Transcript
Page 1: Airway Management. Outline Review of airway anatomy Airway evaluation Mask ventilation Endotracheal intubation The difficult airway

Airway ManagementAirway Management

Page 2: Airway Management. Outline Review of airway anatomy Airway evaluation Mask ventilation Endotracheal intubation The difficult airway

OutlineOutline

Review of airway anatomyReview of airway anatomy

Airway evaluationAirway evaluation

Mask ventilationMask ventilation

Endotracheal intubationEndotracheal intubation

The difficult airwayThe difficult airway

Page 3: Airway Management. Outline Review of airway anatomy Airway evaluation Mask ventilation Endotracheal intubation The difficult airway

Airway AnatomyAirway Anatomy

Ab-ductorAb-ductor– Posterior Posterior

cricoarytenoidcricoarytenoid

TensorTensor– CricothyroidCricothyroid

Ad-ductorsAd-ductors– All the restAll the rest

Page 4: Airway Management. Outline Review of airway anatomy Airway evaluation Mask ventilation Endotracheal intubation The difficult airway

Airway AnatomyAirway Anatomy

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

External branch – motor External branch – motor to cricothyroid m.to cricothyroid m.Internal branch – Internal branch – sensory larynx above sensory larynx above TVC’sTVC’s

– Recurrent laryngeal n.Recurrent laryngeal n.Right – subclavianRight – subclavianLeft – Aortic arch (board Left – Aortic arch (board question)question)Motor to all other Motor to all other muscles, Sensory to muscles, Sensory to TVC’s and tracheaTVC’s and trachea

Page 5: Airway Management. Outline Review of airway anatomy Airway evaluation Mask ventilation Endotracheal intubation The difficult airway

Airway AnatomyAirway Anatomy

Innervation of Innervation of oropharynxoropharynx– Glossopharyngeal n. Glossopharyngeal n.

innervates tongue innervates tongue base and oropharynxbase and oropharynx

Page 6: Airway Management. Outline Review of airway anatomy Airway evaluation Mask ventilation Endotracheal intubation The difficult airway

Airway AnatomyAirway Anatomy

MembranesMembranes– ThyrohyoidThyrohyoid– CricothryoidCricothryoid

CartilagesCartilages– HyoidHyoid– ThyroidThyroid– CricoidCricoid

Page 7: Airway Management. Outline Review of airway anatomy Airway evaluation Mask ventilation Endotracheal intubation The difficult airway
Page 8: Airway Management. Outline Review of airway anatomy Airway evaluation Mask ventilation Endotracheal intubation The difficult airway

Airway EvaluationAirway Evaluation

Take very seriously Take very seriously history of prior difficultyhistory of prior difficulty

Head and neck Head 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 and scleroderma, short and thick neckthick neck

Page 9: Airway Management. Outline Review of airway anatomy Airway evaluation Mask ventilation Endotracheal intubation The difficult airway

Airway EvaluationAirway Evaluation

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

anterior subluxationanterior subluxation– <3.5cm inter-incisor gap <3.5cm inter-incisor gap

concerningconcerning– Inability to sublux lower Inability to sublux lower

incisors beyond upper incisors beyond upper incisorsincisors

Receding mandibleReceding mandible

Protruding Maxillary Protruding Maxillary Incisors (buck teeth)Incisors (buck teeth)

Page 10: Airway Management. Outline Review of airway anatomy Airway evaluation Mask ventilation Endotracheal intubation The difficult airway

Airway EvaluationAirway Evaluation

ObesityObesity– Distribution, i. e. short, Distribution, i. e. short,

thick neck more thick neck more concerningconcerning

– Neck circumferenceNeck circumference

Page 11: Airway Management. Outline Review of airway anatomy Airway evaluation Mask ventilation Endotracheal intubation The difficult airway

Airway EvaluationAirway Evaluation

Thyromental distance: Thyromental distance: bony point on bony point on mentum (mandible) to mentum (mandible) to thyroid notchthyroid notch

If short (<3FB’s or If short (<3FB’s or 6cm), pharyngeal and 6cm), pharyngeal and laryngeal axis offlaryngeal axis off

Page 12: Airway Management. Outline Review of airway anatomy Airway evaluation Mask ventilation Endotracheal intubation The difficult airway

Airway EvaluationAirway EvaluationOropharyngeal visualizationOropharyngeal visualization

Mallampati ScoreMallampati Score

Sitting position, protrude tongue, don’t say Sitting position, protrude tongue, don’t say “AHH”“AHH”

Page 13: Airway Management. Outline Review of airway anatomy Airway evaluation Mask ventilation Endotracheal intubation The difficult airway

Airway EvaluationAirway Evaluation

Difficulty ventilatingDifficulty ventilating– Age >55Age >55– BeardBeard– History of snoringHistory of snoring– Lack of teethLack of teeth– BMI >26BMI >26

Page 14: Airway Management. Outline Review of airway anatomy Airway evaluation Mask ventilation Endotracheal intubation The difficult airway

