CHAPTER

Airway Management
in ICU
2
Anamika Chaudhary, Manish Munjal, Neeru Gaur, Neena Rungta, Narendra Rungta

INTRODUCTION ANATOMY OF AIRWAYS

Airways are devices to ensure open pathway between
the mouth and nose and the patient’s lungs. Airway man­
agement is primary consideration in cardio­ pulmonary
resuscitation, emergency medicine, anesthesia and inten­
sive care medicine. Upper airways obstruction is a life
threatening emergency and rapid assessment and estab­
lishment of patent airway takes priority. Inten­sive care unit
(ICU) physician should be capable of performing a variety
of airway management techniques. Most com­monly used
techniques are being described below:
Successful intubation, cricothyroidotomy and tracheo­
stomy need detailed knowledge of airway anatomy. There
are two openings to airways, mouth and nose leading
to oropharynx and nasopharynx respectively (Fig. 1).
Oral and nasal cavity are separated by hard and soft
palate. The pharynx is a fibromuscular structure extend­
ing from skull base up to cricoid cartilage, at the level
of opening of esophagus. It is divided into nasopha­
rynx and oropharynx, as mentioned above, and laryn­go­­
pharynx (or hypopharynx). It is separated by oropharynx

Airway Management Techniques

• Noninvasive (above the glottis)
–– Oro/nasopharyngeal airways
ƒƒ Bag and mask ventilation
ƒƒ Combitube
ƒƒ Laryngeal mask airway
• Invasive (through/below glottis)
–– Nonsurgical
ƒƒ Endotracheal intubation (ET)
–– Surgical
ƒƒ Tracheostomy
-- Percutaneous
-- Surgical
ƒƒ Cricothyroidotomy
-- Percutaneous
Fig. 1: Laryngoscopic view of the glottic opening.
-- Surgical.
10 Section 1: General
by epiglottis. Larynx is composed of nine cartilages, which
are unpaired thyroid, cricoid, epiglottis and paired aryt­
enoids, cunei­form and corniculate (Fig. 2).
Nerve Supply
Sensory innervation of the airway is by three cra­ nial
nerves trigeminal, glossopharyngeal and nerve. Nose
is inner­vated by V1 and V2 branches of trigeminal nerve.
V3 Glossopharyngeal nerves and V3 branch supply ante­
rior two-thirds and posterior one-third tongue respec­
ti­vely. Pharynx above epiglottis is innervated by ninth
nerve and below it by vagus through superior and recur­
rent laryngeal nerves. Superior laryngeal nerve divides
Fig. 2: Sagittal section—head and neck showing anatomy of the airway.
A B
Figs. 3A and B: (A) Tongue obstructing the airway; (B) Head tilt opens up the airway.
into external and internal laryngeal nerves to supply areas
between epiglottis and vocal cords. Recurrent laryngeal
nerve supplies larynx below vocal cords and trachea. All
muscles of larynx are innervated by recurrent laryngeal
nerve except crico­thyroid, which is supplied by external
laryngeal nerve, a branch of superior laryngeal nerve.
Posterior cricoarytenoid muscles abduct vocal cords
and lateral cricoarytenoid muscles are the principal addu­
ctors.
Acute bilateral recurrent laryngeal nerve palsy with
intact superior laryngeal nerve can result in stridor and
respiratory distress because of unopposed tension of cri­
cothyroid muscles.
Blood supply of larynx is derived from branches of
superior and inferior thyroid arteries which arise from
external carotid artery. Cricothyroid artery arises from
superior thyroid artery (which extends along lateral edge
of cricothyroid membrane) and crosses upper margin of
cricothyroid membrane. So, best approach during cri­
cothyroidotomy is to stay in midline and at midpoint
between thyroid and cricoid cartilages.
BASIC AIRWAY MANAGEMENT
TECHNIQUES
• Head tilt-chin lift: This is the simplest technique to
ensure open airway in an unconscious patient, lift­
ing the tongue away from posterior wall of pharynx
(Figs. 3A and B). Palm of one hand applies pressure
on patient’s forehead to tilt the head back while first
two fingers of opposite hand lift the chin (Fig. 4).

