MANAGEMENT OF

DIFFICULT
AIRWAY

ATUL KUMAR

DIFFICULT AIRWAY:
DEFINITIONS
DIFFICULT AIRWAY:
A clinical situation in which a conventionally
trained anaesthesiologist experiences difficulty
with mask ventilation, difficulty with tracheal
intubation or both
Difficult airway: spectrum
Difficult : Spontaneous/mask ventilation
Laryngoscopy
Tracheal intubation
Tracheostomy.

DIFFICULT MASK VENTILATION

It is not possible for the unassisted anaesthesiologist to maintain

SPO2>90% using 100% O2 and positive pressure mask ventilation in a

patient whose SPO2 was > 90% before anaesthetic intervention and/or It is
not possible for the unassisted anesthesiologist to prevent or reverse signs
of inadequate ventilation during positive pressure mask ventilation.
.

Absent or inadequate chest movement.

Absent breath sounds.
Gastric air entry or dilatation.
Signs of inadequate
Cyanosis.
Haemodynamic changes due to hypoxia or
hypercarbia.
Decreasing oxygen saturation.
Absent or inadequate exhaled CO2

mask ventilati

DIFFICULT LARYNGOSCOPYIt is not possible to visualize any portion of the vocal

cords with conventional laryngoscopy.
DIFFICULT ENDOTRACHEAL INTUBATION :
Using conventional laryngoscopy, it requires>3 attempts
to insert an ETT and/or the insertion of an ETT requires>
10 min. using conventional laryngoscopy

Beard

Predictors of Difficult Mask

Ventilation (mnemonic BONES)
Obesity with BMI > 26 kg/m

No teeth

Elderly > 55years

Snorers

BEST ATTEMPT
LARYNGOSCOPY
Laryngoscopy performed by
reasonably experienced
laryngoscopist with the pt in optimal
sniff position having no significant
muscle tone & the laryngoscopist has
an option of change of blade type &
length.

Degree of difficult mask

ventilation
1. Easy chin lift only
( zero)
2. One person jaw thrust / mask seal.
3. As above + oropharyngeal or
nasopharyngeal
airway or both.
4. Two person jaw thrust / mask seal.
5. Two person jaw thrust / mask seal + airway.
6. Impossible mask ventilation despite
maximal
external effort & full use of
airway
(infinite)

Degree of difficult tracheal

intubation
1.
2.
3.
4.

Easy endotracheal intubation

( zero)
One attempt, increasing lifting force.
As above + use better sniff position
Multiple attempts,external laryngeal pressure
and multiple blades.
5. As above + multiple attempt by the
laryngoscopist.
6. Impossible to intubate despite above maneuvers
and using multiple blades.
( infinite)

Indication For Interruption Of

Tracheal Intubation
Intubation attempt if exceeds 30
seconds
Cyanosis or pallor if develops
Change in heart rhythm if occurs
Patient if developed significant hypoxia.

Causes of difficult
intubation

Anaesthesiologist : Inadequate preoperative

assessment
Inadequate equipment preparation
Inexperience
Poor technique

Equipment :

Patient : Congenital & acquired causes.

Malfunction / Unavailability

CAUSES OF DIFFICULT
INTUBATION
Pierre Robin
Syndrome

Micrographia, Macroglossia, Cleft

soft palate

Treacher Collins
Syndrome

Auricular & ocular defect, molar &

mandibular hypoplasia.

Goldenhars
Syndrome

Auricular and ocular defects, molar

and mandibular hypoplasia;
occipitalization of atlas.

Downs Syndrome

Poorly developed or absent bridge

of the nose, macroglossia

Kilppel-Feil
Syndrome

Congenital fusion of a variable

number of cervical vertebrae;
restriction of neck movement.

Supraglottitis

Laryngeal oedema

ACQUIRED

Croup

Laryngeal oedema

Infections

Abscess

Distortion of the airway and trismus

Ludwigs angina

Distortion of the airway and

trismus.

