MUKESH SUNDARARAJAN

OBJECTIVES:

 At the end of the class the student will be:

 To define Airway management.
 To enlist the clinical features of airway obstruction.
 To discuss the respiration arrest.
 To demonstrate the Basic airway maneuvers.
 To demonstrate the basic air adjuncts.
 To demonstrate the advance air device.
 To explain procedure of the Intubation.
 To elaborate the Adjuncts for intubation.
 To discuss about the Surgical Airway management.
 INTRODUCTION
• Patients in any healthcare setting can quickly become acutely unwell, and
assessment and management of the airway is always the priority in any
clinical situation (Resuscitation Council UK, 2021). When patients are
critically unwell, there is a high risk of respiratory deterioration, and many
patients require an artificial airway to facilitate their treatment. Knowing how
to assess and manage the airway is a key skill for the nurse working in
critical care.
 INTRODUCTION

• Airway management is the practice of evaluating, planning and

using a wide array of medical procedures and device for the
purpose of maintaining or restoring a safe, effective pathway for
oxygenation and ventilation. These procedures are indicated in
patient with airway obstruction, respiratory failure, or a need for
airway protection.
 DEFINITION O F AIRWAY MANAGEMENT

• Airway management involves ensuring that the patient has a patent

airway through which effective ventilation can take place.
Obstruction of the airway may be partial or complete and may
occur at any level from the nose to the trachea.
 C L INICAL FEATUR E S O F
AIRWAY OBSTRUCTION

Complete Airway Obstruction Partial airway obstruction


Inability to speak or cough  Noisy breathing

Inaudible breath sounds  Snoring

Paradoxical movement of the chest  Stridor
and abdomen  Hoarse voice

Profound hypoxia  Gurgling from secretions
 Hypoxia or hypercarbia
 CLIN ICAL F E AT U R E S O F
Airway obstruction
AIRWAY OBSTRUCTION
Loss of airway protective
• Facial trauma reflexes
• Burn injury and/or inhalational 
Reduced GCS (traditionally ≤ 8)
injury

Ability to comfortably tolerate an
• Progressive angioedema
oral airway
• Known or suspected foreign 
Inability to swallow secretions
body aspiration

Procedural sedation or general
• Known laryngeal or anaesthesia.
pharyngeal cancer
R E S P IRATION A R R E ST

• Definition
“Respiratory arrest is the
complete cessation of
breathing in patients with
a pulse.”
 ETIOLOGY – EXTRAPULMONARY

Respiratory
CNS External
muscle
Depression forces
weakness

Airway
obstruction
 ETIOLOGY – PULMONARY

Impaired
Airway
Obstruction
alveolar
diffusion
 CLIN ICAL F EAT UR E O F
R E S P IRATORY A R R E ST
General
 Cyanosis
 Tachycardia
 Diaphoresis
 CNS impairment (e.g., altered mental status, agitation, coma)
Additional in imminent respiratory arrest
 Abnormal respiration (eg, gasping, expiratory wheezing, inspiratory
stridor)
 Sternoclavicular and/or intercostal retractions.
 RESPIRATORY A R R E ST
Diagnostics

 Clinical evaluation (ABCDE approach)

 ABG: decreased PaO and increased PaCO
 Pulse oximetry

Management

 Intubation
 Mechanical ventilation
 In case of obstruction, airway opening maneuvers
 Respiratory and cardiac monitoring
 Treatment of underlying conditions
R E S P IRATORY A R R E ST

• Complications

 Hypoxic organ
damage (eg., Hypoxic
brain injury)

• Cardiac arrest
•BASIC AIRWAY MANEUVERS
 HEAD -TILT/CHIN-LIFT MANEUVER
“A method of opening the airway that involves head
and neck repositioning. It should be avoided if there
is concern for C-spine injury.”

• • Technique

• 1. Tilt the head of the patient posteriorly to 15-

30°.

• 2. Lift the chin with the fingers to pull the

tongue
and oropharyngeal soft tissue anteriorly.

• 3. Use the fingers of the same hand to apply

pressure below the lip, slightly opening the mouth.

