Professional Documents
Culture Documents
UNIVERSITY OF MANITOBA
Airway Training Module for
Para Professional Personnel
Preamble
The Department of Anesthesia at the University of Manitoba is committed to the
promotion of patient safety and quality of care. Education of providers of airway and
resuscitation support from all disciplines is a fundamental part of that mission. For this
educational effort to be effective, it is important to consider and incorporate the particular
needs of each group for whom skills development is contemplated. This document
outlines the structure, and goals and objectives of a program designed to meet the
developmental needs of paramedical personnel providing care for patients with respect to
airway support.
Program Outline
Each trainee will be provided with a program outline, including a reference manual,
orientation and contact information, and evaluation logs. At the end of the rotation, the
trainee will be expected to keep evaluation logs and provide them to the Coordinator of
the sponsoring program as proof of completion of the educational program.
The trainee will present to the assigned hospital OR suite on the first day of the rotation,
at the time and place indicated in the orientation manual. The senior resident or site
coordinator will direct the trainee to a primary staff person. This primary staffperson
shall
Review the educational material with the trainee
Provide resource discussion
Evaluate the degree to which the trainee has met the knowledge objectives
Record the results of that evaluation on the evaluation log
Coordinate access to airway management techniques with him/herself, and other
staff as available
Minor
Omissions
No
Omissions
Complete
Discussion
Outstanding
o Direct laryngoscopy
o Endotracheal intubation
o Extubation
o Mask ventilation
o Positive pressure ventilation
Correctly assesses adequacy of ventilation
Major
Errors
Minor
Errors
Competent
technique
Efficient
technique
Outstanding
Mask ventilation
Confirmation of endotracheal tube placement
Securing an endotracheal tube for transport
Laryngoscopy #1
Laryngoscopy #2
Laryngoscopy #3
Laryngoscopy #4
Laryngoscopy #5
Laryngoscopy #6
Laryngoscopy #7
Laryngoscopy #8
Laryngoscopy #9
Laryngoscopy #10
Laryngoscopy #11
Laryngoscopy #12
Laryngoscopy #13
Laryngoscopy #14
Cognitive Objectives
Describes the indications for, contraindications to
and complications of
Airway Management
Gerry Bristow , MD FRCP
Rob Brown, MD FRCP
Proper airway management is the most fundamental step in the provision of life
support. Effective respiration is necessary for any other bodily function to occur, and
without it, any efforts to treat other problems will be in vain. This is well reflected in the
priority placed on assessment of the airway and adequacy of respiration in the acute care
protocols learned in the ACLS and ATLS courses. It is important to stress, however, that
airway management is not confined to the resuscitation of critically ill or injured patients.
It begins with attention to the status of the airway in any patient, in order to predict and
prevent the occurrence of problems.
In anesthesia, we deal with the management of airways on a daily basis.
Sometimes the need for airway management comes in the form of a patient who arrives
with airway pathology. More commonly, it is simply the physiologic impact of the
anesthetic itself that necessitates airway management. Whatever the cause, the goals of
airway management remain the same: the provision of a patent, secure airway; protection
of the lungs from aspiration; and maintenance of adequate gas exchange.
Airway Assessment
The first goal in assessing the upper airway is to identify any conditions that may
threaten the integrity of the airway. The assessment of upper airway obstruction will be
dealt with later in this chapter. Most patients presenting for elective procedures do not
have airway pathology, but still need airway assessment for another reason.
The second reason to assess an airway would be to predict the likelihood of
difficulty with managing the airway should that become necessary. Inducing anesthesia
and being unable to control the airway is a potentially life threatening event, and can
usually be predicted and prevented. There is a spectrum of difficulty that ranges from
easy to impossible. Moderate difficulty is relatively common, while impossible
intubations are rare. As the difficulty of laryngoscopy increases, so does the likelihood of
and severity of injury related to laryngoscopy. It has been estimated that ~30% of deaths
attributable to anesthesia are related to airway mishaps.
