2. OBJECTIVES
To know the maneuvers for opening the airway
Suctioning
To understand about airway devices
Sizing and insertion of the airway
To understand about Oxygen delivery devices
Technique of ETT insertion
3. OPENING THE AIRWAY
MANUAL AIRWAY MANEUVERS
The tongue is the most common cause of airway
obstruction in an unresponsive patient. If the patient
is breathing, snoring respirations are a sign of airway
obstruction due to displacement of the tongue. If the
patient is not breathing, airway obstruction due to the
tongue may go undetected until ventilation is
attempted.
Manual airway maneuvers are:
Head-Tilt/Chin-Lift
Jaw Thrust without Head Tilt
4. Head-Tilt/Chin-Lift
Place one hand on the patient’s
forehead and apply firm pressure
with your palm to tilt the patient’s
head back.
Place the tip of the fingers of your
other hand under the bony part of
the patient’s chin and gently lift up
and pull the jaw forward.
Positioning your fingers under the
bony part of the patient’s chin is
important because compression
of the soft tissue under the
patient's chin can obstruct the
airway.
Open the patient’s mouth by
pulling down on the patient’s
lower lip using the thumb of the
same hand used to lift the chin.
5. Jaw Thrust without Head-Tilt
While stabilizing the patient’s
head in a neutral position,
grasp the angles of the
patient’s lower jaw with both
hands, one on each side,
and displace the mandible
forward.
Indicated in possible cervical
spine injury.
6. Suctioning the Upper Airway
Remove vomitus, saliva, blood, and other material from the
patient’s airway.
Depth of catheter insertion:
same length from patient’s earlobe to the corner of the
mouth.
Duration:
Suction should not be applied for more than 10 to 15
seconds (adults)
Ventilate the patient with 100% oxygen for about 30 seconds
before repeating the procedure.
7. Suctioning the Lower Airway
Depth:
Nose to ear and the nose to the sternal notch.
Duration:
10 to 15 seconds (adults)
Ventilate the patient with 100% oxygen for 30
seconds before repeating the procedure.
12. Sizing of Airway
To get the right size, use the device
itself as a measure. When you place it
on the patient's cheek with the flange
parallel to his front teeth, the tip of the
oropharyngeal airway should reach no
further than the angle of the jaw. If the
airway is too long, it could obstruct
breathing by displacing the tongue
against the oropharynx. If it's too short,
it won't be able to hold the tongue
away from the pharynx, and patency
won't be restored.
13. Inserting an Oral Airway
Before inserting an oral airway make sure that the mouth
and throat are clear of secretions, blood and vomitus.
(Why?)
After selecting an oropharyngeal airway of proper size,
hold the device at its flange end and insert it into the
patient’s mouth with the tip pointing towards the roof of the
patient’s mouth. Slide the airway along the roof of the
mouth. When the distal end nears the back of the throat,
rotate the airway 180 degrees so that it is positioned over
the tongue.
14. Another method of OPA insertion requires the use
of a tongue blade to depress the tongue. If this
method is used, the OPA is inserted with the tip of
the OPA facing the floor of the patient’s mouth
(curved side down). Using the tongue blade to
depress the tongue, the OPA is gently advanced
into place over the tongue. When properly inserted
the flange of the device should rest comfortably on
the patient’s lips or teeth. Proper placement of the
device is confirmed by ventilating the patient.
15. Proper placement of an
oropharyngeal airway,
showing effective
separation of dorsal
tongue from posterior
oropharyngeal wall.
15
16. Improper size and
placement of
oropharyngeal airway,
showing potential
increase in obstruction
from tongue
displacement.
16
17. NASAL AIRWAY
(NASOPHARYNGEAL AIRWAY)
Sizing: Tip of nose to
angle of the jaw or tip of
the ear.
18. Inserting a Nasal Airway
Lubricate the distal tip of the device liberally with
water-soluble lubricant to minimize resistance and
decrease irritation to the nasal passage.
