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AIRWAY MANAGEMENT a) Nasopharynx

Rashelle Lopez-Salvatierra, MD  An upper area, separated from the lower


oropharynx by soft palate
b) Oropharynx
Airway management  Extends from the soft palate to the base of the
 Expertise in airway management is important in every tongue
medical specialty  Tongue is the principal source of airway
 Maintaining a patent airway is essential for adequate obstruction, usually due to decreased tone of the
oxygenation and ventilation genioglossus muscle
 Failure to do so, even for a brief period of time, can be life C) Laryngopharynx
threatening.
Anatomy of the Airway LARYNX
 Airway  Begins at the base of the tongue and ends at the
 Extrapulmonary air passages beginning of the trachea
( nasal and oral cavities, pharynx, larynx, trachea LARYNX (C3-C6)
and large bronchi)  Functions as:
- Open valve in respiration
- Partially closed valve during
phonation
- Closed valve during swallowing,
protecting the lower airway against
aspiration
 Its closure also insists in the development of
intrathoracic pressure associated with coughing,
defacation, micturation and lifting heavy objects
Comparative anatomy of the pediatric and adult airway
Anatomic Newborn Adult
Features

Size 4 cm 10-13 cm

Shape funnel cylindrical

Position of the C3-C4 C6


Function glottis
1. Acts as a conducting system for air to enter the lower
Narrowest point 1 cm below At vocal cords
airway the vocal cords
2. Acts as a protective mechanism to prevent foreign material (cricoid
from entering the pulmonary tree cartilage)
3. Acts as an “air conditioner” of inspired gases
4. Plays an important role in the processes of speech Vocal cords slanting Transverse or
anteriorly slightly slanting
Nose and Mouth
posteriorly
 Normal breathing: Air is warmed and humidified as it
passes through the nares Mucous Loose (swells More firmly bound
 The ophthalmic and maxillary divisions of the trigeminal membranes easily)
nerve- innervates nasal mucosa
 Palatine nerves- innervates the hard and soft palate A) Laryngeal Cartilages
 Lingual nerve- branch of the mandibular division of the  Made up of 9 cartilages to form a box-like structure at the
trigeminal nerve upper end of the trachea. There are 3 single and 3 paired
- provides sensation to the anterior 2/3 of the cartilages
tongue  Single (ETC) Paired (CAC)
 Posterior 3rd of the tongue, soft palate, oropharynx- - Epiglottis -Arytenoids
innervated by the glossopharyngeal nerve - Thyroid - Corniculate
PHARYNX - Cricoid - Cuneiform
 Serves as a common musculomembranous passage way for
the digestive & respiratory systems.

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o Action – draws hyoid bone inferiorly &
1. Epiglottis draws thyroid cartilage superiorly (elevators
 Landmark in performing tracheal intubation of the larynx)
 Fibrous cartilage shaped like a leaf attached to the top of c. Inferior constrictors
the larynx in a hinge like fashion o A pharyngeal muscle
 Small depression - called the valleculae, which is the site o Action – solely as constrictor of pharynx
of placement of curved MAC laryngoscope blade Extrinsic Muscles of the Larynx
 During swallowing as laryngeal muscles contract,
downward movement of the epiglottis and closure &
upward movement of the glottis prevents food from
entering the larynx
 When acutely inflamed and swollen, life-threatening
airway obstruction may occur
2. Thyroid Cartilage
 Largest cartilage of the larynx
 Shield-like structure
 Consists of two laminae fused in the midline of neck to
form a subcutaneous projection termed laryngeal
prominence (Adam’s apple)
3. Cricoid Cartilage
 Shaped like a signet ring with the bulky portion placed
posteriorly
 Forms a complete ring – only tracheal ring is complete
 Narrowest portion of the upper airway in the infant and 2. Intrinsic muscles
small child  Responsible for moving the cartilages of larynx
 Smaller but thicker and stronger than thyroid one against the other
 Separated from the thyroid cartilage by the cricothyroid 3 fold function:
membrane  Open cords in inspiration
4. Arytenoid Cartilage  Close the cords and laryngeal inlet during
 Pyramidal structures located on the supero-lateral aspect of swallowing
the cricoid cartilages  Alter the tension of cords during speech
 Provide anatomic attachment for the inter-arytenoids and
vocalis muscle
5. Corniculate Cartilage
 Small conical nodules attached to superior aspect of
arytenoid
 Also known as cartilage Santorini
6. Cuneiform Cartilage
 Small and spheroidal embedded within aryepiglottic fold
on each side
 Also known as cartilage of Wrisberg