Rheumatoid

TMJ ankylosis, cricoarytenoid,

deviation of restricted mobility of
Cervical spine.

Arthritis
Larynx,

Arthritis

spondylitis

Ankylosis of cervical spine, less

commonly ankylosis of TMJ; lack of
mobility of cervical spine.

Benign Tumor

Stenosis or distortion of the airway

Malignant Tumor

Fixation of larynx to adjacent

tissues.

Ankylosing

Tumour
Trauma

Oedema of airway, unstable#,

haematoma

Obesity

Short thick neck, sleep apnoea

Acromegaly

Macroglossia, Prognanthism

Assessment of Difficult
Airway
History
General physical examination
Specific tests for assessment
Difficult mask ventilation
Difficult laryngoscopy
Difficult surgical airway access

Radiologic assessment

AIRWAY ANATOMY

ANATOMY OF LARYNX

History
Congenital airway abnormalities: e.g. Pierre Robin,
Klippel-Feil, Downs syndromes
Acquired
Rheumatoid arthritis, Acromegaly, Benign and malignant
tumors of tongue, larynx etc.

Iatrogenic
Oral/pharyngeal
radiotherapy,
surgery, TMJ surgery.

Laryngeal/tracheal

Reported previous anaesthetic problems

Dental damage, Emergency tracheostomy, Med-alerts
from
the previous record etc.

GENERAL EXAMINATION

Adverse anatomical features: e.g. small mouth,

receding chin, high arched palate, large tongue, morbid
obesity
Mechanical limitation: reduced mouth opening, postradiotherapy fibrosis, poor cervical spine movement
Poor dentition: Prominent/loose teeth
Orthopaedic/orthodontic equipment.
Patency of the nasal passage
Basic categories AIRWAY EVALUATION

Evaluation of tongue size relative to pharynx

Mandibular space

Assesment of glottic opening.

Mobility of the joints

TMJ
Neck mobility

Airway assessment
indices
1. Individual indices.
2. Group indices - Wilsons score
- Benumofs analysis
- Saghei & safavi test
- Lemon assesment
etc
3. Radiological indices

MALLAMPATI TEST

Patient in sitting position

Head in neutral position
Maximal tongue protrusion
No phonation
SAMPSOON-YOUNGS MODIFICATION (1987)
added Class IV and correlated b/w ability to observe intraoral
strucures and incidence of subsequent difficult intubations.

CLASS ZERO MALLAMPATI

Visualisation of any part of epiglottis during MMP
test
Associated with easy laryngoscopy
Difficult airway possible large epiglottis hinder

SIGNIFICANCE OF MMP SCORE

Class III or IV: signifies that the angle between
the base of tongue and laryngeal inlet is more
acute and not conducive for easy laryngoscopy
Limitations
Poor interobserver reliability
Limited accuracy
Good predictor in pregnancy, obesity, acromegaly

EVALUATION OF
MANDIBULAR SPACE
THYROMENTAL
TEST)

DISTANCE

(PATILS

Distance from the tip of thyroid cartilage to the tip of

inside of the mentum.
Neck fully extended / mouth closed

>6.5 cm No problem with

laryngoscopy & intubation
6 6.5 cm Difficult
laryngoscopy but possible
<6 cm Laryngoscopy may be
impossible
Significance

Negative result the larynx is reasonably anterior to

the base of tongue

Limitations
Little reliability in prediction
Variation according to height, ethnicity
Modification to improve the accuracy
Ratio of height to thyromental distance (RHTMD)
Useful bedside screening test
RHTMD > 23.5 very sensitive predictor of
difficult laryngoscopy

Thyromental Distance
PATILS TEST

HYO MENTAL DISTANCE

Distance between
mentum and hyoid bone
Grade I : > 6cm
Grade II: 4 6cm
Grade III : < 4cm
Impossible laryngoscopy
& Intubation

STERNOMENTAL DISTANCE
(SAVVA TEST)
Distance from the upper border of the manubrium
to the tip of mentum, neck fully extended, mouth
closed
Minimal acceptable value 12.5 cm
Single best predictor of difficult laryngoscopy and
intubation ( Has high sensitivity & specificity).

