Airway

Management
Dr Cecilia Kong
Learning Objectives

At the end of this session, students will learn how to:

• perform an airway examination that includes a history of any

difficulty and a physical examination.
• prepare the appropriate basic and advanced airway equipment
• develop an initial plan and backup plans before proceeding
• describe the methods to maintain the airway
• identify the different types of artificial airways
• familiar the importance of advanced airway management
 Introduction
• Airway management is one of the most high-risk procedures in medicine. If done
poorly, patients suffer significant morbidity and mortality.

• Patients undergoing emergent AM are at a higher risk and complexity due to the
urgent nature and impending threat to life.

• Effective airway management is central to the care of critically ill and injured patients

• With any upper airway problems, whether complete or partial obstruction, help must
be urgently as this is a medical emergency.

• The location for emergency airway management; such as anesthetic room, ED, but
most commonly in general ward
 Clinical Situations in Difficult Airway
In the American Society of Anesthesiologists
(ASA) Practice Guidelines, patient may be difficult with:

Facemask ventilation of the upper airway

Tracheal intubation

The bag valve mask (BVM)

https://www.researchgate.net/publication/297601274_Hot_Topics_in_Airway_Mana
gement_During_Gastrointestinal_Endoscopy
Bag-mask ventilation (BMV)
• Bag-mask ventilation (BMV) is the
cornerstone of basic airway management
but is not a skill easily mastered
• This skills is most often needed because of
inadequate ventilation
• The reason for inadequate ventilation can
results from impaired respiratory effort or
airway obstruction
 Anticipate a difficult airway

1. Review past medical history, including anesthesia notes an notes

and alert of difficult intubation before.
2. Note special situations where neck protection is needed. {e.g.
rheumatoid arthritis RA, *ankylosing spondylitis (AS), cervical spine
trauma}
3. Due to limited neck extension {e.g. nasopharyngeal carcinoma
(NPC) post-radiotherapy, previous cervical spine surgery}

*Ankylosing spondylitis (AS) is a long-term condition in which the spine and other areas of the body
become inflamed.
Commonly used mnemonics and score
assessing airway difficulty
Mask seal
(Beard,
facial injury)
Obese
C-Spine /Obstruction
(BMI >26)

MOANS

Stiff lung Age (55

years)

No teeth
 Commonly used mnemonics and score
assessing airway difficulty

Look externally

The Evaluate using

Neck Mobility LEMON the 3-3-2 rule
Rule

Mallampati
Obstruction
score
 Commonly used mnemonics and score
assessing airway difficulty

Look externally

The Evaluate using

Neck Mobility LEMON the 3-3-2 rule
Rule

Mallampati
Obstruction
score
Competency assessment
• Competency in assessment and maintenance of the
airway using basic airway maneuvers
• Application of advanced skills in assisting advanced
airway management
• Rapid sequence induction (RSI) and tracheal
intubation are essential skills for all nursing staff
 RSI
• Administration of a potent induction agent (anaesthetic) followed by a
rapidly acting neuromuscular blocking agent (usually suxamethonium) to
induce unconsciousness and motor paralysis for tracheal intubation.

• If the patient has a full stomach, and is therefore at risk of aspiration of

gastric contents.

• Maintenance of oxygenation throughout the process is mandatory.

• https://www.youtube.com/watch?v=NAQ42rVybpI
Causes of inadequate ventilation -
Respiratory effort
• Inadequate respiratory effort may be due to:

i. intrinsic factor e.g intracranial hemorrhage

ii. extrinsic factor. e.g. opioid overdose.

• Poor respiratory effort causing inadequate ventilation.

• Difficult to detect: e.g. often silent and the detection

i. close observation of the rate, pattern and depth of breathing, use of

accessory muscles, abnormal sounds and signs of injury.
 When compared to poor
respiratory effort, noises
produced by the
Airway
obstruction obstructed upper airway
often make such
obstruction easier to
detect.
Airway assessment
If the upper airway becomes obstructed due to:

i. swelling

ii. Presence of a foreign body

• Hypoxia, respiratory arrest and death will occur quickly unless prompt action is
taken.

