AIRWAY MANAGEMENT

Dr. M.Husni T,SpAnRSUD dr.Moewardi

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Airway Management

• Types of artificial airways• Indications• Complications• Placement

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Types of Artificial Airways

• Pharyngeal• Endotracheal Tubes• Tracheostomy

Tubes• Laryngeal Masks

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Pharyngeal Airways• Indications

– Prevent obstruction from tongue in unconscious patient

– Facilitate suctioning– Facilitate mask/bag ventilation

• Complications– May stimulate gag reflex in conscious or

semi-conscious patient– Vomiting and aspiration

• Oral or nasal pharyngeal airways

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Oral Pharyngeal Airways• Types

– Berman– Guedel

• Placement– Cross-finger technique– Horizontal then turn down– Correct size - estimate from

lips to earlobe or angle of jaw

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GuedelBerman

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Nasopharyngeal• nasal “Trumpet”• Indicated when oral

airway not feasible– Lock jaw– Fractured mandible– Pt conscious

• Facilitates frequent nasotracheal suctioning (NTS)

• Placement - lubricant• Hazards

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Nasopharyngeal Airways

Trumpets

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Combitube

100 ml

15 ml

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Esophageal Obturator Airway

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If tip of tube in esophagus

If no breath sounds, connect bag to clear tube

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Old combitubeNo longer used

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Endotracheal Tubes (ETT)

• Tube inserted through nose or mouth• Between vocal cords• Into trachea• Tip of tube 2 inches above carina

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Indications ETT

• Airway of choice during CPR• Cuff inflated in trachea protects lower

airway and maintains a seal for ventilation

• Facilitates suctioning of lower airway

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Types of Endotracheal tubes

• Single lumen• Double lumen (Carlen’s tube)• Cole tube

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Cole

FomeLanz

Shiley

RuschPortex

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Double Lumen Tubes

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ET Tube markings• Brand name• ID and OD• Z-79 - ANSI Committee for Review of

Anesthesia Equipment• IT - Implantation Tested• Murphy eye• Radiopague line• Length in cm

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Tube sizes• Adult male

– 34 - 36 French or 8.0 - 8.5 mm ID– (mm ID x 4) + 2 = French– Usually no cuff on tubes < 6.5 mm

• Adult female– 32 - 34 French or 7.5 - 8.0 mm ID

• Pediatric sizes (> 2 y.o.)– 4.5 + (Age/4)

• Pediatric sizes (< 2 y.o.)– As large as child’s little finger

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Estimating Tube Size (ID)

• ID = (Age + 16) / 4• ID = Height (cm) / 20

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Estimating Tube Length (cm )

• Oral: 12 + (Age / 2)• Nasal: 15 + (Age / 2)

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Distances

• Teeth - cords adult - 12 - 15 cm• Teeth - carina approximately 27 cm• Trachea - 11 - 13 cm• Adult trachea diameter 1.5 - 2.5 cm• Infant trachea diameter 4 mm

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AverageAverage depth of ETT insertion:

• 23 cm from the teeth23 cm from the teeth

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~ 1.5 inchesor 3.81 cm

1 in = 2.54 cm

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Hi-Low Evac ETT

Fig 6-50, p 183 Cairo & Pilbeam

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Intubation

• Larynx is visualized and the endotracheal tube is placed through the glottis.

• Want to actually visualize the cuff passing through the glottis.

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Straight or Miller blade lifts epiglottis

“sniffing”position

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Curved or Macintosh blade tip placed at vallecula (area just

above epiglottis)

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Difficult airway management algorithm

From Benumof, J. L. (1991) Management of the difficult adult airway. Anesthesiology 74, 1087-1110.

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Laryngoscopic view

Grade II or III requiring multiple intubation attempts relatively common ( 1 - 18%).

Grade III or IV with unsuccessful intubation rare (.05 - .35%)Cannot ventilate by mask or intubate -> transtracheal jet

ventilation, tracheostomy (.0001 - .02%).

From Benumof, J. L. (1991) Management of the difficult adult airway. Anesthesiology 74, 1087-1110.

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Relative tongue/pharyngeal size airway view

If patient in class I airway view then laryngoscopic view is grade I 99-100% of the time. If class IV airway view then laryngoscopic view is grade III or IV 100% of the time.

From Benumof, J. L. (1991) Management of the difficult adult airway. Anesthesiology 74, 1087-1110.

