ACC Teaching

Week 1 – Airway

Ben Hughes
Medical Education Fellow
[email protected]
Contents
• Part 1:
• Anatomy
• How to check an airway
• Causes of obstructed airway
• Managing an airway – simple/suction/adjuncts/definitive/surgical
• Part 2:
• Oxygenation – modes of delivery/hypoxic drive/LTOT
• Ventilation – bag and mask/NIV
• Part 3:
• Airway scenarios – anaphylaxis/choking/epiglottitis
• Mock qs – MCQ/slideshow
Anatomy 1
Anatomy 2
Associated Structures
• Thyroid gland

• Carotid arteries

• Jugular veins

• Sinuses
Assessing an airway?
Assessing an airway
• During ABCDE approach need to check to see if
an airway is:
• Patent
• Partially obstructed
• Completely obstructed

• Also need to identify if their airway is their own

– do they already have an airway in situ?
Assessing an airway
• Need to look, listen and feel

• Patent airway:

• Partially obstructed airway:

• Completely obstructed airway

ABCDE
• Stridor • Cyanotic

• Grunting • Clasping for throat

• Panic
• Noisy

• Silent
• Spluttering

• Unconscious
• Gasping
Assessing an airway
• Patent airway:
= can speak to you

• Partially obstructed airway:

Listen Look
Snoring Drooling
Stridor See saw respirations
Wheeze Use of accessory muscles
Gurgling Agonal breathing
Choking Central cyanosis(central)
Hoarse voice Paediatric – nasal flaring,
Grunting intercostal/subcostal recession,
tracheal tug

• Completely obstructed airway

= silent
• Stridor
https://m.youtube.com/watch?v=5WEoxXST9DI

Agonal breathing -
https://m.youtube.com/watch?v=CBMxH4xtE8w
A brief look at Paediatrics
• Greater risk of obstruction & larger tongue

• Smaller swelling has a more devastating effect

• Larger occiput
• Neck neutral rather than head tilt

• Softer trachea cartilage

Recurrent laryngeal nerve
• Supplies – all intrinsic muscles of larynx except cricothyroid
muscles. These muscles are lateral cricoarytenoid, posterior
cricoryatenoid, transverse and oblique interarytenoid and
thyroarytenoid
Respiratory Arrest
• If not breathing at all remember this is a respiratory arrest!!
This can also include agonal breathing

• Respiratory arrest means they are not breathing or agonal

breathing but have a cardiac output (have a pulse)

• Crash call
• 2222
Causes of obstructed airway?
Causes of obstructed airway
• Foreign body • Congenital (vascular ring,
laryngeal web)
• Infection (epiglottitis, tracheiitis,
tetanus) • Poisoning and toxic exposures
(smoke inhalation)
• Immune:
• Angioedema • Laryngospasm
• Anaphylaxis
• Other:
• Tumour • Low GCS
• Cranial nerve palsies
• Trauma (burns, fracture, • Paralysis
bleeding) • Hysterical stridor
• Myoedema
Airway Management
Airway Management
• Airway opening manoeuvres

• Suction

• Airway adjuncts

• Supraglottic airways

• Definitive airway

• Surgical airway
Match them up…
• Airway opening manoeuvres • Nasopharyngeal

• Suction • Oropharyngeal

• Airway adjuncts • LMA / Igel

• Supraglottic airways • Head tilt/chin lift

• Definitive airway • Cricothyroidotomy

• Surgical airway • ETT

Airway opening manoeuvres
• Head tilt and chin lift
• Place one hand on patient's forehead and tilt the head back gently
• Use finger tips of other hand to open airway

• Not to be used if cervical spine injury suspected

Simple Management
• Jaw thrust
• Identify angle of mandible, place fingers behind here and apply
steady upwards and forward pressure to lift mandible
Suction
• Golden rule is only suction what you can see!!

• Normally Yankauer suction catheter

• Remember suction needs to be attached to something to work

• You need to put your finger over the hole

Adjuncts – Oropharyngeal
Adjuncts – Oropharyngeal
• Insertion – insert the wrong way up and then rotate 180o
during insertion so follows curve of pharynx
Step 1
Step 2
Step 3
Step 4
Step 5
Step 6
Adjuncts – Nasopharyngeal
Adjuncts – Nasopharyngeal
• Best tolerated of the adjuncts - can be used on patients who
are awake

• Sizes – airway sized in mm according to the internal diameter

(length increases respectively). Normal size for adult = 6-7mm

• Measuring for correct size – simply check width against nostril

or little finger

• Contra-indications:
• Suspected basal skull fracture
NPA
• Insertion – lubricate using THEIR saliva