• The airway may become partially obstructed or completely obstructed.

• Accurate assessment and recognition of the problem will determine the

appropriate and effective action to take.
 The correct approach to airway assessment
▪ Are they able to speak?
▪ Their pattern of breathing
and whether they are
conscious. Lack of ▪ Does not always indicate
verbal
▪ Ability to speak indicates response an obstructed airway?
the airway is patent as air
is able to pass over the
vocal cords. If the
patient is
▪ Whilst reassuring, the conscious
ability to speak does not
necessarily mean all is Look at the
well, as there may be a person:
▪ Their pattern of
degree of partial breathing and
obstruction. whether they are
conscious.
 Causes of inadequate ventilation
- Airway obstruction

Obstruction by:
▪ Foreign bodies such as food bolus in elderly
patient
▪ Injured tissue such as traumatic facial injury
▪ Bleeding esophageal varies
▪ Sputum secretion
▪ Tumors of the neck.
▪ Enlarged thyroid or local lymph glands.
▪ Blockage by vomit, blood secretions or an
inhaled foreign body (removed by suctioning,
https://aspergillosis.org/zh/haemoptysis/ removal of foreign body and/or positioning).
Partial airway obstruction
• Noisy
• Inspiratory stridor – caused by obstruction at, or above,
the larynx.
• Gurgling – suggests liquid in the upper airway.
• Snoring – the pharynx is semi-occluded by the tongue.
• Crowing or stridor – caused by laryngeal spasm or
obstruction.
• Expiratory wheeze – suggests constriction or spasm of
the lower airways
Complete airway obstruction

• Silent

• Paradoxical or ‘see-saw’ breathing, as attempts are

made to draw in air: the chest is drawn in and the
abdomen distends.

• The opposite occurs on exhalation.

Causes of airway obstruction
Upper Airway Lower Airway
• Laryngospasm • Bronchospasm: asthma
• Secretions/blood • Congestive heart failure
• Foreign body • Pulmonay edema
• Large tongue • Bronchial blood clots
• Obstruction / • Mucous plugging
Endotracheal tube
• Sleep Apnoea
• Bilateral recurrent
laryngeal nerve injury
Causes of inadequate ventilation
- Airway obstruction

• In unconscious patient, soft tissue airway obstruction can

occur:
– Prolapse of the tongue into the posterior pharynx
– Loss of muscular tone in the soft palate
 Airway maneuvers
• 2 position maneuvers can be
performed to improve airflow in
the patient receiving basic airway
management:

– Head-tilt Chin-lift

– Jaw thrust
Head-tilt chin-lift
• Primary airway maneuver used in any
patient
• Avoid in cervical instability or cervical
spine injury
• Performed by using two hands to extend
the patient’s neck and open the airway
• While one hand applies downward pressure
to the patient’s forehead, the tips of the
index and middle finger of the second hand
lift the mandible at the mentum, which lifts
the tongue from the posterior pharynx in
order to improve the airway patency.
Head-tilt chin-
lift

Avoid extreme
hyperextension
Jaw-thrust maneuver
• An effective airway techniques especially for patient with
suspected or confirmed cervical spine injury

• This maneuver moves the tongue anteriorly with the

mandible, minimizing the tongue’s ability to obstruct the
airway

• Techniques is performed by placing the heels on both hands

on the parieto-occipital areas on each side of the patient’s
head, then grasping the angles of the mandible with the
index and long fingers, displacing the jaw anteriorly.
 Maintain a clear airway

• If the airway is obstructed or at

risk of obstruction due to
blood, vomit or secretions,
gentle oral suction should be
applied using a wide bore oral
suction device. Yanker
Sucker
 Maintaining the airway with adjuncts
• 2 airway devices can help us to achieving this goal and commonly seen
and available in clinical area:

