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11dii Airway Module - para Professionals
11dii Airway Module - para Professionals
UNIVERSITY OF MANITOBA
Preamble
The Department of Anesthesia at the University of Manitoba is committed to the
promotion of patient safety and quality of care. Education of providers of airway and
resuscitation support from all disciplines is a fundamental part of that mission. For this
educational effort to be effective, it is important to consider and incorporate the particular
needs of each group for whom skills development is contemplated. This document
outlines the structure, and goals and objectives of a program designed to meet the
developmental needs of paramedical personnel providing care for patients with respect to
airway support.
Program Outline
Each trainee will be provided with a program outline, including a reference manual,
orientation and contact information, and evaluation logs. At the end of the rotation, the
trainee will be expected to keep evaluation logs and provide them to the Coordinator of
the sponsoring program as proof of completion of the educational program.
The trainee will present to the assigned hospital OR suite on the first day of the rotation,
at the time and place indicated in the orientation manual. The senior resident or site
coordinator will direct the trainee to a primary staff person. This primary staffperson
shall
Review the educational material with the trainee
Provide resource discussion
Evaluate the degree to which the trainee has met the knowledge objectives
Record the results of that evaluation on the evaluation log
Coordinate access to airway management techniques with him/herself, and other
staff as available
Each individual staff physician or resident who supervises airway management
techniques will
Observe the trainee and provide formative feedback
Evaluate the trainee’s competence with the technique
Record the evaluation on the provided log
As applicable review and evaluate elements of the curriculum as discussed with
the primary mentor
Laryngoscopy #1
Laryngoscopy #2
Laryngoscopy #3
Laryngoscopy #4
Laryngoscopy #5
Laryngoscopy #6
Laryngoscopy #7
Laryngoscopy #8
Laryngoscopy #9
Laryngoscopy #10
Laryngoscopy #11
Laryngoscopy #12
Laryngoscopy #13
Laryngoscopy #14
Airway Management
Airway Assessment
The first goal in assessing the upper airway is to identify any conditions that may
threaten the integrity of the airway. The assessment of upper airway obstruction will be
dealt with later in this chapter. Most patients presenting for elective procedures do not
have airway pathology, but still need airway assessment for another reason.
The second reason to assess an airway would be to predict the likelihood of
difficulty with managing the airway should that become necessary. Inducing anesthesia
and being unable to control the airway is a potentially life threatening event, and can
usually be predicted and prevented. There is a spectrum of difficulty that ranges from
easy to impossible. Moderate difficulty is relatively common, while impossible
intubations are rare. As the difficulty of laryngoscopy increases, so does the likelihood of
and severity of injury related to laryngoscopy. It has been estimated that ~30% of deaths
attributable to anesthesia are related to airway mishaps.
Neck Extension
The ideal position for
intubating is the “sniff” position (fig
2). This refers to flexion at C7-T1,
Fig 3
combined with extension at C1-2. It is not
Fig 3
uncommon for people to have limitations of
extension at C1-2. Neck extension is a movement
involving multiple joints, and it is possible to
make up for the lack of mobility at C1-2 by
extension at the other levels of the cervical spine.
From the point of view of ease of laryngoscopy, it
is, therefore, very important to examine
extension at C1-2 specifically. Watch from the side while a patient extends the c-spine.
The amount of extension can be measured by looking at the occlusal surface of the upper
molars (see Fig 3). A normal range of motion at C1-2 is from 0-35o.
A review of the above three airway measurements by Benumof showed that they
are highly predictive of difficulty with laryngoscopy. Used in combination, they should
allow the detection of 99% of difficult airways. Although important, these are not all of
the characteristics of an airway that might be relevant to the ease of laryngoscopy.
On examination of the oropharynx, prominent, loose, capped or missing teeth, or
a narrow or cleft palette would be indicators of possible difficulty. The presence of dental
prostheses should be noted. Laryngoscopy is best done with the prosthesis out, but in
some cases, ventilation by face mask can be difficult in the edentulous patient, due to the
loss of the normal facial contour for which the mask is designed. In these cases, it may be
easier to ventilate with the prosthesis in place, keeping in mind that the prosthesis also is
a foreign body, with the potential to dislodge and obstruct!
Two other ranges of motion that are important are mouth opening and anterior
displacement. Mouth opening can be measured in a manner similar to that described for
hyo-mental distance. A patient should be able to get 2 fingers between his incisors. The
inability to anteriorly displace the mandible far enough so that the lower incisors are
anterior to the uppers is also a concern.
Even with a relatively mild degree of obstruction, most patients will complain of a
sensation of increased resistance to breathing, or suffocation. As the degree of obstruction
increases, this gives way to air hunger. The sensation of airway obstruction is very
distressing, and most patients experience fear, often to the point of panic. In an acute
upper airway obstruction, such as a foreign body, the typical posture of clutching the
throat and leaning forward is usually observed (fig 4).
