Ebook Manual of ICU procedures: Part 1

Manual
of
ICU PROCEDURES

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Manual
of
ICU PROCEDURES
Editor

Mohan Gurjar
MD PDCC FICCM

Associate Professor
Department of Critical Care Medicine
Sanjay Gandhi Postgraduate Institute of Medical Sciences
Lucknow, Uttar Pradesh, India

Foreword

Arvind Kumar Baronia

The Health Sciences Publisher
New Delhi | London | Philadelphia | Panama

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Jaypee Brothers Medical Publishers (P) Ltd.
Headquarters
Jaypee Brothers Medical Publishers (P) Ltd.
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© 2016, Jaypee Brothers Medical Publishers
The views and opinions expressed in this book are solely those of the original contributor(s)/author(s) and do not
necessarily represent those of editor(s) of the book.
All rights reserved. No part of this publication may be reproduced, stored or transmitted in any form or by any
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All brand names and product names used in this book are trade names, service marks, trademarks or registered
trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in
this book.
Medical knowledge and practice change constantly. This book is designed to provide accurate, authoritative
information about the subject matter in question. However, readers are advised to check the most current
information available on procedures included and check information from the manufacturer of each product to be
administered, to verify the recommended dose, formula, method and duration of administration, adverse effects

and contra­indications. It is the responsibility of the practitioner to take all appropriate safety precautions. Neither
the publisher nor the author(s)/editor(s) assume any liability for any injury and/or damage to persons or property
arising from or related to use of material in this book.
This book is sold on the understanding that the publisher is not engaged in providing professional medical services.
If such advice or services are required, the services of a competent medical professional should be sought.
Every effort has been made where necessary to contact holders of copyright to obtain permission to reproduce
copyright material. If any have been inadvertently overlooked, the publisher will be pleased to make the necessary
arrangements at the first opportunity.
Inquiries for bulk sales may be solicited at:

Manual of ICU Procedures
First Edition: 2016
ISBN: 978-93-5152-422-9
Printed at

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Dedicated to
All men and women (including our patients)
who, over the years, have contributed to develop
standards for procedures, which being done
in critically ill patients, to improve safety with
better skills.

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Contributors
A Ebru Salman  MD
Associate Professor
Department of Anesthesiology
and Reanimation
Atatürk Training and Research Hospital
Ankara, Turkey

Ankur Bhatnagar  MS MCh
Associate Professor
Department of Plastic Surgery
Sanjay Gandhi Postgraduate
Institute of Medical Sciences
Lucknow, Uttar Pradesh, India

Abhishek Kumar  MD

Anupam Wakhlu  MD DM

Chief Intensivist
Patel Hospital
Jalandhar, Punjab, India

Associate Professor
Department of Rheumatology
King George’s Medical University
Lucknow, Uttar Pradesh, India

Abraham Samuel Babu  MPT
Assistant Professor
Department of Physiotherapy
School of Allied Health Sciences
Manipal University
Manipal, Karnataka, India

Aditya Kapoor  DM FACC
Professor
Department of Cardiology
Sanjay Gandhi Postgraduate
Institute of Medical Sciences
Lucknow, Uttar Pradesh, India

Afzal Azim  MD PDCC FICCM
Additional Professor
Department of Critical Care Medicine
Sanjay Gandhi Postgraduate
Institute of Medical Sciences
Lucknow, Uttar Pradesh, India

Amit Keshri  MS
Assistant Professor
Unit of Neuro-otology
Department of Neurosurgery
Sanjay Gandhi Postgraduate
Institute of Medical Sciences
Lucknow
Uttar Pradesh, India
Amol Kothekar  MD IDCC

Assistant Professor
Intensive Care Medicine
Department of Anesthesia
Critical Care and Pain
Tata Memorial Hospital
Mumbai
Maharashtra, India

Anju Dubey  MD
Assistant Professor
Department of Transfusion Medicine
All India Institute of Medical Sciences
Rishikesh, Uttarakhand, India

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Armin Ahmed  MD PDCC
Senior Research Associate
Department of Critical Care Medicine
Sanjay Gandhi Postgraduate
Institute of Medical Sciences
Lucknow, Uttar Pradesh, India

Arun G Maiya  PhD PT
Dr TMA Pai Endowment Chair in Exercise
Science and Health Promotion
Professor
Department of Physiotherapy
School of Allied Health Sciences
Manipal University

Manipal, Karnataka, India

Arun K Srivastava  MS MCh
Associate Professor
Department of Neurosurgery
Sanjay Gandhi Postgraduate
Institute of Medical Sciences
Lucknow, Uttar Pradesh, India
Arun Sharma  MD PDCC
Consultant
Critical Care Medicine
Santokba Durlabhji Memorial Hospital
Jaipur, Rajasthan, India
Atul P Kulkarni  MD
Professor and Head
Division of Critical Care
Department of Anesthesia
Critical Care and Pain
Tata Memorial Hospital
Mumbai, Maharashtra, India
Atul Sonker  MD
Additional Professor
Department of Transfusion Medicine
Sanjay Gandhi Postgraduate
Institute of Medical Sciences
Lucknow, Uttar Pradesh, India

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viii  Manual of ICU Procedures
Banani Poddar  MD

Dharmendra Bhadauria  MD DM

Professor
Department of Critical Care Medicine
Sanjay Gandhi Postgraduate
Institute of Medical Sciences
Lucknow, Uttar Pradesh, India

Assistant Professor
Department of Nephrology and
Renal Transplantation
Sanjay Gandhi Postgraduate
Institute of Medical Sciences
Lucknow, Uttar Pradesh, India

Barnali Banik  MD
Clinical Fellow
Department of Hematology
Peter MacCallum Cancer Center
Melbourne, Australia
Basant Kumar  MS MCh
Associate Professor
Department of Pediatric Surgical
Superspecialty
Sanjay Gandhi Postgraduate
Institute of Medical Sciences
Lucknow, Uttar Pradesh, India

Bhaskar P Rao  MD PDCC
Assistant Professor
Department of Anesthesiology
All India Institute of Medical
Sciences, Bhubaneswar
Odisha, India

Bhuwan Chand Panday  MD
Consultant
Department of Anesthesia
Sir Ganga Ram Hospital
New Delhi, India

Biju Pottakkat  MS MCh PDF FICS
Additional Professor and Head
Department of Surgical
Gastroenterology Jawaharlal
Institute of Postgraduate
Medical Education and Research
Puducherry, India

Devendra Gupta  MD PDCC
Additional Professor
Department of Anesthesiology
Sanjay Gandhi Postgraduate
Institute of Medical Sciences
Lucknow, Uttar Pradesh, India