After selecting an NPA of the proper size, hold the
device at its flange end like a pencil and slowly insert
it into the patient's nostril with the bevel pointing
toward the nasal septum. Advance the airway along
the floor of the nostril, following the natural curvature
of the nasal passage, until the flange is flush with the
nostril.
19. During insertion, do not force the airway because it
may cut or scrape the nasal mucosa and result in
significant bleeding, increasing the risk of aspiration.
If resistance is encountered, a gentle back-and-forth
rotation of the device between your fingers may ease
insertion. If resistance continues, withdraw the NPA,
reapply lubricant, and attempt insertion in the
patient’s other nostril.
20. Proper placement of a
nasopharyngeal airway,
showing effective
separation of soft palate
from posterior wall of
nasopharynx.
20
21. Improper size of
nasopharyngeal airway,
showing failed
separation of soft palate
from nasopharyngeal
wall.
21
24. SIMPLE FACE MASK
Simple face mask can deliver an oxygen
concentration of 40% to 60% with an oxygen flow
rate of 6 to 10 L/min.
Recommended flow rate is 8 to 10 L/min.
What is the problem if flow is less than 5 L/min ?
25. PARTIAL REBREATHING
MASK
Partial Rebreathing mask can deliver an oxygen
concentration of 35% to 60% with an oxygen
flow rate of 6 to 10 L/min.
26. NON REBREATHING MASK
Non rebreathing mask
can deliver an oxygen
concentration of 100%
with an oxygen flow rate
of 10 to 15 L/min.
29. Mask Size
Selection of a mask of proper size is necessary to
ensure a good seal between the patient’s face and
the mask. A mask of correct size should extend
from the bridge of the nose to the groove between
the lower lip and chin.
If the mask is not properly positioned and a tight
seal maintained, air will leak from between the
mask and the patient’s face, resulting in less tidal
volume delivery to the patient.
If you do not have a mask of the proper size
available, use a larger mask and turn it upside
down.
30. BAG-VALVE-MASK
VENTILATION
A BVM device consists of a self-inflating bag; a
nonrebreathing valve with an adapter that can be
attached to a mask, tracheal tube, or other invasive
airway device; and an oxygen inlet valve.
A BVM device without supplemental oxygen will
deliver 21% oxygen and with supplemental oxygen
set at a flow rate of 15 L/min will deliver about 40% to
60% oxygen to the patient.
31. Cricoid Pressure
(Sellick’s manoeuvre)
Apply firm pressure on the cricoid cartilage with the thumb and
index or middle finger, just lateral to the midline.
This pressure compresses the esophagus between the cricoid
cartilage and the 5th and 6th cervical vertebrae. The cricoid is
used because it forms the only complete ring of the larynx and
trachea.
This helps reduce inflation of the stomach during positive-
pressure ventilation, reducing the likelihood of vomiting and
aspiration.
Cricoid pressure should be maintained until the ET tube cuff is
inflated and proper tube position is verified.
If active vomiting occurs, release cricoid pressure to avoid
rapture of the esophagus.
Cricoid pressure is not intended to aid visualization of the vocal
cords during intubation.
34. Endotracheal Intubation
Equipments:
Laryngoscope with proper size blade. (A blade of proper
size should reach between the patient’s lips and the larynx.
If you are unsure of the correct size, it is usually best to
select a blade that is too long, rather than too short.
ETT of various sizes
10-ml syringe for inflation of the ET tube cuff
Stylet and water-soluble lubricant (Not for ETT)
BVM device with supplemental oxygen and reservoir
Suction equipment
Tube-holder or tape
Oral airway
Exhaled CO2 detector and /or esophageal detector device.