Physical findings that suggest airway compromise
include: tachypnea, tachycardia, hypertension, use of
accessory muscles, nasal flaring, intercostal and suprasternal
indrawing, and decreased air entry. Several different sounds
are associated with the obstructed airway. The classic upper
airway sound is inspiratory stridor. This is a high-pitched,
wheezing, which must be distinguished from the wheezing of
lower airway obstruction, which occurs in expiration. Other
sounds may include snoring, in the case of obstruction by the
tongue. This occurs most commonly in patients with a
depressed level of consciousness, although it may be found in
patients with muscle weakness or a swollen pharynx. As with
lower airway obstruction, sounds only occur if there is
passage of air, and as obstruction worsens, any abnormal
Fig 4 sounds may become attenuated.
Many patients without obstruction at presentation are at risk of developing
obstruction due to a progressive lesion. This would include mass lesions (tumour), edema
(anaphylaxis, burns, epiglottitis), abcsess, hematoma, and airway trauma. In any patient
with pathology of the upper airway, one must consider whether it is a progressive lesion,
and if so, at what rate it can be expected to progress. Further investigations, such as
lateral neck x-rays, CT scans, or flow-volume loops, may be undertaken if it is judged
that there is no immediate risk to the airway. If, however, the airway integrity is
compromised, the establishment of a secure airway takes priority over further evaluation.
Extrinsic Abscess,
Tumour,
Hematoma
Trachea Edema
Tracheomalacia
Fracture/disruption
Stenosis
Extrinsic Tumour
Hematoma
Thyroid
Treating Upper Airway Obstruction
The basic principles governing the management of unobstructed airway are the
same for all obstructed airways. The underlying cause, although important in
determining ultimate definitive therapy, is not the primary concern. The initial
management is determined by the degree of obstruction, with the goal of
maintaining oxygenation.
The first step in the management of airway obstruction is to recognize it, as
discussed above. In any patient presenting with some symptoms or signs of airway
obstruction, the first step is to provide oxygen. The next step is to achieve sufficient
patency to allow for adequate respiration. One does this by progressing through a series
of maneuvers. In an awake patient who is already making maximal attempts to open his
own airway, airway resistance can be reduced by breathing a mixture of helium and
oxygen. Gentle positive pressure coordinated with spontaneous breaths will counteract
the negative intraluminal pressure of spontaneous breathing and thus help to distend the
airway.
In a patient with impaired airway control, or if the above is ineffective, proceed to
try to support the airway physically. Begin with positioning in the sniff position (see
above). Often, applying a face mask with gentle neck extension will relieve obstruction
by the tongue. Beware, if there is any possibility of c-spine injury, the neck should not be
extended! The next step is to perform a jaw thrust with one hand, then two hands if
needed. If this is unsuccessful, then an oral or nasal airway may be inserted. If this fails,
sometimes a two-person jaw thrust will alleviate the obstruction. This done by having a
second rescuer stand at the patient’s side and augment the jaw thrust by applying anterior
pressure to the angle of the jaw along with the first rescuer.
If none of these techniques is successful in providing patency, it will be necessary
to instrument the airway. This usually means intubation (see below), but there are other
adjuncts that may be useful as bridge to intubation. It cannot be overemphasized that, in
this situation, time is critical. At this point, pick the method you are best at. These other
adjuncts in inexpert hands often only have the ultimate effect of delaying control.
Tracheal Intubation
Indications
There are many different situations in which intubation of the trachea is indicated.
One could simply make an exhaustive list of the individual indications. As discussed in
the section on airway obstruction, it is important in the emergency situation to have an
organized approach to the question of endotracheal intubation. An endotracheal tube can
perform three basic functions. It can provide airway maintenance, protection, and
positive pressure ventilation. Thus, the indications for intubation would be: risk to airway
patency; risk of airway contamination; or need for positive pressure ventilation.
When airway patency is already compromised, the need for intubation is usually
obvious. Equally important is the need to predict impending airway obstruction, as
discussed above. Prophylactic intubation may be indicated in these conditions. Patients
presenting obstructed due to level of consciousness are usually easily supported by mask,
but it may be hours before their ability to maintain their own airway returns, if at all. It
may, therefore, be expedient to intubate a patient whose airway is supportable by mask,
to free yourself for other activities.
Complications
The complications of intubation relate to damage during insertion, as well as
damage from the presence of the tube over time. Damage that can occur during insertion
includes trauma to the lips, teeth, tongue, oro- and nasopharyngeal soft tissues, cords,
arytenoids, amd trachea. This may manifest as local laceration and bleeding, which is
generally short-lived. Damage to the arytenoids and cords may cause premanent voice
changes. It is also possible to jeopardize airway patency with an expanding hematoma, or
the creation of a false lumen, as in the case of tracheal mucosal laceration. A less obvious
vulnerable structure is the eyes, and corneal laceration is one of the most common
injuries related to anesthesia.
