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Difficult airway management for nursing staff
1. Difficult Intubation
&
Difficult Airway Trolley
Rashid M Khan
Sr. Consultant
National Trauma Centre
Muscat, Sultanate of Oman
2. Objectives of this talk
• Introduction to the difficult airway for the nurse
assistants.
• How to assess, manage & assist with difficult airway!
• The algorithm and its purpose!
• The difficult airway trolley!
• Understanding of different airway devices!
4. To Maximize Success…
…recognize and predict difficult airway
…choose appropriate technique and
equipment
…possess technical skills to assist
intubation, drugs, and devices
5. The anesthesia nurses role!
• Should Predict the difficult airway!
• Provide assistance & support!
• Has equipment/drugs ready!
• Has experience to offer!
22. Always start with Pre-oxygenation
• Provides oxygen reservoir within
lungs, blood and body tissues.
• Allows for several minutes of
apnea without desaturation.
• Nitrogen washout.
• Use NRB, BVM or NIV for 3-5
mins.
23. Helping Preoxygenation and
mask ventilation prior to intubation
• Keep appropriate size oral airway or nasal
trumpet ready.
• Leave dentures.
• In bearded patients, apply water-soluble
lubricant or opsite to get good seal, especially
if lots of facial hair
24. Apneic Oxygenation
• New Concept!
• Involves maintaining
Nasal Prongs
patent upper airway
passage & oxygenation
during apneic period.
• Use Nasal prongs @ 15l
02.
25. Always start intubation attempts:
• After a good preoxygenation.
• Using technique with which you
are most experienced and
comfortable.
• Don’t repeat the same technique
more than twice, you will not get
a different result.
27. Role of the nurse anesthetist
during laryngoscopic attempts:
• Providing adequately checked laryngoscope & ETT.
• Providing cricoid pressure, if full stomach.
• Applying BURP maneuver to facilitate laryngeal
visualization.
• Inflating the cuff and ETT fixation after ascertaining
correct tracheal intubation.
35. LMA Take-Home Points for Nurses
• Always test cuff before use
• Don’t lubricate anterior mask
• Insert only in comatose patient
• Keep cuff inflated until patient awake
• Don’t throw out!! Used 40 – 50 times
38. No
.2
15
ml
No
.2
N o. 1
N o. 1
100 m l
2. Combitube®
39. 2. Combitube®
• Double lumen tube functions as
esophageal obturator airway plus standard
cuffed endotracheal tube
• Insert blindly 90% esophageal
• Inflate proximal balloon: 100 mL
• Inflate distal balloon: 5 –15mL
40. 2. Combitube®
• Seals oropharyngeal and nasopharyngeal
cavities
• Ventilate through blue port
– Good breath sounds and no air in stomach
continue ventilating
– No breath sounds and air in stomach use
white tube
41. Indications of LMA, Combitube
• Routine / emergency procedures
• Known / unknown difficult airway
• During resuscitation in profoundly
unconscious patient with no
glossopharyngeal or laryngeal reflexes
when tracheal intubation not possible
42. Contraindications of LMA, Combitube
…has limited mouth opening
…has not fasted, except in emergency
…has lung compliance
…is not profoundly unconscious
…has oropharyngeal growth, trauma
48. 4. Flexible Fiberoptic Scope
Advantages
• Allows direct airway visualization
• Causes little hemodynamic stress
• Nasotracheal or orotracheal route
• Can be done in all age groups
• Requires minimal neck movement
49. 4. Flexible Fiberoptic Scope
Disadvantages
• Expensive
• Expertise requires practice
• Delicate equipment needs careful
maintenance
• Visual field easily impaired by blood and
secretions
55. 6. Intubating Stylet (Bougie)
• Gum elastic – use as guidewire
Advantages
• Aids placement of definitive airway
• Easy to learn
• Inexpensive
• Can be used blindly
56. 6. Intubating Stylet (Bougie)
• Gum elastic – use as guidewire
Disadvantages
• Expertise requires practice
• Not recommended in “can’t intubate / can’t
ventilate” scenario
57. When you fail to secure the
airway and patient is rapidly
desaturating!!!
59. 7. Transtracheal Jet Ventilation
Advantages
• Surgical airway of choice if 8 years or
younger
• Effective
• Can serve as temporary airway before
permanent airway
• Relatively simple procedure
60. 7. Transtracheal Jet Ventilation
Disadvantages
• Significant complications if misplaced
• Need proper equipment
• Need high-pressure oxygen
• Does not protect against aspiration
62. 8. Cricothyrotomy
• Life-saving technique
• Surgical vs. needle / Seldinger vs.
percutaneous kit
• You must know this procedure before
starting rapid sequence
63. 8. Cricothyrotomy
• Final common pathways for all cannot
intubate / cannot ventilate scenarios
• “The hardest part of doing a
cricothyrotomy is picking up the knife.” –
Peter Rosen
64. BURP your patient – grab the larynx
and give…
…Backward
…Upward
…Rightward
…Pressure
66. Conclusions
• Recognize the difficult airway
– How much time do you have?
– Who else is around?
– What is your backup procedure
• Know both old and new methods
• Choose backups based on skills
An adequately stocked Difficult Airway Cart, that can be quickly wheeled in is an absolute must! The dedicated trolley must be mobile, robust ,contain everything you may need to manage various difficult airway situations and it must be capable of facilitating fibreoptic bronchoscopy. Also, don’t forget it needs to pass the standards of Infection Control Manager!!
