AirwayManagement

KEYCONCEPTS
.

1Improperfacemasktechniquecanresultincontinueddeflationoftheanesthesia

reservoirbagwhentheadjustablepressurelimitingvalveisclosed,usually
indicatingasubstantialleakaroundthemask.Incontrast,thegenerationofhigh
breathingcircuitpressureswithminimalchestmovementandbreathsounds
impliesanobstructedairwayorobstructedtubing.
.

2Thelaryngealmaskairwaypartiallyprotectsthelarynxfrompharyngeal

secretions,butnotgastricregurgitation.
.

3Afterinsertionofatrachealtube(TT),thecuffisinflatedwiththeleastamount

ofairnecessarytocreateasealduringpositivepressureventilationtominimize
thepressuretransmittedtothetrachealmucosa.
.

4AlthoughthepersistentdetectionofCO2byacapnographisthebest

confirmationoftrachealplacementofaTT,itcannotexcludebronchialintubation.
Theearliestevidenceofbronchialintubationoftenisanincreaseinpeak
inspiratorypressure.
.

5Afterintubation,thecuffofaTTshouldnotbefeltabovethelevelofthe

cricoidcartilage,becauseaprolongedintralaryngeallocationmayresultin

Expertairwaymanagementisanessentialskillinanestheticpractice.Thischapter
reviewstheanatomyoftheupperrespiratorytract:describesthenecessary
equipmentforsuccessfulmanagement,
CHAPTER

19
postoperativehoarsenessandincreasestheriskofaccidentalextubation.
6Unrecognizedesophagealintubationcanproducecatastrophicresults.Prevention

ofthiscomplicationdependsondirectvisualizationofthetipoftheTTpassing
throughthevocalcords,carefulauscultationforthepresenceofbilateralbreath
soundsandtheabsenceofgastricgurgling

whileventilatingthroughtheTT,analysisofexhaledgasforthepresenceofCO 2
(themostreliableautomatedmethod),chestradiography,oruseoffiberoptic
bronchoscopy.
7Cluestothediagnosisofbronchialintubationincludeunilateralbreathsounds,

unexpectedhypoxiawithpulseoximetry(unreliablewithhighinspiredoxygen
concentrations),inabilitytopalpatetheTTcuffinthesternalnotchduringcuff
inflation,anddecreasedbreathingbagcompliance(highpeakinspiratory
pressures).

8Thelargenegativeintrathoracicpressuresgeneratedbyastrugglingpatientin

laryngospasmcanresultinthedevelopmentofnegativepressurepulmonary
edemaeveninhealthypatients.

presentsvariousmanagementtechniques:anddiscussescomplicationsof
laryngoscopy,intubation,andextubation.Patientsafetydependsonathorough
understandingofeachofthesetopics.

309
310SECTIONIIIAnestheticManagement

ANATOMY
Theupperairwayconsistsofthepharynx,nose,mouth,larynx,trachea,andmain
stembronchi.Themouthandpharynxarealsoapartoftheuppergastrointestinal
tract.Thelaryngealstructuresinpartservetopreventaspirationintothetrachea.
Therearetwoopeningstothehumanairway:thenose,whichleadstothe
nasopharynx,andthemouth,whichleadstotheoropharynx.Thesepassagesare
separatedanteriorlybythepalate,buttheyjoinposteriorlyinthepharynx(Figure
191).ThepharynxisaUshapedfibromuscularstructurethatextendsfromthe
baseoftheskulltothecricoidcartilageattheentrancetotheesophagus.Itopens
anteriorlyintothenasalcavity,themouth,thelarynx,andthenasopharynx,
oropharynx,andlaryngopharynx,respectively.Thenasopharynxisseparated
fromtheoropharynxbyanimaginaryplanethatextendsposteriorly.Atthebaseof
thetongue,theepiglottisfunctionallyseparatestheoropharynxfromthe
laryngopharynx(orhypopharynx).
Theepiglottispreventsaspirationbycoveringtheglottistheopeningofthe
larynxduringswallowing.Thelarynxisacartilaginousskeletonheldtogether
byligamentsandmuscle.Thelarynxiscomposedofninecartilages(Figure19
2):thyroid,cricoid,epiglottic,and(inpairs)arytenoid,corniculate,and
cuneiform.Thethyroidcartilageshieldstheconuselasticus,whichformsthevocal
cords.
Thesensorysupplytotheupperairwayisderivedfromthecranialnerves(Figure
193).Themucousmembranesofthenoseareinnervatedbytheophthalmic
division(V1)ofthetrigeminalnerveanteriorly(anteriorethmoidalnerve)andby
themaxillarydivision(V2)posteriorly(sphenopalatinenerves).Thepalatine
nervesprovidesensoryfibersfromthetrigeminalnerve(V)tothesuperiorand
inferiorsurfacesofthehardandsoftpalate.Theolfactorynerve(cranialnerve
I)innervatesthenasalmucosatoprovidethesenseofsmell.Thelingualnerve(a
branchofthemandibulardivision[V3]ofthetrigeminalnerve)andthe
glossopharyngealnerve(theninthcranialnerve)providegeneralsensationtothe
anteriortwothirdsandposterioronethirdofthetongue,respectively.Branchesof
thefacialnerve(VII)andglossopharyngealnerveprovidethesensationoftasteto
thoseareas,respectively.Theglossopharyngealnervealsoinnervatestheroof

ofthepharynx,thetonsils,andtheundersurfaceofthesoftpalate.Thevagus
nerve(thetenthcranialnerve)providessensationtotheairwaybelowthe
epiglottis.Thesuperiorlaryngealbranchofthevagusdividesintoanexternal
(motor)nerveandaninternal(sensory)laryngealnervethatprovidesensory
supplytothelarynxbetweentheepiglottisandthevocalcords.Anotherbranch
ofthevagus,therecurrentlaryngealnerve,innervatesthelarynxbelowthe
vocalcordsandthetrachea.
Themusclesofthelarynxareinnervatedbytherecurrentlaryngealnerve,withthe
exceptionofthecricothyroidmuscle,whichisinnervatedbytheexternal(motor)
laryngealnerve,abranchofthesuperiorlaryngealnerve.Theposterior
cricoarytenoidmusclesabductthevocalcords,whereasthelateralcrico
arytenoidmusclesaretheprincipaladductors.
Phonationinvolvescomplexsimultaneousactionsbyseverallaryngealmuscles.
Damagetothemotornervesinnervatingthelarynxleads
HardpalateSoftpalate
Nasopharynx
Oropharynx
Hypopharynx

Tongue

Epiglottis
VocalcordsLarynx
Trachea

FIGURE191Anatomyoftheairway.

CHAPTER19

AirwayManagement311

EpiglottisHyoidbone
Thyrohyoidmembrane
Superiorcornuofthyroidcartilage
Cuneiformcartilage(paired)ThyroidcartilagelaminaCorniculatecartilage(paired)Arytenoid
cartilage(paired)Cricothyroidligament

Inferiorcornuofthyroidcartilage
CricoidcartilageTrachea

Anterior
Posterior

FIGURE192Cartilaginousstructurescomprisingthelarynx.(Withpermission,fromThe
MayoFoundation.)

V1

V2V3
IL
IX
SL
V1Ophthalmicdivisionoftrigeminalnerve(anteriorethmoidalnerve)

V2Maxillarydivisionoftrigeminalnerve(sphenopalatinenerves)
V3Mandibulardivisionoftrigeminalnerve(lingualnerve)
IXGlossopharyngealnerve
XVagusnerveSLSuperiorlaryngealnerve
ILInternallaryngealnerveRLRecurrentlaryngealnerve

RL
X

FIGURE193Sensorynervesupplyoftheairway.
312SECTIONIIIAnestheticManagement

TABLE191Theeffectsoflaryngealnerveinjuryonthevoice.
LeftRight

FIGURE194Carina.
thethyroidcartilage.Thesuperiorthyroidarteryisfoundalongthelateraledgeof
theCTM.
Thetracheabeginsbeneaththecricoidcartilageandextendstothecarina,the
pointatwhichtherightandleftmainstembronchidivide(Figure194).
Anteriorly,thetracheaconsistsofcartilaginousrings;posteriorly,thetracheais
membranous.

ROUTINEAIRWAY

MANAGEMENT
Routineairwaymanagementassociatedwithgeneralanesthesiaconsistsof:
Airwayassessment
Preparationandequipmentcheck
Patientpositioning
Preoxygenation
Bagandmaskventilation(BMV)
Intubation(ifindicated)
Confirmationofendotrachealtubeplacement
Intraoperativemanagementandtroubleshooting
Extubation

AIRWAYASSESSMENT
Airwayassessmentisthefirststepinsuccessfulairwaymanagement.Several
anatomicalandfunctionalmaneuverscanbeperformedtoestimatethedifficulty
ofendotrachealintubation;however,itisimportanttonotethatsuccessful
ventilation(withorwithoutintubation)mustbeachievedby

Nerve

EffectofNerveInjury

SuperiorlaryngealnerveUnilateralBilateral

MinimaleffectsHoarseness,tiringof
voice

RecurrentlaryngealnerveUnilateralBilateral

Hoarseness

AcuteChronic

Stridor,respiratorydistressAphonia

VagusnerveUnilateralBilateral

HoarsenessAphonia

toaspectrumofspeechdisorders(Table191).Unilateraldenervationofa
cricothyroidmusclecausesverysubtleclinicalfindings.Bilateralpalsyofthe
superiorlaryngealnervemayresultinhoarsenessoreasytiringofthevoice,but
airwaycontrolisnotjeopardized.
Unilateralparalysisofarecurrentlaryngealnerveresultsinparalysisofthe
ipsilateralvocalcord,causingdeteriorationinvoicequality.Assumingintact
superiorlaryngealnerves,acutebilateralrecurrentlaryngealnervepalsycanresult
instridorandrespiratorydistressbecauseoftheremainingunopposedtension
ofthecricothyroidmuscles.Airwayproblemsarelessfrequentinchronicbilat
eralrecurrentlaryngealnervelossbecauseofthedevelopmentofvarious
compensatorymechanisms(eg,atrophyofthelaryngealmusculature).
Bilateralinjurytothevagusnerveaffectsboththesuperiorandtherecurrent
laryngealnerves.Thus,bilateralvagaldenervationproducesflaccid,
midpositionedvocalcordssimilartothoseseenafteradministrationof
succinylcholine.Althoughphonationisseverelyimpairedinthesepatients,
airwaycontrolisrarelyaproblem.
Thebloodsupplyofthelarynxisderivedfrombranchesofthethyroidarteries.
Thecricothyroidarteryarisesfromthesuperiorthyroidarteryitself,thefirst
branchgivenofffromtheexternalcarotidartery,andcrossestheupper
cricothyroidmembrane(CTM),whichextendsfromthecricoidcartilageto

Uvula
Pillars
A
HardpalateSoftpalate
Hardpalate
CHAPTER19
AirwayManagement313

CLASSI
CLASSII
Vocalcords
GRADEII
CLASSIII

Epiglottis
GRADEIII
CLASSIV

GRADEI
GRADEIV

FIGURE195A:Mallampaticlassificationoforalopening.B:Gradingofthe

laryngealview.Adifficultorotrachealintubation(gradeIIIorIV)maybepredictedby
theinabilitytovisualizecertainpharyngealstructures

theanesthetistifmortalityandmorbidityaretobeavoided.Assessmentsinclude:

Mouthopening:anincisordistanceof3cmorgreaterisdesirableinanadult.

