LARYNX

AIRWAY
- Laryngeal skeleton consists of nine
Reported by: Dr. Zyrell James D. Gutierrez cartilages (3 paired & 3 unpaired)
Level I Resident that houses the vocal folds
- The tracheal cartilages are
interconnected by fibroelastic tissue,
AIRWAY ANATOMY: which allows for expansion of the
trachea in both length and
Upper airway: nasal & oral cavities, diameter: it is for inspiration or
pharynx, larynx, trachea & principal bronchi expiration, flexion or extension
MAJOR LANDMARK OF AIRWAY - Extrinsic muscle moves the larynx
MECHANISMS: as a whole
- Intrinsic muscle move the various
Significant changes in its size, shape & cartilages in relation to one another
relationship to the cervical spine from The larynx is innervated by the
infancy to childhood superior and recurrent laryngeal
nerve, which are branches of the
vagus nerve. Recurrent laryngeal
nerves supply all of the intrinsic
muscles of the larynx (with the
exception of cricothyroid muscle)

ANATOMIC DIFFERENCE BETWEEN

ADULT AND INFANT
- Infant larynx proportionately smaller
- Vertical location: C3-C5 in infant;
C4-C6 in adult
- Pliable laryngeal cartilage in the
infant/child
- Vocal cords: Anterior angle with
respect to perpendicular axis of
larynx in infant/child
- Aryepiglottic folds closer to midline
in infant/child
- Epiglottis: Relatively longer,
narrower, and stiffer in infant
- Mucosa more vulnerable to trauma
in infant
 made in its inferior third and be
directed posteriorly

Hoarseness is present if there is unilateral

recurrent laryngeal nerve injury and
complete airway obstruction if bilateral TRACHEA
because of fixed cord adduction - Adults: 15cm
- Circumferentially supported by 17 to
19 C-shaped cartilages
- 1st tracheal ring - C6
- Ends at carina/T5
- Aspirated materials & deeply
inserted endotracheal tube - Right
principal bronchus

HISTORY AND PHYSICAL EXAM

CRICOTHYROID MEMBRANE
- CTM: joins the superior aspect of the
cricoid cartilage and the inferior
edge of the thyroid cartilage
- Directly beneath is laryngeal mucosa
- Incision or needle punctures on
CTM: inferior third and directed
posteriorly
Physical exam
- It is suggested that any incisions or
- Airway management always begins
needle punctures to the CTM be
with a thorough airway-relevant
 history and physical examination Conditions with airway management
- clinicians should seek the anesthetic implication:
record of past surgical visits and
refer to a different facility or
practitioner due to airway
management concerns
Mouth opening - >3cm, thyromental
distance - 3 finger breaths,
sternomental - 12.5-13.5 cm, NECK
CIRCUM - 13.7±1.1 inches in
women and 16.1±1.2 inches in men

Indexes of measurement
- Mallampati and thyromental distance
indices have historically been
considered important because they
approximate the relative mass of the
tongue and the anterior-posterior
borders of space in which it will be
displaced by the laryngoscope
-  test sensitivity is the ability of a
test to correctly identify those with
the disease (true positive rate),
whereas test specificity is the ability
of the test to correctly identify those
without the disease (true negative
rate).

Summary of Pooled Sensitivity and

Specificity of Commonly used methods of In general, tracheal intubation should be
Airway Evaluation considered nonroutine under the following
conditions:

1. The presence of equally important

priorities to the management of the airway
(such as a “full stomach” or emergency
surgery);
2. Abnormal airway anatomy; or
3. Direct injury to the upper airway, larynx, PRE-INDUCTION AIRWAY
spine, and or trachea MANAGEMENT
Preoxygenation/ Denitrogenation
Simplified risk score of difficult intubation