• Can always try the other nostril if you encounter an

obstruction

• Insert right way round

Basal Skull #
• Basal skull # = occurs in the floor of the skull, the areas around the
eyes, ears, nose, or back, near the spine
• Signs:
• ‘panda eyes’ (periorbital ecchymosis), CSF rhinorrhoea, CSF otorrhoea,
‘battle’s sign’ (mastoid ecchymosis)
• Risk of cerebral placement of NPA through #
LMA/i-gel 1
• Both supraglottic airway devices
• Easy insertion and sit on top of the glottis and forms an
airtight seal
• i-gel is similar but doesn’t require inflating
• Sizing – different sizes based on different weights
• Sometime also used for anaesthetic
LMA/i-gel 2
• Hold like a pen

• Slide along the hard palate, pushing it back against the palate

• Advance with gentle pressure until resistance

• I-gel doesn’t need inflating, LMA does need inflating (air in

inflatable cuff)
Definitive airway indications?
• Should only be attempted by someone who is competent!
Definitive airway Indications
• Should only be attempted by someone who is competent!
• Indications for definitive airway:

Airway protection: Ventilation and Oxygenation:

• GCS<8 • Respiratory arrest
• Severe maxillofacial / • Respiratory failure
Multiple Trauma • Need for
• Aspiration Risk prolonged ventilatory
• Airway obstruction risk support
• Head Injury with abnormal • Class III or
mental status IV Haemorrhage with poor
perfusion
• Severe Chest Injury
• Severe Closed Head
Injury (GCS<8)
Definitive airway - Assessing
• Important to first assess patient’s airway

• Anatomy:
• Mouth opening
• Mandible
• Position, number and health of teeth
• Size of tongue
• Deviation of trachea

• Neck movements
Definitive airway - Criteria
• Mallampati criteria – used to grade potentially difficult intubations.
Definitive airway - Criteria
• Mallampati criteria
• Used to grade potentially difficult intubations.

• With patient sitting upright ask to open their mouth and maximally
protrude their tongue.

• View of pharyngeal structures is graded I-IV (grades III and IV suggest

difficult intubation)

• I = faucial pillars, soft palate and uvula present

• II = faucial pillars and soft palate visible, uvula masked by base of
tongue
• III = only soft palate visible
• IV = soft palate not visible
Definitive airway - Intubation
Definitive airway - Intubation
• Insertion of endo-tracheal tube

• Sizes based on internal diameter

• Generally adult female 7.5mm, adult male 8.5mm, but varies with the
individual

• Insertion = insert blade of laryngoscope using non-

dominant hand, insert ETT, inflate cuff and secure

• Check in correct place?

Intubation
• Check in correct place:

• Colour of patient – pink

• Chest movements – equal rise and fall of chest
• Chest auscultation – equal bilateral air entry
• Misting of tube
• O2 sats
• CO2 trace
Surgical Airway
• Just to be aware of!

• Last resort

• In an emergency situation (where airway is needed

immediately) cricothyroidotomy may be necessary
Part 2
• Oxygenation:
• Modes of delivery
• Hypoxic drive
• LTOT

• Ventilation:
• Bag and mask
• NIV
Oxygenation
• Methods of O2 delivery?

• Inspired O2 concentration in air?

• The only method which has fixed oxygen delivery is the

Venturi mask
• If you put a patient on this you know exactly how much O2 they
are getting!
Oxygenation
• Methods of O2 delivery:

• Nasal cannula
• Simple face mask
• Non-rebreathe mask
• Venturi mask

• Inspired O2 concentration in air

• 21%

• % inhaled variable (RR, position, mask, etc)

Actually turning on the O2!
Nasal cannula

• Oxygen flow rate = 4L/min

• Oxygen delivery at 1 litre = 24% (add 4% for each

litre after this)

• Remember to consider putting under ears to

minimise discomfort
Simple face mask

• Hudson face mask

• Oxygen flow rate = 5-10 L/min

• Oxygen delivery at 5 litres = 35-60%

Non-rebreathe mask

• Oxygen flow rate = 10-15 L/min

• Do not run at <10 L/min as if insufficient to meet

inspiratory demands bag may collapse

• Oxygen delivery = 60-80/100%

• Used for patients who require high concentration of O2

• Always ensure reservoir bag is filled before putting

on patient
Venturi mask

• Fixed delivery of oxygen

• Used when controlled oxygen therapy is required (COPD)