• Jaw thrust maneuver (Figs. 5A and B): Jaw thrust is
helpful in patient who may have cervical spine inju­
ry. In supine position, with index and middle fingers,
the health care worker pushes the posterior aspect of
Fig. 4: Head tilt and chin lift procedures combined.
A B
Figs. 5A and B: (A) Bimanual elevation of lower jaw; (B) Bimanual elevation of lower jaw along with mouth opening.
Chapter 2: Airway Management in ICU 11
mandible, while thumb pushes down the chin to open
the mouth. The mandible displaces tongue forward
with it and lifts it ensuring a patent airway.
• Cervical spine immobilization: It is used in suspected
cervical spine trauma patients, to limit the movement
of C-spine at time of airway management. Do not
hyperextend the neck. In-line cervical immobiliza­tion
should be applied by a second rescuer, who places
himself/herself by the side of the patient, below the
patient’s shoulder level and stabilizes the jaw, neck and
head. In this position, the rescuer providing cer­vical
spine immobilization will not hinder the intu­bator’s
line of vision.
NONINVASIVE AIRWAY
MANAGEMENT
Oropharyngeal Airways
These are J-shaped devices used to lift tongue and soft
hypopharyngeal structures away from posterior wall
of pharynx. These are available in different sizes along
with color coding of bite portion as shown in the Figure 6.
Airways usually used are Guedel’s airways which have
a large flange (rests outside lips), a bite portion (lies
between teeth) and tubular channel, pharyngeal end of
which rests between posterior oropharynx and base of
tongue.
12 Section 1: General
Insertion
It should be used only in unconscious or semiconsci­
ous patients to avoid coughing or laryngospasm. Size
is estimated by placing airway next to patient’s mouth
and the pharyngeal tip lies next to angle of mandible
(Fig. 7). The jaw is opened by left hand and airway is
inserted with its concave side facing palate. Before the
bite portion reaches the teeth, airway is rotated at 180°
and slipped further in position. Alternatively, a tongue
depressor is used to push down while airway is inserted
with concave side down (Figs. 8A to D).
Uses
• To maintain patent airway in self-breathing semi­
conscious patients or during mask ventilation of semi­
conscious/unconscious patients.
• To prevent biting of ET or tongue or fiberscope or
orogastric tube.
• To keep mouth open for suctioning.
Nasopharyngeal Airway
Nasopharyngeal airways are longer than oropharyngeal
airway. It is passed through the nose and extends to just

Fig. 6: Oropharyngeal airway Fig. 7: Sizing the oropharyngeal airway

A B
Figs. 8A and B: (A) Insertion of an oral airway using a tongue blade; (B) The airway may be placed "upside down".
 Chapter 2: Airway Management in ICU 13

C D
Figs. 8C and D: (C) Rotating the oro-pharngeal airway for the final placement; (D) Nasopharyngeal and orotracheal tube in place.

A B
Figs. 9A and B: (A) Nasopharyngeal airway; (B) Nasopharyngeal airway in place.

above epiglottis. It is better tolerated than oropharyn­ • Pathology, deformity of nose

