AIRWAY MANAGMENT

Applied Anatomy of the Airway

Nose --> Nasopharynx
Mouth --> Oropharynx
Pharynx
u-shaped muscular structure
extend from base of skull to cricioid cartilage
3 Anterior Openings
a.
Nasal Cavity nasopharynx
b.
Mouth oropharynx
c.
Larynx laryngopharynx
Epiglotis
separates the oropharynx from the hypopharynx
prevents aspiration during swallowing
???
Larynx
-

9 Cartilages

thyroid

cricoid

epiglottic

arytenoid (paired)

corniculate (paired)

cuneiform (paired)

Rima glottidis (glottis)

narrowest portion of airway above 8 years old
Cricoid ring
narrowest portion of airway in young children
INNERVATION
Sensory
CN V
CN IX --> tongue posterior 3rd, pharynx, tonsils, soft palate
CNVII
CN X --> airway below the epiglottis
Sensory
CN V
CN IX
-

Nerve Supply of the Airway

V1 --> ophthalmic division (anterior ethmoidal nerve)
V2 --> maxillary division (sphenopalatine nerve)
V3 mandibular division (lingual nerve)

Superior laryngeal nerve

Internal laryngeal n.
Recurrent laryngeal n.

Motor Nerve Supply

Vagus Nerve

Superior Laryngeal Branch

External Laryngeal (motor)

Internal Laryngeal (sensory)

Effects of Laryngeal Nerve Injury

NERVE
Superior Laryngeal Nerve
- Unilateral
- Bilateral
Right Laryngeal Nerve
Unilateral
Bilateral

Acute

Chronic
Vagus Nerve
Unilateral
Bilateral

EFFECT OF NERVE INJURY

Minimal effects
Hoarseness, tiring of voice
Hoarseness
Stridor, Respiratory distress
Aphonia
Hoarseness
Aphonia

Trachea

extends from the lower of the cricoid cartilage to the carina

4cm in neonate
10 -14 cm in adult

Causes of Difficult Airway

Anatomic features
Pathologic states
Technical and mechanical factors
Physical
-

Findings that suggest Difficult Airway Managemet

Obesity
Pregnancy
Ascites
Whiskers, flat nasal bridge, large face
Small mouth
Limited cervico-occipital extension
Short neck
Stridor, retractions
Hoarseness
underwater voice
Nasogasric tube in situ
Mallampatis sign
Large goiter or neck mass
Tracheostomy scar
Airway Obstruction

Hypoventilation

Hypercapnia

Hypoxemia

Hyperventilation

Hypoxemia

Steps in Effective Denitrogenation

Pressure
o
relief valve fully open to avoid excessive airway pressure

O2 flow at 8-10LPM

Leak-free mask fit to prevent room air entertainment

2-3 minutes of tidal breathing or 4 vital capacity breaths

Airway Management without Tracheal Intubation (Equipment)
face mask
laryngeal mask airway
combitube
Relief of Airway Obstruction
Hypoxemia is a threat
(+) Pressure ventilation may fill the stomach
Pulmonary edema 2 inhalation or gastric contents
Tracheal Intubation: INDICATIONS
A. During Anesthesia

ensure ventilation or oxygenation

airway patency

protection against pulmonary aspiration

provide separate ventilation to each lung

B.

Post Anesthesia or Critical Care

provide ventilation or other pressure therapy

maintain airway patency

protect airway from contamination

Laryngoscopy (Cormack and Lehane)
GRADE
DESCRIPTION
I
Entire glottis seen
Only posterior structures of glottis
II
seen
III
Only the epiglottis seen
IV
Even the epiglottis not seen
Monitoring the Anesthesized Patient
Essential Monitors
Observation
Stet
BP
Pulse oximeter
ECG
Capnograph
Temperature
Nerve Stimulator
Anesthesia Record
Stet

BP

precordial
esophageal

every 5 minutes --> patient is stable

monitor continuously or every 2 minutes --> induction of anesthesia
Central Venous Pressure
index of the preload and circulatory blood volume to the R ventricle
decreased CVP
o
hypovolemia
o
increased venous capacitance
increased CVP
o
hypervolemia
o
vasoconstriction
o
increased intrathoracic pressure
o
cardiac dysfunction (with hypotension)
o
cardiac tamponade
o
incompetent tricuspid valve
Pulse Oximetry
mandatory intraoperative monitor
measures the O2 saturation of Hgb in arterial blood at 660-940nm --> indicate relative proportion of oxyhemoglobin and deoxyhemoglobin
ECG
most sensitive and practical monitor fro detection of disorders of cardiac rhythm and conduction
V5 --> the most sensitive lead for the detection of peri-operative myocardial ischemia
Temperature
Hypothermia
Deleterious Effects of Hypothermia
cardiac dysrhythmias
increased peripheral vascular resistance
shift of Hb-O2 saturation curve to the left
altered mental status
decreased drug metabolism
impaired renal function
Urinary Output
reflection of kidney perfusion and function
indicator of renal, cardiovascular and fluid volume status
normal urine output --> o.5-1.0ml/kg/hour
Standard for Basic Anesthesia Monitoring (ASA 1998)
2008 International Standards for Safe Practice of Anesthesia
Monitoring during Anesthesia
Oxygenation
Airway and ventilation
Circulation
Tempearature
Neuromuscular Function
Depth of Anesthesia
Audible signals and alarms