Airway Anatomy and Management - PDF

‫دکتر احمد رنجبر‬ ‫متخصص بیهوشی‬ ‫فوق تخصص مراقبت های ویژه‬ ‫هیأت علمی دانشگاه علوم پزشکی‬ ‫شاهرود‬  Air way anatomy ‫عصب دهی حسی و‬ ‫حرکتی حنجره‬  Anatomy !!! Children are very different than adults Nose Nose is responsible for 50% of total airway resistance at al...

‫دکتر احمد رنجبر‬ ‫متخصص بیهوشی‬ ‫فوق تخصص مراقبت های ویژه‬ ‫هیأت علمی دانشگاه علوم پزشکی‬ ‫شاهرود‬  Air way anatomy ‫عصب دهی حسی و‬ ‫حرکتی حنجره‬  Anatomy !!! Children are very different than adults Nose Nose is responsible for 50% of total airway resistance at all ages Infant: blockage of nose = respiratory distress  Tongue Large Loss of tone with sleep, sedation, CNS dysfunction Frequent cause of upper airway obstruction Larynx High position Infant : C 1 months: C 3 6 Adult: C 5-6 Anterior position Children are different  Larynx Narrowest point = cricoid cartilage in the child Epiglottis Relatively large size in children Omega shape Floppy – not much cartilage Physiology: Effect of Edema Poiseuille’s law =R n l 8  r4 If radius is halved, resistance increases 16fold  ‫اندازه زبان نسبت به حلق‬ ‫اکستانسیون مفصل اطلسی‬ ‫‪-‬پشت سری‬ ‫فاصله ماند یبول‬ ‫قدامی(فاصله تیرو منتال)‬  ‫احتمال آسانتر بودن‬ ‫الرنگوسکپی مستقیم‬ ‫فاصله تیرو منتال‬ ‫بیشتر‬ ‫از ‪ 6‬سانتی متر‬ ‫باشد فک تحتانی‬ ‫طول‬ ‫بیشتر‬ ‫از ‪ 9‬سانتی متر‬  ‫‪ -1‬دندانهای لق‬ ‫‪-2‬پروتزهای دندانی‬ ‫‪ -3‬دندانهای غیر طبیعی‬  Class I Class II Class III Class IV Mallampati sign ‫عصب دهی حسی و‬ ‫حرکتی حنجره‬  ‫‪Upper lip bite test‬‬ ‫‪‬درجه ‪ :1‬دندانهای پیشین پایین بتوانندتمام حاشیه‬ ‫ورمیلیون لب فوقانی را گاز بگیرند‬ ‫‪‬درجه ‪ :2‬دندانهای پیشین پایین به تمام حاشیه‬ ‫ورمیلیون نمیرسند‬ ‫‪‬درجه ‪:3‬دندانهای پیشین پایین نمی توانند لب باالیی‬ ‫را گاز بگیرند‬ Schematic view of the glottis openining Oropharyngeal Airway/Guedel SIZE COLOUR Different colours = different size Neonate to large adult 000 Violet OO Blue O Black 1 White 2 Green 3 Orange 4 Red 5 Yellow  ?So what do we do ……A,B,C’s A is for clearing, opening and or securing the airway Clearing - turn on side suction - !no more blind finger sweeps -  Opening Jaw thrust Head Tilt Chin lift Combined Remember : C-spine stabilization Opening or securing the Airway BMV OPA/NPA LMA Combitube ETT Mask Most basic piece of “airway” kit Different types - clear, black - cushion around edge Won’t maintain airway by self Needs head tilt/chin lift or jaw thrust Also needs Positive Pressure Ventilation Mask with one-way valve  Length: Length:Nostril Nostrilto toTragus Tragus Contraindications:  Basilar skull fracture  CSF leak  Coagulopathy Oral Airway Correct size Oral Airway Wrong size: Too Long Oral Airway Wrong size: Too Short Oropharyngeal Airway/Guedel :How to put it in Depress tongue Slip over spatula with curve caudal direction Place bite block between teeth NO TWISTING MOVEMENT Oropharyngeal Airway/Guedel :Indications To open and maintain an airway in a patient with a depressed level of consciousness With FMO2 or BMV Oropharyngeal Airway/Guedel :Contra indications Patient won’t accept it LOC Risk of vomiting & aspiration Nasopharyngeal Airway For maintaining airway in “more awake” patients Sits in nasopharynx and opens airway Does NOT protect against aspiration Nasopharyngeal Airway ?How to size it Estimate by comparing to patients little finger ?How to insert it Lubricate Gently push posteriorly towards ear on same side Fix with a safety pin Nasopharyngeal Airway :Contra-indications Base of skull fracture Serious midline facial fractures When definitive airway needed Laryngoscope Blades Macintosh Miller “Sniffing Position” In the child older than 2 years Towel is placed under the head Nasopharyngeal Airway :Contra-indications Base of skull fracture Serious midline