airway management may

8/3/2019 Airway Management May

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Airway Management Airway Management

Augusto Torres, MD Augusto Torres, MD

Department of AnesthesiologyDepartment of AnesthesiologyMetroHealth Medical Center MetroHealth Medical Center


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O utlineO utline

Review of airway anatomyReview of airway anatomy Airway evaluation Airway evaluation

Mask ventilationMask ventilationEndotracheal intubationEndotracheal intubationThe difficult airwayThe difficult airway


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Airway Anatomy Airway Anatomy

Ab Ab--ductor ductor Posterior Posterior

cricoarytenoidcricoarytenoid

Tensor Tensor CricothyroidCricothyroid

Ad Ad--ductorsductors

All the rest All the rest


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InnervationInnervationVagus n.Vagus n. Superior laryngeal n.Superior laryngeal n.

External branchExternal branch motor motor to cricothyroid m.to cricothyroid m.Internal branchInternal branch sensorysensorylarynx above TVCslarynx above TVCs

Recurrent laryngeal n.Recurrent laryngeal n.

RightRight subclaviansubclavianLeftLeft Aortic arch (board Aortic arch (boardquestion)question)Motor to all other Motor to all other muscles, Sensory tomuscles, Sensory toTVCs and tracheaTVCs and trachea


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Innervation of Innervation of oropharynxoropharynx Glossopharyngeal n.Glossopharyngeal n.

innervates tongueinnervates tonguebase and oropharynxbase and oropharynx


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MembranesMembranes ThyrohyoidThyrohyoid CricothryoidCricothryoid

CartilagesCartilages HyoidHyoid ThyroidThyroid CricoidCricoid


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Airway Evaluation Airway Evaluation

Take very seriouslyTake very seriouslyhistory of prior difficultyhistory of prior difficultyHead and neckHead and neck

movement (extension)movement (extension) Alignment of oral, Alignment of oral,

pharyngeal, laryngeal axespharyngeal, laryngeal axes Cervical spine arthritis or Cervical spine arthritis or

trauma, burn, radiation,trauma, burn, radiation,

tumor, infection,tumor, infection,scleroderma, short andscleroderma, short andthick neckthick neck


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Jaw MovementJaw Movement Both inter Both inter- -incisor gap andincisor gap and

anterior subluxationanterior subluxation


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O besityO besity Distribution, i. e. short,Distribution, i. e. short,

thick neck morethick neck more

concerningconcerning Neck circumferenceNeck circumference


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Thyromental distance:Thyromental distance:bony point onbony point onmentum (mandible) tomentum (mandible) to

thyroid notchthyroid notchIf short (


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Airway Evaluation Airway EvaluationO ropharyngeal visualizationO ropharyngeal visualizationMallampati ScoreMallampati ScoreSitting position, protrude tongue, dont saySitting position, protrude tongue, dont say

AHHAHH


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Difficulty ventilatingDifficulty ventilating Age >55 Age >55

BeardBeard History of snoringHistory of snoring Lack of teethLack of teeth BMI >26BMI >26


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PreoxygenationPreoxygenation

Replaces the nitrogen volume of the lungsReplaces the nitrogen volume of the lungs(69% of FRC) with oxygen(69% of FRC) with oxygenFunctional residual capacity (residualFunctional residual capacity (residualvolume and expiratory reserve volume)volume and expiratory reserve volume)Preoxygenation with 100% oxygen viaPreoxygenation with 100% oxygen viatighttight--fitting mask for 5 minutesfitting mask for 5 minutes up to 10up to 10

min of oxygen reserve following apneamin of oxygen reserve following apneaFour vital capacity breaths over 30Four vital capacity breaths over 30seconds (time to desaturation quicker)seconds (time to desaturation quicker)


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Patient PositioningPatient Positioning

Sniffing positionSniffing position Lower neck flexionLower neck flexion Upper neck extensionUpper neck extension Important in obesityImportant in obesity


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Mask VentilationMask Ventilation

Induction of Induction of anesthesia producesanesthesia producesupper airwayupper airwayrelaxation andrelaxation andpossible collapsepossible collapseDownwardDownwarddisplacement of maskdisplacement of maskwith thumb and indexwith thumb and indexfinger finger

www.aic.cuhk.edu.hk


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Upward traction of Upward traction of remaining fingersremaining fingersupwardupwardFingers on bonyFingers on bonymandiblemandibleFifth digit at angleFifth digit at angledisplacing mandibledisplacing mandibleanteriorlyanteriorly

www.aic.cuhk.edu.hk


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O ral airwayO ral airwayTwoTwo--handed techniquehanded technique

www.aic.cuhk.edu.hk

www.haworth21.karoo.net


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LMA PlacementLMA Placement

Carries prominentCarries prominentposition in ASA algorithmposition in ASA algorithmMay be held like a pencilMay be held like a pencil

Balloon partially inflatedBalloon partially inflatedDirected posteriorly andDirected posteriorly andupwards towards theupwards towards thepalatepalate

Jaw thrust and sniffingJaw thrust and sniffingposition may helpposition may helpplacementplacement

www.brandianestesia.it/Images/LMA-ins.jpg


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LMA PlacementLMA Placement

Verify placement by ventilatingVerify placement by ventilating Check for good chest rise, ETC O 2, andCheck for good chest rise, ETC O 2, and

adequate tidal volumesadequate tidal volumes Check for leakCheck for leak if significant leak at aroundif significant leak at around