Upperlipbitetest:thelowerteetharebroughtinfrontoftheupperteeth.The
degreetowhichthiscanbedoneestimatestherangeofmotionofthe
temperomandibularjoints.

Mallampaticlassification:afrequentlyperformedtestthatexaminesthesizeofthe
tongueinrelationtotheoralcavity.Thegreaterthetongueobstructstheviewof
thepharyngealstructures,themoredifficultintubationmaybe(Figure195).
ClassI:theentirepalatalarch,includingthebilateralfaucialpillars,arevisible
downtotheirbases.
(classIIIorIV)duringthepreoperativeexaminationofaseatedpatient.(Reproduced,with
permission,fromMallampatiSR:Clinicalsignstopredictdifficulttrachealintubation[hypothesis].CanAnaesthSocJ
1983;30:316.)

ClassII:theupperpartofthefaucialpillarsandmostoftheuvulaarevisible.

ClassIII:onlythesoftandhardpalatesarevisible.

ClassIV:onlythehardpalateisvisible.

Thyromentaldistance:thedistancebetweenthementumandthesuperiorthyroid
notch.Adistancegreaterthan3fingerbreadthsisdesirable.

Neckcircumference:aneckcircumferenceofgreaterthan27inissuggestiveof
difficultiesinvisualizationoftheglotticopening.Althoughthepresenceofthese
findingsmaynotbeparticularlysensitivefordetectingadifficultintubation,the
absenceofthesefindingsispredictiveforrelativeeaseofintubation.
314SECTIONIIIAnestheticManagement

Increasingly,patientspresentwithmorbidobesityandbodymassindicesof30
kg/m2orgreater.Althoughsomemorbidlyobesepatientshaverelativelynormal
headandneckanatomy,othershavemuchredundantpharyngealtissueand
increasedneckcircumference.Notonlymaythesepatientsprovetobedifficultto
intubate,butroutineventilationwithbagandmaskalsomaybeproblematic.

EQUIPMENT
Preparationismandatoryforallairwaymanagementscenarios.Thefollowing
equipmentisroutinelyneededinairwaymanagementsituations:

Anoxygensource

BMVcapability

Laryngoscopes(directandvideo)

Severalendotrachealtubesofdifferentsizes

Other(notendotrachealtube)airwaydevices(eg,oral,nasalairways)

Suction

OximetryandCO2detection

Stethoscope

Tape

Bloodpressureandelectrocardiography(ECG)monitors

Intravenousaccess

Oral&NasalAirways

Lossofupperairwaymuscletone(eg,weaknessofthegenioglossusmuscle)in
anesthetizedpatientsallowsthetongueandepiglottistofallbackagainstthepos
teriorwallofthepharynx.Repositioningtheheadorajawthrustisthepreferred
techniqueforopeningtheairway.Tomaintaintheopening,anartificialairway
canbeinsertedthroughthemouthornosetomaintainanairpassagebetweenthe
tongueandtheposteriorpharyngealwall(Figure196).Awakeorlightly
anesthetizedpatientswithintactlaryngealreflexesmaycoughorevendevelop
laryngospasmduringairwayinsertion.Placementofanoralairwayissometimes
facilitatedbysuppressingairwayreflexes,and,inaddition,sometimesby
depressingthetonguewithatongueblade.Adultoralairwaystypicallycomein
small(80mm[GuedelNo.3]),medium(90mm[GuedelNo.4]),andlarge(100
mm[GuedelNo.5])sizes.
Thelengthofanasalairwaycanbeestimatedasthedistancefromthenarestothe
meatusoftheearandshouldbeapproximately24cmlongerthanoralairways.
Becauseoftheriskofepistaxis,nasalairwaysarelessdesirableinanticoagulated
orthrombocytopenicpatients.Also,nasalairways(andnasogastrictubes)should
beusedwithcautioninpatientswithbasilarskullfractures,wheretherehasbeena
casereportofanasogastrictubeenteringthecranialvault.Alltubesinserted
throughthenose(eg,nasalairways,nasogastric

AB

FIGURE196A:Theoropharyngealairwayinplace.Theairwayfollowsthe

curvatureofthetongue,pullingitandtheepiglottisawayfromtheposteriorpharyngeal

wallandprovidingachannelforairpassage.B:Thenasopharyngealairwayinplace.The
airwaypasses
throughthenoseandextendstojustabovetheepiglottis.(Modifiedandreproduced,with
permission,fromFacemasksandairways.In:UnderstandingAnesthesiaEquipment,4thed.DorschJA,DorschSE,
eds.Williams&Wilkins,1999.)

catheters,nasotrachealtubes)shouldbelubricatedbeforebeingadvancedalong
thefloorofthenasalpassage.

FaceMaskDesign&Technique
Theuseofafacemaskcanfacilitatethedeliveryofoxygenorananestheticgas
fromabreathingsystemtoapatientbycreatinganairtightsealwiththepatients
face(Figure197).Therimofthemaskiscontouredandconformstoavarietyof
facialfeatures.Themasks22mmorificeattachestothebreathingcircuitofthe
anesthesiamachinethrougharightangleconnector.Severalmaskdesignsare
available.Transparentmasksallowobservationofexhaledhumidifiedgasand
immediaterecognitionofvomitus.Retaininghookssurroundingtheorificecan
beattachedtoaheadstrapsothatthemaskdoesnothavetobecontinuallyheld
inplace.Somepediatricmasksarespeciallydesignedtominimizeapparatus
deadspace(Figure198).
Effectivemaskventilationrequiresbothagastightmaskfitandapatentairway.
Improperfacemasktechniquecanresultincontinued
deflationoftheanesthesiareservoirbagwhentheadjustablepressurelimiting
valveisclosed,usuallyindicatingasubstantialleakaroundthemask.Incontrast,
thegenerationofhighbreathingcircuitpressureswithminimalchestmovement
andbreathsoundsimpliesanobstructedairwayorobstructedtubing.
Orifice
CHAPTER19
AirwayManagement315

Body
Rim

FIGURE198TheRendellBakerSoucekpediatricfacemaskhasashallowbodyand
minimaldeadspace.

Ifthemaskisheldwiththelefthand,therighthandcanbeusedtogenerate
positivepressureventilationbysqueezingthebreathingbag.Themaskisheld
againstthefacebydownwardpressureonthemaskbodyexertedbytheleftthumb
andindexfinger(Figure199).Themiddleandringfingergraspthemandible
tofacilitateextensionoftheatlantooccipitaljoint.Thisisamaneuverthatis
easiertoteachthantodescribe.Fingerpressureshouldbeplacedonthebony
mandibleandnotonthesofttissuessupportingthebaseofthetongue,which
mayobstructtheairway.Thelittlefingerisplacedundertheangleofthejawand
usedtothrustthejawanteriorly,themostimportantmaneuvertoallowventi
lationtothepatient.

Orifice
Retaininghooks

Body
Rim

FIGURE197Clearadultfacemask.
FIGURE199Onehandedfacemasktechnique.
316SECTIONIII
AnestheticManagement

FIGURE1910Adifficultairwaycanoftenbemanagedwithatwohanded
technique.

Indifficultsituations,twohandsmaybeneededtoprovideadequatejawthrust
andtocreateamaskseal.Therefore,anassistantmaybeneededtosqueezethe
bag,orthemachinesventilatorcanbeused.Insuchcases,thethumbsholdthe
maskdown,andthefingertipsorknucklesdisplacethejawforward(Figure19
10).Obstructionduringexpirationmaybeduetoexcessivedownwardpressure
fromthemaskorfromaballvalveeffectofthejawthrust.Theformercanbe
relievedbydecreasingthepressureonthemask,andthelatterbyreleasingthejaw
thrustduringthisphaseoftherespiratorycycle.Itisoftendifficulttoforman
adequatemaskfitwiththecheeksofedentulouspatients.Positivepressure
ventilationusingamaskshouldnormallybelimitedto20cmofH2Otoavoid

stomachinflation.
Mostpatientsairwayscanbemaintainedwithafacemaskandanoralornasal
airway.Maskventilationforlongperiodsmayresultinpressureinjuryto
branchesofthetrigeminalorfacialnerves.Becauseoftheabsenceofpositive
airwaypressuresduringspontaneousventilation,onlyminimaldownwardforce
onthefacemaskisrequiredtocreateanadequateseal.Ifthefacemaskandmask
strapsareusedforextendedperiods,thepositionshouldbe
regularlychangedtopreventinjury.Careshouldbeusedtoavoidmaskorfinger
contactwiththeeye,andtheeyesshouldbetapedshuttominimizetheriskof
cornealabrasions.

POSITIONING
Whenmanipulatingtheairway,correctpatientpositioningisrequired.Relative
alignmentoftheoralandpharyngealaxesisachievedbyhavingthepatientinthe
sniffingposition.Whencervicalspinepathologyissuspected,theheadmust
bekeptinaneutralpositionduringallairwaymanipulations.Inlinestabilization
oftheneckmustbemaintainedduringairwaymanagementinthesepatients,
unlessappropriatefilmshavebeenreviewedandclearedbyaradiologistor
neurologicalorspinesurgeon.Patientswithmorbidobesityshouldbepositioned
ona30upwardramp,asthefunctionalresidualcapacity(FRC)ofobesepatients
deterioratesinthesupineposition,leadingtomorerapiddeoxygenationshould
ventilationbeimpaired.

PREOXYGENATION
Whenpossible,preoxygenationwithfacemaskoxygenshouldprecedeallairway
managementinterventions.Oxygenisdeliveredbymaskforseveralminutes
priortoanestheticinduction.Inthisway,thefunctionalresidualcapacity,the
patientsoxygenreserve,ispurgedofnitrogen.Upto90%ofthenormalFRCof
2LfollowingpreoxygenationisfilledwithO2.Consideringthenormaloxygen
demandof200250mL/min,thepreoxygenatedpatientmayhavea58min
oxygenreserve.Increasingthedurationofapneawithoutdesaturationimproves
safety,ifventilationfollowinganestheticinductionisdelayed.Conditionsthat
increaseoxygendemand(eg,sepsis,pregnancy)anddecreaseFRC(eg,morbid
obesity,pregnancy)reducetheapneicperiodbeforedesaturationensues.

BAGANDMASKVENTILATION

Bagandmaskventilation(BMV)isthefirststepinairwaymanagementinmost
situations,withtheexceptionofpatientsundergoingrapidsequence
intubation.RapidsequenceinductionsavoidBMVtoavoidstomachinflationand
toreducethepotentialfortheaspirationofgastriccontentsinnonfastedpatients
andthosewithdelayedgastricemptying.Inemergencysituations,BMVprecedes
attemptsatintubationinanefforttooxygenatethepatient,withtheunderstanding
thatthereisanimplicitriskofaspiration.
Asnotedabove,theanesthetistslefthandsupportsthemaskonthepatients
face.Thefaceisliftedintothemaskwiththethird,fourth,andfifthfingersofthe
anesthesiaproviderslefthand.Thefingersareplacedonthemandible,andthe
jawisthrustforward,liftingthebaseofthetongueawayfromtheposterior
pharynxopeningtheairway.Thethumbandindexfingersitontopofthemask.If
theairwayispatent,squeezingthebagwillresultintheriseofthechest.If
ventilationisineffective(nosignofchestrising,noendtidalCO2detected,no
mistintheclearmask),oralornasalairwayscanbeplacedtorelieveairway
obstructionsecondarytoredundantpharyngealtissues.Difficultmaskventilation
isoftenfoundinpatientswithmorbidobesity,beards,andcraniofacial
deformities.
Inyearspast,anestheticswereroutinelydeliveredsolelybymaskadministration.
Inrecentdecades,avarietyofsupraglotticdeviceshaspermittedbothairway
rescue(whenBMVisnotpossible)androutineanestheticairwaymanagement
(whenintubationisnotthoughttobenecessary).

