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Airway management
A. Cortegiani
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“The most common… is the obstruction of the oropharynx by the relaxed tongue which is pushed against the posterior pharingeal wall… “ Safar P et al. J App Physiol. 1959
“The result is that the epiglottis and not the tongue is the main cause of obstruction of the upper airways.” Boidin MP et al Brit Journal Anest 1985
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Signs of complete airways obstruction with respiratory efforts
• See-saw respirations
• Diaphragm flattens
• Abdo contents pushed down
• Abdo rises
• Chest “sucked in”
• Paradoxical
Diaphragm Lung
Air
Normal inspiration
Lung Diaphragm
Air
See-saw respirations
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Signs of partial airways obstruction with respiratory efforts
Snoring: Pharynx is partially ocluded by soft palate or
epiglottis
Gurgling: caused by liquid or semisolid foreign material
in the large airways
Inspiratory stridor: Obstruction at laryngeal level
Crowing: sound of the laryngeal spasm
Expiratory wheeze: obstruction of the lower airways
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Open the airways: head tilt & chin lift
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Open the airways: Jaw thrust
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Guedel cannula
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Airway obstruction associated with the use of the guedel
airway. Marsh AM et al Br. J. Anaesth. (1991) 67 (5): 517-523.
It may cause vomiting or laringospam if glossopharyngeal and
laryngeal reflexes are present
Part of the tongue can occlude the end of the airway
the airway can lodge in the vallecula
the airway can be obstructed by the epiglottis
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Nasopharyngeal airway
• It is tolerated better
• Usefull in clenched jaw, trismus
and maxillofacial injury
• Be careful if a skull base
fracture is suspected
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Ventilation
“…Provide artificial ventilation as soon as possible for any patient in whom spontaneous ventilation is inadequate or absent…”
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Pocket mask
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Bag – mask ventilation
FiO2 21%
10 L/min O2
FiO2 85%
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Bag – mask ventilation
1° & 2°: “C” on the mask
3°: “Thrust the chin up”
4°: On the ascending mandibular ramus
5°: On the mandibular
angle
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How to squeeze the bag?
“Give a volume that corresponds to normal chest movement
“…Approximately 500 – 600 ml…” “2 breaths after 30 compression” “…Each breath over 1 second….”
Not exceed 5 seconds Avoid rapid or forceful breaths”
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• Laringeal Mask (LMA)
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LMA Supreme • High pressure supported
(37 cmH2o ?) • Enables passive and active removal of gastric content through dedicated channel
• More rapid insertion • Bite block
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LMA PRO
Quicker and easier to insert than a tracheal tube
More efficient and easier ventilation than with a bag – mask
ventilation
High successful ventilation rates during CPR in in-hospital
studies (86 – 100%)
Not so high in out-of-hospital cardiac arrest (71 – 90%)
When inserted, ventilate at 10 BPM (as via tracheal tube)
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LMA CONS
Increased risk of aspiration in
comparison to tracheal intubation
Inability to provide adequate
ventilation in patients with low lung
and/or lung compliance
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Blue cuff: 50-100 ml air White cuff: 5 – 15 ml air
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Tracheal intubation: who should be intubated?
Is there a failure of airway maintenance or protection?
Is there a failure of ventilation or oxygenation?
What is the anticipated clinical course?
R. Walls 2000
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?
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“…A recent systematic review: There was no overall benefit for tracheal intubation…”
Is about PREHOSPITAL!!!
AND…
Lecky et al: Emergency intubation for acutely ill and injured patients. Cochrane Database syst Rev 2008
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“…A recent systematic review: There was no overall benefit for tracheal intubation…”
Is about paramedics!
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Positioning
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Back – Up- Right – Pressure:
BURP
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Take it easy and…
Always let him….