• 4. Maintain this "sniffing position" to align the

oral, pharyngeal, and laryngeal axes.
 JAW -THRUST MANEUVER
“The mandible is moved anteriorly to open the
airway. May be used in conjunction with
head- tilt/chin-lift or alone in patients with
suspected C-spine injury.”

• • Technique

• 1. With the patient supine, place fingers

behind the angles of the lower jaw.

• 2. Move the jaw anteriorly to pull the base of

the tongue and soft tissues away from the
airway.
• 3. Use the thumbs to open the mouth
slightly.
https://www.youtube.com/watch?v=5iwogajl-n8
 THE R E C O V E RY POSITION

“ positioning of the patient in

a lateral decubitus position
with slight neck extension “

• Aim

1. Prevention of airway occlusion

by the tongue and soft
tissues
2. Reduction in the risk of
aspiration if patients
regurgitate
 THE R E C O V E RY POSITION

• Indications

1. Prehospital settings
2. Temporal airway compromise
that can be managed by
positioning alone (e.g procedural
sedation, alcohol intoxication)
• Contraindications

1. C-Spine immobilization
2. Anticipated worsening of airway
compromise
3. Transportation outside of a
monitored environment
 BAG-MASK VENTILATION
“Delivery of oxygen and provider-assisted breaths using a bag-valve-mask unit to
patients with inadequate ventilation.”
• Indications

 Bridge to intubation

• - Patients with acute respiratory failure

• - Preoxygenation prior to general anaesthesia

 Rescue ventilation: Use after failed intubation attempt (e.g., when safe apnea
time has been exceeded) or accidental oversedation.
 CPR
 P RO C E D U R E O F BMV
Create a mask seal

EC-clamp technique (one-person

technique): commonly used in elective
perioperative situations when the provider
is alone.

• 1. With the patient supine, lift the jaw

towards the mask using the 3rd, 4th, and
5th fingers of one hand, forming an E-
shape

• 2. Squeeze the mask onto the face with

the thumb and index finger of the
same hand, forming a C-shape.

• 3. Deliver breaths with the second

hand.
 P RO C E D U R E O F BMV
Two-person bag-mask-ventilation technique:
used in emergency settings in which the patient is
deteriorating or ventilation is difficult, since it is more
effective.
• 1.One provider makes a seal and opens the airway
with both hands:
• - Squeeze the mask to the face using the eminences
of both hands, placed along the sides of the mask
with the thumbs pointing inferior
• - Perform a jaw-thrust maneuver using all 4 fingers
of both hands.
• - A two-handed EC-clamp technique may also be
used.
• 2. The second provider delivers breaths.

https://www.youtube.com/watch?v=zUGw90iL0Qw
 P RO CE D U R E O F BMV
Provide breaths: Set minute ventilation

• Aim: Deliver 500-600 mL (6-7 mL/kg) volume at 10-12 breaths/minute.

•Procedure: Squeeze the bag slowly and gently over approx. 1 second before allowing it to fully reinflate. Repeat
every 5 seconds.

•Adjust based on the clinical situation: E.g., follow compression-to-breath ratio in patients undergoing CPR without
an advanced airway (e.g., 30:2).

Confirm adequacy of BMV

• Clinical: No leaks around mask, Bilateral chest rise, Air entry on auscultation of bilateral lung fields

• Monitoring

- Oxygen saturations in target range

- Normal capnometry (waveform and EtCO2 value)

 ANTICIPATION AND COMPLICATION O F BMV
COMPLICATION
Poor mask seal or difficulty opening airway:

• Recommendation:

 Switch to 2 person BMV technique

 If this fails, insert a supraglottic device (eg, LMA) for ventilation.

Poor chest rise:

 Reposition, Check for obstruction, Use basic airway adjuncts.

Inadvertent hyperventilation

 Commonly occurs in stressful resuscitation scenarios, can lead to: stomach hyperinflation, vomiting, and aspiration, increase
intrathoracic pressure, decease cardiac output.
 Prevention: maintain steady pressure and depth of bag compression.

Hypoxia during apneic period

 Ensure adequate preoxygenation.

