy according to the extent to which laryngeal and glottic structures can be seen
CL grading bull Grade 1 laryngoscopy all or nearly all of the glottic aperture is seen bull Grade 2 laryngoscopy visualizes only a portion of the glottis
(arytenoid cartilages alone or arytenoid cartilages plus part of the vocal cords)
bull Grade 3 laryngoscopy visualizes only the epiglottis bull Grade 4 laryngoscopy not even the epiglottis is visible
Percentage Of Glottic Opening (POGO) score
Confirmation of Endotracheal Tube Placement
bull Direct visualisation bull Chest auscultation bull Gastric auscultation bull Bag resistance bull Exhaled volume bull Visualization of condensation within the ETT bull Chest radiography bull All are prone to failure as means of confirming tracheal intubation
ETCO2bull End-tidal carbon dioxide (ETCO2) detection
device to the ETT and assess it through six manual ventilations
bull Disposable colorimetric ETCO2 detectors are highly reliable convenient and easy to interpret indicating adequate CO2 detection by color change
End tidal CO2 detection
USG- EDDbull When ETCO2 detection
is not possible tracheal tube position can be confirmed with other techniques
bull One novel approach Bedside ultrasound
USG guided Intubation and placement confirmation
Esophageal Detector Devices (EDD)
EDD - how to work
Recognize Adequacy of Ventilations
Pulse oximeter
Approximate Blood oxygen level
SpO2 100 = PaO2 100mm of Hg SpO2 90= PaO2 60mm of Hg SpO2 60= PaO2 30mm of Hg SpO2 50= PaO2 27mm of Hg
Chest X raybull Although chest
radiography is universally recommended after ETT placement its primary purpose is to ensure that the tube is well positioned below the cords and above the carina
Other methods Gold standard
bull Fiberoptic confirmation
Difficult Airway Assessment
bull 4 Drsquos ndash Distortion Disproportion Dysmobility Dentition
bull BONES ndash Beard Obese No teeth Elderly Snores (sleep apnea)
bull SHORT ndash Surgery (headneckjaw) Hematoma Obese Radiation Tumor
bull LEMON bull MALLAMPATI bull Always have a ldquoRescue Airwayrdquo technique ready
McI
ntyr
e T
he d
iffic
ult t
rach
eal i
ntub
atio
n
Rescue Airways
bull Gum Elastic Bougie (GEB) bull Laryngeal Mask Airway (LMAILMA) bull Combitube bull Surgical Cricothyrotomy
Gum elastic bougie
Gum elastic bouge bull Useful only when
larynges is visualise at least partially
bull Difficulty intubation bull Tube changing bull Provision to
supplement oxygen
Advanced airway ndashBest choice Intubation
Equipments Needed
Laryngoscope with different types of blade
ET tube with proper size and type Average adult male 85 mm Average adult female 75 mm Low pressure cuff tubes above 5 years Uncuffed tubes below 5 years
lt 4 Age + 35
3
gt 4 Age + 45
4
Laryngoscope
Macoy Laryngoscope
Align the airway axis by proper positions
Intubation Axis
ET Tube insertion
Reverse Ramp Position
Cricoid pressure
Pressure on Cricoid cartilage Compress oesophagus between Cricoid ring and Vertebral column Prevent Regurgitation and Aspiration Make cord visualisation difficult Not recommended in Crash airway
External Laryngeal manipulation
BURP - Backward - Upward - Right- Posterior Pressure over thyroid cartilage Better vocal cord visualisation A grade 3 larynx become grade 2 with ELM It is not Cricoid pressure
Blind insertion devices
LMA Combitube Kingrsquos airway
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
CL grading bull Grade 1 laryngoscopy all or nearly all of the glottic aperture is seen bull Grade 2 laryngoscopy visualizes only a portion of the glottis
(arytenoid cartilages alone or arytenoid cartilages plus part of the vocal cords)
bull Grade 3 laryngoscopy visualizes only the epiglottis bull Grade 4 laryngoscopy not even the epiglottis is visible
Percentage Of Glottic Opening (POGO) score
Confirmation of Endotracheal Tube Placement
bull Direct visualisation bull Chest auscultation bull Gastric auscultation bull Bag resistance bull Exhaled volume bull Visualization of condensation within the ETT bull Chest radiography bull All are prone to failure as means of confirming tracheal intubation
ETCO2bull End-tidal carbon dioxide (ETCO2) detection
device to the ETT and assess it through six manual ventilations
bull Disposable colorimetric ETCO2 detectors are highly reliable convenient and easy to interpret indicating adequate CO2 detection by color change
End tidal CO2 detection
USG- EDDbull When ETCO2 detection
is not possible tracheal tube position can be confirmed with other techniques
bull One novel approach Bedside ultrasound
USG guided Intubation and placement confirmation
Esophageal Detector Devices (EDD)
EDD - how to work
Recognize Adequacy of Ventilations
Pulse oximeter
Approximate Blood oxygen level
SpO2 100 = PaO2 100mm of Hg SpO2 90= PaO2 60mm of Hg SpO2 60= PaO2 30mm of Hg SpO2 50= PaO2 27mm of Hg
Chest X raybull Although chest
radiography is universally recommended after ETT placement its primary purpose is to ensure that the tube is well positioned below the cords and above the carina
Other methods Gold standard
bull Fiberoptic confirmation
Difficult Airway Assessment
bull 4 Drsquos ndash Distortion Disproportion Dysmobility Dentition
bull BONES ndash Beard Obese No teeth Elderly Snores (sleep apnea)
bull SHORT ndash Surgery (headneckjaw) Hematoma Obese Radiation Tumor
bull LEMON bull MALLAMPATI bull Always have a ldquoRescue Airwayrdquo technique ready
McI
ntyr
e T
he d
iffic
ult t
rach
eal i
ntub
atio
n
Rescue Airways
bull Gum Elastic Bougie (GEB) bull Laryngeal Mask Airway (LMAILMA) bull Combitube bull Surgical Cricothyrotomy
Gum elastic bougie
Gum elastic bouge bull Useful only when
larynges is visualise at least partially
bull Difficulty intubation bull Tube changing bull Provision to
supplement oxygen
Advanced airway ndashBest choice Intubation
Equipments Needed
Laryngoscope with different types of blade
ET tube with proper size and type Average adult male 85 mm Average adult female 75 mm Low pressure cuff tubes above 5 years Uncuffed tubes below 5 years
lt 4 Age + 35
3
gt 4 Age + 45
4
Laryngoscope
Macoy Laryngoscope
Align the airway axis by proper positions
Intubation Axis
