【Look at the picture and talk】A brief discussion on airway and endotracheal intubation tools

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Arrangement by cat typesetting by Dingdang Maruko Ma look at pictures and talk from here (notes and pictures are waiting for your interpretation) Mallampati classification and laryngeal view Grading system
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 Why do an assessment? Airway Assessment: The first 3 items in the assessment refer to the degree of mouth opening
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 Indicates the length of the mandibular space The position of the larynx relative to the base of the tongue Which illustration version do you prefer? Schematic diagram of the anatomy of the larynx, including muscles, the most important anatomical standard is the cricothyroid membrane, which can perform cricothyroidotomy trachea and extrapulmonary bronchi and their relationships Masks of various sizes, from infant to adult watering cans, choose the appropriate size Oropharyngeal airways are necessary to relieve airway obstruction
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 Nasopharyngeal airways vary in size Open airway: Use the lower jaw to "create a lower bite" to relieve upper airway obstruction thrust action
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This is the most important technique for opening and maintaining the airway
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Starting at the head of the bed, grasp the closed mandible with the thumbs of both hands
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The mandible is wide open
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C: The open mandible is displaced anteriorly from the temporomandibular joint
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D: The mandible is closed on the bite block of the OPA (oropharyngeal airway) to maintain the thrust of the mandible, and the lower teeth are in front of the upper teeth
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 Supraglottic Airways A number of SGAs are illustrated here.
From left to right: Baska mask, LMA protector, Ambu Aura-i, intubating LMA, Gastro-LT, laryngeal tube suction II, laryngeal tube, classic LMA, ProSeal LMA, LMA Supreme, Guardian CPV, Cobra perilaryngeal airway, i-gel, Streamlined liner of the pharynx airway (SLIPA).
LMA family
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From left to right: Classic LMA, Flexible LMA, ProSeal LMA with Introducer, ILMA endotracheal tube, ILMA and ILMA stabilizer bar
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 Correct way to deflate the LMA cuff Correct position of the finger when inserting the LMA The LMA Classic and LMA Unique Start Insertion Position Insert the LMA to the limit of the finger length, push the LMA with the other hand to complete the insertion (picture below) Inflate the LMA AC : Insert LMA Fastrach
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Note that only a small portion of the tubular portion of the device extends beyond the lips
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The metal tube accepts bag-mask device accessories to make the BMV
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 Raise the LMA Fastrach handle when the endotracheal tube is about to enter the larynx to improve intubation success
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This is called the Chandy maneuver, named after Dr.
Archie.
The stabilizer bar is used to ensure that the ETT is not inadvertently pulled out of the trachea when the LMA Fastach is removed
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 The guide balloon of the ETT emerges intact from the end of the LMA Fastra Extraglottic device: retroglottic (a and b) ProSeal LMA showing (a) the airway above the glottis and (b) the drainage tube and passage to the esophagus
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 The cuffpilot technology on the LMA protector provides a visual indication that the pressure inside the bladder is safe
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 SGAS suitable or designed for intubation
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From left to right: I-Gel, LMA Classic Excel, Intubation LMA, Ambu Aura-I, AirQ
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Ambu AuraGain has no photos
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 (af) SGA was replaced with a tracheal tube using an Aintree intubation catheter (AIC), described
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The Aintree Intubation Catheter (AIC) was placed on an appropriately sized (<4.
5 mm) flexible optical bronchoscope (FOB)
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• Connect a corner piece with a rubber septum between the SGA and the catheter holder, through which the FOB can be inserted
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The patient's ventilation should be continued throughout, and it is recommended to increase FiO2
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It is also important to be careful during insertion of the SGA and to optimize the ease of ventilation (to increase the likelihood that the SGA is above the glottis)
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· The FOB and AIC combination is slightly lubricated on the outside, inserts the SGA rod through the diaphragm, and advances to the mask part through the SGA rod
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If the glottis is easily visible, the FOB/AIC will pass and advance just above the carina
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If the glottis is not accessible, the procedure should be stopped, the FOB/AIC removed, the SGA repositioned, and the procedure restarted
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• The FOB is then removed without removing the AIC, while keeping the AIC at the same insertion depth
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· SGA is also removed, again will not replace AIC
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• Use the track to place a suitable endotracheal tube over the AIC, and once the tube is in place, the AIC is removed
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Correct placement of the endotracheal tube was confirmed by bicarbonate mapping and auscultation
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The type of endotracheal intubation should be suitable for FOB-guided intubation
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For most endotracheal tubes, a 7.