Table 1, Likelihood of Difficult Intubation
Degree of Difficulty
Successful- multiple attempts
Successful- multiple attempts and laryngoscopists
Not successful- ventilate by mask
Cant intubate-cant ventilate- cricothyrotomy, TTJV or death
Incidence
100-1800
100-400
5-35
.01-2
Modified from Benumof, J. management of the Difficult Airway, Anesthesiology, 75(6):1087-1110, 1991
%
1-18
1-4
.05-.35
.0001-.02
The incidences above were generated from an anesthesia data base, and thus
would reflect the risk with a relatively high skill level in intubation as well as assessment.
It would not include those that were recognized by appropriate evaluation and managed
by other means.
Any patient with an obvious anatomic distortion of the airway, or with ongoing
airway obstruction should be considered to have a difficult airway, and managed
accordingly. This will be expanded upon later in this chapter. Many patients present with
no pathology, but may be difficult to intubate simply due to their anatomy. A careful
airway assessment will help you to identify the majority of those.
The examination of the airway with a view to ease of intubation involves
inspection of internal dimensions, external dimensions and range of motion. This has
been reviewed recently, focussing on three main predictors of difficult intubation: the
Malampati score; depth of the mandible; and neck extension.
The Malampati Scoring System
The scoring system developed by Malampati attempts to describe the size of the
soft tissues in the floor of the mouth relative to the mandible. Patients with a relatively
smaller submandibular space will be less able to depress the floor of the mouth to expose
the tonsillar pillars. Similarly, with direct laryngoscopy, one is attempting to depress the
floor of the mouth into the submandibular space to expose the glottis. Thus, inability to
visualize the posterior pharynx correlates with inability to visualize the cords. To generate
the Malampati score, have the patient sit upright, open his mouth and stick out his tongue,
with the neck in a neutral position. Without saying ah try to get him to depress the base
of the tongue as much as possible. The score is based on the amount of the pharynx you
can see, (Fig 1). The table 2 shows the increasing likelihood of difficulty with
laryngoscopy with increasing Malampati score.
Fig 3
Fig 3
Level
Oropharynx
Structure Involved
Intraluminal
Soft tissue
Tongue, peritonsillar,
Uvula
Glottis
Subglottic
Cause
Foreign body
Tumour
Laxity (paralysis, LOC)
Edema
Abscess
Hematoma
Congenital anomaly
Extrinsic
Abscess,
Tumour,
Hematoma
Intraluminal
Foreign body
Tumour
Epiglottis
Edema (epiglottitis)
Tumour
Trauma
Aryepiglottic folds,
Edema
Trauma
Tumour
Vocal
Cords/arytenoids
Intraluminal
Foreign body
Tumour
Web
Trachea
Edema
Tracheomalacia
Fracture/disruption
Stenosis
Extrinsic
Tumour
Hematoma
Thyroid
Fig 5
Tracheal Intubation
Indications
There are many different situations in which intubation of the trachea is indicated.
One could simply make an exhaustive list of the individual indications. As discussed in
the section on airway obstruction, it is important in the emergency situation to have an
organized approach to the question of endotracheal intubation. An endotracheal tube can
perform three basic functions. It can provide airway maintenance, protection, and
positive pressure ventilation. Thus, the indications for intubation would be: risk to airway
patency; risk of airway contamination; or need for positive pressure ventilation.
When airway patency is already compromised, the need for intubation is usually
obvious. Equally important is the need to predict impending airway obstruction, as
discussed above. Prophylactic intubation may be indicated in these conditions. Patients
presenting obstructed due to level of consciousness are usually easily supported by mask,
but it may be hours before their ability to maintain their own airway returns, if at all. It
may, therefore, be expedient to intubate a patient whose airway is supportable by mask,
to free yourself for other activities.
Indications for endotracheal intubation
Airway maintenance
Obstruction
Potential Obstruction
Prolonged airway support
Airway protection
present the potential for aspiration include blood, pus or foreign body. Secondly, there
must be some impairment of airway protective reflexes. With intact reflexes, a patient
should be able to prevent the contamination of the airway. Reflexes may be impaired by
level of consciousness, sensory, or motor abnormalities.
Positive pressure ventilation is indicated for treatment of respiratory failure. There
are many underlying disease states that may ultimately end in respiratory failure. This
section will not expand on these, nor the management of positive pressure ventilation,
except in so far as to deal with the decision to intubate. Respiratory failure itself may be
either hypercapnic, hypoxic, or a combination. The precise point in time at which
intubation is required in the setting of respiratory distress is a clinical decision.
