Basic Airway

Management
Chris Strouse, MD
University of Texas, Houston
Chief Resident, Anesthesiology
July 24, 2008
 Covered Topics

Anatomy of the Airway

Evaluation of the Airway
Airway Algorithm
Equipment/Drugs
Basic Airway Management
Advanced Airway Management
Review Key Points
Questions
Airway Anatomy (cont)
(Sagittal View)
Airway Anatomy
(Superior View)
Airway Innervation
Airway Anatomy
(Sniffing Position)
 Airway Evaluation
Malampati scoring: I to IV
 ESSENTIAL ROUTINE PREOPERATIVE
AIRWAY EVALUATION

1) Length of upper incisors 6) Narrowness of palate

2) Involuntary: maxillary 7) Mandibular space
teeth anterior to TMD < 6 cm compliance
mandibular teeth
8)8) Mandibular space
3) Upper lip bite
Voluntary: test
protrusion SMD < 12 cm
of
? >40 cm
length
mandibular teeth anterior
to maxillary teeth
to maxillary teeth 9) Length of neck

4) Interincisor distance,
Cricoid
10) Range of motion of
mouth opening (< 4 cm) head and neck

5) Oropharyngeal class 11) Thickness of neck

(MP 3 or 4) Anesthesiology 2003 98:1269-77
 Airway Algorithm (a) Other options include (but are
not limited to):
AWAKE INTUBATION INTUBATION ATTEMPTS AFTER i. Surgery utilizing face mask or
LMA anesthesia
A INDUCTION OF GENERAL ANESTHESIA

ii. Local anesthesia infiltration

Airway Approached by Airway Secured by
Initial Intubation
Attempts Successful*
Initial Intubation Attempts
UNSUCCESSFUL
iii. Regional nerve block
Non-Invasive Intubation Invasive Access*
Invasive airway access includes
FROM THIS POINT ONWARDS
CONSIDER: (b)
1. Calling for help. surgical or percutaneous
tracheostomy or cricothyrotomy
2. Returning to spontaneous
ventilation
Succeed FAIL 3. Awakening the patient
(c) Alternative non-invasive
approaches to difficult
Cancel Case Consider Feasibility of Invasive Airway intubation include (but are not
Other Options (a) Access (b)*
limited to):
i. Different laryngoscope blades
FACE MASK VENTILATION ADEQUATE FACE MASK VENTILATION INADEQUATE ii. LMA as an intubating conduit
CONSIDER/ATTEMPT
(with or without FOB guidance)
LMA iii. FOB
iv. Intubating stylet or tube
LMA ADEQUATE*
LMA INADEQUATE
OR NOT FEASIBLE
exchanger
v. Light wand
NON-EMERGENCY PATHWAY
EMERGENCY PATHWAY vi. Retrograde intubation
vii. Blind oral intubation
IF BOTH
viii. Blind nasal intubation
Alternative Approaches
to Intubation (c)
FACE MASK Call for help
(d) Consider re-preparation of the
AND LMA
VENTILATION patient for awake intubation or
canceling surgery
BECOME Emergency Non-Invasive
INADEQUATE Airway Ventilation (e)

(e) Options for emergency non-

Successful Intubation*
FAIL invasive airway ventilation
After Multiple Attempts Successful Ventilation FAIL
include (but are not limited to):
Emergency i. Rigid bronchoscope
Invasive Airway
Access (b)*
Consider Feasibility
Of Other Options (a)
Awaken
Patient (d)
Invasive ii. Esophageal-
Esophageal-tracheal combitube
ventilation
Airway
Access (b)*
iii. Transtracheal jet ventilation
 Basic Airway Equipment
Suction (working)
Oxygen source
Ambu Bag
Oral/Nasal Airways
Endotracheal tubes/Stylets
CO2 Detectors
Laryngoscope blades
Macintosh (Mac), Miller, Wisconsin
Supraglottic devices
LMA, Combitube, etc
Adjuncts
Eschmann, Cook catheters, Aintree catheters
Oral/Nasal Airways
Macintosh Blades
Miller Blades
LMA (Laryngeal Mask Airway)
Combitube
Cook/Eschmann/Aintree
 Pharmacology
Sedative/Hypnotics
Propofol (dose 1 to 2 mg/kg, conc. 10 mg/cc)
Etomidate (dose 0.2 mg/kg, conc. 2 mg/cc)
Caution with elderly/septic/hypovolemic
Succinylcholine (depolarizing)
Dose 1 to 1.5 mg/kg, conc. 20 mg/cc
Beware of hyperkalemia (ESRD, paralysis, chronic
bedridden, crush injuries)
NDMR (Rocuronium, Vecuronium, etc)
? BMV, ? Difficult intubation
Benzodiazepines (Versed, Ativan, etc)
Herman Floor Crash Carts
 Indications for Intubation
RR > 35 bbp
Apnea
VC <15 cc/kg, restrictive, pain (rib fx), MS
insufficiency
Pa02 < 60 to 70 mmHg
PaCO2 > 55 mmHG (except in chronic retainers)
A-a gradient >350 on 100%
GCS < 6 or inability to protect airway
Tracheobronchial toilet, i.e. organophosphate
poisoning
Head Trauma Hyperventilation required
 Application
Call for help/CODE
ABCs
Spontaneous ventilating
Assist, 100%, nasal airway, jaw thrust
Apnea
BMV adequate vs inadeqate
Maneuvers to help in BMV