- Involves replacement of the nitrogen

LEMON AIRWAY ASSESSMENT volume of the lung as much 95% of
METHOD: the functional residual capacity with
oxygen in order to provide an apneic
L Look externally (facial trauma, large reservoir
incisors, beard or moustache, large - It provides at least 8 minutes
tongue reservoir for apneic time, but if with
nasal cannula, it gives another 5
minutes more
E Evaluate the 3-3-2 rule
- A healthy patient breathing room air
- Incisor distance: 3 FB
(FI02 = 0.21) will experience
- Hyoid-mental distance: 3FB
oxyhemoglobin desaturation to a
- Thyroid-to-mouth distance: 2
level of less than 90% after
FB
approximately 1 to 2 minutes of
apnea
M Mallampati score >3 - However in patient with pulmonary
disease, obesity or conditions
O Obstruction: Presence of any affecting metabolism frequently
conditions like epiglottitis, peritonsillar evidence desaturation appears
abscess, trauma sooner (3 minutes apneic time)

N Neck mobility (limited mobility)

Time-sparing method
- 4 vital capacity breaths of 100% O2
over a 30 second period
Criteria for difficult mask ventilation:
Modified vital capacity technique
- 8 deep breaths in a 60 second
period
Preferred Technique
- Applying a tight-fitting mask for 5
minutes or more of tidal volume
breathing 100% oxygen at flows of
10-12 L/min
Pharyngeal insufflation of oxygen
- Oxygen is inflated at a rate of 3-15
 L/min via nasal cannula or
nasal-only facemask upon induction
of anesthesia
Pre-induction Airway Management
- Leak as small as 4 mm can cause
significant reductions in the inspired
O2 content
Support of the Airway With the Induction
of Anesthesia
- AWAKE competent & protected
airway to UNCONSCIOUS STATE
w/ unprotected & potentially
obstructed airway – ventilatory
depression – hypercapnia and
hypoxia
Anesthesia Facemask
- MC used to deliver anesthetic
gasses and ventilate an apneic
patient
- Highly effective, minimally invasive
and requires the least sophisticated
equipment
HOLDING
- Thumb and 1st finger: grip the mask
- 3rd finger: mentum
- Fourth finger: under the angle of the
mandible
TROUBLESHOOTING
- Leaks: gentle downward pressure
(awake) / pulling the mandible
upward into the mask (unconscious
- Loose-fitting mask - MC reason for
suboptimal preoxygenation
- Appropriate positioning of the patient
is paramount for delivery of positive
pressure ventilation via facemask
- Head & neck: sniffing position
- Jaw thrust maneuver
- Reverse trendelenburg position
- Two hands or mask strap: obese,
edentulous or bearded
- Well-secured dentures – improved
mask seal
- Alternate mask placement: mask is
shifted upward, so the lower edge
meets the lower lip directly
- Normal lung compliance: no more
than 20-25 cm H2O for lung inflation
Oral and Nasal airway
- Oral and nasal airway can bypass
upper airway obstruction
- Nasal airway — avoided because of
high risk for bleeding
- Oral airway – inserted to the level of
the oropharynx, the device is rotated
180 degrees and insertion is
continued to its ultimate position
Laryngospasm
- Caused obstruction to mask
ventilation
Triggered by a foreign body, saliva, blood,
or vomitus touching the glottis
- Management
1. Removing the offending stimulus
2. Administering oxygen with
continuous CPAP
 3. Deepening the place of anesthesia LMA Flexible
4. Administering a rapid-acting muscle
relaxant
If there are no contraindication, mask
ventilation can be the primary ventilatory
technique for anesthetic maintenance

