AIRWAY MANAGEMENT

Dr. J. Sisnorio-Chan

Difficult Intubation / larynoscopy

 Successful intubation requiring more than three
attempts or taking longer than 10 minutes

**Competence in airway management is a critical skill

for safely administering anesthesia.

AIRWAY ANATOMY
 Upper Airway – structures located above the
glottis opening PHARYNX
 Nostrils, nasal cavity, paranasal sinuses **The nasal and oral cavities are connected to the
 Pharynx (Glossopharyngeal, Vagus) larynx and esophagus by the pharynx. The pharynx is a
 Larynx musculofascial tube that can be divided into the
 Trachea nasopharynx, the oropharynx, and the hypopharynx.
 Principal bronchi The nasopharynx is separated from the oropharynx by
the soft palate. The epiglottis demarcates the border
 Lower Airway – below the vocal cords and into between the oropharynx and the hypopharynx.
the lungs Innervation is by way of cranial nerves IX
(glossopharyngeal) and X (vagus)
**Air is warmed and humidified as it passes through the
nares during normal breathing

LARYNX
**Innervation of the nasal cavity.
The adult larynx is between the third and the sixth
cervical vertebrae.12 It functions in the modulation of
A diagram of the lateral wall of the nasal cavity
sound and separates the trachea from the esophagus
illustrates its sensory nerve supply. The anterior
during swallowing. This protective mechanism, when
ethmoidal nerve, a branch of the ophthalmic division of
exaggerated, becomes laryngospasm. The larynx is
the trigeminal nerve, supplies the anterior third of the
composed of muscles, ligaments, and cartilages
septum and lateral wall (A). The maxillary division of the
(thyroid, cricoid, arytenoids, corniculates, and
trigeminal nerve via the sphenopalatine ganglion
epiglottis).
supplies the posterior two thirds of the septum and the
lateral wall
The vocal cords are formed by the thyroarytenoid
ligaments and are the narrowest portion of the adult
airway. The anterior-posterior dimension of the vocal
cords is approximately 23 mm in males and 17 mm in cartilage, the cricoid, is the only one that has a full ring
females. The vocal cords are 6 to 9 mm in the structure.
transverse plane but can expand to 12 mm. It is shaped like a signet ring, wider in the cephalocaudal
dimension posteriorly.
This calculates to a glottic aperture of 60 to 100 mm. An
understanding of the motor and sensory innervation of AIRWAY ASSESSMENT
the laryngeal structures is important for performing
anesthesia of the upper airway. History and Anatomic Examination
 Identify any possible problem with maintaining,
Motor and Sensory Innervation of Larynx protecting, and providing a patent airway
Nerve Sensory Motor during anesthesia
Superior Epiglottis None  Evaluation with physical examination and
laryngeal, Base of the tongue review of patient’s history and anesthetic
internal Supraglottic records
division mucosa **Why should we assess a patient’s airway
Thyroepiglottic preoperatively?
joint The goal of evaluating a patient’s airway is to attempt
Cricothyroid joint to identify any possible problem with maintaining,
Superior Anterior subglottic Cricothyroid protecting, and providing a patent airway during
laryngeal, mucosa muscle anesthesia.
External
The evaluation is performed with the aid of physical
division
examination and a review of the patient’s history and
Recurrent Subglottic mucosa Thyroarytenoid
anesthetic records.
laryngeal Muscle spindles m.
Lateral
cricoarytenoid m.
Interarytenoid m.
Posterior
cricoarytenoid m.