facial fractures When definitive airway needed Provide patent airway ‫بر قراری راه هوایی مناسب‬ prevent aspiration of gastric content ‫جلوگیری از آسپیراسیون‬ Need for frequent suctioning ‫محتویات معده‬ Facilitate positive pressure ventilation ‫نیاز به ساکشن مکرر راه‬ of the lungs Operative position other than supine ‫هوایی‬ ‫تسهیل تهویه ریه ها با‬ Operative site near or involving ‫فشارمثبت‬ the upper airway ‫وضعیتی غیر وضعیت خوابیده‬ Airway maintenance by mask difficult Disease involving upper air way ‫به پشت‬ Indications for Intubation Inadequate oxygenation(decreased arterial PO2) that is not corrected by supplemental oxygen via.mask/nasal.Inadequate ventilation (increased arterial PCO2).Any patient in cardiac arrest Indications for Intubation Ant patient in deep coma who cannot protect his.airway.(Gag reflex absent.) Any patient in imminent danger of upper airway.obstruction (e.g. Burns of the upper airways).Any patient with decreased L.O.C, GCS 55mmhg Arterial hypoxemia refractory.2 to O2 Contraindications for Intubation.Patients with an intact gag reflex Patients likely to react with laryngospasm to an intubation attempt. e.g. Children with.epiglottitis Basilar skull fracture – avoid naso-tracheal.intubation and nasogastric/pharyngeal tube Complications …Continued Damage to the endotracheal tube cuff, resulting in.a cuff leak and poor seal Intubation of the esophagus, resulting in gastric distention and regurgitation upon attempting.ventilation Baro-trauma resulting from over ventilating with a bag without a pressure release.valve( phneumothorax) Complications …Continued Over stimulation of the larynx resulting in laryngospasm, causing a complete airway.obstruction Inserting the tube to deep resulting in unilateral.intubation (right bronchus) Tube obstruction due to foreign material, dried.respiratory secretion and/or blood …Equipment Cont.Laryngoscope with relevant size blades.Magill forceps.Flexible introducer.ml syringe 10-20.Oropharangeal airways – all sizes.Tape or adhesive plaster.E.T tubes – relevant sizes.Bag-valve-mask with oxygen connected Suction unit with Yankauer nozzle and endotracheal suction.catheter …Technique Cont Position the patient supine, open the airway with a head-tilt chin-lift maneuver.(Suspected spinal injury, attempt naso-tracheal intubation, spine in.neutral position.) Open mouth by separating the lips and pulling on.upper jaw with the index finger Hold laryngoscope in left hand, insert scope into.mouth with blade directed to right tonsil Once right tonsil is reached, sweep the blade to the.midline keeping the tongue on the left Rules of Intubation.Always have a suction unit available An intubation attempt should never exceed 30.seconds Oxygenate the patient pre and post intubation.with a bag-valve-mask.(100% O2) Have sedative medication available if needed. (e.g. Midazolam 15mg/3ml) Always recheck tube placement manually.guided by oxygen saturation readings.(Spo2) Rules of Suctioning 4.Never suction further than you can see.Always suction on the way out.Never suction for longer than15 seconds Always oxygenate the patient before and after.suctioning Scissors maneuver Laryngoscopy view grades ‫لوله گذاری داخل تراشه با‬ ‫الرنگوسکپ تیغه خمیده‬ ‫لوله گذاری داخل تراشه با‬ ‫الرنگوسکپ تیغه صاف‬ ‫الرنگوسکپی دو دستی‬ ET T  ‫عوامل خطر آسپیراسیون‬ ‫محتویات معده‬ Intubation Age kg ETT Length (lip) Newborn 3.5 3.5 9 3 mos 6.0 3.5 10 1 yr 10 4.0 11 2 yrs 12 4.5 12 Children Children >> 22 years: years: ETT ETT size: size: Age/4 Age/4 ++ 44 ETT ETT depth depth (lip): (lip): Age/2 Age/2 ++ 12 12 Thyromental hieght test Sternomental distance/Savva test  Wilson’s Score Wilson and colleagues proposed a score based on five risk factors for predicting