AIRWAY MANAGEMENT

dr Nopian Hidayat, SpAn

SMF Anestesi dan Terapi Intensif
RSUD Arifin Ahmad - FKUR
ANATOMY
OF UPPER
AIRWAY
A Epiglottis
B Mandible
C Frontal Sinus
D Soft Palate
E Trachea
F Glottis
G Esophagus
H Vocal Cords
LOWER AIRWAY ANATOMY
 ASSESMENT AIRWAY

• Identify 4 areas of airway difficulty

• Predict a difficult airway using the following
mnemonics:
• MOANS
• LEMONS
 AIRWAY DIFFICULTIES

1 2 3 4

Difficult to Difficult Difficult to Difficult to

ventilate with a laryngoscopy intubate perform
BVM cricothyrotomy
 Mask Seal

Obesity or Obstruction
DIFFICULT TO
BAG (MOANS) Age > 55

No Teeth

Stiff
 MASK SEAL - MOANS

Wrong Oddly
Small Hands Bushy Beard
Mask Size Shaped Face

Facial
Blood/Vomit
Trauma
 • Obesity
• Heavy chest
• Abdominal contents inhibit
movement of the diaphragm
OBESITY OR • Increased supraglottic airway
OBSTRUCTION - MOANS resistance
• Billowing cheeks
• Difficult mask seal
• Quicker desaturation
 • Obstructions

• Foreign Body
• Angioedema
• Abscesses
OBESITY OR
OBSTRUCTION - MOANS • Epiglottitis
• Cancer
• Traumatic
Disruption/Hematoma/Burns
 • Associated with BVM difficulty, possibly due to
AGE > 55 - MOANS loss of tone in the upper airway
 NO TEETH - MOANS

Consider leaving
Face tends to dentures in for
“cave in” BVM and remove
for intubation
 STIFF - MOANS

• Refers to Poor Compliance

• Reactive Airway Disease
• COPD
• Pulmonary Edema/Advance Pneumonia
• History of Snoring/Sleep Apnea
• Also predicts a higher Mallampati score
 • LEMONS
• Look Externally
DIFFICULT • Evaluate 3-3-2
LARYNGOSC • Mallampati Score
OPY & • Obstruction
INTUBATION • Neck Mobility
• Scene and Situation
 LOOK EXTERNALLY - LEMONS

Broken teeth
Beards or Morbidly Facial or neck
Short, fat neck (can lacerate
facial hair obese patients trauma
balloons)

Dentures A narrow or
Protruding
(should be Large teeth abnormally
tongue
removed) shaped face
 EVALUATE 3-3-2 - LEMONS

• Bottom of Jaw/Chin to Neck > 3 fingers

• Jaw/Palate/Open mouth > 3 fingers wide
• Mandibulohyoid 2 fingers wide
MALLAMPATI
SCORING -
LEMONS
• Class I: Uvula/tonsillar pillars visible
• Class II: Tip of uvula/pillars hidden by
tongue
• Class III: Only soft palate visible
• Class IV: Only hard palate visible
 OBSTRUCTION -
LEMONS

• Laryngoscopy or intubation
may be more difficult in the
presence of an obstruction
• Anatomy
• Trauma
• Foreign body obstruction
• Edema (burns)
 • Grade 1: Full aperture visible
• Grade 2: Lower part of cords visible
• Grade 3: Only epiglottis visible
OBSTRUCTIONS • Grade 4: Epiglottis not visible
LARYNGOSCOPI
C VIEW GRADES
- LEMONS
 NECK MOBILITY - LEMONS

• Ideally the neck should be able to extend back approximately 35°

• Problems:

• Cervical Spine Immobilization

• Ankylosing Spondylitis
• Rheumatoid Arthritis
• Halo fixation
 1. Discussion with colleagues in advance.
MANAGEMENT 2. Equipment tested before.
PLAN OF 3. Senior help backup.

ANTICIPATED 4. Definite initial plan (A) for ventilation and

intubation.
DIFFICULT 5. Definite plan (B) than option of awake
AIRWAY intubation.
6. Ideal situation surgery team standby
 UNEXPECTED DIFFICULT AIRWAY

Problems
• Unexpected encounter with difficult airway is mostly gone
worse because mainly GA is already given
• Equipment may not be in hand.
• Senior and back up plan not available so delay occur in active
resuscitation
TECHNIQUE OF MANAGEMENT

1. Manipulation of the patients airway.

2. Laryngeal pressure.
3. Nasal or oral airway.
4. Different blades of larangoscope like
Miller, Magill, Robershaw , Mackintosh,
laryngoscope McCoy.
5. Bougies and stylet
6. LMA.
7. Combitube.
 1
1
Manipulation of airway alternative
different blade, bugie

2
2
LMA, ILMA, Combitube
alternative

3
Trantracheal Jet Ventilation 3
alternative

4 4
Cricothireotomy, Tracheostomy
alternative
SOME EQUIPMENT, OLD & NEW
 EQUIPMENT

• Bag valve mask

• Combitube™
• LMA
• Intubation LMA
• ETT
• Mayo
• Nasotracheal Tube
BAG VALVE MASK
 2.
COMBITUBE®
 Indications
• Routine / emergency procedures
• Known / unknown difficult airway
3. LARYNGEAL • During resuscitation in profoundly
MASK AIRWAY unconscious patient with no glossopharyngeal
or laryngeal reflexes when tracheal intubation
not possible
LMA
 Contraindications
…has not fasted
…may have gastric contents
LMA …has fixed  lung compliance
…is not profoundly unconscious
…resists LMA airway insertion
 4.
INTUBATING
LMA
 5.
E N D OT
R AC H E
AL TUBE
 The size of the tube
The size quoted usually is the internal
diameter.
For adult male require normally a tube of
7.0-7.5 mm ID.
For adult female normally 6.5-7.0 mm.
For oral intubation the length should be 18-

ETT 20 cm
For pediatric can be calculated from the
formula (age/4) + 4mm
For oral intubation in children the length
required approximately (age/2) + 12cm
For nasal intubation in children the ID can
be calculated by the formula (age/2) + 15
cm
6. OROPHARYNGEAL(GUEDEL).
7. NASOPHARYNGEAL.
 AIRWAY MANAGEMENT PROCEDURES
• A. Noninvasive procedures
1. Back Blows
2. Head Tilt Chin lift procedure
3. Heimlich maneuver (Abdominal thrust)
4. Chest thrust
5. Finger sweep
6. Ambu -Bag
• B. Invasive procedures
1. Oropharangeal airway
2. Nasopharangeal airway
3. Cricothyroidectomy
4. Tracheotomy
5. Endotracheal tube
6. Laryngeal Mask Airway
 •Which ?????????

technique??
TERIMA KASIH