Airway Assessment

Can be more challenging in critically

ill.
Must avoid the cannot intubate,
cannot ventilate scenario.
Must assess
1) Risk for difficult mask ventilation
2) Risk for difficult intubation
 Bag Mask Ventilation
Crucial airway management skill.
Takes practice to perform correctly.
Gives time for well-planned approach
to definitive airway management.
3 keys:
Patent airway
Good mask seal
Proper ventilation
 Bag Mask Ventilation :
Opening Airway
Head Tilt and Chin
Jaw Thrust
Lift

One hand applies downward

pressure to forehead and
index and middle finger of
the second hand lift at chin.
Lifts tongue from posterior
pharynx
For unstable cervical spine
Place heels of hands on parieto-occipital
Grasp angles of mandible with fingers, a
displace jaw anteriorly.
 Adjuncts for Opening
Airway

Need to size properly

Avoid pushing tongue into posterior pharynx.
Start with curve of OPA inverted and rotate 180 degrees as tip
reaches posterior pharynx.
Avoid in awake patient aspiration risk
 Bag Mask Ventilation
One-handed Two-handed techniques
technique

Three facial landmarks that must be covered bySmall tidal volumes

mask: Squeeze steadily dont force
1. Bridge of the nose air too quickly
2. Two malar eminences 10-12 breaths/minute
3. Mandibular alveolar ridge
Assess for rise and of fall
chest
 Steps for Endotracheal
Intubation
1. The 4Ps:
Preparation
Pre-oxygenation
Positioning
Premedication
2. Achieving Intubating Conditions:
Laryngoscopy/Intubation
3. Post-intubation Care
 Preparation
Airway assessment
Signs of difficult bag mask ventilation
Signs of difficult intubation
Assembling necessary equipment and
medications.
Developing an airway management plan
Back-up plan
Back-up to back-up plan
 Preparation
Equipment
S uction
T ools (laryngoscope, blade, extra
batteries)
O xygen
P ostioning/plan
M onitors (pulse ox, BP, capnography)
A mbu bag, airway devices
I ntravenous access
D rugs (premeds, induction, NMB)
 Preparation:
Preoxygenation
Establishment of oxygen reservoir
Replace nitrogenous mixture of room air
FRC = 30ml/kg
Preferable time = 5 minutes
Bag mask ventilation not needed if good
preoxygenation.
Preoxygenation often challenging in ICU
NIPPV
Elevating head of bed
 Preoxygenation: Apnea Time
(VE= 0)

- Time from 90%

to 0% MUCH
shorter than
time from 100%
to 90%.
- Obese and
critically-ill
desaturate
quicker.
 Preparation:
Pretreatment
Drugs to mitigate adverse effects of
intubation
L idocaine (reactive airways or elevated ICP)
O pioids ( blunts sympathetic response and
increased BP)
A tropine ( bradycardia mainly kids)
D efasiculating Agents (low dose
competitive
neuromuscular blocker in elevated ICP)
 Preparation:
Head Positioning

Supine

Head Elevated

Head Elevated and Neck

Extending = Sniffing
Position
 Preparation:
The Need for a Plan

Main Airway
 Induction Agents
Midazolam: (dosage 0.1-0.3 mg/kg; time to effect
>5 minutes; hypotension)
Etomidate: (rapid onset; no hypotension; no
analgesia; concerns with sepsis unjustified)
Propofol: 1.5 to 3 mg/kg; rapid onset;
hypotension; no analgesia.
Ketamine: sedation and analgesia; no
hypotension; bronchodilator effect; respiratory
drive preserved; good for awake look.
Thiopental: rapid onset; no analgesia; myocardial
depressant; severe hypotension
Neuromuscular Blockade
Succinylcholine
Onset 45-60 seconds; duration 6-10 minutes
1-1.5 mg/kg
Contraindications: hx of malignant hyperthermia,
neuromuscular disease with denervation (MD, stroke
> 72 hours, burns >72 hours) rhabdomyolysis,
hyperkalemia.
Non-depolarizing neuromuscular blockers
Rocuronium 0.8 -1.2mg/kg: fast onset, longer duration
than succinylocholine; can be reversed
Cisatracurium (Nimbex): not for RSI as slow onset
Vecuronium
 Laryngoscopes

Macintosh Blade Miller Blade

Laryngoscopy Technique
Inserting Laryngoscope

Macintosh Blade in Miller Blade Under

Vallecula Epiglottis
 Epiglottoscopy

Blade inserted with Tip of blade gets With full insertion of

laryngoscope handle around base of curved blade into
pointed at the tongue, permitting vallecula the angle of
patients feet. change in angle of lifting changes to ~40
Tongue and jaw are lifting and better degrees from the
distracted downward mechanical horizontal.
to insert the blade. advantage. Now the lifting force
Minimal force required Epiglottis edge lifted can be increased as
off pharyngeal wall. needed.
(Epiglottis often Tip position (not
camouflaged against force) is the main
mucosa of posterior determinant of
 Lifting the Scope

Yes No
 Laryngoscopy:
Optimizing Glottic View

Cormack-Lehane Scoring of Glottic View

Cricoid Pressure
Sellick maneuver or
BURP

Avoid regurgutation
of gastric contents

Imaging studies
undermine theory

May worsen glottic

view
Optimizing Glottic View:
Bimanual Laryngoscopy

1) Drives tip of blade into proper

position optimizing mechanics of
indirect epiglottis elevation.
2) Moves larynx downward into line of
sight.
Inserting Endotracheal
Tube

Yes,
good

No, bad