ET Tube insertion
Reverse Ramp Position
Cricoid pressure
Pressure on Cricoid cartilage Compress oesophagus between Cricoid ring and Vertebral column Prevent Regurgitation and Aspiration Make cord visualisation difficult Not recommended in Crash airway
External Laryngeal manipulation
BURP - Backward - Upward - Right- Posterior Pressure over thyroid cartilage Better vocal cord visualisation A grade 3 larynx become grade 2 with ELM It is not Cricoid pressure
Blind insertion devices
LMA Combitube Kingrsquos airway
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
Percentage Of Glottic Opening (POGO) score
Confirmation of Endotracheal Tube Placement
bull Direct visualisation bull Chest auscultation bull Gastric auscultation bull Bag resistance bull Exhaled volume bull Visualization of condensation within the ETT bull Chest radiography bull All are prone to failure as means of confirming tracheal intubation
ETCO2bull End-tidal carbon dioxide (ETCO2) detection
device to the ETT and assess it through six manual ventilations
bull Disposable colorimetric ETCO2 detectors are highly reliable convenient and easy to interpret indicating adequate CO2 detection by color change
End tidal CO2 detection
USG- EDDbull When ETCO2 detection
is not possible tracheal tube position can be confirmed with other techniques
bull One novel approach Bedside ultrasound
USG guided Intubation and placement confirmation
Esophageal Detector Devices (EDD)
EDD - how to work
Recognize Adequacy of Ventilations
Pulse oximeter
Approximate Blood oxygen level
SpO2 100 = PaO2 100mm of Hg SpO2 90= PaO2 60mm of Hg SpO2 60= PaO2 30mm of Hg SpO2 50= PaO2 27mm of Hg
Chest X raybull Although chest
radiography is universally recommended after ETT placement its primary purpose is to ensure that the tube is well positioned below the cords and above the carina
Other methods Gold standard
bull Fiberoptic confirmation
Difficult Airway Assessment
bull 4 Drsquos ndash Distortion Disproportion Dysmobility Dentition
bull BONES ndash Beard Obese No teeth Elderly Snores (sleep apnea)
bull SHORT ndash Surgery (headneckjaw) Hematoma Obese Radiation Tumor
bull LEMON bull MALLAMPATI bull Always have a ldquoRescue Airwayrdquo technique ready
McI
ntyr
e T
he d
iffic
ult t
rach
eal i
ntub
atio
n
Rescue Airways
bull Gum Elastic Bougie (GEB) bull Laryngeal Mask Airway (LMAILMA) bull Combitube bull Surgical Cricothyrotomy
Gum elastic bougie
Gum elastic bouge bull Useful only when
larynges is visualise at least partially
bull Difficulty intubation bull Tube changing bull Provision to
supplement oxygen
Advanced airway ndashBest choice Intubation
Equipments Needed
Laryngoscope with different types of blade
ET tube with proper size and type Average adult male 85 mm Average adult female 75 mm Low pressure cuff tubes above 5 years Uncuffed tubes below 5 years
lt 4 Age + 35
3
gt 4 Age + 45
4
Laryngoscope
Macoy Laryngoscope
Align the airway axis by proper positions
Intubation Axis
ET Tube insertion
Reverse Ramp Position
Cricoid pressure
Pressure on Cricoid cartilage Compress oesophagus between Cricoid ring and Vertebral column Prevent Regurgitation and Aspiration Make cord visualisation difficult Not recommended in Crash airway
External Laryngeal manipulation
BURP - Backward - Upward - Right- Posterior Pressure over thyroid cartilage Better vocal cord visualisation A grade 3 larynx become grade 2 with ELM It is not Cricoid pressure
Blind insertion devices
LMA Combitube Kingrsquos airway
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
Confirmation of Endotracheal Tube Placement
bull Direct visualisation bull Chest auscultation bull Gastric auscultation bull Bag resistance bull Exhaled volume bull Visualization of condensation within the ETT bull Chest radiography bull All are prone to failure as means of confirming tracheal intubation
ETCO2bull End-tidal carbon dioxide (ETCO2) detection
device to the ETT and assess it through six manual ventilations
bull Disposable colorimetric ETCO2 detectors are highly reliable convenient and easy to interpret indicating adequate CO2 detection by color change
End tidal CO2 detection
USG- EDDbull When ETCO2 detection
is not possible tracheal tube position can be confirmed with other techniques
bull One novel approach Bedside ultrasound
USG guided Intubation and placement confirmation
Esophageal Detector Devices (EDD)
EDD - how to work
Recognize Adequacy of Ventilations
Pulse oximeter
Approximate Blood oxygen level
SpO2 100 = PaO2 100mm of Hg SpO2 90= PaO2 60mm of Hg SpO2 60= PaO2 30mm of Hg SpO2 50= PaO2 27mm of Hg
Chest X raybull Although chest
radiography is universally recommended after ETT placement its primary purpose is to ensure that the tube is well positioned below the cords and above the carina
Other methods Gold standard
bull Fiberoptic confirmation
Difficult Airway Assessment
bull 4 Drsquos ndash Distortion Disproportion Dysmobility Dentition
bull BONES ndash Beard Obese No teeth Elderly Snores (sleep apnea)
bull SHORT ndash Surgery (headneckjaw) Hematoma Obese Radiation Tumor
bull LEMON bull MALLAMPATI bull Always have a ldquoRescue Airwayrdquo technique ready
McI
ntyr
e T
he d
iffic
ult t
rach
eal i
ntub
atio
n
Rescue Airways
bull Gum Elastic Bougie (GEB) bull Laryngeal Mask Airway (LMAILMA) bull Combitube bull Surgical Cricothyrotomy
Gum elastic bougie
Gum elastic bouge bull Useful only when
larynges is visualise at least partially
bull Difficulty intubation bull Tube changing bull Provision to
supplement oxygen
Advanced airway ndashBest choice Intubation
Equipments Needed
Laryngoscope with different types of blade
ET tube with proper size and type Average adult male 85 mm Average adult female 75 mm Low pressure cuff tubes above 5 years Uncuffed tubes below 5 years
lt 4 Age + 35
3
gt 4 Age + 45
4
Laryngoscope
Macoy Laryngoscope
Align the airway axis by proper positions
Intubation Axis
ET Tube insertion
Reverse Ramp Position
Cricoid pressure
Pressure on Cricoid cartilage Compress oesophagus between Cricoid ring and Vertebral column Prevent Regurgitation and Aspiration Make cord visualisation difficult Not recommended in Crash airway
External Laryngeal manipulation