SUPRAGLOTTIC
AIRWAYDEVICES
Supraglotticairwaydevices(SADs)areusedwithbothspontaneouslyand
ventilatedpatientsduringanesthesia.Theyhavealsobeenemployedasconduits
toaidendotrachealintubationwhenbothBMVandendotrachealintubationhave
failed.AllSADsconsistofatubethatisconnectedtoarespiratorycircuitor
breathingbag,whichisattachedtoahypopharyngealdevicethatsealsanddirects
airflowtotheglottis,trachea,andlungs.Additionally,theseairwaydevices
occludetheesophaguswithvaryingdegreesofeffectiveness,reducinggasdis
tensionofthestomach.Differentsealingdevicesto
preventairflowfromexitingthroughthemoutharealsoavailable.Someare
equippedwithaporttosuctiongastriccontents.Noneoffertheprotectionfrom

aspirationpneumonitisofferedbyaproperlysited,cuffedendotrachealtube.

LaryngealMaskAirway
Alaryngealmaskairway(LMA)consistsofawideboretubewhoseproximal
endconnectstoabreathingcircuitwithastandard15mmconnector,andwhose
distalendisattachedtoanellipticalcuffthatcanbeinflatedthroughapilottube.
Thedeflatedcuffislubricatedandinsertedblindlyintothehypopharynxsothat,
onceinflated,thecuffformsalowpressuresealaroundtheentrancetothe
larynx.Thisrequiresanestheticdepthandmusclerelaxationslightlygreaterthan
thatrequiredfortheinsertionofanoralairway.Althoughinsertionisrelatively
simple(Figure1911),attentiontodetailwillimprovethesuccessrate(Table
192).Anideallypositionedcuffisborderedbythebaseofthetonguesuperiorly,
thepyriformsinuseslaterally,andtheupperesophagealsphincterinferiorly.Ifthe
esophaguslieswithintherimofthecuff,gastricdistentionandregurgitation
becomepossible.Anatomicvariationspreventadequatefunctioninginsome
patients.However,ifanLMAisnotfunctioningproperlyafterattemptsto
improvethefitoftheLMAhavefailed,mostpractitionerswilltryanotherLMA
onesizelargerorsmaller.Theshaftcanbesecuredwithtapetotheskinofthe
face.
TheLMApartiallyprotectsthelarynxfrompharyngealsecretions(butnot

gastricregurgitation),anditshouldremaininplaceuntilthepatienthasregained
airwayreflexes.Thisisusuallysignaledbycoughingandmouthopeningon
command.TheLMAisavailableinmanysizes
(Table193).TheLMAprovidesanalternativetoventila
tionthroughafacemaskorTT(Table194).Relativecontraindicationsforthe
LMAincludepatientswithpharyngealpathology(eg,abscess),pharyngeal
obstruction,fullstomachs(eg,pregnancy,hiatalhernia),orlowpulmonary
compliance(eg,restrictiveairwaysdisease)requiringpeakinspiratorypressures
greaterthan30cmH2O.Traditionally,theLMAhasbeenavoidedinpatients
CHAPTER19AirwayManagement317

318SECTIONIIIAnestheticManagement

AB
CD

FIGURE1911A:Thelaryngealmaskreadyforinsertion.Thecuffshouldbe

deflatedtightlywiththerimfacingawayfromthemaskaperture.Thereshouldbeno
foldsnearthetip.B:Initialinsertionofthelaryngealmask.Underdirectvision,themask
tipispressedupwardagainstthehardpalate.Themiddlefingermaybeusedtopushthe
lowerjawdownward.Themaskispressedforwardasitisadvancedintothepharynxto
ensurethatthetipremainsflattenedandavoidsthetongue.Thejawshouldnotbeheld
openoncethemaskisinsidethe

withbronchospasmorhighairwayresistance,butnewevidencesuggeststhat
becauseitisnotplacedinthetrachea,useofanLMAisassociatedwithless
bronchospasmthanaTT.Althoughitisclearlynot
mouth.Thenonintubatinghandcanbeusedtostabilizetheocciput.C:Bywithdrawing
theotherfingersandwithaslightpronationoftheforearm,itisusuallypossibletopush
themaskfullyintopositioninonefluidmovement.Notethattheneckiskeptflexedand
theheadextended.D:Thelaryngealmaskisgraspedwiththeotherhandandtheindex
fingerwithdrawn.Thehandholdingthetubepressesgentlydownwarduntilresistanceis
encountered.(Reproduced,withpermission,fromLMANorthAmerica.)

asubstitutefortrachealintubation,theLMAhasprovenparticularlyhelpfulasa
lifesavingtemporizingmeasureinpatientswithdifficultairways(thosewho
cannotbeventilatedorintubated)becauseof

TABLE192Successfulinsertionofalaryngealmaskairwaydepends
uponattentiontoseveraldetails.

TABLE193Avarietyoflaryngealmaskswithdifferentcuffvolumesare
availablefordifferentsizedpatients.
CHAPTER19AirwayManagement319

1.

Choosetheappropriatesize(Table193)andcheckforleaksbeforeinsertion.

2.

Theleadingedgeofthedeflatedcuffshouldbewrinklefreeandfacingawayfromtheaperture(Figure
1911A).

3.

Lubricateonlythebacksideofthecuff.

4.

Ensureadequateanesthesiabeforeattemptinginsertion.

5.

Placepatientsheadinsniffingposition(Figure1911BandFigure1923).

6.

Useyourindexfingertoguidethecuffalongthehardpalateanddownintothehypopharynxuntil
anincreasedresistanceisfelt(Figure1911C).Thelongitudinalblacklineshouldalwaysbe
pointingdirectlycephalad(ie,facingthepatientsupperlip).

7.

Inflatewiththecorrectamountofair(Table193).

8.

Ensureadequateanestheticdepthduringpatientpositioning.

9.

Obstructionafterinsertionisusuallyduetoadownfoldedepiglottisortransientlaryngospasm.

10.

Avoidpharyngealsuction,cuffdeflation,orlaryngealmaskremovaluntilthepatientisawake(eg,
openingmouthoncommand).
MaskSize

PatientSize

Weight(kg)

CuffVolume
(mL)

Infant

6.5

24

Child

6.520

Upto10

212

Child

2030

Upto15

Smalladult

30

Upto20

Normaladult

70

Upto30

Largeradult

70

Upto30

itseaseofinsertionandrelativelyhighsuccessrate(95%to99%).Ithasbeen
usedasaconduitforanintubatingstylet(eg,gumelasticbougie),ventilatingjet
stylet,flexibleFOB,orsmalldiameter(6.0mm)TT.SeveralLMAsareavailable
thathavebeenmodifiedtofacilitateplacementofalargerTT,withorwithoutthe
useofaFOB.Insertioncanbe
performedundertopicalanesthesiaandbilateralsuperiorlaryngealnerveblocks,if
theairwaymustbesecuredwhilethepatientisawake.
VariationsinLMAdesigninclude:
TheProSealLMA,whichpermitspassageofagastrictubetodecompressthe
stomach
TheIGel,whichusesageloccluderratherthaninflatablecuff
TheFastrachintubationLMA,whichisdesignedtofacilitateendotracheal

intubationthroughtheLMAdevice
TheLMACTrach,whichincorporatesacameratofacilitatepassageofan
endotrachealtube

TABLE194Advantagesanddisadvantagesofthelaryngealmaskairway
comparedwithfacemaskventilationortrachealintubation.1
Advantages

Dis

Comparedwithfacemask

HandsfreeoperationBettersealinbeardedpatientsLesscumbersomein Mo
ski
ENTsurgeryOfteneasiertomaintainairwayProtectsagainstairway
secretionsLessfacialnerveandeyetraumaLessoperatingroompollution mo

Comparedwithtrachealintubation

Inc
LessinvasiveVeryusefulindifficultintubationsLesstoothandlaryngeal pro
traumaLesslaryngospasmandbronchospasmDoesnotrequiremuscle
sec
relaxationDoesnotrequireneckmobilityNoriskofesophagealor
Gre
endobronchialintubation
dis

ENT,ear,nose,andthroat;TMJ,temporomandibularjoint;PPV,positivepressureventilation.

320SECTIONIIIAnestheticManagement

SorethroatisacommonsideeffectfollowingSADuse.Injuriestothelingual,
hypoglossal,andrecurrentlaryngealnervehavebeenreported.Correctdevice
sizing,avoidanceofcuffhyperinflation,andgentlemovementofthejawduring
placementmayreducethelikelihoodofsuchinjuries.

EsophagealTrachealCombitube
TheesophagealtrachealCombitubeconsistsoftwofusedtubes,eachwitha15
mmconnectoronitsproximalend(Figure1912).Thelongerbluetubehasan
occludeddistaltipthatforcesgastoexitthroughaseriesofsideperforations.The
shortercleartubehasanopentipandnosideperforations.TheCombitubeis
usuallyinsertedblindlythroughthemouthandadvanceduntilthetwoblackrings
ontheshaftliebetweentheupperandlowerteeth.TheCombitubehastwo
inflatablecuffs,a100mLproximalcuffanda15mLdistalcuff,bothofwhich
shouldbefullyinflatedafterplacement.ThedistallumenoftheCombitube
usuallycomestolieintheesophagusapproximately95%ofthetimesothat
ventilationthroughthelongerbluetubewillforcegasoutofthesideperforations
andintothelarynx.Theshorter,cleartubecanbeusedforgastric
FIGURE1912Combitube.
FIGURE1913Kinglaryngealtube.
decompression.Alternatively,iftheCombitubeentersthetrachea,ventilation
throughthecleartubewilldirectgasintothetrachea.

KingLaryngealTube
Kinglaryngealtubes(LTs)consistoftubewithasmallesophagealballoonanda
largerballoonforplacementinthehypopharynx(Figure1913).Bothtubes
inflatethroughoneinflationline.Thelungsareinflatedfromairthatexitsbetween
thetwoballoons.Asuctionportdistaltotheesophagealballoonispresent,
permittingdecompressionofthestomach.TheLTisinsertedandthecuffs
inflated.Shouldventilationprovedifficult,theLTislikelyinsertedtoodeep.
Slightlywithdrawingthedeviceuntilcomplianceimprovesamelioratesthe
situation.

ENDOTRACHEALINTUBATION
Endotrachealintubationisemployedbothfortheconductofgeneralanesthesia
andtofacilitatetheventilatormanagementofthecriticallyill.