BASIC AIRWAY ADJUNCTS
• These devices may be used alongside bag-mask ventilation or airway opening
maneuvers to improve airway patency.
 OROPHARYNGEAL AIRWAY (OPA)
Description: a rigid curved device placed in the mouth to prevent the tongue from occluding the
airway

Indications

• Unconscious patients with a large tongue, obstructed nasal passages, or copious nasal secretions

• Typically used as a bridge to intubation

Contraindications: conscious patient with intact gag reflex

Sizing rule: from the incisors to the angle of the mandible, or corner of the mouth (oral commissure)
to the earlobe

Insertion technique: Adults: Insert concave up or concave lateral until past the tongue and then
rotate until concave down. Ensure OPA has bypassed the tongue and is not pushing it backwards.

Further management: Toleration of an oropharyngeal airway indicates an at-risk airway;

preparations should be made for intubation.
Procedure Additional information/rationale
If too short the airway would not separate the soft palate
1. Select appropriate size. from the posterior wall of the pharynx; too long may displace
the epiglottis.

2. Where no risk of cervical spine injury exists, hyperextend the Stretches the anterior neck structures to relieve obstruction of
head and neck. Grasp the patient’s jaw and lift anteriorly. the soft palate and epiglottis.

3. Using other hand, hold the OPA at its proximal end and insert it Avoids unnecessary trauma to the delicate tissues in the mouth
into the patients mouth with the tip pointing towards the roof of and inadvertent blocking of the airway by pushing the tongue
the mouth. back.

4. Once the tip reaches the level of the soft palate, gently rotate
Brings the OPA into the alignment required for use.
the airway 180° until it comes to rest over the tongue.

5. The flattened, reinforced section of a correctly sized OPA should

lie between the patient’s teeth/dentures or gums. The lips should
Acts as a bite block.
not be pulled over the flange of the OPA as this may cause damage
to the labial frenulum.

6. Verify appropriate position by listening for clear breath sounds

Ensures correct placement.
and looking for chest rise and fall.
SIZE O F OPA
• https://www.youtube.com/watch?v=Hzc_T4QBp4E
 NASOPHARYNGEAL AIRWAY
•Description: a long flexible tube inserted into the nostril and down into the nasopharynx to prevent the
tongue from occluding the airway

• Indications: conscious or unconscious patients with current or potential oropharyngeal obstruction

• Contraindications: facial fractures, basilar skull fractures

• Sizing rule: nostril to the ipsilateral tragus

• Equipment required

 Range of nasopharyngeal airways

 Sterile gloves

 Sanitizer

 Sterile tray

 Water-based lubricant
Procedure Additional information/rationale

1. Select appropriate size, 7.0 as a starting point for an average adult male
and 6.0 for an average adult female.
If too short the airway would not separate the soft palate from
2.Once the selection has been made, measure from the tip of the nose to
the posterior wall of the pharynx; if too long may enter either
the tragus of the ear. Insert safety pin to mark the maximum depth of
the larynx or vallecula where the airway could become
insertion (this should be at the proximal end of the NPA).
obstructed.
3.Where no risk of cervical spine injury exists, hyperextend the head and Stretches the anterior neck structures to relieve obstruction of
neck. the soft palate and epiglottis.
4. Lubricate the exterior of the tube with a water-soluble gel. Minimises trauma during insertion.
5.If there is no obvious nasal deformity, it is recommended that the right The bevel of the NPA is designed to cause less trauma to the
nostril be used. mucosa when inserted into the right nostril.
6. Where deformity exists, the most patent nostril should be selected.
7. If inserting into the left nostril the bevel is placed alongside the
To minimise trauma to the internal nares.
septum
and the airway rotated through 180° when it enters the nasopharynx.
This ensures correct location and reduces risk of cranial
8.Insert the tube into the selected nostril and follow the nasal floor parallel
insertion where basal skull fracture exists.
to the mouth. It is imperative that the airway is not pushed in a cephalad
direction.
Pushing against resistance may cause bleeding and kinking of
9.Avoid pushing against any resistance. If resistance is felt, remove the the NPA.
airway, review technique and reinsert using the other nostril.
10.Verify appropriate position by listening for clear breath sounds and
looking for chest rise and fall. Air may also be felt at the proximal end of the Ensures correct placement.
airway in the spontaneously breathing patient.