BURP - Backward - Upward - Right- Posterior Pressure over thyroid cartilage Better vocal cord visualisation A grade 3 larynx become grade 2 with ELM It is not Cricoid pressure
Blind insertion devices
LMA Combitube Kingrsquos airway
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
ETCO2bull End-tidal carbon dioxide (ETCO2) detection
device to the ETT and assess it through six manual ventilations
bull Disposable colorimetric ETCO2 detectors are highly reliable convenient and easy to interpret indicating adequate CO2 detection by color change
End tidal CO2 detection
USG- EDDbull When ETCO2 detection
is not possible tracheal tube position can be confirmed with other techniques
bull One novel approach Bedside ultrasound
USG guided Intubation and placement confirmation
Esophageal Detector Devices (EDD)
EDD - how to work
Recognize Adequacy of Ventilations
Pulse oximeter
Approximate Blood oxygen level
SpO2 100 = PaO2 100mm of Hg SpO2 90= PaO2 60mm of Hg SpO2 60= PaO2 30mm of Hg SpO2 50= PaO2 27mm of Hg
Chest X raybull Although chest
radiography is universally recommended after ETT placement its primary purpose is to ensure that the tube is well positioned below the cords and above the carina
Other methods Gold standard
bull Fiberoptic confirmation
Difficult Airway Assessment
bull 4 Drsquos ndash Distortion Disproportion Dysmobility Dentition
bull BONES ndash Beard Obese No teeth Elderly Snores (sleep apnea)
bull SHORT ndash Surgery (headneckjaw) Hematoma Obese Radiation Tumor
bull LEMON bull MALLAMPATI bull Always have a ldquoRescue Airwayrdquo technique ready
McI
ntyr
e T
he d
iffic
ult t
rach
eal i
ntub
atio
n
Rescue Airways
bull Gum Elastic Bougie (GEB) bull Laryngeal Mask Airway (LMAILMA) bull Combitube bull Surgical Cricothyrotomy
Gum elastic bougie
Gum elastic bouge bull Useful only when
larynges is visualise at least partially
bull Difficulty intubation bull Tube changing bull Provision to
supplement oxygen
Advanced airway ndashBest choice Intubation
Equipments Needed
Laryngoscope with different types of blade
ET tube with proper size and type Average adult male 85 mm Average adult female 75 mm Low pressure cuff tubes above 5 years Uncuffed tubes below 5 years
lt 4 Age + 35
3
gt 4 Age + 45
4
Laryngoscope
Macoy Laryngoscope
Align the airway axis by proper positions
Intubation Axis
ET Tube insertion
Reverse Ramp Position
Cricoid pressure
Pressure on Cricoid cartilage Compress oesophagus between Cricoid ring and Vertebral column Prevent Regurgitation and Aspiration Make cord visualisation difficult Not recommended in Crash airway
External Laryngeal manipulation
BURP - Backward - Upward - Right- Posterior Pressure over thyroid cartilage Better vocal cord visualisation A grade 3 larynx become grade 2 with ELM It is not Cricoid pressure
Blind insertion devices
LMA Combitube Kingrsquos airway
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
End tidal CO2 detection
USG- EDDbull When ETCO2 detection
is not possible tracheal tube position can be confirmed with other techniques
bull One novel approach Bedside ultrasound
USG guided Intubation and placement confirmation
Esophageal Detector Devices (EDD)
EDD - how to work
Recognize Adequacy of Ventilations
Pulse oximeter
Approximate Blood oxygen level
SpO2 100 = PaO2 100mm of Hg SpO2 90= PaO2 60mm of Hg SpO2 60= PaO2 30mm of Hg SpO2 50= PaO2 27mm of Hg
Chest X raybull Although chest
radiography is universally recommended after ETT placement its primary purpose is to ensure that the tube is well positioned below the cords and above the carina
Other methods Gold standard
bull Fiberoptic confirmation
Difficult Airway Assessment
bull 4 Drsquos ndash Distortion Disproportion Dysmobility Dentition
bull BONES ndash Beard Obese No teeth Elderly Snores (sleep apnea)
bull SHORT ndash Surgery (headneckjaw) Hematoma Obese Radiation Tumor
bull LEMON bull MALLAMPATI bull Always have a ldquoRescue Airwayrdquo technique ready
McI
ntyr
e T
he d
iffic
ult t
rach
eal i
ntub
atio
n
Rescue Airways
bull Gum Elastic Bougie (GEB) bull Laryngeal Mask Airway (LMAILMA) bull Combitube bull Surgical Cricothyrotomy
Gum elastic bougie
Gum elastic bouge bull Useful only when
larynges is visualise at least partially
bull Difficulty intubation bull Tube changing bull Provision to
supplement oxygen
Advanced airway ndashBest choice Intubation
Equipments Needed
Laryngoscope with different types of blade
ET tube with proper size and type Average adult male 85 mm Average adult female 75 mm Low pressure cuff tubes above 5 years Uncuffed tubes below 5 years
lt 4 Age + 35
3
gt 4 Age + 45
4
Laryngoscope
Macoy Laryngoscope
Align the airway axis by proper positions
Intubation Axis
ET Tube insertion
Reverse Ramp Position
Cricoid pressure
Pressure on Cricoid cartilage Compress oesophagus between Cricoid ring and Vertebral column Prevent Regurgitation and Aspiration Make cord visualisation difficult Not recommended in Crash airway
External Laryngeal manipulation
BURP - Backward - Upward - Right- Posterior Pressure over thyroid cartilage Better vocal cord visualisation A grade 3 larynx become grade 2 with ELM It is not Cricoid pressure
Blind insertion devices
LMA Combitube Kingrsquos airway
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
USG- EDDbull When ETCO2 detection
is not possible tracheal tube position can be confirmed with other techniques
bull One novel approach Bedside ultrasound
USG guided Intubation and placement confirmation
Esophageal Detector Devices (EDD)
EDD - how to work
Recognize Adequacy of Ventilations
Pulse oximeter
Approximate Blood oxygen level
SpO2 100 = PaO2 100mm of Hg SpO2 90= PaO2 60mm of Hg SpO2 60= PaO2 30mm of Hg SpO2 50= PaO2 27mm of Hg
Chest X raybull Although chest
radiography is universally recommended after ETT placement its primary purpose is to ensure that the tube is well positioned below the cords and above the carina
Other methods Gold standard
bull Fiberoptic confirmation
Difficult Airway Assessment
bull 4 Drsquos ndash Distortion Disproportion Dysmobility Dentition
bull BONES ndash Beard Obese No teeth Elderly Snores (sleep apnea)
bull SHORT ndash Surgery (headneckjaw) Hematoma Obese Radiation Tumor