Divyesh Patel  MD IDCCM

Consultant Intensivist
Deenanath Mangeshkar Hospital
Pune, Maharashtra, India

Eti Sthapak  MS
Assistant Professor
Department of Anatomy
Era’s Lucknow Medical College and Hospital
Lucknow, Uttar Pradesh, India
Fahri Yetisir  MD
Associate Professor
Department of General Surgery
Atatürk Training and Research Hospital
Ankara, Turkey

Gaurav Srivastava  MD
Clinical Fellow
Department of Hematology
Peter MacCallum Cancer Center
Melbourne, Australia
Girija Prasad Rath  MD DM
Additional Professor
Department of Neuroanesthesiology
All India Institute of Medical Sciences
New Delhi, India

Harsh Vardhan  MD DM
Assistant Professor
Department of Nephrology
Indira Gandhi Institute of Medical Sciences

Patna, Bihar, India
Hemanshu Prabhakar  MD
Additional Professor
Department of Neuroanesthesiology
All India Institute of Medical Sciences
New Delhi, India

Consultant
Department of Anesthesiology
Fortis Escorts Heart Institute
New Delhi, India

Hemant Bhagat  MD DM
Associate Professor
Department of Anesthesia and Intensive Care
Postgraduate Institute of
Medical Education and Research
Chandigarh, India

Devesh K Singh  MS MCh
Senior Resident
Department of Neurosurgery
Sanjay Gandhi Postgraduate
Institute of Medical Sciences
Lucknow, Uttar Pradesh, India

Hira Lal  MD
Additional Professor
Department of Radiodiagnosis
Sanjay Gandhi Postgraduate

Institute of Medical Sciences
Lucknow, Uttar Pradesh, India

Devesh Dutta  MD FNB

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Contributors  ix
Indu Lata  MD MNAMS
Associate Professor
Department of Maternal and
Reproductive Health
Sanjay Gandhi Postgraduate
Institute of Medical Sciences
Lucknow, Uttar Pradesh, India

Jayantee Kalita  MD DM
Professor
Department of Neurology
Sanjay Gandhi Postgraduate
Institute of Medical Sciences
Lucknow, Uttar Pradesh, India

Jugal Sharma  MD
Senior Resident
Department of Cardiology
Sanjay Gandhi Postgraduate

Institute of Medical Sciences
Lucknow, Uttar Pradesh, India

JV Divatia  MD FICCM FCCM
Professor and Head
Department of Anesthesia,
Critical Care and Pain
Tata Memorial Hospital
Mumbai, Maharashtra, India

Jyoti Narayan Sahoo  MD PDCC
Consultant Intensivist
Department of Critical Care Medicine
Apollo Health City
Hyderabad, Telangana, India

Kamal Kataria  MS
Research Associate
Department of Trauma Surgery
JPN Apex Trauma Center
All India Institute of Medical Sciences
New Delhi, India

Kamal Kishore  MD
Associate Professor
Department of Anesthesiology
Sanjay Gandhi Postgraduate
Institute of Medical Sciences
Lucknow, Uttar Pradesh, India

Kapil Dev Soni  MD
Assistant Professor
Critical and Intensive Care
JPN Apex Trauma Center
All India Institute of Medical Sciences
New Delhi, India

Kirti M Naranje  MD
Assistant Professor
Department of Neonatology
Sanjay Gandhi Postgraduate
Institute of Medical Sciences
Lucknow, Uttar Pradesh, India

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Kranti Bhavana  MS DNB
Assistant Professor
Department of Otorhinolaryngology
All India Institute of Medical
Sciences, Patna
Bihar, India
Kundan Kumar  MD DNB DM
Senior Resident
Department of Gastroenterology
Sanjay Gandhi Postgraduate
Institute of Medical Sciences
Lucknow, Uttar Pradesh, India

Kuntal Kanti Das  MS

Assistant Professor
Department of Neurosurgery
Sanjay Gandhi Postgraduate
Institute of Medical Sciences
Lucknow, Uttar Pradesh, India

Manish Gupta  MD FNB EDIC
Senior Consultant and Head
Department of Critical Care Medicine
Max Superspecialty Hospital
New Delhi, India

Manish Paul  MD
Clinical Observer
Department of Critical Care Medicine
Sanjay Gandhi Postgraduate
Institute of Medical Sciences
Lucknow, Uttar Pradesh, India

Mohan Gurjar  MD PDCC FICCM
Associate Professor
Department of Critical Care Medicine
Sanjay Gandhi Postgraduate
Institute of Medical Sciences
Lucknow, Uttar Pradesh, India
MS Ansari  MS MCh
Additional Professor
Department of Urology
Sanjay Gandhi Postgraduate
Institute of Medical Sciences

Lucknow, Uttar Pradesh, India

Namita Mehrotra  MD
Assistant Professor
Department of Radiodiagnosis
Sanjay Gandhi Postgraduate
Institute of Medical Sciences
Lucknow, Uttar Pradesh, India

Narendra Agrawal  MD DM
Consultant
Hemato-oncology and
Bone Marrow Transplantation
Rajiv Gandhi Cancer Institute
and Research Center
New Delhi, India

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x  Manual of ICU Procedures
Neeta Bose  MD

Prasad Rajhans  MBBS MD FICCM

Associate Professor
Department of Anesthesia
Gujarat Medical Education and
Research Society Medical College
Vadodara, Gujrat, India

Chief Intensivist
Deenanath Mangeshkar Hospital, Pune
Consultant in Emergency
Medical Services
Symbiosis International University
Pune, Maharashtra, India

Neha Singh  MD
Assistant Professor
Department of Anesthesiology
Institute of Medical Sciences and SUM Hospital
Bhubaneswar, Odisha, India
Nikhil Kothari  MD PhD
Assistant Professor
Department of Anesthesiology
Critical Care and Pain Medicine
All India Institute of Medical Sciences
Jodhpur, Rajasthan, India

Nirvik Pal  MD
Resident
Department of Anesthesiology
Washington University
St Louis, Missouri, USA

Nishant Verma  MD
Assistant Professor
Department of Pediatrics
King George’s Medical University

Lucknow, Uttar Pradesh, India

Nitin Garg  MD FNB EDIC
Senior Consultant and Head
Department of Critical Care Medicine
Rockland Hospital
New Delhi, India

Oskay Kaya  MD
Associate Professor
Department of General Surgery
Dışkapı Yıldırım Beyazit Research
and Training Hospital
Ankara, Turkey