11. Check to make sure there is no blanching of the patient’s nostrils. If

Prevents necrosis of the tissues.
there is, remove NPA and select a smaller diameter.
• https://oxfordmedicaleducation.com/clinical-skills/procedures/nasopharyngeal-airway/
SIZ E
•ADVANCE AIRWAY DEVICE
 SUPRAGLOTTI C AIRWAY D E V I C E
Definition: a collection of advanced airway devices that are inserted via the
oropharynx to provide ventilation from above the glottis
Indications
•Cardiac arrest (pre-hospital and in-hospital), as they can be inserted by
providers untrained in intubation
• First-line for short durations of anesthesia
• As an alternative advanced airway if intubation has failed

Contraindications: Avoid in conscious patients with an intact gag

reflex.
Caution: does not offer complete protection against aspiration, unlike an
endotracheal tube
LARYNG EA L M AS K AIRWAY
(LMA)
• The laryngeal mask airway (LMA)
comprises a wide-bore tube with an
elliptical inflatable cuff designed to seal
around the laryngeal inlet. The proximal
end of the tube is fitted with a standard
15/22 mm connector. The LMA can be
placed blind, requires less skill and is
easier to insert than a tracheal tube. The
LMA provides for more efficient ventilation
than with a bag-valve-mask (BVM)
 A. LARYNGEAL
MASK AIRWAY
(LMA)
“a supraglottic device consisting
of an inflatable mask attached to
the end of a tube.”

•Second-generation LMAs
feature safety adaptations such
as bite blocks and a drainage
tube.

•Intubating LMAs (ILMA)

feature additional adaptations to
allow passage of an ET tube
through the LMA.
 B. I-GEL®:

a type of supraglottic
airway that is similar in
structure to the LMA.
However, the mask is
anatomically-molded,
noninflatable, and made
of a soft gel-like material.
 C. LARYNGEAL
TUBE AIRWAY (LTA)
• An airway device consisting of a tube

with 2 inflatable c)uffs and

ventilation holes between them.
• • Intubating LTAs feature additional
adaptations to allow passage of an ET
tube through the LTA.
 SIZING OF A LARYNGEAL MASK AIRWAY

Maximum cuff inflation (mL

Size Age/weight range
air)

1 Neonates up to 5 kg 4

1.5 Children 5–10 kg 7

2 Children 10–20 kg 10

2.5 Children 20–30 kg 14

3 Children 30–50 kg 20

4 Small/normal adults 30

5 Normal/large adults 40
 EQUIPMENT REQUIRED

• LMA – range of sizes

• 50 mL syringe
• Tie
• Lubrication
• Stethoscope
• Gloves
• Sanitizers
 PROCEDURE
1. Choose the appropriate size for the patient:

• Small adult: size 3

• Medium adult: size 4

• Large adult: size 5

2. LMAs and LTAs: inflate cuffs fully to check for leaks before deflating.

3. Lubricate the tip of the device, being careful not to block ventilatory openings.

4. Place the patient in the sniffing position.

5. Open the patient's mouth wide.

6.Hold the device firmly (at the junction of the tube and mask for an LMA, at the bite block for an
i-gel®, or at the connector for an LTA).
 PROCEDURE
7. Insert the device.
•LMA and i-gel®: Insert smoothly along the hard palate and downwards with the
outlet facing caudally.
•LTA: Insert the tube rotated at 45-90° from midline (towards concave lateral)
until past the base of the tongue, where it should be rotated back to midline
(towards concave up).

8.Stop when the device has passed the base of the tongue and resistance is felt
(LMA or i-gel®) or the connector reaches the teeth (LTA).

9. LMAs and LTAs: inflate the cuff.

10. confirm supraglottic tube placement.