Collect supplies crash cart, suction,

prepare for intubation/airway management
48998 Anesthesia airway phone (24hr)
 Airway Algorithm (a) Other options include (but are
not limited to):
AWAKE INTUBATION INTUBATION ATTEMPTS AFTER i. Surgery utilizing face mask or
LMA anesthesia
A INDUCTION OF GENERAL ANESTHESIA

ii. Local anesthesia infiltration

Airway Approached by Airway Secured by
Initial Intubation
Attempts Successful*
Initial Intubation Attempts
UNSUCCESSFUL
iii. Regional nerve block
Non-Invasive Intubation Invasive Access*
Invasive airway access includes
FROM THIS POINT ONWARDS
CONSIDER: (b)
1. Calling for help. surgical or percutaneous
tracheostomy or cricothyrotomy
2. Returning to spontaneous
ventilation
Succeed FAIL 3. Awakening the patient
(c) Alternative non-invasive
approaches to difficult
Cancel Case Consider Feasibility of Invasive Airway intubation include (but are not
Other Options (a) Access (b)*
limited to):
i. Different laryngoscope blades
FACE MASK VENTILATION ADEQUATE FACE MASK VENTILATION INADEQUATE ii. LMA as an intubating conduit
CONSIDER/ATTEMPT
(with or without FOB guidance)
LMA iii. FOB
iv. Intubating stylet or tube
LMA ADEQUATE*
LMA INADEQUATE
OR NOT FEASIBLE
exchanger
v. Light wand
NON-EMERGENCY PATHWAY
EMERGENCY PATHWAY vi. Retrograde intubation
vii. Blind oral intubation
IF BOTH
viii. Blind nasal intubation
Alternative Approaches
to Intubation (c)
FACE MASK Call for help
(d) Consider re-preparation of the
AND LMA
VENTILATION patient for awake intubation or
canceling surgery
BECOME Emergency Non-Invasive
INADEQUATE Airway Ventilation (e)

(e) Options for emergency non-

Successful Intubation*
FAIL invasive airway ventilation
After Multiple Attempts Successful Ventilation FAIL
include (but are not limited to):
Emergency i. Rigid bronchoscope
Invasive Airway
Access (b)*
Consider Feasibility
Of Other Options (a)
Awaken
Patient (d)
Invasive ii. Esophageal-
Esophageal-tracheal combitube
ventilation
Airway
Access (b)*
iii. Transtracheal jet ventilation
 BMV One Handed
Mask held with left hand
Right hand to compress
breathing bag
L thumb/Index form C to grip
mask
Middle/Ring/Small fingers grip
bony mandible and angle of
mandible
Avoid soft tissue compression
Seal is combination
Downward pressure of mask
Upward movement of mandible
Confirm chest rise and BBS
DIFFICULT MASK VENTILATION
PREOPERATIVE RISK FACTORS

Mask seal (M)

BMI > 26 kg/m2 (O)
Age > 55 yrs (A)
Lack of teeth (N)
History of snoring (S)

Langeron O et al: Prediction of Difficult Mask Ventilation. ANESTHESIOLOGY 2000; 92:1229-36

Device Assisted BMV
Jaw Thrust
OPTIMAL ATTEMPT AT BMV

2 person effort
Triple airway maneuver
Tilt head (T)
Advance mandible (A)
Mouth open (M)