Pradeep Bhatia  MD
Professor and Head
Department of Anesthesiology
Critical Care and Pain Medicine
All India Institute of Medical Sciences
Jodhpur, Rajasthan, India
Pralay K Sarkar  MD DM MRCP (UK) FCCP
Assistant Professor
Division of Pulmonary and
Critical Care Medicine
Department of Medicine
Baylor College of Medicine
Ben Taub General Hospital
Houston, Texas, USA

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Prashant Saxena  MD EDIC FCCP
Consultant
Department of Pulmonology,
Critical Care and Sleep Medicine
Saket City Hospital
New Delhi, India

Praveer Rai  MD DM
Additional Professor
Department of Gastroenterology
Sanjay Gandhi Postgraduate
Institute of Medical Sciences
Lucknow, Uttar Pradesh, India

Puja Srivastava  MD
Senior Resident
Department of Clinical Immunology
Sanjay Gandhi Postgraduate
Institute of Medical Sciences
Lucknow, Uttar Pradesh, India
Puneet Goyal  MD DM
Associate Professor
Department of Anesthesiology
Sanjay Gandhi Postgraduate
Institute of Medical Sciences
Lucknow, Uttar Pradesh, India

Puneet Khanna  MD

Assistant Professor
Department of Anesthesiology
All India Institute of Medical Sciences
New Delhi, India
Rabi N Sahu  MS MCh
Additional Professor
Department of Neurosurgery
Sanjay Gandhi Postgraduate
Institute of Medical Sciences
Lucknow, Uttar Pradesh, India
Raj Kumar Mani  MD
Director Critical Care
Pulmonology and Sleep Medicine
Saket City Hospital
New Delhi, India
Rajanikant R Yadav  MD
Assistant Professor
Department of Radiodiagnosis
Sanjay Gandhi Postgraduate
Institute of Medical Sciences
Lucknow, Uttar Pradesh, India

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Contributors  xi
Rajendra Kumar  BPT
Physiotherapist Grade I
Department of Critical Care Medicine
Sanjay Gandhi Postgraduate

Institute of Medical Sciences
Lucknow, Uttar Pradesh, India

Sandeep Sahu  MD PDCC FACEE

Rakesh Garg  MD
Assistant Professor
Department of Anesthesiology
All India Institute of Medical Sciences
New Delhi, India

Sanjay Dhiraaj  MD

Rakesh Lodha  MD
Additional Professor
Department of Pediatrics
All India Institute of Medical Sciences
New Delhi, India

Associate Professor
Department of Anesthesiology
Sanjay Gandhi Postgraduate
Institute of Medical Sciences
Lucknow, Uttar Pradesh, India
Additional Professor
Department of Anesthesiology
Sanjay Gandhi Postgraduate
Institute of Medical Sciences
Lucknow, Uttar Pradesh, India

Sanjay Singhal  MD
Graded Chest Specialist and Intensivist
Command Hospital
Lucknow, Uttar Pradesh, India

Additional Professor
Department of Anesthesiology
All India Institute of Medical Sciences
New Delhi, India

Sanjeev Bhoi  MD
Additional Professor
Department of Emergency Medicine
JPN Apex Trauma Center
All India Institute of Medical Sciences
New Delhi, India

Ravindra M Mehta  MD FCCP

Sanjeev K Bhoi  MD DM

Ravinder Kumar Pandey  MD

Chief
Critical Care and Pulmonology Apollo
Hospitals
Bengaluru, Karnataka, India

Richa Misra  MD

Assistant Professor
Department of Neurology
Sanjay Gandhi Postgraduate
Institute of Medical Sciences
Lucknow, Uttar Pradesh, India

Assistant Professor
Department of Microbiology
Sanjay Gandhi Postgraduate
Institute of Medical Sciences
Lucknow, Uttar Pradesh, India

Saswata Bharati  MD FIPM

Ritesh Agarwal  MD DM

Saurabh Saigal  MD IDCC PDCC EDIC

Associate Professor
Department of Pulmonary Medicine
Postgraduate Institute of
Medical Education and Research
Chandigarh, India

RK Singh  MD PDCC
Additional Professor
Department of Critical Care Medicine
Sanjay Gandhi Postgraduate
Institute of Medical Sciences
Lucknow, Uttar Pradesh, India

Rohan Aurangabadwalla  MD
Pulmonologist
Apollo Hospitals
Bengaluru, Karnataka, India

Samir Mohindra  MD DM
Associate Professor
Department of Gastroenterology
Sanjay Gandhi Postgraduate
Institute of Medical Sciences
Lucknow, Uttar Pradesh, India

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Ex-Assistant Professor
Department of Anesthesiology
Calcutta National Medical College
Kolkata, West Bengal, India
Assistant Professor
Department of Trauma and
Emergency Medicine
All India Institute of Medical Sciences
Bhopal, Madhya Pradesh, India

Saurabh Taneja  MD FNB
Consultant
Department of Critical Care Medicine
Sir Ganga Ram Hospital
New Delhi, India

Sumit Ray  MD FICCM
Senior Consultant
Department of Critical Care Medicine
Sir Ganga Ram Hospital
New Delhi, India

Sushma Sagar  MS FACS
Additional Professor
Department of Trauma Surgery
JPN Apex Trauma Center
All India Institute of
Medical Sciences
New Delhi, India

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xii  Manual of ICU Procedures
Usha K Misra  MD DM
Professor and Head
Department of Neurology
Sanjay Gandhi Postgraduate
Institute of Medical Sciences
Lucknow, Uttar Pradesh, India
V Darlong  MD
Additional Professor
Department of Anesthesiology
All India Institute of Medical Sciences
New Delhi, India

Vandana Agarwal  MD FRCA
Associate Professor
Department of Anesthesia,
Critical Care and Pain
Tata Memorial Hospital
Mumbai, Maharashtra, India

Vijai Datta Upadhyaya  MS MCh
Associate Professor
Department of Pediatric Surgical
Superspecialty
Sanjay Gandhi Postgraduate
Institute of Medical Sciences
Lucknow, Uttar Pradesh, India

Vikas Agarwal  MD DM
Additional Professor
Department of Clinical Immunology
Sanjay Gandhi Postgraduate
Institute of Medical Sciences
Lucknow, Uttar Pradesh, India

Vishal Shanbhag  MD IDCCM
Intensivist
Kasturba Medical College
Manipal University, Manipal, India
Physician and Specialist
Critical Care Medicine
Hamad Medical Corporation
Doha, Qatar

Vivek Ruhela  MD
Senior Resident
Department of Nephrology and
Renal Transplantation
Sanjay Gandhi Postgraduate
Institute of Medical Sciences
Lucknow, Uttar Pradesh, India

