Airway devices and adjuncts
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The document discusses various airway devices and adjuncts used in emergency medicine, specifically focusing on supraglottic and infraglottic airway devices. It provides an overview of the classification, development, advantages, and disadvantages of these devices, including classic laryngeal mask airway (CLMA), ProSeal LMA, i-gel, and combitube, among others. Additionally, it outlines the characteristics and specifications of endotracheal tubes and suction catheters.
Airway devices and adjuncts
- 1. AIRWAY DEVICES & ADJUNCTS Dr. Anoop James DNBTrainee, Emergency Medicine
- 2. Airway Devices Supraglottic Airway Devices Lies above the laryngeal inlet Infraglottic Airway Devices Lies below the laryngeal inlet in the trachea
- 5. Airway Devices ■ Supraglottic Devices Airway devices that facilitate oxygenation and ventilation without endotracheal intubation. Bridge between BMV and endotracheal intubation Useful in “Cannot Intubate, CannotVentilate” situations.
- 7. Dr. Archie Brain - credited with invention and development of LMA Airway Device Year Classic Laryngeal Mask Airway (cLMA) 1988 Combitube 1988 LMA Fastrach 1995 LMA Proseal 2000 LaryngealTube 2003 Air- Q 2004 I- Gel 2007 LMA Supreme 2007 Baska Mask 2012 Supraglottic Airway Devices - Genesis
- 8. • First generation devices- simple airway tubes Classic LMA Flexible LMA Cobra PLA • Second generation – includes drainage tubes ProSeal LMA I-Gel LMA Supreme SLIPA • Third generation - cuffless, two drain tubes, small bowl Baska mask. Supraglottic Airway Devices – Evolution
- 9. Supraglottic Devices - Classification Cuffed Peri-laryngeal Sealers All LMAs Cuffed Pharyngeal Sealers Combitube King LaryngealTube (King LT) Cobra Peri-laryngeal Airway (PLA) Cuffless Pre-shaped Sealers With Esophageal Sealing Baska Mask I-Gel Without Esophageal Sealing SLIPA AirQ - SP
- 10. Laryngeal Mask Airway (LMA) Classic LMA ProSeal LMA LMA Supreme LMA Fastrach
- 11. 15 mm Connector Airway Tube Inflation Balloon Cuff Aperture Bar Classic LMA
- 12. Classic LMA cLMA Size Patient 1 Neonates/infants up to 5 kg 1.5 Infants between 5 and 10 kg 2 Infants/children between 10 and 20 kg 2.5 Children between 20 and 30 kg 3 Children 30 to 50 kg
- 14. Classic LMA Advantages ■ Increased speed and ease of placement ■ Improved hemodynamic stability ■ Reduced anesthetic requirements ■ Less coughing and sore throat ■ Can be done by inexperienced personnel Disadvantages ■ Low pressure seal – increased risk of gastric aspiration ■ Suction not possible ■ Tip may get folded causing obstruction ■ Inadequate seal – PPV is difficult
- 15. Manual Vent ProSea l LMA Inflation Balloon Drain Tube Drain Tube Orifice Cuff Airway Tube Integrated Bite Block 15 mm Connector Internal Drain Tube
- 16. Classic LMA ProSeal LMA Modifications over classic LMA Larger and deeper bowl with no grille Gastric drainage tube running parallel to airway Larger deeper bowl and dorsal extension of cuff Bite block
- 17. LMA-ProSeal LMA Size Weight (kg) Max Cuff Inflation Volume (mL) Max. Fiberoptic Scope Size (mm) Max. gastric Tube Size (Fr) Length of Drain Tube (cm) Largest Tracheal Tube (ID in mm) 1.5 5 to 10 7 - 10 18.2 4.0 uncuffed 2 10 to 20 10 - 10 19.0 4.0 uncuffed 2.5 20 to 30 14 - 14 23.0 4.5 uncuffed 3 30 to 50 20 - 16 26.5 5.0 uncuffed 4 50 to 70 30 4 16 27.5 5.0 uncuffed 5 70 to 100 40 5 18 28.5 6.0 cuffed
- 18. ProSeal LMA
- 19. Classic LMA vs Proseal LMA Advantages ■ Separate gastric tube port - for gastric access, checking correct positioning ■ Bougie guided insertion f ETT ■ Dorsal cuff -provides better seal and higher sealing pressures ■ With drain tube occluded – less incidence of gastric aspiration ■ Bite block. ■ Can be used for both spontaneous and controlled ventilation