LARYNGEAL MASK AIRWAY
(LMA)
LARYNGEAL MASK AIRWAY
(LMA)
LARYNGEAL TUBE AIRWAY
(LTA)
• https://www.youtube.com/watch?v=vNvymbRD5b4
 CONFIRMATION OF CORRECT PLACEMENT

• Air movement heard on auscultation

• of chest
• Visible chest rise and fall
• Continuous CO2 waveform on capnography
• Stable or improving oxygenation
 INTUBATION
General principles
•Defined as placement of a cuffed endotracheal (ET) tube below the vocal cords via direct
laryngoscopy or videolaryngoscopy
• Mostly commonly placed orally (orotracheal intubation), although it may be placed
nasally (nasotracheal intubation)
• Typically, sedation and paralysis are required to tolerate the procedure and subsequent
mechanical ventilation.
• Goals: maximize first-pass success, reduce the risk of aspiration
• Involves the rapid induction of anaesthesia and paralysis, followed by intubation
• Differs from traditional intubation in few ways:
- BMV is not performed (to avoid potential aspiration of stomach contents).
 INTUBATION
• Indications for endotracheal intubation

• Inability (or anticipated inability) to maintain the

airway: e.g., general anesthesia, airway obstruction
or reduced GCS
• Failure (or pending failure) of ventilation or
oxygenation: e.g., in severe acute asthma or COPD
(see "Indications for invasive mechanical
ventilation)

• Conditions in which there is a high risk of

deterioration: e.g., multisystem trauma,
anaphylaxis, severe septic shock
Contraindications
• Do-not-intubate order

• Consider adjuncts to intubation or proceed to surgical airway management in:

• Copious blood/secretions

• Upper airway distortion

• Mouth opening limited

• Severe kyphosis
Preoxygenation
• administration of 100% oxygen prior to induction to denitrogenate air in
the lungs .
• Intubation medications

• Typically two classes of medication are given prior to intubation, a sedating (induction) agent
and neuromuscular blocking agent to paralyze the patient.

• Induction agents for intubation

• • Used to induce a state of sedation, which reduces airway reflexes and facilitates intubation

• • Options include:

• • Propofol

• • Etomidate

• • Ketamine

• • The choice of induction agent depends on patient characteristics and operator experience.

• • The duration of bolus doses is typically short (~ 10 minutes) and infusions are required for
ongoing sedation
• Paralytic agents for intubation : Clinical applications

• • Improving airway visualization by relaxing the jaw muscles

• • Decreasing the risk of injuries, e.g., vocal cord damage

• Types

• • Depolarizing NMJ blockers: e.g., succinylcholine

• - Widely used due to rapid onset and offset time (spontaneous respirations normally
return within 10 minutes)

• - Rarely, prolonged paralysis occurs in patients with limited cholinesterase activity.

• • Nondepolarizing NMJ blockers: e.g., rocuronium

• - Used in patients with contraindications to succinylcholine

 INTUBATION VIA DIRECT LARYNGOSCOPY

• • Positioning: Place patient in sniffing

position unless C-spine injury is suspected.
• Head elevated to a height of 10 cm

• The neck is mildly flexed at the lower

cervical vertebrae and extended at the
atlanto-occipital joint.
• • Technique: The majority of patients
should have received induction agents and
been preoxygenated. Equipment should
always be on hand to manage a failed
intubation.
ARTICLES AND POSITIONING
ET TUBE
 INTUBATION VIA DIRECT LARYNGOSCOPY
1. Wear appropriate PPE.

2. Choose the correct ET tube size. = (22)

3. Gently open the patient's mouth,

4. Insert the laryngoscope blade, using the groove to sweep the tongue aside.

5. Advance steadily until the tip is at the vallecula and the epiglottis is visible below it.

6.Lift gently forward and upward to raise the epiglottis and reveal the arytenoid cartilages and vocal
cords.

7. Insert the ET tube with the stylet.

8. Once the tip is at the glottis, remove the stylet and gently advance until the cuff is past the cords.

9. Inflate the cuff to protect the airway from secretions and form a seal around the tube.
• https://www.youtube.com/watch?v=3uvQO6ty5HU
 CONFIRMATION OF TUBE PLACEMENT
Auscultation of bilateral breath sounds over the lungs

• Consistent condensation visible in the tube upon exhalation

• Capnometry

- A visual indicator changes colour from purple to yellow upon contact with CO2.

- Consistent colour changing with each breath > 3 times correlates with tracheal placement.

• Capnography: measurement of end-tidal CO2

• Direct visualization of endotracheal tube markers

• Proximal numbered tube markers should indicate approx. 21-23 cm at the patient's teeth.