TRACHEA
The trachea begins at the sixth cervical vertebra and
extends to the carina, which overlies the fifth thoracic
vertebra. It is 10 to 15 cm long and supported by 16 to
20 horseshoe-shaped cartilages. The most cephalad
History
 Documented history of difficulties with general 1. Disproportion
anesthesia or, more specifically, mask  Size of the tongue in relation to the
ventilation or endotracheal intubation oropharyngel size
 Congenital syndromes associated with difficult  A high mallampati score (class 3 or 4) is
endotracheal intubation associated with more difficult intubation
 Pathologic states that influence airway
management **Mallampati Classification- maximal mouth
opening and tongue protrusion in the sitting
Congenital Syndromes Associated with Difficult position (originally described without
Endotracheal Intubation phonation)
Syndrome Description
Trisomy 21 Large tongue, small mouth
make laryngoscopy
difficult
Small group subglottic
diameter possible
Goldenhar Mandibular hypoplasia
(oculoauriculovertebral and cervical spine
anomalies) abnormality make
laryngoscopy difficult
Klippel-feil Neck rigidity because of
cervical vertebral fusion
Pierre robin Small mouth, large
tongue, mandibular
anomaly
Treaher Collins Laryngoscopy is difficult
(mandibular dysostosis)
Turner High likelihood of difficult
tracheal intubation ** Mallampati proposed a classification system
(Mallampati score) to correlate the oropharyngeal
6-D Method of Airway Assessment space with the ease of direct laryngoscopy and tracheal
intubation.
Six signs that can be associated with a difficult With the observer at eye level, the patient holds the
intubation head in a neutral position, opens the mouth maximally,
1. Disproportion and protrudes the tongue without phonating. The
2. Distortion airway is classified according to the visible structures:
3. Decreased thyromental distance Class I: The soft palate, fauces, uvula, and tonsillar
4. Decreased inter-incisor gap pillars are visible.
5. Decreased range of motion in any or all joints of Class II: The soft palate, fauces, and uvula are visible.
the airway Class III: The soft palate and base of the uvula are
6. Dental overbite visible.
Class IV: The soft palate is not visible.
There is a correlation between the Mallampati score, 5. Decreased range of motion in any or all joints
what can be seen on direct laryngoscopy, and the ease of the airway
of intubation. The laryngoscopic view is classified  Atlanto-occipital joint, cervical spine and TMJ
according to the Cormack and Lehane score (Fig. 16-7).  SNIFFING POSITION
Grade I: Most of the glottis is visible. - Head extension <350
Grade II: Only the posterior portion of the glottis is - Neck flexion <350
visible. - Short thick neck
Grade III: The epiglottis, but no part of the glottis, can - Cervical spine collar or C spine
be seen. immobilization
Grade IV: No airway structures are visualized.
**Sniffing position – 8-10 cm elevation under
2. Distortion the occiput
 Etiology
o neck mass, neck hematoma, neck 6. Dental overbite
abscess, previous surgery or trauma)  Large angled teeth disrupt the alignment of
 Predicting airway distortion problems: the airway axes and possibly result in
- Voice change decreased inter-incisor opening
- Subcutaneous emphysema  Protruding maxillary incisors
- Laryngeal immobility
- Nonpalpable thyroid and/or cricoid Signs of Upper Airway Obstruction / Distress
- Neck asymmetry/tracheal deviation  Hoarse voice
 Decreased air in and out
3. Decreased thyromental distance  Stridor
 Thyromental distance : <7cm (<3  Retraction of
fingerbreadths)) suprasternal/supraclavicular/intercostals space
 Underdeveloped mandible  Cyanosis
ESTABLISHING A PATENT AIRWAY
Non-equipment
o Head tilt/ chin lift/ jaw thrust
With equipment
o Oro/nasopharyngeal airway
o Endotracheal intubation
o Laryngeal mask airway (LMA)

AIRWAY MANGEMENT TECHNIQUE

**Reflects an anterior larynx and decreased Ventilation with a Facemask
submandibular space

4. Decreased inter-incisor gap

 Distanced between the upper and lower
incisor is <4cm (<2FB)
 Reduced mouth opening
- Mandibular condyle fracture
- Rigid cervical collar
- TMJ dysfunction

