Maintainance of airway

Ventilation vs oxygen therapy

In most emegrencies airway and breathing is first except for actrostrophic haemorrhage where you tend to the bleeding. Very small incidence rate where airway and breathing isnt first.

Diffcult airway protocols Different types of air way and how to do each?????

Algorithms pics can add from the whhatsapp appt group. ........................................................................ ways to know breathing

Can put hand on top of mouth and feel the air going out and in

Can put ear close to mouth and here whether air moves in and out

See chest expansion from that side

Not breathing 1. Stridor

2. Accessory muscles

3 chest not expanding

4. fail upper stuff First do simple arousal to see whether airway opens otherwise must do it yourself !!!!

Triple manoeuvre

Not to be used in C spine injury ⇒ for trauma assume C spine and fixate that until proven otherwise by x ray

If c pine then direct ambu bag without sniffing position If C spine injury do only jaw thrust and maintain stable head and neck position like below

Tongue falls back down/

Child above has large occiput so no need

1. head tilt and chin lift (left hand right hand) 2 jaw thrust (from head of the bed) IF airway is not opened only you do these things. If open then you can just give oxygen therapy only since the patient has airway opened but with bad breathing so give oxygen to make it easier to saturate even with worse breathing.

And mouth open. Dont press on soft tissue but bony structure not because of pain but because it can obstruct the airway itself.

Putting pressure between the angle of the jaw and ear can be painful but helps to arouse the patient and make him breathe on his or her own.

Triple airway maneuver combines the three techniques

head tilt and chin lift

2. jaw thrust and chin lift

3. open mouth using thumb

see whether the 3 + 4 signs above increase or decrease

Mouth to Mouth Resustitation

Must close the nose by pinching it And then form a seal over the patients mouth and then blow in and out ⇒ 16% oxygen from exhale air

Then must use ait way adjuncts if failed

Oropharyngeal tube

Also called guedal airway

Airway is not protected here so vomitus can come up and go into the trachea! Careful in full stomach

Check size of the guedal air way by

corner of the mouth to ear lobe pinnae

Incissors to angle of mandible

Can insert upside down with the thing facing otherway to avoid the tongue and then flip it When taking out can directly take it out But first attempt to put it directly in failing which put it the other direction and then turn

Then can use other airway adjuncts to ventilate using this guedel airway. Learn about these devices in oxygen therapy.

Thumb above. 2.d and 3rd on the mask. 4th and 5th helping put the chin up and head tilt. Make sure you seal it. Can ask the patient to remove off the oropharngeal airway because it means hes concious and in control of breathing. So should be removed. But otherwise you can remove it. Just take it off.

Mask and bag - Ambu bag (brand name) - BVM

Articficial manual breathing unit Can add this to the orophrngeal or guedel airway

For viva must say 1. Parts of the ambu bag 2. how the ambu bag works 3. technique to put it on 4. Where it fits in the entire resuscitation story

Oxygen comes in and fills in the reservoir bag and then goes in

Can use the one hand technique or the 2 hand technique with assistant involved with the bag

Or press the bag onto your belly and use the belly

Theres a difference between using masks for ventilation and oxygen therapy. In ventilation you need a tight seal. For oxugen therapy you dont so, just around it but still good if seal. And be careful because oxygen rich enviornment and can explode when deciding to shock, so pull the cyllinders and stuff away. Another reason is cause of metal electical conduction?

Self inflating bag and reservoir and OTebb device

can conenct the reserviur bag to oxygen like above

Valve closes whenever you sqeeze the bag one way valve

If the reservoir bag for oxygen isnt filled with oxgen, then another valve opens to suck in air from the atmosphere. but when after filled that valve closes and the air now comes from the reservoir bag.