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Grade 1 = no appreciable reduction of extensionGrade 2 = approximately 1/3 reductionGrade 3 = approximately 2/3 reductionGrade 4 = no appreciable extensionFrom Benumof, J. L. (1991) Management of the difficult adult airway. Anesthesiology 74, 1087-1110.

35o normal

Atlanto-occipital joint extension

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Tongue / Pharyngeal size

NeckExten

4 3 2 1

1 D A A A2 E B B A3 E C B B4 E D C B

A = Likelihood of Difficulty negligible < 1%B = LOD 1 - 5%C = LOD possibly 20%D = LOD likely 50%E = LOD highly probable 95%

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Nasal Intubation• Spray 2% lidocaine

and 0.25% Neosynephrine in nose

• Do blind intubation or

• Use Magill forceps to guide tube into place

• Use smaller ID tube

• Average distance from mid-trachea to naris is 25 cm

p 142 Principles of Airway Management

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Infant Intubation

• Place tip of either straight or curved blade at the vallecula.

• Do not try and lift epiglottis with straight blade.

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Types of Cuffs

• Low Pressure - High Volume• High Pressure - Low Volume (old)• Fome Cuff - Ambient pressure (do not

inflate)

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Cuff Pressure

Cuff pressure < 20 cm H2O (≤ 15 torr)

Cuff pressure > 5 torr blocks lymphatic drainage

Cuff pressure > 18 blocks venous drainageCuff pressure > 30 blocks arterial flow

Shapiro, p 273

trach

eal w

all tracheal w

all

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Two Methods of Cuff Inflation

• Minimal Leak• Minimal Occlusion

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Audible leak only at Audible leak only at endend inspiration inspiration

Minimal Leak

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Disadvantages ETT

• By-passes upper airway– 100% RH at 32 - 34o C

• May be trauma during insertion• Patient cannot talk• Numerous complications

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Complications of ETT

• During intubation• While tube in place• During extubation• After extubation

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Complications During Intubation

• Trauma• Right mainstem intubation• Esophageal intubation

– Easy Cap CO2 detectors – turns yellow with CO2

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Right mainstem intubation

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Complications While Tube in Place

• Pressure necrosis• Mucosal edema• Laryngeal/tracheal granulomas• Tracheoesophageal fistula• Dislocated tube• Problems with cuff• Patient Disconnection from tube• Nosocomial infection

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Tube Changer

• Insert in ET tube to change• Note cm at teeth• Slip old tube off keeping changer in

place• Slip new tube on changer down to the

same level

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Complications During Extubation

• Laryngeal spasm• Vocal cord trauma

• Treat by applying slight positive pressure via mask and bag until anesthesiology gets there with succinylcholine, a rapid acting muscle relaxant.

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When Extubating

• Have oxygen ready (APN)• Have bag and mask ready• Have racemic epinephrine handy

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Complications After Extubation• Hoarseness – temporary vocal cord injury (if

lasts > week → granuloma formation*)• Glottic edema (adults) → Inspiratory Stridor

– Aerosolize racemic epinephrine (0.5 ml of 2.25%) and steroid (1 mg of dexamethasone) in 4 ml NS

– Will need to re-intubate if aerosol fails to reduce swelling

• Subglottic edema (infants) → Inspiratory Stridor– because cricoid ring narrowest point along infant

larynx and trachea it’s exposed to > potential injury during intubation

– must re-intubate• Tracheal stenosis – rarely occurs if cuff properly

inflated and maintained* Shapiro, p 269

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Laryngeal Masks• Positioned in the hypopharynx

– Separates esophagus from trachea– Doesn’t keep esophageal sphincter open

(EOA)– Doesn’t keep glottis open (ETT)

• Indications– Used instead of face masks for anesthesia– In cases of difficult intubation– Emergency cases waiting for intubation

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Laryngeal mask airway LMA

CobraPLA perilaryngealairway

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Contra-indications for Laryngeal Masks

• Full stomach• Hiatal hernia - protrusion of a portion

of the stomach up through the diaphragm - occurs in about 40% pop --> Gastroesophageal reflux

• Need for controlled ventilation

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Placement (show videos)• Deflate cuff• Hyperextend neck• Insert mask parallel to palate• When esophageal sphincter is reached will

feel resistance• Inflate cuff• Black line must always be up

– Mask must not rotate• Secure in place

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Tracheostomy Tubes

• Indications– Provide long term airway – Intubated > 21 days– Allows better mouth care– Oral feeding

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Tracheotomy• Tracheotomy = Surgical procedure• Incision between 2nd and 3rd

cartilaginous rings• Best done as elective surgical

procedure under sterile conditions• Tracheostomy = opening or stoma• Percutaneous tracheotomy proced

ure (Real Player)