TWO GROUPS OF MUSCLES


 Extrinsic Muscles
o Moves the larynx as a whole
 Intrinsic Muscles
o Moves the various cartilages in relation to one
another
B) Laryngeal Muscles
Blood supply of laryngeal muscles
1. Extrinsic muscles
1. Superior Laryngeal Artery
a. Sternothyroid
o Branch of superior thyroid artery
o An infrahyoid muscle
o Accompanies internal branch of superior laryngeal
o Action – depressors of larynx
nerve
b. Thyrohyoid
o Pierces the thyrohyoid membrane
o An infrahyoid muscle
o Supplies the interior of larynx

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2. Inferior Laryngeal Artery
Superior Minimal effects
o Inferior thyroid branch of the thyro cervical trunk
laryngeal nerve Hoarseness/tiring of voice
o Accompanies recurrent laryngeal nerve into larynx Unilateral
Bilateral
Innervation
1. Superior Laryngeal Nerve Recurrent Hoarseness
 Arises from ganglion nodusum laryngeal nerve Stridor, respiratory distress
Unilateral Aphonia
 Divides into an external (motor) branch to supply the
Bilateral
cricothyroid membrane; internal (sensory) branch a) Acute
pierces the thyrohyoid membrane b) Chronic

Internal branch divides into: Vagus nerve Hoarseness


o Upper branch Unilateral Aphonia
supplies mucous Bilateral
o Lower branch membrane of base of
tongue, pharynx,
epiglottis & larynx