geal air­way by patients with intact airway reflexes (Figs. 9 • A history of nasal bleed requiring treatment.
A and B).
Uses
Indications • To facilitate suctioning
• Trauma/pathology of oral cavity • Infants with Pierre Robin syndrome
• When mouth cannot be opened • As a guide for fiberscope
• Teeth are loose or in poor condition. • To treat hiccups
• To maintain patent airway during dental surgery.
Contraindications
• Hemorrhagic disorder
Description
• Anticoagulant therapy It has a flange and a slightly curved body (Figs. 9A and B).
• Skull base fracture Diameters are same as for tracheal tubes. For adult male,
14 Section 1: General
7–7.5 mm and for female, 6.5–7 mm size is used. For
insertion, airway is lubricated thoroughly, it is held per­
pen­dicularly in line with nasal passage with bevel facing
against septum, and then it is inserted.
Complications
Airway obstruction: A incorrectly placed airway or one
of small size may push tongue base against posterior
pharyngeal and cover laryngeal aperture. Tip of airway
can push epiglottis down over laryngeal opening causing
blockade.
• Tongue edema/damage
• Trauma to nose, posterior pharynx, lip, tongue
• Dental damage
• Laryngospasm
• Ulceration and necrosis of soft tissue
• Retention, aspiration or swallowing of airway
• CNS trauma: In case of basilar skull fracture, trauma to
anterior fossa may occur.
Bag and mask ventilation is an important skill that
everyone must practice and learn. It may be difficult in
certain situations like obesity, presence of a beard, eden­
tulous patients, severely limited jaw protrusion, and
snoring, a small thyromental distance (less than 6 cm)
and trauma to the face or neck. Emergency care providers
must also ensure airway cleared of vomitus or blood.
The self-inflating bag-valve mask system is the most
commonly used system for emergency department
and pre-hospital resuscitation. An appropriate mask is
one that does not cover the patient's eyes and does not
Fig. 10: Bag and mask ventilation
extend beyond the chin (Fig. 10). Typically, this mask is
of ana­tomic design, with the pointed portion over the nose.
The bag-valve mask unit should be attached to high-flow
oxygen at 15 L/min. Place the patient in the “sniffing” or
ear-to-sternal notch position, provided the patient does
not require cervical spine immobilization. Additional
maneuvers to assist with adequate positioning for BVM
ventilation like head tilt-chin lift or jaw thrust can be used.
The oropharyngeal and nasopharyngeal airways can be
used as adjuncts if there is difficulty in ventilating.
Traditionally, the “EC” hand position is utilized to
obtain a seal with the mask. This position involves the
thumb and index fingers holding the mask at the infe­
rior and superior mask borders respectively. The other
three fingers hold the mandible while performing the jaw
thrust. If using the two-provider technique, one person
should hold the mask with both hands, while the other
provider bags the patient. The rate of ventilation for an
adult is 10–12 breaths/min. Adequate chest rise should
be seen.
Laryngeal Mask Airway
These are supraglottic devices used to secure airway by
forming an inflatable circum­ferential seal over laryngeal
inlet. They are used as a temporary airway management
technique when bag–mask ventilation is difficult or in
condition of failed endotracheal intubation.
Description
Laryngeal mask airway (LMA) consists of a shaft (i.e. a
curved tube) attached to an elliptical cup-shaped mask
at 30°. At the connection of mask with tube, there are
two vertical bars to prevent obstruction of tube by epi­
glottis. The mask has an inflatable cuff, tube and a pilot
balloon (Fig. 11). A black line runs longitudinally along
the posterior aspect of tube which should be facing up­
per incisors after insertion. LMA is available in different
sizes (Table 1).
Insertion Technique
Remove any visible obstruction or secretions from airway.
Ensure IV access, pulse oximetry, electrocardiography
(ECG) and blood pressure monitoring except in emergen­
cy situations.
Select appropriate size LMA and check cuff by inflat­
ing maximum allowable air into it. (which is 50% greater
 Chapter 2: Airway Management in ICU 15
Table 1: Selection of laryngeal mask airway (LMA) sizes.
LMA Patient’s Cuff inflation Largest endotracheal
sizes weight (in kg) volume (mL) intubation allowable (mm)
15 5 3
1.5 < 10 8 3.5
2 10–20 12 4.5
2.5 20–30 20 5.5
3 30–50 20 6.0
4 50–70 30 6.5
5 > 70 40 6.5

and bilateral air entry is checked. Position is further

Fig. 11: Laryngeal mask airway
confirmed by ETCO2 monitoring. The tube is then secured
by tape to maxilla.