Another valve to protect when the pressure is too high and to stop filling

Valves 1. between bag and reservoir to prevrnt back flow 2. on top to open if theres oxugen filled in otherwise taken in from the atmosphere 3 rd valve for portection if theres too much pressure in the reservoir it closes

There's another valve on the left hand side to prevent back flow from the patient to the bag...and it flows out instead to the atmosphere on the left side

Expiratory port on the left side

The last valve is the high pressure blow off valve

Can manuall override that to give high pressure but most of the time it should be left out

How it works is important for the viva?

Steps: Turn oxgen on. Put sniffing position and then put an air way like oropharngeal guedel airway and can put the mask above this when put in.

Then two ways to use it and hold it in place Pointed side to the nose and rounded side to the chin like above.

thumb and pointer finger either side of the mask and the rest of the fingers onto the other parts of the mask and chin. tWO FINGERS MAKE A C AND THE REST 3 MAKES AN E

But since there is no resistance to the expired air, the lungs wil collpase immediately. This can be prevented by fixing an additional valve to the expiratory port and adjusting it by screweing it. So theres resistance and the lung collapse slowly.

5/6 SECONDS EVERY BREATHE = 12 BREATHS PER MINUTE

In cardiac arrest the patient is on the floor so can instead of pressing agasint the belly can press agasint the lap

2. If two people available can hold mask with two fingers and do it much easier. To make a better seal so the other guy can press sqeeeze.

How to select sizes = there are differetn szies for babies, pead and dif adults.

How to check whether working properly

check outlet like this

MUST GIVE ABOUT 40/60 BREATHS A MINUTE .tHATS FOR PEADIATRIC PATIENTS. Pediatric neonatal resucitation is a little bit different. LEarn neonatal resusictation later on with peads.

LMA

hydra airway

Put it in directly and then you'l feel resistance when its in place. But doesnt protect against aspiraion. (patency and protection both needs to be looked after) It should sit on the oesophagus and face the trachea. So the mouth facing front if the patient is supine/.

Can then take off mask from the bag and connect directly and use Check whether its the right way around by seeing the line on the incisors And all the signs of airway and breathing comes back

LMA can be used 40 times or manufacturer's define times autoclaving in between

Back and forward motion.

First deflate it. Then put gel/lubricant on the outer ring and then use fingers to press the cuff down over the hard palate firmly. rub /3 over heard palate to lubricate. Down and in manoevere with the index finger. Line should be towards the nasal center. In the ward and Ho/MO setting do triple manoevre and then oropharyngeal and then LMA and call up anesthesists to do the ETT. In ICU setting can directly go to the ETT. LMA is good because ow skill is needed but not gold standard (patency and protection)

Locate the peal here tag ad peal it firmly

The 2 indicates single use. Maximum volume to inflate it. And patient weight in kg and size. How to select sizes in sri lanka?

Line is used to align to the septum of the nose The top side can be used to fit to acessories

Before use remove the valve and decompression tap - in sri lanka not so because we autoclave and resuse

Deflate it

Lubricate it on the back. Dont put jel on inner surface.

Massage the lube over the back side

head tilt and jaw thrust it

OPENING FACING THE CHIN

Rub it over the hard palete a few times to lubricate reervoir there and the tube can collect it as it goes down

Advance with defintiive force

Allow the cuff and ctube to follow hard palatae and curvature until positve resistance is met

Match the colour of the LMA to the level indicated The indicator line should be facing the nasal septum

When patient regains control of airway and breathing the tube can be removed by simply appying force away from the palate. Can remain insitu until that connected to acessories Patient itself can remove it - because thats an indication its no longer needed.

ETT tube

Laryngscopy

Give pre-oxgenation to build up buffer because can be given propofol etc and can be restricted - can use nasal cannular and non rebreathing bag

Need sunction tube and macintosh blade 4 ..mac 3 for smaller adults or chidren and peads what blade? and need 7.5 7.0 ETT (usually these tow is enough) - the trachea is the size of the thumb so must be smaller than that

6.0 8.0

Stylet it - leave some at the end so it doesnt pierce and also there needs to be a 30 degree curvature so that it doesnt go into oesophagus or get stuck

Need to check whether it inflates and no leaks

Need bag valve mask as well (acessories)

Mask also in case fail to intubate so can re re oygenate using the masks and bag

Bougie - have - in case of trouble Have guedal air way and LMA

Must have an end tidal indicator seal device or can check suing the monitor

Also have mcgill forceps in case there is a foreign body blocking

Have the patient in the lower end of your sternum - that is the right height

Have the patient in a sniffing position Elevation down on the occiput (using a small pillow) and flexion on top - pillow on occiput and not on the head

Then ask nurse to hynotise (2-2.5) and paralyse and anagensic . Can check fot paralsis using the jaw whether its relaxed.