Large oropharyngeal
and/or nasopharyngeal
airways
 Airway Algorithm (a) Other options include (but are
not limited to):
AWAKE INTUBATION INTUBATION ATTEMPTS AFTER i. Surgery utilizing face mask or
LMA anesthesia
A INDUCTION OF GENERAL ANESTHESIA

ii. Local anesthesia infiltration

Airway Approached by Airway Secured by
Initial Intubation
Attempts Successful*
Initial Intubation Attempts
UNSUCCESSFUL
iii. Regional nerve block
Non-Invasive Intubation Invasive Access*
Invasive airway access includes
FROM THIS POINT ONWARDS
CONSIDER: (b)
1. Calling for help. surgical or percutaneous
tracheostomy or cricothyrotomy
2. Returning to spontaneous
ventilation
Succeed FAIL 3. Awakening the patient
(c) Alternative non-invasive
approaches to difficult
Cancel Case Consider Feasibility of Invasive Airway intubation include (but are not
Other Options (a) Access (b)*
limited to):
i. Different laryngoscope blades
FACE MASK VENTILATION ADEQUATE FACE MASK VENTILATION INADEQUATE ii. LMA as an intubating conduit
CONSIDER/ATTEMPT
(with or without FOB guidance)
LMA iii. FOB
iv. Intubating stylet or tube
LMA ADEQUATE*
LMA INADEQUATE
OR NOT FEASIBLE
exchanger
v. Light wand
NON-EMERGENCY PATHWAY
EMERGENCY PATHWAY vi. Retrograde intubation
vii. Blind oral intubation
IF BOTH
viii. Blind nasal intubation
Alternative Approaches
to Intubation (c)
FACE MASK Call for help
(d) Consider re-preparation of the
AND LMA
VENTILATION patient for awake intubation or
canceling surgery
BECOME Emergency Non-Invasive
INADEQUATE Airway Ventilation (e)

(e) Options for emergency non-

Successful Intubation*
FAIL invasive airway ventilation
After Multiple Attempts Successful Ventilation FAIL
include (but are not limited to):
Emergency i. Rigid bronchoscope
Invasive Airway
Access (b)*
Consider Feasibility
Of Other Options (a)
Awaken
Patient (d)
Invasive ii. Esophageal-
Esophageal-tracheal combitube
ventilation
Airway
Access (b)*
iii. Transtracheal jet ventilation
 Supraglottic Devices
(LMA, Combitube)

VIDEO LMA placement

 Supraglottic Devices
First step after inability to BMV
Does not protect airway from aspiration
Combitube and some LMAs have a second
port that allows for gastric emptying
Allows for a fiberoptic intubation of
difficult airways
Placement is a vital skill all physicians
should be able to perform
 Endotracheal Tubes
Adult
Male
Average size 7.5 8
Average depth of insertion, 22-24 cm (lips)

Female
Average size 6.5 7.0
Average depth of insertion, 20-22 cm (lips)

Pediatric - Age/4 + 4
Average depth of insertion, 3x the diameter of the
tube
 Direct Laryngoscopy
Preparation
Sniffing position (very important)
Suction ready

Multiple sized ETT, balloons checked, styleted

Laryngoscope blades checked (light, fxn)

Height of bed (pt head level of waist or higher)

Space (move bed out from wall)

Preoxygenated patient

Paralysis/unconscious

Cricoid pressure (controversial), approx. 5 kg

pressure
 Direct Laryngoscopy (Macintosh)

Laryngoscope held in L hand

Blade inserted in right side of mouth/tongue and
tongue is swept medially
Tip is inserted into the vallecula
Blade is then lifted up and away, perpendicular to
the mandible to expose VC
Suction may be necessary to visualize VC
ETT is then placed in the R hand (without removing
view of VC) and placed past the VC
Air is inserted into balloon until adequate ventilation
is obtained
Confirm placement
 Direct Laryngoscopy (Miller)
Narrower and without flange
Inserted midline and placed past the epiglottis
Blade is then lifted up and away, then slowly
withdrawn until epiglottis flops back into
visualization
Pressure on blade is slightly reduced and
reinserted until tip of blade is able to lift the
epiglottis out of line of sight
Place ETT and inflate balloon