than recommended cuff volumes). Shape of cuff should
be elliptical when inflated and there should be no kink­ing
or abrasions on it.
The cuff should be then deflated to form a flat oval disk
by pressing hollow side down against a clean flat surface.
The deflated cuff should be wrinkle free.
The operator stands at head of the bed. Lubrication is
applied on posterior surface of the cuff before insertion
with a water soluble jelly. Patient is sedated to obtund
airway reflexes, though not as deep as that required for
endotracheal intubation. Adequacy of sedation can be
judged by absence of motor response to jaw thrust.
The head should be extended and neck flexed (sniff­
ing position). The left hand goes under head of patient
and stabilizes occiput while right hand holds LMA (for
right-handed persons) in a pen holding position and
index finger presses at the point where tube joins the
mask. With the concave surface of mask facing ante­ri­
orly and black line facing patient’s upper lip, the LMA
is inserted into mouth while pressing mask against hard
palate to avoid folding of the deflated cuff (Figs. 12A to D).
Advance the LMA further down the oral cavity into
hypopharynx by index finger maintaining backward
pressure with slight pronation of forearm till definite
resistance is felt. If not, withdraw index finger and push
the shaft further down with left hand until resistance
encountered.
Confirm correct positioning, by ensuring black line
facing midline of upper lip. The cuff is inflated causing
slight upward movement of entire LMA and a slight bulge
at the front of the neck. Breathing system is connected
Flexible LMA (Fig. 13)
It is a version of LMA with a flexible reinforced tube. It
is available in five sizes; in each, the tube is longer and
of smaller diameter than standard LMA. Being wire
reinforced, it is more resistant to kinking while tube is
positioned away from surgical field.
Intubating LMA (Fastrach™)
The tube of intubating LML (iLMA) is shorter and wider
with a more acute curve and a metal handle attached to it
(Fig. 14). There is a epiglottis elevating bar at the aperture to
direct the endotracheal tube to the glottis. While inserting
ensure the curved metal tube is towards chin. Rest tech­
nique is similar. A laryngoscope can be used to assist
placement.
A well lubricated ET is passed down the iLMA through
epiglottis elevating bar while gently lifting the iLMA with
metal handle. Inflate ET cuff and conform placement.
Position stabilizer rod on ET connector. Deflate iLMA
cuff and remove it over ET-stabilizer assembly. Remove
stabilizer rod, reconfirm ET placement and secure it with
tapes.
LMA ProSeal (Fig. 15) is designed to provide additional
bene­fits over the original LMA. It has a double tube
arrangement, with a flexible wire reinforced airway tube
and a drain tube. The drain tube opens at the upper
esophageal sphincter and permits drainage of gastric
secretions and is intended to prevent inadvertent gastric
insufflation. The drain tube also protects the air­way tube
from occlusion by the epiglottis.
16 Section 1: General

A B

C D
Figs. 12A to D: (A) Insertion of laryngeal mask airway (LMA); (B) Insertion of LMA—sliding along the hard palate; (C) Insertion of LMA—finger
guide for correct placement of LMA; (D) Final placement and cuff inflation.

Fig. 13: Flexometallic laryngeal mask airway.