– Oropharyngeal airway (OPA)

– Nasopharyngeal airway (NPA)

• Both will prevent the tongue from occluding the airway and provide an
open conduit for air to pass
 Oropharyngeal airway (OPA)
• Available in different size For infant, small, medium and large adults,
OPA sizes 2, 3 and 4 respectively are used
• Should only be used in a deeply unresponsive patient who is unable to
maintain his or her airway
• In conscious or responsive patient, OPA insertion can stimulate the
gag reflex and induce vomiting and aspiration
• Once inserted they help maintain airway patency and are used in
conjunction with the pocket mask or bag valve mask devices as an aid
to ventilation as necessary.
 Keywordhut.com.com

OPA
 How to estimate the correct size of OPA for
a patient?
Hence, a rough method for choosing
the correct OPA size is:

– Hold the airway beside the

patient’s mandible

– It should be placed at the level of

the incisors, and it should reach to
the angle of the jaw (patient’s
mandible)
 How to insert the OPA?
• Always avoid pushing the tongue into the posterior pharynx

• Starting with the curve of the OPA inverted.

• The airway is inserted upside down and then turned 180° once contact has
been made with the back of the throat.

• Once in situ the OPA can assist with the maintenance of the airway and
enables access to the oropharynx with a fine bore flexible suction catheter, to
clear secretions.

• https://www.youtube.com/watch?v=caxUdNwjt34
Why we need to
estimate the
size of OPA
before • If too BIG, it may occlude the patient’s
inserting? airway by displacing the epiglottis,
hinder the use of a face mask and
damage laryngeal structures
• If too SMALL, it may occlude the airway
by pushing the tongue backward and
causing occlusion
Potential hazards of using the OPA
• Pushing the tongue posteriorly and exacerbating the airway obstruction
• Catching the tongue or lips between the airway and the teeth and
traumatizing the soft tissue
• May induce vomiting if patient’s airway reflexes still intact
• OPAs ensure a patent airway but give no protection from *aspiration of
vomit or secretions.

*Aspiration is inhalation of either oropharyngeal or gastric contents into the lower

airways. Gastric acid causes inflammation of the lung tissue or pneumonitis.
Nasopharyngeal airway (NPA)
• A soft rubber or plastic hollow tube that is passing through

the nose into the posterior pharynx

• NPAs can facilitate removal of secretions in patients who

have a weak cough, as a suction catheter can be passed

down into the lower airway

• It is inserted into the nasal passageway and sits just above

the epiglottis, separating the soft palate from the wall of

the oropharynx and maintaining airway patency

Nasopharyngeal airway (NPA)
• Usually, patient tolerate NPAs more easily than OPAs, it does

not stimulate the gag reflex.

• NPA can be used when the use of an OPA is difficult such as

when the patient’s jaw is clenched, or patient is awake or

semiconscious and cannot tolerate the OPA

 The correct
position of NPA
sits just above
the epiglottis

Original Source: Leach R.M.,

2014.
How to estimate the correct
size of NPA for a patient?

• NPAs come in sizes based on their

INTERNAL diameter
• The larger the internal diameter of the
airway, the longer the tube will be Usually
• A length of 8.0 – 9.0 cm is used for a large
adult
• A length of 7.0 – 8.0 cm is used for a
medium adult
• A length of 6.0 – 7.0 cm is used for a small
adult
How to estimate the
correct size of NPA
for a patient?

• A rough method to
choose a correct NPA
size is to hold the airway
beside the patient’s
mandible
• From the patient’s
earlobe to the tip of the
nostril.
 Assessment and inserting of NPA
• The nostril should be inspected for polyps prior to
insertion, and if necessary, the other nostril used.

• A water-based lubricant (KY Jelly) is used prior to insertion.