SUPRAGLOTTIC AIRWAYS
Lower incidence of:
- Sore Throat, coughing, and
● Airway within the surgical field or
laryngospasm on
shared with the surgical team
emergence. Reversible
(ophtha/ENT)
bronchospasm
● Movement of the head during head
● Lower pharyngeal mucosa trauma &
surgery or when the LMA barrel
hemodynamic effects
cannot be secured in midline
● Less increase in HR, BP, and IOP
● It has inflatable cuff that fills the
Advantages of the Laryngeal Mask
hypopharyngeal space, creating a
Airway in Supraglottic Surgery
seal that allows positive-pressure
ventilation with up to 20cm H2)
pressure
● Adequacy depends on correct
placement, appropriate size, and
patient anatomy
● Manufacturer recommends that the
clinician choose the largest size that
will fit comfortably within the oral
cavity.
● LMA insertion technique mimics the Bailey Maneuver
processes of swallowing
● - prior to attachment of the
anesthesia circuit, the LMA is
inflated with the minimum amount of
pressure that allows ventilation to 20
cm H20 without an air leak
● Manufacturer recommends keeping
the intracuff pressure 44 mmHg -
60cmH20 ● Deflated LMA is placed behind the in
● Gastric contents - SGA left in place, situ ETT, ETT is removed, the LMA
the barrel suctioned, placed in is inflated and the patient is emerged
trendelenburg position and 100% on the :LMA
oxygen administered
● LMA classic: TV limited to 8mL/kg SGA Removal
and airway pressure to 20cm H20;
use successfully with supine, prone,
lateral, oblique, trendelenburg, and
lithotomy positions
● Recommendation: 2-3 hours; >24
hours exist
 ● SGA should be removed either when Tracheal Intubation
the patient is deeply anesthetized
or after the protective airway
reflexes have returned; patient is
able to open the mouth on command
● Excitation stages: coughing and/ or
laryngospasm
● LMA fully inflated - “scoop”

SGA Contraindications
● Full stomach
● Hiatus hernia with significant - First method encourages extension
gastroesophageal reflux, intestinal of the atlantoccipital joint by the use
obstruction of the right hand under the occiput
● Delayed gastric emptying
● Unclear history, high airway
resistance, glottic or subglottic
obstruction
● Limited mouth opening (<1.5cm)
● Full stomach
● Hiatus hernia with significant
gastroesophageal reflux, intestinal
obstruction
● Delayed gastric emptying
● Unclear history, high airway
resistance, glottic or subglottic - Second method: Opening the mouth
obstruction with your right by placing your thumb
● Limited mouth opening (<1.5cm) on the lower jaw and your middle
finger on the upper jaw. Snipping
Tracheal Intubation finger
- Goal: produce a direct line of sight
from the operator’s eye to the larynx Direct Laryngoscope blades
- Maximal alignment of the axes of the
oral and pharyngeal cavities, and
displacement of the tongue
- Sniffing position: neck is flexed by
35 degrees and head is extended by
15 degrees
- Lingual tonsil hyperplasia is the most
common cause of unanticipated
difficult DL

● The Macintosh (curved)

- Used to displace the
epiglottis by placement of the
distal tip in the vallecula and
tensing of the
glossoepigiglottic ligament
 epiglottis, the tongue is swept
leftward and compressed into the
mandibular space. Once reaching the base
of the tongue (with the Macintosh blade in
the vallecula or the Miller blade
compressing the epiglottis against the base
of the tongue), the operator’s arm
and shoulder lift in an anterior–caudad
direction.

Special cases: Child and Infant

● The Miller (straight) blade
- Reveals the glottis by ◉ Relatively larger size of the occiput
compressing the epiglottis in children, elevation of the head is
against the base of the not required to achieve a sniffing
tongue position
◉ Hyperextension at the
atlanto-occipital joint, as done in
adults, may cause airway
obstruction from the relative pliability
Macintosh Miller blade of the trachea

- Advantage - Better in
ous the patient
whenever who has a
there is small
little room mandibular
to pass an space,
ETT (e.g. large
small incisors or ◉ Due to the short length of the
mouth) a large trachea, there is a higher risk of
epiglottis endobronchial intubation or
accidental extubation with head
movement
The optimal blade tends to be the one with
◉ Because the cricoid cartilage is the
which the provider has the most experience.
most rigid portion of the airway
until 6 to 8 years of age, the
intubator must be sensitive to
resistance to advancement of an
ETT that has easily passed the vocal
folds.