VN Maturu  MD
Senior Resident
Department of Pulmonary Medicine
Postgraduate Institute of
Medical Education and Research
Chandigarh, India

Zafar Neyaz  MD
Associate Professor
Department of Radiodiagnosis
Sanjay Gandhi Postgraduate
Institute of Medical Sciences
Lucknow, Uttar Pradesh, India

Virendra K Arya  MD
Visiting Professor
Department of Anesthesia and
Perioperative Medicine
Winnipeg Regional Health Authority
University of Manitoba, Canada
Additional Professor

Cardiac Anesthesia Unit
Advanced Cardiac Center
Department of Anesthesia
and Intensive Care
Postgraduate Institute of Medical
Education and Research
Chandigarh, India

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Foreword
I am confident that the first edition of Manual of ICU Procedures will serve as a
single source of valuable information to the students and practitioners of critical
care. The 61 procedures described in this manual represent the core-competency
of intensive care services. All the contributors have provided actionable guidance
on how to perform the ICU procedures safely and successfully. Dr Mohan Gurjar
has done a marvelous job by maintaining the uniformity in content, style and
standard of information for each chapter, beginning with basic principles and
progressing to more complex issues. This manual holds a great potential for its
extensive educational value.

Arvind Kumar Baronia  MD

Professor and Head
Department of Critical Care Medicine
Sanjay Gandhi Postgraduate Institute of Medical Sciences
Lucknow, Uttar Pradesh, India

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Preface
As specialty, critical care medicine is now entering in its adulthood, there is a
lot of scope for improvement in teaching and training in this field. Critical care
medicine is a unique specialty, where the sickest patients are being managed
with a wide spectrum of procedures. In fact, there is need of hour to have a book
with a compilation of all common procedures being done in critically ill patients
for education and training purpose, despite easily available information on
individual topic in current era.
Manual of ICU Procedures has 61 chapters, covering almost all relevant
procedures, including simple as well as more complex, done in critically and
acutely ill patients.
The book has five different sections, such as airway and respiratory procedures,
vascular and cardiac procedures, neurological procedures, gastrointestinal/
abdominal/genitourinary related procedures; while section miscellaneous covers
a few other procedures. This book will be helpful to various clinicians across
specialty including critical care physicians, emergency physicians, anesthetists,
pulmonologists, pediatricians, general physicians and general surgeons.
The splendid chapters are written by experts with their vast experience and
knowledge from various specialties, keeping in mind that it is also intended for the
trainee students to help them to understand the procedures. Most of the chapters
outline somewhat similar with headings such as introduction, indication, contra­
indication, applied anatomy, technique and equipment, preparation, steps of
procedure, the post-procedure care, and complication/problem associated with
the procedure.

All the procedures described in the book may not be necessarily done by
critical care physicians depend upon the local ICU policy, but understanding
these procedures will lead towards the optimal management of critically ill
patients. As ever-evolving fast information and technology, changes may happen
in procedure’s technique and equipment, author advice to keep updated on
these issues in the future. Readers should also be aware that complications and
problems for each procedure are highlighted briefly in the chapter, which may
not cover exhaustive list. This is highly recommended by the author that being
nature of patients, procedures are supposed to learn under supervision as per
local policy, to achieve better skills while taking utmost care for safety to the
patient.
The highlighted feature of the book is that procedures are described step by
step along with images. I hope that the book will serve as a ready resource in any
ICU and emergency room and for all clinicians who are dealing with critically
ill patients.
So, have a great satisfaction from treating the sickest patients with better
understanding and skill for a safe procedure.

Mohan Gurjar

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Acknowledgments
The concept of Manual of ICU Procedures is the result of feedbacks from students
in critical care medicine about the urgent need of such a book. My inspiration
to write a book comes from (Late) Mr NL Verma, a great teacher of Physics in
Rajasthan University. With this thought and initial guidance from Professor

Amit Agarwal, I met Shri Jitendar P Vij (Group Chairman) of M/s Jaypee Brothers
Medical Publishers (P) Ltd, New Delhi, India, who obliged me by accepting
this project.
At the beginning of the project, Professor Arvind K Baronia and Dr Afzal Azim
helped me with careful selection of the content of the book as well as developing
format for the chapters.
I am indebted to all contributors, from various institutes and specialties,
without their contribution, the book was not possible. They kept patience with
me while making changes in the chapter for improvement and provided good
quality images.
I would also like to sincerely thank the production team at M/s Jaypee Brothers
Medical Publishers (P) Ltd, New Delhi, India, for their effort to make the book in
present form.
Throughout this project, I received much-needed moral support from my
colleagues, friends, staffs and students of my department and Sanjay Gandhi
Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow, Uttar Pradesh,
India.
I owe for blessings from my parents Dr Ganga Bishan Gurjar and Dr Gulab
Gurjar, and also best wishes from my sister Divya Kasana.
Finally, I acknowledge the tolerance and support of my wife Dr Sheetal Gurjar
and daughters Ishani and Bhavya during this endeavor, without whom the book
could never have been completed.

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Contents
Section 1  Airway and Respiratory Procedures

1. Bag-Mask Ventilation

Ravinder Kumar Pandey, Rakesh Garg, V Darlong

3

Indication  3  •  Contraindication  4  •  Applied
Anatomy and Physiology  4  •  Technique and
Equipment  5  •  Preparation  8  •  Procedure  11  •  Complication/Problem  15

2. Endotracheal Intubation
Pradeep Bhatia

17

Indication  17  •  Contraindication  17  •  Applied Anatomy  18
•  Technique and Equipment  18  •  Preparation  20  •  Procedure  24
•  Post-procedure Care  27  •  Complication/Problem  27

3. Laryngeal Mask Airway Insertion
Neeta Bose

30

Indication  30  •  Contraindication  30  •  Applied Anatomy  31
•  Technique and Equipment  31  •  Preparation  40  •  Procedure  41
•  Post-procedure Care  45  •  Complication/Problem  46

4. Fiberoptic Intubation

Amol Kothekar, JV Divatia

49

Indication  49  •  Contraindication  50  •  Applied Anatomy  50
•  Technique and Equipment  50  •  Preparation  53  •  Procedure  56
•  Post-procedure Care  59  •  Complication/Problem  59

5. Video Laryngoscopy

Manish Paul, Banani Poddar

62

•  Indication   62  •  Contraindication  63  •  Technique and Equipment  63
•  Preparation  64  •  Procedure   65  •  Complication/Problem  68

6. Double Lumen Endotracheal Tube Placement
Kamal Kishore

71

Indication  71  •  Contraindication  71  •  Applied Anatomy  72
•  Technique and Equipment  72  •  Preparation  73  •  Procedure (For Left-Sided
Double Lumen Tube)  74  •  Post-procedure Care  76  •  Complication/Problem  76