Fig. 14: Intubating LMA (iLMA).
Fig. 16: Combitube.
The double cuff design (on adult sizes) enables good
seal with minimal mucosal pressure.
A removable introducer tool is available to aid inser­
tion. LMA ProSeal has a bite block to protect the airway
tube.
Contraindication
• Inability to open mouth
• Pharyngeal pathology
• Obstruction at/below larynx
• Low lung compliance or high airway resistance.
Chapter 2: Airway Management in ICU 17
Fig. 15: ProSeal flexometallic LMA.
Complications
• Aspiration
• Gastric distention
• Coughing/laryngospasm/bronchospasm
• Kinking/misplacement of LMA
• Partial airway obstruction.
INVASIVE AIRWAY MANAGEMENT
Esophageal-Tracheal Combitube (Fig. 16)
It is a double lumen tube used in emergency airway
management. It has two lumens, one is esophageal tube
that is blocked at distal end and has side openings and
other is tracheal lumen which has a distal open end. It
has two cuffs: a distal one and a proximal pharyngeal
one. Usually, the tube enters esophagus and when both
proximal and distal cuffs are inflated, patient is ventilated
by side pharyngeal holes on esophageal tube. If not in
esophagus, then breathing circuit is connected to tracheal
tube and distal cuff is inflated. Barotrauma, esophageal
rupture has been reported.
Endotracheal Intubation
This is most common definitive airway management
technique used in ICU. Indications are respiratory failure
needing ventilator support or high inspiratory concen­
tration of oxygen and positive end-expiratory pressure
(PEEP), acute upper airway obstruction, inability to clear
secretions (low Glasgow coma scale), or at risk of aspira­
tion (heavy post nasal bleed).
18 Section 1: General
Initial Assessment and Preparation
Prior to attempting intubation, availability of all relevant
equipment should be checked. Difficult airway manage­
ment facility should be assessable with in few minutes
adequate preoxygenation (at least 3 minutes) is to be
highly emphasized to with stand apnea during intubation.
Critical patients may desaturate very fast during apnea
periods due to under lying lung/heart pathology. High
flow oxygen by mask and Ambu bag or Bain’s circuit
should be used. Head tilt/chin lift or jaw-thrust maneu­
ver to mask ventilate the patients, and double handed
technique may have to be used to ensure good chest rise
while patients is being sedated.
A beard, heavy jaw, edentulous patient, facial injury/
burns may make mask ventilation difficult.
The oropharyngeal secretions can be cleared by suc­
tioning and airway patency can be achieved with oro/
nasopharyngeal airway, if there is airway obstruction due
to the tongue or pharyngeal soft tissue making mask ven­
tilation difficult.
Call for help if difficult airway management is anti­
cipated (discussed ahead). Cap, mask, and gloves are
donned by ICU physician after good hand wash. Ventila­
tor is set up, drugs to be used for sedation/anesthesia are
kept ready at hand.
Direct Laryngoscopy
Cricoid pressure is usually required as ICU patients
are usually not kept fasting for adequate time. Aspirate
nasogastric tube, if in place. Position patient’s head at
waist of physician, flex the neck and extend head (morning
air sniffing position) to align oral, pharyngeal and laryn­
geal axes with visual axis of the operator.
Selected drug therapy is given intravenously slowly.
A combination therapy of fentanyl (0.05–0.4 mg/kg)/
mor­phine (0.05–0.2 mg/kg) with midazolam (0.02–0.2 mg/
kg) intravenously can be used. Other drugs like ketamine,
thiopentone, propofol may be used. Preferred anesthetic
agent is ketamine in hemodynamically unstable patients.
Muscle relaxants may be used if adequate relaxation is
not achieved by anesthetic/sedative drugs. Succinylcho­
line is ideal for rapid sequence intubation (RSI) but it is
to be avoided in patients with hyperkalemia, severe
acidosis, acute/chronic neuromuscular diseases, exten­
sive burns and cervical trauma. ICU patients are at high
risk for severe hypotension following use of sedatives.
Therefore adequate hydration and availability of vasop­
ressor with close monitoring of blood pressure during
and after intubation is necessary.
During laryngoscopy, operator holds laryngoscope
in left hand. Mouth is opened with right hand. Optimum
size blade is inserted between teeth from right side and
the tongue is swept toward left as the blade is advanced
further into oral cavity. The tip of blade rests into the
valleculla. With upward and forward motion of hand
the epiglottis is lifted up, allowing the visualization of
glottis opening. A well-lubricated ET is held in right
hand and is passed through vocal cords under vision,
cuff is inflated and bilateral air entry is checked by five
point auscultation. Then tube is secured with tapes.
Confirm tube placement further by ETCO2 monitoring.
Visualization of water vapors in the tube or chest rise
may be less reliable. In case of difficulty BURP techni­que
(backward, upward, rightward pressure) on larynx by
an assistant may bring glottis into vision. A stylet can
also be used with ET. In a difficult to visualize ante­
rior larynx, a gum elastic bougie can be advanced into
trachea in midline directed anteriorly and then ET
can be guided over it. A hollow ET exchanger or a light­
ed stylet can also be used. If multiple attempts are to be
made, restrict maximum interruptions in ventilation to
about 30 seconds.
Complications
• Malplacement/endobronchial intubation leading to
collapse of unventilated lung or barotrauma to venti­
lated lung. Esophageal intubation leading to hypoxia,
bradycardia and cardiac arrest
• ET disconnection, displacement, blockage, kinking
• Hypertension, tachycardia, myocardial ischemia,
raised intracranial pressure, raised intraocular pres­
sure by laryngoscopy
• Severe hypotension by sedative or anesthetic drugs
• Airway trauma, bleeding in patients with coagulopathy.
• Aspiration pneumonitis
• Negative pressure pulmonary edema
• Sudden release of severe airway obstruction.
Cricothyroidotomy
Percutaneous or surgical, it is method of choice for severe
airway obstruction in emergency. A horizontal incision
is given in cricothyroid membrane. It is held wide open
by a scalpel handle or forceps while a small tracheostomy
or ET is inserted through it. Commercial cricothyroido­tomy
sets are also available using Seldinger technique. A tube
of 3.0 mm will provide adequate ventilation with self-
inflating bag connected to oxygen.