Narrowest portion of airway: adult glottis ;

child - cricoid

As the blade is advanced toward the

Cormack & Lehane
◼ If a satisfactory laryngeal view is not
achieved, the backward–upward–
rightward pressure (BURP)
maneuver may be applied.
◼ larynx is displaced backward (B)
against the cervical vertebrae,
upward (U,
◼ superiorly) and to the patient’s right
(R), using pressure (P) over the
thyroid
◼ Cartilage.
Grade 1 - visualization of the entire glottic
aperture, Grade 2 - includes visualization of
the only the posterior aspects of the glottic
aperture
Grade 3 - visualization of the tip epiglottis
Grade 4 - visualization of no more than the
soft palate
Grade 2A - partial vocal cord view
Grade 2B - arytenoids and epiglottis were
visualized
Grade 3A - when the epiglottis can be
SELLICK MANEUVER
manipulated with repositioning or an
intubating bougie - Cricoid pressure: block gastric
Grade 3B - nonmovable epiglottis contents from moving up the
esophagus, into the pharynx, and
into the tracheobronchial tree
BURP MANEUVER
- Sellick maneuver - entails the
B - backward posterior displacement of the cricoid
cartilage against the vertebral
U - upward
bodies, compressing the esophagus
R - Right - From beginning of induction until
confirmation of ETT placement
P - Pressure
✔ An assistant to provide cricoid
pressure (CP) to block gastric
contents from moving up the
esophagus, into the pharynx, and
into the tracheobronchial tree
✔ cricoid pressure (Sellick maneuver),
which entails the posterior
displacement of the cricoid cartilage
against the vertebral bodies,
compressing the esophagus
✔ and is held from the beginning of
induction until confirmation of ETT
 placement. ◉ 7.5-8 - adult male

Common indications for implementing ◼ The tracheal tube cuff should be

cricoid pressure include: advanced at least 2 cm past the
- Patients who have recently eaten glottic opening to approximate a
- Gastroparesis midtracheal placement.
- Gravidity ◼ This should correlate to depths of 21
- Nausea and 23 cm at the teeth for the typical
- Recently vomited adult female and male, respectively.
- Hiatal hernia, or known incompetent ◼ a size 7 to 7.5 ET tube is typically
esophageal sphincter(s) used in the adult female and size 7.5
- Increased intraabdominal pressure to 8 ET in the adult male.
- Inebriation
- Impaired neurological
- Upper respiratory reflexes VERIFICATION OF TRACHEAL
INTUBATION
◉ Gold standard: sustained
Contraindication detection of exhaled carbon
- Active vomiting (risk of esophageal dioxide
rupture) ◉ Visualization of tube
- Cervical spine or laryngeal fracture placement through the vocal
folds
◉ Auscultation over the chest
(OELM) Optimal external laryngeal and abdomen
manipulation ◉ Visualization of chest
excursion
◉ Observation of humidity in
the ETT
◉ Flexible scope identification
of tracheal anatomy
◉ Radiologic confirmation

COMPONENTS OF AIRWAY
EXAMINATION THAT SUGGEST
DIFFICULT INTUBATION
- Pressing posteriorly and cephalad
over the thyroid, hyoid and cricoid
cartilage

TRACHEAL INTUBATION
◉ Tracheal tube: advance at least 2cm
past the glottic opening to
approximate a midtracheal
placement
◉ Depth at the teeth:
Male: 23cm
Female 21 cm
◉ 7-7.5 ID - adult female
VIDEOLARYNGOSCOPY with Macintosh DL
- Use of a stylet is advised if some
difficulty in maneuvering the ETT

◼ The Glidescope has been

successfully used with limited
cervical spine movement because of
ankylosing spondylitis and cervical
spine trauma
◼ it may be difficult to use in
patients with limited mouth
opening. >17.4mm