• Valve has a small hole in it: oxygen is forced through the small hole
and the change in pressure once it is through also sweeps along
room air – inhaling mix of O2 and room air
Venturi Valve Inspired O2 Oxygen flow
Colour concentration
Blue 24% 2-4 l/min
White 28% 4-6 l/min
Yellow 35% 8-10 l/min
Red 40% 10-12 l/min
Green 60% 12-15 l/min
Respiratory drive?
Hypoxia vs. hypercapnia

Rise in blood CO2

Fall in blood pH
Rise in bloodO2 ( acidotic)

Detected by
Impulses trigger central
inspiration chemoreceptors
in medulla
Hypoxia vs. hypercapnia
• COPD patients have chronic high CO2

• The chemoreceptors in the brain become blunted

• In these patients inspiration is prompted by low O2 (hypoxic

drive)

• Giving high-flow O2 therapy may reduce their respiratory drive

and cause retention of CO2

• However, hypoxia kills before hypercapnia

• Can monitor with ABGs

Long Term O2 Therapy
• Patients may be on long term O2 therapy at home

• Need to know:
• How long have on for
• O2 flow rate (l/min)

• Generally should stick to what they have at home when they

come into hospital (unless they are acutely unwell and their
oxygen requirements have increased)
Titrating O2 to Sats
• Acutely unwell = 15L NRB

• Target sats:
• 94-98% = most people
• 88-92% = mainly COPD (CO2 retainers)

• Then alter your therapy to achieve this

• Remember to use oxygen prescription charts

Titrating O2 to Sats
Ventilation - Bag and Mask
• Can be attached to face mask

• 2 person technique is easier

• Need to try to get a tight seal

• Aim for normal RR

Non-invasive ventilation
Non-invasive ventilation
• Ventilatory support through the patient's upper airway

• CPAP = Continuous Positive Airway Pressure

• = fixed positive pressure throughout respiratory cycle

• BiPAP = Bilevel Positive Airway Pressure

• = ventilator delivers different level sof pressure during inspration
and expiration
Part 3
• Special airway scenarios:
• Anaphylaxis
• Choking
• Epiglottitis

• Cardiac arrest

• Mock MCQs

• Mock slideshow
Anaphylaxis
Anaphylaxis
• Severe, life-threatening, generalised hypersensitivity
reaction

• Pathology = Type-1 IgE mediated

• Causes (nuts, latex, stings, drugs)

Anaphylaxis symptoms?
Anaphylaxis
Anaphylaxis management?
Anaphylaxis management
1. Assess airway
1. If at risk, put out a crash call

2. Identify features of anaphylaxis

3. Remove the precipitant

4. Give 15L NRB

5. Refrain from airway adjunct at this stage

Medical management

1. IM Adrenaline 500mcg 1:1000

2. IV Hydrocortisone 200mg

3. IV Chlorphenamine 10mg

4. IV fluids

5. Ensure allergy status is updated + mast cell tryptase sample

Choking
Choking

• Check after each intervention

Epiglottitis
Epiglottitis
• Medical emergency - life threatening-swelling of the epiglottis

• Pathology = Haemophilus influenzae type b infection (HIB)

• Age range = usually aged 2-5 years

• DO NOT…
• EXAMINE THE THROAT OF A CHILD WITH SUSPECTED EPIGLOTTITIS – risk
of laryngeal obstruction
Signs & symptoms?
Epiglottitis management
• ABCDE

• You will not be managing alone!

• Important to keep the patient calm, minimal intervention and

immediate escalation

• Antibiotics - Cephalosporin IV for 7-10 days, e.g.: cefuroxime

• May require intubation and management on ICU

• Rifampicin prophylaxis to close contacts

Cardiac arrest
• Use ALS algorithm
Cardiac arrest
Cardiac arrest
• Use ALS algorithm
Cardiac arrest
1. Confirm cardiac arrest – check for breathing and pulse

2. Crash call – pull crash buzzer and 2222 (adult/paed/obstetric,

location)

3. Start CPR – 30:2 + apply defib pads + airway mx + IV access

4. Pause CPR for rhythm analysis and pulse check

5. Continue with relevant arm of algorithm (shockable or non-

shockable)
Shockable rhythms
Shockable rhythms
VF

Pulseless VT
Shockable rhythms
If rhythm analysis shows shockable rhythm…

6. Resume chest compressions

7. Set up defib and charge
8. Once charged asked everyone to ‘stand clear’
9. Deliver shock
10. Re-start CPR
11. Continue CPR for 2 mins
12. Rhythm re-check

Drugs – give adrenaline 1mg IV after alternate shocks (every 3-5

mins)
Non-shockable rhythms
Non-shockable rhythms
PEA

Asystole
Non-shockable rhythms
If rhythm analysis shows non-shockable rhythm…

6. Resume chest compressions

7. Continue CPR for 2 mins
8. Rhythm re-check

Drugs – give adrenaline 1mg IV as soon as IV access is achieved.