- 20. Classic LMA vs Proseal LMA *Brimacombe J, Keller C, Fullekrug B, et al. A multicenter study comparing the ProSeal™ and Classic™ laryngeal mask airway in anesthetized, nonparalyzed patients. Anesthesiology 2002; 96: 289–95. Disadvantages* ■ More incidence of trauma ■ Equivocal incidence of sore throat as compared to cLMA ■ Slightly longer insertion time compared to cLMA ■ 20% more airway resistance than classic airway in spontaneously breathing patients. ■ Less suitable as an intubation device ■ Requires a greater depth of anesthesia for insertion
- 21. LMA Supreme Drain Tube AirwayTube Bite- block Pilot Balloon Valve Modified Cuff Drain Tube Orifice Unique Elliptical Rigid Airway Tube Reinforced Tip and Moulded Distal Cuff Moulded Fins Fixation Tab
- 22. Modifications of LMA Supreme 1. FixationTab (FT) : Facilitates easy insertion and fixation of the LMA Visual guide to ‘correct’ size select - after inflation of the cuff, the FT should be 1.5–2 cm from the upper lip If distance is less, the size chosen may be too small If >3.0 cm from the upper lip the size chosen may be too large
- 23. Modifications of LMA Supreme 2. AirwayTube: Unique, flattened, firm, anatomically shaped airway tube - elliptical in cross-section Elliptical shape facilitates insertion in patients with reduced interdental space, without increasing the resistance to breathing Firm, anatomical shape facilitates easy insertion without placing fingers in the mouth Helps to minimize accidental rotation, once in place Lateral grooves on either side prevent kinking
- 24. Modifications of LMA Supreme 3. DrainageTube: Runs from its rigid proximal end, through the middle of the airway tube, continues along the posterior surface of the cuff Equalizes the pressure between UES and atmosphere Vents gastrointestinal gases and liquids Serves as a conduit for the passage of nasogastric tube Indicator of correct tube positioning
- 25. Modifications of LMA Supreme 4. Cuff: Modified and enlarged inflatable cuff Enhances the anatomical fit into the pharynx Glottic seal pressures between cLMA and ProSeal LMA Moulded distal cuff - strengthens the tip and prevent it from ‘folding over’ during insertion Modified fins - prevent the epiglottis from becoming wedged in the airway
- 26. LMA Fastrach Airway Tube Handle Epiglottic Elevating Bar 15 mm Connector LMA Fastrach ETT Shaft
- 27. LMA Fastrach “Intubating Laryngeal Mask Airway” Uses: To facilitate tracheal intubation Can also be used as a primary airway device Rescue device for failed intubation Blind or fiberscopic guided insertion
- 28. LMA Fastrach Disadvantages: Pharyngeal pathology or limited mouth opening Cannot be used for intubation in patients below 30 kg Expensive & prolonged use is to be avoided The tracheal tube may be displaced downward or dislodged Unsuitable for use in the MRI unit Increased incidence of sore throat and difficulty swallowing Esophageal intubation
- 29. LMA Unique
- 30. LMA Flexible
- 31. LMA C-Trach
- 32. Proximal Cuff • stabilizes tubes • seals oro/nasopharynx King LT Distal Cuff • seals esophageal inlet • prevents gastric inflation Ventilation Holes • lies in front of the larynx Pilot Balloon Radio Opaque Line 15 mm Connector • Color coded to determine size Length Marker Ramp • Passage of tube exchanger or fiberoptic bronchoscope
- 33. King LT Advantages: Easy insertion – less skill Minimal mouth opening required. High ventilation pressure can be used Can be used to intubate trachea
- 34. Combitub e