TrachealTubes
StandardsgovernTTmanufacturing(AmericanNationalStandardforAnesthetic
Equipment;ANSIZ79).TTsaremostcommonlymadefrompolyvinyl

chloride.Inthepast,TTsweremarkedI.T.or

Cuff
Connector
CHAPTER19AirwayManagement321

Beveledtip
Murphyeye

Inflatingtube

PilotballoonValve

FIGURE1914Murphytrachealtube.
Z79toindicatethattheyhadbeenimplanttestedtoensurenontoxicity.The
shapeandrigidityofTTscanbealteredbyinsertingastylet.Thepatientendof
thetubeisbeveledtoaidvisualizationandinsertionthroughthevocalcords.
Murphytubeshaveahole(theMurphyeye)todecreasetheriskofocclusion,
shouldthedistaltubeopeningabutthecarinaortrachea(Figure1914).
Resistancetoairflowdependsprimarilyontubediameter,butisalsoaffectedby
tubelengthandcurvature.TTsizeisusuallydesignatedinmillimetersofinternal

diameter,or,lesscommonly,intheFrenchscale(externaldiameterinmillimeters
multipliedby3).Thechoiceoftubediameterisalwaysacompromisebetween
maximizingflowwithalargersizeandminimizingairwaytraumawithasmaller
size(Table195).
MostadultTTshaveacuffinflationsystemconsistingofavalve,pilotballoon,
inflatingtube,and

TABLE195Oraltrachealtubesizeguidelines.
cuff(Figure1914).Thevalvepreventsairlossaftercuffinflation.Thepilot
balloonprovidesagrossindicationofcuffinflation.Theinflatingtubeconnects
thevalvetothecuffandisincorporatedintothetubeswall.Bycreatingatracheal
seal,TTcuffspermitpositivepressureventilationandreducethelikelihoodof
aspiration.Uncuffedtubesareoftenusedininfantsandyoungchildrento
minimizetheriskofpressureinjuryandpostintubationcroup;however,inrecent
years,cuffedpediatrictubeshavebeenincreasinglyfavored.
Therearetwomajortypesofcuffs:highpressure(lowvolume)andlowpressure
(highvolume).Highpressurecuffsareassociatedwithmoreischemicdamageto
thetrachealmucosaandarelesssuitableforintubationsoflongduration.Low
pressurecuffsmayincreasethelikelihoodofsorethroat(largermucosalcontact
area),aspiration,spontaneousextubation,anddifficultinsertion(becauseofthe
floppycuff).Nonetheless,becauseoftheirlowerincidenceofmucosaldamage,
lowpressurecuffsaregenerallyemployed.
Cuffpressuredependsonseveralfactors:inflationvolume,thediameterofthe
cuffinrelationtothetrachea,trachealandcuffcompliance,andintrathoracic
pressure(cuffpressuresincreasewithcoughing).Cuffpressuremayincrease
duringgeneralanesthesiafromdiffusionofnitrousoxidefromthetracheal
mucosaintotheTTcuff.
TTshavebeenmodifiedforavarietyofspecializedapplications.Flexible,spiral
wound,wirereinforcedTTs(armoredtubes)resistkinkingand
Age

InternalDiameter
(mm)

CutLength(cm)

Fullterminfant

3.5

12

Child

Age4

14

Age
2

AdultFemale
Male

7.07.57.59.0

2424

322SECTIONIIIAnestheticManagement

mayprovevaluableinsomeheadandnecksurgicalproceduresorintheprone
patient.Ifanarmoredtubebecomeskinkedfromextremepressure(eg,anawake
patientbitingit),however,thelumenwilloftenremainpermanentlyoccluded,and
thetubewillneedreplacement.Otherspecializedtubesincludemicrolaryngeal
tubes,doublelumenendotrachealtubes(tofacilitatelungisolationandonelung
ventilation),endotrachealtubesequippedwithbronchialblockers(tofacilitate
lungisolationandonelungventilation),metaltubesdesignedforlaserairway
surgerytoreducefirehazards,andpreformedcurvedtubesfornasalandoral
intubationinheadandnecksurgery.

LARYGOSCOPES
Alaryngoscopeisaninstrumentusedtoexaminethelarynxandtofacilitate
intubationofthetrachea.Thehandleusuallycontainsbatteriestolightabulbon
thebladetip(Figure1915),or,alternately,topowerafiberopticbundlethat
terminatesatthetipoftheblade.Lightfromafiberopticbundletendstobemore
preciselydirectedandlessdiffuse.Also,laryngoscopeswithfiberopticlight
bundlesintheirbladescanbemademagneticresonanceimagingcompatible.
TheMacintoshandMillerbladesarethemostpopularcurvedandstraightdesigns,
respectively,in
theUnitedStates.Thechoiceofbladedependsonpersonalpreferenceandpatient
anatomy.Becausenobladeisperfectforallsituations,theclinicianshould
becomefamiliarandproficientwithavarietyofbladedesigns(Figure1916).

VIDEOLARYNGOSCOPES
Inrecentyears,amyriadoflaryngoscopydevicesthatutilizevideotechnology
haverevolutionizedmanagementoftheairway.Directlaryngoscopywitha
MacintoshorMillerblademandatesappropriatealignmentoftheoral,pharyngeal,
andlaryngealstructurestofacilitateadirectviewoftheglottis.Various
maneuvers,suchasthesniffingpositionandexternalmovementofthelarynx
withcricoidpressureduringdirectlaryngoscopy,areusedtoimprovetheview.
Videooropticallybasedlaryngoscopeshaveeitheravideochip(DCIsystem,

GlideScope,McGrath,Airway)oralens/mirror(Airtraq)atthetipofthe
intubationbladetotransmitaviewoftheglottistotheoperator.Thesedevices
differintheangulationoftheblade,thepresenceofachanneltoguidethetubeto
theglottis,andthesingleuseormultiusenatureofthedevice.
Videoorindirectlaryngoscopymostlikelyoffersminimaladvantageinpatients
withuncomplicatedairways.However,useinthesepatientsisvaluableasa
trainingguideforlearners,especiallywhenthetraineeisperformingadirect
laryngoscopywiththedevicewhiletheinstructorviewstheglottisonthevideo
screen.Additionally,useinuncomplicatedairwaymanagementpatients
improvesfamiliaritywiththedevicefortimeswhendirectlaryngoscopyisnot
possible.
Indirectlaryngoscopesgenerallyimprovevisualizationoflaryngealstructuresin
difficultairways;however,visualizationdoesnotalwaysleadtosuccessful
intubation.Anendotrachealtubestyletisrecommendedwhenvideo
laryngoscopyistobeperformed.Somedevicescomewithstyletsdesignedto
facilitateintubationwiththatparticulardevice.Bendingthestyletand
endotrachealtubeinamannersimilartothebendinthecurveofthebladeoften
facilitatespassageoftheendotrachealtubeintothetrachea.Evenwhentheglottic
openingisseenclearly,directingtheendotrachealtubeinto
Bulb
Blade
Electricalcontact
Handle
Flange

FIGURE1915Arigidlaryngoscope.

FIGURE1916Anassortmentoflaryngoscopeblades.
thetracheacanbedifficult.Shouldthetubebecomecaughtonthearytenoids,
slightlypullingthebladefartheroutmaybetterpermittubepassage.
Indirectlaryngoscopymayresultinlessdisplacementofthecervicalspine;
however,allprecautionsassociatedwithairwaymanipulationinapatientwitha
possiblecervicalspinefractureshouldbemaintained.
Varietiesofindirectlaryngoscopesinclude:

VariousMacintoshandMillerbladesinpediatricandadultsizeshavevideo
capabilityintheStorzDCIsystem.Thesystemcanalsoincorporateanoptical
intubatingstylet(Figure1917).Thebladesaresimilartoconventionalintubation
blades,permittingdirectlaryngoscopyandindirectvideolaryngoscopy.Assistants
andinstructorsareabletoseetheviewobtainedbytheoperatorandadjusttheir
maneuversaccordinglytofacilitateintubationortoprovideinstruction,
respectively.

TheMcGrathlaryngoscopeisaportablevideolaryngoscopewithabladelength
thatcanbe
adjustedtofacilitateachildofage5yearsuptoanadult(Figure1918).The
bladecanbedisconnectedfromthehandletofacilitateitsinsertioninmorbidly
obesepatientsinwhomthespacebetweentheupperchestandheadisreduced.
Thebladeisinsertedmidline,withthelaryngealstructuresviewedatadistanceto
enhanceintubationsuccess.
FIGURE1917Opticalintubatingstylet.
CHAPTER19AirwayManagement323

Macintosh
Miller
Wisconsin

324SECTIONIIIAnestheticManagement

FIGURE1918McGrathlaryngoscope.

TheGlideScopecomeswithdisposableadultandpediatricsizedblades(Figure
1919).Thebladeisinsertedmidlineandadvanceduntilglotticstructuresare
identified.TheGlideScopehasa60angle,preventingdirectlaryngoscopyand
necessitatingtheuseofstyletthatissimilarinshapetotheblade.

Airtraqisasingleuseopticallaryngoscopeavailableinpediatricandadultsizes
(Figure1920).Thedevicehasachanneltoguidetheendotrachealtubetothe
glottis.Thisdeviceisinsertedmidline.Successismorelikelywhenthedeviceis
notpositionedtooclosetotheglottis.

Videointubatingstyletshaveavideocapabilityandlightsource.Thestyletis
introduced,andtheglottisidentified.Intubationwithavideostyletmayresultin
lesscervicalspinemovementthanwithothertechniques.Flexible

FiberopticBronchoscopesInsomesituationsforexample,patients
withunstablecervicalspines,poorrangeofmotionofthetemporomandibular
joint,orcertaincongenital
FIGURE1919Glidescope.

oracquiredupperairwayanomalieslaryngoscopywithdirectorindirect
laryngoscopesmaybeundesirableorimpossible.AflexibleFOBallowsindi
rectvisualizationofthelarynxinsuchcasesorinanysituationinwhichawake
intubationisplanned(Figure1921).Bronchoscopesareconstructedofcoated
glassfibersthattransmitlightandimagesbyinternalreflection(ie,alightbeam
becomestrapped

FIGURE1920Airtraqopticallaryngoscope.
A
Aspirationchannel
B
CHAPTER19
AirwayManagement325

Lightsource

Lightsourcebundle

Objectivelenscoveringimagebundle

Insertiontube

Eyepiece

FIGURE1921A:Crosssectionofafiberopticbronchoscope.B:Aflexible
fiberopticbronchoscopewithafixedlightsource.

notariskfreeprocedure,andnotallpatientsreceivinggeneralanesthesiarequire
it.ATTisgenerallyplacedtoprotecttheairwayandforairwayaccess.Intubation
isindicatedinpatientswhoareatriskofaspirationandinthoseundergoing
surgicalproceduresinvolvingbodycavitiesortheheadandneck.Mask
ventilationorventilationwithanLMAisusuallysatisfactoryforshortminor
proceduressuchascystoscopy,examinationunderanesthesia,inguinalhernia
repairs,extremitysurgery,andsoforth.

PreparationforDirectLaryngoscopy
Preparationforintubationincludescheckingequipmentandproperlypositioning
thepatient.TheTTshouldbeexamined.Thetubescuffinflationsystemcanbe
testedbyinflatingthecuffusinga10mLsyringe.Maintenanceofcuffpressure
afterdetachingthesyringeensurespropercuffandvalvefunction.Some
anesthesiologistscuttheTTtoapresetlengthtodecreasethedeadspace,therisk
ofbronchialintubation,andtheriskofocclusionfromtubekinking(Table19
5).Theconnectorshouldbepushedfirmlyintothetubetodecreasethelikelihood
ofdisconnection.Ifastyletisused,itshouldbeinserted
withinafiberandexitsunchangedattheoppositeend).Theinsertiontube
containstwobundlesoffibers,eachconsistingof10,000to15,000fibers.One
bundletransmitslightfromthelightsource(lightsourceorincoherentbundle),
whichiseitherexternaltothedeviceorcontainedwithinthehandle(Figure19
21B),whereastheotherprovidesahighresolutionimage(imageorcoherent
bundle).Directionalmanipulationoftheinsertiontubeisaccomplishedwith
angulationwires.Aspirationchannelsallowsuctioningofsecretions,insufflation
ofoxygen,orinstillationoflocalanesthetic.Aspirationchannelscanbedifficultto
clean,and,ifnotproperlycleanedandsterilizedaftereachuse,mayprovidea
nidusforinfection.

