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
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 Cut Length

Diameter (cm)
(mm)
Full-term infant 3.5 12

Child

Adult

Female 6.5-7.0 24

Male 7.5–9.0 24
Airway Equipment
• Loss of upper airway muscle tone in
anesthetized patients allows the tongue and
epiglottis to fall back against the posterior
wall of the pharynx.
• Repositioning the head or a jaw thrust is the
preferred technique for opening the airway
• An artificial airway can be inserted through
the mouth or nose to create an air passage
between the tongue and the posterior
pharyngeal wall
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 (5–10 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