35. Sizing of ETT
Diameter:
Neonate: 3.0 mm
0-6 months: 3.5mm
6-12 months: 4.0 mm
Predicted Size Uncuffed Tube = (Age / 4) + 4 (Pediatrics)
Predicted Size Cuffed Tube = (Age / 4) + 3 (Pediatrics)
Adult male 8 to 9 & female 7 to 8
Length
In children for oral tube: Age/2 + 12
Adult 20 to 22 cm
36. Technique
Place the patient’s head in “sniffing” position. Open the patient’s
mouth and inspect the oral cavity. Remove dentures and/or
debris, if present.
Holding the laryngoscope in the left hand and with the tip of the
blade pointing away from you, insert the blade into the right side
of the patient’s mouth between the teeth, sweeping the tongue
to the left. Advance the laryngoscope blade until the distal end
reaches the base of the tongue.
Lift the laryngoscope to elevate the mandible without putting
pressure on the front teeth. Do not allow the blade to touch the
patient’s teeth.
If using a curved blade, advance the tip of the blade into the
vallecula.
If using a straight blade, advance the tip under the epiglottis.
37. Technique cont’d
Once the vocal cords are visualized grasp the ETT
with your right hand and introduce it into the right
corner of the patient’s mouth. Advance the tube
through the glottic opening until the distal cuff
disappears past the vocal cords. The black marker on
the ETT should be at the level of the vocal cords.
Firmly hold the tube and remove the stylet (if used).
Inflate the cuff.
Attach the tube to a ventilation device.
Confirm proper placement of the tube and record the
depth.
38. BURP Technique
Viewing the vocal cords may be aided with the use of the BURP
(backward, upward, rightward pressure) technique. With this
maneuver, the larynx is displaced in the three specific directions
(1) posteriorly against the cervical vertebrae, (2) superiorly as
possible, and (3) slightly laterally to the right. This maneuver
improves visualization of the larynx more easily than simple
backpressure on the larynx (cricoid pressure) because the
BURP technique moves the larynx back to the position from
which it was displaced by a right- handed (held in operator’s left
hand) laryngoscope.
40. View of glottis without View of glottis with external
external laryngeal pressure. laryngeal pressure.
40
41. An advanced airway that is misplaced or becomes
dislodged can be fatal. Make it a habit to recheck
placement of an advanced airway immediately after
insertion, after securing the tube, during transport,
and whenever the patient is moved.
42. If breath sounds are absent bilaterally after intubation and
gurgling is heard over the epigastrium, assume
esophageal intubation. Deflate the ET cuff, remove the
tube, and preoxygenate before reattempting intubation.
If breath sounds are diminished on the left after intubation
but present on the right, assume right mainstem bronchus
intubation. Deflate the ET cuff, pull back the ET tube
slightly, reinflate the cuff, and reevaluate breath sounds.
Secure the ET tube with tape or tube holder and recheck
and record the tube depth at the patient’s teeth.
43. Possible Complications
Bleeding
Laryngospasm
Vocal cord damage
Mucosal necrosis
Aspiration
Esophageal intubation
Right mainstem intubation
Occlusion caused by patient biting the tube or secretions
Laryngeal or tracheal edema
Trauma to the lips, teeth, tongue, or soft tissues of the
oropharynx.
44. Confirming ETT Placement
Visualizing the passage of the ETT between the vocal
cords
Auscultating the presence of bilateral breath sounds
Confirming absence of sounds over the epigastrium
during ventilation
Observing adequate chest rise with each ventilation
Observing absence of vocal sounds after placement of
the ETT
Capnography
Esophageal detector device
45. Endotracheal intubation is a commonly performed
procedure in life-threatening situations in the operating
room, intensive care unit, emergency department and in
the prehospital setting. Inadvertent, undetected
esophageal intubation is catastrophic and can occur in
the hands of the most experienced people.
The usual clinical methods of confirming endotracheal
tube (ETT) position, such as bilateral breath sound
auscultation, chest movement visualization, clouding of
the ETT, auscultation over the stomach, etc.,
occasionally fail.
46. After visualizing the ET tube passing through the vocal
cords and confirming placement of the tube by
auscultation, be sure to verify tube placement using an
exhaled CO2 detector and /or esophageal detector
device.
