Airway Instruments

Asbar Javed, DPT

UIPT, UOL

Objectives

Review airway anatomy

Review basic airway maneuvers
Review blind insertion airways
Review advanced airway techniques

Upper and Lower Airways

Airway Anatomy
Upper Airway

Pharynx
Epiglottis
Glottis
Vocal cords
Larynx

Lower Airway

Trachea
Bronchi
Alveoli
Lung tissue, consisting
of lobes and lobules (3
on the right and 2 on
the left)
Pleura

Basic Airway Maneuvers

ALWAYS REMEMBER THE BASICS
These skills should be used prior to
initiating any advanced airway technique

Head-tilt/chin lift
Jaw thrust
Modified jaw thrust (for trauma patients)
Sellicks maneuver

1.Oropharyngeal Airway
Size is measured from the corner of the
mouth to the angle of the jaw
Sizes range from 0-6
It holds the tongue away from the posterior
pharynx, but does not isolate the trachea

Oral Airway continued

The oral airway is
inserted with the curve
towards the side of the
mouth
Then rotated so that
the curve of the airway
matches the curve of
the tongue

2.Nasopharyngeal Airway
Soft plastic or rubber tube that is designed to pass just
inferior to the base of the tongue
Passed through one of the nares and can be used in
patients with an intact gag reflex
CONTRAINDICATED in cases of suspected or possible
basilar skull fracture
Sizes range from 17-26 cm in length and 6-9 mm internal
diameter
Measured from tip of the nose to the corner of the patients
ear

Nasal Airway continued

The nasal airway is
lubricated with a water
soluble lubricant
The beveled tip is inserted
directed towards the septum,
with the airway directed
perpendicular to the face
If resistance is met, rotating
the airway may help or the
other nare may be used

Blind Insertion Airways

Combi-tube
LMA (Laryngeal
Mask Airway)
King Airway

Blind insertion
airways considered an
alternative airway
control device to be
used when intubation
is unsuccessful
They do not require
visualization of the
vocal cords

3. Combitube

Combi-tube
This is a multi-lumen airway that works whether it
is inserted into the esophagus or the trachea
It either blocks the esophagus above and below the
glottic opening or by directly ventilating the trachea
Contraindicated in patients under 5 foot tall or those
under 14 years old, in patients who have ingested
caustic substances, patients with esophageal trauma
or disease, and in patients with an intact gag reflex

Combi-tube continued

4.Laryngeal Mask Airway

Sits over the glottic
opening
Available in different sizes
Has a drain tube to aid in
gastric suctioning
With some versions an
endotracheal tube may be
passed through to aid in
intubation

LMA Positioning

Advanced Airways

Orotracheal Intubation
Nasotracheal Intubation
Digital Intubation
Surgical Airways

5.Orotracheal Intubation
Requires direct visualization of the vocal cords with
the use of a laryngoscope
Completely isolates the esophagus from the trachea
At least two forms of placement verification are
required
Physical assessment (color improvement, equal breath
sounds, absence of gurgling over epigastrim, and direct
visualization of tube passing through cords)
End-tidal CO2 detector
Esophageal detector device (EDD)

Orotracheal Intubation Procedure

Assemble all needed equipment, while patient is being
ventilated
Choose appropriate ET tube size
Check balloon with 10cc of air
OPTIONAL-Place stylet, stopping approximately inch
short of end of tube
Assemble laryngoscope and check light
Connect and check suction

Position patient in sniffing postion, (neck flexed

forward, head extended back, and back of head should
be level with or above the shoulders). IMPORTANT-If
C-spine injury is suspected have an assistant hold the
patients head in a neutral position.

Intubation Continued
Pre-oxygenate the patient with 100% oxygen
Insert laryngoscope to right of midline. Move to
midline, pushing the tongue to the left.
Lift straight up on the blade to expose posterior pharynx.
Identify the epiglottis; tip of curved (Macintosh) blade
should sit in valeculla, (in front of epiglottis), straight
blade should slip over the epiglottis. With further, gentle
traction, identify trachea and arytenoid cartilages and
vocal cords
Insert ET tube along the blade, into the trachea and
advance the tube 1-1.5 inches beyond the cords and
inflate the cuff.

Intubation Continued
Ventilate and watch for chest rise and fall. Listen
for breath sounds, over stomach, four lung fields
and axillae. (If breath sounds are diminished or
absent on left side, indicating a right mainstem
intubation, slightly pull tube back and reassess
breath sounds).
Note number on the side of the ET tube at the
central incisor and secure the tube.
Reassess breath sounds, now and any time the
patient is moved.

Nasotracheal Intubation
Can be done blind or with the aid of a
laryngoscope.
If done blind, the patient must be breathing.

Cannot be performed on patients with a

suspected basilar skull fracture.
Can be performed on patients with an intact
gag reflex.

6. Intubating LMA

LMA Take-Home Points

Test cuff before use

Dont lubricate anterior mask
Insert only in comatose patient
Keep cuff inflated until patient awake
Dont throw out!! Used 40 50 times

7.Digital Intubation
Useful if unable to reach
patient well.
Head manipulation is
minimal.
Performed by physically
finding the epiglottis with
middle and index fingers,
and then sliding the tube
interiorly into the trachea.

A. Flexible Fiberoptic Scope

Flexible Fiberoptic Scope

Advantages

Allows direct airway visualization

Causes little hemodynamic stress
Nasotracheal or orotracheal route
Can be done in all age groups
Requires minimal neck movement

Flexible Fiberoptic Scope

Disadvantages
Expensive
Expertise requires practice
Delicate equipment needs careful
maintenance
Visual field easily impaired by blood and
secretions

B. Rigid Fiberoptic Scope

Rigid Fiberoptic Scope

Bullard

Wu Scope

Rigid Fiberoptic Scope

Upsher

GlideScope

Rigid Fiberoptic Scope

Levitan Scope

Rigid Fiberoptic Scope

Advantages

Direct airway visualization

Minimal neck movement
May overcome difficult view
Useful in disrupted airway
Durable, sturdy instruments

Rigid Fiberoptic Scope

Disadvantages
Expensive
Expertise requires practice
Visual field easily impaired by blood and
secretions
Not readily available

C. Lightwand (Trachlight)

Lightwand (Trachlight)

Lightwand (Trachlight)
Disadvantages

Blind technique
May damage airway
Usually requires darkened room
Expertise requires practice

8.Nu-Trake
Surgical airways
should only be used
when all other
methods have been
exhausted
It is not intended for
children under the age
of 5 years old.

Nu-Trake Procedure
Hyperextend the patients neck, if c-spine injury is not
possible, and identify the cricothyroid membrane
Pinch 1 cm of skin and insert scapel blade through
skin, cutting in an outward, upward motion.
Use housing with stylet and puncture membrane at
same angle as the lower edge of the housing.
Aspirate. Easy movement of syringe plunger indicates
proper entry into trachea.
Twist Luer adapter counterclockwise and remove
stylet and syringe.

Nu-Trake Procedures continued

Advance split needles until the housing rests on the
skin. Housing should rock freely to confirm
proper insertion depth.
Inset 4.5 mm airway/obturator assembly into
housing. Use palm of hand to advance obturator.
DO NOT USE HOUSING WINGS.
Remove obturator and ventilate patient. Secure
housing with twill ties.
For larger airway, remove 4.5 mm airway and
repeat last two steps with 6.0 mm and 7.2 mm
airways.

Summary
Always remember the ABCs, without an
airway your patient will not survive.
There are several ways to manage a
patients airway.
Dont forget the basics, all your patient may
need is for someone to open their airway, to
start improving.