• Insert gently, as trauma and bleeding can occur in around

30% of insertions. Image provided by Bechara Ghorayeb,
MD.https://www.merckmanuals.com
/home/ear,-nose,-and-throat-
• If resistance is felt do not continue, try the other nostril. disorders/nose-and-sinus-
disorders/nasal-polyps

• When inserted the flange should rest just below the

patient’s nostril.
 Common • If using an airway that is too long, this
potential may cause the tip to enter the
hazards of esophagus and hence increasing the
using the NPA gastric distention and decreasing
ventilation during rescue efforts
• Bleeding may occur during insertion
when injury to nasal mucosa happened.
Aspiration of blood or clots may happen
• For any suspected or head trauma until the possibility of a fractured
base of skull has been ruled out. (Two reported case of intracranial
NPA placement in patients with basilar skull fractures)

• Even with an OPA or NPA in situ the airway can obstruct if the head
is not correctly positioned.
• NEITHER OPA or NPA will
protect patient’s trachea from
aspiration of secretion, blood or
gastric contents.
• Suction should be performed to
clear the airway
• Endotracheal tube should be
inserted as soon as possible in
any patient unable to protect his
or her airway
Laryngeal mask airway (LMA)
• It is a supraglottic airway device.

• The LMA consists of a large tube with an elliptical mask on the

distal end.

• This mask’s inflatable cuff covers the tracheal opening

covering the supraglottic structures and allows isolation of the
trachea from the oesophagus, reducing risk of aspiration.
Laryngeal mask
airway (LMA)
• It is placed above the level of the
glottis. It is often used in the
emergency setting to enable
establishment of a secure airway
relatively quickly and easily.
• In addition to tracheal suction to
remove secretions, and effective
ventilation.
Preparation of Staff

• Personal protective equipment

• Appropriate personnel and suitable manpower
• 1 doctor & 2 nurses
 Bag-Mask ventilation
• An important airway management skill and one of the most difficult skill
to perform correctly
• Require basic knowledge on how to assemble the bag valve-mask
(BVM) unit (You will practice it during lab exercise)
• Properly performed bag-mask ventilation enables the health care
provider to provide adequate ventilation and oxygenation to a patient
requiring airway support and hence gives more time for us to pursue
a controlled, well-planned approach to definitive airway
management, such as endotracheal intubation
 Bag-Mask-Valve (BVM) Unit
• Also called Ambu Bag
• Ambu stands for Airway Mask Breathing Unit
• First launched in 1953
• Consists of 3 (+1) units:
i. Self-filtering bag
ii. Reserve Bag
iii. Non-rebreathing valve
iv. Bacterial filter
Use HEPA filter to remove
aerosolized contaminant
 Bag-Mask ventilation
• Successful bag-mask ventilation depends on 3 things:

• A patent airway (already discussed)

• An adequate mask seal

• A proper ventilation including proper volume, rate and rhythm

Bag-Mask ventilation – Mask
placement

• Hence, three facial landmarks that MUST be covered by

the mask are:
✓ The bridge of the nose
✓ The two malar eminences (兩顴骨)
✓ The mandibular alveolar ridge (下頜)

• Neither the provider’s wrists nor the mask should rest on

patient's eyes during as this can a vagal response
(bradycardia) or damage to eyes.
Method of holding Mask
• There are two method to
holding the mask in place with
the application of EC Clamp
techniques:
– Single hand (one hand, one-
person mask hold)
– Two hand (two hand, two-
person mask) hold (more
effective mask seal up)
EC Clamp
Technique
Tips for inadequate mask seal

• Patients with facial hair may need KY jelly or water

applied to improve the seal

• Edentulous (無牙頜) patients should have their teeth

reinserted

• Lower lip placement which placed the end of the mask

between the lower lip and the alveolar ridge, this improve
ventilation for patient with teeth
• The correct technique is to lift the
mandible is into the mask with the
middle, ring and little fingers while
holding the mask tightly against
the patient’s face with the thumb
and index finger

