Airway

management
Hello!
I am Jose Seclon
And this is Anesthesia Basics, Airway
management.
 Airway management

Competence in airway management requires:

� Knowledge of the anatomy and physiology of the
airway
� Ability to assess the patient’s airway for the
anatomic features that correlate with difficult
airway management
� Skill with the many devices for airway
management
� Appropriate application of ASA algorithm for
difficult airway management
 Anatomy and
Physiology of the
upper airway
Foundations of airway management
 “
“When you use a guide wire it
is presumed that you are in
need of help”
-Dr. Espina 1993
Components of the upper airway

�Nose and mouth

�Pharynx
�Larynx
�Trachea
Nose and Mouth
 Pharynx

�Nasopharynx
�Oropharynx
�Hypopharynx
Larynx

�thyroid,
�cricoid,
�arytenoids,
�Corniculates
�epiglottis
Trachea

�10-15 cm long
�16-20 horse shoe shaped
cartilage
�Cricoid – only complete ring
structure
Airway assessment
It’s easy as… 1 2 3?
History and anatomic examination

� Oropharyngeal space
� Atlanto-occipital
extension / Neck mobility
� Thyromental Distance /
Sternomental distance
� Submandibular
compliance
� Body habitus
Oropharyngeal space

� Interincisor gap
� Size and position of the
maxillary and mandibular
teeth
� Conformation of the
palate
Oropharyngeal space

Upper lip bite test (ULBT):

� Class 1: Lower incisors can bite

above the vermillion border of the
upper lip.
� Class 2: Lower incisors cannot
reach the vermillion border.
� Class 3: Lower incisors cannot bite
the upper lip.
Mallampati classification
Cormack Lehane score
Atlanto-occipital Extension / Neck
mobility
Thyromental Distance

� Estimated in fingerbreadths
� 3 ordinary fingerbreadths
� < 6-7 cm correlates with a poor
laryngospic view (receding mandible
and short neck)
 Body Habitus

� Obesity
Airway management
techniques
Foundations of Ventilation
Oxygen supplementation

� Nasal Cannula
� Face tent
� Face mask
Airway management techniques

Predictors of difficult facemask

ventilation:
� Age older than 55 years
� BMI > 26 kg/m2
� A Beard
� Lack of teeth
� Snoring
� Mallampati III to IV
� Limited ability to protrude mandible
 Technique: facemask

� One hand
� E-C clamp
� Chin lift
� Jaw thrust
� Maintain proper
alignment
 Technique: facemask

� Two hand
technique
� Three hand
technique
� Chin lift
� Jaw thrust
� Proper alignment
 Airway adjuncts

Oral airways
� Hard plastic
� Shaped to curve
behind tongue

Nasal airway
� Better tolerated
� Epistaxis
 Endotracheal intubation

Indications:
� Provide patent airway
� Prevent inhalation
(aspiration)
of gastric contents
� Positive pressure
ventilation
� Operative site near upper
airway
� Airway maintenance
 Endotracheal intubation

Equipments:
� Properly sized endotracheal tube
� Laryngoscope
� Appropriate anesthetic drug
� Equipment for providing positive
pressure ventilation
Technique of Direct Laryngoscopy and
intubation
Cricoid pressure

� Sellicks manuever
 Laryngoscopes

� Curved
(macintosh)
� Straight (Miller)
� Flextip (Heine,
CLM)
Curved vs straight
Flex Tip
 Advantages

Curved (Macintosh) blade

� Less traumatic to teeth
� More room for passage of ET tube
� Less bruising

Straight (Miller) blade

� Better exposure of glottic opening
 Characteristics of ET tube

� 2-10 mm (0.5 mm ID increments)

� Lengthwise centimeter markings
� Clear, inert polyvinyl chloride plastic
� Radiopaque
� Transparent
 Insertion technique

� Like a pencil
� Right side
� Curve anteriorly directed
� Advanced until 1-2 cm
past vocal cords
� Cuff inflated to seal
 Gum elastic bougie

� Neither made of gum or elastic

� Relatively cheap
� Malleable / flexible
� Bent tip at 30 degree angle
 Schroeder

