Airway Management

Azzam Nawab
MBBS
aanawab@imamu.edu.sa

30 SEPT 2021
Learning Objectives
• Airway anatomy and function
• Identify important anatomical structures related to the intubation of a patient
• Evaluation of the airway
• Clinical management of the airway
• Intubation
• Difficult airway management
• Complications of airway management procedures
“The term airway management refers to the
practice of establishing and securing a
patent airway and is a cornerstone of
anesthetic practice”

Miller’s Anesthesia 2015

 The Nasal Cavity

• Nasal passages divided by the

nasal septum (medial wall)
• The septum is formed by the
septal cartilage anteriorly, and
two bones posteriorly (the
ethmoid and vomer)
• Lateral wall of the passages has 3
turbinates
• Roof is made of cribriform plate
• Highly vascular
Oral Cavity
• Many airway procedures require adequate mouth opening, achieved by rotation within TMJ and
subsequent sliding (protrusion or subluxation).
• leads to the oropharynx and is inferiorly bounded by the tongue and superiorly by the hard and
soft palates.
• inferiorly bounded by the tongue and superiorly by the hard and soft palates
• Genioglossus muscle attaches the inferior border of the tongue to the mandible
• Beneath the tongue, the mylohyoid muscles separate the floor of the mouth into the sublingual
space superiorly and the submental space inferiorly.
Oral Cavity
Pharynx
• A muscular tube connects the nasal and oral cavities with the larynx and esophagus
• The posterior wall of the pharynx is made up of the buccopharyngeal fascia, which separates the pharynx
from the retropharyngeal space
• loss of pharyngeal muscle tone is one of the primary causes of upper airway obstruction during anesthesia
• Head-tilt maneuver stretches the muscle, thus opening the airway
• The pharynx can be divided into the :
• Nasopharynx: adenoid tonsils located in the posterior aspect
• Oropharynx: The lateral walls contain the palatoglossal folds and the palatopharyngeal fold these folds
contain the palatine tonsils
• Hypopharynx: begins at the level of the epiglottis and terminates at the level of the cricoid cartilage, where it is
continuous with the esophagus
Larynx
• complex structure of cartilage, muscles, and ligaments that serves as the inlet to the trachea
• Main functions: phonation and airway protection
• The thyroid cartilage is the largest of all cartilages and supports most of the soft tissues of the larynx.
• The cricoid cartilage, at the level of the sixth cervical vertebra, is the inferior limit of the larynx
Larynx
Trachea and Bronchi
• The trachea begins at the level of the cricoid cartilage and
extends to the carina at the level of the fifth thoracic
vertebra
• 10 to 15 cm in the adult
• consists of 16 to 20 C-shaped cartilaginous rings
• the right mainstem bronchus branches off at a more vertical
angle than the left mainstem bronchus
 Airway Assessment
• Airway assessment should begin with a directed patient history:
• Previous difficult intubation.
• Changes in weight
• Medical history (OSA, Snoring, DM, connective tissue disorders.. Etc)
• Physical examination of the airway should include:
• Visual inspection of the face and neck (deformities, burns, goiter, short or thick, receding mandible,
beard, collars)
• Neck circumference greater than 43 is associated with difficult intubation
• Assessment of mouth opening, Mallampati score and nasal patency
• Evaluation of oropharyngeal anatomy and dentition
• Assessment of neck range of motion
• Assessment of the submandibular space
• mandibular prognathism
# Evaluation of Difficult Airway
# To Assess for Ventilation Difficulty
LEMON
Look – obesity, beard, dental/facial
BONES
abnormalities, neck, facial/neck trauma
Beard
Evaluate – 3-2-1 rule
Obesity (BMI>26)
Mallampati score
No teeth
Obstruction – stridor, foreign bodies
Elderly (age>55)
Neck mobility
Snoring Hx (sleep apnea)
Methods of Supporting Airways
• . non-definitive airway (patent airway)
jaw thrust/chin lift
oropharyngeal and nasopharyngeal airway
bag mask ventilation
laryngeal mask airway
• 2. definitive airway (patent and protected airway)
endotracheal tube
surgical airway (cricothyrotomy or tracheostomy
Oral Cavity
Objective Criteria for Intubation
• Oxygenation
Pa02 < 70 mm Hg with Fi02 = 70%
A-a DO2 gradient > 350 mm Hg.
• Ventilation
RR > 35 /min
PaC02 > 60 in normal adults.
PaC02 > 45 In status asthmaticus
pH < 7.20 In COPD
• Mechanics
VC < 15 mL / kg
NIF > -25 cm H20
Subjective Criteria for Intubation

• 1- Real or impending airway obstruction.

• 2- Protection of the airway. (e.g., decreased level of
consciousness, drug overdose, etc.).
• 3- "Tracheal bronchial toilet." For patients who are unable to
clear their secretions, the ETT provides a direct access for
suctioning secretions, (e.g., COPD patient with pneumonia.)
• 4- Shock not immediately reversed with medical treatment
Subjective Criteria for Intubation

• 5- To provide positive pressure ventilation during general anesthesia.