CORMACK - LEHANE
Grading at direct laryngoscopy
Grade 1:

Full exposure of glottis (anterior + posterior

commissure)
Grade 2:

Anterior commissure not visualised

Grade3:

Epiglottis only
Grade 4:

No glottic structure visible.

ASSESSMENT OF TMJ
FUNCTION

TM joint exhibits 2 function.

1.
Rotation of the condyle in the s.cavity.
2.
Forward displacement of the condyle.
First movement is responsible for 2-3cm mouth opening &
the second is responsible for further 2-3cm mouth
opening.

SUBLUXATION OF THE
MANDIBLE
Index finger is placed in front of the tragus &

the thumb is placed in front of the the lower part

of the mastoid process. patient is asked to open
his mouth as wide as possible. Index finger in
front of the tragus can be intented in its space
and the thumb can feel the sliding movement of
the condyle as the condyle of the mandible slides

INTER-INCISOR
GAP
Inter-incisor distance with maximal
opening
Normal value > 5 cm / admits 3 fingers.

mouth

Significance :
Positive results: Easy insertion of a 3 cm deep
flange of the laryngoscope blade
< 3 cm: difficult laryngoscopy
< 2 cm: difficult LMA insertion
Affected by TMJ and upper cervical spine mobility

SignificanceClass B and C: difficult laryngoscopy

UPPER LIP BITE

/CATCH TEST
Class I:
Lower incisors can bite the upper lip
above vermilion line
Class II:
line

can bite the upper lip below vermilion

Class III:

cannot bite the upper lip

Significance
Assessment of mandibular movement and dental
architecture
Less inter observer variability

Evaluation of Neck Mobility

Patient is asked to hold the head erect, facing

directly to the front maximal head extension
angle traversed by the
occlusal surface of upper teeth( can also
measured by
goniometer).
Minimum 35
extension is
possible at
AOJ in normal
individuals.

Attlanto.Occipital.Extension

Grading of reduction in A.O.Extension

Grade
Grade
Grade
Grade

Grade

I
II
III
IV

: > 35
: 22-34
: 12-21
: < 12

Reduction of A.O.Extension

none

One third

Two third

complete
Grades 3 and 4 : Difficult lar

ASSESMENT OF A.O. EXTENSION

can also be done by asking the patient to
look at the floor and at wall after fully flexing
and fixing the neck as shown

Flexion movement of the cervical spine can

be assessed by asking the patient to touch his
manubrium sternii with his chin. If done, the
above maneuver assures a neck flexion of 25- 35
degree. Flexion and the extension movement if
within the normal range ,three axis

Warning sign of
DELIKAN

Place the index finger of each hand, one underneath the

chin and one under the inferior occipital prominence with
the head in neutral position. The patient is asked to fully
extend the head on neck. If the finger under the chin is
seen to be higher than the other, there would appear to
be no difficulty with intubation. If level of both fingers
remains same or the chin finger remains lower than the
other, increased difficulty is predicted.

PALM PRINT &

PRAYER SIGN
Palm print sign:
Patients fingers and palms painted with blue ink and
pressed firmly against a white paper
Grade 1- all phalangeal areas visible
Grade 2- deficient interphalangeal areas of 4th and
5th digits
Grade 3- deficient interphalangeal areas of 2nd to
5th digits
Grade 4- only tips seen.