• Always take care not to apply any

pressure to the soft tissues of the
neck as this may occlude the
airway
Bag-Mask ventilation – ventilation volumes,
rates and rhythm
• Three critical errors should be avoided:
i. Giving excessive tidal volumes (no more than 8-10ml/kg with a visible
chest movement).The volume of the bag reserve is around 1.5 – 2L
ii. Forcing air too quickly (the bag should not squeeze explosively, it
should be squeezed steadily over approximately one full second)
iii.Ventilating too rapidly (around 10 breaths per minute)
• It can reduce the likelihood of creating sufficient pressure to open the
gastroesphageal sphincter, which leads to gastric inflation and hence
vomiting of gastric contents.
Cricoid pressure (Sellicks
maneuver)

• Play a key role in intubation

• Prevent gastric reflux, by
compressing the cricoid
cartilage against the cervical
vertebrae.
• Reduce gastric insufflation
during bag-mask ventilation
 Cricoid pressure after intubation
• Once applied it should only be removed once, when indicated by the
person intubating (i.e. once the trachea is intubated, the cuff is inflated,
and both of the lungs are ventilating)
Commonly used mnemonics in cricoid
pressure

Backwards
Right lateral
displacement of
the thyroid
cartilage to
improve the grade
Pressure BURP Upwards
of glottic exposure

Rightwards
https://twitter.com/wmasl
stubbs/status/9619239131
13620480
Difficult airway devices – 1. Stylets

• A device loaded within the

lumen of an endotracheal
tube (ETT) in order to
assist tracheal placement
• A standard metal or
plastic stylet is inserted
into an ETT to lend greater
stiffness and thereby
improve control
 Standard stylet
• Should be inserted into the endotracheal tube and bent to resemble a
hockey stick to facilities intubation
• Apply KY jelly on the surface of stylet to facilities withdraw of the
stylet after successful intubation
• The distal tip of the stylet should within the lumen of the
endotracheal tube to prevent any injury to patient’s airway
• During removal of the stylet, one should secure the position of the
endotracheal tube by one hand and withdraw the style by the other
hand (Accidentally removal of the endotracheal tube together with the
stylet has been happened clinically)
Difficult airway devices – 2. Endotracheal tube introducers
(gum elastic bougie)

• Consists of a 60cm stylet

with the distal tip bent at a
30-degree angle
• The bend angle allows the
introducer to direct the tip
anteriorly under the
epiglottis
Intubation
 Indicators for endotracheal intubation
• Acute respiratory failure
• Inadequate oxygenation
• Inadequate ventilation
• Airway protection in a patient with altered mental status or
unconscious
• Prepare for general anesthesia
• Surgery involving or adjacent to the airway
Process of endotracheal intubation
Equipment:
• Laryngoscope (please ensure good lighting with
sufficient battery)
• Video laryngoscope
• Stylet (guidewire)
• Magill’s forceps
• Endotracheal tube (internal diameter, range 6.0–10.5 mm)
• 10-mL syringe
• Suctioning equipment
• Oxygen equipment and bag-valve mask
• Tapes to secure tube
Process of endotracheal
intubation
Equipment:
• scissors
• stethoscope
• intravenous cannula
• Capnography (CO2 detectors)
• Cardiac monitoring equipment (e.g. heart rate,
saturations, blood pressure)
• nasogastric tube (this can be inserted at the same
time, or if already present can be aspirated to empty
the stomach contents; ensure that feed is stopped)
• catheter mount, ventilation tubing, and mechanical
ventilator.
 Intubation
• The patient should be prepared for the procedure by informing
patient and their relatives of what will be happening
• Patient position in supine with their neck slightly flexed to avid airway
obstruction.
• Use of OPA, best to have 2-person BVM ventilation
• Pre-oxygenated (100% Oxygen for 3-5 mins)
• Fast-track preoxygenation of 4 maximal breath in 30 seconds , to
provide store of O2 during intubation.
• Intubation should take no longer than 30 s (i.e. from loss of airway
protection to secured airway and ventilation).
• Rapid sequence induction (RsI)
Rapid Sequence Intubation Checklist

Source:https://resusreview.com/2013/rapid-
sequence-intubation-checklist/
 The nurse’s role in intubation
• Inform the person intubating of the vital signs and observe for complications.

