Dr Rehan Masroor

MBBS, MCPS, MIARS, FCPS Consultant Anaesthesiologist

People say life can't exist without air, but it does under water; in fact, it started in the sea. ---- Richard Feynman

AIRWAY MANAGEMENT

An opening must be attempted in trunk of Trachea, into which a tube of reed or cane should be put; you will then blow into this, so that lung may rise againand the heart becomes strong
----

In : De humani corporis fabrica

by Andreas Vesalius (1555 AD)

Is so much attention to airway warranted?

Three main causes of death following anaesthesia as per ASA are Inadequate vaentilation (38%) Oesophageal intubation(18%) Difficult tracheal intubation(17%)

The airway conducts gases between the atmosphere and the alveoli.
Effective airway management keeps the airway free of secretions, contamination and obstruction minimizes the complications.
---- Actual causes of death in the United States in 2000. JAMA 2004

Critical illness often causes weakness and obtundation sufficient enough to impair air exchange.
---- Post-injury multiple organ failure. In: Trauma. 5th ed. New York: McGraw-Hill, 2004.

The sedative, narcotic, anaesthetic, and relaxant drugs that facilitate surgery predictably compromise airway patency and protection.
---- JCAHOs patient safety goals: preventing med errors. RN 2007

Mastery of the airway demands:

Familiarity with normal and variant anatomy and The alterations caused by abnormal states.
---- Management of the difficult airway: with special emphasis on awake tracheal intubation. Anesthesiology 1997.

Essential attributes for the expert airway manager include:

Knowledge,

Sound judgment,
Skills for a range of techniques, and Planning for conceivable contingencies.
----- Airway Management: Principles and Practice. St. Louis: Mosby-Year Book, 2003.

A little bit of Anatomy

Mouth:
Tongue
variable in size attached inferior to epiglottis

Mandible Uvula

Pharynx
Tonsils Merges with larynx anterior, esophagus posterior Epiglottis
high long flaccid and narrow in child

----- Airway Management: Principles and Practice. St. Louis: Mosby-Year Book, 2003.

A little more Anatomy The Larynx

Narrowest part of the airway:
Cricoid smaller in child, narrow part of airway

vocal cord narrowest part of adult airway

----- Airway Management: Principles and Practice. St. Louis: Mosby-Year Book, 2003.

Nasopharynx Oropharynx Laryngopharynx

Diagram of sagittal section and posterior view of the pharynx illustrating the three subdivisions of the pharynx.
----- Airway Management: Principles and Practice. St. Louis: Mosby-Year Book, 2003.

Hyoid Bone

Thyrohyoid Ligament

Thyroid Cartilage Cricothyroid Ligament

Cricoid Cartilage

Trachea

Diagrammatic illustration of the anterior view of the larynx. The larynx is suspended from the hyoid bone by the thyrohyoid ligament.
----- Airway Management: Principles and Practice. St. Louis: Mosby-Year Book, 2003.

BAG MASK VENTILATORY DEVICE

AMBU BAG

Face Masks

Artificial Oropharyngeal and Nasopharyngeal Airways

Laryngeal Mask Airways

Blades of Different Direct Laryngoscopes

Different Endotracheal Tube

Laser Tube

Mod-RAE Tube

Armoured Tube

LMA flexible Tube Regular ETT Ring-Adair-Elwyn Tube

When you cant breath, nothing else matters

Maintenance of Airway
Triple Manauver
Head Tilt Chin Lift Jaw Thrust

Mask Ventilation Oropharyngeal Airway Nasopharyngeal Airway

Laryngeal Mask Airway

Head Tilt Chin Lift Jaw Thrust

Jaw Thrust

Mask Ventilation

Oropharyngeal Airway Nasopharyngeal Airway Laryngeal Mask Airway

Head Tilt and Chin Lift

Head Tilt And Chin Lift in Children

Oropharyngeal Airway
Head Tilt Chin Lift Jaw Thrust Mask Ventilation

Oropharyngeal Airway Nasopharyngeal Airway Laryngeal Mask Airway

Nasopharyngeal Airway

Head Tilt Chin Lift Jaw Thrust Mask Ventilation

Oropharyngeal Airway Nasopharyngeal Airway

Laryngeal Mask Airway

Head Tilt Chin Lift Jaw Thrust Mask Ventilation

Oropharyngeal Airway Nasopharyngeal Airway Laryngeal Mask Airway

Mask Ventilation

Can deliver a high FIO2 Avoids the potential trauma of intubation Does not protect against aspiration May result in gastric distension Laryngospasm can occur Requires use of both hands

Head Tilt Chin Lift Jaw Thrust Mask Ventilation

Oropharyngeal Airway Nasopharyngeal Airway Laryngeal Mask Airway

Using Single Hands

Using Two Hands

Indications for Definitive Airway

Need for Airway Protection
Unconscious

Need for Ventilation

Apnea Neuromuscular Paralysis Unconscious Inadequate Respiratory Effort Tachypnea Hypoxia Hypercarbia Cyanosis Severe closed head injury with need for hyperventilation

Severe Maxillofacial fractures

Risk for aspiration Bleeding Vomiting Risk for obstruction Neck hematoma Laryngeal, tracheal injury/burn Stridor

