Gradian Health Systems
Simulation-Based Product Training
AIRWAY MANAGEMENT
Agenda
I. Airway Anatomy
II. Airway Assessment
III. Oxygenation & Ventilation
IV. Airway Management
a. Basic maneuvers
b. Airway adjuvants
c. Advanced maneuvers
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I. Airway Anatomy
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Airway Anatomy-Pharynx
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Airway Anatomy-Larynx
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Airway Anatomy-Larynx
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Airway Anatomy-Glottis
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II. Airway Assessment
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Airway Assessment
GENERAL INFORMATION
• Important part of pre-operative workup
• Aimed at predicting potential problems which may be
encountered in the OR
• Plan for problems with standard laryngoscopy/intubation as
well as with ventilation/oxygenation
• Take thorough history
• Do clinical exam
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Airway Assessment
PREDICTING A DIFFICULT AIRWAY
Difficulty in establishing or maintaining gas exchange via a
mask, artificial airway, or both
LEMON
L - Look externally (obesity, short neck)
E - Evaluate 3-3-2
M - Mallampati
O - Obstruction (tumor, epiglottitis, foreign body)
N - Neck mobility (elderly, trauma)
Dr. Binnions Lemon
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Airway Assessment
EVALUATE 3-3-2
3 cm mouth opening 3 cm thyromental distance 2 cm between hyoid bone &
thyroid notch
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Airway Assessment
MALLAMPATI SCORING:
Oropharyngeal assessment in an upright seated patient
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Airway Assessment
CORMACK-LEHANE GRADING
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III. Oxygenation & Ventilation
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Oxygenation & Ventilation
Oxygenation
• Process of oxygen entering the body
• Oxygen therapy refers to the process of administering supplementary
oxygen to patients at concentrations greater than that found in the
atmosphere (21%)
• Oxygen therapy is important for proper respiratory care and airway
management
• Initiated when oxygen levels in the blood are low (low saturation)
• Variables: flow rate, concentration, duration
• Sources: cylinders, pipeline, concentrators
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Oxygenation & Ventilation
Ventilation
• Process of inhalation and exhalation
• Spontaneous – when a patient is breathing on their own
• Mechanical/assisted – when the patient’s breathing is controlled or
supported by artificial means
• Minute Ventilation (MV) = Tidal Volume (TV) x Respiratory Rate (RR)
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Oxygenation & Ventilation
Nasal Cannula / Prongs
• Best for patients needing long-term oxygen
therapy
• Delivers 24-44% FiO2 at a flow rate of 1-6
L/min
• The slower the inspiratory flow, the higher
the FiO2
• If flow is >6 L/min, variable FiO2 needs
humidification
• 1L/min=24% FiO2
• 2L/min=28% FiO2
• 3L/min=32% FiO2
• 4L/min=36% FiO2
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Oxygenation & Ventilation
Oxygen Face Mask
Simple Face Mask Face Mask with Reservoir Bag
6-10 L/min 10-15 L/min
FiO2: 0.44 – 0.60 FiO2 > 0.9
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Oxygenation & Ventilation
Bag-Valve Mask (BVM) or Ambu Bag
• Bag-Valve-Mask (BVM) is a device used to provide positive pressure
ventilation to patients
• It is indicated in patients who are not breathing effectively or not
breathing at all
• Properly position the patient’s head by aligning ear with sternum
• Hold the mask in place to make airtight seal with the face and squeeze
bag till the chest visibly rises
• Squeeze every 5-6 secs for adults, 3-5 seconds for children, as patient
inhales
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Oxygenation & Ventilation
Bag-Valve Mask (BVM) or Ambu Bag
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Oxygenation & Ventilation
BAG-VALVE MASK (BVM)
One-person BVM Ventilation Two-person BVM Ventilation
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IV. Airway Management
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Airway Management
PRINCIPALS
First Relieve airway obstruction (head-tilt, chin-lift, jaw-thrust,
finger sweep, suctioning)
Second Prevent aspiration (ex: blood, foreign materials, gastric
contents) good positioning
Third Maintain adequate ventilation/gas exchange
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Airway Management
Basic Maneuvers: Recovery Position
• If you find an unresponsive patient in the prone position, move to a supine
position
• Assess for breathing
• If breathing adequately and uninjured, move to recovery position
Hand supports head
Knee prevents body from
rolling onto stomach
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Airway Management
If the unresponsive patient has a
pulse but is NOT breathing:
the airway must be opened
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Airway Management
Basic Maneuvers: Head Tilt / Chin Lift
• Relieve airway occlusion by the tongue
• Only use if no cervical spine injury
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Airway Management
Airway Suctioning
• After opening airway,
suctioning efficiently removes
materials or secretions from
the mouth or throat; prevents
aspiration
• It also removes oxygen, so
pre-oxygenate before and re-
oxygenate after suctioning