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Parts to Tracheostomy Tube

Obturator Inner cannula Outer cannula

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Complications of Tracheostomy Tubes

• Stoma• Cuff site• Tip of trach tube

–snowplowing

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Tracheal Stenosis

• Tracheal stenosis – scar tissue narrows trachea, usually at point where cuff was in contact with tracheal wall. Scar tissue can also accumulate at stoma site

Cuff site

stoma site

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Types of Tracheostomy Tubes

• Temporary tubes• Permanent metal tubes• Fenestrated• Speaking tubes/valves• Trach buttons

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Communitrach

Trachadapters

Passy Muirvalve

Fenestrated

Jackson

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Temporary Trach TubesPilot Balloon

FoamCuff

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Bivona Fome-Cuff Peds Trach Tube

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Jackson Metal Trach Tube

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Fenestrated Trach Tube

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Passy-Muir Tracheostomy Speaking Valve

• One-way valve fits on trach tube• Allows inspiration through trach tube• Allows expiration through larynx• Must DEFLATE CUFF when used with

cuffed tubes• Warning labels should be placed on

pilot balloon

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Passy-Muirvalve

Must be

Deflated

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Considerations

• Can be applied 48-72 hours after tracheotomy

• As soon as surgical secretions have minimized

• Cuffless tracheostomy tube preferred• Tracheostomy tube should be 2/3 size

of trachea

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Precautions

• Observe patient for difficulty using valve• Upper airway obstruction may be

present– Stenosis– Masses– Secretions– Tracheostomy tube too large

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Complications

• Secretions may cause valve to stick• Cuff not deflated

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Contraindications for Passy-Muir Valve

• Severe tracheal or laryngeal stenosis• Laryngectomized patients

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Trach Buttons

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Tracheostomy Care

• Trach Care– Suction– Replace disposable inner cannula on temporary

tubes [Make sure replacement inner cannula is the correct sizecorrect size!] – clean inner cannula on metal tubes and reuse

– Disinfect around stoma/ replace trach tube ties– Change trach dressing [or when soiled]

• Monitor cuff pressure [check that MOT/MLT]

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Special Emergency Airway Situations

• Foreign Body Obstruction• Laryngeal Trauma• Laryngospasm

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Two Emergency Procedures

• Cricothyroidotomy (used to be preferred route)

• Transtracheal catherization (preferred route)

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Cricothyroidotomy

• Laryngotomy not tracheotomy• Surgical opening through

cricothyroid membrane– Directly below Adam’s apple

(thyroid cartilage)• Safer, quicker, and easier than

tracheotomy

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Cricothyroid membrane

• Easy to locate• Below vocal cords• Well supported by

surrounding cartilage• Less vascular than

anterior trachea• Not hidden by thyroid

tissue

thyroidthyroidcartilagecartilage

cricoidcricoidcartilagecartilage

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Cricothyroidotomy

• Not suitable in small children or infants

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Procedure• Neck is hyper-extended• Thyroid and cricoid cartilage palpated• Vertical midline incision made between the

two cartilages• Incision spread• Cricothyroid membrane cut horizontally,

just above cricoid cartilage• At least a 6-mm ID trach tube can be

inserted into trachea - can also use endotracheal tube through stoma

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Complications of Cricothyroidotomy

• Hemorrhage• Permanent vocal cord damage• Esophageal trauma

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Alternative Procedure - Transtracheal Catherization

• Puncture cricothyroid membrane with large bore needle (14 - 16 gauge) surrounded by plastic catheter

• Direct needle caudally at 45o angle• Withdraw plunger as insert needle• Air indicates needle in trachea• Advance catheter over needle into

trachea• Attach IV tubing to gas source for

ventilation

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Transtracheal ventilation

• IV tubing connected to 15 LPM oxygen• Opening in tubing used as a thumb

control• Cover hole to inflate chest• Uncover hole to allow exhalation

through nose and mouth• Opening can be 3-way stop-cock

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Complications of Transtracheal Catheterization

• Misplacement of catheter into esophagus

• Puncture of artery• Subcutaneous and mediastinal

emphysema• Inadequate exhalation if upper

airway blocked

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Also Devices like NuTrak

• Larger needle• Inserted the same way• Can connect larger tubing to

NuTrak for easier ventilation

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These emergency airways should be replaced with

appropriate airways ASAP - tracheotomy under sterile O.R.

conditions