Limited-mobility joint syndrome (stiff-joint sydrome) 30-4

Prayer sign.
Type I diabetics positive "prayer sign. TM joint and C-sp
atlanto-occipital joint) may be involved

PRAYER SIGN
A positive "prayer sign" can be
elicited
on examination with the patient
unable
to approximate the palmar surfaces
of
the phalangeal joints while pressing
their hands together; this represents
cervical spine immobility and the
potential for a difficult endotracheal
intubation.

Palm Print as a Predictor of

Difficult Airway in DM

Group indices

1. SAGHEI &
SAFAVIS

Weight
Tongue protrusion
Mouth opening
Upper incisor length
Mallampati class
Head extension

Any 3 indices if present

-

>80kg
< 3.2cm
<5cm
>1.5cm
>1
<70 degree

Prolonged laryngoscopy

2.LEMON Assessment
L Look externally (facial trauma, large
incisors,
beard, large tongue)
E Evaluate 3-3-2 rule
3 - Inter incisor gap
3 - Hyomental distance
2 - Distance between thyroid cartilage and
floor of the mouth.
MON-

MMP score
Obstruction (epiglottitis, quinsy)
Neck mobility.

3. WILSON SCORING
SYSTEM
5 factors - Weight, upper cervical
spine mobility, jaw movement, receding

mandible, buck teeth

Each factor: score 0-2
Total score < 5 Easy laryngoscopy.
6 to 7 - Moderate difficulty.
> 7 - Severe difficulty.

Parameter

Risk

Weight (kg)

< 90

90 110

> 110

Head & neck movement

> 90

= 90

< 90

IID (cm)
SL

>5
>0

=5
=0

<5
<0

Receding mandible

None

Moderate

severe

Buck teeth

None

Moderate

severe

IID Interincisor Gap

SL Maximal Forward Protrusion of Lower incisors beyond upper incisors.

4. BENUMOFS 11 PARAMETER
ANALYSIS
Parameter
Minimum acceptable
value

1. Upper inciors length

<1.5cm
2. Buck teeth
Absent
3. Subluxation
Yes
4. Interincisor gap
5. Palate configuration >3cm
No arching/narrowness
4-2-2-3 rule
6. Mallampati class
7. TM distance
>
5cm
<2
4 for tooth
8. SMS compliance Soft to palpation.
2 for inside of mouth
9. Neck thickness Qualitative ( >33cm DI) 2 for mandibular spa
10. Length of neck >8cm
3 for neck examinatio
11. Head /neck mvt Normal range

Rule
of
1-2-3
1 finger breadth for subluxation of mandible.
2 finger breatdh for adequacy of mouth opening.
3 finger breathd for hyomental distance.
In emergency situation, above test can be rapidly performed
within 15sec to assess the TMJ function,mouth opening and
SM Space. Significant difficulty in 2 or more of these
components requires detailed examination.

Rule
of
1-2-3-4-5
4 finger breath for thyromental distance

5 movements- ability to flex the neck upto the manubrium

sterni, extension at the AOJ, rotation of the head along with
right & left movement of the head to touch the shoulder.

RULE OF THREE`S

3 finger in the interdental space.

3 finger between mentum and hyoid bone.
3 finger between thyroid cartilage & sternum.

RADIOGRAPHIC PREDICTORS
1. X-Ray neck (lateral view) :
Occiput - C1 spinous process
distance< 5mm.
Increase in posterior mandible
depth > 2.5cm.
Ratio of effective mandibular
length to its posterior depth
<3.6.
Tracheal compression.