2. Recurrent Laryngeal Nerve


Trachea
 Loops around subclavian artery on right side & aortic  p  Suspended from the cricoid cartilage by the cricotracheal
arch on left side
 Innervates all intrinsic muscles of larynx except
p ligament
 Measures 15 cm in adults
cricothyroid l
 Supported by 17-18 C shaped cartilages
 Supplies sensory branch to mucous membrane of i  Cartilages are interconnected by fibroelastic tissue which
larynx below the vocal cords
e allows for expansion of the trachea with expiration or
Laryngeal Innervationv
s inspiration and flexion and extension of the thoracocervical
NERVE SENSORY MOTOR spine
 1st tracheal ring is anterior to the 6th cervical vertebrae
Superior Epiglottis, base of None m  Ends at the carina T5
laryngeal the tongue Right and Left Main Bronchus
u
(internal division) Supraglottis  Right is larger, wider and deviates from the plane of the
musoca c trachea in less acute angle
Thyroepiglottic o
joint u Airway assessment
Cricothyroid joint Why should we asses a patient’s airway preoperatively ?
s
Super laryngeal Anterior subglottic Cricothyroid
The goal of evaluating a patient's airway
(external musoca (adductor, tensor)
m -attempt to identify any possible problems with
division)
e maintaining, protecting, and providing a patent airway
during anesthesia.
Recurrent Subglottic musoca Thyarytenoid m NOTE:
laryngeal Lateral b 1) The Laryngoscope’s function is to visualize the
cricoarytenoid r mouth/Pharynx/Epiglottis
Inter arytenoids 2) With your left hand insert the Blade to the right of the tongue so
(adductors) a
that the tongue moves toward the left
Posterior n 3) Once the tip of the blade is at the base of the tongue pull the
cricoarytenoids e laryngoscope forward and upward in 45 degrees from the horizontal
(abductors) line(don’t rotate as u might damage the upper teeth).
 L
Effects of Laryngeal Nerve Injury on the Voice Assessment
o  Begins with a comprehensive history and physical
NERVE EFFECT OF NERVE INJURY w examination
e
HISTORY: History related to airway problems (aspiration risk)
r
o hx of voice changes
o Vocal cord polyps
b
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a
n
c
o Frequent pneumonias Pierre-Robin syndrome Micrognathia, macroglossia, cleft soft
o Coughing after eating/ drinking palate
o Acute narcotic therapy Treacher-Collins syndrome Auricular and ocular defects, malar and
o Acute trauma mandibular hypoplasia
o ICU admission (current) Goldenhar’s syndrome Auricular and ocular defects, malar and
o Pregnancy mandibular hypolasia
o Immediate postpartum Down’s syndrome Poorly developed or absent bridge of
o Systemic diseases associated with gastroparesis: DM, the nose, macroglossia
postvagotomy thyroid dysfunction, liver disease,CNS Kippel-Feil syndrome Congenital fusion of a variable number
tumors, chronic renal insufficiency, collagen vascular of cervical vertebrae, restriction of neck
disease Parkinson disease movement
Goiter Compression of trachea, deviation of
HISTORY: larynx/trachea
 difficult laryngoscopy/SGA ventilation SYNDROMES ASSOCIATED WITH DIFFICULT AIRWAY
 History of surgical manipulation in or around the MANAGEMENT
airway
 History of radiation therapy of the head/neck Acquired :
 Various congenital and acquired syndromes Infections:
Supraglottis Laryngeal edema
 obstructive sleep apnea Croup Laryngeal edema
 Body mass index > 35 kg/m2 Abscess (intraoral,
 Loud snoring retropharyngeal) ` Distortion of the airway and
 Pauses in breathing during normal sleep trismus
 Sleep interruption Ludwig’s angina Distortion of the airway and
 Daytime somnolence/napping trismus
 Airway affecting craniofacial abnormalities Arthritis:
Rheumatoid arthritis Temporomandibular joint
 lingual tonsil hyperplasia ankylosis,cricoarytenoid arthritis,
 Chronic sore throat deviation of larynx, restricted mobility
 Voice change of cervical spine
 Dysphagia Ankylosing spondylitis Ankylosis of cervical spine, less
 Obstructive sleep apnea commonly ankylosis
 Hx of tonsillectomy temporomandibular joints, lack of
 thyroglossal duct cyst mobility of cervical spine
 Asymptomatic anterior cervical mass that moves with Benign tumors:
deglutination Cystic hygroma, lipoma, adenoma, goiter
 Complications: cyst infection, fistula, spontaneous Stenosis or distortion of the airway, fixation of larynx or
rupture, voice change, dysphagia, dyspnea and snoring adjacent tissues secondary to infiltration or fibrosis from
 signs and symptoms related to airway irradiation
o Snoring Malignant tumor, facial injury, cervical spine injury,
o Changes in voice laryngeal/tracheal trauma
o Dysphagia Edema of the airway, hematoma, unstable fraction(s) of the
o Stridor maxillae, mandible and cervical vertebrae.
o Bleeding
o Cervical spine pain or limited range of motion Obesity Short thick neck, redundant tissue in the
o Upper extremity neuropathy oropharynx,sleep apnea
o TMJ dysfunction Acromegaly Macroglossia, prognathism
 sequelae of previous intubation Acute burns edema of airway
o Chipped teeth
o Significant prolonged sore throat Physical Examination:
 Patency of nares : polyps, deviated nasal septum
SYNDROMES ASSOCIATED WITH DIFFICULT AIRWAY  Teeth (edentulous)
MANAGEMENT  Palate (high arched palate or a long narrow
Congenital : mouth)
 Prognathism