More difficult and takes much more practice

 YENTIS-LEE MODIFICATION
CORMACK-LEHANE CLASSIFICATION

Grade 1 Grade 2a

Grade 2b Grade 3 Grade 4

Proper Blade Movement
 Common problems with DL
Secretions/blood - Suction
Esophageal intubation No BBS, epigastric sounds, gastric contents
May not need to remove Shows where not to go, can suction gastric content
Tongue
Mac blade withdrawn and then tongue reswept to left
Miller common problem, practice
Anterior VC (IIb - V)
Improper positioning Sniffing, sag of bed
Cricoid pressure inadequate, manipulate with R hand
VC off midline
Cricoid pressure notorious for hampering visualization
Release cricoid and self manipulate
Inability to pass tube
Anterior VC Pass eschmann/bougie, track ETT over bougie
Small opening/swelling Down size ETT, tube exchange easy
Cricoid can compress VC release some pressure
Inadequate relaxation, paralysis
 Failure to Pass ETT
Failed intubation should not be followed
by repeated attempts of the same
Change position
Downsize ETT

If able to BMV, wait until more experienced

personnel available
If unable to BMV, move to more invasive
ways to secure airway (LMA, surgical)
Repeated attempts can lead to a situation
of an INABILITY to BMV
 ET Confirmation
Direct visualization (BEST)
CO2 detector (EZ cap)
Chest rise
Bilateral breath sounds
Absence of epigastric sounds
Condensation in ETT
Chest X-ray
Fiberoptic confirmation
 Airway Algorithm (a) Other options include (but are
not limited to):
AWAKE INTUBATION INTUBATION ATTEMPTS AFTER i. Surgery utilizing face mask or
LMA anesthesia
A INDUCTION OF GENERAL ANESTHESIA

ii. Local anesthesia infiltration

Airway Approached by Airway Secured by
Initial Intubation
Attempts Successful*
Initial Intubation Attempts
UNSUCCESSFUL
iii. Regional nerve block
Non-Invasive Intubation Invasive Access*
Invasive airway access includes
FROM THIS POINT ONWARDS
CONSIDER: (b)
1. Calling for help. surgical or percutaneous
tracheostomy or cricothyrotomy
2. Returning to spontaneous
ventilation
Succeed FAIL 3. Awakening the patient
(c) Alternative non-invasive
approaches to difficult
Cancel Case Consider Feasibility of Invasive Airway intubation include (but are not
Other Options (a) Access (b)*
limited to):
i. Different laryngoscope blades
FACE MASK VENTILATION ADEQUATE FACE MASK VENTILATION INADEQUATE ii. LMA as an intubating conduit
CONSIDER/ATTEMPT
(with or without FOB guidance)
LMA iii. FOB
iv. Intubating stylet or tube
LMA ADEQUATE*
LMA INADEQUATE
OR NOT FEASIBLE
exchanger
v. Light wand
NON-EMERGENCY PATHWAY
EMERGENCY PATHWAY vi. Retrograde intubation
vii. Blind oral intubation
IF BOTH
viii. Blind nasal intubation
Alternative Approaches
to Intubation (c)
FACE MASK Call for help
(d) Consider re-preparation of the
AND LMA
VENTILATION patient for awake intubation or
canceling surgery
BECOME Emergency Non-Invasive
INADEQUATE Airway Ventilation (e)

(e) Options for emergency non-

Successful Intubation*
FAIL invasive airway ventilation
After Multiple Attempts Successful Ventilation FAIL
include (but are not limited to):
Emergency i. Rigid bronchoscope
Invasive Airway
Access (b)*
Consider Feasibility
Of Other Options (a)
Awaken
Patient (d)
Invasive ii. Esophageal-
Esophageal-tracheal combitube
ventilation
Airway
Access (b)*
iii. Transtracheal jet ventilation
 Advanced Airway Management

Fiberoptic Intubation
Glidescopes
Intubating LMA
Retrograde Intubation
Cricothyrotomy
Blind Nasal
Jet Ventilation
Glidescope
Retrograde Intubation
Percutaneous Cricothyrotomy
Cricothyrotomy Airway
 Review Key Points
Know the general flow of the algorithm
Positioning is extremely vital
BMV saves more lives than ETTs (hours)
Supraglottic devices (LMA) high on
algorithm
Multiple DLs can lead to can NOT
ventilate situations
Emergent airways not the best way to
learn DL, controlled in OR welcome
 References
www.metrohealthanesthesia.com
www.glidescope.com
www.emedicine.com
Handbook of Clinical Anesthesia, 5th edition,
Barash, Cullen, Stoelting.
Basics of Anesthesia, 4th edition, Stoelting,
Miller.
Millers Anesthesia, 6th edition, Miller.
Clinical Anesthesia, 4th edition, Morgan, Mikhail,
Murray.
Dr. Carin Hagberg, Dr. Steve Larson
? Questions ?