2. CT Scan:

Tumors of floor of mouth, pharynx, larynx

Cervical spine trauma, inflammation

Mediastinal mass

3. Helical CT (3D-reconstruction):

Exact location and degree of airway compression

ADVANCED INDICES

Flow volume loop

Acoustic response measurement
Ultra sound guided
CT / MRI
Flexible bronchoscope

ASA TASK FORCE ON

MANAGEMENT OF DIFFICULT
AIRWAY

Portable storage unit

Basic preparation Rigid laryngoscope blades
ETTs
Inform
ETT guides/bougie
Ascertain help
LMAs
Preoxygenation
FOI equipments
Supplemental Retrograde intubation kit
oxygenation
Emergency non invasive airway
throughout
ventilation device.
Emergency invasive airway
access
Exhaled CO2 detector

What are we going to do if we dont get the

Tube placement??
Plans A, B and C

Plan A: (ALTERNATE)

Different length of blade

Different type of blade
Different position
Bougie or lightwand guided
Call for help
Best attempt laryngoscopy

Plan B: (BVM and other

ventilation Techniques )
Can we Ventilate with a BVM?
(Consider two NPAs or a OPA, gentle
Ventilation)
Two person ventilation?
LMA an Option? Or other
supraglottic airway ?
ILMA?
Combi-Tube?
Retrograde Intubation?
we should have an assistant at this
stage

What do we do when faced

with a Cant Intubate,Cant
Ventilate situation?
Plan C
Needle, Surgical cricothyroidectomy
TTJV
Tracheostomy
Try to wake up the patient from the
time we fail intubation.

MANAGEMENT OF DIFFICULT INTUBATION :

Correct position of the patient
- A pillow (10 cm) should be placed under the head but not under the
shoulders.
- Morton and colleagues (1989) defined this position as lower neck
flexion 35o and extension of the plane of face 15o (both angles relative to horizontal
plane)

SIMPLE TECHNIQUES :
i)

Pressure on cricothyroid/thyroid cartilage or External laryngeal manipulation.

- Knill postulated Backward, Upward and Rightward pressure known as
BURP to the thyroid cartilage when the larynx is anterioly placed for
improving the view.

ii)

Stylet :
- Elongated metal or plastic rod with a smooth surface and no
sharp edges over which an ETT can be passed.
Should be stiff and flexible enough to change the shape
and curve of the ETT.
Facilitate intubation by directing the tube tip
towards the glottis.

iii)

Guedel Airways :

iv)

Gum elastic Bougie or Tube changers.-used by Sir Robert Macintosh

(1943)
- Elongated;flexible,soft and smooth rods over which the ETT can be
passed but these can not alter the shape of ETT.
- Useful when the posterior portion of the larynx is barely visible for the
epiglottis can not be elevated. It is important to bend the distal end forward
after it has been passed through the tracheal tube. The bougie can then be
advanced blindly towards the cords and then the tube can be rail-roaded
over the bougie.
- Hollow bougies are also available for attachment to oxygen

BURP & External

Laryngeal Manipulation
Backward, Upward,
Rightward
Pressure:
manipulation of the
trachea
90% of the time the
best view will be
obtained by
pressing over the
thyroid cartilage

Differs from the Sellick Maneuver

v)

Magill forceps : Double angled forceps have grasping ends in the axis of
ETT and handle at the right angle.

vi)

Tube bender forceps (Aillon forceps) : These have unequal limbs which
can bend the distal end of the ETT in the desired direction.

vii) Flexible lumen finder (Flexguide) : It is designed to be used with right

hand after insertion through the ETT. It has a handle thumb ring, inner rod
and notched outer tube. The distal tip of the tube can be manoeuvred with
the help of the proximal thumb ring.
viii) Schroeder Stylet :
ix)

Laryngoscope blade and handles :

Bozzoni invented first laryngoscope in 1805.
In 1907 Jackson designed a U-shaped laryngoscope with the aim to
divert force away from upper teeth.
Two commonly used designs the curved (Macintosh) and the
straight (Miller) blades.
It is essential that the force applied to the laryngoscope handle is
directed along the long axis of handle.

Specialised curved blades

1-

Left handed Macintosh blade - for left handed laryngoscopists

- For anatomical abnormalities on the right side of the face mouth and
oral cavity.

2-

Improved vision Macintosh blade

3-

Polio Blade The angle between the blade and the handle is made
obtuse.