- 35. Combitube “EsophagealTracheal Airway” Blind insertion airway device (BIAD) Double lumen airway device designed for emergency ventilation of a patient when visualization of the airway and endotracheal intubation are not possible Ventilation can be achieved with either tracheal or esophageal placement of tube
- 36. Combitube Proximal Lumen (blue colored) - sealed at the end, contains fenestrations distal to the pharyngeal balloon Used in case of esophageal intubation (90% - 95 %) Distal Lumen (transparent) - ends beyond the distal cuff; similar to an ETT Used when trachea is intubated
- 37. Combitube
- 38. Combitube Advantages: Blind insertion without the need for light, laryngoscope, or direct visualization Effective ventilation and oxygenation with moderate protection against aspiration Proximal pharyngeal balloon provides better air seal Gastric contents can be aspired through lumen #2 when the device is in the esophagus
- 39. Combitube Disdvantages: Pediatric sizes not available Expensive Increased chance of laryngeal and tracheal injury Latex hypersensitivity (the pharyngeal balloon contains latex)
- 40. Combitube Contraindications: The patient has intact gag-reflex The patient is less than 5 feet tall or under 16 years old History of ingestion of caustic substance Burns involving the airway History of esophageal disease History of latex hypersensitivity
- 41. Epiglottic Rest i-GEL Distal Part of Drainage Tube Proximal Part of Drainage Tube 15 mm Connector Bite Block Non-inflatable Cuff
- 42. i-GEL Second generation supraglottic airway device – 2007 (Intersurgical) Mask made of medical grade thermoplastic elastomer - Styrene Ethylene Butadiene Styrene (SEBS) Adapts to patients airway - anatomical seal of the pharyngeal, laryngeal and peri-laryngeal structures Provides effective seal without a cuff
- 43. i-GEL Soft, gel-like, non-inflatable cuff, designed to provide an anatomical impression fit over the laryngeal inlet. The shape, softness and contours accurately mirror the peri-laryngeal anatomy - no cuff inflation is required. Compression and displacement trauma are significantly reduced or eliminated.
- 44. i-GEL Firmness of material – facilitates easy insertion Tip design – prevent folding back of tip edge Epiglottic rest – prevents downfolding of epiglottis Buccal stabilizer and broad mask – provides stability, reduce kinking and midline positioning Gastric channel – helps to vent gastric secretions
- 45. i-GEL
- 46. i-Gel Advantages: Better anatomical fit – less compression trauma Less risk for injuries related to cuff hyperinflation Easy insertion - reduces the time for successful insertion Greater airway seal pressures and superior fibreoptic views as compared to other SGAs* Wide lumen allows for airway rescue and assisted intubation Effective in prone position ventilation *Lisa S Razan N Narasimhan J, Update on Airway Devices Curr Anesthesiol Rep. (2015) 5:147–155
- 47. Airway RescueWith i-Gel i-Gel is established in emergency airway control. Case reports are present where it has been used for airway rescue when cLMA and PLMA have failed I-gel has been used for airway rescue in prone position* * Dingeman RS, Goumnerova LC, Goobie SM. The use of a laryngeal mask airway for emergent airway management in a prone child, Anesth Analg. 2005 Mar; 100(3):670-1
- 48. SLIPA - Streamlined Liner of the Pharynx Airway ■ Plastic uncuffed disposable ■ Hollow boot shaped distal part ■ Anatomically fits pharynx – Toe rests in esophageal entrance – Bridge fits in pyriform fossa – Heel – anchors to soft palate – Large size prevents aspiration of regurgitated fluid
- 49. Advantges ■ Better airway sealing pressures for PPV ■ Cuffless Disadvantages • More traumatic • Occupies space upto soft palate.