0 mm ID tube is suitable
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An ILMA endotracheal tube with a diameter of 6.
5 mm is also suitable
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  The light-transmitting light bar spot of the cricothyroid membrane The simulated helmet offers more options for airway intervention (left)
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The mobile mask helmet (right) provides full access to the patient's nose, mouth and neck and uses the mask for ventilation
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 Light-guided nasotracheal intubation was performed through a full-face modular helmet (BMW System IV helmet) using Trachlight's
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Using a gentle chin thrust, the ETI/TL is inserted through the nostrils into the nasopharynx
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A bright annular glow (arrow) is seen below the thyroid eminence as the tip enters the glottis opening
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Direct Laryngoscopy Although video laryngoscopy (VL) has become the device of choice for many emergency physicians, direct laryngoscopy is still a common technique for emergency endotracheal intubation
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In the hands of experienced people, DL has a high success rate, cheap and reliable equipment, and a wide range of sources
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However, DL requires extensive experience to gain proficiency and has inherent limitations that manifest when there are factors such as reduced cervical mobility, a large tongue, a retracted chin, or protruding incisors
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 Direct laryngoscopy with (Macintosh Blade)
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Note that the tip of the knife fits properly into the base of the epiglottis and elevates the epiglottis by pushing on the epiglottis ligaments
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 Direct laryngoscopy with (Miller Blade)
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The tip of the knife is used to lift the epiglottis directly
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 Direct laryngoscopy with Macintosh Blade
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The mouth is wide open and the tongue is well controlled by the large flange of the Macintosh Blade, completely to the left
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The epiglottis is visualized and the tip of the knife is pushed into the gully, raising the epiglottis and exposing the vocal cords
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The force is applied by lifting the entire blade upwards, not by tilting the handle of the blade toward the front teeth
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 Direct laryngoscopy with Miller Blade
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The mouth is wide open and the tongue is difficult to control with the small flange of the Miller Blade, but it is completely left
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The epiglottis is identified and then lifted with the tip of the knife (so it is not visible here), exposing the vocal cords
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The force is applied by lifting the entire blade upwards, not by tilting the handle of the blade toward the front teeth
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 Paralingual (postmolar) straight edge technique
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The Miller blade enters the right corner of the mouth with the tip advanced toward the midline, while the proximal blade remains on the right side of the mouth
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Note that the tongue is completely on the left side of the blade
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This technique may improve glottal visualization in difficult situations, but does not leave much room for ETT to pass
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Ask the assistant to retract the lips to make more room as shown
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 Optimal endotracheal tube/>
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A relatively straight ETT in the shape of a "hockey stick" with a bend angle < 35°
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This shape allows passage through the windpipe without blocking the view
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 Bimanual laryngoscopy
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The laryngoscope manipulates the thyroid cartilage with his/her right hand
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Optimal external manipulation usually involves applying firm pressure to the thyroid cartilage and moving to the right (backward, upward (cephalic), and rightward pressure)
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The advantage of the laryngoscope (rather than the assistant) performing this maneuver is that he/she has immediate visual feedback and can quickly determine what is the best external maneuver
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 The assembly and shaping of the tracheal introducer was checked with different direct laryngoscopes (Macintosh, Miller Blade) and channel/non-safety video diagnostic scopes
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In each lower lower data, Bougie has to bend to match the curve of the recorder to achieve its goal
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 A "bougie"-guided open cricothyroidotomy
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 This photo shows a morbidly obese patient lying on his back with his shoulders, neck and head resting on a stacked "slope" of hospital linen
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This is the best position for airway management and laryngoscope intubation in obese patients because the external auditory canal is at the same level as the sternal angle Macintosh blade (upper) and Miller (lower) Laryngoscope blade Laryngoscope view (with Cormack-Lehane system related)
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A: Panorama of vocal cords (level 1)
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B: Only posterior glottis structures/cartilage are visible (grade 2)
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C: Only the epiglottis is visible (level 3)
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D: Neither epiglottis nor glottis structures are visible, only the soft palate (grade 4)
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Anatomy of the larynx with cricothyroidotomy
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The cricothyroid membrane (arrow) is above the thyroid cartilage and below the cricoid cartilage.