� Disposable
� Plastic
� Adjustable angle
� Both oral and nasal
 Lighted stylets

� Blunt curved tip

� Can be passed blindly
When visualization is
inadequate
� Jet ventilation
 Lighted stylets

� malleable
� Light at distal tip
� Transillumination through
neck
 Seeing Optical stylet

� malleable
� High resolution
� Fiber optic
 Confirmation of endotracheal tube

� Capnography
(ETCo2 of >30 mmHg for 3-5 breaths)
� Symmetrical bilateral movement of
the
chest
� Bilateral breath sounds
� Characteristic feel of the reservoir
bag
� Breath fogging
 Techniques for routine intubation

� Preoxygenation
� Administration of inducting agents
� Adequate mask ventilation
� Administration of rapidly acting
neuromuscular agent
� Intubation
� Confirmation of tube in trachea
 Fiberoptic endotracheal intubation

� Difficult tracheal intubation is

anticipated
� Can be performed before induction of
GA
� Unstable cervical spine
� Sustained an injury to the upper
airway
 Contraindications of Fiberoptic
endotracheal intubation

� Lack of time (absolute)

� Field of vision obstructed
� Blood and secretions
� Pharyngeal abscess
 Technique of Fiberoptic endotracheal
intubation

� Oral or nasal approach

� Awake or anesthesized
 Preparation of Fiberoptic endotracheal
intubation

� Antisialogogue (glycopyrrolate 0.2 mg IV)

� Sedation
� Nasal mucosa must be anesthesized and
Vasoconstricted
� Local anesthetic sprayed, aresolized or
Nebulized into the airway
 Fiberoptic endotracheal intubation

� Sedation
� Topical anesthesia
� ET tube on scope
� Insert past
epiglottis
� Remove
endoscope
� Check placement
Laryngeal mask airway
 Insertion technique

� Open mouth
� Press tip upward
against palate
� Use index finger to
guide pressing
backwards along
palate
� Until resistance is
felt
 Insertion technique

� Use other hand to

press
down on LMA tube
while
removing index finger
� Inflate seal (60 cm
h20)
� Don’t hold tube while
inflating the balloon
 Cricothyrotomy

� Invasive airway
� Emergency access
� Incision through skin
and cricothyroid
membrane
� Last resort
 Cricothyrotomy technique

� Identify cricothyroid
membrane
� Horizontal stab
� Leave blade in place
until hook is in
position
� Caudal and outward
traction
� Insert tube and
 Tracheal extubation criteria

Subjective Clinical Criteria:

� Follows commands
� Clear oropharynx / hypopharynx
� Intact gag reflex
� Sustained head lift for 5 seconds
� Sustained hand grasp
� Adequate pain control
� Minimal end expiratory concentration
of inhaled anesthetics
 Tracheal extubation criteria

Objective Criteria:
� Vital capacity > 10 cc/kg
� Peak voluntary negative inspiratory
pressure
> 20 cm h2o
� Tidal volume > 6 cc/kg
� Alveolar-arterial PaO2 gradient <350
mmhg
� Dead space tidal volume ratio <0.6
 Difficult airway algorithm

Assess
likelihood of
clinical
impact of
basic
management
problems

Deliver
Supplement
al O2

Consider:
 Complications of tracheal intubation

Direct laryngoscopy and tracheal

intubation:
� Dental and soft tissue damage
� Systemic hypertension and tachycardia
� Cardiac dysrythmias
� Myocardial ischemia
� Inhalation of gastric contents
 Complications of tracheal intubation

While tracheal tube is in place:

� Tracheal tube obstruction
� Endobronchial intubation
� Esophageal intubation
� Tracheal tube cuff leak
� Pulmonary barotrauma
� Nasogastric distention
� Accidental dissconection from anesthesia
machine
 Complications of tracheal intubation

Immediate and delayed complications after

extubation:
� Laryngospasm
� Inhalation of gastric contents
� Pharyngitis
� Laryngitis
� Laryngeal edema
� Laryngeal ulceration
� Tracheal stenosis
 “
“Just because you are
breathing doesn’t mean that
you are alive”
-Siao 2015
Thank you!
Any questions?
You can email me at joseseclon@yahoo.com
and I answer them when I get the chance to
study.