See how to hold it = hypothena eminence on the blade, 4 fingers on the shaft and thumb that way. Bceause have to lift using the thumb.

Can oull sheeth and put the blade on the right side of the tongue Sweeping the tongue towards the left as you put the blade into the midline Dont use teeth as fulcrum Avoid touching the lips and teeth. Because ou break the teeth.

And then lift....not twist but lift. Like lfiting the chin upto the sky. 90 degree at the elbow and be close to the patient.

Lifting lifts the tongue and the mandible Once you're doing that you're looking. For the epiglottis and once you see then epiglottis use the blade on the valecular ABOVE the epiglottis and lift it

Tuck it in the valecular which will push it away

Then you can see the two white lines of the cord

You can use external thyroid manupulation to bring the vocal cords into view

Push down on the thyroid to bring the vocal cords into view

Then ask assitant to put fingers down there or altertively you can manipulate their fingers

External laynngeal manipualtion is done to visualise vocal cords well. Bougie is down if intibation desnt go down

Then put the ET tube in and watch it go trhough the vocal cords and push it 3/4 cm in from there below the vocal cords. External laryngeal manipulation ⇒ 1. cricoid pressure 2 thyrodi cartiage pressure

Assitant can do these manuevrews !!

How to choose correct size of ET tube?

Take off the blade and hold the ET tube agasint the teeth while removing it off And then inflate the baloon How to know whether inflated appriorpiately? You wont be able t hear breathe sounds on either side of the mouth after fixing the ventilator or bag ...patient may not be breathing initially so must wait till ventilation is adequate to check it. ITs needed for protection. USe the end tidal co2 strip to check for high co2 or the capngraphy levels on the monitor.

how to check whether ventilating? Check co2 levels using an indicator or the minotor or check for lung expansion bilaterally and look for breath sounds in the two lungs and epigastrium

There after can take x ray to see position And then fix to ventilator And attach tube to mouth using plaster or commercial product And then post sedation medications And then need other forms of feeding like orogastric or nasogastric or stomies or parenterally to other forms of parenteral nutrition and pain control and sedation to not take it off

Its endo traceal because its in the trachea And need to check whether it deflates and infates well After putting it inside check whether the line and numbers are right = not too down where its in the right bronchus and not too up where its above the trachea. And then inflate it as much as needed....can hear the sound of breathing around the mouth reducing and reducing and at one point it dissapears - when its sealed and only comes from the tube. can connect the tube to adjunct devices or to the machine. Its the gold standard for airway because 1 patency and 2 protection. in case vomits can sunction it out before extubation Can sunction the stuff out before extubation - deflating and pulling. The ETT has an radioopaque line where it shows up in x ray and can be checked for location

Can be kept for 3 weeks. and then removed after single use. IF needed longer airway management must use tracestomy and do it that way

Differecne in ETT tube between adult and pediatric patients? Cuff and no cuff?????

How to check whether in airway and not oesophagus? Other types of intubation 1. USing LMA

2. Nasal intubation

must use macgill forcep to lift 3. using fiber optic bronscope

For wake intubation need to spray some lidocaine to make it easier

Cricothyroidotomy (surgical airways)

Fidn the mebrane. Cut vertically. two or three times until you find the membrane. Then horizontally Blood might come out use that as lube to put finger in the air way Exchange it with guidewire down Then put the ETT tube down that and take out the gause Then ventilate And patch up