Professional Documents
Culture Documents
Airway Management
Outline
Overview
Normal airway
Difficult intubation
Structured approach to airway
management
Causes of failed intubation
Esophageal intubation
Failure to ventilate
Difficult Intubation
Ventilatory Support
Decreased GCS
Protection of Airway
Ensuring Airway patency
Anesthesia and surgery
Suctioning and Pulmonary Toilet
Hypoxic and Hypercarbic respiratory Failure
Pulmonary lavage
Endotracheal Intubation
Depends Upon Manipulation of:
Cervical spine
Atlanto-occipital Joint
Mandible
Oral soft tissues
Neck hyoid bone
Additionally:
Dentition
Pathology - Acquired
and Congenital
Patent nares
Ability to open mouth widely
with TMJ rotation and
subluxation (3 4 cm or two
finger breaths)
Mallampati Class I
Laryngeal Abnormalities
Macroglossia
Deep, narrow, high arched oropharynx
Protruding teeth
Mallampati Class 3 and 4
Neck Abnormalities
Thoracoabdominal abnormalities
Age 50 59
Male gender
Previous Intubations
Dental problems (bridges, caps, dentures, loose
teeth)
Respiratory Disease (sleep apnea, smoking, sputum,
wheeze)
Arthritis (TMJ disease, ankylosing spondylitis,
rheumatoid arthritis)
Clotting abnormalities (before nasal intubation)
Congenital abnormalities
Type I DM
NPO status
Palm Print
General:
Facies:
Nose:
Pierre Robin
Treacher Collins
Klippel Feil
Aperts syndrome
Fetal Alcohol syndrome
Acromegaly
Pierre Robin
Treacher Collins
Rheumatoid arthritis
Ankylosing spondylitis
Psoriatic arthritis
Degenerative join disease
Oral Cavity
Foreign bodies
Teeth:
Tongue:
Mallampati Classification
Difficult to Intubate
Mallampati Classification
Structured Approach to
Airway Management
MOUTHS
Componen
t
Description
Assessment Activities
Mandible
Opening
Uvula
Visibility
Teeth
Dentition
Head
Flexion, extension,
rotation of head/neck
and cervical spine
Silhouett
Upper body
abnormalities, both
Bag/Valve/Mask Ventilation
Beard
BMI > 26
Edentulous
Age > 55 years of age
History of snoring (obstruction)
DMV
Intubation Technique
Preparation:
Equipment Check
100% oxygen at high flows (> 10 Lpm)
during bask/mask ventilation
Suction apparatus
Intubation tray
Pre - oxygenation
Traditional:
Rapid
Positioning
Optimal position:
Positioning
Positioning
Large teeth or
tethered tongue
Short mandible
Protruding upper
incisors
Pathology in floor
of mouth
Reduced size of
intra and sub
mandibular space
Visualization
Visualization
Visualization
Visualization
Laryngoscopy Grade
Grade I - 99%
Grade II - 1%
Grade III - 1/2000
Grade IV - 1/ 10,000
Insertion
Cuff Inflation
Inflate to 20 cm H2O
Listen for leak at patients mouth
Over inflation can lead to ischemia of trachea
Gold standard
Auscultation
Visualization of tube through cords
Fiberoptic bronchoscopy
Pulse oximetry not improving or worsening
Movement of the chest wall
Condensation in ET tube
Negative Pressure Test
CXR
Airway Maneuvers
2.
3.
4.
Summary
Esophageal intubation
Failure to ventilate
Difficult Intubation
Massive Hemoptysis
Massive Hemoptysis
Localized bleeding
Diffuse Bleeding
Localized Bleeding
Infections
Bronchitis
Bacterial Pneumonia
Streptococcus and
Klebsiella
Tuberculosis
Fungal Infections
Aspergillus
Candida
Bronchiectasis
Lung Abscess
Leptospirosis
Tumors
Bronchogenic
Necrotizing
parenchymal cancer
Squamous
Adenocarcinomas
Bronchial adenoma
Cardiovascular
Mitral Stenosis
Localized Bleeding
Pulmonary
Vascular Problems
Pulmonary AV
malformations
Rendu-Osler-Weber
Syndrome
Pulmonary embolism with
infarction
Behcet syndrome
Pulmonary artery
catheterization with
pulmonary artery rupture
Trauma
Others
Broncholithiasis
Sarcoidosis
(cavitary lesions
with mycetoma)
Ankylosing
spondylitis
Diffuse Bleeding
Anticoagulants
D-penicillamine (seen
with treatment of
Wilsons disease)
Trimellitic anhydride
(manufacturing of
plastics, paint, epoxy
resins)
Cocaine
Propylthiouracil
Amiodarone
Phenytoin
Hemosiderosis
Blood dyscrasias
Thrombotic
thrombocytopenic purpura
Hemophilia
Leukemia
Thrombocytopenia
Uremia
Antiphospholipid antibody
syndrome
Pulmonary Renal
Syndrome
Goodpasture syndrome
Wegener
granulomatosis
Pauci-immune vasculitis
Diffuse Bleeding
Vasculitis
Pulmonary capillaritis
With or without connective tissue disease
Polyarteritis
Churg-Strauss syndrome
Henoch-Schonlein Purpura
Necrotizing vasculitis
Connective Tissue diseases
Systemic lupus erythematosus
Rheumatoid arthritis
Mixed connective tissue disease
Scleroderma (rare)
Tuberculosis
Bronchiectasis
Cancer
Mycetoma
Iatrogenic causes
Alveolar Hemorrhage
Trauma
Vascular malformation
Pulmonary embolism
Other Infectious Causes
Pathophysiology
Bronchial circulation
Pulmonary circulation
Low-pressure circulation
Multiple anastomoses exist between bronchial
and pulmonary circulations
Clinical Findings
Differential Diagnosis
Upper GI Bleeding
Dark blood
Food particles
Acid pH
Consider endoscopy
Laboratory Tests
No specific tests
CBC, diff, INR, PTT, platelet count
Electrolytes, BUN, Cr
Sputum culture and AFB
Urinalysis
ECG
ABGs
Type and Screen
Imaging Studies
Chest X-ray
CT scan
Stabilization
Treatment
General Measures:
1.
2.
3.
4.
5.
6.
Bronchoscopy required.
Intubate prior to bronchoscopy.
Rigid bronchoscopy
Bronchoscopic Interventions
Mycetoma
Resectable carcinoma
Localized bronchiectasis
Prognosis
Etiology of hemoptysis
Underlying co-morbid illnesses
Surgical vs. medical treatment
Mortality
Conclusion
Tuberculosis
Bronchiectasis
Cancer
Mycetoma
Iatrogenic causes
Alveolar Hemorrhage
Trauma
Vascular malformation
Pulmonary embolism