Hypercapnia and/or hypoxia do not warrant intubation on their own merit unless severe.
Additional factors may precipitate the decision to intubate in milder
hypercapnia/hypoxia. Progressive deterioration, or signs of fatigue would suggest that the
patient will ultimately fail and should likely be intubated while there is still some reserve
left.
Techniques of Tracheal Intubation
There are many different ways to intubate the trachea. In choosing a technique,
there are three basic decisions to be made. The first is whether to intubate awake, or after
inducing anesthesia. The second is which route to use, oral, nasal, or transtracheal. The
third is. whether to use a blind or visualized technique. This section will provide a general
discussion of these choices. The mechanics of intubation will be taught during the clinical
sessions in the OR. An in depth discussion of intubation techniques can be found in any
basic anesthesia text.
Probably the most important decision to be made is whether to intubate the patient
awake or not. In elective anesthetics, by far the most common approach is to intubate
after the induction of anesthesia, unless there is a reason not to. This is because intubation
awake, although safer, is unpleasant. When deciding whether to intubate asleep, there are
three conditions that must be satisfied. First, you must be confident that you will be able
to intubate this patient. The greatest risk of inducing first is that it may prove impossible
to intubate the now apneic patient. If it also proved impossible to ventilate, that would be
fatal. You can be confident that you will be able to intubate if, 1) you have sufficient skill,
equipment and assistance and, 2) a thorough assessment of the patient shows no reason to
suspect difficulty. Secondly, the patient must be able to tolerate apnea. When an
induction is done, the patient will be rendered apneic. If it is not possible to adequately
oxygenate the patient prior to induction, this apnea will lead to rapid and profound
hypoxia. Finally, the patient must be able to tolerate the cardiovascular impact of
induction. The drugs used to induce anesthesia all have cardiovascular depressant
properties. Any patient, who starts out unstable hemodynamically, is at risk of collapse
with induction. Considering these principles, it is not surprising that most emergency
intubations are done awake, as they usually satisfy one or all the criteria.
The decision of which route to use must consider the relative advantages and
disadvantages of each. The oral route is the most common, having the advantage of ease,
familiarity, the ability to see and assess the glottis, and avoidance of the specific problems
of the others. There are a few disadvantages of the oral route. It is sometimes impossible
The entry point to the algorithm is the recognition that you have a difficult
intubation. One of the most common errors is to persist with initial attempts at intubation
prior to realizing or admitting that you are in trouble. If, after one attempt, you are unable
to intubate, search for immediately correctable causes (too small a laryngoscope blade,
poor positioning etc). If there is something obviously causing the problem, it is
reasonable to correct it and try again once, providing that the patient is well saturated. If
the saturation is already falling, there is no obvious correctable cause, or the second
attempt fails, immediately attempt to ventilate the patient. Proceed through the series of
airway maneuvers as outlined in the section on the obstructed airway. There are only two
possible outcomes at this point. You will either be able to ventilate or not.
If you cannot ventilate, proceed directly to airway instrumentation. For most
situations, the method of choice will be cricothyrotomy. Legitimate alternatives would
include needle cricothyrotomy, or LMA, with the proviso that they are immediately
available. Equipment for cricothyrotomy should be available in all intubating locations,
but the equipment for TTJV and LMA are rarely available outside of ORs. There is no
time to look for equipment at this stage, and unless you have checked beforehand, they
are not options.
The second, more favourable outcome would be that you are able to ventilate. The
first thing to do is to apply cricoid pressure, and to take a moment to calm down. There is
no immediate threat to life, and injudicious action at this point may change that. The
question at this point is how urgently intubation is required. It may be feasible to simply
ventilate the patient until he is awake, and proceed with an awake intubation. This may
not be a realistic option, either due to the need to proceed with a surgical procedure, or
because the patient is not expected to awaken. If that is the case, try to wait for expert
assistance. If that is not available proceed with whatever other techniques are available at
which you are skilled. The most important thing to remember at this point is that
whatever other technique is used, it must be done gently. Persistent attempts to intubate
will inevitably traumatize the airway, resulting in progressive edema, bleeding and
eventual obstruction. Then youre back in the cant intubate, cant ventilate scenario.