Advanced airway management

Advanced airway management skills are needed. Person must be unconscious for all these procedures

Laryngeal mask airway (LMA)

  • Used for unconscious person to make sure they have enough oxygen or as alternative to endotracheal intubation
  • 2 types of LMAs available
    • Gel cuff — preferred if available
    • Inflatable cuff
  • Should take no more than 30 seconds to put in — about as long as you can hold your breath
  • Can be done by 1 person
  • In unconscious person, replace oropharyngeal/nasopharyngeal airway with LMA if
    • Obstructing despite positioning and simple airway opening manoeuvres
    • OR able to ventilate but remains in coma

Attention

Risks of using LMA

  • If not unconscious — may cause gagging, vomiting or spasm of larynx (rare)
  • Doesn't fully protect against aspiration
  • If tube is in wrong place — fills stomach with air
  • Can be dislodged accidently — needs constant monitoring
  • If trauma, protect cervical spine when putting in the LMA — airway comes first
  • Remember support inadequate ventilation with bag-mask-valve ventilation

Positioning head

Figure 3.25  

If cervical spine injuries suspected — take great care when positioning head

Gel cuff technique

There are several brands, become familiar with yours. The technique for all brands of gel cuffs is the same. Inflatable cuff LMA’s — refer to manufacturers instructions.

What you need

  • 1–2 helpers if available
  • Person on oxygen by non-rebreather mask with monitoring attached
  • Rigid sucker attached to tubing within reach and turned on
  • Flexible suction tubes within reach
  • Bag-valve-mask with oxygen connected
  • Right size disposable LMA
  • Water-based lubricant
  • Adhesive tape to secure LMA to face (eg 2.5cm brown Elastoplast)
  • Stethoscope
  • End tidal CO2 detector if available

What you do

  • Select LMA. Suggested size guide
    • Size 5 — adult large (more than 70kg)
    • Size 4 — adult normal (51–70kg)
    • Size 3 — adult small (30–50kg)
    • Size 2 — child (5–29kg)
    • Size 1 — neonate (less than 5kg)
  • Apply a thin smear of lubricant to both surfaces of the cuff
  • Pre-oxygenate for 2 minutes with firmly applied bag-valve-mask OR non-rebreather mask
  • Open the mouth with your non-dominant hand
  • Hold LMA by stem so opening faces tongue — Figure 3.26

Figure 3.26  

 
  • Push the LMA along hard palate and down until it stops — may be a slight give as it slides into final position
  • Tip of mask is now seated in upper oesophageal sphincter above the larynx — Figure 3.27

Figure 3.27  
  • Attach CO2 detector between tube and bag -valve-mask unit if available
  • Connect bag-valve-mask to tube with oxygen running at 12–15L/min
  • Deliver assisted breath
  • Listen with stethoscope over lungs and epigastrium, watch chest wall to see if it expands on inflation
  • If stomach gurgles, chest doesn’t expand — LMA is in wrong place
    • Pull it out
    • Hyperventilate with oxygen by bag and mask for at least 1 minute before trying again
  • Secure to face with tape. Skilled operator must keep hands on LMA until securely taped
  • Continue manual bag-valve-mask ventilation unless person is breathing well for themselves

Intubation — with endotracheal tube

  • Only used when person unconscious, airway obstructed and can't be established by other methods including simple airway opening manoeuvres or LMA
  • Needs 2 or more trained practitioners

Attention

  • You need a helper to do this procedure
  • Putting in endotracheal tube should take approximately 20 seconds but no more than 30 seconds — about as long as you can hold your breath
  • Always double check that tube is in right place — if it isn’t person can quickly die

Risks of intubation include

  • Oesophageal intubation and death if not fixed quickly
  • Tube dislodgement and occlusion resulting in death if not fixed promptly
  • Right main bronchus intubation with left lung collapse and underventilation
  • Regurgitation and aspiration
  • Chipped or dislodged teeth
  • Bruised lips

Cricoid pressure can be used to help prevent regurgitation of stomach contents. Only use if asked to by person doing procedure

If cervical spine injuries suspected — take great care when positioning head

What you need

  • 1–2 helpers if possible
  • Person on oxygen by non-rebreather mask with monitoring attached
  • Rigid sucker attached to tubing within reach and turned on
  • Flexible suction tubes within reach
  • Bag-valve-mask with CO₂ detection device fitted and oxygen connected
  • PEEP valve fitted to bag resuscitator if available (start at 3–5mmHg or cm of H₂O)
  • Laryngoscope — usually a size 3 or 4 curved blade, sometimes straight blade for children. Check that light is bright
  • Endotracheal tube of correct size