• Maximum suctioning time in
adults is 15 seconds and
children is 10 seconds
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Airway Management
Airway Adjuncts
• Once airway has been established and appropriately suctioned,
adjuncts can inserted and used to maintain the airway
• Two types:
• Oropharyngeal airway
• Nasopharyngeal airway
• Both types prevent occlusion by the tongue
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Airway Management
Airway Adjuncts: Oropharyngeal Airway
• Curved hard plastic that fits over
back of tongue
• Helps prevent tongue from
obstructing posterior pharynx
• Indicated in unresponsive patients
with no gag reflex
• Non-invasive and easily placed by
the direct method or rotation method
• Measure from corner of mouth to
angle of jaw to estimate size
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Airway Management
Airway Adjuncts:
Oropharyngeal Airway
Sizing and Placement
Correct
placement of the
airway
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Airway Management
Airway Adjuncts: Nasopharyngeal Airway
• Soft rubber tube that is inserted through
the nose
• Indicated in unresponsive patients with
no gag reflex or semi-responsive
patients who cannot use OPA due to gag
reflex
• Used for patients requiring frequent
nasal-tracheal suctioning
• Does not require the mouth to be open
• Contraindicated in facial fracture or
basilar skull fracture
• Measure from tip of the nares to tragus
of the ear to estimate size
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Airway Management
Advanced Maneuvers: Endotracheal Intubation
• Passing of a tube (called an endotracheal tube or ET tube)
through a patient’s nose or mouth and into the trachea:
• Orotracheal intubation = inserting ET tube via the mouth
• Nasotracheal intubation = inserting ET tube via the nose
• Purpose:
• Maintain an airway during
general anesthesia
• Maintain an imperiled airway
• Facilitate the administration of
certain drugs
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Airway Management
Endotracheal Tubes (ET Tubes)
• Used for endotracheal intubation
• ET tube passes through the opening in the glottis and is
sealed with a cuff that is inflated against the tracheal wall
• Secures the airway and protects against aspiration
• ET tube size is approximated by the diameter of the little
finger or size of the thumbnail
• Always have three sizes ready
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Airway Management
Endotracheal Tubes (ET Tubes)
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Airway Management
Laryngoscopes
• Device used to perform orotracheal intubation to facilitate
insertion of the ET tube
• Consists of a handle and interchangeable blades
• Blade sizes range from 0-4:
• Sizes 0-2 for children
• Sizes 3-4 for adults
• A semi-rigid wire (stylet) is inserted into the ET tube to mold and
maintain the shape of the tube
• Types:
• Straight – Miller and Wisconsin blades
• Curved – Macintosh blades
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Airway Management
Laryngoscopes: Straight
• Miller and Wisconsin
blades
• The tip extends below the
epiglottis and lifts it up
• Useful in infants and small
children
• More likely to damage
teeth in adults
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Airway Management
Laryngoscopes: Curved
• Macintosh blades
• Curve of the blade conforms to
the shape of the tongue &
pharynx
• Blade’s tip is placed in the
vallecula
• Indirectly lifts the epiglottis to
reveal the vocal cords
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Airway Management
Advanced Maneuvers: Endotracheal Intubation
1. Place the patient in the “sniffing position” to aid airway visualization
2. Pre-oxygenate patient for 3-5 minutes before intubating to prevent
hypoxia
3. Use “scissor” technique to open mouth
4. Insert blade into the right side of mouth
5. Sweep tongue to the left while slowly moving blade to the midline
6. Apply gentle forward traction at 45° angle to lift the patient’s jaw
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Airway Management
Advanced Maneuvers: Endotracheal Intubation
7. Look down the blade and work the tip into position even as you
continue lifting the laryngoscope.
8. The vocal cords in the glottic opening should soon come into view
9. Pick up the ET tube and insert it from the right corner of the mouth
through the vocal cords
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Airway Management
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Airway Management
Advanced Maneuvers: Endotracheal Intubation
10. Continue until the proximal end of the cuff is 1-2 cm past the vocal cords
11. Gently remove the blade
12. Pick up the ET tube and insert it from the right corner of the mouth through
the vocal cords
13. Secure tube with right hand
14. Remove stylet from tube
15. Inflate cuff with 5-10ml of air and detach syringe
16. Attach bag-mask device to ET tube and continue ventilation
17. Confirm tube placement (bilateral chest wall rise and auscultation)
18. Secure tube with tape
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Airway Management
ADVANCED MANEUVERS
• Remember: oxygenation is more important than
endotracheal intubation
• You can improve oxygenation by administering O2 via
face mask and bag prior to intubation or intermittently
during a difficult intubation
• Keep calm and call for help if you have a failed
intubation (decreasing O2 saturations after one or more
failed attempts; or total of three failed attempts)
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