It is useful in situations when the antero-posterior diameter of

the chest is such that insertion of the laryngoscope into the mouth is
difficult or impossible.

4.

Laryngoscope with stunted or short handle : useful in obese

patients and in patients with large breast.

5.

Oxiport Macintosh : It has an oxygen port in the blade allowing

oxygen insufflation during intubation attempts.

6.

Tull Macintosh : This blade has a suction port.

7.

Siker blade : has stainless steel mirrored surface which permits

visualisation of an anterior larynx. It gives an inverted image.

8.

Huffman Prism : Images are real.

Prism should be placed in warm water for 30 sec on anti-fog solution

to prevent fogging

9.

Bullard Laryngoscope : This is a fiber-optic laryngoscope with a

built in rigid 900 curved blade. It is battery operated Eye piece is attached
to the main body of the scope at 450 angle.
- Useful in mid-facial hypoplasia syndrome and unstable cervical
spines.

10.
McCoy levering Laryngoscope The tip of the Macintosh
blade is hinged (approx. 2.5 cm from the blade tip) and the angle of
the hinged portion can be altered by a lever attached to the
handle.

Shucman-Pro
Levering
Laryngoscope

11.

Upsher fibrecoptic laryngoscope combines fibreoptic round the

corner viewing with maneuverability.
- The tip of blade is advanced until it comes to rest close to the

cords.
The tube sits in the semi-enclosed space in the blade.
- The variable focus eye piece enables the operator
to obtain uninterrupted
view of the procedure. The eye piece can be attached to T.V. Camera for
teaching purposes.

-12.

Belscope Long angulated blade with 450 bend at midpoint and a

detachable prism.
- It minimizes damage to teeth, due to angulation the blade stays
away
from upper teeth.
- It gives a good view of larynx when the macintosh blade gives grade 3
view.
13.
Specialised
straight
blades
Racz-Allen blade, Choi blade,
Belscope blade, Bainton blade, Guedel blade,
Bennett blade, Whitehead blade, Flagg blade,
Eversole
blade,
Snow
blade.

WU SCOPE

Truview evo2
Laryngoscope

Glidescope L with video

intubating system

AIRTRACH

Indirect rigid laryngoscopy

Minimum mouth opening required
Less hemodynamic stimulation compared
to conventional L

Utilises the paraglossal technique of intubation

BONFILS retromolar intubation fibrescope is a 5mm optical, distally curved stylet
which can accommodate a 6mm or larger ET tube
Permits continous oxygen insufflation
Light supplied via remote Xenon source
Can be attached to a module with image display

BLIND NASAL INTUBATION : can be performed in anaesthetised or

-

awake patients.
Position - sniffing the morning air position
A well lubricated nasal tube is gently passed through the most patent
nostril.
The nasal mucous membrane should be constricted by the use of
vasoconstrictor (xylometazoline or any other nasal decongestant).
The bevel of the tube should be pointing laterally so as to avoid trauma to
choncha. The opposite nostril should be occluded with the mouth shut
and the chin lifted forward.
The tube is then advanced while listening to the breath sounds,
manipulation of thyroid cartilage and at times of head facilitates the
alignment of the tube.
At times acute flexion of neck may be required if the obstruction occurs
during passage of the tube.
The tip of the tube may get placed at five positions
1- Into the trachea
2. Against the anterior commissure 3. In the
vallecula at the base of tongue. 4. Laterally into pyriform recess. 5. In
the Oesophagus.

Awake Intubation

SPECIALIZED TECHNIQUE :
1.
Light wand : it has battery handle and copper stylet (about 45
cms) covered in white plastic. As it enters trachea, transilluminated light is
seen as bright, circumscribed below cricoid cartilage if it enters esophagus,
light is not easily seen.
Once position of light wand is confirmed then the tube is threaded
and guided through it.