bull LEMON bull MALLAMPATI bull Always have a ldquoRescue Airwayrdquo technique ready
McI
ntyr
e T
he d
iffic
ult t
rach
eal i
ntub
atio
n
Rescue Airways
bull Gum Elastic Bougie (GEB) bull Laryngeal Mask Airway (LMAILMA) bull Combitube bull Surgical Cricothyrotomy
Gum elastic bougie
Gum elastic bouge bull Useful only when
larynges is visualise at least partially
bull Difficulty intubation bull Tube changing bull Provision to
supplement oxygen
Advanced airway ndashBest choice Intubation
Equipments Needed
Laryngoscope with different types of blade
ET tube with proper size and type Average adult male 85 mm Average adult female 75 mm Low pressure cuff tubes above 5 years Uncuffed tubes below 5 years
lt 4 Age + 35
3
gt 4 Age + 45
4
Laryngoscope
Macoy Laryngoscope
Align the airway axis by proper positions
Intubation Axis
ET Tube insertion
Reverse Ramp Position
Cricoid pressure
Pressure on Cricoid cartilage Compress oesophagus between Cricoid ring and Vertebral column Prevent Regurgitation and Aspiration Make cord visualisation difficult Not recommended in Crash airway
External Laryngeal manipulation
BURP - Backward - Upward - Right- Posterior Pressure over thyroid cartilage Better vocal cord visualisation A grade 3 larynx become grade 2 with ELM It is not Cricoid pressure
Blind insertion devices
LMA Combitube Kingrsquos airway
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
USG guided Intubation and placement confirmation
Esophageal Detector Devices (EDD)
EDD - how to work
Recognize Adequacy of Ventilations
Pulse oximeter
Approximate Blood oxygen level
SpO2 100 = PaO2 100mm of Hg SpO2 90= PaO2 60mm of Hg SpO2 60= PaO2 30mm of Hg SpO2 50= PaO2 27mm of Hg
Chest X raybull Although chest
radiography is universally recommended after ETT placement its primary purpose is to ensure that the tube is well positioned below the cords and above the carina
Other methods Gold standard
bull Fiberoptic confirmation
Difficult Airway Assessment
bull 4 Drsquos ndash Distortion Disproportion Dysmobility Dentition
bull BONES ndash Beard Obese No teeth Elderly Snores (sleep apnea)
bull SHORT ndash Surgery (headneckjaw) Hematoma Obese Radiation Tumor
bull LEMON bull MALLAMPATI bull Always have a ldquoRescue Airwayrdquo technique ready
McI
ntyr
e T
he d
iffic
ult t
rach
eal i
ntub
atio
n
Rescue Airways
bull Gum Elastic Bougie (GEB) bull Laryngeal Mask Airway (LMAILMA) bull Combitube bull Surgical Cricothyrotomy
Gum elastic bougie
Gum elastic bouge bull Useful only when
larynges is visualise at least partially
bull Difficulty intubation bull Tube changing bull Provision to
supplement oxygen
Advanced airway ndashBest choice Intubation
Equipments Needed
Laryngoscope with different types of blade
ET tube with proper size and type Average adult male 85 mm Average adult female 75 mm Low pressure cuff tubes above 5 years Uncuffed tubes below 5 years
lt 4 Age + 35
3
gt 4 Age + 45
4
Laryngoscope
Macoy Laryngoscope
Align the airway axis by proper positions
Intubation Axis
ET Tube insertion
Reverse Ramp Position
Cricoid pressure
Pressure on Cricoid cartilage Compress oesophagus between Cricoid ring and Vertebral column Prevent Regurgitation and Aspiration Make cord visualisation difficult Not recommended in Crash airway
External Laryngeal manipulation
BURP - Backward - Upward - Right- Posterior Pressure over thyroid cartilage Better vocal cord visualisation A grade 3 larynx become grade 2 with ELM It is not Cricoid pressure
Blind insertion devices
LMA Combitube Kingrsquos airway
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
Esophageal Detector Devices (EDD)
EDD - how to work
Recognize Adequacy of Ventilations
Pulse oximeter
Approximate Blood oxygen level
SpO2 100 = PaO2 100mm of Hg SpO2 90= PaO2 60mm of Hg SpO2 60= PaO2 30mm of Hg SpO2 50= PaO2 27mm of Hg
Chest X raybull Although chest
radiography is universally recommended after ETT placement its primary purpose is to ensure that the tube is well positioned below the cords and above the carina
Other methods Gold standard
bull Fiberoptic confirmation
Difficult Airway Assessment
bull 4 Drsquos ndash Distortion Disproportion Dysmobility Dentition
bull BONES ndash Beard Obese No teeth Elderly Snores (sleep apnea)
bull SHORT ndash Surgery (headneckjaw) Hematoma Obese Radiation Tumor
bull LEMON bull MALLAMPATI bull Always have a ldquoRescue Airwayrdquo technique ready
McI
ntyr
e T
he d
iffic
ult t
rach
eal i
ntub
atio
n
Rescue Airways
bull Gum Elastic Bougie (GEB) bull Laryngeal Mask Airway (LMAILMA) bull Combitube bull Surgical Cricothyrotomy
Gum elastic bougie
Gum elastic bouge bull Useful only when
larynges is visualise at least partially
bull Difficulty intubation bull Tube changing bull Provision to
supplement oxygen
Advanced airway ndashBest choice Intubation
Equipments Needed
Laryngoscope with different types of blade
ET tube with proper size and type Average adult male 85 mm Average adult female 75 mm Low pressure cuff tubes above 5 years Uncuffed tubes below 5 years
lt 4 Age + 35
3
gt 4 Age + 45
4
Laryngoscope
Macoy Laryngoscope
Align the airway axis by proper positions
Intubation Axis
ET Tube insertion
Reverse Ramp Position
Cricoid pressure
Pressure on Cricoid cartilage Compress oesophagus between Cricoid ring and Vertebral column Prevent Regurgitation and Aspiration Make cord visualisation difficult Not recommended in Crash airway
External Laryngeal manipulation
BURP - Backward - Upward - Right- Posterior Pressure over thyroid cartilage Better vocal cord visualisation A grade 3 larynx become grade 2 with ELM It is not Cricoid pressure
Blind insertion devices
LMA Combitube Kingrsquos airway
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
EDD - how to work
Recognize Adequacy of Ventilations
Pulse oximeter
Approximate Blood oxygen level
SpO2 100 = PaO2 100mm of Hg SpO2 90= PaO2 60mm of Hg SpO2 60= PaO2 30mm of Hg SpO2 50= PaO2 27mm of Hg
Chest X raybull Although chest
radiography is universally recommended after ETT placement its primary purpose is to ensure that the tube is well positioned below the cords and above the carina
Other methods Gold standard