•CXR: The distal tip of the endotracheal or tracheal tube should be 2-6 cm above the carina
Ultrasound may be used to confirm tube position
 COMPLICATION OF INTUBATION
• Early complications • Late complications
• Hypoxia • • Vocal cord injuries
• Bradycardia
• • Vocal cord granuloma: a complication of
•Respiratory acidosis
endotracheal intubation caused by
Trauma
inflammation and ulceration during the
• - Dental damage
intubation process. Can cause vocal
• - Tracheal
hoarseness that manifests~ 4 weeks after
perforation
intubation.
•- Hemorrhage

Pulmonary aspiration
Laryngospasm
Bronchospasm
•Surgical airway management
 SURGICAL CRICOTHYROTOMY

• Definition: an emergency procedure in which an incision is made through the skin, cervical
fascia, and median cricothyroid ligament (cricothyroid membrane) to obtain airway access.

• Indications: CICV scenario (if orotracheal intubation has failed or is contraindicated)

Failure to maintain oxygenation or ventilation in between intubation attempts or after 3 attempts

at intubation
May be required in:
- Severe oropharyngeal edema
- Foreign body aspiration causing complete occlusion of the upper airway
- Severe oropharyngeal/nasal haemorrhage
- Acute epiglottitis
- Severe maxillofacial trauma
 SURGICAL CRICOTHYROTOMY

Contraindications
• Young children and infants

•Some airway injuries: e.g., tracheal transection or laryngeal fracture

o Obstruction distal to the cricothyroid membrane

o Inability to identify anatomical landmarks
• Tumor or infection at the incision site
EQUIPMENT
• https://www.youtube.com/watch?v=bRfQeHtv7pM
•Planned Surgical Airway
 TRACHEOSTOMY
•Definition: a permanent or temporary opening (stoma) in the cervical trachea created
through a surgical incision below the cricoid cartilage
Indications
• For emergency indications, same as for cricothyroidotomy
• Long-term mechanical ventilation (> 3 weeks)
•Malignancy

Options
• Percutaneo
us
tracheosto
my
HTTPS://WWW.YOUTUBE.COM/WATCH?V=78B-
UNUYWR8
 LARYNGECTOMY

•Definition: the removal of all of the laryngeal structures, including the

epiglottis and part of the upper trachea, with the trachea brought to the
front of the neck to create a stoma

• Indications: laryngeal cancer

•Caution: As the upper airway is no longer connected to the trachea,

patients with a laryngectomy cannot be oxygenated or intubated through
the upper airway.
COMPLICATION OF SURGICAL AIRWAY
• Early complications Late complications
 Bleeding • Dysphonia
 Creation of a false lumen • Scarring
 Laceration of the back wall of the trachea
• Stenosis
Damage to the surrounding structures:
e.g., esophageal, mediastinal, or thyroid • Tracheomalacia
perforation, vocal cord injury, or recurrent
laryngeal nerve injury
 Pneumothorax
 Subcutaneous emphysema
 C H E C K LIST F O R EQUIPMENT REQUIRED
FOR MANAGING AIRWAY.
• PPE
• Monitor connection to patient- BP, SPO2, PR,
• I V access, tourniquet, cannula.
• Oxygen face mask, tubing's.
• OPA, NPA
• B M V device
• Suction device
• Laryngoscope and blades- all size.
 NURSING R E S P ONSIBILITY
• Assess the airway for patency.
• Use manual methods to open an obstructed airway.
• Use basic airway adjuncts to intervene if the airway is compromised, eg: suction.
• Assist in the maintenance of the airway using advance airway adjuncts, e.g. intubation, surgical
airway.
• Deliver O2, when required, using appropriate methods.
• Continually assess airway patency and ventilatory status of the patient using clinical
observation
and relevant monitoring.
• Monitor G C S .
• Maintain correct tube placement, proper cuff inflation.
• Maintain and monitor ventilation status. (ABG)
• Providing mouth care.
• Fostering communication and comfort.
 TO S U M M A R I S E …

• Always check airway patency for any patient.

• Always bear in mind- Look, listen and feel.
• Assign the role of team leader, airway nurse and IV nurse.
• All Equipment's and drugs should be checked regularly.
• Knowledge regarding different airway device, drugs and team work are
essential for the better management of the patient.
THANK YOU