Dr.Anand.Tiwari ,lecture on airway for EMS

1. Dr Anand.M.Tiwari
Head of department,
intensive care unit
wanowarie ruby hall clinic

2. Journey from
 A---B----C
C---A-----B

3.  WHY I SHOULD MANAGE AIRWAY?

4.  Ensure unobstructed gas exchange
 Prevent macroscopic airway soiling
 Airway obstruction is a medical emergency
 (you usually have little more than 5 minutes to achieve
airway patency)

5.  Review of anatomy and physiology
 Equipment for airway control
 Airway assessment
 Airway management
◦ Control of the cervical spine

6.  Nasopharynx
goes straight
back. Vascular
 The tongue is
attached to the
epiglottis.
 Pressure over
the cricoid will
close the
esophagus.

7.  Nose- filtering effects,humidification-
warming,
 Nasal airway insertion precautions
 Tongue fall in unconscious patient
 Larynx anatomy-imp of anatomical
landmark—level c3-c6
 Tracheal length- c6- t5
/angulation/movement of head 30%
increase
 Posterior segment of upperlobe/ apical
segment of lower lobe

9. Inspiration Expiration
Active process Passive process
Chest cavity expands Chest cavity size decreases
Intrathoracic pressure falls Intrathoracic pressure rises
Air flows in until pressure Air flows out until pressure
equalizes equalizes

10.  Airway
◦ Anticipate airway problems with
 Decreased LOC
 Head trauma
 Maxillofacial trauma
 Neck trauma
 Chest trauma
OPEN—CLEAR—MAINTAIN

11.  Breathing
◦ Is patient moving air?
◦ Is air moving adequately?
◦ Is the patient’s blood being
oxygenated?

13.  Non invasive ways
 Triple maneuver
 Recovery position

14. Jaw thrust Head tilt–chin lift

15.  Modified jaw
thrust
 Chin lift
 Jaw lift

17.  MANUAL RESUSCITATORS
 AIRWAY DEVICES
FACE MASK
AIRWAYS
ENDOTRACHEAL TUBES
L.M.A
 laryngoscope

19.  Ambulatory Manual Breathing Unit<AMBU>
 TYPES
 COMPONENTS
self expanding bag
non rebreathing valve
bag refill valve
oxygen enrichment device

20.  Tidal volume
◦ Amount taken with each breath
◦ 400 to 600cc (adult)
 Minute volume equals
tidal volume x breaths per minute
◦ 500 x 12/min = 6 liters (adult)

21.  Function Analysis.--- minute volume
tidal volume . R.r
 Hazards
wrong assembly
hypoxia ,hypoventilation
sticking of N.R.V<Increase airway
pressure>

22. Fingers: jaw thrust upward Fingers: head tilt–chin lift

24.  Key—ventilation volume: “enough to
produce
obvious chest rise”
1-Person: 2-Person:
difficult, less effective easier, more effective

25.  TYPES
 PARTS
mask body
face seal—cushion/ flange
connector
 Tecq of mask holding

26.  Aspirations
 Ocular injury
 Movement of cervical spine
 Latex allergy
 Users fatigue

28.  TYPES—oropharyngeal/nasopharyngeal
 Mechanism
 Parts
flange
bite block
air channel
 Selection of size
 Technique of insertion

30. Insertion technique

31.  Local trauma—dental ,lip
 Airway obstruction –mis/wrongly placed
 Aspiration risk
 Epistaxis/basal skull bone injury=avoid nasal
airway=

33. Too short

36. IT IS LIFE SAVING

37.  U are in ER.when young male trauma victim is
brought unconscious how will you proceed
with airway management?
 Assesment
 steps

38. U ask the sister to bring airway kit? Enumerate
the list of equipments you will need?

39. Questions?
Please feel free to contact me
For any references @ help.
dranandtiwari@gmail.com
9822545093

40. 3. Ambu bag
1. Manual Inline Axial Stabilisation
Avoid hypoxia &
No traction hypercapnia
2. Release anterior cervical collar
Allows mouth opening
Permits cricoid pressure / ‘BURP’
New Horizons1995; 3: 479-87. Access to cricothyroid membrane

43.  Types-macintosh/miller
 Parts—handle$blade---tongue
flange
web
heel
tip/beak
 Technique of using

45. A Mouth
A B
B
C
C
Pharynx
Trachea
Extend-the-head-on-neck (“look up”): aligns axis A relative to B
Flex-the-neck-on-shoulders (“look down”): aligns axis B relative to C

47.  Local trauma—dental. Lip.soft tissue in
pharynx
 Cervical spine injury
 Circulatory changes
 Aspiration/hypoxia
 Bulb malfunction

51. Neonate:Premature -2 mm-2.5 mm;
Mature –3 kg-3 mm; 3.5 kg – 3.5
mm.
Infant : 3.5 mm - 4.0 mm
Above 2 yrs : mm (ID) = age (yrs)/4 + 4.5,
2 yrs : 2/4+4.5=5.0, 4 yrs : 4/4+4.5=5.5
6 yrs : 6/4+4.5=6.0, 8 yrs : 8/4+4.5=6.5
8 yrs : 8/4+4.5=6.5, 10 yrs:10/4+4.5=7.0
12yrs:12/4+4.5=7.5

54.  Types-red rubber/portex
 Parts
 Choosing of size male/female
 Children 1-6months—3-4mm
6-1yr----3.5-4.5mm
>1yr----16+age/4
roughly size of little finger

57. End-tidal colorimetric CO2 indicators

58.  Confirmation of correct positioning
clinical
monitors-pulse ox/ETCO2
Radiological
fibre –optic
 Complication—intubation trauma
placement trauma
post extubation-stridor /hoarseness

59.  The ET tube tip
should be at the
sternal notch.
 The right
mainstem
bronchus is
more in line with
the trachea.

63. The LMA is an adjunctive airway that consists
of a tube with a cuffed mask-like projection
at distal end.

65.  Low pressure seal around laryngeal inlet
 Types—size1-2.5ml newborn
2-<=10ml 6.5-20kg
2.5<=15ml…30kg
3---20ml--30kg
4---30ml adult
 Insertion technique
 complications

69. A = esophageal obturator; ventilation into trachea through side openings = B
E C = tracheal tube; ventilation through open end if proximal end inserted in trachea
D = pharyngeal cuff; inflated through catheter = E
Distal End
F = esophageal cuff; inflated through catheter = G
H = teeth marker; blindly insert Combitube until marker is at level of teeth
A
C
H Proximal End
B
D
F
G

70. A
H
D
D
B F
A = esophageal obturator; ventilation into
trachea through side openings = B
D = pharyngeal cuff (inflated)
F = inflated esophageal/tracheal cuff
H = teeth markers; insert until marker lines at
level of teeth

71.  Table 2.6 Contraindications to blind nasotracheal
 intubation
 • Apnea
 • Cribriform plate injury, basilar skull fracture,
 midface fracture
 • Combative patients
 • Increased intracranial pressure
 • Coagulopathy or bleeding disorders
 • Neck hematoma
 • Upper airway obstruction or anatomic alteration
 from trauma, edema or infection
 • Any patient requiring immediate airway
management

72. Questions?
Please feel free to contact me
For any references @ help.
dranandtiwari@gmail.com
9822545093