Advance airway Mx

1) Laryngeal mask airway (LMA) 2) Esophageal-tracheal combitube

May provide superior ventilation compare bag mask ventilation in victim of cardiac arrest Health care provider should complete initial training &maintain their knowledge& skill

 Bag-mask ventilation is difficult to perform effectively (esp. by lone rescuer)

But remains single most important skill in airway mx

It is difficult to learn tracheal intubation &maintain high level of skill without frequent use &refresher training Tracheal intubation is much more dangerous intervention

Laryngeal mask airway (LMA)

Laryngeal mask airway (LMA)

Is a adjunctive airway device compose of a tube with a cuffed-mask like projection at the distal end

Insertion technique
LMA introduce into the pharyx and is blindly advance until resistant is felt
Resistance indicates that the distal end of the tube has reached the hypopharynx

The inflate the cuff of the mask

This pushes the mask up against the tracheal opening; providing an effective seal

Ventilation occurs through the opening in the center of the mask

Indication
Are the same as those for the tracheal tube and combitube;
Inability of rescuer to ventilate the unresponsive patient with less invasive methods. Inability of patient to protect his/her airway (eg coma, absent reflexes, cardiac arrest) Continuing cardiac arrest with continuing need for cardiac compressions

Evidence
Insertion:
Successful insertion rate :64%-100%

Ventilation :
Provide more secure and reliable means of ventilation than facemask Ventilation achieved is equivalent with tracheal tube

Airway protection
Regurgitation is less likely(than with the bag-mask) and aspiration is uncommon

Patient access
Advantage over tracheal tube when access to patient is limited / positioning of patient (for tracheal intubation) is impossible

Training
Simpler than tracheal intubation (because skilled laryngoscopy for the purpose of cord visualization is not necessary)

Esophageal-tracheal combitube

 Invasive double lumen airway device with 2 inflatable balloon cuffs.

1. lumen contain ventilating side holes at the hyphopharyngeal level& is closed at the end 2.Open end

Inserted without visualization of vocal cord

Insertion technique
Advance the tube blindly until the 2 marks printed on the tube are located at the patients teeth then inflate pharyngeal(proximal) and esophageal(distal) balloons; isolating the oropharynx above the upper balloon and the esophagus(or trachea) below the lower balloon. Asses the location of the distal orifice and then ventilate patient through appropriate lumen.

 Following blind insertion, the tip of combitube most frequently rests in esophagus, although tracheal intubation may occur;
If the tip of tube (and orifice) lie within the trachea, the tracheal tube (the shorter white or light lumen) is use for ventilation directly into the trachea If the tips of tube (and the orifice) lie within esophagus, the esophageal obdurator end is used to deliver ventilation from the side opening of the tube.
The combitube has no stylet in the distal lumen & immediate suctioning of gastric content is possible

Indication
Are the same as those for tracheal tube;
Inability of rescuer to ventilate the unresponsive patient with less invasive methods. Inability of patient to protect his/her airway (eg coma, absent reflexes, cardiac arrest) Continuing cardiac arrest with continuing need for cardiac compressions

Advantage over the facemask;

Isolates the airway Reduces risk of aspiration Provides more reliable ventilation

 Advantage over the tracheal tube;

Less difficult to learn and acquire skill in the technique Supports more effective and efficient skills maintenance

Complication
Esophageal trauma Subcutaneous emphysema

Providers should receive adequate training and practice using the devise regularly.