7.Cricothyroidotomy

Kapil Dev Soni, Sanjeev Bhoi

78

Indication  78  •  Contraindication  78  •  Applied Anatomy  79
•  Technique  80  •  Preparation  80  •  Procedure  81
•  Post-procedure Care  88  •  Complication/Problem  89

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xx  Manual of ICU Procedures
8. Percutaneous Tracheostomy
Devendra Gupta

90

Indication  90  •  Contraindication  90  •  Applied Anatomy  91
•  Technique and Equipment  92  •  Preparation  102  •  Procedure  103
•  Post-tracheostomy Care  110  •  Complication/Problem  112

9. Surgical Tracheostomy

Kranti Bhavana, Amit Keshri

117

Functions and Indications of Tracheostomy  117  •  Contraindication  119
•  Applied Anatomy  119  •  Technique and Equipment  120  •  Preparation  122 
•  Procedure  122  •  Post-procedure Care  125  •  Complication/Problem  126

10. Bronchoscopy

Ravindra M Mehta, Rohan Aurangabadwalla

129

Indication  129  •  Contraindication  132  •  Anatomical Details and
Physiological Considerations  133  •  Technique and Equipment  135
•  Preparation  137  •  Procedure  139  •  Post-procedure Care  142
•  Complication/Problem  144

11. Bronchoalveolar Lavage (BAL) and Mini-BAL
Sanjay Singhal

146

Indication  146  •  Contraindication  147  •  Technique  147  •  Preparation  148
•  Procedure  150  •  Post-procedure Care  151  •  Complication/Problem  152

12. Thoracentesis
Pralay K Sarkar

153

Indication  153  •  Contraindication  153  •  Applied Anatomy   153
•  Technique and Equipment  154  •  Preparation  155  •  Procedure  157
•  Post-procedure Care  161  •  Complication/Problem  161

13. Tube Thoracostomy

VN Maturu, Ritesh Agarwal

163

Indication  163  •  Contraindication  164  •  Applied Anatomy  165
•  Technique and Equipment  167  •  Preparation  172  •  Procedure  172
•  Post-procedure Care  180  •  Complication/Problem  181

14. Non-invasive Ventilation for Acute Respiratory Failure
Raj Kumar Mani, Prashant Saxena

187

Indications of Non-invasive Ventilation  187  •  Contraindications of
Non-invasive Ventilation  188  •  Technique and Basic Principles of
Non-invasive Ventilation  188  •  Preparation for Non-invasive Ventilation  194
•  Starting, Monitoring and Weaning of Non-invasive Ventilation  196
•  Complications of Non-invasive Ventilation  198

15. Aerosol Drug Delivery

Sanjay Singhal, Mohan Gurjar

200

Indications for Uses of Aerosol Therapy  200  •  Contraindication  200
•  Principles of Aerosol Therapy  200  •  Preparation  205
•  Procedures for Delivering Aerosol Therapy  205  •  Post-procedure Care  208
•  Complication and Preventive Measures  209

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Contents  xxi
16. Prone Positioning

Puneet Khanna, Girija Prasad Rath

210

Indication  210  •  Contraindication  210  •  Applied Anatomy
and Pathophysiology  211  •  Clinical Aspect and Technique  212
•  Preparation  214  •  Procedure  215  •  Post-procedural Care  215
•  Complication/Problem  216

17. Manual Chest Physiotherapy in Ventilated Patients
Rajendra Kumar

218

Indication  218  •  Contraindication  219  •  Applied Anatomy  219
•  Technique  221  •  Preparation  225  •  Procedure  225
•  Post-procedure Care  231  •  Complication/Problem  232

Section 2  Vascular and Cardiac Procedures
18. Venous Cannulation: Peripheral
Nikhil Kothari, Arun Sharma

237

Indication  237  •  Contraindication  237  •  Applied Anatomy  238
•  Technique and Equipment  239  •  Preparation  241  •  Procedure  241
•  Post-procedure Care  242  •  Complication/Problem  243

19. Venous Cannulation: Central Venous Catheter
Afzal Azim, Abhishek Kumar

246

Indication  246  •  Contraindication  246  •  Applied Anatomy  247
•  Technique and Equipment  247  •  Preparation  253  •  Procedure  253
•  Post-procedure Care  258  •  Complication/Problem  258

20. Venous Cannulation: Peripherally Inserted Central Catheter
Vandana Agarwal, Atul P Kulkarni

261

Indication  261  •  Contraindication  261  •  Applied Anatomy  261
•  Technique and Equipment  262  •  Preparation  263  •  Procedure  264
•  Post-procedure Care  265  •  Complication/Problem  266

21. Tunneling of Central Venous Catheter
Dharmendra Bhadauria, Vivek Ruhela

268

Indication  268  •  Contraindication  268  •  Applied Anatomy  269
•  Technique and Equipment  270  •  Preparation  270  •  Procedure  271
•  Complication/Problem  272

22. Intraosseous Cannulation

Nishant Verma, Rakesh Lodha

276

Indication  276  •  Contraindication  276  •  Applied Anatomy  277
•  Technique and Equipment  277  •  Preparation  279  •  Procedure  280
•  Post-procedure Care  286  •  Complication/Problem  287

23. Umbilical Vascular Catheterization
Kirti M Naranje, Banani Poddar

288

Indication  288  •  Contraindication  289  •  Applied Anatomy  289
•  Technique and Equipment  289  •  Preparation  292  •  Procedure  293
•  Post-procedure Care  296  •  Complication/Problem  296

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xxii  Manual of ICU Procedures
24. Arterial Blood Sampling and Cannulation

Afzal Azim, Saurabh Saigal

298

Indication  298  •  Contraindication  299  •  Applied Anatomy  299
•  Technique and Equipment  299  •  Preparation   302  •  Procedure   303
•  Post-procedure Care  307  •  Complication/Problem  308

25. Pulmonary Artery Catheterization
Puneet Goyal

309

Indication  309  •  Contraindication  310  •  Applied Anatomy  310
•  Technique and Equipment  311  •  Preparation  312  •  Procedure  314
•  Post-procedure Care  320   •  Complication/Problem  320

26. Transducer and Pressure Monitoring
Jyoti Narayan Sahoo

322

Indication  322  •  Technique and Basic Principles of Pressure Transducer  323
•  Transducer Preparation and Pressure Measurement  328
•  Troubleshooting  333