Contraindications
Age less than 12 years.
Tracheostomy
Indications
• Glottis/supraglottic obstruction
• Tracheobronchial toilet
• A more comfortable airway in case of anticipated pro­
longed ventilation
• Protection against aspiration.
In uncomplicated patients, bedside percutaneous
tracheostomy (PCT) performed by experienced ICU physi­
cian is more convenient, cost effective and as safe as surgi­
cal tracheostomy in OT. And also less infection rates have
been suggested in PCT.
Contraindications
• Coagulopathy; international normalized ratio greater
than 2; APC lesser than 40 × 107/L
• Significant anatomical abnormality in anterior neck
• tracheostomy scar
• Unstable cervical spine injury.
Techniques
Ciaglia’s technique: A horizontal skin incision is made
above or below the second tracheal ring, i.e. about two
finger breadth above the vocal cords. A J-wire is inserted
into trachea through needle at incision site. A series of
curved dilators or a single modified tapered dilator is used
to enlarge stoma. Tracheostomy tube is then inserted over
guidewire and ET is removed.
Grigg’s Technique: A Kelly’s forceps is threaded over J wire
to dilate the stoma prior to insertion of tympanostomy
tube.
Complications
• Hemorrhage
• Surgical emphysema and pneumothorax
• Cricoid damage
• Infection of tracheostomy site
• Mucosal ulceration
• Tracheoesophageal fistula
• Tracheal stenosis
• Tracheomalacia.
Chapter 2: Airway Management in ICU 19
DIFFICULT AIRWAY MANAGEMENT
Though 1–3% of patients in operating theatre are repor­
ted to have diffi­culty in managing airway, this percentage
is significantly higher in ICU patients. Also the risk of
rapid desaturation due to underlying lung or cardiac
pathology is present. If a difficulty in managing airway
is anticipated, call the senior most help available imme­
diately. Failed repeated attempts may result in hypoxia
or laryngeal trauma or edema, making successful airway
control even more difficult.
Assessment of Difficult Airway
Following features help in predicting an airway problem,
a combination of which is more reliable rather than
individual factors. Muscle relaxation should be strictly
avoided if there is a suspicion of difficulty in airway.
Anatomical Features
• Short neck or thyromental distance less than 6 cm
(three finger)
• Limited neck mobility, i.e. inability to touch chest
with chin or extend neck
• Long upper incisors, small mouth, long high curved
palate, receding mandible
• Limited mouth opening, i.e. inter incisor distance
less than 3 cm (two finger)
• Space occupying lesion or trauma of face/oropharynx/
larynx.
Mallampati Classification
• Though to be examined in a sitting patient with
mouth wide open eyes of examiner at level of mouth
of patient, it is not a ideal position for ICU patient.
Class more than 2 predicts difficulty in intubation
(Fig. 17).
Cormack–Lehane Classification
It is based on examination of laryngeal structures on
direct laryngoscopy. More than grade 2 predicts difficulty
in intubation.
Grade 1: Complete glottis visible.
Grade 2: Anterior glottis not visible.
Grade 3: Only epiglottis visible: (a) mobile, (b) not mobile
Grade 4: Epiglottis not visible.
The techniques used in difficult intubation and
difficult ventilation are listed in Table 2.
20 Section 1: General

Fig. 17:  The mallampati score: Class 1. Complete visualization of the soft palate; Class 2. Complete visualization of the uvula; Class 3. Visuali-
zation of only the base of the uvula; Class 4. Soft palate is not visible at all

Table 2: Techniques for difficult airway management.

Techniques for difficult intubation Techniques for difficult ventilation
• Alternative laryngoscope blades • Esophageal tracheal Combitube
• Awake intubation • Intratracheal jet stylet
• Blind intubation (oral or nasal) • Laryngeal mask airway
• Fiberoptic intubation • Oral and nasopharyngeal airways
• Intubating stylet or tube changer • Rigid ventilating bronchoscope
• Laryngeal mask airway as an intubating conduit • Invasive airway access
• Light wand • Transtracheal jet ventilation
• Retrograde intubation • Two-person mask ventilation
• Invasive airway access