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 Observation of patient’s neck (short, thick)
(masses, extension, neck mobility, ability to Quick airway assessment
assume a sniffing position)  Can the patient open the mouth widely?
 Presence of hoarse voice/stridor or previous  Can the patient maximally protrude the tongue?
tracheostomy  Patients ability to move jaw forward?
 Infections of the airway  Can the patient fully bend/ extend the head and move it
 Physiologic conditions ( pregnancy and obesity) sidewards?
TMJ movement  Indicative of TMJ movement
 Ask the patient to sit up with his head in the neutral  Inspects posterior aspect of mouth/pharyngeal structures
position and open his mouth as wide as possible.  Indicates ease to maneuver the laryngoscope
 The condyle should rotate forward freely such that the  Indicates neck movement
space created between the tragus of the ear and the
mandibular condyle is approximately one fingerbreadth in Management of the airway:
width. Preoxygenation
Mouth opening and tongue protrusion  “denitrogenation”
 The aperture of the patient's mouth should admit at least 2  Replacement of the nitrogen volume of the lung with
fingers between his teeth oxygen in order to provide reservoir for diffusion into the
Thyromental distance/ Sternomental distance alveolar capillary blood after the onset of apnea
 It is measured from the lower border of the chin.  Preoxygenation for 5 minutes- furnish up to 10 minutes of
 This measurement is done with the adult patient's neck oxygen reserve following apnea
fully extended  Four vital capacity breaths of 100% oxygen over a 30 sec
 Adults who have less than 3 fingerbreadths between their period
mentum and thyroid notch may have either an anterior  Eight deep breaths in a 60 second period
larynx or a small mandible, which will make intubation  Aids in prolonging the time of desaturation
difficult. Methods of supporting the airway
 Anesthesia face Mask
SPECIFIC TEST FOR ASSESSTMENT:  Supraglottic airways
Mallampati Classification  LMA
 relates tongue size to pharyngeal size  ET tube
 performed with the patient in the sitting position, the head Uses of face mask
held in a neutral position, the mouth wide open, and the  Pre-oxygenation prior to induction of anaesthesia
tongue protruding to the maximum.  Inhalational induction of anaesthesia
 classification is assigned based upon the pharyngeal  Bag-mask ventilation (BMV) prior to intubation
structures that are visible.  Maintenance of anaesthesia
 If the patient phonates, this falsely improves the view  Non-invasive ventilation for respiratory failure

 Class I = visualization of the soft palate, fauces, Techniques in using face mask:
uvula, anterior and posterior pillars. One-handed technique
 Class II = visualization of the soft palate, fauces and  correct sized mask over the nose and mouth
uvula  non-dominant hand to position the facemask,
 Class III = visualization of the soft palate and the  Holding the body of the mask between thumb and
base of the uvula. index finger
 Class IV = only the hard palate is visible; soft palate  Use remaining 3 fingers to support the jaw, with
is not visible at all the little finger hooked behind the angle of the
mandible
Direct Laryngoscopy • Lift the mandible upwards, towards and into the mask to create
 Cormack and Lehane an air-tight seal
Grades of Laryngoscopic View • Slight head extension may improve airway patency
 Grade I = visualization of the entire laryngeal • Ventilate the patient with dominant hand by squeezing the
aperture. bag or using bellows
 Grade II = visualization of just the posterior portion of • Continually assess the adequacy of the technique by observing
the laryngeal aperture. bilateral chest movement, listening for air leaks and assessing for
 Grade III = visualization of only the epiglottis. signs of inadequate facemask ventilation
 Grade IV = visualization of just the soft palate only,
not even the epiglottis is visible