PreoxygenationPreoxygenation

Replaces the nitrogen volume of the lungs Replaces the nitrogen volume of the lungs (69% of FRC) with oxygen(69% of FRC) with oxygenFunctional residual capacity (residual Functional residual capacity (residual volume and expiratory reserve volume)volume and expiratory reserve volume)Preoxygenation with 100% oxygen via Preoxygenation with 100% oxygen via tight-fitting mask for 5 minutes tight-fitting mask for 5 minutes up to 10 up to 10 min of oxygen reserve following apneamin of oxygen reserve following apneaFour vital capacity breaths over 30 Four vital capacity breaths over 30 seconds (time to desaturation quicker)seconds (time to desaturation quicker)

Page 15: Airway Management. Outline Review of airway anatomy Airway evaluation Mask ventilation Endotracheal intubation The difficult airway

Patient PositioningPatient Positioning

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

Page 16: Airway Management. Outline Review of airway anatomy Airway evaluation Mask ventilation Endotracheal intubation The difficult airway

Mask VentilationMask Ventilation

Induction of Induction of anesthesia produces anesthesia produces upper airway upper airway relaxation and relaxation and possible collapsepossible collapse

Downward Downward displacement of mask displacement of mask with thumb and index with thumb and index fingerfinger

www.aic.cuhk.edu.hk

Page 17: Airway Management. Outline Review of airway anatomy Airway evaluation Mask ventilation Endotracheal intubation The difficult airway

Mask VentilationMask Ventilation

Upward traction of Upward traction of remaining fingers remaining fingers upwardupward

Fingers on bony Fingers on bony mandiblemandible

Fifth digit at angle Fifth digit at angle displacing mandible displacing mandible anteriorlyanteriorly

www.aic.cuhk.edu.hk

Page 18: Airway Management. Outline Review of airway anatomy Airway evaluation Mask ventilation Endotracheal intubation The difficult airway

Mask VentilationMask Ventilation

Oral airwayOral airway

Two-handed techniqueTwo-handed technique

www.aic.cuhk.edu.hk

www.haworth21.karoo.net

Page 19: Airway Management. Outline Review of airway anatomy Airway evaluation Mask ventilation Endotracheal intubation The difficult airway

LMA PlacementLMA Placement

Carries prominent Carries prominent position in ASA algorithmposition in ASA algorithm

May be held like a pencilMay be held like a pencil

Balloon partially inflatedBalloon partially inflated

Directed posteriorly and Directed posteriorly and upwards towards the upwards towards the palatepalate

Jaw thrust and sniffing Jaw thrust and sniffing position may help position may help placementplacement

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

Page 20: Airway Management. Outline Review of airway anatomy Airway evaluation Mask ventilation Endotracheal intubation The difficult airway

LMA PlacementLMA Placement

Verify placement by ventilatingVerify placement by ventilating– Check for good chest rise, ETCO2, and Check for good chest rise, ETCO2, and

adequate tidal volumesadequate tidal volumes– Check for leak – if significant leak at around Check for leak – if significant leak at around

10cm H2O problematic10cm H2O problematic– May try size larger or smallerMay 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 upside If difficulty passing may try inserting upside

down and then flipping arounddown and then flipping around

Page 21: Airway Management. Outline Review of airway anatomy Airway evaluation Mask ventilation Endotracheal intubation The difficult airway

Endotracheal IntubationEndotracheal IntubationOpen the mouth with right Open the mouth with right handhand

– Scissor techniqueScissor technique

Gently insert laryngoscope Gently insert laryngoscope into right side of mouth into right side of mouth pushing tongue to the leftpushing tongue to the left

Careful with insertion not Careful with insertion not to hit teethto hit teeth

Advance laryngoscope Advance laryngoscope further into oropharynx further into oropharynx with applied traction 45 with applied traction 45 degrees degrees

Page 22: Airway Management. Outline Review of airway anatomy Airway evaluation Mask ventilation Endotracheal intubation The difficult airway

Endotracheal IntubationEndotracheal IntubationLook for epiglottisLook for epiglottis– If initially not found insert If initially not found insert

laryngoscope furtherlaryngoscope further– If this maneuver does If this maneuver does

not work slowly pull not work slowly pull laryngoscope backlaryngoscope back

Once epiglottis visualized, Once epiglottis visualized, push laryngoscope into push laryngoscope into vallecula and apply traction vallecula and apply traction at 45 degree angle to at 45 degree angle to “push” epiglottis up and out “push” epiglottis up and out of the wayof the way

www.int-med.uiowa.edu/Research/TLIRP/Bronchos

Page 23: Airway Management. Outline Review of airway anatomy Airway evaluation Mask ventilation Endotracheal intubation The difficult airway

Endotracheal IntubationEndotracheal IntubationLook for vocal cords or arytenoid Look for vocal cords or arytenoid cartilages and try to optimize viewcartilages and try to optimize view– (i.e. lift head, apply more (i.e. lift head, apply more

traction at 45 degree angle if traction at 45 degree angle if necessary)necessary)