Table 3: Suggested contents of the portable storage unit for diffi­cult airway management.
1. Rigid laryngoscope blades of alternate design and size from those routinely used; this may include a rigid fiberoptic laryngoscope
2. Tracheal tubes of assorted sizes
3. Tracheal tube guides. Examples include (but are not limited to) semirigid stylets, ventilating tube changer, light wands, and forceps
designed to manipulate the distal portion of the tracheal tube
4. Laryngeal mask airways of assorted sizes; this may include the intubating laryngeal mask airway and the LMA-ProSealTM (LMA North
America, Inc., San Diego, CA)
5. Flexible fiberoptic intubation equipment
6. Retrograde intubation equipment
7. At least one device suitable for emergency noninvasive airway ventilation. Examples include (but are not limited to) an esophageal tra-
cheal Combitube (Kendall-Sheridan Catheter Corp., Argyle, NY), a hollow jet ventilation stylet, and a transtracheal jet ventilator
8. Equipment suitable for emergency invasive airway access (e.g. circothyrotomy)
9. An exhaled CO2 detector
The items listed in this table represent suggestions. The contents of the portable storage unit should be customized to meet the specific needs,
preferences, and skills of the practitioner and healthcare facility.

The American Society of Anesthesiologists algorithm equip­ment required in the difficult airway cart is listed in
for difficult airway is described in the Flowchart 1. The Table 3.
 Chapter 2: Airway Management in ICU 21
Flowchart 1: Difficult airway management.
22 Section 1: General
BIBLIOGRAPHY
1. American Society for Testing and Materials. Standard
specification for anesthetic equipment-oropharyngeal and
nasopharyngeal airways (F 1573-95). West Conshohocken
PA: ASTM, 1995.
2. Biodin MP, Airway patency in unconscious patient. Br J
Anesthesia. 1985;57:306-1.
3. Brain AIJ, Verghese C. The Intubating Laryngeal Mask
(FasTrach) Instruction Manual. San Deigo, CA: LMA North
America; 1998.
4. Brain AIJ. The laryngeal mask: a new concept in airway
management. Br J Anesthesia. 1983;55:801-4.
5. Brimacombe J,Berry A, Verghese C. The laryngeal mask
airway:its uses in anesthesiology. Anesthesiology. 1994;
80:706-7.
6. Ciaglia P, Firsching R, Syniec C. Elective percutaneous
dilatational tracheostomy. Chest. 1985;87:715-9.
7. Cormack RS, Lehane J. Difficult tracheal intubation in
obstetrics. Anaesthesia. 1984;39:1105-11.
8. Delany A, Bagshaw SM, Nalos M. Percutaneous diala­
tational tracheostomy versus surgical tracheostomy in
critically ill patients: a systematic review and meta-analysis.
Crit Care. 2006;10:R55.
9. Frass M, Frenzer R, Rauscha F, et al. Evaluation of esophageal
tracheal combitube cardiopulmonary resuscitation. Crit
Care Med. 1986;15:609-11.
10. Griggs WM, Worthley LIG, Gilligan JE, et al. A simple per­
cutaneous tracheostomy technique. Surg Gynaecol Obstet.
1990;170:543-5.
11. Konrad C, Schupfer G, Witlisbach M, et al. Learning manual
skills in anesthesiology: is there a recommended number
of cases for anesthetic procedures? Anesth Analg. 1998;86:
635-9.
12. Kress TD, Balasubramaniam S. Cricothyroidotomy. Ann
Emergency Medicine. 1982;11:197-201.
13. Mallampati SR, Gugino LD, Desai SP et al. A clinical sign
to predict difficult tracheal intubation: a prospective study.
Can J Anaesth. 1985;32:429-34.
14. Marsh AM, Nunn JF, Taylor SJ, et al. Airway obstruction
associated with use of the Guedel airway. Br J Anesthesia.
1991;67:517-23.
15. McGee JP, Vender JS. Nonintubation management of the
airway. In clinical procedures in anesthesia and intensive
care. JL Benumofed.,Philadelphia, PA: JB Lippincott Co;
1992. pp 89-114.
16. Pryor JP, Reilly PM, Schapiro MB. Surgical airway
management in ICU. Crit Care Clin. 2000;16:473-88.
17. Silvester W, Goldsmith D, Uchino S, et al. Percutaneous
versus surgical tracheostomy; a randomized controlled
study with long-term follow-up. Crit Care Med. 2006;34:
2145-52.
18. Stoneham MD. The nasopharyngeal airway. Assessment
of position by fiberoptic laryngoscopy. Anesthesia. 1993;
48:575-80.
19. The American Heart Association in Collaboration with the
International Liaison Committee on Resuscitation (ILCOR):
Guidelines 2000 for cardiopulmonary resuscitation and
emergency cardiovascular care. Circulation. 200;102:1.