10cm H2 O problematic10cm H2 O problematic May try size larger or smaller May try size larger or smaller May try to inflate/deflate cuff to obtain better May try to inflate/deflate cuff to obtain better

sealseal If difficulty passing may try inserting upsideIf difficulty passing may try inserting upside

down and then flipping arounddown and then flipping around


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Endotracheal IntubationEndotracheal IntubationO pen the mouth with rightO pen the mouth with righthandhand Scissor techniqueScissor techniqueGently insertGently insertlaryngoscope into rightlaryngoscope into rightside of mouth pushingside of mouth pushingtongue to the lefttongue to the leftCareful with insertion notCareful with insertion notto hit teethto hit teeth

Advance laryngoscope Advance laryngoscopefurther into oropharynxfurther into oropharynxwith applied traction 45with applied traction 45degreesdegrees


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Endotracheal IntubationEndotracheal IntubationLook for epiglottisLook for epiglottis If initially not foundIf initially not found

insert laryngoscopeinsert laryngoscopefurther further

If this maneuver doesIf this maneuver doesnot work slowly pullnot work slowly pulllaryngoscope backlaryngoscope back

O nce epiglottisO nce epiglottisvisualized, pushvisualized, pushlaryngoscope intolaryngoscope intovallecula and applyvallecula and applytraction at 45 degreetraction at 45 degreeangle to push epiglottisangle to push epiglottis

up and out of the wayup and out of the way www.int-med.uiowa.edu/Research/TLIRP/Bronchos


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Endotracheal IntubationEndotracheal IntubationLook for vocal cords or Look for vocal cords or

arytenoid cartilages and try toarytenoid cartilages and try tooptimize viewoptimize view (i.e. lift head, apply more(i.e. lift head, apply more

traction at 45 degree angletraction at 45 degree angleif necessary)if necessary)

Do not move once view isDo not move once view isoptimized!optimized! Assistant will hand you Assistant will hand you

ETTETTInsert ETT into far right aspectInsert ETT into far right aspectof mouthof mouth Traction of laryngoscopeTraction of laryngoscope

slightly to left may assistslightly to left may assist Traction of laryngoscope atTraction of laryngoscope at

45 degrees will also help45 degrees will also helpkeep mouth openkeep mouth open


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Endotracheal IntubationEndotracheal Intubation

Insert ETT above and between arytenoidsInsert ETT above and between arytenoidsand through vocal cordsand through vocal cords

Try to visualize the ETT passing betweenTry to visualize the ETT passing betweenthe vocal cordsthe vocal cords If this is not possible, then you must visualizeIf this is not possible, then you must visualize

the ETT passing above and between thethe ETT passing above and between thearytenoidsarytenoids


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Endotracheal IntubationEndotracheal IntubationCommon problems:Common problems: I cant see anything!I cant see anything!

Make sure tongue isMake sure tongue isswept to the leftswept to the left

You are probably tooYou are probably tooshallow or too deep.shallow or too deep.Even with difficultEven with difficultintubations theintubations theepiglottis can beepiglottis can be

visualizedvisualizedInsert laryngoscope inInsert laryngoscope infurther looking for further looking for epiglottisepiglottisPull laryngoscope backPull laryngoscope backif this failsif this fails


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Endotracheal IntubationEndotracheal Intubation

Common problemsCommon problems I cant see the cords!I cant see the cords! Epiglottis is visualized, vocal cords are notEpiglottis is visualized, vocal cords are not Removing the epiglottis partly from view isRemoving the epiglottis partly from view is

necessary to visualize the vocal cords belownecessary to visualize the vocal cords below Push the end of the laryngoscope bladePush the end of the laryngoscope blade

further into the vallecula and toe upfurther into the vallecula and toe up Lifting the patients head with your other handLifting the patients head with your other hand

may improve the sniffing position and bringmay improve the sniffing position and bringthe vocal cords into viewthe vocal cords into view


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Endotracheal IntubationEndotracheal IntubationCommon problemsCommon problems I can see the cords. But I cant get the tubeI can see the cords. But I cant get the tube

there!there! You may not be giving yourself adequateYou may not be giving yourself adequate

room in the oral cavityroom in the oral cavity Push up and to the left with the laryngoscopePush up and to the left with the laryngoscope

to make sure the mouth is still fully openedto make sure the mouth is still fully openedand the tongue adequately swept awayand the tongue adequately swept away

Slide the ETT in the mouth all the way to theSlide the ETT in the mouth all the way to theright side, perhaps even sidewaysright side, perhaps even sideways


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Difficult IntubationDifficult Intubation

ASA Difficult Airway Algorithm ASA Difficult Airway Algorithmwww.metrohealthanesthesia.comwww.metrohealthanesthesia.com


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Fiberoptic IntubationFiberoptic Intubation

O ral or nasal routesO ral or nasal routesTopicalization is keyTopicalization is key

Aerosolized lidocaine 4% Aerosolized lidocaine 4% Airway blocks Airway blocks

Thin bronchoscope inserted into tracheaThin bronchoscope inserted into trachea


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O ther airway optionsO ther airway options

GlideScopeGlideScopeNeedle cricothyroidotomyNeedle cricothyroidotomy


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ConclusionConclusion

Airway management is an extremely important Airway management is an extremely importantaspect of the practice of anesthesiology andaspect of the practice of anesthesiology andcritical carecritical care

A firm basis in airway anatomy is needed A firm basis in airway anatomy is neededSkills such as mask ventilation, endotrachealSkills such as mask ventilation, endotrachealintubation, LMA placement are necessaryintubation, LMA placement are necessary

In the case of a difficult airway, a logicalIn the case of a difficult airway, a logicalalgorithm and airway equipment assist thealgorithm and airway equipment assist thephysician in safely managing the situationphysician in safely managing the situation

airway management may

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