TECHNIQUESOFDIRECTANDINDIRECT
LARYNGOSCOPY&INTUBATIONIndications

forIntubation
Insertingatubeintothetracheahasbecomearoutinepartofdeliveringageneral
anesthetic.Intubationis
326SECTIONIII
AnestheticManagement

Stylet

fadingindicatesdepletedbatteries.Anextrahandle,blade,TT(onesizesmaller
thantheanticipatedoptimalsize),andstyletshouldbeimmediatelyavailable.A
functioningsuctionunitisneededtocleartheairwayincaseofunexpected
secretions,blood,oremesis.
Successfulintubationoftendependsoncorrectpatientpositioning.Thepatients
headshouldbelevelwiththeanesthesiologistswaistorhighertoprevent
unnecessarybackstrainduringlaryngoscopy.
Directlaryngoscopydisplacespharyngealsofttissuestocreateadirectlineof
visionfromthemouthtotheglotticopening.Moderateheadelevation(510cm
abovethesurgicaltable)andextensionoftheatlantooccipitaljointplacethe
patientinthedesiredsniffingposition(Figure1923).Thelowerportionofthe
cervicalspineisflexedbyrestingtheheadonapilloworothersoftsupport.
Preparationforinductionandintubationalsoinvolvesroutinepreoxygenation.

Administrationof100%oxygenprovidesanextramarginofsafetyin

FIGURE1922Atrachealtubewithastyletbenttoresembleahockeystick.
intotheTT,whichisthenbenttoresembleahockeystick(Figure1922).This
shapefacilitatesintubationofananteriorlypositionedlarynx.Thedesiredblade
islockedontothelaryngoscopehandle,andbulbfunctionistested.Thelight
intensityshouldremainconstantevenifthebulbisjiggled.Ablinkinglight
signalsapoorelectricalcontact,whereas

FIGURE1923ThesniffingpositionandintubationwithaMacintoshblade.(Modified
andreproduced,withpermission,fromDorschJA,DorschSE:UnderstandingAnesthesiaEquipment:Construction,
Care,andComplications.Williams&Wilkins,1991.)

10cm

Epiglottis

AryepiglotticfoldVentricularfoldVocalfoldCuneiform
GlottiscartilageCorniculatecartilage

FIGURE1924Typicalviewoftheglottisduringlaryngoscopywithacurvedblade.

(Modifiedandreproduced,withpermission,fromBarashPG:ClinicalAnesthesia,4thed.Lippincott,2001.)
CHAPTER19
AirwayManagement327

casethepatientisnoteasilyventilatedafterinduction.Preoxygenationcanbe
omittedinpatientswhoobjecttothefacemask;however,failingtopreoxygenate
increasestheriskofrapiddesaturationfollowingapnea.
Becausegeneralanesthesiaabolishestheprotectivecornealreflex,caremustbe
takenduringthisperiodnottoinjurethepatientseyesbyunintentionally
abradingthecornea.Thus,theeyesareroutinelytapedshut,oftenafterapplying
anophthalmicointmentbeforemanipulationoftheairway.

OrotrachealIntubation
Thelaryngoscopeisheldinthelefthand.Withthepatientsmouthopenedthe
bladeisintroducedintotherightsideoftheoropharynxwithcaretoavoidthe
teeth.Thetongueisswepttotheleftandupintothefloorofthepharynxbythe
bladesflange.Successfulsweepingofthetongueleftward
clearstheviewforTTplacement.Thetipofacurvedbladeisusuallyinsertedinto
thevallecula,andthestraightbladetipcoverstheepiglottis.Witheitherblade,the
handleisraisedupandawayfromthepatientinaplaneperpendiculartothe
patientsmandibletoexposethevocalcords(Figure1924).Trappingalip
betweentheteethandthebladeandleverageontheteethareavoided.TheTTis
takenwiththerighthand,anditstipispassedthroughtheabductedvocalcords.
Thebackward,upward,rightward,pressure(BURP)maneuverapplied
externallymovesananteriorlypositionedglottisposteriortofacilitatevisualiza
tionoftheglottis.TheTTcuffshouldlieintheuppertrachea,butbeyondthe
larynx.Thelaryngoscopeiswithdrawn,againwithcaretoavoidtooth
damage.Thecuffisinflatedwiththeleastamountofairnecessarytocreatea

sealduringpositivepressureventilationtominimizethe

328SECTIONIII
AnestheticManagement

visualizationofthetrachealringsandcarinawilllikewiseconfirmcorrect
placement.Otherwise,thetubeistapedortiedtosecureitsposition.
AlthoughthepersistentdetectionofCO2bya
capnographisthebestconfirmationoftrachealplacementofaTT,itcannot
excludebronchialintubation.Theearliestevidenceofbronchialintubationoften
isanincreaseinpeakinspiratorypressure.Propertubelocationcanbe
reconfirmedbypalpatingthecuffinthesternalnotchwhilecompressingthepilot
balloonwiththeotherhand.
Thecuffshouldnotbefeltabovethelevelof
thecricoidcartilage,becauseaprolongedintralaryngeallocationmayresultin
postoperativehoarsenessandincreasestheriskofaccidentalextubation.Tube
positioncanalsobedocumentedbychestradiography.
Thedescriptionpresentedhereassumesanunconsciouspatient.Oralintubationis
usuallypoorlytoleratedbyawake,fitpatients.Intravenoussedation,applicationof
alocalanestheticsprayintheoropharynx,regionalnerveblock,andconstant
reassurancewillimprovepatientacceptance.
Afailedintubationshouldnotbefollowedbyidenticalrepeatedattempts.Changes
mustbemadetoincreasethelikelihoodofsuccess,suchasrepositioningthe
patient,decreasingthetubesize,addingastylet,selectingadifferentblade,using
anindirectlaryngoscope,attemptinganasalroute,orrequestingtheassistanceof
anotheranesthesiologist.Ifthepatientisalsodifficulttoventilatewithamask,
alternativeformsofairwaymanagement(eg,LMA,Combitube,cricothyrotomy
withjetventilation,tracheostomy)mustbeimmediatelypursued.The
guidelinesdevelopedbytheAmericanSocietyofAnesthesiologistsforthe
managementofadifficultairwayincludeatreatmentplanalgorithm(Figure19
26).
Useofvideoorindirectlaryngoscopesisdependentuponthedesignofthedevice.
Somedevicesareplacedmidlinewithouttherequirementtosweepthetongue
fromview.Otherdevicescontainchannelstodirecttheendotrachealtubetothe
glotticopening.Practitionersshouldbefamiliarwiththefeaturesofavailable
deviceswellinadvanceofusingoneinadifficultairwaysituation.Thecom
bineduseofavideolaryngoscopeandanintubation

FIGURE1925Sitesforauscultationofbreathsoundsattheapicesandoverthe
stomach.

pressuretransmittedtothetrachealmucosa.Overinflationbeyond30mmHgmay
inhibitcapillarybloodflow,injuringthetrachea.Compressingthepilotballoon
withthefingersisnotareliablemethodofdeterminingwhethercuffpressureis
eithersufficientorexcessive.
Afterintubation,thechestandepigastriumareimmediatelyauscultated,anda
capnographictracing(thedefinitivetest)ismonitoredtoensureintratracheal
location(Figure1925).Ifthereisdoubtastowhetherthetubeisinthe
esophagusortrachea,repeatthelaryngoscopytoconfirmplacement.Endtidal
CO2willnotbeproducedifthereisnocardiacoutput.FOBthroughthetubeand
DifficultAirwayAlgorithm
1.Assessthelikelihoodandclinicalimpactofbasicmanagementproblems.A.Difficult
ventilationB.DifficultintubationC.Difficultywithpatientcooperationorconsent
D.Difficulttracheostomy2.Activelypursueopportunitiestodeliversupplementaloxygen
throughouttheprocessofdifficultairwaymanagement.3.Considertherelativemeritsand
feasibilityofbasicmanagementchoices:
A.B.C.
vs.vs.vs.
4.Developprimaryandalternativestrategies.
CHAPTER19
AirwayManagement329

Awakeintubation
Noninvasivetechniqueforinitialapproachto
intubation
Preservationofspontaneousventilation

Intubationattemptsafterinductionofgeneral
anesthesia
Invasivetechniqueforinitialapproachtointubation
Ablationofspontaneousventilation
A.AwakeIntubation
AirwayapproachedbyAirwaysecuredbynoninvasiveintubationinvasiveaccess *

Succeed*
Cancelcase
FAIL

ConsiderfeasibilityInvasiveairwayofotheroptionsaaccessa*

B.IntubationAttemptsafterInductionofGeneralAnesthesia

Initialintubationattemptssuccessful*
InitialintubationattemptsUNSUCCESSFULFROMTHISPOINTONWARDCONSIDER:
1.Callingforhelp.2.Returningtospontaneousventilation3.Awakeningthepatient

Facemaskventilationadequate

LMAadequate*Ventilationadequate,intubationunsuccessful
Alternativeapproachestointubationc
Facemaskventilationnotadequate
Consider/attemptLMA

NonemergencyPathway

LMAnotadequateornotfeasible
EmergencyPathway
Ventilationinadequate,intubationunsuccessful
Callforhelp
Emergencynoninvasiveairwayventilatione

Successfulintubation*FAILaftermultipleattempts Successfulventilation*FAILEmergency
invasive
airwayInvasiveairwayventilationb*ConsiderfeasibilityofotheroptionsaAwakenpatientd
accessb*

FIGURE1926DifficultAirwayAlgorithmdevelopedbytheAmericanSocietyof
Anesthesiologists.*ConfirmtrachealintubationorLMAplacementwithexhaledCO2.
(Reproduced,withpermission,fromtheAmericanSocietyof
AnesthesiologistsTaskForceonManagementoftheDifficultAirway.Practiceguidelinesformanagementofthe
difficultairway:anupdatedreportbytheAmericanSocietyofAnesthesiologistsTaskForceonManagementofthe
DifficultAirway.Anesthesiology2003;98:1269.)

330SECTIONIIIAnestheticManagement

FIGURE1927Bougie.
bougieoftencanfacilitateintubation,whentheendotrachealtubecannotbe
directedintotheglottisdespitegoodvisualizationofthelaryngealopening
(Figure1927).

NasotrachealIntubation
NasalintubationissimilartooralintubationexceptthattheTTisadvanced

throughthenoseandnasopharynxintotheoropharynxbeforelaryngoscopy.The
nostrilthroughwhichthepatientbreathesmosteasilyisselectedinadvanceand
prepared.Phenylephrinenosedrops(0.5%or0.25%)vasoconstrictvesselsand
shrinkmucousmembranes.Ifthepatientisawake,localanestheticointment(for
thenostril),spray(fortheoropharynx),andnerveblockscanalsobeutilized.
ATTlubricatedwithwatersolublejellyisintroducedalongthefloorofthenose,
belowtheinferiorturbinate,atanangleperpendiculartotheface.Thetubes
bevelshouldbedirectedlaterallyawayfromtheturbinates.Toensurethatthe
tubepassesalongthefloorofthenasalcavity,theproximalendoftheTTshould
bepulledcephalad.Thetubeisgraduallyadvanced,untilitstipcanbevisualized
intheoropharynx.Laryngoscopy,asdiscussed,revealstheabductedvocalcords.
OftenthedistalendoftheTTcanbepushedintothetracheawithoutdifficulty.If
difficultyisencountered,thetipofthetubemaybedirectedthroughthevocal
cordswithMagillforceps,beingcarefulnottodamagethecuff.Nasalpassageof
TTs,airways,ornasogastriccatheterscarriesgreaterriskinpatientswithsevere
midfacialtraumabecauseoftheriskofintracranialplacement(Figure1928).
Althoughlessusedtoday,blindnasalintubationofspontaneouslybreathing
patientscanbeemployed.Inthistechnique,afterapplyingtopicalanestheticto
thenostrilandpharynx,abreathingtubeispassedthroughthenasopharynx.
Using
FIGURE1928Radiographdemonstratinga7.0mmtrachealtubeplacedthroughthe
cribriformplateintothecranialvaultinapatientwithabasilarskullfracture.

breathsoundsasaguide,itisdirectedtowardtheglottis.Whenbreathsoundsare
maximal,theanesthetistadvancesthetubeduringinspirationinaneffortto
blindlypassthetubeintothetrachea.