Surface dissection of the airway
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A: The thumb and long fingers hold the upper corner of the larynx.
B: The index finger is used to touch the cricothyroid membrane.
Moving the index finger to the side, but continuing to hold the larynx firmly, make a vertical midline skin incision to the depth of the laryngeal structure
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 After incising the skin, the index finger can now directly touch the cricothyroid membrane
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 Make a horizontal membrane incision near the lower edge of the cricothyroid membrane
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The index finger can be moved aside or left in the wound, touching the lower edge of the thyroid cartilage and guiding the scalpel towards the membrane
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B: The low cricothyroid incision avoids the supra cricothyroidal vessels, which extend laterally near the top of the membrane
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 The tracheal hook is oriented laterally during insertion
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B and C: After insertion, the Cephalad traction was applied to the inferior border of the thyroid cartilage
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 The Trouseau dilator is inserted a short distance into the incision
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B: In this orientation, the dilator expands the opening vertically, which is crucial
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Notes: Insert a tracheostomy tube
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B: Rotation of the Trorouseau dilator, which rotates the blades longitudinally in the airway to facilitate passage of the tracheostomy tube
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C: The tracheostomy tube is fully inserted, and the instrument is removed
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One-handed "EC" grip mask technology
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One-handed "chin lift" grip applied to the sagittal plane to optimize head extension Two-handed "EV" grip applied symmetrically to the mask and jaw to optimize triple airway maneuvers
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 Head and neck positioning for airway management
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(A) Obese patient with standard head lift: the external auditory canal is in the same horizontal plane as the sternal notch (white dashed line), resulting in poor flatness of the quadratic curve (solid red line), making direct laryngoscopy difficult
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(B) Obese patient with oblique position, head elevated, and shoulder rami: the external auditory canal is at the same level as the sternal notch (white dashed line), resulting in a flattening of the quadratic curve (solid red line), facilitating direct laryngoscopy
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(C) Obese patient in the supine position: similar to the slope position with the external auditory canal and the sternal notch at the same level (white dashed line), resulting in a flattening of the quadratic curve (solid red line), facilitating direct laryngoscopy
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(D) Standard suboccipital non-obese patient: the external auditory canal is at the same level as the sternal notch (white dashed line), resulting in a flattening of the quadratic curve (solid red line)
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(E) Small occiput (i.
e.
, the head is smaller relative to the anteroposterior diameter of the chest): the external auditory canal is in the same horizontal plane as the sternal notch (white dashed line), resulting in a flattening of the secondary curve (solid red line)
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Bronchoscopy using nasotracheal endoscopy for upper airway anatomy
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The endoscopist is standing behind a patient lying on his back
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(a) Select the right nostril
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(b) The tip of the FOB advances forward in the triangular space enclosed by the nasal septum (left), inferior turbinate (lower), and nasal lateral wall (right) in the visual field
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(c) The tip of the FOB above the inferior turbinate, i.
e.
the right side of the field of view
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(d) The posterior opening of the nasal cavity refers to the disappearance of the inferior turbinate (at the 5 o'clock position)
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The posterior pharyngeal wall can be seen in the center of the field of view
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(e) The upper part is the soft palate and the lower part is the base of the tongue
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(f) Epiglottis
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(g) The entrance to the larynx has the vocal cords, vocal cords, cuneiform and horn cartilages
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(h) True and false vocal cords
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(i) Trachea with tracheal rings
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(j) Carina with left and right main bronchus openings
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