A quick way to choose size is to match to diameter of person’s little finger

  • Women — 7.0–7.5mm id (internal diameter)
  • Men — 8.0–8.5mm id
  • Children — (age ÷ 4) + 4 (for uncuffed tubes — reduce by a half size for cuffed tubes)
  • Disposable introducer stylet to stiffen tube (recommended)
  • 10mL syringe
  • Long-nose/Magill forceps (may be needed)
  • Water-based lubricant
  • Cloth tape long enough to tie around tube then around base of head
  • End tidal CO2 detector if available
  • Oropharyngeal airway
  • Stethoscope

What you do

  • Position sucker within reach of right hand
  • Put in lubricated stylet within ETT. Ensure it is 15mm short of the leading edge of ETT and not poking through — kink it over at top to stop it slipping in too far
  • Test cuff then fully deflate
  • Lubricate cuff
  • Test blade light
  • Attach oximeter, rhythm monitor, BP cuff
  • Attach nasal prongs for apnoeic oxygenation at 15L/minute (only if there are two oxygen sources)
  • Put head in sniffing position
  • In trauma ask helper to support head — see Manual in-line immobilisation
  • Pre-oxygenate for 2 minutes with firmly applied bag-valve-mask OR non-rebreather mask
  • Turn on sucker
  • If using cricoid pressure ask skilled person to apply until cuff inflated
  • Remove oropharyngeal airway
  • Open person’s mouth using fingers of right hand
  • Hold laryngoscope in left hand, put blade into right side of mouth, push tongue to left
  • Advance toward base of tongue, at the same time push lower lip away from blade with  finger
  • Suction out secretions
  • Using curved blade
    • Slide tip of blade into groove between base of tongue and pharyngeal surface of epiglottis (vallecula) — Figure 3.28

Figure 3.28  

Figure 3.29  
  • Using straight blade — cover the epiglottis with the blade
    • Maintain angle of 45° to horizontal, lift to expose glottic opening. Do not tilt against teeth for leverage
  • Should be able to clearly see vocal cords — Figure 3.29
  • If you can’t see vocal cords — try BURP (Backward Upward Rightward Pressure) on thyroid cartilage
  • If you still can’t see vocal cords — do not put in tube
    • Stop procedure, continue bag-valve-mask ventilation, re-adjust positioning
  • Put in endotracheal tube from the right side of the mouth until you see cuff pass between vocal cords
    • In average-sized adult, between 19–23cm at front teeth
  • Remove laryngoscope while holding tube — heel of hand stabilised on person’s cheek
  • Remove introducer while holding tube
  • Inflate cuff with just enough air (5–10mL) to seal it within person’s airway
  • Attach bag resuscitator
  • Holding ETT in position with heel of your hand resting softly on the person’s cheek, give several breaths and confirm placement by observing for chest rise and fall, fogging of the ETT and CO₂ detection by colour change (colourimetric device) or waveform
  • Hold tube until it is tied in
  • Ventilate — oxygen running at 12–15L/min — Figure 3.30
  • Ensure  CO2 detector between ETT and bag resuscitator
  • Look for
    • Chest movement
    • Rectangular CO2 trace
    • OR if using a colourimetric detector — cyclical colour changes from purple to yellow to purple with ventilation
  • Listen for
    • Air entry over top of both lungs (apices)
    • Gurgling at epigastrium (tube in the oesophagus)
  • Use enough oxygen to maintain O2 sats at 94–98% OR if moderate/severe COPD 88–92%

Figure 3.30  
  • If stomach gurgles OR no CO2 or colour change OR chest doesn’t expand — tube is in wrong place
    • Use suction with large soft catheter through endotracheal tube to suction out air and fluids then deflate cuff and pull out
    • Give oxygen by bag-valve-mask for at least 1 minute before trying again
  • If no gurgling and chest expands
    • Listen to top of both lungs to check for air entry
    • If only 1 side of chest inflating — release air from cuff, pull tube back 1–2cm and reinflate
    • Listen again
  • Release cricoid pressure
  • Recheck position of depth marker, tie tape around tube then around base of head to secure
  • Continue manual ventilation with bag and mask as per CPR schedule

Emergency cricothyroidotomy — mini-tracheostomy

For wide bore airway over trocar device eg Quicktrach OR Cricothyroidotomy with scalpel 

Finding the cricothyroid membrane
  • Cricothyroid membrane is below thyroid cartilage (Adam's apple) and above cricoid cartilage — Figure 3.31, Figure 3.32 