FlexibleFiberopticIntubation
Fiberopticintubation(FOI)isroutinelyperformedinawakeorsedatedpatients
withproblematicairways.FOIisidealfor:
Asmallmouthopening
Minimizingcervicalspinemovementintraumaorrheumatoidarthritis
Upperairwayobstruction,suchasangioedemaortumormass
Facialdeformities,facialtrauma

FOIcanbeperformedawakeorasleepviaoralornasalroutes.
AwakeFOI:predictedinabilitytoventilatebymask,upperairwayobstruction
CHAPTER19
AirwayManagement331

AsleepFOI:Failedintubation,desireforminimalCspinemovementinpatients
whorefuseawakeintubation

OralFOI:Facial,skullinjuries

NasalFOI:ApoormouthopeningWhenFOIisconsidered,carefulplanningis
necessary,asitwilllikelyaddtotheanesthesiatimepriortosurgery.Patients
shouldbeinformedoftheneedforawakeintubationasapartoftheinformed
consentprocess.Theairwayisanesthetizedwithalocalanestheticspray,and
patientsedationisprovided,astolerated.Dexmedetomidinehastheadvantageof
preservingrespirationwhileprovidingsedation.Airwayanesthesiaisdiscussed
intheCaseDiscussionbelow.IfnasalFOIisplanned,bothnostrilsareprepared
withvasoconstrictivedrops.Thenostrilthroughwhichthepatientbreathesmore
easilyisidentified.Oxygencanbeinsufflatedthroughthesuctionportanddown
theaspirationchanneloftheFOBtoimproveoxygenationandblowsecretions
awayfromthetip.Alternatively,alargenasalairway(eg,36F)canbeinsertedin
thecontralateralnostril.Thebreathingcircuitcanbedirectlyconnectedtothe
endofthisnasalairwaytoadminister100%oxygenduringlaryngoscopy.Ifthe
patientisunconsciousandnotbreathingspontaneously,themouthcanbeclosed
andventilationattemptedthroughthesinglenasalairway.Whenthistechniqueis
used,adequacyofventilationandoxygenationshouldbeconfirmedby
capnographyandpulseoximetry.ThelubricatedshaftoftheFOBisintroduced
intotheTTlumen.Itisimportanttokeeptheshaftofthebronchoscoperelatively
straight(Figure1929)sothatiftheheadofthebronchoscopeisrotatedinone
direction,thedistalendwillmovetoasimilardegreeandinthesamedirection.
AsthetipoftheFOBpassesthroughthedistalendoftheTT,theepiglottisor
glottisshouldbevisible.Thetipofthebronchoscopeismanipulated,asneeded,to
passtheabductedcords.Havinganassistantthrustthejawforwardorapply
cricoidpressuremayimprovevisualizationindifficultcases.Ifthepatientis
breathing
FIGURE1929Correcttechniqueformanipulatingafiberopticbronchoscope

throughatrachealtubeisshowninthetoppanel;avoidcurvatureinthebronchoscope,
whichmakesmanipulationdifficult.

spontaneously,graspingthetonguewithgauzeandpullingitforwardmayalso
facilitateintubation.
Onceinthetrachea,theFOBisadvancedtowithinsightofthecarina.The
presenceoftrachealringsandthecarinaisproofofproperpositioning.TheTTis
pushedofftheFOB.Theacuteanglearoundthearytenoidcartilageandepiglottis
maypreventeasyadvancementofthetube.Useofanarmoredtubeusually
decreasesthisproblemduetoitsgreaterlateralflexibilityandmoreobtusely
angleddistalend.ProperTTpositionisconfirmedbyviewingthetipofthetube
anappropriatedistance(3cminadults)abovethecarinabeforetheFOBis
withdrawn.

OralFOIproceedssimilarly,withtheaidofvariousoralairwaydevicestodirect
theFOBtowardtheglottisandtoreduceobstructionoftheviewbythetongue.
332SECTIONIIIAnestheticManagement

FIGURE1930Cricothyrotomy.Slidecatheterintotrachea.(Photocontributor:LawrenceB.
Stack,MD.)

SURGICALAIRWAY
TECHNIQUES
Invasiveairwaysarerequiredwhenthecantintubate,cantventilate
scenariopresentsandmaybeperformedinanticipationofsuchcircumstancesin
selectedpatients.Theoptionsinclude:surgicalcricothyrotomy,catheterorneedle
cricothyrotomy,transtrachealcatheterwithjetventilation,andretrograde
intubation.
SurgicalcricothyrotomyreferstosurgicalincisionoftheCTMandplacementofa
breathingtube.Morerecently,severalneedle/dilatorcricothyrotomykitshave
becomeavailable.Unlikesurgicalcricothyrotomy,whereahorizontalincisionis
madeacrosstheCTM,thesekitsutilizetheSeldingercatheter/wire/dilator
technique.AcatheterattachedtoasyringeisinsertedacrosstheCTM(Figure19
30).Whenairisaspirated,aguidewireispassedthroughthecatheterintothe
trachea(Figure1931).Adilatoristhenpassedovertheguidewire,anda
breathingtubeplaced(Figure1932).

Catheterbasedsalvageprocedurescanalsobeperformed.A16or14gauge
intravenouscannulaisattachedtoasyringeandpassedthroughtheCTMtoward
thecarina.Airisaspirated.Ifajetventilationsystemisavailable,itcanbe
attached.ThecatheterMUSTbesecured,otherwisethejetpressurewillpushthe
catheteroutoftheairway,leadingto
FIGURE1931Cricothyrotomy.Incisionatwireentrysite.Removecatheterand
makeincisionatthewireentrysite.(Photocontributor:LawrenceB.Stack,MD.)

potentiallydisastroussubcutaneousemphysema.Short(1s)burstsofoxygen
ventilatethepatient.Sufficientoutflowofexpiredairmustbeassuredtoavoid
barotrauma.Patientsventilatedinthismannermaydevelopsubcutaneousor
mediastinalemphysemaandmaybecomehypercapneicdespiteadequate
oxygenation.Transtrachealjetventilationwillusuallyrequireconversiontoa
surgicalairwayortrachealintubation.
Shouldajetventilationsystemnotbeavailable,a3mLsyringecanbeattachedto
thecatheterandthesyringeplungerremoved.A7.0mminternal
FIGURE1932Cricothyrotomy.Inserttracheostomytube/introducer.Insertboth
devicesoverthewireandintothetrachea.(Photocontributor:LawrenceB.Stack,MD.)

diameterTTconnectorcanbeinsertedintothesyringeandattachedtoabreathing
circuitoranambubag.Aswiththejetventilationsystem,adequateexhalation
mustoccurtoavoidbarotraumas.
Retrogradeintubationisanotherapproachtosecureanairway.Awireispassed
viaacatheterplacedintheCTM.Thewireisangulatedcephaladandemerges
eitherthroughthemouthornose.Thedistalendofthewireissecuredwitha
clamptopreventitfrompassingthroughtheCTM.Thewirecanthenbethreaded
intoanFOBwithaloadedendotrachealtubetofacilitateandconfirmplacement.
Conversely,asmallendotrachealtubecanbeguidedbythewireintothetrachea.
Onceplaced,thewireisremoved.Alternatively,anepiduralcathetercanbe
placedviaanepiduralneedleintheCTM.Afterthedistalendisretrievedfromthe
mouth,anendotrachealtubemaybepassedoverthecatheterintothetrachea.

PROBLEMSFOLLOWING
INTUBATION
Followingapparentlysuccessfulintubation,severalscenariosmaydevelopthat
requireimmediateattention.AnesthesiastaffMUSTconfirmthatthetubeis
correctlyplacedwithbilateralventilationimmediatelyfollowingplacement.
DetectionofendtidalCO2remainsthegoldstandardinthisregard,withthe
caveatthatcardiacoutputmustbepresentforendtidalCO2production.
Decreasesinoxygensaturationcanoccurfollowingtubeplacement.Thisisoften
secondarytoendobronchialintubation,especiallyinsmallchildrenandbabies.
Decreasedoxygensaturationperioperativelymaybeduetoinadequateoxygen
delivery(oxygennotturnedon,patientnotventilated)ortoventilation/perfusion
mismatch(almostanyformoflungdisease).Whensaturationdeclines,the
patientschestisauscultatedtoconfirmbilateraltubeplacementandtolistenfor
wheezes,rhonchi,andralesconsistentwithlungpathology.Thebreathingcircuit
ischecked.Anintraoperativechestradiographmaybeneededtoidentifythecause
ofdesaturation.Intraoperativefiberopticbronchoscopycanalsobeperformedand
usedtoconfirmpropertubeplacementandtoclearmucousplugs.
Bronchodilatorsanddeeperplanesofinhalationanestheticsare
administeredtotreatbronchospasm.Obesepatientsmaydesaturatesecondarytoa
reducedFRCandatelectasis.Applicationofpositiveendexpiratorypressuremay
improveoxygenation.

ShouldtheendtidalCO2declinesuddenly,pulmonary(thrombus)orvenousair
embolismshouldbeconsidered.Likewise,othercausesofasuddendeclinein
cardiacoutputoraleakinthecircuitshouldbeconsidered.
ArisingendtidalCO2maybesecondarytohypoventilationorincreasedCO2
production,asoccurswithmalignanthyperthermia,sepsis,adepletedCO2
absorber,orbreathingcircuitmalfunction.
Increasesinairwaypressuremayindicateanobstructedorkinkedendotracheal
tubeorreducedpulmonarycompliance.Theendotrachealtubeshouldbe
suctionedtoconfirmthatitispatentandthelungsauscultatedtodetectsignsof
bronchospasm,pulmonaryedema,endobronchialintubation,orpneumothorax.
Decreasesinairwaypressurecanoccursecondarytoleaksinthebreathing
circuitorinadvertentextubation.

