AIRWAY

MANAGEMENT
F. Heru Irwanto
Dept. Anestesi-Reanimasi
FK UNPAD-FK UNSRI

ANATOMY
Successful intubation, ventilation,
cricothyrotomy, and regional anesthesia of
the larynx require detailed knowledge of
airway anatomy.
There are two openings to the human airway:
- pars nasalis
- pars oralis

Anatomy of the airway

 Loss of upper airway muscle tone in anesthetized

patients allows the tongue and epiglottis to fall back
against the posterior wall of the pharynx
Technique for opening the airway : triple airway
maneuver : head tilt, chin lift, jaw trust
To maintain the opening, though, an artificial airway
can be inserted through the mouth or nose to create
an air passage between the tongue and the posterior
pharyngeal wall

 Because of the risk of epistaxis, nasal airways should not

be used in anticoagulated patients or in children with
prominent adenoids
also, nasal airways should not be used in any patient who
has a basilar skull fracture

Common indications for tracheal

intubation

A. Provide patent airway.

B. Protection from aspiration from gastric
contents.
C. Facilitate positive-pressure ventilation.
D. Operative position other than supine.
E. Operative site near or involving the upper
airway.
F. Airway maintenance by mask is difficult.
G. Disease involving the upper airway.
H. One-lung ventilation.
I. Altered level of consciousness.
J. Tracheobronchial toilet.
K. Severe pulmonary or multisystem injury.

EQUIPMENT
STATICS
S : scope -> stethoscope, laryngoscope
T : tube
A : airway equipment
T : tape
I : introducer , stylet, mandrain
C: connector
S : suction

Rigid Laryngoscopes
A laryngoscope is an instrument used to
examine the larynx and to facilitate intubation
of the trachea.
The Macintosh and Miller blades are the
most popular curved and straight designs
The choice of blade depends on personal
preference and patient anatomy

A rigid laryngoscope

Tracheal Tubes
TTs can be used to deliver anesthetic gases
directly into the trachea and allow the most
control of ventilation and oxygenation
TTs are most commonly made from polyvinyl
chloride
The patient end of the tube is beveled to aid
visualization and insertion through the vocal
cords
Murphy tubes have a hole (the Murphy eye)
to decrease the risk of occlusion should the
distal tube opening abut the carina or trachea

 TTs have been modified for a variety of

specialized applications
Flexible, spiral-wound, wire-reinforced TTs
resist kinking and may prove valuable in
some head and neck surgical procedures or
in the prone patient

Oral Tracheal Tube Size Guidelines

Age

Internal
Diameter
(mm)

Cut Length
(cm)

Full-term infant

3.5

12

Female

6.5-7.0

24

Male

7.59.0

24

Child
Adult

Face Mask Design

The use of a face mask can facilitate delivery
of oxygen or of an anesthetic gas from a
breathing system to a patient by creating an
airtight seal with the patient's face
Transparent masks allow observation of
exhaled humidified gas and immediate
recognition of vomiting
Black rubber masks are pliable enough to
adapt to uncommon facial structures

 Effective ventilation requires both a gas-tight

mask fit and a patent airway
The mask is held against the face by
downward pressure on the mask body
exerted by the left thumb and index finger
The middle and ring finger grasp the
mandible to facilitate extension of the
atlantooccipital joint
The little finger is placed under the angle of
the jaw and used to thrust the jaw anteriorly,
the most important maneuver to allow
ventilation to the patient

TECHNIQUES OF DIRECT
LARYNGOSCOPY & INTUBATION
Intubation is not a risk-free procedure,
however, and not all patients receiving
general anesthesia require it
Successful intubation often depends on
correct patient positioning
Moderate head elevation (510 cm above
the surgical table) and extension of the
atlantooccipital joint place the patient in the
desired sniffing position

Orotracheal Intubation
The laryngoscope is held in the left hand
With the patient's mouth opened widely, the
blade is introduced into the right side of the
oropharynx
The tongue is swept to the left and up into the
floor of the pharynx by the blade's flange
The TT is taken with the right hand, and its tip
is passed through the abducted vocal cords

 After intubation, the chest and epigastrium

are immediately auscultated
If there is doubt about whether the tube is in
the esophagus or trachea, it is prudent to
remove the tube and ventilate the patient
with a mask

Difficult Airway
Other clues to a potentially difficult
laryngoscopy include :
limited neck extension (< 35)
a distance between the tip of the patient's mandible
and hyoid bone of less than 7 cm
a sternomental distance of less than 12.5 cm with
the head fully extended and the mouth closed
a poorly visualized uvula during voluntary tongue
protrusion (Mallampati classification)

Complications of Intubation
During laryngoscopy and intubation
Malpositioning
Esophageal intubation
Bronchial intubation

Airway trauma

Dental damage
- Lip, tongue, or mucosal laceration
- Sore throat
- Dislocated mandible

Physiological reflexes

Hypoxia, hypercarbia
Hypertension, tachycardia
Intracranial hypertension , Intraocular hypertension
Laryngospasm

Complications of Intubation
While the tube is in place
Malpositioning
Unintentional extubation, Bronchial intubation, Laryngeal
cuff position

Airway trauma
Mucosal inflammation and ulceration

Following extubation
Airway trauma
Edema and stenosis
Hoarseness (vocal cord granuloma or paralysis)
Laryngeal malfunction and aspiration

Laryngospasm