Exhaled CO2 monitoring has been suggested as the
“sixth vital sign” that should be monitored in patients in
addition to heart rate, blood pressure, respiratory rate,
and blood oxygen saturation.
47. Because CO2 is exhaled through the trachea and is not
usually detected in the esophagus, capnometry can
distinguish between endotracheal and esophageal
intubation. This has been studied in animals and humans
in both the non-arrest and arrest settings. Measurement of
ETCO2 has been shown to be superior to pulse oximetry in
the early detection of esophageal intubation, especially in
patients preoxygenated with 100% oxygen.
48. During cardiac arrest, ETCO2 has been shown to fall
abruptly to low levels at the onset of arrest because of the
sudden decrease in cardiac output and pulmonary
perfusion. This is followed by an increase in ETCO2 after
the onset of effective CPR, and then returning to normal or
higher-than-normal levels at return of spontaneous
circulation. During CPR ETCO has been shown to correlate
with cardiac output, coronary perfusion pressure, efficacy of
cardiac compression, return of spontaneous circulation and
even survival. Thus, capnometry has been shown to be a
useful non-invasive monitoring tool.
49. Exhaled Carbon Dioxide Detection
Capnography: Continuous analysis and recording of
CO2 concentrations in respiratory gases.
Capnograph: A device that provides a numerical reading
of exhaled CO2 concentrations and a waveform (tracing)
Capnometer: A device used to measure the
concentration of CO2 at the end of exhalation.
Capnometers use infrared absorption or mass. They are
used to monitor patients in the operating rooms and
intensive care units.
Capnometry: A numerical reading of exhaled CO2
concentrations without a continuous written record or
waveform.
50. Exhaled CO 2 detector (End-tidal CO2 detector): A
capnometer that provides a noninvasive estimate of
alveolar ventilation, the concentration of exhaled CO2
from the lungs.
Because the air in the esophagus normally has very
low levels of CO2, capnometry is considered a rapid
method of preventing unrecognized esophageal
intubation.
52. A non-toxic, pH-sensitive chemical indicator (metacresol
purple), visible through a clear dome, detects CO2 in
gas mixtures flowing through it. Concentrations of CO2
are indicated by reversible color changes. Color ranges
are marked on a reference chart and indicate
approximate CO2 concentrations [A (purple : 4 mm Hg);
B (tan : 4-<15 mm Hg); C (yellow : 15-38 mm Hg). The
device responds to breath-by-breath CO2 changes and
works for about 2 hours.
53. When the detector is attached to the ETT of a correctly
intubated patient it is yellow during expiration and purple
during inspiration; when attached to an ETT placed in the
esophagus, it remains purple.
Readings are obtained after six breaths, as per the
manufacturer's recommendation, in order to avoid false
positive readings (i.e. yellow color despite esophageal ETT
position) caused by the presence of CO2 in the esophagus
immediately after ingestion of carbonated beverages or
after bag-valve-mask ventilation.
Indicator color is to be interpreted only if there is reversible
color change, as permanent yellow discoloration can occur
in gastric juice or when drugs such as epinephrine come in
direct contact with the indicator membrane
54. Why Capnography ?
Pulse oximeter is a direct monitor to reflect the status of oxygenation of
the patient.
Capnography, on the other hand, is a indirect monitor and helps in the
differential diagnosis of hypoxia to enable remedial measures to be
taken expeditious before hypoxia results in an irreversible brain
damage.
Capnography provides information about CO2 production, pulmonary
perfusion, alveolar ventilation, respiratory patterns, and elimination of
CO2 from the ventilator.
Capnography has been shown to be effective in the early detection of
adverse respiratory events.
Capnography and pulse oximetry together could have helped in the
prevention of 93% of avoidable mishaps.
Capnography has also been shown to facilitates better detection of
potentially life-threatening problems than clinical judgment alone.