Give further 1mg IV adrenaline every 3-5 minutes (every
alternate CPR cycle)
Drugs
• Adrenaline 1:10,000
• Immediately if non-shockable
• Shockable rhythm = after 3rd cycle (then every alternate cycle)

• Anaphylaxis dose = ’a little of a lot’

• 0.5ml 1:1000 IM
• Cardiac arrest dose = ‘a lot of a little’
• 10ml 1:10,000 IV

• Amiodarone 300mg IV
• ALWAYS after 3rd cycle
Consider reversible causes
4 Hs:

4 Ts:
Consider reversible causes
4 Hs:
• Hypoxia
• Hypovolaemia
• Hyperkalaemia/hypokalaemia/hypoglycaemia/hypocalcaemia,
etc.
• Hypothermia

4 Ts:
• Tension pneumothorax
• Cardiac tamponade
• Toxic substance
• Thromboembolic
MCQ Q1
Q1. Which airway would be best tolerated in a patient with a GCS
of 14/15?
A. LMA
B. i-gel
C. Oropharyngeal airway
D. Nasopharyngeal airway
MCQ 1
Q1. Which airway would be best tolerated in a patient with a GCS
of 14/15?
A. LMA
B. i-gel
C. Oropharyngeal airway
D. Nasopharyngeal airway
MCQ Q2
Q2. Which of the following is a contra-indication for performing a
head-tilt and chin lift?
A. Basal skull #
B. Cervical spine injury
C. GCS 15/15
D. Clinical suspicion of epiglottitis
MCQ 2
Q2. Which of the following is a contra-indication for performing a
head-tilt and chin lift?
A. Basal skull #
B. Cervical spine injury
C. GCS 15/15
D. Clinical suspicion of epiglottitis
MCQ Q3
Q3. What is the correct management of a patient with
anaphylaxis?
A. Adrenaline 500 mg IM + hydrocortisone 200mg IV IV +
chlorphenamine 10mg IV
B. Adrenaline 500 micrograms IM + hydrocortisone 200mg IV +
chlorphenamine 10mg IV
C. Adrenaline 500 micrograms IV + hydrocortisone 200mg IV +
chlorphenamine 10mg IV
D. Adrenaline 500 micrograms IV + hydrocortisone 10mg IV +
chlorphenamine 2000mg IV
MCQ 3
Q3. What is the correct management of a patient with
anaphylaxis?
A. Adrenaline 500 mg IM + hydrocortisone 200mg IV IV +
chlorphenamine 10mg IV
B. Adrenaline 500 micrograms IM + hydrocortisone 200mg IV +
chlorphenamine 10mg IV
C. Adrenaline 500 micrograms IV + hydrocortisone 200mg IV +
chlorphenamine 10mg IV
D. Adrenaline 500 micrograms IV + hydrocortisone 10mg IV +
chlorphenamine 2000mg IV
MCQ Q4
Q4. If a patient is choking but able to cough effectively what is
your initial management?
A. Encourage cough and observe
B. 5x back blows
C. 5x abdominal thrust
D. Insert airway adjunct
MCQ 4
Q4. If a patient is choking but able to cough effectively what is
your initial management?
A. Encourage cough and observe
B. 5x back blows
C. 5x abdominal thrust
D. Insert airway adjunct
Slideshow Q5
Q5. Assess the pharyngeal structures of this patient and assign a
Mallampati criteria:
A. Grade I
B. Grade II
C. Grade III
D. Grade IV
Slideshow Q5
Q5. Assess the pharyngeal structures of this patient and assign a
Mallampati criteria:
A. Grade I
B. Grade II
C. Grade III
Soft palate
D. Grade IV
Faucial pillars

Uvula
Slideshow Q6
Q6. Which of the following mechanisms of O2 delivery results in a fixed
concentration of O2 being delivered?

A. C.

B.
D.
Slideshow Q6
Q6. Which of the following mechanisms of O2 delivery results in a fixed
concentration of O2 being delivered?

A. C.

B.
D.
 Questions?

• Next room for demonstrations & practice

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