2.
Bronchoscopes : Both rigid and fibreoptic bronchoscopes have
been used as an aid to intubation.

Flexible fibreoptic intubation. It consists of

A.

Insertion tube Flexible part extending from control

section to distal tip of scope.
B.
Control section Contain the tip control knob which
controls movement of insertion tube.
C.
Eye piece section.
D.
Light transmission cord from external light source to
hand of fiberscope.
E.
Light source.

Principle

Internal reflection - Beam of light entering one

end of glass rod
will repeated internally reflex off the
walls of rod, eventually emerging from other end.
Optical lenses Light that is internally reflected
is completely blurred. it is focused with a series of
optical lenses.
Gold standard for anticipated difficult intubation
any age, any position.
Requires good experience.

ADJUNCTS TO DIFFICULT AIRWAY MANAGEMENT

1.

Nasopharyngeal airway

Connells Nasopharyngeal Airway

Esophageal Obturator Airway

2.

Oesophageal Obturator Airway By Don Michael and Gordon in 1968. Consist

of two parts first 30 cms plastic oesophageal tube occluded at distal end.

There are perforation in the tube which are intended to be located in hypopharynx.
A large balloon is located at distal end to create a seal in the oesophagus.

Second part of the device is face mask with ap inflatable cuff designed to make a
tight seal with the face. After lubrication tube is inserted blindly without
laryngoscope.

3.

Patils syracuse oral airway- allows fibreoptic intubation

4.

Ovassapian fiberoptic intubating airway Accommodates

tracheal tube upto 9 mm diameter.

5. COPA (Cuffed Oropharyngeal airway )Disposable device that combines a guided airway with an inflatable
distal high volume lowpressure cuff and a proximal 15mm adapter. distal tip should be behind base of tongue

6.

Pharyngo-tracheal lumen airway - it is double lumen tube consisting

of a long tube with a distal cuff (15 cc) designed to be inflated in
esophagus and shorter tube that protrudes through the larger tube and
past alarge proximal cuff (100 cc) to ventillate the lungs.

7.

4.

Oesophageal tracheal combi tube (OTC) :

Disposable double lumen tube with a low volume inflatable distal cuff
and a larger proximal cuff.
- Distal
cuff => Oesophagus
Proximal cuff => Oropharynx
Ventilation is possible witheither tracheal or esophageal intubation. If it
enters oesophagus (common) Ventilation is through multiple proximal
apertures situated above distal cuff. Both cuffs have to be inflated. - If it
enters trachea ventillation is through distal lumen as with a standard tracheal
tube.

LMA classic (standard LMA)

LMA PROSEAL & LMA

SUPREME

- LMA unique (disposable)

 Is a non cuffed
supraglottic device with the
shape of the LMA
Disposable
made of gel ,softer
has a gastric drain
(ProSeal LMA-like)

bite block

and an epiglottis
blocker

10.

I GEL

11.

Pharyngeal airway Xpress Curved tube with anatomically

shaped gilled distal tip, large oropharyngeal cuff and an open

hooded window that allows ventilation. More effective seal than
LMA.

Pharyngeal
Express Airway

12.

new type of SLA device that does not have a cuff, rather, it
has a preformed plastic that fits anatomically to the shape of
the pharynx. This device allows one to give positive pressure
ventilation to the patient without cuff. This device also
contains a chamber (about 50 mls) as storage for regurgitant
fluids to collect.

Transtracheal Techniques :
- Usually a small IV cannula (14/16) is required. It is advisable to
keep this fitted with usual 15 mm connector of 3.5 mm
endotracheal tube.
- The patients should be positioned to achieve maximum
extension of neck. Thyroid and cricoid cartilages are identified and the
skin overlying the cricothyroid membrane is fixed. A 14 IV
needle is
inserted through the membrane into the trachea and directed towards
carina. The correct intratracheal position is verified by free aspiration of
air through a syringe containing
saline.
- Begin with 5 psi and increase in increments of 5 psi until
adequate chest excursion occurs.
- No more than 25 psi and no more than half a second inspiratory
time.