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two -handed technique  If unsuccessful, consider using laryngeal mask
 uses a similar approach to the one-handed technique airway early
described above, with the additional hand adopting an Presence of facial hair
identical position on the other side of the mask and face  Consider using larygneal mask airway or endotracheal tube
early.
Assessment and Predictability of Difficult Mask Ventilation Patients with dentures, edentulous patients or sunken cheeks
 Criteria for Difficult Mask Ventilation  Consider leaving dentures in place if secure.
 Inability for one anesthesiologist to maintain  Use oropharyngeal airway and/or nasopharyngeal airway.
oxygen saturation > 92%  Consider placing lower pole of face mask over lower lip
 Significant gas leak around face mask itself in edentulous patients.
 Need for ≥ 4 LPM gas flow ( or use of fresh gas  Ask assistant to support soft tissue of cheeks against mask.
flow button more than twice) Obese patients
 No chest movement  Pre-oxygenation is essential
 Two handed mask ventilation is needed  Recognize that facemask ventilation and maintaining
 Changed of operator required adequate oxygenation can be difficult.
 When facemask ventilating, keep patient 5-10° head up
Patient factors associated with difficult facemask ventilation position, with anaesthetist standing on a platform or step if
 • Presence of facial hair/ beard necessary to achieve this.
 • Lack of teeth (edentulous)  Use two-handed technique with oropharyngeal airway.
 • Patients with sunken cheeks  Endotracheal intubation is often indicated for surgery.
 • Obesity (BMI >26)
 • History of obstructive sleep apnea LARYNGEAL MASK AIRWAY
 • Age >55yrs  The LMA was invented by Dr. Archie Brain at the London
 • History and signs of upper airway obstruction (snoring) Hospital, Whitechapel in 1981
 The LMA consists of two parts:
Problems and suggested solutions for inadequate facemask  The mask
ventilation  The tube
Poor mask seal  The LMA has proven to be very effective in the
 Indicated by audible leak, poor chest management of airway crisis
expansion or difficulty generating positive pressure in bag  The LMA design:
 Solutions:  Provides an “oval seal around the laryngeal inlet”
 Use two-handed technique and ensure good jaw once the LMA is inserted and the cuff inflated.
thrust.  Once inserted, it lies at the crossroads of the
 Ask assistant to support soft tissues of cheek digestive and respiratory tracts.
around rim of mask. Contraindications of the LMA
 Consider using an oropharyngeal or  Risk of gastric content aspiration (full stomach, hiatal
nasopharyngeal airway to improve airway hernia with significant gastroesophageal reflux, intestinal
patency. obstruction, delayed gastric emptying, poor history)
 Ensure no leaks in equipment or circuit Preparation of the LMA for Insertion
 If unsuccessful, consider using laryngeal mask  Step 1: Size selection
airway early  Step 2: Examination of the LMA
Partial or complete airway obstruction  Step 3: Check deflation and inflation of
 Indicated by high airway pressures, poor chest movement, the cuff
cyanosis or low oxygen saturations  Step 4: Lubrication of the LMA
 Solutions:  Step 5: Position the Airway
 Optimize patient head position with slight head Size Selection
extension.  Verify that the size of the LMA is correct for the patient
 Use two-handed technique and ensure good jaw  Recommended Size guidelines:
thrust  Size 1: under 5 kg (4 ml)
 Use an oropharyngeal or nasopharyngeal airway  Size 1.5: 5 to 10 kg (7 ml)
 Consider possibility of laryngospasm – often  Size 2: 10 to 20 kg (10 ml)
giving additional intravenous anaesthetic agent  Size 2.5: 20 to 30 kg (14 ml)
(e.g. propofol) can improve this.  Size 3: 30 kg to 50 kg (20 ml)
 Ensure no occlusion in equipment or circuit –  Size 4: 50-70 kg (30 ml)
consider reverting to self-inflating bag and mask.  Size 5: 70 to 100 kg (40 ml)