bull Fiberoptic confirmation
Difficult Airway Assessment
bull 4 Drsquos ndash Distortion Disproportion Dysmobility Dentition
bull BONES ndash Beard Obese No teeth Elderly Snores (sleep apnea)
bull SHORT ndash Surgery (headneckjaw) Hematoma Obese Radiation Tumor
bull LEMON bull MALLAMPATI bull Always have a ldquoRescue Airwayrdquo technique ready
McI
ntyr
e T
he d
iffic
ult t
rach
eal i
ntub
atio
n
Rescue Airways
bull Gum Elastic Bougie (GEB) bull Laryngeal Mask Airway (LMAILMA) bull Combitube bull Surgical Cricothyrotomy
Gum elastic bougie
Gum elastic bouge bull Useful only when
larynges is visualise at least partially
bull Difficulty intubation bull Tube changing bull Provision to
supplement oxygen
Advanced airway ndashBest choice Intubation
Equipments Needed
Laryngoscope with different types of blade
ET tube with proper size and type Average adult male 85 mm Average adult female 75 mm Low pressure cuff tubes above 5 years Uncuffed tubes below 5 years
lt 4 Age + 35
3
gt 4 Age + 45
4
Laryngoscope
Macoy Laryngoscope
Align the airway axis by proper positions
Intubation Axis
ET Tube insertion
Reverse Ramp Position
Cricoid pressure
Pressure on Cricoid cartilage Compress oesophagus between Cricoid ring and Vertebral column Prevent Regurgitation and Aspiration Make cord visualisation difficult Not recommended in Crash airway
External Laryngeal manipulation
BURP - Backward - Upward - Right- Posterior Pressure over thyroid cartilage Better vocal cord visualisation A grade 3 larynx become grade 2 with ELM It is not Cricoid pressure
Blind insertion devices
LMA Combitube Kingrsquos airway
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
Recognize Adequacy of Ventilations
Pulse oximeter
Approximate Blood oxygen level
SpO2 100 = PaO2 100mm of Hg SpO2 90= PaO2 60mm of Hg SpO2 60= PaO2 30mm of Hg SpO2 50= PaO2 27mm of Hg
Chest X raybull Although chest
radiography is universally recommended after ETT placement its primary purpose is to ensure that the tube is well positioned below the cords and above the carina
Other methods Gold standard
bull Fiberoptic confirmation
Difficult Airway Assessment
bull 4 Drsquos ndash Distortion Disproportion Dysmobility Dentition
bull BONES ndash Beard Obese No teeth Elderly Snores (sleep apnea)
bull SHORT ndash Surgery (headneckjaw) Hematoma Obese Radiation Tumor
bull LEMON bull MALLAMPATI bull Always have a ldquoRescue Airwayrdquo technique ready
McI
ntyr
e T
he d
iffic
ult t
rach
eal i
ntub
atio
n
Rescue Airways
bull Gum Elastic Bougie (GEB) bull Laryngeal Mask Airway (LMAILMA) bull Combitube bull Surgical Cricothyrotomy
Gum elastic bougie
Gum elastic bouge bull Useful only when
larynges is visualise at least partially
bull Difficulty intubation bull Tube changing bull Provision to
supplement oxygen
Advanced airway ndashBest choice Intubation
Equipments Needed
Laryngoscope with different types of blade
ET tube with proper size and type Average adult male 85 mm Average adult female 75 mm Low pressure cuff tubes above 5 years Uncuffed tubes below 5 years
lt 4 Age + 35
3
gt 4 Age + 45
4
Laryngoscope
Macoy Laryngoscope
Align the airway axis by proper positions
Intubation Axis
ET Tube insertion
Reverse Ramp Position
Cricoid pressure
Pressure on Cricoid cartilage Compress oesophagus between Cricoid ring and Vertebral column Prevent Regurgitation and Aspiration Make cord visualisation difficult Not recommended in Crash airway
External Laryngeal manipulation
BURP - Backward - Upward - Right- Posterior Pressure over thyroid cartilage Better vocal cord visualisation A grade 3 larynx become grade 2 with ELM It is not Cricoid pressure
Blind insertion devices
LMA Combitube Kingrsquos airway
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
Approximate Blood oxygen level
SpO2 100 = PaO2 100mm of Hg SpO2 90= PaO2 60mm of Hg SpO2 60= PaO2 30mm of Hg SpO2 50= PaO2 27mm of Hg
Chest X raybull Although chest
radiography is universally recommended after ETT placement its primary purpose is to ensure that the tube is well positioned below the cords and above the carina
Other methods Gold standard
bull Fiberoptic confirmation
Difficult Airway Assessment
bull 4 Drsquos ndash Distortion Disproportion Dysmobility Dentition
bull BONES ndash Beard Obese No teeth Elderly Snores (sleep apnea)
bull SHORT ndash Surgery (headneckjaw) Hematoma Obese Radiation Tumor
bull LEMON bull MALLAMPATI bull Always have a ldquoRescue Airwayrdquo technique ready
McI
ntyr
e T
he d
iffic
ult t
rach
eal i
ntub
atio
n
Rescue Airways
bull Gum Elastic Bougie (GEB) bull Laryngeal Mask Airway (LMAILMA) bull Combitube bull Surgical Cricothyrotomy
Gum elastic bougie
Gum elastic bouge bull Useful only when
larynges is visualise at least partially
bull Difficulty intubation bull Tube changing bull Provision to
supplement oxygen
Advanced airway ndashBest choice Intubation
Equipments Needed
Laryngoscope with different types of blade
ET tube with proper size and type Average adult male 85 mm Average adult female 75 mm Low pressure cuff tubes above 5 years Uncuffed tubes below 5 years
lt 4 Age + 35
3
gt 4 Age + 45
4
Laryngoscope
Macoy Laryngoscope
Align the airway axis by proper positions
Intubation Axis
ET Tube insertion
Reverse Ramp Position
Cricoid pressure
Pressure on Cricoid cartilage Compress oesophagus between Cricoid ring and Vertebral column Prevent Regurgitation and Aspiration Make cord visualisation difficult Not recommended in Crash airway
External Laryngeal manipulation
BURP - Backward - Upward - Right- Posterior Pressure over thyroid cartilage Better vocal cord visualisation A grade 3 larynx become grade 2 with ELM It is not Cricoid pressure
Blind insertion devices
LMA Combitube Kingrsquos airway
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
Chest X raybull Although chest
radiography is universally recommended after ETT placement its primary purpose is to ensure that the tube is well positioned below the cords and above the carina
Other methods Gold standard
bull Fiberoptic confirmation
Difficult Airway Assessment
bull 4 Drsquos ndash Distortion Disproportion Dysmobility Dentition
bull BONES ndash Beard Obese No teeth Elderly Snores (sleep apnea)