Figure 3.31  

Figure 3.32  
  • Practice on yourself
    • Put finger on Adam’s apple and swallow to feel it go up and down
    • Now slide your finger down to just below Adam's apple — Figure 3.33
    • Small dip here indicates cricothyroid membrane. Pressure is uncomfortable and you may want to cough or gag

Figure 3.33  

Mini-tracheostomy — cricothyroidotomy with trocar kit 

Attention

  • Use for children over 5 years and adults
  • Follow the instructions related to the product you are using
  • If you have a kit make yourself familiar with it before the need arises
  • Device is made to fit a bag-valve-mask unit
  • For puncture site — see Finding the cricoid membrane
  • Be ready for moderate soft tissue resistance when advancing airway catheter
  • Do not delay to apply antiseptic or clean site if unconscious

What you need

  • Mini-tracheostomy kit — Figure 3.34
    • Needle trocar cannula unit
    • Scalpel 
    • Suction catheter
    • Adaptor 
    • Tape
  • 5mL syringe x 2
  • Normal saline
  • Pulse oximeter

Figure 3.34  

What you do

Prepare patient and kit

  • Hyperextend neck with the head over the end of the bed or rolled blankets under the shoulders
  • If kit contains cuffed unit  — fully deflate 
  • Draw up 2mL saline in a 5mL syringe and attach to needle trocar cannula unit if time permits (filling the 5ml syringe with 1–2mL of saline will allow you to see air bubbles when the airway is entered)
  • Hold set in dominant hand
  • Stand beside person so windpipe is held between non-dominant thumb and middle fingers 
    • If right handed, stand on left of the person

Mini-tracheostomy

  • Locate cricoid membrane from below with non-dominant index finger 
    • Aiming towards feet, puncture the membrane at 60–90° and aspirate air (bubbling)
    • Advance the needle cannula unit 10–12mm at 45° while aspirating air
    • Hold the persons head, neck and shoulders firmly
    • Slide the airway cannula over the needle trocar into the trachea
  • Hold airway cannula in position with non-dominant hand and remove trocar needle
    • Inflate cuff if present
    • Attach adaptor
  • Attach bag-valve-mask and ventilate slowly (every 6 seconds — watch for chest rise and fall)
    • Monitor for rising oxygen saturation 
    • Secure with strap provided or tape
    • Elevate head to 30° unless blood pressure is low

Cricothyroidotomy with scalpel

Use for children over 12 years and adults

Use when no other way to keep airway open AND person unconscious

Attention

  • Do not use if person under 12 years old — unless needle cricothyroidotomy and jet ventilation fails
  • Do not delay to apply antiseptic or clean site 
  • For incision site — see Finding the cricoid membrane
  • Average adult carina (end of trachea) is only 9cm below cricoid membrane — put in tube to about 6cm

What you need

  • Gloves
  • Goggles
  • Scalpel — preferably size 10
  • Airway device — tracheostomy tube OR Mini Trach tube OR size 6 ETT, OR prepared oxygen tubing or other firm tubing
    • Can use oxygen tubing as alternate airway by cutting the end off and cutting a small hole about 15cm from the end
  • Padding to hyperextend neck
  • Artery forceps
  • Oxygen tubing and bag-valve-mask
  • Pulse oximeter

What you do

  • Prepare airway device
  • Hyperextend the neck — position head off the end of the bed or pillow under shoulders
  • Stand beside — preferably with non-dominant hand towards person’s feet
  • Locate cricoid membrane with non-dominant index finger, either holding trachea (from below, preferred) — or Adam’s apple (from above) — swap sides to hold Adam’s apple
  • Do not let go until airway established
  • In one movement, with blade directed horizontally across trachea, stab cricothyroid membrane and drag (cut) toward you 20mm — Figure 3.35
  • Widen opening with artery forceps — Figure 3.36 or gloved little finger

Figure 3.35  

Figure 3.36  
  • Put in airway aiming toward feet — stabilize your hand on person’s chest and do not let go of tube for anything
  • Give oxygen at 15L/min
    • If using tracheostomy tube, ETT, Mini Trach tube — attach bag-valve
    • If using prepared oxygen tubing — attach to oxygen source
  • Jet ventilation with oxygen tubing
    • Thumb over hole for 1 second on — 6 seconds off
  • Check O2 sats with pulse oximeter
  • Person may require sedation as they start waking up — be prepared

Supporting resources

  • Airway-LMA insertion iGel instructional video
  • Needle cricothyroidotomy and jet ventilation instructional video