27. Pericardiocentesis

Jugal Sharma, Aditya Kapoor

336

Indication  336  •  Contraindication  336  •  Applied Anatomy and Physiology  336
•  Technique  338  •  Preparation  339  •  Procedure  340
•  Post-procedure Care  343  •  Complication/Problem  344

28. Electrical Cardioversion
Saurabh Taneja, Sumit Ray

345

Indication  345  •  Contraindication  345  •  Applied Physiology and Anatomy  346
•  Technique and Equipment  346  •  Preparation  349  •  Procedure  350
•  Post-procedure Care  350  •  Complication/Problem  352

29. Temporary Cardiac Pacing

Saswata Bharati, Nirvik Pal, Devesh Dutta

353

Indication  353  •  Contraindication  354  •  Technique and Basic Principles  355
•  Preparation  362  •  Procedure  362  •  Post-procedure Care  364
•  Complication/Problem  365

30. Intra-aortic Balloon Pump Counterpulsation
Virendra K Arya

367

Indication  367  •  Contraindication  368  •  Technique: Basic Principles  368
•  Technique: Insertion and Operation  374  •  Main Points of Care  380
•  Weaning from Intra-aortic Balloon Pump Counterpulsation  381
•  Complication/Problem  381  •  Special Situations  382
•  Permanent Intra-aortic Balloon Pump  383

31. Tourniquet for Vascular Injuries
Sushma Sagar, Kamal Kataria

386

Indication  386  •  Contraindication  386  •  Applied Physiology  387
•  Technique  387  •  Preparation and Procedure  388
•  Post-procedure Care  389  •  Complication/Problem  390

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Contents  xxiii

Section 3  Neurological Procedures
32. Jugular Venous Oximetry
Hemant Bhagat

395

Indication  395  •  Contraindication  395  •  Applied Anatomy  395
•  Technique and Basic Principles  396  •  Preparation  397

•  Procedure  397  •  Post-procedure Care  398
•  Complication/Problem  399

33. Lumbar Puncture

Bhaskar P Rao, Neha Singh

401

Indication  401  •  Contraindication  402  •  Applied Anatomy  402
•  Technique and Equipment  403  •  Preparation  408
•  Procedure  408  •  Post-procedure Care  411
•  Complication/Problem  412

34. Epidural Analgesia
Sanjay Dhiraaj

415

Indication  415  •  Contraindication  416  •  Applied Anatomy  416
•  Technique and Basic Principles of Epidural Analgesia  417
•  Preparation  421  •  Procedure  421  •  Post-procedure Care  427
•  Complication/Problem  427

35. Cranial Burr Hole

Rabi N Sahu, Kuntal Kanti Das, Arun K Srivastava

430

Indication  430  •  Contraindication  430  •  Applied Anatomy  431
•  Preparation  431  •  Procedure  432  •  Post-procedure Care  433
•  Complication/Problem  434

36. External Ventricular Drainage

Devesh K Singh, Arun K Srivastava, Kuntal Kanti Das, Rabi N Sahu

435

Indication  435  •  Contraindication  436  •  Applied Anatomy
and Physiology  436  •  Technique and Basic Principles  439
•  Preparation  442  •  Procedure  442  •  Post-procedure Care  443
•  Complication/Problem  445

37. Intracranial Pressure Monitoring
Hemanshu Prabhakar

447

Indication  447  •  Contraindication  448  •  Applied Anatomy and Physiology  448
•  Technique and Equipment  449  •  Preparation  451  •  Procedure  452
•  Post-procedure Care  452  •  Complication/Problem  453

38. Nerve and Muscle Biopsy

Sanjeev K Bhoi, Jayantee Kalita, Usha K Misra

454

Indication  454  •  Contraindication  454  •  Technique and
Basic Principles  455  •  Preparation  456  •  Procedure  456
•  Post-procedure Care  459  •  Complication/Problem  459

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xxiv  Manual of ICU Procedures
39. Spine Immobilization in Trauma Patient
Sandeep Sahu, Indu Lata

460

Indication  461  •  Contraindication of Spine Immobilization  461
•  Applied Spine Anatomy  461  •  Technique and Equipment  463
•  Preparation  466  •  Procedure Steps of Spine Immobilization and
Logrolling  468  •  Spine Immobilization During Imaging and Transport  470
•  Post-procedure Care  470  •  Complication/Problem  471

Section 4  Gastrointestinal/Abdominal/Genitourinary Procedures
40. Nasogastric Tube Placement
Bhuwan Chand Panday

477

Indication  477  •  Contraindication  477  •  Applied Anatomy  478
•  Technique and Equipment  478  •  Preparation  481  •  Procedure  481
•  Post-procedure Care  483  •  Complication/Problem  483

41. Nasojejunal Tube Placement
Zafar Neyaz, Praveer Rai, Hira Lal

486

Indication  486  •  Contraindication  486  •  Applied Anatomy  486
•  Technique and Equipment  487  •  Preparation  488  •  Procedure  489
•  Post-procedure Care  494  •  Complication/Problem  495

42. Percutaneous Endoscopic Gastrostomy
Samir Mohindra, Kundan Kumar

497

Indication  497  •  Contraindication  498  •  Technique and Equipment  498
•  Preparation  499  •  Procedure  500  •  Post-procedure Care  502
•  Complication/Problem  504

43. Balloon Tamponade in Upper GI Bleed
Praveer Rai

506

Indication  506  •  Contraindication  506  •  Technique and Equipment  506
•  Preparation  508  •  Procedure  508  •  Post-procedure Care  509
•  Complication/Problem  510

44. Gastric Lavage

Manish Gupta, Nitin Garg

512

Indication  512  •  Contraindication  513  •  Technique  513  •  Preparation  515
Procedure  515  •  Post-procedure Care  517  •  Complication/Problem  518

45. Intra-abdominal Pressure Monitoring
RK Singh

520

Indication  520  •  Contraindication  521  •  Applied Pathophysiology   521
•  Technique  521  •  Preparation  522  •  Procedure  522
•  Post-procedure Care  525  •  Complication/Problem  525

46. Paracentesis

Prasad Rajhans, Divyesh Patel

527

Indication  527  •  Contraindication  527  •  Applied Anatomy  528
•  Technique  528  •  Preparation  529  •  Procedure  530
•  Post-procedure Care  534  •  Complication/Problem  535

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Contents  xxv
47. Percutaneous Abdominal Drain

Hira Lal, Rajanikant R Yadav, Zafar Neyaz

537

Indication  537  •  Contraindication  537  •  Applied Anatomy  537
•  Technique and Equipment  538  •  Preparation  540  •  Procedure  541
•  Post-procedure Care  549  •  Complication/Problem  549