STEPS TO AVOID SOFT TISSUE TRAUMA

◼ VL mimics the operator actions of
direct laryngoscopy but places an
imaging device toward the distal end
of the laryngoscope blade.
◼ This moves the provider’s point of
view past the tongue, avoiding the
need for a direct line of sight to the
glottis.
◼ An added benefit is decreased
cervical motion when compared with
DL
◼ A) McGrath Mac and (B) Mcgrath
Series 5 (Medtronic, Dublin, Ireland),
◼ (C) Glidescope Multiuse blade and
(D) Glidescope Cobalt single-use
blade (Verathon,
◼ Bothell, WA), and (E) Gliderite rigid
stylet (Verathon, Bothell, WA
INCLUDE:
- Stylet is within the bevel of the ETT
- Maintaining the ETT in a midline
position and as close to the blade as
possible
- Attention is turned to the video
image only when the distal ETT can
be seen on the image monitor
- Avoid levering the blade inward, as
this increases the blind spot
inferiorly
- Using the least force necessary to
advance the ETT
STORZ CMAC

GLIDESCOPE BLADE

- Consists of an electronic
laryngoscopic handle with
exchangeable metal blades imitating
(Macintosh, miller, glidescope)
- Used as either a videolaryngoscope
or a standard direct laryngoscope

- 60 degree angulation, making it an

acute angle videolaryngoscope that
reduces cervical spine motion by
50% at C2-C5 segments compared
CONTROL OF GASTRIC CONTENTS: and a rapid onset paralytic (i.e.,
succinylcholine or double dose
● Omeprazole is most effective when
rocuronium)
administered the night before
✔ Avoidance of mask ventilation and
immediate laryngoscopy and
intubation, following induction

NORMAL VS. RAPID SEQUENCE

INDUCTION:

Normal Sequence Rapid-Sequence

Induction Induction

Indication: Indication
- Patient - Any full
does not stomach
have a full patient
stomach
- Not known
or Induction: IV
suspected anesthetic
“difficult Do not mask
airway” ventilate
Induction: IV and Sellick maneuver
inhaled anesthetics
Pulmonary Aspiration: Patients at Risk for Mask Ventilation
Aspiration, Methods to Reduce Aspiration
Risk, and ASA recommended Fasting
Do not mask ventilate because this may
guidelines
insufflate air in the stomach and increases
the risk of vomiting/aspirating
RAPID SEQUENCE INDUCTION:
◼ The goal of a rapid sequence ETT CUFF INHALATION: 20-30 mmHg
induction is to minimize the time pressure
when neither the patient nor you can
protect the patient’s airway. I.e. the
time between induction (the time the
patient looses control) and intubation
(the time you gain control).
◼ Induction of anesthesia profoundly
depresses intrinsic reflexes that
protect the airway from the entrance
of foreign bodies, including
regurgitated material.
◼ Established method to rapidly secure
an airway with an endotracheal tube
in a patient who is at increased risk
of aspiration
✔ Rapid injection of anesthetic agents

CRITERIA FOR ROUTINE AWAKE POST
SURGICAL INTUBATION:
◼ Sign of inadequate ventilation
couldnt be reversed by mask
ventilation OR O2sat could not be
maintained above 90%
REQUIREMENT FOR DEEP INTUBATION:
◉ Easy mask ventilation following
induction
◉ Non-airway surgery
◉ Empty stomach
DIFFICULT AIRWAY:
If a trained anesthetist using convention
laryngoscope take more than 3 attempts or
more than 10 minute are required to
complete a tracheal intubation
AIRWAY APPROACH ALGORITHM:
● Is airway control necessary? Can
regional, neuraxial, or infiltrative
anesthesia be applied
● Could tracheal intubation be (at all)
difficult? may be difficulty with rapid
tracheal intubation, the AAA is
followed to the next question
● Can supraglottic ventilation be used
if needed “cannot intubate (Question
2)—cannot ventilate (Question 3)”
Box A (awake intubation) of the
ASA-DAA may be the preferred root
entry point.
● Is there an aspiration risk? The
patient at risk for aspiration is not a
candidate for elective SGA use. The
juncture of “cannot intubate/should
not ventilate” can be avoided by
entering the ASA-DAA at Box A.
● Will the patient tolerate an apneic
period?
○ If time to oxyhemoglobin
desaturation is limited, Box A
may be prophylactically
chosen.
 VORTEX APPROACH:
- Simple cognitive aid to be used
during the critical cannot
intubate/cannot oxygenate (CICO)
scenario