bull SHORT ndash Surgery (headneckjaw) Hematoma Obese Radiation Tumor
bull LEMON bull MALLAMPATI bull Always have a ldquoRescue Airwayrdquo technique ready
McI
ntyr
e T
he d
iffic
ult t
rach
eal i
ntub
atio
n
Rescue Airways
bull Gum Elastic Bougie (GEB) bull Laryngeal Mask Airway (LMAILMA) bull Combitube bull Surgical Cricothyrotomy
Gum elastic bougie
Gum elastic bouge bull Useful only when
larynges is visualise at least partially
bull Difficulty intubation bull Tube changing bull Provision to
supplement oxygen
Advanced airway ndashBest choice Intubation
Equipments Needed
Laryngoscope with different types of blade
ET tube with proper size and type Average adult male 85 mm Average adult female 75 mm Low pressure cuff tubes above 5 years Uncuffed tubes below 5 years
lt 4 Age + 35
3
gt 4 Age + 45
4
Laryngoscope
Macoy Laryngoscope
Align the airway axis by proper positions
Intubation Axis
ET Tube insertion
Reverse Ramp Position
Cricoid pressure
Pressure on Cricoid cartilage Compress oesophagus between Cricoid ring and Vertebral column Prevent Regurgitation and Aspiration Make cord visualisation difficult Not recommended in Crash airway
External Laryngeal manipulation
BURP - Backward - Upward - Right- Posterior Pressure over thyroid cartilage Better vocal cord visualisation A grade 3 larynx become grade 2 with ELM It is not Cricoid pressure
Blind insertion devices
LMA Combitube Kingrsquos airway
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
Other methods Gold standard
bull Fiberoptic confirmation
Difficult Airway Assessment
bull 4 Drsquos ndash Distortion Disproportion Dysmobility Dentition
bull BONES ndash Beard Obese No teeth Elderly Snores (sleep apnea)
bull SHORT ndash Surgery (headneckjaw) Hematoma Obese Radiation Tumor
bull LEMON bull MALLAMPATI bull Always have a ldquoRescue Airwayrdquo technique ready
McI
ntyr
e T
he d
iffic
ult t
rach
eal i
ntub
atio
n
Rescue Airways
bull Gum Elastic Bougie (GEB) bull Laryngeal Mask Airway (LMAILMA) bull Combitube bull Surgical Cricothyrotomy
Gum elastic bougie
Gum elastic bouge bull Useful only when
larynges is visualise at least partially
bull Difficulty intubation bull Tube changing bull Provision to
supplement oxygen
Advanced airway ndashBest choice Intubation
Equipments Needed
Laryngoscope with different types of blade
ET tube with proper size and type Average adult male 85 mm Average adult female 75 mm Low pressure cuff tubes above 5 years Uncuffed tubes below 5 years
lt 4 Age + 35
3
gt 4 Age + 45
4
Laryngoscope
Macoy Laryngoscope
Align the airway axis by proper positions
Intubation Axis
ET Tube insertion
Reverse Ramp Position
Cricoid pressure
Pressure on Cricoid cartilage Compress oesophagus between Cricoid ring and Vertebral column Prevent Regurgitation and Aspiration Make cord visualisation difficult Not recommended in Crash airway
External Laryngeal manipulation
BURP - Backward - Upward - Right- Posterior Pressure over thyroid cartilage Better vocal cord visualisation A grade 3 larynx become grade 2 with ELM It is not Cricoid pressure
Blind insertion devices
LMA Combitube Kingrsquos airway
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
Difficult Airway Assessment
bull 4 Drsquos ndash Distortion Disproportion Dysmobility Dentition
bull BONES ndash Beard Obese No teeth Elderly Snores (sleep apnea)
bull SHORT ndash Surgery (headneckjaw) Hematoma Obese Radiation Tumor
bull LEMON bull MALLAMPATI bull Always have a ldquoRescue Airwayrdquo technique ready
McI
ntyr
e T
he d
iffic
ult t
rach
eal i
ntub
atio
n
Rescue Airways
bull Gum Elastic Bougie (GEB) bull Laryngeal Mask Airway (LMAILMA) bull Combitube bull Surgical Cricothyrotomy
Gum elastic bougie
Gum elastic bouge bull Useful only when
larynges is visualise at least partially
bull Difficulty intubation bull Tube changing bull Provision to
supplement oxygen
Advanced airway ndashBest choice Intubation
Equipments Needed
Laryngoscope with different types of blade
ET tube with proper size and type Average adult male 85 mm Average adult female 75 mm Low pressure cuff tubes above 5 years Uncuffed tubes below 5 years
lt 4 Age + 35
3
gt 4 Age + 45
4
Laryngoscope
Macoy Laryngoscope
Align the airway axis by proper positions
Intubation Axis
ET Tube insertion
Reverse Ramp Position
Cricoid pressure
Pressure on Cricoid cartilage Compress oesophagus between Cricoid ring and Vertebral column Prevent Regurgitation and Aspiration Make cord visualisation difficult Not recommended in Crash airway
External Laryngeal manipulation
BURP - Backward - Upward - Right- Posterior Pressure over thyroid cartilage Better vocal cord visualisation A grade 3 larynx become grade 2 with ELM It is not Cricoid pressure
Blind insertion devices
LMA Combitube Kingrsquos airway
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
McI
ntyr
e T
he d
iffic
ult t
rach
eal i
ntub
atio
n
Rescue Airways
bull Gum Elastic Bougie (GEB) bull Laryngeal Mask Airway (LMAILMA) bull Combitube bull Surgical Cricothyrotomy
Gum elastic bougie
Gum elastic bouge bull Useful only when
larynges is visualise at least partially
bull Difficulty intubation bull Tube changing bull Provision to
supplement oxygen
Advanced airway ndashBest choice Intubation
Equipments Needed
Laryngoscope with different types of blade
ET tube with proper size and type Average adult male 85 mm Average adult female 75 mm Low pressure cuff tubes above 5 years Uncuffed tubes below 5 years
lt 4 Age + 35
3
gt 4 Age + 45
4
Laryngoscope
Macoy Laryngoscope
Align the airway axis by proper positions
Intubation Axis
ET Tube insertion
Reverse Ramp Position
Cricoid pressure
Pressure on Cricoid cartilage Compress oesophagus between Cricoid ring and Vertebral column Prevent Regurgitation and Aspiration Make cord visualisation difficult Not recommended in Crash airway
External Laryngeal manipulation
BURP - Backward - Upward - Right- Posterior Pressure over thyroid cartilage Better vocal cord visualisation A grade 3 larynx become grade 2 with ELM It is not Cricoid pressure
Blind insertion devices
LMA Combitube Kingrsquos airway
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
Rescue Airways