48. Bedside Laparoscopy
Biju Pottakkat

552

Indication  552  •  Contraindication  553  •  Preparation  553
•  Technique and Equipment  553  •  Procedure  554
•  Post-procedure Care  555  •  Complication/Problem  555

49. Dynamic Abdominal Wall Closure for Open Abdomen
Fahri Yetisir, A Ebru Salman, Oskay Kaya

556

Indication  556  •  Contraindication  556  •  Technique  558  •  Preparation  558
Procedure  559  •  Post-procedure Care  560  •  Complication/Problem  561

50. Urethral Catheterization

Vijai Datta Upadhyaya, Eti Sthapak

563

Indication  563  •  Contraindication  563  •  Applied Anatomy  564
•  Technique and Equipment  564  •  Preparation  566
•  Procedure (In Male Patient)  566  •  Post-procedure Care  572
•  Complication/Problem  572

51. Suprapubic Cystostomy
Vijai Datta Upadhyaya

574

Indication  574  •  Contraindication  574  •  Applied Anatomy  575
•  Technique and Equipment  576  •  Preparation  577  •  Procedure  577
•  Post-procedure Care  578  •  Complication/Problem  581

52. Peritoneal Dialysis Catheter Placement
Basant Kumar, MS Ansari

585

Indication  586  •  Contraindication  586  •  Applied Anatomy  587
•  Technique and Equipment  587  •  Preparation  590  •  Procedure  592
•  Post-procedure Care  595  •  Complication/Problem  596

53. Hemodialysis

Harsh Vardhan, Dharmendra Bhadauria

598

Indication  598  •  History and Basic Principle  598  •  Modalities of Renal
Replacement Therapy  599  •  Preparation  608  •  Procedure  608
•  Post-procedure Care  610  •  Complication/Problem  610

Section 5  Miscellaneous
54. Bone Marrow Aspiration and Biopsy

Gaurav Srivastava, Barnali Banik, Narendra Agrawal

615

Indication  615  •  Contraindication  616  •  Applied Anatomy  616
•  Technique and Equipment  616  •  Preparation  618  •  Procedure  619
•  Post-procedure Care  623  •  Complication/Problem  623

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xxvi  Manual of ICU Procedures
55. Postmortem Organ Needle Biopsy
Rajanikant R Yadav, Namita Mehrotra

625

•  Indication  625  •  Contraindication  625
•  Applied Anatomy and Technique  626  •  Preparation  626
•  Procedure  627  •  Post-procedure Care and Problems  628

56. Managing Pressure Ulcer
Ankur Bhatnagar

631

Pathophysiology of Pressure Ulcer  631  •  Prevention  632
•  Treatment of Pressure Ulcer  636  •  Preparation  636  •  Procedure  641

57. Mobilization of Patient

Abraham Samuel Babu, Vishal Shanbhag, Arun G Maiya

646

Indication for Early Mobilization  646  •  Contraindication for Early
Mobilization  646  •  Technique and Basic Principles of Mobilization  647 
•  Preparation and Assessment  650  •  Physiotherapy Treatment  652
•  Post-procedure Care  655  •  Complication/Problem  656

58. Surveillance of ICU-acquired Infection
Armin Ahmed, Richa Misra

658

Objective  658  •  ICU-acquired Infection and Surveillance System  658
•  Method of Surveillance: Basic Principles  660

•  Surveillance for Specific ICU-acquired Infection  662

59. Blood and Urine Sampling for Microbiology
Armin Ahmed

667

Blood Sampling  667  •  Technique and Basic Principles (Blood Sampling)  668
•  Preparation and Procedure (Blood Sampling)  669
•  Post-procedure Care (Blood Sampling)  671  •  Urine Sampling  671
•  Technique and Basic Principle (Urine Sampling)  671
•  Preparation and Procedure (Urine Sampling)  671
•  Post-procedure Care (Urine Sampling)  673

60. Blood Component Handling at Bedside
Atul Sonker, Anju Dubey

674

Blood Components: Basic Properties  674  •  Bedside Handling of Blood
Components  678  •  Adverse Reaction Due to Blood Components  684

61. Managing Needle-Stick Injury

Puja Srivastava, Anupam Wakhlu, Vikas Agarwal

690

Definitions  690  •  Prevention from Needle-stick Injury  691
•  Post-exposure Prophylaxis  692  •  Post-exposure Counseling  699

Index703

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SECTION

1

Airway and Respiratory
Procedures
1. Bag-Mask Ventilation

Ravinder Kumar Pandey, Rakesh Garg, V Darlong

2. Endotracheal Intubation
Pradeep Bhatia

3. Laryngeal Mask Airway Insertion
Neeta Bose

4. Fiberoptic Intubation
Amol Kothekar, JV Divatia

5. Video Laryngoscopy
Manish Paul, Banani Poddar

6. Double Lumen Endotracheal Tube Placement
Kamal Kishore

7.Cricothyroidotomy

Kapil Dev Soni, Sanjeev Bhoi

8. Percutaneous Tracheostomy
Devendra Gupta

9. Surgical Tracheostomy
Kranti Bhavana, Amit Keshri

10. Bronchoscopy

Ravindra M Mehta, Rohan Aurangabadwalla

11. Bronchoalveolar Lavage (BAL) and Mini-BAL
Sanjay Singhal

12. Thoracentesis
Pralay K Sarkar

13. Tube Thoracostomy
VN Maturu, Ritesh Agarwal

14. Non-invasive Ventilation for Acute Respiratory Failure
Raj Kumar Mani, Prashant Saxena

15. Aerosol Drug Delivery

Sanjay Singhal, Mohan Gurjar

16. Prone Positioning

Puneet Khanna, Girija Prasad Rath

17. Manual Chest Physiotherapy in Ventilated Patients
Rajendra Kumar

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1

Bag-Mask Ventilation
Ravinder Kumar Pandey, Rakesh Garg, V Darlong

INTRODUCTION
The adequate oxygenation is paramount in a critically ill patient. In such patients,
ventilatory assistance with patent airway may be required for optimizing the
oxygenation.1 Effective bag and mask ventilation is an important skill required
in such cases. It may not only provide optimal ventilation till the establishment
of definite airway but also prove to be life-saving where endotracheal intubation
has failed and surgical or other definitive airway management technique has
been explored.2-4 Hence, positive-pressure ventilation using bag-mask-valve
device provides positive-pressure ventilation and thus may be life-saving.
Though bag and mask ventilation appears to be simplest as well as single most
important emergency airway management technique but it has been reported

that in 2–5% of patients, bag and mask ventilation is difficult even by experienced
anesthesiologists.5,6 Hence, a good knowledge and understanding of the airway
anatomy, airway equipment, skill and regular practice is paramount for effective
and successful bag and mask ventilation. The learning curve for bag and mask
ventilation has been studied in interns and the authors reported a failure rate of
less than 20% after 25 attempts of bag and mask ventilation.7 This emphasizes the
need for training and regular practice to maintain such an important skill of bag
and mask ventilation using bag-mask-valve device.