Additional indications for intubation under general anaesthesia
include: long procedure anticipated, difficult mask ventilation,
operative site near patients airway, thoracic cavity opened, muscle
relaxants required, and if the patient is in a difficult position to
maintain mask anaesthesia.
• 6- Clinical signs of respiratory failure and fatigue. (e.g., diaphoresis,
tachypnea, tachycardia, accessory muscle use, pulsus paradoxus,
cyanosis, etc.).
ETT steps
• Assure standard monitoring
• Check your equipment & medication
• Assure sniffing position
• Allow the patient to breath 100% oxygen ( preoxygenation)
• Induce the patient
• Check for easy ventilation before giving muscle relaxant
• Intubate the patient
preoxygenation
The aim of preoxygenation is to replace nitrogen in the FRC with oxygen; this process is also
referred to as denitrogenation. This has a significant
impact on body oxygen store and therefore increases tolerance to apnea substantially.

The functional residual capacity (FRC) is the most important store of oxygen in the body. The greater
the FRC, the longer apnea can be tolerated before critical hypoxia develops.

For an adult with a normal FRC and VO2, the oxygen content of the lungs will be consumed within 1
min (290 ml).
Confirmation of Tracheal Placement of ETT
• direct
visualization of ETT passing through cords
bronchoscopy visualization of ETT in trachea
• indirect
ETCO2 in exhaled gas measured by capnography
auscultate for equal breath sounds bilaterally and absent breath sounds over epigastrium
bilateral chest movement, condensation of water vapor in ETT visible during exhalation and
no abdominal distention
refilling of reservoir bag during exhalation
CXR (rarely done): only confirms position of the tip of ETT and not that ETT is in the trachea
esophageal intubation suspected when
• Blind insertion of the tube
• ETCO2 zero
• Abnormal auscultation
• No chest excursion
• Hypoxia/cyanosis
• Gastric contents in ETT
• Distention of stomach with ventilation
Predictors of difficult laryngoscopy
• Long upper incisors
• Prominent overbite
• Inability to protrude mandible
• Small mouth opening
• Mallampati classification III or IV
• High, arched palate
• Short thyromental distance
• Short, thick neck
• Limited cervical mobility
Complications During Laryngoscopy and
Intubation
• dental damage
• laceration (lips, gums, tongue, pharynx, esophagus)
• laryngeal trauma
• esophageal or endobronchial intubation
• accidental extubation
• insufficient cuff inflation or cuff laceration: results in leaking and aspiration
• laryngospasm / bronchospasm
• Tachycardia
• Bradycardia
Bag mask Ventilation
• Advantages: basic, Non invasive, Readily available, Can use oropharyngeal/nasopharyngeal
airway
• Disadvantages: Risk of aspiration if decreases LOC, Cannot ensure airway Patency, Inability to
deliver precise tidal volume, Operator fatigue.
• Indications:
• Failure of ventilation
• Failure of oxygenation
• Contra indications:
• Sever facial trauma
• Complete upper airway obstruction
• Complications: inability to ventilate & gastric inflation
LMA
• Advantages : easy to insert, less airway trauma / irritation
• Disadvantages : doesn’t protect against laryngospasm & gastric aspiration
• Indications:
• An acceptable alternative to mask anesthesia in OR
• Used in short procedures when ETT is unnecessary
• Contra indications :
• Cannot open mouth
• Complete airway obstruction
• Any one with increase risk of aspiration
• Need for high positive pressure ventilation
• Complications :aspiration of gastric content , local irritation , obstruction, laryngospasm
ETT
 Advantages : ensure airway patency, protect against aspiration
 Disadvantages : can be difficult to be insert, muscle relaxant needed , sympathetic stress
during intubation
 Indications :
 Airway protection in unconscious patient
 To provide positive pressure ventilation
 To protect lung from aspiration
Contra indications : any situation when the pharynx is obstructed , maxilla facial trauma
Complications : accidental esophageal intubation, teeth damage, endobronchial intubation,
oropharyngeal trauma
Oropharyngeal / nasopharyngeal
• Indications :
• Oropharyngeal : risk for airway obstruction due to relaxed upper airway muscles or
blockage of the airway by the tongue. For unconscious patient
• Nasopharyngeal : keep the airway open and is especially helpful in semi-conscious
patients.
• Contra- indications :
• Oropharyngeal : a conscious patient with an intact gag reflex.
• Nasopharyngeal : basal skull fracture , nasal bleeding ,central facial fracture
Difficult airway algorithm
Backup tools/ plan B examples
• Awake fiber optic
• Video laryngoscopy
• Intubating LMA
• Needle criciothyroidotomy
• Surgical tracheostomy
Intubating LMA
Flexible fiberoptic bronchoscope
Needle cricothyroidotomy
Surgical tracheostomy
Thank You