bull Gum Elastic Bougie (GEB) bull Laryngeal Mask Airway (LMAILMA) bull Combitube bull Surgical Cricothyrotomy
Gum elastic bougie
Gum elastic bouge bull Useful only when
larynges is visualise at least partially
bull Difficulty intubation bull Tube changing bull Provision to
supplement oxygen
Advanced airway ndashBest choice Intubation
Equipments Needed
Laryngoscope with different types of blade
ET tube with proper size and type Average adult male 85 mm Average adult female 75 mm Low pressure cuff tubes above 5 years Uncuffed tubes below 5 years
lt 4 Age + 35
3
gt 4 Age + 45
4
Laryngoscope
Macoy Laryngoscope
Align the airway axis by proper positions
Intubation Axis
ET Tube insertion
Reverse Ramp Position
Cricoid pressure
Pressure on Cricoid cartilage Compress oesophagus between Cricoid ring and Vertebral column Prevent Regurgitation and Aspiration Make cord visualisation difficult Not recommended in Crash airway
External Laryngeal manipulation
BURP - Backward - Upward - Right- Posterior Pressure over thyroid cartilage Better vocal cord visualisation A grade 3 larynx become grade 2 with ELM It is not Cricoid pressure
Blind insertion devices
LMA Combitube Kingrsquos airway
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
Gum elastic bougie
Gum elastic bouge bull Useful only when
larynges is visualise at least partially
bull Difficulty intubation bull Tube changing bull Provision to
supplement oxygen
Advanced airway ndashBest choice Intubation
Equipments Needed
Laryngoscope with different types of blade
ET tube with proper size and type Average adult male 85 mm Average adult female 75 mm Low pressure cuff tubes above 5 years Uncuffed tubes below 5 years
lt 4 Age + 35
3
gt 4 Age + 45
4
Laryngoscope
Macoy Laryngoscope
Align the airway axis by proper positions
Intubation Axis
ET Tube insertion
Reverse Ramp Position
Cricoid pressure
Pressure on Cricoid cartilage Compress oesophagus between Cricoid ring and Vertebral column Prevent Regurgitation and Aspiration Make cord visualisation difficult Not recommended in Crash airway
External Laryngeal manipulation
BURP - Backward - Upward - Right- Posterior Pressure over thyroid cartilage Better vocal cord visualisation A grade 3 larynx become grade 2 with ELM It is not Cricoid pressure
Blind insertion devices
LMA Combitube Kingrsquos airway
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
Gum elastic bouge bull Useful only when
larynges is visualise at least partially
bull Difficulty intubation bull Tube changing bull Provision to
supplement oxygen
Advanced airway ndashBest choice Intubation
Equipments Needed
Laryngoscope with different types of blade
ET tube with proper size and type Average adult male 85 mm Average adult female 75 mm Low pressure cuff tubes above 5 years Uncuffed tubes below 5 years
lt 4 Age + 35
3
gt 4 Age + 45
4
Laryngoscope
Macoy Laryngoscope
Align the airway axis by proper positions
Intubation Axis
ET Tube insertion
Reverse Ramp Position
Cricoid pressure
Pressure on Cricoid cartilage Compress oesophagus between Cricoid ring and Vertebral column Prevent Regurgitation and Aspiration Make cord visualisation difficult Not recommended in Crash airway
External Laryngeal manipulation
BURP - Backward - Upward - Right- Posterior Pressure over thyroid cartilage Better vocal cord visualisation A grade 3 larynx become grade 2 with ELM It is not Cricoid pressure
Blind insertion devices
LMA Combitube Kingrsquos airway
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
Advanced airway ndashBest choice Intubation
Equipments Needed
Laryngoscope with different types of blade
ET tube with proper size and type Average adult male 85 mm Average adult female 75 mm Low pressure cuff tubes above 5 years Uncuffed tubes below 5 years
lt 4 Age + 35
3
gt 4 Age + 45
4
Laryngoscope
Macoy Laryngoscope
Align the airway axis by proper positions
Intubation Axis
ET Tube insertion
Reverse Ramp Position
Cricoid pressure
Pressure on Cricoid cartilage Compress oesophagus between Cricoid ring and Vertebral column Prevent Regurgitation and Aspiration Make cord visualisation difficult Not recommended in Crash airway
External Laryngeal manipulation
BURP - Backward - Upward - Right- Posterior Pressure over thyroid cartilage Better vocal cord visualisation A grade 3 larynx become grade 2 with ELM It is not Cricoid pressure
Blind insertion devices
LMA Combitube Kingrsquos airway
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
Equipments Needed
Laryngoscope with different types of blade
ET tube with proper size and type Average adult male 85 mm Average adult female 75 mm Low pressure cuff tubes above 5 years Uncuffed tubes below 5 years
lt 4 Age + 35
3
gt 4 Age + 45
4
Laryngoscope
Macoy Laryngoscope
Align the airway axis by proper positions
Intubation Axis
ET Tube insertion
Reverse Ramp Position
Cricoid pressure
Pressure on Cricoid cartilage Compress oesophagus between Cricoid ring and Vertebral column Prevent Regurgitation and Aspiration Make cord visualisation difficult Not recommended in Crash airway
External Laryngeal manipulation
BURP - Backward - Upward - Right- Posterior Pressure over thyroid cartilage Better vocal cord visualisation A grade 3 larynx become grade 2 with ELM It is not Cricoid pressure
Blind insertion devices
LMA Combitube Kingrsquos airway
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
Laryngoscope
Macoy Laryngoscope
Align the airway axis by proper positions
Intubation Axis
ET Tube insertion
Reverse Ramp Position
Cricoid pressure
Pressure on Cricoid cartilage Compress oesophagus between Cricoid ring and Vertebral column Prevent Regurgitation and Aspiration Make cord visualisation difficult Not recommended in Crash airway
External Laryngeal manipulation
BURP - Backward - Upward - Right- Posterior Pressure over thyroid cartilage Better vocal cord visualisation A grade 3 larynx become grade 2 with ELM It is not Cricoid pressure
Blind insertion devices
LMA Combitube Kingrsquos airway
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
Macoy Laryngoscope
Align the airway axis by proper positions
Intubation Axis
ET Tube insertion
Reverse Ramp Position
Cricoid pressure
