AIRWAY MANAGEMENTAIRWAY MANAGEMENT

AngkanaAngkana LurngnateetapeLurngnateetape, MD., MD.Department of AnesthesiologyDepartment of Anesthesiology

Siriraj HospitalSiriraj Hospital

Perhaps the most important responsibility of the anesthesiologist is “management of the patient’s airway”

Miller RD’s Anesthesia 2000Barash PG, Cullen BF, Stoelting RK’sClinical Anesthesia 2001

What should we know about “airway management”?

- Maintenance and ventilation- Intubation and extubation- Difficult airway management

● Airway anatomy and function● Evaluation of airway● Clinical management of the airway

Airway anatomy The term “airway” refers to the upper

airway consisting of

● Nasal and oral cavities● Pharynx● Larynx● Trachea● Principle bronchi

Anterior view of Larynx

Lateral view of Larynx

Single CartilageSingle Cartilage

••EpiglottisEpiglottis

••ThyroidThyroid

••CricoidCricoid

Posterior of Larynx

Double CartilageDouble Cartilage

••CorniculatesCorniculates

••ArythenoidsArythenoids

••CuneiformsCuneiforms

Larynx in Laryngoscopic view

Nerves

Vagus nerve• Superior laryngeal n

– External br(Motor)

• cricothyroid m– Internal br

(Sensory)• area above cord

• Recurrent laryngeal n- Motor br

• intrinsic m – Sensory br

• area below cord

Evaluation of the airway

● History ● Physical examination● Special investigation

Evaluation of the airway

● Previous history of difficult airway● Airway-related untoward events● Airway-related symptoms/diseases

“History”

Evaluation of the airway

● Ease of open airway and maintenance● Ease of tracheal intubation● Teeth● Neck movement● Intubation hazards● Signs of airway distress

Physical examination

Evaluation of the airway

● Short muscular neck● Receding mandible● Protruding maxillary incisors● Long high-arched palate● Inability to visualize uvula● Limited temporomandibular joint mobility● Limited cervical spine mobility

Anatomic characteristics associated with difficult airway management

Evaluation of the airway

● Mallampati’s classification● Atlanto-occipital joint extension● Hyomental distance● Thyromental distance● Horizontal length of mandible● Sternomental distance

Assessment of airway associated with difficult airway management

> Class III< 35O

< 3 cm or 2 FB< 6 cm or 3 FB< 9 cm< 12 cm

Mallampati’s classificaton

Soft palateFaucesUvula

Soft palate Hard palateSoft palateFaucesUvulaPillar

Laryngoscopic view

Signs of upper airway obstruction/airway distress● Hoarse voice● Decreased air in and out● Stridor● Retraction of suprasternal /

supraclavicular / intercostal space● Tracheal tug● Restlessness● Cyanosis

How to open the airway?Non equipment :- head tilt / chin lift/jaw thrustWith equipment :- oro/nasopharyngeal airway

- endotracheal intubation- laryngeal mask airway (LMA)- combitube

Indication for tracheal intubation● Airway protection● Maintenance of patent airway● Pulmonary toilet● Application of positive pressure● Maintenance of adequate oxygenation

Face Mask

22 mm orifice22 mm orificeTransparent/ black rubberTransparent/ black rubberHookHookMinimize dead spaceMinimize dead space

One-handed face mask technique

Two-handed face mask technique

Preparation for Rigid Laryngoscopy

● Suction● Airway● Laryngoscope● ETT● Stylet● Anesthetic machine / Breathing system /

Self-inflating bag● Monitoring : Pulse Oximeter, Capnograph● Local infiltration, spray

Technique of Direct Laryngoscopy & Intubation

Oral endotracheal tube size guideline

20-2221-24

7.0 – 7.57.5 – 8.0

AdultFemale

Male

12+ Age/24 + Age/4Child

123.5Full term

Length(cm)

Int diameter(mm)

Age

Sign of Tracheal Intubation

• ETT visualized between cord

• Fiberoptic visualized of cartilaginious rings of the trachea and tracheal carina

Sign of Tracheal Intubation• Resp gas moisture disappearing on inhalation

and reappearing on exhalation

• Chest rise & fall

• No gastric distention

• ICS filling out during inspiration

Sign of Tracheal Intubation● Reservoir bag having the appropriate

compliance

Sign of Tracheal Intubation

● Breath sound over chest

● No breath sound over stomach

● Sound air exit from ETT when

chest is compressed

● Large spontaneous exhaled TV

Sign of Tracheal Intubation● CO2 excretion waveform

● Rapid expansion of an esophageal or tracheal indicator bulb

Techniques for routine intubation

● (Preoxygenation)

● Administration of induction agent

● Adequate mask ventilation

● Administration of rapidly acting

neuromuscular blocking agent

● Intubation

● Confirm tube in trachea

Technique for “rapid-sequence”(crash) induction and intubation● Preoxygenation 5 min

● Administration of induction and NM blocking agents

● Cricoid pressure (Sellick maneuver)

● “No” mask ventilation

● Check breath sound

● Release cricoid pressure

● Techniques for Difficult Ventilation

● Techniques for Difficult Intubation

Techniques for Difficult Airway Management

Techniques for Difficult Ventilation● Oral/Nasal Airway ● Two-person mask ventilation● Laryngeal Mask Airway (LMA) ● Surgical Airway Access● Esophageal-tracheal Combitube

Two person Mask Ventilation

Laryngeal Mask Airway

The Esophageal-tracheal Combitube

Techniques for Difficult Intubation● Stylet● Intubating stylet-tube changer● Alternative laryngoscope blades (e.g. Mc Coy

laryngoscope)● Awake intubation● Blind intubation (oral or nasal)● Fiberoptic intubation● Illuminating Stylet / Light wand ● Retrograde intubation● Surgical airway access

Stylet

Bullard rigid fiberoptic laryngoscope

Illumination StyletLight wand

Retrograde intubation

LMA,

COMBITUBE,

TTJV

INTUBATION

CHOICE *

INTUBATION

CHOICE *

AWAKE

INTUBATION

CHOICE *

Complication

During Laryngoscopy & IntubationWhile tube in placeFollowing Extubation

During Laryngoscopy & Intubation● Malposition

– Esophageal Intubation– Bronchial Intubation

● Trauma – Tooth damage– Lip, tongue, mucosal laceration– Dislocated mandible– Retropharyngeal dissection– Cervical spine

● Aspiration

Complication:

● Physiologic reflexes– HT, Arrthymia– Intracranial HT– Intraocular HT– Bronchospasm

● Tube malfunction– Cuff perforation

During Laryngoscopy & IntubationComplication:

● Malpositioning– Unintentional Extubation– Endobronchial Intubation– Laryngeal cuff malposition

● Airway trauma– Mucosal inflammation– Excoriation of nose

● Tube malfunction– Ignition – Obstruction / Kinking

● Aspiration

While tube in placeComplication:

● Airway trauma– Edema, Stenosis– Hoarseness / Sorethroat– Laryngeal malfunction

● Physiologic reflexes● Laryngospasm● Aspiration

Following Extubation

Complication:

Thank youand

Good Luck