INDICATION
The bag and mask ventilation may be life-saving in critically ill patients.8 Broadly,
the bag and mask ventilation is required for any patient requiring ventilatory
assistance to maintain oxygenation till a definitive airway with mechanical
ventilation using ventilator is initiated. The indications include:8,9
• Preoxygenation prior to securing definitive airway
• Failed tracheal intubation as rescue measure
• During cardiopulmonary resuscitation
• Respiratory failure:
– Failure of ventilation: Central nervous diseases
– High spinal trauma
– Neuromuscular diseases
• Failure of oxygenation:
– Increased metabolic demand, sepsis
– Lung diseases with desaturation

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4  Section 1: Airway and Respiratory Procedures

CONTRAINDICATION
Bag-mask ventilation is contraindicated only in a selected group of patients like
complete upper airway obstruction or severe facial trauma (due to inadequate
mask seal and risk of aspiration due to bleeding). Before initiating bag and
mask ventilation, any visible foreign body in oral cavity should be removed. The
technique of bag-mask ventilation requires caution in patients with suspected
cervical spine instability and should be avoided in patients with full stomach as
well as those planned for rapid sequence intubation (RSI).10-12

APPLIED ANATOMY AND PHYSIOLOGY
The upper airway comprises of nose oral cavity and pharynx.2,5,8,9 The pharynx
may be further divided into nasopharynx, oropharynx and laryngopharynx. Any
insult of these anatomical structures may compromise the passage of airway
to glottis and then to lungs. The provision of artificial airway may bypass these
structures to maintain passage of the air/oxygen to lungs. The lower airway is
made up of trachea, bronchus and its divisions till alveoli. It provides smooth
passage of air from upper airway till alveolar capillary membrane for its diffusion
into the blood and then to body tissues. Any abnormality in these structures may
again compromise the oxygenation of the tissues and cells. Not only these internal
complex but also the supportive structures like ribcage (ribs and muscles) and
diaphragm may also hamper the transfer of oxygen from outside into the blood.
There are anatomical differences in the airway of children and adults and are
important for airway management.13 The occiput of children is large and when
laid supine may lead to neck flexion leading to airway obstruction. The tongue
is relatively larger with respect to oral cavity and can cause airway obstruction.
Even a trivial trauma in the airway or tongue can lead to edema which may cause
airway obstruction. The epiglottis is large and floppy; larynx is more anterior
and more angulated. All these airway differences in children make their airway

more prone for obstruction and lead to difficult airway management including
bag and mask ventilation. Children also have high respiratory rate and oxygen
metabolism. They have lesser functional residual capacity and increased chest
wall compliance leading to their faster desaturation as compared to adults in
cases of any airway compromise.
Ventilation is the movement of air in and out of the lungs. Inspiration is an
active process and requires the work of muscles including intercostal muscles
and diaphragm. But in cases of labored breathing, certain accessory muscles are
also activated to maintain optimal ventilation. On the other hand, exhalation is
passive process and may sometimes be an issue in conditions like obstructive
lung disease.
The hypoxemia/hypoxia may happen due to inadequate alveolar oxygenation,
alveolocapillary diffusion abnormalities, increased dead space, ventilationperfusion mismatch, or inadequate supply of oxygenated blood to cells. In
presence of such problems, supplementing with high concentration of oxygen
may temporarily prevent hypoxia at tissue levels till the definitive measures
are taken care of. During airway management, oxygen reserves may further be
increased with preoxygenation. The preoxygenation can be accomplished by
providing 100% oxygen with tight-fitted mask for approximately three minutes

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Bag-Mask Ventilation  5
or by providing eight vital capacity breaths with 100% oxygen.14 Bag-valve-mask
(BVM) assembly attached with a reservoir and attached to oxygen source may
deliver more than 90–100% of inspired oxygen concentration and may be used
for preoxygenation. The oxygen source should deliver oxygen with at least a flow
of 12–15 L/min.

TECHNIQUE AND EQUIPMENT
The BVM assembly was proposed by a German engineer, Dr Holger Hesse and
Danish anesthetist, Henning Ruben in 1953.
The bag and mask ventilation may be required both for conscious and
unconscious patient.14 The unconscious patient should follow basic resuscitation
protocols including bag and mask ventilation followed by accomplishment of
definitive airway. The adequacy of breathing should be assessed by “look, listen
and feel”.15 Patient should be exposed and looked for chest rise (both sides), or any
abnormal pattern in breathing movement. The rate, rhythm, quality and depth of
breathing movements should be assessed. Listen for any abnormal breath sound
like gurgling, gasping, crowing, wheezing, snoring and stridor. Also, auscultation
of chest needs to be done for checking the air entry on both sides and for assessing
any abnormal breath sound like rhonchi or crepts. Feel for the air movements at
the external nares. These assessments should be done in addition to other signs
of inadequate oxygenation like presence of cyanosis. The sign of inadequate
breathing includes:
• Minimal or uneven chest movements
• Abdominal breathing and noises
• Rate of breathing, too rapid (more than 30 breaths/min) or too slow (less than
10 breaths/min)
• Shallow and labored breathing (use of accessory muscles of breathing)
• Retractions (pulling in of the muscles) above the clavicles and between and
below the ribs
• Nasal flaring (widening of the nostrils of the nose with respiration)
• Prolonged inspiration (indicating a possible upper airway obstruction) or
• Prolonged expiration (indicating a possible lower airway obstruction)
• Patient is not able to speak full sentences.
The effective technique of bag and mask ventilation requires appropriate
equipment, patient preparation including their positioning and most importantly

is appropriate technique using airway adjuncts, if required. A good seal is required
along with maintenance of a patent airway. Mask holding can be done by either
one-hand technique or two-hand technique (see below). Certain adjuncts like
oral or nasal airway may aid in maintaining a patent airway. This is achieved by
providing a support to oral structures, especially tongue and thus making the
hypopharynx patent for airflow.

Cricoid Pressure (Sellick’s Maneuver)
Sellick’s maneuver provides external force to the anterior cricoid ring. This
compresses the esophagus against the vertebra and prevents air entry into the
stomach and also prevents regurgitate entering the airway during positivepressure ventilation.16,17 The cricoid ring can be found by palpating the Adam’s

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