TECHNIQUESOFEXTUBATION
Mostoften,extubationshouldbeperformedwhenapatientiseitherdeeply
anesthetizedorawake.Ineithercase,adequaterecoveryfromneuromuscular
blockingagentsshouldbeestablishedpriortoextubation.Ifneuromuscular
blockingagentsareused,thepatienthasatleastaperiodofcontrolledmechanical
ventilationandlikelymustbeweanedfromtheventilatorbeforeextubationcan
occur.
Extubationduringalightplaneofanesthesia(ie,astatebetweendeepand
awake)isavoidedbecauseofanincreasedriskoflaryngospasm.Thedistinction
betweendeepandlightanesthesiaisusuallyapparentduringpharyngeal
suctioning:anyreactiontosuctioning(eg,breathholding,coughing)signalsa
lightplaneofanesthesia,whereasnoreactionischaracteristicofadeepplane.
Similarly,eyeopeningorpurposefulmovementsimplythatthepatientis
sufficientlyawakeforextubation.
Extubatinganawakepatientisusuallyassociatedwithcoughing(bucking)onthe
TT.This
CHAPTER19AirwayManagement333

334SECTIONIIIAnestheticManagement

reactionincreasestheheartrate,centralvenouspressure,arterialbloodpressure,
intracranialpressure,intraabdominalpressure,andintraocularpressure.Itmay

alsocausewounddehiscenceandincreasedbleeding.ThepresenceofaTTinan
awakeasthmaticpatientmaytriggerbronchospasm.Somepractitionersattemptto
decreasethelikelihoodoftheseeffectsbyadministering1.5mg/kgof
intravenouslidocaine12minbeforesuctioningandextubation;however,
extubationduringdeepanesthesiamaybepreferableinpatientswhocannot
toleratetheseeffects(providedsuchpatientsarenotatriskofaspirationand/ordo
nothaveairwaysthatmaybedifficulttocontrolafterremovaloftheTT).
Regardlessofwhetherthetubeisremovedwhenthepatientisdeeplyanesthetized
orawake,thepatientspharynxshouldbethoroughlysuctionedbefore
extubationtodecreasethepotentialforaspirationofbloodandsecretions.In
addition,patientsshouldbeventilatedwith100%oxygenincaseitbecomes
difficulttoestablishanairwayaftertheTTisremoved.Justpriortoextubation,
theTTisuntapedoruntiedanditscuffisdeflated.Thetubeiswithdrawnina
singlesmoothmotion,andafacemaskisappliedtodeliveroxygen.Oxygen
deliverybyfacemaskismaintainedduringtheperiodoftransportationtothe
postanesthesiacarearea.

COMPLICATIONSOFLARYNGOSCOPY&
INTUBATION
Thecomplicationsoflaryngoscopyandintubationincludehypoxia,hypercarbia,
dentalandairwaytrauma,tubemalpositioning,physiologicalresponsestoairway
instrumentation,ortubemalfunction.Thesecomplicationscanoccurduring
laryngoscopyandintubation,whilethetubeisinplace,orfollowingextubation
(Table196).

AirwayTrauma
InstrumentationwithametallaryngoscopebladeandinsertionofastiffTToften
traumatizesdelicateairwaytissues.Toothdamageisacommoncauseof
(relativelysmall)malpracticeclaimsagainstanesthesiologists.Laryngoscopy
andintubationcanlead

TABLE196
Complicationsofintubation.
DuringlaryngoscopyandintubationMalpositioning
EsophagealintubationBronchialintubationLaryngealcuffposition

AirwaytraumaDentaldamageLip,tongue,ormucosallacerationSorethroatDislocatedmandible
Retropharyngealdissection
PhysiologicalreflexesHypoxia,hypercarbiaHypertension,tachycardiaIntracranialhypertension
IntraocularhypertensionLaryngospasm
TubemalfunctionCuffperforation
WhilethetubeisinplaceMalpositioning
UnintentionalextubationBronchialintubationLaryngealcuffposition
AirwaytraumaMucosalinflammationandulcerationExcoriationofnose
TubemalfunctionFire/explosionObstruction
FollowingextubationAirwaytrauma
Edemaandstenosis(glottic,subglottic,ortracheal)Hoarseness(vocalcordgranulomaor
paralysis)Laryngealmalfunctionandaspiration
LaryngospasmNegativepressurepulmonaryedema

toarangeofcomplicationsfromsorethroattotrachealstenosis.Mostofthese
areduetoprolongedexternalpressureonsensitiveairwaystructures.Whenthese
pressuresexceedthecapillaryarteriolarbloodpressure(approximately30mm
Hg),tissueischemiacanleadtoasequenceofinflammation,ulceration,
granulation,andstenosis.InflationofaTTcufftotheminimumpressurethat
createsasealduringroutinepositivepressureventilation(usuallyatleast20mm
Hg)reducestrachealbloodflowby75%atthecuffsite.Furthercuffinflationor
inducedhypotensioncantotallyeliminatemucosalbloodflow.
Postintubationcroupcausedbyglottic,laryngeal,ortrachealedemais
particularlyseriousinchildren.Theefficacyofcorticosteroids(eg,dexamethasone
0.2mg/kg,uptoamaximumof12mg)inpreventingpostextubationairway
edemaremainscontroversial;however,corticosteroidshavebeendemonstratedto
beefficaciousinchildrenwithcroupfromothercauses.Vocalcordparalysisfrom
cuffcompressionorothertraumatotherecurrentlaryngealnerveresultsin
hoarsenessandincreasestheriskofaspiration.Theincidenceofpostoperative
hoarsenessseemstoincreasewithobesity,difficultintubations,andanesthetics
oflongduration.Curiously,applyingawatersolublelubricantoralocal
anestheticcontaininggeltothetiporcuffoftheTTdoesnotdecreasethe
incidenceofpostoperativesorethroatorhoarseness,and,insomestudies,actu
allyincreasedtheincidenceofthesecomplications.Smallertubes(size6.5in
womenandsize7.0inmen)areassociatedwithfewercomplaintsofpostoperative

sorethroat.Repeatedattemptsatlaryngoscopyduringadifficultintubationmay
leadtoperiglotticedemaandtheinabilitytoventilatewithafacemask,thus
turningabadsituationintoalifethreateningone.

ErrorsofTrachealTubePositioning
Incontrast,inadequateinsertiondepthwillpositionthecuffinthelarynx,
predisposingthepatienttolaryngealtrauma.Inadequatedepthofinsertioncanbe
detectedbypalpatingthecuffoverthethyroidcartilage.
BecausenoonetechniqueprotectsagainstallpossibilitiesformisplacingaTT,
minimaltestingshouldincludechestauscultation,routinecapnography,and
occasionallycuffpalpation.
Ifthepatientisrepositioned,tubeplacementmustbereconfirmed.Neckextension
orlateralrotationmostoftenmovesaTTawayfromthecarina,whereasneck
flexionmostoftenmovesthetubetowardthecarina.
Atnotimeshouldexcessiveforcebeemployedduringintubation.Esophageal
intubationscanresultinesophagealruptureandmediastinitis.Mediastinitis
presentsasseveresorethroat,fever,sepsis,andsubcutaneousairoften
manifestingascrepitus.Earlyinterventionisnecessarytoavoidmortality.If
esophagealperforationissuspected,consultationwithanotolaryngologistor
thoracicsurgeonisrecommended.

PhysiologicalResponsestoAirwayInstrumentation

Laryngoscopyandtrachealintubationviolatethepatientsprotectiveairway
reflexesandpredictablyleadtohypertensionandtachycardiawhenperformed
underlightplanesofgeneralanesthesia.TheinsertionofanLMAistypically
associatedwithlesshemodynamicchange.Hemodynamicchangescanbe
attenuatedbyintravenousadministrationoflidocaine,opioids,or blockersor
deeperplanesofinhalationanesthesiaintheminutesbeforelaryngoscopy.
Hypotensiveagents,includingsodiumnitroprusside,nitroglycerin,esmololand
nicardipine,havealsobeenshowntoeffectivelyattenuatethetransient
hypertensiveresponseassociatedwithlaryngoscopyandintubation.Cardiac
arrhythmiasparticularlyventricularbigeminysometimesoccurduring
intubationandmayindicatelightanesthesia.
Laryngospasmisaforcefulinvoluntaryspasmofthelaryngealmusculature
causedbysensorystimulationofthesuperiorlaryngealnerve.Triggeringstimuli
includepharyngealsecretions

ducecatastrophicresults.Preventionofthiscomplicationdependsondirect
visualizationofthetipoftheTTpassingthroughthevocalcords,careful
auscultationforthepresenceofbilateralbreathsoundsandtheabsenceofgastric
gurglingwhileventilatingthroughtheTT,analysisofexhaledgasforthepresence
ofCO2(themostreliableautomatedmethod),chestradiography,ortheuseofan
FOB.
Eventhoughitisconfirmedthatthetubeisinthetrachea,itmaynotbecorrectly
positioned.Overlydeepinsertionusuallyresultsinintubationoftheright(rather
thanleft)mainstembronchusbecauseoftherightbronchuslessacuteanglewith
CHAPTER19AirwayManagement335

6
Unrecognizedesophagealintubationcanpro

7
thetrachea.Cluestothediagnosisofbronchial
intubationincludeunilateralbreathsounds,unexpectedhypoxiawithpulse
oximetry(unreliablewithhighinspiredoxygenconcentrations),inabilityto
palpatetheTTcuffinthesternalnotchduringcuffinflation,anddecreased
breathingbagcompliance(highpeakinspiratorypressures).
336SECTIONIIIAnestheticManagement

orpassingaTTthroughthelarynxduringextubation.Laryngospasmisusually
preventedbyextubatingpatientseitherdeeplyasleeporfullyawake,butitcan
occuralbeitrarelyinanawakepatient.Treatmentoflaryngospasmincludes
providinggentlepositivepressureventilationwithananesthesiabagandmask
using100%oxygenoradministeringintravenouslidocaine(11.5mg/kg).If
laryngospasmpersistsandhypoxiadevelops,smalldosesofsuccinylcholine
(0.250.5mg/kg)mayberequired(perhapsincombinationwithsmalldosesof
propofoloranotheranesthetic)torelaxthelaryngealmusclesandtoallow
controlled
ventilation.Thelargenegativeintrathoracic

pressuresgeneratedbyastrugglingpatientduringlaryngospasmcanresultinthe
developmentofnegativepressurepulmonaryedema,eveninhealthypatients.
Whereaslaryngospasmmayresultfromanabnormallysensitivereflex,aspiration
canresultfromdepressionoflaryngealreflexesfollowingprolongedintubation
andgeneralanesthesia.
Bronchospasmisanotherreflexresponsetointubationandismostcommonin
asthmaticpatients.Bronchospasmcansometimesbeacluetobronchialintubation.
Otherpathophysiologicaleffectsofintubationincludeincreasedintracranialand
intraocularpressures.

TrachealTubeMalfunction
TTsdonotalwaysfunctionasintended.Polyvinylchloridetubesmaybeignited
bycauteryorlaserinanoxygen/nitrousoxideenrichedenvironment.Valveor
cuffdamageisnotunusualandshouldbeexcludedpriortoinsertion.TT
obstructioncanresultfromkinking,fromforeignbodyaspiration,orfromthick
orinspissatedsecretionsinthelumen.

CASEDISCUSSION
Evaluation&ManagementofaDifficultAirwayA17yearoldgirl
presentsforemergencydrainageofasubmandibularabscess.

TABLE197Conditionsassociatedwithdifficultintubations.
TumorsCystichygromaHemangiomaHematoma1
InfectionsSubmandibularabscessPeritonsillarabscessEpiglottitis
CongenitalanomaliesPierreRobinsyndromeTreacherCollinssyndromeLaryngealatresia
GoldenharsyndromeCraniofacialdysostosis
ForeignbodyTrauma
LaryngealfractureMandibularormaxillaryfractureInhalationburnCervicalspineinjury
ObesityInadequateneckextension
Rheumatoidarthritis2AnkylosingspondylitisHalotraction
AnatomicvariationsMicrognathiaPrognathismLargetongueArchedpalateShortneckProminent
upperincisors

8
Canoccurpostoperativelyinpatientswhohavehadanynecksurgery.2Alsoaffectsarytenoidsmakingthemimmobile.

Whataresomeimportantanestheticconsiderationsduringthepreoperativeevaluation
ofapatientwithanabnormalairway?
Inductionofgeneralanesthesiafollowedbydirectlaryngoscopyandoralintubationis
dangerous,ifnotimpossible,inseveralsituations.(Table197).Todeterminethe
optimalintubationtechnique,theanesthesiologistmustelicitanairwayhistoryand
carefullyexaminethepatientsheadandneck.Anyavailableprioranesthesiarecords
shouldbereviewedforpreviousproblemsinairwaymanagement.Ifafacialdeformity
issevereenoughtoprecludeagoodmaskseal,positivepressureventilationmaybe
impossible.