Do not move once view is Do not move once view is optimized!optimized!– Assistant will hand you ETTAssistant will hand you ETT

Insert ETT into far right aspect of Insert ETT into far right aspect of mouthmouth– Traction of laryngoscope Traction of laryngoscope

slightly to left may assistslightly to left may assist– Traction of laryngoscope at 45 Traction of laryngoscope at 45

degrees will also help keep degrees will also help keep mouth openmouth open

Page 24: Airway Management. Outline Review of airway anatomy Airway evaluation Mask ventilation Endotracheal intubation The difficult airway

Endotracheal IntubationEndotracheal Intubation

Insert ETT above and between arytenoids Insert ETT above and between arytenoids and through vocal cordsand through vocal cords

Try to visualize the ETT passing between Try to visualize the ETT passing between the vocal cordsthe vocal cords– If this is not possible, then you must visualize If this is not possible, then you must visualize

the ETT passing above and between the the ETT passing above and between the arytenoidsarytenoids

Page 25: Airway Management. Outline Review of airway anatomy Airway evaluation Mask ventilation Endotracheal intubation The difficult airway

Endotracheal IntubationEndotracheal IntubationCommon problems:Common problems:– ““I can’t see anything!”I can’t see anything!”

Make sure tongue is Make sure tongue is swept to the leftswept to the left

You are probably too You are probably too shallow or too deep. Even shallow or too deep. Even with difficult intubations with difficult intubations the epiglottis can be the epiglottis can be visualizedvisualized

Insert laryngoscope in Insert laryngoscope in further looking for further looking for epiglottisepiglottis

Pull laryngoscope back if Pull laryngoscope back if this failsthis fails

Page 26: Airway Management. Outline Review of airway anatomy Airway evaluation Mask ventilation Endotracheal intubation The difficult airway

Endotracheal IntubationEndotracheal IntubationCommon problemsCommon problems– ““I can’t see the cords!”I can’t see the cords!”– Epiglottis is visualized, vocal cords are notEpiglottis is visualized, vocal cords are not– Removing the epiglottis partly from view is Removing 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 blade Push the end of the laryngoscope blade

further into the vallecula and “toe up”further into the vallecula and “toe up”– Lifting the patient’s head with your other hand Lifting the patient’s head with your other hand

may improve the sniffing position and bring may improve the sniffing position and bring the vocal cords into viewthe vocal cords into view

Page 27: Airway Management. Outline Review of airway anatomy Airway evaluation Mask ventilation Endotracheal intubation The difficult airway

Endotracheal IntubationEndotracheal IntubationCommon problemsCommon problems– ““I can see the cords. But I can’t get the tube I can see the cords. But I can’t get the tube

there!”there!”– You may not be giving yourself adequate You may not be giving yourself adequate

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

to make sure the mouth is still fully opened to make sure the mouth is still fully opened and the tongue adequately swept awayand the tongue adequately swept away

– Slide the ETT in the mouth all the way to the Slide the ETT in the mouth all the way to the right side, perhaps even sidewaysright side, perhaps even sideways

Page 28: Airway Management. Outline Review of airway anatomy Airway evaluation Mask ventilation Endotracheal intubation The difficult airway

Difficult IntubationDifficult Intubation

ASA Difficult Airway Algorithm ASA Difficult Airway Algorithm

www.metrohealthanesthesia.comwww.metrohealthanesthesia.com

Page 29: Airway Management. Outline Review of airway anatomy Airway evaluation Mask ventilation Endotracheal intubation The difficult airway

Fiberoptic IntubationFiberoptic Intubation

Oral or nasal routesOral or nasal routes

Topicalization is keyTopicalization is key– Aerosolized lidocaine 4%Aerosolized lidocaine 4%– Airway blocksAirway blocks

Thin bronchoscope inserted into tracheaThin bronchoscope inserted into trachea

Page 30: Airway Management. Outline Review of airway anatomy Airway evaluation Mask ventilation Endotracheal intubation The difficult airway

Other airway optionsOther airway options

GlideScopeGlideScope

Needle cricothyroidotomyNeedle cricothyroidotomy

Page 31: Airway Management. Outline Review of airway anatomy Airway evaluation Mask ventilation Endotracheal intubation The difficult airway

ConclusionConclusion

Airway management is an extremely important Airway management is an extremely important aspect of the practice of anesthesiology and aspect of the practice of anesthesiology and critical carecritical care

A firm basis in airway anatomy is neededA firm basis in airway anatomy is needed

Skills such as mask ventilation, endotracheal Skills such as mask ventilation, endotracheal intubation, LMA placement are necessaryintubation, LMA placement are necessary

In the case of a difficult airway, a logical In the case of a difficult airway, a logical algorithm and airway equipment assist the algorithm and airway equipment assist the physician in safely managing the situationphysician in safely managing the situation


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