- 50. Baska Mask 3rd generation supraglottic airway device Smaller bowl compared to other LMAs - less risk of including oesophageal opening Adjustable tab in shaft to increase angulation - allows easy negotiation of oropharyngeal curve Double gastric channel - one channel is open to air so less chance of oesophageal wall impinging the gastric opening during suction
- 51. BASKA MASK
- 52. SupraglotticAirway Guided ET Intubation and Fibre Optic Laryngoscopy LMA Fastrach LMA ProSeal LMA Supreme i-Gel SLIPA
- 53. Infraglottic Airways Supraglottic Access Infraglottic Access EndotrachealTube Fibre optic devices Cricothyroidotomy Tracheostomy Retrograde Intubation
- 54. Endotracheal Tube Universal Connector Pilot Balloon Inflation Tube Radio-opaque line PVC Tube Cuff Murphy’s Eye
- 55. EndotrachealTube Machine end – Universal Connector Tracheal end – Atraumatic BeveledTip Murphy’s eye – Murphy’sTip ETTube
- 56. Types of EndotrachealTube ■ Cuffed ■ Uncuffed ■ Double lumen
- 57. Markings on an ETTube The markings are situated on the bevel side above the cuff & are read from patient end to machine end
- 58. Markings on an ETTube ID – Inner Diameter OD – Outer Diameter Type of tube – Oral/nasal IT – ImplantTested Single use Name of manufacturer Markings for length of insertion Indicator for position of vocal cords “Conformité Européenne” European Conformity - indicates conformity with health, safety, and environmental protection standards for products sold within the European EconomicArea (EEA)
- 59. Requirements of an Ideal ETTube Smoothness of outer surface to avoid damage to mucosa Smooth & non-wettable inner surface. Non-inflammable Transparent Easily sterilizable Non-kinking
- 60. Requirements of an Ideal ETTube Sufficiently strong - to allow thin wall framework Thermoplasticity - to conform to anatomic passage and to be self centering within the trachea. Non reactive with lubricants or anesthetic agents Latex free Non injurious catheter tip
- 61. ETTube Cuff ■ The cuff is an inflatable sleeve near the patient end of ETT. ■ The cuff material should be strong and tear resistant but thin, soft and pliable. ■ Cuffs are usually made of the same material as the ETT.
- 62. ETTube Cuff Provides a seal between tube & tracheal wall to prevent aspiration of gastric contents Prevents air-leak Serves to center the tube in trachea Can be high volume - low pressure system or low volume - high pressure system
- 64. ETTube Cuff Normal recommended cuff pressure - Damage to tracheal mucosa - >30 cm H2O Total obstruction of tracheal blood flow - >50 cm H2O Usually 10 ml of air is sufficient for adequate cuff pressure 20 – 30 cm H2O
- 65. Factors Affecting Cuff Pressures ■ Positive pressure ventilation ■ Ventilation with N2O ■ Bronchoconstriction ■ Laryngeal spasm ■ Edema ■ Sedation ■ Neuromuscular blockade ■ Reduced core temperature ■ Time ■ Changes in body position Increase in cuff pressure Decrease in cuff pressure Athiraman U, Gupta R, Singh G. Endotracheal cuff pressure changes with change in position in neurosurgical patients. Int J Crit Illn Inj Sci. 2015 Oct-Dec;5(4)
- 66. THE GUIDELINESTO DETERMINETHE SIZE OF ETT: Ideal tube in average adult male – 8.5mm ID Ideal tube in an average adult female - 7.5mm ID. Age is recognized as the most reliable indicator of appropriate ETT size for children. 3 months & less ------ 3 mm ID 3 - 9 months ------ 3.5 mm ID Older than 1 year ------ ID in mm = (16 + age in years)/4
- 67. Younger than 6 years --- 3.5 + age in years/3 = ID in mm Older than 6years --- 4.5 + age in years / 4 = ID in mm Choosing a tube whose external diameter is same width as the patient's distal end of little finger THE GUIDELINESTO DETERMINETHE SIZE OF ETT:
- 68. Principles of ETTube Internal diameter – Smaller tubes offer greater resistance Length – Increase in length of tube increases airway resistance Configuration - Abrupt change in the diameter and direction increases the resistance
- 71. Ideal Suction Catheter Size Measured in French (French/3.14 = size in mm) Diameter of catheter < ½ inner diameter of tube Infants 6 - 8 Fr 2 – 6 years 10 Fr 7 – 15 years 12 Fr >16 years 12 - 14 Fr Size 10 ETT 14 Fr Size 8 ETT 12 Fr Size 6 ETT 10 Fr
- 72. Ideal Suction Pressures Adult – -100 to -120 mmHg Child – -80 to -100 mmHg Infant – -60 to -80 mmHg
- 73. Hazards of Suctioning Trauma Hypoxia – Arrhythmias, Cerebral hypoxia Vagal Stimulation Atelectasis Infection Bronchospasm Raised ICP Stimulation of gag Reflex
- 75. OROPHARYNGEAL AIRWAY Sizes Length (mm) 000 30 00 40 0 50 1 60 2 70 3 80 4 90 5 100 •Sizes available •Colour coding
- 76. OROPHARYNGEAL AIRWAYS ■ Uses – 1) To maintain open airway 2) Prevent endotracheal tube occlusion 3) Prevent tongue bite 4) Facilitate suction 5) Conduit for passing devices into oropharynx 6) Obtain a better mask fit ■ Contraindications – 1) Intact gag reflex 2) Oropharyngeal growth
- 77. Bougie Eschmann Stylet / Endotracheal Tube Introducer Gum Elastic Bougie - neither made of gum nor is it elastic Made from beige colored resin covering a fiberglass core Size – 15 Fr or 5mm diameter Total length – 60 – 70 cm Distal tip angulation - 30-45 degrees
- 78. “Kiwi Grip”
- 79. Bougie Tracheal intubation - in difficult airways or during CPR Tracheal intubation via supraglottic airway device Surgical airway (cricothyrotomy) Selective endobronchial intubation Confirmation of endotracheal tube position Endotracheal tube exchange Bougie-assisted intercostal catheter insertion
- 80. Spotters….