• Once the tube is inserted, the cuff should be inflated (10 ml air) and the
patient’s chest observed and auscultated for bilateral expansion.

• Secure the tube and the patient attached to the ventilator and a check x-ray
performed.

• Assist Dr to take an arterial blood gas sampling should be performed to

confirm the initial ventilation settings and inform any changes that are
required.
Roles in Elective Intubation

Nurse A (equipment) Nurse B (medication)

• Hand over equipment (ready on • Drug administration
table) to doctor if needed
• Cricoid pressure if required
• Inflate ETT cuff
• Monitor vital signs
• Collect used equipment /
disposable tools in plastic bags • Secure ETT with tapes
• On site primary disinfection of • Connect ventilator to ETT
used equipment and pack in
plastic bags
*Drugs used during intubation

• Safe intubation of a patient outside of a cardiac https://www.indiamart.com/prodd

arrest situation will require the administration of etail/suxamethonium-chloride-
drugs to enable insertion of the tube. injection-bp-12380732433.html

https://zh.wikipedia.org/wiki/%E5
• The drugs used are subdivided into sedatives, %BC%82%E4%B8%99%E9%85%
neuromuscular blocking agents (NMBAs), and 9A
sympathomimetics sedatives (e.g. propofol,
etomidate, midazolam, ketamine)
• NMBAs (e.g. suxamethonium, which is a
depolarizing muscle relaxant, or atracurium,
pancuronium, and vecuronium, which are non-
depolarizing muscle relaxants) sympathomimetics
(e.g. adrenaline).
“STOP MAID”
• S: Suction
• T: Tools for intubation
• O: Oxygen
• P: Position
• M: Monitors, including ECG, pulse oximetry,
blood pressure, CO2 detectors
• A: Assistant e,g BMV, different size of airway
devices, ETT, 10ml syringe, stylets)
• I:Intravenous access
• D: Drug
Usual size of the ET tube
• Adult male: ID 7.0 – 8.0mm

• Adult female: ID 7.0 – 7.5mm

• New born – 3 months: ID 3.0mm

• 3-9 months: ID 3.5mm

• 9-18 months: ID 4.0mm

• 2‐6 yrs: ID = (age/3) + 3.5

 Depth of insertion
• Basic principle: midtrachea or below vocal cord 2 cm

• Adult male: 21-23 cm

• Adult female: 20-22 cm

• Children: Oral ETT = (age/2) + 12cm

Reference Only
 Reference
• Creed, F., & Hargreaves. J (2016) Oxford Handbook of Critical Care Nursing, edited by Heather Baid, Oxford
University Press
• Dutton, H., & Finch, J., (2018) Acute and Critical Care Nursing at a Glance, John Wiley & Sons,
Incorporated.
• Frerk, C., Mitchell, V., McNarry, A., Mendonca, C., Bhagrath, R., Patel, A.,Ahmad, I. (2015). Difficult
Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. British
Journal of Anaesthesia : BJA, 115(6), 827-848..
• Scott, J., Heard, S., Zayaruzny, M., & Walz, J. (2020). Airway Management in Critical Illness: An Update.
Chest, 157(4), 877-887.nger.
• UpToDate. (2001). UpToDate [electronic resource]. Wellesley, Mass.: UpToDate.
• Hong Kong Society of Critical Care Medicine (2019) Critical Care Respiratory Medicine. HKSCCM