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1

The American Society for Testing and Materials (ASTM) and the International Standards Organization (ISO) recommend that manual resuscitators be capable of delivering a minimum fractional inspired oxygen of ________ with an oxygen flow of _____L/min.

0.85; 15

2

Little’s Area (Kiesselbach’s Plexus)

A highly vascular area located on the anterior aspect of the nasal septum in each nostril

Most nosebleeds will often originate from this area

3

Nasopharynx

In theory it is a passage for air alone

Extends from the base of the skull to the uvula

Contains pharyngeal tonsils (adenoids) and tubal tonsils

4

5 Openings to Nasopharynx

The nasopharynx contains 5 openings which is important during intubation as we can have infection

These openings are

  • 2 eustachian tubes
  • 2 Internal nares
  • 1 opening to the oropharynx

5

Oropharynx

Extends from tip of uvula to upper rim of the epiglottis

Common pathway for food and air

Contains palatine tonsils, which are commonly removed during tonsillectomy

6

Larynx

Conducts air into the lungs

Acts a switch mechanism to ensure that food bypasses the trachea and proceeds down the esophagus

Larynx is the most heavily sensory inervated organ in the body.

Stimulation of unaesthetized larynx causes very strong sympathetic response-HR and BP may double.

7

Cartilage of the Larynx

There is 9 Cartilages of the Larynx

  • 2 Arytenoid Cartilages
  • 2 Cuneiform Cartilages
  • 2 Corniculate Cartilages
  • 1 Thyroid Cartilage
  • 1 Cricoid Cartilage
  • 1 Epiglottis Cartilage

8

Trachea

When we are intubating we want to go into the trachea we have to manipulate things because if we don’t manipulate things then the path of least resistance for intubation is through the esophagus

If doing an emergency cricoid cartilage you don’t have to go through the cric you can go through a ring that is not continuous but C shaped

 

9

Thyroid Cartilage

Thryroid cartilage forms anterior wall of larynx

10

Trachea Measurements

Extends from the larynx to the main stem bronchi

12-15 cm in length

~2 cm in diameter

16-20 C-shaped cartilage rings

11

Carina Topography

Carina sits behind “angle of Louis” anteriorly and level of T4 posteriorly

12

Loss of Airway Patency

Causes of loss of airway patency can be divided into 2 general categories

Central Causes-Any condition that leads to a depression of the CNS (i.e. <8)

Peripheral Causes-Airway obstruction caused by something originating outside the body

13

Central Causes of Loss of Airway Patency

When the CNS is depressed and comes from within the body

The causes of CNS depression varies

Most common cause of upper airway obstruction is the tongue

Includes-Decrease in cardiac output, TBI, Anesthesia, drug overdose, hypoxemia/hypercarbia, hypothermia/hyperthermia, metbolic derrangements

14

Central Causes

Decrease in Cardiac Output

Acute myocardial infarction (MI)

Cardiac tamponade-But when cause through a infection it is considered to be a peripheral cause

CHF

V fib or V tach

Hypovolemic Shock

Septic Shock

Massive Pulmonary Embolism

15

Mechanisms of Upper Airway Obstruction

Decrease in tone of submandibular muscles leads to posterior displacement of tongue against the posterior pharyngeal wall

While in a comatose state the position of the chin will worsen the obstruction

C-spine adopts a semi flexed position, narrowing the distance between the tongue and posterior pharyngeal wall

Epiglottis gravitates towards the larynx partially occluding the airway

Negative pressure cause by respiratory efforts in presence of obstruction draws tongue towards the airway

16

Peripheral Causes

  • Peripheral causes come from outside of the body  
  • Infection
  • Abscess
  • Neoplastic (carcinomas)
  • Physical and Chemical Agents
  • Thermal
  • Caustic Injuries- Can cause swelling
  • Inhaled toxins
  • Allergic/Idiopathic
  • Traumatic 

17

Signs of Loss of Airway Patency

• Tachypnea and dyspnea • Noisy snoring respirations • Paradoxical breathing • Tracheal tug or retractions • Nasal flaring o Usually seen in babies • Expiratory Grunting o Is a compensation for collapse o Usually seen in babies o Cardiac dysrhythmias • Pressure in chest and low oxygen levels will affect the heart • Stridor • Absence of breath sounds or visible chest movement • Cyanosis o Can be misleading due to polycythemia or hypothermia o Will be check at the inside of the lips

18

Peripheral Causes-Infection

Viral and bacterial infection laryngotracheobronchitis (e.g. croup)

Parapharyngeal and retropharyngeal abscess

Lingual tonsillitis

Hematomas or abscess of the tongue or floor of the mouth

Epiglottitis (also known as supraglottitis)

Similar to croup but the patient will have low energy and is very serious and in this case we do not manipulate the airway

19

Peripheral Causes-Neoplastic

Laryngeal carcinomas Hypopharyngeal and lingual (tongue) carcinomas

20

Peripheral Causes-Physical and Chemical Agents

Foreign bodies Chocking something shoved up a nose Thermal injuries-Can cause swelling Caustic Injuries- Can cause swelling Inhaled toxins

21

Peripheral Causes- Allergic/Idiopathic

Angiotensin converting enzymes inhibitors induced angioedema

22

Peripheral Causes- Traumatic

Blunt and penetrating neck and upper airway trauma

23

Central Causes-Hypoxemia/Hypercarbia

COPD, Asthma, ARDS, Pneumonia, moderate PEs 

24

Central Causes-Metabolic Derangements

Hypo/hyperglycemia

hypo/hypernatremia

hypokalemia (lead to heart malfunction)

metabolic acidosis

hepatic encephalopathy

25

Signs of Loss of Airway Patency

Tachypnea and dyspnea

Noisy snoring respirations

Paradoxical breathing

Tracheal tug or retractions

Nasal flaring-Usually seen in babies

Expiratory Grunting-Is a compensation for collapse and usually seen in babies

Cardiac dysrhythmias-Pressure in chest and low oxygen levels will affect the heart

Stridor

Absence of breath sounds or visible chest movement

Cyanosis-Can be misleading due to polycythemia or hypothermia, will be check at the inside of the lips

26

Presentation of Obstructed Airway 

 

Hot Potato Voice- Horse Voice

Difficultly in Swallowing Secretions

Drooling is a very serious sign

Dyspnea

STRIDOR-Means a complete obstruction is imminent

Cough

27

Stridor

High pitched inspiratory sound

Indicated that airway has already lost at least 50% of its usual caliber

Complete obstruction may be imminent

The volume and pitch are related to the velocity of air flow-Air flow is dependent on patient’s level of consciousness and inspiratory muscle strength

Often audible but may be detected early via auscultation over the trachea-Can normally be heard without a stethoscope

If it is epiglottitis don’t place the stethoscope near the throat just keep them calm

28

OPA Contraindications for Use

Patients with obvious oral trauma

Awake or semi-conscious patients

May cause vomiting or gagging

IMPORTANT-If a patent is awake enough to spit or tongue the device out then they are too awake for the device to be used

 

29

OPA Sizing

Proper sizing

Place the airway next to the face with the flange at the mouth and the tip of the airway should reach the angle of the jaw (tragus of the ear)

 

30

Complications of OPA

May cause trauma to the lips, mouth, or teeth-Rare

May cause pressure necrosis

Difficult to perform mouth care

May cause gagging and vomiting-May push the tongue back