Furthermore,patientswithhypopharyngealdiseasearemoredependentonawake
muscletonetomaintainairwaypatency.Thesetwogroupsofpatientsshouldgenerally
notbeallowedtobecomeapneicincludinginductionofanesthesia,sedation,or
muscleparalysisuntiltheirairwayissecured.
Ifthereisanabnormallimitationofthetemporomandibularjointthatmaynotimprove
withmuscleparalysis,anasalapproachwithanFOBshouldbeconsidered.Infection
confinedtothefloorofthemouthusuallydoesnotprecludenasalintubation.Ifthe
hypopharynxisinvolvedtothelevelofthehyoidbone,however,anytranslaryngeal
attemptwillbedifficult.Othercluestoapotentiallydifficultlaryngoscopyincludelim

itedneckextension(35),adistancebetweenthetipofthepatientsmandibleandhyoid
boneoflessthan7cm,asternomentaldistanceoflessthan12.5cmwiththeheadfully
extendedandthemouthclosed,andapoorlyvisualizeduvuladuringvoluntarytongue
protrusion.Itmustbestressedthatbecausenoexaminationtechniqueisfoolproofandthe
signsofadifficultairwaymaybesubtle,theanesthesiologistmustalwaysbeprepared
forunanticipateddifficulties.
Theanesthesiologistshouldalsoevaluatethepatientforsignsofairwayobstruction(eg,
chestretraction,stridor)andhypoxia(agitation,restlessness,anxiety,lethargy).
Aspirationpneumonia
ismorelikelyifthepatienthasrecentlyeatenorifpusisdrainingfromanabscessinto
themouth.Ineithercase,techniquesthatablatelaryngealreflexes(eg,topical
anesthesia)shouldbeavoided.
Cervicaltraumaordiseaseisafactorthatshouldbeevaluatedpriortodirect
laryngoscopy.Cervicalarthritisorpreviouscervicalfusionmaymakeitdifficultforthe
headtobeputinthesniffingposition;thesepatientsarecandidatesforbronchoscopyto
securetheairway,asdiscussedpreviously.Traumapatientswithunstablenecksorwhose
neckhasnotyetbeenclearedarealsocandidatesforbronchoscopyfortracheal
intubation.Alternatively,laryngoscopywithinlinestabilizationcanbeperformed
(Figure1933).
Inthecaseunderdiscussion,physicalexaminationrevealsextensivefacialedemathat
limitsthemandiblesrangeofmotion.Maskfitdoesnotseemtobeimpaired,however.
Lateralradiographsoftheheadandnecksuggestthattheinfectionhasspreadoverthe
larynx.Frankpusisobservedinthemouth.
Whichintubationtechniqueisindicated?
Routineoralandnasalintubationshavebeendescribedforanesthetizedpatients.Bothof
thesecanalsobeperformedinawakepatients.Whetherthepatientisawakeorasleepor
whetherintubationistobeoralornasal,itcanbeperformedwith
CHAPTER19AirwayManagement337

FIGURE1933Techniqueforairwaymanagementofapatientwithsuspectedspinal

cordinjury.Oneindividualholdstheheadfirmlywiththepatientonabackboard,the
cervicalcollarleftaloneifinplace,ensuringthatneithertheheadnorneckmoveswith
directlaryngoscopy.Asecondpersonappliescricoidpressureandthethirdperforms
laryngoscopyandintubation.
338SECTIONIIIAnestheticManagement


directlaryngoscopy,fiberopticvisualization,orvideolaryngoscopytechniques.
Intubationmaybedifficultinthispatient;however,thereispusdrainingintothemouth,
andpositivepressureventilationmaybeimpossible.Inductionofanesthesiashould,
therefore,bedelayeduntilaftertheairwayhasbeensecured.Therefore,thealternatives
areawakefiberopticintubation,awakevideolaryngoscopy,orawakeuseofoptical

stylets.Thefinaldecisiondependsontheavailabilityofequipmentandtheexperiences
andpreferencesoftheanesthesiacaregivers.
Regardlessofwhichalternativeischosen,anemergencysurgicalairwaymaybe
necessary.Therefore,anexperiencedteam,includingasurgeon,shouldbeinthe
operatingroom,allnecessaryequipmentshouldbeavailableandunwrapped,andthe
neckshouldbepreppedanddraped.
Whatpremedicationwouldbeappropriateforthispatient?
Anylossofconsciousnessorinterferencewithairwayreflexescouldresultinairway
obstructionoraspiration.Glycopyrrolatewouldbeagoodchoiceofpremedication
becauseitminimizesupperairwaysecretionswithoutcrossingthebloodbrainbarrier.
Parenteralsedativesshouldbeverycarefullytitrated.Dexmedetomidineandketamine
preserverespiratoryeffortandarefrequentlyusedassedatives.Psychologicalprepa
rationofthepatient,includingexplainingeachstepplannedinsecuringtheairway,may
improvepatientcooperation.
Whatnerveblockscouldbehelpfulduringanawakeintubation?
Thelingualandsomepharyngealbranchesoftheglossopharyngealnervethatprovide
sensationtotheposteriorthirdofthetongueandoropharynxareeasilyblockedby
bilateralinjectionof2mLoflocalanestheticintothebaseofthepalatoglossalarch
(alsoknownastheanteriortonsillarpillar)witha25gaugespinalneedle(Figure19
34).
Bilateralsuperiorlaryngealnerveblocksandatranstrachealblockwouldanesthetize
theairway

FIGURE1934Nerveblock.Whilethetongueislaterallyretractedwithatongue

blade,thebaseofthepalatoglossalarchisinfiltratedwithlocalanesthetictoblockthe
lingualandpharyngealbranchesoftheglossopharyngealnerve.Notethatthelingual
branchesoftheglossopharyngealnervearenotthesameasthelingualnerve,whichisa
branchofthetrigeminalnerve.
belowtheepiglottis(Figure1935).Thehyoidboneislocated,and3mLof2%
lidocaineisinfiltrated1cmbeloweachgreatercornu,wheretheinternalbranchofthe
superiorlaryngealnervespenetratesthethyrohyoidmembrane.
AtranstrachealblockisperformedbyidentifyingandpenetratingtheCTMwhilethe
neckisextended.Afterconfirmationofanintratrachealpositionbyaspirationofair,4
mLof4%lidocaineisinjectedintothetracheaatendexpiration.Adeepinhalation
andcoughimmediatelyfollowinginjectiondistributetheanestheticthroughoutthe
trachea.Althoughtheseblocksmayallowtheawakepatienttotolerateintubationbetter,
theyalsoobtundprotectivecoughreflexes,depresstheswallowingreflex,andmaylead

toaspiration.Topicalanesthesiaofthepharynxmayinduceatransientobstructionfrom
thelossofreflexregulationofairwaycaliberattheleveloftheglottis.
Becauseofthispatientsincreasedriskforaspiration,localanesthesiamightbestbe
limitedto

CHAPTER19AirwayManagement339

FIGURE1935Superiorlaryngealnerveblockandtranstrachealblock.
thenasalpassages.Fourpercentcocainehasnoadvantagescomparedwithamixtureof
4%lidocaineand0.25%phenylephrineandcancausecardiovascularsideeffects.The
maximumsafedoseoflocalanestheticshouldbecalculatedandnotexceeded.Local
anestheticisappliedtothenasalmucosawithcottontippedapplicatorsuntilanasal
airwaythathasbeenlubricatedwithlidocainejellycanbeplacedintothenariswith
minimaldiscomfort.Benzocainesprayisfrequentlyusedtotopicalizetheairway,but
canproducemethemoglobinemia.
Whyisitnecessarytobepreparedforasurgicalairway?
Laryngospasmisalwaysapossiblecomplicationofintubationinthenonparalyzed
patient,evenifthepatientremainsawake.Laryngospasmmaymakepositivepressure
ventilationwithamaskimpossible.Ifsuccinylcholineisadministeredtobreakthespasm,
theconsequentrelaxationofpharyngealmusclesmayleadtoupperairwayobstruction
andcontinuedinabilitytoventilate.Inthissituation,anemergencycricothyrotomymay
belifesaving.
Whataresomealternativetechniquesthatmightbesuccessful?
Otherpossiblestrategiesincludetheretrogradepassageofalongguidewireorepidural
catheterthroughaneedleinsertedacrosstheCTM.Thecatheterisguidedcephaladinto
thepharynxandoutthroughthenoseormouth.ATTispassedoverthecatheter,which
iswithdrawnafterthetubehasenteredthelarynx.Variationsofthistechniqueinclude
passingtheretrogradewirethroughthesuctionportofaflexibleFOBorthelumenofa
reintubationstyletthathasbeenpreloadedwithaTT.ThesethickershaftshelptheTT
negotiatethebendintothelarynxmoreeasily.Obviously,avastarrayofspecialized
airwayequipmentexistsandmustbereadilyavailableformanagementofdifficult
airways(Table198).Eitherofthesetechniqueswouldhavebeendifficultinthepatient
describedinthiscase

TABLE198Suggestedcontentsoftheportablestorageunitfordifficult
airwaymanagement.1,2

Rigidlaryngoscopebladesofalternatedesignandsizefromthoseroutinelyused.

Trachealtubesofassortedsize.

Trachealtubeguides.Examplesinclude(butarenotlimitedto)semirigidstyletswithorwithouta
hollowcoreforjetventilation,lightwands,andforcepsdesignedtomanipulatethedistalportion
ofthetrachealtube.

Laryngealmaskairwaysofassortedsizes.

Fiberopticintubationequipmentandassortedvideoandindirectlaryngoscopes.

Retrogradeintubationequipment.

Atleastonedevicesuitableforemergencynonsurgicalairwayventilation.Examplesinclude(but
arenotlimitedto)transtrachealjetventilator,hollowjetventilationstylet,andCombitube.

Equipmentsuitableforemergencysurgicalairwayaccess(eg,cricothyrotomy).

AnexhaledCO2detector.
Modifiedandused,withpermission,fromtheAmericanSocietyofAnesthesiologists:Practiceguidelinesfor
managementofthedifficultairway:AreportbytheAmericanSocietyofAnesthesiologistsTaskForceonManagement
oftheDifficultAirway.Anesthesiology2003;98:1272.
1

Theitemslistedinthistablearesuggestions.Thecontentsoftheportablestorageunitshouldbecustomizedtomeet
thespecificneeds,preferences,andskillsofthepractitionerandhealthcarefacility.
2

340SECTIONIII
AnestheticManagement

FIGURE1936Intubatinglaryngealmaskairway.
becauseoftheswellingandanatomicdistortionoftheneckthatcanaccompanya
submandibularabscess.

Whataresomeapproacheswhentheairwayisunexpectedlydifficult?
Theunexpecteddifficultairwaycanpresentbothinelectivesurgicalpatientsandalsoin
emergencyintubationsinintensivecareunits,theemergencydepartment,orgeneral
hospitalwards.Shouldvideolaryngoscopyfailevenafterattemptswithanintubating
bougie,anintubatingLMAshouldbeattempted(Figure1936).Ifventilationis
adequate,anFOBcanbeloadedwithaTTandpassedthroughtheLMAintothetrachea.
Correcttubepositionisconfirmedbyvisualizationofthecarina.

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