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LMA Insertion Technique  Syringe for tracheal tube inflation
LMA Insertion  Suction apparatus
 Laryngoscope handle
 Different laryngoscope blades
Step 1  stethoscope
 Grasp the LMA by the tube, holding it like a pen as near as
possible to the mask end.
 Place the tip of the LMA against the inner surface of the
patient’s upper teeth
Step 2
 Under direct vision:
 Press the mask tip upwards against the hard
palate to flatten it out.
 Using the index finger, keep pressing upwards as
you advance the mask into the pharynx to ensure
the tip remains flattened and avoids the tongue.
Step 3
 Keep the neck flexed and head extended:
 Press the mask into the posterior pharyngeal wall
using the index finger.
Step 4 Tracheal Tube size and length
 Continue pushing with your index finger. Age Internal Diameter Length
 Guide the mask downward into position. Child 4+ age/4 14+age/4
Step 5 Adult
 Grasp the tube firmly with the other hand female 7.0-7.5 21-24
 then withdraw your index finger from the male 7.5-9.0 23-24
pharynx.
 Press gently downward with your other hand to  The height of the supine patient’s airway should be at the
ensure the mask is fully inserted. level of the laryngoscopist’s xyphoid cartilage. The
Step 6 clinician performing the intubation must have unobstructed
 Inflate the mask with the recommended volume of air. access to the head
 Do not over-inflate the LMA.  Extension of the head at the atlanto-occipital joint (sniffing
 Do not touch the LMA tube while it is being inflated unless position) serve to align the oral, pharyngeal and laryngeal
the position is obviously unstable. axes such that the passage and line of vision from the lips
 Normally the mask should be allowed to rise up to the glottic opening are most nearly a straight line.
slightly out of the hypopharynx as it is inflated to  Laryngoscope is held in the left hand
find its correct position.  The blade is inserted in the right side of the patient’s mouth
 Choose the largest size that will fit comfortably in the oral and the tongue is deflected to the left
cavity then inflate to the minimum pressure that allows  Pressure on the teeth and gums must be avoided
ventilation to 20 cm water  Tube is advanced until the proximal end is 1-2 cm past the
vocal cords (midway between the vocal cords and carina)
ENDOTRACHEAL INTUBATION  Low pressure high volume cuff that prevents leaks during
IndicationS for endotracheal intubation positive ventilation pressure (20 to 30 cm H2O), minimizes
 Provide a patent airway the likelihood of mucosal ischemia
 Prevent aspiration of gastric contents  Gold standard: VISUALIZATION OF THE VOCAL
 Need for frequent suctioning CORDS AND END TIDAL CO2 DETECTION
 Operative position other than supine
 Facilitate positive-pressure ventilation of the lungs The ASA calls a Failed/Difficult Laryngoscopy if:
 Operative site near or involving the upper airway  Any airway that takes more than 3 attempts
 Airway maintenance by mask is difficult  Any airway that takes more than 10 minutes to secure
Equipment for laryngoscopy Npo status and the Rapid sequence induction
 Oxygen source and self inflating ventilation bag  Performed to gain control of the airway in the shortest
 Face mask amount of time
 Oropharyngeal and nasopharyngeal airway
 Tracheal tube and stylets

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 Administration of intravenous anesthetic induction agent is
immediately followed by a rapidly acting neuromuscular
blocking drugs
 Intubation should be performed as soon as muscle
relaxation is confirmed
 Cricoid pressure (Sellick’s maneuver) is applied by an
assistant from the beginning of induction until confirmation
of the ETT placement

Awake intubation
 Maintenance of spontaneous ventilation in the event that
the airway cannot be secured rapidly
 Confers maintenance of upper and lower esophageal
sphincter tone, thus reducing the risk of reflux

Transtracheal Techniques
 Cricothyrotomy
DIFFICULT EXTUBATION  Transtracheal jet ventilation
 LARYNGOSPASM- can be triggered by respiratory  Needle cricothyrotomy— involves passing an over-the-
secretions, vomitus, blood, or foreign body in the airway needle catheter through the cricothyroid membrane
 Contraction of the lateral  Surgical cricothyroidotomy — is an emergent airway
criciarytenoid,thyroarytenoid and cricothyroid approach in which the clinician makes an incision in the
muscles cricothyroid membrane and passes a tracheostomy or
 Tx: removal of the offending stimulus, endotracheal tube into the trachea.
administratyion of O2, small dose of short acting  Percutaneous transtracheal ventilation — involves
muscle relaxants oxygenation and ventilation via a needle or surgical
DIFFICULT AIRWAY cricothyroidotomy using an improvised ventilation device.
 ‘Difficult airway’  Transtracheal jet ventilation — refers to high frequency,
 one in which there is a problem in establishing or low tidal volume ventilation provided via a laryngeal
maintaining gas exchange via a mask, an artificial catheter by specialized ventilators that are usually only
airway or both. available in the operating room or intensive care unit .This
 Recognizing before anaesthesia the potential for a procedure is occasionally employed in the operating room
difficult airway (DA) allows time for optimal when a difficult airway is anticipated
preparation, proper selection of equipment and
technique and participation of personnel
experienced in DA management.
ASA defines…
 difficult airway as “the situation in which the
conventionally trained anesthesiologist experiences
difficulty with intubation, mask ventilation or both”.

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