Emergency tracheostomy :
- It is always better to oxygenate the patient via transtracheal I.V.
cannula while also performing tracheostomy.
- Percutaneous dilatational tracheostomy (PCDT) takes time and
is usually not recommended where urgency is there

- Minitracheostomy is preferred. A single vertical incision 3-5 mm in length

over cricothyroid membrane is made and then through obturator the 4 mm

uncuffed tracheal tube is guided.
-Compared with I.V. cannula the minitrach has larger diameter and is better
for jet ventilation and even for assisted spontaneous respiration for a short
period.

MINI TRACHEOSTOMY

MINI TRACHEOSTOMY (CONT.)

Cricothyrotomy
Quicktrach I
Standard-Set
Available for adults (I.D. 4mm

children (I.D. 2mm) and

infants (I.D. 1.5mm)

Quicktrach II with cuf

Set with cuff
Thin cuff seals trachea and allows efficient ventilation with aspiration
protection. Stopper and safety clip reduce the risk of posterior tracheal
wall injury. Anatomically shaped cannula adjusts to the trachea due to
memory effect. Available for adults (I.D. 4mm)

Confirm the airway

METHODS OF
CONFIRMATION
Traditional
Direct
Visualization
Lung Sounds
Tube
Condensation

Technology
Based
ETCO2
(monitor)
EDD (bulb)
Colormetric
(cap)
Pulse Ox

Causes of difficult
intubation in
1.. MMP Class 3 or 4
PREGNANCY

2.Supraglottic and glottic areas oedema.

3.Large breasts.
4.Full dentition.
5.Mucosal congestion of
nose, pharynx,etc.
6.Enlargement of
tongue.

7.Fat deposition in oropharyngeal region.

8.Elevation of hyoid bone.
9..Weight gain.
10Improperly applied cricoid pressure.
11Improperly applied hip wedge causes
decreased chin chest distance.

Difficult airway :OBESITY

Difficult spontaneous ventilation in obstructive
sleep apnea
BMI > 26 predicts difficult mask ventilation
Difficult intubation predictorsMMP Score >3
Neck circumference > 16
inches

ositioning for morbidly obese patie

Whelan - Calicott
position

AIRWAY MANAGEMENT IN TRAUMA

RSI involves 4 experienced personnel
AMPLE history
Allergies
Medication
Past medical history
time of Last meal
Events leading
No definition of safe cervical spine movement
Equipment option depend on operator experience & skill

CERVICAL SPINE INJURY: MANAGEMENT

OPTIONS

Manual in-line stabilization

Airway interventions requiring less neck movement
Jaw-thrust (ventilation)
Adjunctive device ILMA, combitube
Cricothyrotomy
Least movement (0.1 mm) with fibre optic nasal intubation

Airway management in trauma

EXTUBATION STRATEGIES
Cuff leak test
Performed in a spontaneously ventilating patient at
risk of obstruction after extubation.
Circuit
disconnected occlusion of ETT end and deflation
of cuff ability to breath around the ETT.

Conventional awake extubation

Extubation over a bougie.
Extubation over a fibreoptic bronchoscope.
Endotracheal ventilation and exchange
catheters e.g.
Cooks airway exchange catheter

Do`s in the management of

difficult airway

Use antisialogue in premedication.

Aspiration prophylaxis.
ET of assorted size.
LMA of assorted size.
Tracheostomy set.
Check special airway equipment.
Keep help of senior anaesthesiologist.
Preoxygenate patient / End tidal CO2
device.

Dont`s in the management of

difficult airway
Dont produce deep plane of anaesthesia.
Dont use technique that you are not familiar.
Avoid multiple attempts.
Dont render the patient apnoeic, unless you are
certain that mask ventilation can be
maintained

THANK YOU