diffcult airway A total score of 2 or more is associated with an increased incidence of diffcult intubation El-Ganzouri Risk Index/ Simplifed Airway Risk Index (SARI) A score of ≥3 has also been found to be the optimal cutoff for predicting a DMV with a sensitivity of 66% and a specifcity LMA Advanced airway Useful alternative for “difficult ”intubation Easy to use Sits on larynx - ?Protects lungs Insert the LMA Gently advance the LMA with one single movement, applying continuous pressure against the palatopharyngeal curvature.with the index finger The vector of the force applied must be.directed cranially and not caudally Continue pushing the LMA against the soft  palate so that the cuff passes along the posterior pharyngeal wall and the tip locates itself in the hypopharynx.that is, it cannot be pushed further inwards  Figure 2 Demonstration of correct anatomical positioning of the laryngeal mask airway cuff around laryngeal inlet.. Laryngeal tube Combitube Down syndrome Turner syndrome ‫‪Klippel feil‬‬ ‫‪syndrome‬‬ ‫به علت اتصال مهره ها‬ ‫به یکدیگرگردن غیر قابل‬ ‫حرکت است‬ ‫‪Pierre robin syndrome‬‬ ‫‪‬دهان کوچک‬ ‫‪‬زبان بزرگ‬ ‫‪‬هیپوپالزی مندیبل‬ ‫الرنگوسکپ قابل انعطاف فیبر‬ ‫اپتیک‬ intubating fibreoptic stylets ‫کریکوتیروتومی‬ Glidescope wuscope Retrograde intubation  LMA(Laryngeal mask airway) Advanced airway Useful alternative for ”“difficult intubation Easy to use Sits on larynx - Protects ?lungs ILMA(intubating laryngeal airway) Proseal LMA Proseal LMA Combitube combitube Combitube Indications Use only in patients who are unresponsive and.”without protective reflexes “gag reflex For Paramedics use only in patients that you are.unable to insert an endotracheal tube.Patients in cardiac or respiratory arrest Combitube Contraindications Less 16 years of age Under five feet in height Intact gag reflex Known esophageal disease Ingestion of a caustic substance Combitube Insertion Technique Hyperventilate the patient at a rate of 24 times per minute for at least 2 minutes before attempting insertion, an oropharyngeal airway.should be utilized in this time Assemble equipment, ensure that cuffs are not leaking, and lubricate the distal end of the tube.with water-soluble lubricant Combitube Insertion Technique Place the patient’s head in a neutral in-line position. If spinal injury is suspected maintain.the head in a neutral in line position Perform a tongue-jaw lift maneuver and insert the device until the teeth are between the two.black rings  Combitube Insertion Technique Use the large syringe to inflate the #1 pharyngeal cuff with 100cc of air. The pharynx.will be sealed once this cuff is inflated Inflate the #2 distal cuff with 15cc of air. This will seal the esophagus or trachea depending on.placement Combitube Insertion Technique If equal chest rise and breath sounds bilaterally are present, then continue to ventilate through the tube.#1 If you hear gurgling sounds in the stomach then assume that you have inserted the device in the.trachea and start to ventilate through the #2 tube Combitube Insertion Technique Auscultate over the epigastrum, if gurgling is heard then remove the tube and ventilate.patient with BVM If no gurgling is heard then auscultate breath sounds, if the breath sounds are equal bilaterally then continue to ventilate through the.#2 tube Combitube Insertion Technique Once placement is confirmed hyperventilate the patient for two minutes, then resume.normal ventilation Reassess the tube placement after each patient move, and periodically check the pilot balloons to ensure that the two cuffs are adequately.inflated Combitube Removal Technique.Have suction equipment ready for use.Deflate both cuffs and remove tube gently.Be alert for vomiting