Pressure on Cricoid cartilage Compress oesophagus between Cricoid ring and Vertebral column Prevent Regurgitation and Aspiration Make cord visualisation difficult Not recommended in Crash airway
External Laryngeal manipulation
BURP - Backward - Upward - Right- Posterior Pressure over thyroid cartilage Better vocal cord visualisation A grade 3 larynx become grade 2 with ELM It is not Cricoid pressure
Blind insertion devices
LMA Combitube Kingrsquos airway
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
Align the airway axis by proper positions
Intubation Axis
ET Tube insertion
Reverse Ramp Position
Cricoid pressure
Pressure on Cricoid cartilage Compress oesophagus between Cricoid ring and Vertebral column Prevent Regurgitation and Aspiration Make cord visualisation difficult Not recommended in Crash airway
External Laryngeal manipulation
BURP - Backward - Upward - Right- Posterior Pressure over thyroid cartilage Better vocal cord visualisation A grade 3 larynx become grade 2 with ELM It is not Cricoid pressure
Blind insertion devices
LMA Combitube Kingrsquos airway
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
Intubation Axis
ET Tube insertion
Reverse Ramp Position
Cricoid pressure
Pressure on Cricoid cartilage Compress oesophagus between Cricoid ring and Vertebral column Prevent Regurgitation and Aspiration Make cord visualisation difficult Not recommended in Crash airway
External Laryngeal manipulation
BURP - Backward - Upward - Right- Posterior Pressure over thyroid cartilage Better vocal cord visualisation A grade 3 larynx become grade 2 with ELM It is not Cricoid pressure
Blind insertion devices
LMA Combitube Kingrsquos airway
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
ET Tube insertion
Reverse Ramp Position
Cricoid pressure
Pressure on Cricoid cartilage Compress oesophagus between Cricoid ring and Vertebral column Prevent Regurgitation and Aspiration Make cord visualisation difficult Not recommended in Crash airway
External Laryngeal manipulation
BURP - Backward - Upward - Right- Posterior Pressure over thyroid cartilage Better vocal cord visualisation A grade 3 larynx become grade 2 with ELM It is not Cricoid pressure
Blind insertion devices
LMA Combitube Kingrsquos airway
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
Reverse Ramp Position
Cricoid pressure
Pressure on Cricoid cartilage Compress oesophagus between Cricoid ring and Vertebral column Prevent Regurgitation and Aspiration Make cord visualisation difficult Not recommended in Crash airway
External Laryngeal manipulation
BURP - Backward - Upward - Right- Posterior Pressure over thyroid cartilage Better vocal cord visualisation A grade 3 larynx become grade 2 with ELM It is not Cricoid pressure
Blind insertion devices
LMA Combitube Kingrsquos airway
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
Cricoid pressure
Pressure on Cricoid cartilage Compress oesophagus between Cricoid ring and Vertebral column Prevent Regurgitation and Aspiration Make cord visualisation difficult Not recommended in Crash airway
External Laryngeal manipulation
BURP - Backward - Upward - Right- Posterior Pressure over thyroid cartilage Better vocal cord visualisation A grade 3 larynx become grade 2 with ELM It is not Cricoid pressure
Blind insertion devices
LMA Combitube Kingrsquos airway
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
External Laryngeal manipulation
BURP - Backward - Upward - Right- Posterior Pressure over thyroid cartilage Better vocal cord visualisation A grade 3 larynx become grade 2 with ELM It is not Cricoid pressure
Blind insertion devices
LMA Combitube Kingrsquos airway
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
Blind insertion devices
LMA Combitube Kingrsquos airway
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
Laryngeal Mask Airway
A silicone rubber device that combines Tracheal intubation and the use of a face mask
Used for situations when intubation attempts have failed bag-valve mask ventilation is unsuccessful and the patient needs immediate airway management
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
LMA
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
VenugopalanPP EMCME 2009MIMSCALICUT150309
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 frac12 Pediatric 5 - 10 Kg
2 Infant 10 ndash 20 Kg
2 frac12 Child 20-30 Kg
3 Large child Small Adult 30 ndash 50 Kg
4 Adult 50 ndash 70 Kg
5 Adult gt 70 Kg
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
Combitube
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
Combitube Insertion
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
Surgical Airway
Needle Cric and Surgical Cric
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
Needle cricbull Buying time in
Emergency airway bull Picture cricothyroid
membrane bull Provide some
oxygenation bull Proceed to surgical cric
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
Blind Nasotracheal Intubation
bull BNTI remains a valid method of intubation in the out-of-hospital setting where it occasionally is used In the ED BNTI rarely if ever should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
Awake Oral Intubationbull Awake oral intubation is a technique in which sedative and topical
anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade
bull Topical anesthesia may be achieved by spray nebulization or local anesthetic nerve block After the patient is sedated and topical anesthesia has been achieved gentle direct video or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
Awake intubation
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
Laryngeal Nerve Block
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
What is the Disaster in Airway management
Canrsquot Intubate
Canrsquot Ventilate
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
LMA Combitube Bougie assisted intubation
Surgical Airway
bull Rescue Airway
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
New Airway Devices
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
Video Assisted Laryngoscope
Airway management made easy
Algorithms
THANK YOU
Airway management made easy
Algorithms
THANK YOU
THANK YOU
Related Documents
