11 - Introduction to Airway Management

indications for ET intubation

• airway obstruction

• airway protection

• ventilation

• suctioning

prep for intubation: SOAP ME

S = suction

O = oxygen

A = airway equipment

P = position

M = monitors

E = E_TCO₂

patient position for intubation

sniffing position

• considerations: C-spine, trauma

steps for orotracheal (OT) intubation

1. visualize vocal cords

2. insert and confirm tube

3. STOP if > 30 seconds

tool for nasotracheal (NT) intubation

Magill forceps

laryngoscope blades

• Miller (straight)

• Macintosh (curved)

confirmation of tube placement

primary

• breath sounds

• chest rise

secondary

• capnography

• E_TCO₂ detector

CXR

• 3-6 cm above carina

airway cuff management

• high-volume vs low-volume

• cuff pressure: 20-30 cmH₂O

intubation complications

• trauma

• esophageal placement

• aspiration

tube-in-place complications

• infection

• pressure injuries

• mechanical issues

extubation complications

• sore throat

• hoarseness

• aspiration

• stenosis

video laryngoscopy devices

• GlideScope

• McGrath

• Airtraq

supraglottic airways

• LMA

• i-Gel

• King

• Combitube

airway adjuncts

• gum elastic bougie

• tube exchangers

rapid sequence intubation (RSI)

emergency intubation with immediate sedation and paralysis

indications for RSI

• impending respiratory failure

• inability to protect airway

• severe hypoxia/hypercapnia

• high aspiration risk

contraindications for RSI

• difficult airway with no backup plan

• inability to ventilate/intubate

common medications for RSI

induction

• etomidate

• ketamine

• propofol

paralytics

• succinylcholine

• rocuronium

complications of RSI

• hypotension

• hypoxia

• esophageal intubation

• aspiration

7 P’s of RSI

1. preparation

2. pre-oxygenation

3. pre-treatment (if needed)

4. paralysis with induction

5. positioning

6. placement with proof

7. post-intubation management

7 P’s of RSI

• 1: preparation

• get equipment

  • tube, laryngoscope, suction, BVM, E_TCO₂ monitor, etc.

• ensure O₂, IV, monitors

• have backup plan

7 P’s of RSI

• 2: pre-oxygenation

• 100% F_iO₂ via non-rebreather/BVM for 3-5 minutes

• nitrogen washout to increase safe apnea time

7 P’s of RSI

• 3: pre-treatment

• lidocaine (lowers ICP)

• atropine (pediatrics)

• fentanyl (blunts sympathetic response)

7 P’s of RSI

• 4: paralysis with induction

sedatives and paralytics

7 P’s of RSI

• 5: positioning

• sniffing position or ramped for obese patients

• align airway axes

7 P’s of RSI

• 6: placement with proof

• intubate with laryngoscopy

• confirmation

  • capnography, chest rise, breath sounds, no gastric sounds, CXR for final verification

7 P’s of RSI

• 7: post-intubation management

• secure tube

• begin MV

• administer post-intubation sedation/analgesia

• monitor for complications

extubation readiness criteria

• resolve initial cause for intubation

• adequate oxygenation

  • F_iO₂ < 40%

  • PEEP ≤ 5 cmH₂O

• hemodynamic stability (stable ABGs)

• SBT success (NIF/VC/MV)

• strong cough and gag reflex

• cuff leak test success

contraindications for extubation

• poor mental status

• airway swelling

pre-extubation checklist

1. suction airway (ETT and oropharynx)

2. position patient upright

3. explain procedure to patient

4. cuff deflation and tube removal

5. assess cough/stridor

6. post-extubation oxygen support

   • nasal cannula, HFNC, bland aerosol

indications for tracheostomy

• prolonged ventilation (> 2 weeks)

• airway obstruction

• facial trauma / upper airway anomalies

types of tracheostomies

• surgical vs. percutaneous

• cuff vs. cuffless

• fenestrated vs. non-fenestrated

post-procedure care for tracheostomy

• stoma care

• humidification

• suction

• emergency protocol

  • de-cannulation, blood, block

steps of tracheostomy insertion

1. sterile prep, sedation + paralysis

2. bronchoscope guidance (optional)

3. needle puncture

   • guidewire insertion (Seldinger technique)

4. open tract via dilator

5. trach tube insert and confirm

   • capnograph, chest rise

speaking valves

one-way valve on tracheostomy hub

• allows inspiration through trach, expiration through airway

• common type: Passy-Muir valve (PMV)

indications for speaking valve

• awake and alert trach patients

• patent upper airway

• tolerating cuff deflation

• good secretion management

• stable respiratory status

contraindications for speaking valve

• permanent inflated cuff

• upper airway obstruction

• copious secretions

• poor mental status

• unstable vitals

benefits of speaking valves

• verbal communication

• normal airflow, improving:

  • swallowing

  • secretion clearance

  • smell and taste

  • psychosocial well-being

indications for percutaneous tracheostomy

• prolonged MV

• upper airway obstruction

• neurological compromise needing long-term airway

contraindications for percutaneous tracheostomy

• infection at site

• coagulation

• anatomical abnormalities (goiter, short neck, etc.)

common methods of percutaneous tracheostomy

• ciaglia technique (serial dilators)

• Blue Rhino (single dilator)

steps of Blue Rhino insertion

1. position patient supine with neck extended

2. sedation and analgesia

3. ultrasound/bronchoscope guidance (optional)

4. skin incision, needle insertion

5. guidewire placement (Seldinger technique)

6. tract dilation

7. tube insertion and securing

8. confirmation with E_TCO₂, breath sounds, bronchoscopy

complications of percutaneous tracheostomy

immediate

• bleeding

• loss of airway

• pneumothorax

early

• infection

• subcutaneous emphysema

• tube dislodgment

late

• tracheal stenosis

• tracheomalacia

• fistula

cricothyrotomy

emergency airway through cricothyroid membrane

• done when intubation and ventilation are impossible

indications for cricothyrotomy

• severe upper airway obstruction

• facial trauma

• failed intubation attempts

• swelling

contraindications for cricothyrotomy

• kids < 12 years old

• laryngeal fractures

• tracheal transection

complications of cricothyrotomy

• hemorrhage

• misplacement (esophageal/pre-tracheal)

• subcutaneous emphysema

• vocal cord injury

• infection

cricothyrotomy procedure

• surgical (standard)

1. prep: antiseptic, gloves, scalpel, trach tube/bougie

2. incision over cricothyroid membrane

3. open with hemostat

4. insert trach/ETT (size 6-7)

5. confirm: E_TCO₂, breath sounds, chest rise

cricothyrotomy procedure

• needle (temporary)

1. use 12-14G over-the-needle catheter

2. insert through membrane at 45° angle caudally

3. confirm air return, connect to jet ventilation if available

4. short-term bridge only

laryngectomy tubes

tube inserted into stoma post-laryngectomy

• maintains airway patency

• no upper-airway connection, patient breaths only through tube

• tube types

  • flexible silicone

  • rigid plastic

indications for laryngectomy tubes

• laryngeal cancer (common)

• recurrent airway obstruction

• laryngeal trauma

• salvage after failed laryngectomy/radiation

considerations for laryngectomy tubes

• never bag through nose/mouth!

• intubation through stoma

• tube dislodgment is dangerous!

• management: reinsert tube, use suction, call for help!