Laryngeal Mask Airway

Laryngeal Mask Airway

Indications
1. Surgical anaesthesia without intubation 2. Repeated anaesthetics

3. Emergency ventilation when intubation has failed

4. Improving airway seal without tracheal intubation 5. Patient with facial hair 6. Assisting tracheal intubation

7. Providing a patent airway with minimal haemodynamic changes

Contraindications
1. 2. 3. 4. 5. 6. High risk of aspiration (relative contraindication) Glottic or subglottic obstruction Supraglottic pathology interfering with its placement Extremely limited mouth opening or neck extension Prone position (relative contraindication) Need for high airway pressure ventilation

Preparation for Tracheal Intubation

Skilled assistance Equipment for face mask ventilation Source of positive-pressure oxygen Anaesthesia machine Self-inflating bag Oropharyngeal or nasopharyngeal airways

IV access for Sedation or anaesthetic induction Relaxants Volume administration Cardioactive drugs (e.g., epinephrine, antiarrhythmic) Intubating (Magill) forceps Backup equipment for difficult airway

Bright laryngoscope Straight blade(s) Curved blade(s) Position and environment Access to patients head Proper Height Sniffing position Adequate light Monitors Intubation stylet or introducers

Proper Positioning for Intubation

oropharynx
Epiglottis Hyoid Bone Hypopharynx

Vocal Cords

Trachea

Hyperextension Makes Intubation Difficult

Cricoid Pressure (Sellicks Manoeuvre)

Procedure of Intubation Using Direct Laryngoscope

DO NO HARM!
Take Away Nothing From The Patient You Cannot Replace

Paralytics Have No Sedative Quality Sedative Have No Paralytics Quality

Degree of Difficult Airway Continuum from 0 to infinity

Mask Ventilation
0
Natural Airway

Impossible Gas Exchange

Easy Chin Lift only

One Person Jaw Lift, Mask Seal

One Person Jaw Thrust Mask Seal Oropharyngeal / nasopharygeal airway

Two Person Jaw Thrust, Mask seal Oropharyngeal / nasopharygeal airway

Brain Damage/ Death

Direct Vision Laryngoscopy and Intubation

0
One attempt, increasing lifting force One attempt, increasing lifting Force; Use better sniffing Position Multiple attempts, External Laryngeal Pressure, Different Blades Multiple attempts, External Laryngeal Pressure, Different Blades; Multiple laryngoscopists Impossible, unsuccessful

Some Causes of Difficult Airway Management

Poor Technique, Inexperience and/or Haste Anatomic Features
Short, muscular neck Limited neck mobility Prominent maxillary incisors Awkwardly placed, incomplete dentition Long, highly arched palate with narrow mouth Small mouth opening Receding chin

Abnormal States
Anaphylactic airway edema Arthritis and ankylosis Cervical spine Temporomandibular joint Larynx

Others
Mediastinal masses Myopathies

Congenital syndromes
Klippel-Feil (short, fused neck) Pierre Robin (micrognathia, cleft palate) Treacher Collins (mandibulofacial dysostosis)

Scarring from burns or radiation Trauma and hematomas

Tumors and cysts

Infections
Ludwigs angina Peritonsillar abscess Retropharyngeal abscess Epiglottitis

Technical and Mechanical Factors

Body cast Halo fixation or cervical collar Airway foreign bodies Leaks around a face mask Edentulous Flat bridge of nose Large face and head Whiskers, beard Nasogastric tube

Endocrinopathies
Obesity Acromegaly Hypothyroid macroglossia Goiter

CRICOTHYROIDOTOMY

CRICOTHYROIDOTOMY

Different Types of Face Masks

Simple Face Mask

Partial Rebreather Face Mask

Non-rebreather Face Mask

Venturi Face Mask

OXYGEN DELIVERY (DO2)

DO2(mL O2/min) = cardiac outpwut (Q, L/min) CaO2 (mL/O2/dL)
O2 delivery depends on both cardiac output and arterial O2 content
(Normal values for DO2: 520-570/mL/min/m)

OXYGEN CONSUMPTION (VO2)

VO2(mL O2/min) = Q(L/min) 10 (dL/L) 1.39 mLO2/g Hgb Hgb (g/dL) (SaO2 SvO2) (expressed as fractions, not %).

Oxygen Content

(CaO2)

CaO2= 1.39 mL O2/g Hgb [Hgb] SaO2 + 0.003mL/O2/mmHg (PaO2)

Nasal Prongs Oxygen Mask

Estimated FiO2 with variable-performance oxygen systems

100 % O2 Flow Rate (L/min)
Nasal Cannula
1 2 0.24 0.28

Estimated FiO2

3
4 5 6

0.32
0.36 0.40 0.44

Simple Facemask
5-6 6-7 7-8 0.40 0.50 0.60

Mask with Reservoir Bag

6 7 8 9 10 0.60 0.70 0.80 > 0.80% >0.85%

Flows above 6 to 8 L/minute can lead to patient discomfort, including nasal drying and bleeding.

The flow rate must exceed 5 L/minute to replace exhaled gas with fresh oxygen. Otherwise, the mask would add to the patient's dead space and lead to rebreathing of CO2.

Non re-breather masks incorporate a series of one-way valves to

prevent any exhaled gas from entering the reservoir bag. The reservoir
bag is fully supplied by the delivered oxygen and contains no CO2.. So it provides more Fi O2 than any other device.

Practice makes a man perfect

NEVER GIVE UP!