Complications of long-term intubation are due to the mechanical irritation of the
tube in the trachea, as well as its interference with normal tracheal physiology. Tracheal
stenosis is the result of local irritation and ischemia. The main contributor to risk is the
duration of intubation. After several days the risk of stenosis becomes higher, and after 7-
10 days, if it seems that the tube will not be out soon, tracheostomy is often done. Other
contributors to this risk are larger tubes and high pressures in the cuff. Endotracheal tubes
also interfere with normal mucociliary function, and may contribute to the development
of pneumonias. This presents the clinical dilemma that they may be needed to support
ventilation while at the same time contributing to the deterioration in overall pulmonary
status.
Difficult Intubations
The purpose of airway assessment is to identify the likelihood of difficult
intubation, as outlined above. If it is deemed likely hat an intubation will be difficult, as
discussed in the section on intubation, it should be done awake if at all possible.
Intubating a patient awake involves first anesthetizing the airway. The extent to which
this is possible will depend on the urgency of the situation, as well as the skill of the
clinician. It is a time-consuming, and technically demanding procedure. Appoaches to
freezing an airway range from simple spray topicalization ( the most common, and least
effective) to special topical techniques and injection techniques. The use of sedation is a
very common, and potentially catastrophic practice Awake intubations with poor
topicalization are unpleasant. The solution is to improve the topicalization. The all too
common response of giving sedation in this situation can quickly lead to disaster. The
patient will usually become disinhibited, and struggle even more. Further sedation will
result in a patient who is awake enough to fight off intubation, but too sedated to breathe
effectively, especially since they likely couldn’t in the first place! If sedation is to be used
at all, it should be with great caution, and with reversible agents. As depicted in the
algorithm on difficult intubation, there will be occasional situations when it is truly
impossible to intubate awake. In these, it is better to completely induce the patient than to
wander into the semi-anesthetized realm described above. Induction in this situation
should only be undertaken by an expert in airway management, and with preparation for
immediate surgical airway.
Unfortunately, even with the most conscientious airway assessment, there will
still be occasions when a patient will be induced and then turn out to be difficult to
intubate. There are also situations where the patient may present already unconscious,
needing intubation. Either of these is a life-threatening event. The time frame available to
deal with such an event is, at best, a few minutes. After that time brain damage or death
become increasingly likely. This is, obviously, a very stressful situation. The key to
management, as with all emergency situations, is to have a protocol ready ahead of time.
This is the same philosophy applied in ACLS and ATLS. Although this situation is
incredibly intense and stressful, the problem at hand is very simple. Keeping that in mind
and going through the steps in an organized manner will mean the difference between life
and death. The American Society of Anesthesiologists has published a very useful
algorithm for the management of the difficult airway. The theme to the whole algorithm
is to maintain a focus on ventilation (see Fig 7).
The entry point to the algorithm is the recognition that you have a difficult
intubation. One of the most common errors is to persist with initial attempts at intubation
prior to realizing or admitting that you are in trouble. If, after one attempt, you are unable
to intubate, search for immediately correctable causes (too small a laryngoscope blade,
poor positioning etc). If there is something obviously causing the problem, it is
reasonable to correct it and try again once, providing that the patient is well saturated. If
the saturation is already falling, there is no obvious correctable cause, or the second
attempt fails, immediately attempt to ventilate the patient. Proceed through the series of
airway maneuvers as outlined in the section on the obstructed airway. There are only two
possible outcomes at this point. You will either be able to ventilate or not.
If you cannot ventilate, proceed directly to airway instrumentation. For most
situations, the method of choice will be cricothyrotomy. Legitimate alternatives would
include needle cricothyrotomy, or LMA, with the proviso that they are immediately
available. Equipment for cricothyrotomy should be available in all intubating locations,
but the equipment for TTJV and LMA are rarely available outside of ORs. There is no
time to look for equipment at this stage, and unless you have checked beforehand, they
are not options.
The second, more favourable outcome would be that you are able to ventilate. The
first thing to do is to apply cricoid pressure, and to take a moment to calm down. There is
no immediate threat to life, and injudicious action at this point may change that. The
question at this point is how urgently intubation is required. It may be feasible to simply
ventilate the patient until he is awake, and proceed with an awake intubation. This may
not be a realistic option, either due to the need to proceed with a surgical procedure, or
because the patient is not expected to awaken. If that is the case, try to wait for expert
assistance. If that is not available proceed with whatever other techniques are available at
which you are skilled. The most important thing to remember at this point is that
whatever other technique is used, it must be done gently. Persistent attempts to intubate
will inevitably traumatize the airway, resulting in progressive edema, bleeding and
eventual obstruction. Then you’re back in the can’t intubate, can’t ventilate scenario.
Fig 7: The ASA Difficult Airway Algorithm