Airway Management

• المقرر الدراسي: MEDI045

Airway

Evaluation and Management

• Indications of intubation
• Resuscitation (CPR)
• Prevention of lung soiling
• Positive pressure ventilation (GA)
• Pulmonary toilet
• Patent airway (coma or near coma)
• Respiratory failure(CO2 retention )
   
• Requirement of successful intbatin
• 1-Normal roomy mandible
• 2-Normal T-M, A-O , and C-spine
• Requirements of successful intubation
  3-Alignment of 3 axes or
  Assuming sniffing position
  -Any anomaly in these 3 joints
  A-O, T-M or C-spine can result
  In difficult intubation
• Requirement of successful intubation
   Proper equipment
  -Bag and mask,oxygen source
  -Airways oro and nasopharyngeal
  -Laryngosopes different blades
  -ETT different sizes
  -suction on
• Airway gadgets
• Management
  I-History:
    previous history of difficulty is the best predictor
  Inquire about:-Nature of difficulty
                        -No of trials
                        -Ability to ventilate bet trials
                        -Maneuver used
                        -Complications
  II-Snoring and sleep apnea( prdictors of DMV)
• Examination
  -Look for any obvious anomaly

• Morbid obesity(BMI)
• Skull
• Face
• Jaw
• Mouth,teeth
• Neck
• Examination
  I-The 3 joints movements

• A-O joint(15-20 degrees)

Presence of a gap bet the
Occiput and C1 is essential

• The cervical spine(range>90)
• T.M joint:-interdental gap(3 fingers)
•                  -subluxation  (1 finger)
• Examination
  II-Measurements of the mandible
  -Thyro-mental distance (head extended)
  Normally 6.5 cm
  Less than 6 cm=expect difficulty
• Tests to predict difficulty
  Mallampatti test:
  Based on the hypothesis
  That when the base of the
  Tongue is disproportionally
  Large it will overshadow the
  larynx
  -Simple easy test,correlates with what is seen during laryngoscopy or Cormack-Lehene grades ,but
  1-moderate sensitivity and specificity(12% false +ve)
  2-Inter observer variation
  3-Phonation increases false negative view
• II-Wilson test
  -Consists of 5 easily assessed factors

• Body wight(n=0 ,>90=1,>110=2)
• Head and neck movement
• Jaw movement
• Receding jaw
• Buck teeth

Each factor assigned as o ,1 ,2 max is 10

• Difficult airway
• Expected from history,examination
  Secure airway while awake under LA
• < >Airway gadgets
• Needle cricothyroidotomy
• Confirm tube position
• Direct visualization of ETT between cords
• Bronchoscopy ;carina seen
• Continuous trace of capnography
• 3 point auscultation
• Esophageal detector device
• Other as bilateral chest movement,mist in the tube,CXR
• Rapid sequence induction
• < >Technique:
       -Preoxygenation
       -IV induction with sux
       -Cricoid pressure
       -Intubate, inflate the cuff ,confirm position
       -Release cricoid and fix the tube
• Complications of intubation
  1-Inadequate ventilation
  2-Esophageal intubation
  3-Airway obstruction
  4-Bronchospasm
  5-Aspiration
  6- Trauma
  7-Stress response
• Recommendations
• Adequate airway assessment to pick up expected D.A to be secured awake
• Difficult intubation cart always ready
• Pre oxygenation as a routine
• Maintenance of oxygenation not the intubation should be your aim
• Use the technique you are familiar with
• Always have plan B,C,D in unexpected D.A