Confirm ventilation, tracheal intubation, or

SGA placement with exhaled CO2
- Other options- surgery utilizing face
mask or SGA anesthesia, local
anesthesia, Local anesthesia
infiltrative or regional nerve blockade
- Invasive airway access - surgical or
percutaneous airway, jet ventilation,
and retrograde intubation
- Alternative difficult intubation
approach - video assisted laryngo,
alternative laryngo blades, SGA as
intubation conduit, fiberoptic
intubation, intubating stylet/tube
changer, light wand and blind oral or
nasal intubation
- Emergency non-invasive airway
ventilation consists of a SGA

EXCEPTION TO AAA:

An invasive airway will ideally be initiated

- Unable to cooperate owing to mental
disability, language barriers,
intoxication, anxiety, depressed level
of consciousness, or young age
REGIONAL ANESTHESIA FOR PATIENTS
WITH LIKELY DIFFICULT AIRWAY:
prior to oxyhemoglobin desaturation.
Greenzone, lifeline, neck rescue
VORTEX APPROACH:
An invasive airway will ideally be initiated
prior to oxyhemoglobin desaturation A
AWAKE AIRWAY MANAGEMENT:
● Provide maintenance of
spontaneous ventilation in the event
that the airway cannot be secured
rapidly
● Benefits:
- Increased size and patency
of the pharynx
- Relative forward placement
 of the base of the tongue
- Posterior placement of the
larynx
- Patient’s cooperation
maintenance of upper and
lower esophageal sphincter
tone

An invasive airway will ideally be initiated

prior to oxyhemoglobin desaturation

● Emergency setting cautions:

E.g. cardiovascular stimulation in the Local anesthetic therapy is directed
presence of cardiac ischemia or
ischemic risk, bronchospasm. RETROGRADE WIRE-AIDED TRACHEAL
Increased intraocular or intracranial INTUBATION:
pressure ◉ The technique involves the
● Administration of an antisialogogue antegrade passage of an ETT into
is important to the success of awake the airway using a wire that has
intubation techniques been passed into the larynx via a
● Apply topical local anesthetics percutaneous puncture through the
- Lidocaine topically applied, cricothyroid or cricotracheal
peak analgesia occurs within membrane
15 min
- Benzocaine, very rapid onset
(<1 minute) and short
duration (approximately 10
minutes)
● Local anesthetic therapy is directed
to three anatomic areas
- Nasal cavity/nasopharynx
- Pharynx/base of the tongue
- hypopharynx/larynx/trachea

AIRWAY BOUGIE: ◉ This wire is blindly passed in the

cephalad direction into the
◉ Airway bougies are semimalleable
hypopharynx, pharynx, and out of
stylets that may be blindly
the mouth or nose and then used as
manipulated through the glottis when
a intubating conduit
a poor laryngeal view is obtained
◉ Cricothyrotomy cricothyrotomy,
(Cormack-Lehane grade 3 or 4) An
cricothroidotomy, coniotomy, and
ETT is then “threaded” over the
minitracheastomy are synonyms for
bougie and into the trachea
establishing an air passage through
the CTM
◉ Cricothyrotomy is contraindicated in
children younger than 6 years of age
and in patients with laryngeal
fractures