**Failure to place an endotracheal tube is not the
actual cause of the severe adverse outcomes related to
difficult airway management. The primary problem is an
inability to oxygenate, ventilate, prevent aspiration, or a
combination of these factors.
The mask is gently held on the patient's face with the
left hand, leaving the right hand free for other tasks
(Fig. 29-2). Air leak around the edges of the mask is
prevented by downward pressure. The facemask should
be held to the patient’s face with the fingers of the
anesthesia provider’s left hand lifting the mandible
(chin lift, jaw thrust) to the facemask. Pressure on the
submandibular soft tissue should be avoided because it
can cause airway obstruction. The anesthesia provider’s
left thumb and index finger apply counter pressure on
the facemask. Displacement of the mandible, atlanto-
occipital joint extension, chin lift, and jaw thrust
combine to maximize the pharyngeal space. Differential
application of pressure with individual fingers can
improve the seal attained with the facemask.
The anesthesia provider’s right hand is used to generate
positive pressure by compressing the reservoir bag of
the anesthesia breathing circuit. Ventilating pressure
should be less than 20 cm H2O to avoid insufflation of
the stomach.
Assessment and Predictability of Difficult Mask
Ventilation
Criteria for difficult mask ventilation
 Inability for one anesthesiologist to maintain
oxygen saturation >92%
 Significant gas leak around face mask
 Needs for ≥ 4 liters per minute gas flow (or use
of fresh gas flow button more than a twice)
 No chest movement
 Two-handed mask ventilation needed
 Change of operator required
Independent risk factors for difficult
Mask ventilation odds ratio
Presence of a beard 3.18
Body mass index >26ng/m2 2.75
Lack of teeth 2.28
Age >55 years 2.26
History of snoring 1.84
PREDICTORS OF DIFFICULT FACEMASK VENTILATION
Independent variables associated with difficult
facemask ventilation are (1) age older than 55 years, (2)
a body mass index greater than 26 kg/m2, (3) a beard,
(4) lack of teeth, (5) a history of snoring, (6) repeated
attempts at laryngoscopy,(7) Mallampati class III to IV,
(8) neck radiation, (9) male gender, and (10) limited
ability to protrude the mandible
BASIC AIRWAY ADJUNCTS
 Oropharyngeal airways
 Nasopharyngeal airways
 Endotracheal tubes
 Laryngeal mask airway
 Combitube
 Oropharyngeal airways
 Keep the tongue from blocking the airway
 Allow for easier suctioning of the airway
 Used on unconscious patients without gag
reflex
 Used in conjunction with bag valve mask
**The correct size OPA is chosen by measuring
from the middle of the persons mouth to the
angle of the jaw.
Oral airways relieve airway obstruction by
displacing the tongue anteriorly. Too large an
oral airway will either obstruct the glottis or
may cause coughing, gagging, or laryngospasm
in a patient who is not deeply anesthetized. Too
small an oral airway will push the tongue
posteriorly and make the airway obstruction
worse. Oral airways should be placed with care
to prevent trauma to the teeth
and oropharynx.
 Nasopharyngeal airways
 Conscious patient who cannot maintain
airway
 Can be used with intact gag reflex
 Should not be used with head injuries or
nosebleeds
 **The correct size airway is chosen by
measuring the device on the patient: the TECHNIQUE FOR ENDOTRACHEAL INTUBATION
device should reach from the patient's nostril  Sniffing Position
to the earlobe or the angle of the jaw  Align the axes of the patients mouth pharynx
and larynx permitting direct visualization of
 Endotracheal tubes
the larynx by laryngoscopy
The appropriately sized endotracheal tube for
 Opening the patient’s mouth
infants and children can be estimated by using the
 Scissor maneuver – using the index finger to
following formula:
pull the upper right incisor towards the
 (Age + 16) / 4 = ET size
operator – serves to open the mouth, extend
the AO joint, and protect the lips and teeth.
 Laryngeal mask airway
 Does not protect the airway from aspiration
 LMA classic is reusable

**Laryngeal mask airways are supraglottic

airway devices that can be used for both
routine airway management as well as in
difficult airway situations. LMAs are ideally
suited for situations in which the patient is
breathing spontaneously, but can also be used
to deliver positive pressure Ventilation

LMA does not protect the airway from
aspiration and
should not be routinely used in patients with
full stomachs
or those at increased risk for aspiration. The
LMA Classic is reusable and the LMA Unique is
disposable.
The laryngeal mask is a device for supporting
and maintaining the airway without tracheal
intubation. The laryngeal mask may be used as
an aid to intubation;
**Flexion of the neck, by elevating the head
approximately 10 cm, aligns the laryngeal and
pharyngeal axes. Extension of the head on the atlanto-
occipital joint is important for aligning the oral and
pharyngeal axes to obtain a line of vision during direct
laryngoscopy (Fig. 16-8). These maneuvers place the
head in the “sniffing” position and bring the three axes
into optimal alignment.

