dr Joseph R.

, Sp An
 Ab-ductor
Posterior
cricoarytenoid
Tensor
Cricothyroid
Ad-ductors
All the rest
sagittal-section
of Trachea
 Innervation
Vagus n.
Superior laryngeal n.
External branch motor
to cricothyroid m.
Internal branch sensory
larynx above TVCs
Recurrent laryngeal n.
Right subclavian
Left Aortic arch (board
question)
Motor to all other
muscles, Sensory to
TVCs and trachea
 Innervation of
oropharynx
Glossopharyngeal n.
innervates tongue
base and oropharynx
 Membranes
Thyrohyoid
Cricothryoid
Cartilages
Hyoid
Thyroid
Cricoid
 Head and neck
movement (extension)
Cervical spine arthritis or
trauma, burn, radiation,
tumor, infection,
scleroderma, short and
thick neck
 Jaw Movement
Both inter-incisor gap
and anterior subluxation
<3.5cm inter-incisor
gap concerning
Inability to sublux lower
incisors beyond upper
incisors
Receding mandible
Protruding Maxillary
Incisors (buck teeth)
 Obesity
Distribution, i. e.
short, thick neck
more concerning
Neck circumference
 Thyromental
distance: bony
point on mentum
(mandible) to
thyroid notch
If short (<3FBs or
6cm), pharyngeal
and laryngeal axis
off
 Oropharyngeal visualization
Mallampati Score
Sitting position, protrude tongue, dont say
AHH

Class I : Visualization of the soft palate, fauces; uvula, anterior and the posterior
pillars.
Class II : Visualization of the soft palate, fauces and uvula.
Class III : Visualization of soft palate and base of uvula.
Class IV: Only hard palate is visible. Soft palate is not visible at all.
 Difficulty ventilating
Age >55
History of snoring
Lack of teeth
BMI >26
 Replaces the nitrogen volume of the lungs
(69% of FRC) with oxygen
Functional residual capacity (residual volume
and expiratory reserve volume)
Preoxygenation with 100% oxygen via tight-
fitting mask for 5 minutes up to 10 min of
oxygen reserve following apnea
Lung Volumes
Tidal Volume (Vt).
Normal 500 cc.

Dead space.
150 cc.

Minute Volume.
MV = Tidal volume x respiratory rate.
Normal 6,500-7,500 ml.
 Sniffing position
Lower neck flexion
Upper neck extension
Important in obesity
 Head Tilt Chin Lift
This maneuver should only be used if the physician
is confident there is no risk of injury to the c-spine
 Jaw Trust
Where there is risk of c-spine injury, such as a
patient who is unconscious as a result of a head
injury, the airway should be opened using a
maneuver that does not require neck movement.
 Once an open airway has been established,
the physician may choose to use either an
oropharyngeal or nasopharyngeal airway to
make it easier to maintain an open airway.
Both of these devices prevent the tongue
from occluding the airway and thereby
provide an open conduit for air to pass.
 Oropharingeal airway
 Nasopharingeal airway
 Induction of
anesthesia
produces upper
airway relaxation
and possible
collapse
Downward
displacement of
mask with thumb
and index finger www.aic.cuhk.edu.hk
 Upward traction of
remaining fingers
upward
Fingers on bony
mandible
Fifth digit at angle
displacing mandible
anteriorly

www.aic.cuhk.edu.hk
 Oral airway
Two-handed technique

www.aic.cuhk.edu.hk
www.haworth21.karoo.net
 Carries prominent
position in ASA algorithm
May be held like a pencil
Balloon partially inflated
Directed posteriorly and
upwards towards the
palate
Jaw thrust and sniffing
position may help
placement

www.brandianestesia.it/Images/LMA-ins.jpg
 Verify placement by ventilating
Check for good chest rise, ETCO2, and adequate
tidal volumes
Check for leak if significant leak at around 10cm
H2O problematic
May try size larger or smaller
May try to inflate/deflate cuff to obtain better seal
If difficulty passing may try inserting upside down
and then flipping around
 Open the mouth with
right hand
Scissor technique
Gently insert
laryngoscope into right
side of mouth pushing
tongue to the left
Careful with insertion
not to hit teeth
Advance laryngoscope
further into
oropharynx with
applied traction 45
degrees
 Look for epiglottis
If initially not found
insert laryngoscope
further
If this maneuver does
not work slowly pull
laryngoscope back
Once epiglottis
visualized, push
laryngoscope into
vallecula and apply
traction at 45 degree
angle to push epiglottis
up and out of the way

www.int-med.uiowa.edu/Research/TLIRP/Bronchos
 Look for vocal cords or
arytenoid cartilages and try
to optimize view
(i.e. lift head, apply more
traction at 45 degree angle
if necessary)
Do not move once view is
optimized!
Assistant will hand you ETT
Insert ETT into far right
aspect of mouth
Traction of laryngoscope
slightly to left may assist
Traction of laryngoscope at
45 degrees will also help
keep mouth open
 Insert ETT above and between arytenoids and
through vocal cords
Try to visualize the ETT passing between the
vocal cords
If this is not possible, then you must visualize the
ETT passing above and between the arytenoids
 During laryngoscopy and intubation
I. Malpositioning
a. esophageal intubation
b. endobronchial intubation
II. Airway trauma
a. tooth damage
b. lip, tongue, or mucosal laceration
c. dislocated mandible
d. sore throat
e. retropharyngeal dissection
III. Physiologic reflexes
a. hypertension, tachycardia
b. intracranial hypertension
c. intraocular hypertension
d. laryngospasm
IV. Tube malfunction
a. cuff perforation
 ASA Difficult Airway Algorithm
www.metrohealthanesthesia.com
Difficult Airway Society guidelines
 http://www.jwatch.org/em20010228000001
2/2001/02/28/intubating-position-sniffing-
position-better