- 83. 3. RAETube (Ring, Adair and Elwyn)
- 84. 4. Laryngoscope
- 86. Questions?
- 87. Thank You
Editor's Notes
- #29: Due to esophageal inlet being included in the bowl of the LMA.
- #30: Stiffer tube, Less compliant cuff, suitable for out of hospital use
- #31: Wire reinforced tube, Only small sizes of tracheal tube or bronchoscope can pass through it. Not preferred prolonged spontaneous ventilation. Unsuitable for MRI scanning. Malposition is less easily diagnosed.
- #32: Video Mount; fibre optic light source; better laryngeal view, epiglottis elevator
- #33: Both cuffs are high volume – low pressure type Connector is color coded to determine the appropriate size Can have modifications with separate esophageal drain ports also
- #34: Due to esophageal inlet being included in the bowl of the LMA.
- #37: Lubricate tube, pass the tube down gently along anatomical curvature of the mouth; incisor should be between two black lines; inflate the proximal cuff first with 40 – 80 cc air; inflate distal cuff with 10 mm air; ventilate through the proximal (blue/1) tube first; if gastric inflation ventilate through 2nd port.
- #38: Patient is placed supine. Test cuffs; Lubricate tube, pass the tube down gently along anatomical curvature of the mouth; incisor should be between two black lines; inflate the proximal cuff first with 40 – 80 cc air; inflate distal cuff with 10 mm air; ventilate through the proximal (blue/1) tube first; if gastric inflation ventilate through 2nd port.
- #39: .
- #40: .
- #41: .
- #42: Both cuffs are high volume – low pressure type Connector is color coded to determine the appropriate size Can have modifications with separate esophageal drain ports also
- #45: Lateral stability and midline positioning are promoted by broad back of mask and buccal cavity stabilizer. Widely used in anaesthesia and pre hospital resuscitation
- #58: .
- #59: .
- #60: Prevents pooling of secretions
- #61: Prevents pooling of secretions
- #63: Prevents pooling of secretions
- #65: Prevents pooling of secretions
- #69: Poisoulle’s law. Abrupt changes in direction of tube produces turbulence of gases and hence increased work of breathing.
- #72: Length of Tube 50cm in all sizes Selection of appropriate suction tube size is important
- #74: Hyper-oxygenate the patient, as appropriate. If suctioning nasally, lubricate the catheter Introduce the catheter into the airway, ensuring that no suction is applied during introduction Advance the catheter until resistance is met. Withdraw the catheter 1 to 2 cm. Apply suction continuously, withdraw catheter, rotating catheter during withdrawal (NOTE: apply suction for a maximum of 15 seconds)
- #77: Advantages - 1) Simple to use, cheap. 2) Not associated with sore throat 3) Does not cause bacteremia
- #78: when only epiglottic visualization or partial glottic view is obtained during laryngoscopy Use like seldinger technique Watch for clicks while passing through the trachea
- #79: When you have to intubate using a bougie alone Steering the Bougie will be difficult
- #80: Hollow tube – helps to confirm tracheal position by detection of CO2 Tube position confirmation – resistance felt at 25 -30 cm when bougie is passed down Always go by the side and facing tip anteriorly. Turn 90 degree clockwise when introducing the ETT.
- #84: oral preformed tube in pediatric patients in 1975 (Ring et al., 1975). RAE tubes were designed with the intention to facilitate intra-oral and some types of facial surgery by moving the part of the ET tube outside of the patient away from the surgeon's access.