INDICATION FOR ENDOTRACHEAL INTUBATION

 Provide a patent airway
 Prevent inhalation (aspiration) of gastric
contents
 Need for frequent suctioning
 Facilitate positive-pressure ventilation of the
lungs
 Operative position other than the supine
 Operative site near or involving the upper
airway
 Airway maintenance by mask difficult
PERFORMING LARYNGOSCOPY
 Laryngoscopes
a. Straight blade – favored for children and is
designed to pass epiglottis
b. Curved (Mac) – designed so that the tip lies
anterior to epiglottis
**Straight (Miller) Blade
The tip of the straight blade is passed beneath the
laryngeal surface of the epiglottis (see Fig. 16-12B).
Forward and upward movement of the blade exerted
along the axis of the laryngoscope handle directly
elevates the epiglottis to expose the glottic opening.
Depression or lateral movement of the patient’s thyroid
cartilage externally on the neck (known as optimal
external laryngeal manipulation [OELM] or backward
upward rightward pressure [BURP]) with the
laryngoscopist’s right hand may facilitate
exposure of the glottic opening
Curved (Macintosh) Blade
The tip of the curved blade is advanced into the space
between the base of the tongue and the pharyngeal
surface of the epiglottis (Fig. 16-12A). Forward and
upward movement of the blade exerted along the axis
of the
laryngoscope handle stretches the hyoepiglottic
ligament, elevates the epiglottis, and exposes the glottic
opening.
**The endotracheal tube is held in the anesthesia
provider’s right hand like a pencil and introduced into
the right side of the patient’s mouth with the natural
curve directed anteriorly. It should be advanced toward
the glottis from the right side of the mouth as midline
insertion usually obscures visualization of the glottic
opening. The tube is advanced until the proximal end of
the cuff is 1 to 2 cm past the vocal cords, which should
place the distal end of the tube midway between the
vocal cords and carina.
At this point, the laryngoscope blade is removed from
the patient’s mouth. The cuff of the endotracheal tube
is inflated with air to create a seal against the tracheal
mucosa. This seal facilitates positive-pressure
ventilation
of the lungs and decreases the likelihood of aspiration
of pharyngeal or gastric contents. Use of the minimum
volume of air in a low-pressure high-volume cuff that
prevents leaks during positive ventilation pressure (20
to 30 cm H2O) minimizes the likelihood of mucosal
ischemia resulting from prolonged pressure on the
tracheal wall.
Nevertheless, all aspects of tracheal intubation can
produce some type of laryngotracheal damage. For
example, ciliary denudation has been found to occur
predominantly over the tracheal rings and underlying
the cuff site after only 2 hours of intubation and with
tracheal wall pressure below 25 mm Hg Other serious
complications attributable to endotracheal cuff
pressures include tracheal stenosis, tracheal rupture,
tracheoesophageal fistula, tracheocarotid fistula, and
tracheoinnominate artery fistula. After confirmation of
correct placement (end-tidal CO2, auscultation for
bilateral
breath sounds, ballottement of cuff in the suprasternal
notch), the endotracheal tube is secured in position
CONFIRMATION OF CORRECT ET PLACEMENT
 Immediate absolute proof
 Observing tube passing through vocal cords
 Observing carbon dioxide (ETCO2)
 Visualizing tracheal lumen using fiberoptic
scope
 Indirect confirmation
 Listening over epigastrium = absence of
breath sounds with ventilation
 Observing chest to rise and fall with PPV
 Listening to apex of each lung for breath
sound with ventilation.
BASIC AIRWAY EQUIPMENT
• Suction
• Oxygen source
• Ambu Bag/Bag Valve Mask
 • Oral/Nasal Airways  Lip, tongue, mucosal laceration
• Endotracheal tubes/Stylets  Dislocated mandible
• CO2 Detectors  Retropharyngeal dissection
• Laryngoscope blades (Macintosh (Mac), Miller,  Cervical spine
Wisconsin)
 Airway trauma
• Supraglottic devices
 mucosal inflammation
• LMA
 excoriation of nose
Complications
 Tube malfunction
 Malposition
 esophageal/ bronchial intubation  Obstruction/kinking

 Trauma  Aspiration
 Tooth damage

Pathologic States that Influence Airway Management