Airway Management

Dr. Alembrhan H.
Anesthesiology & critical care , R3

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 Contents
o Introduction
o Functional air way anatomy
o Air way assessment
o Physiologic concept of air way management
o Anesthesia for air way management
o Difficult Air way management
o Extubation of trachea

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 Airway Management
 Practice of establishing & securing a patent airway

 Cornerstone of anesthetic practice

 Development of an airway emergency increases the odds of

death or brain damage by 15-fold. (ASA) .

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 Airway Management
 Successful airway management requires a range of
knowledge and skill sets—specifically ability to:
o Predict difficulty with airway management
o Formulate an airway management plan &
o To have the skills necessary to execute that plan using the wide array
of available airway devices

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 FUNCTIONAL AIRWAY ANATOMY
 The airway can be divided into:
1.Upper airway which includes:
 Nasal cavity
 Oral cavity
 Pharynx
 Larynx
2.Lower airway, which consists:
 Tracheobronchial tree.

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 FUNCTIONAL AIRWAY ANATOMY
Nasal cavity

Figure 1. Lateral wall of the nasal cavity

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 FUNCTIONAL AIRWAY ANATOMY
Oral cavity

Figure 2. Oral cavity

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 FUNCTIONAL AIRWAY ANATOMY
Pharynx

Figure 4. Sagittal section through the head and neck showing the
subdivisions of the pharynx.
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 FUNCTIONAL AIRWAY ANATOMY
Larynx

Figure 5. Cartilaginous and membranous Figure 6. Larynx as visualized from the

components of the larynx. hypopharynx
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 FUNCTIONAL AIRWAY ANATOMY
TRACHEA AND BRONCHI
Trachea begins at the level of the cricoid cartilage at C6 Vertebra &
extends to the carina at the level of T5 vertebra.

Length is 10 to 15 cm in the adult & consists of 16 to 20 C-shaped

cartilaginous rings.

At the carina, the trachea bifurcates into the right & left main stem
bronchi.

Right principal bronchus is larger in diameter & deviates from the

plane of the trachea at less acute angle.

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 Anatomic Differences Between the Pediatric & Adult
Airways

 Head size (large occiput) – causes neck flexion.

 Infant’s tongue is relatively large in proportion to the rest of the oral

cavity.

 No teeth in infancy.

 Proportionately smaller infant/child larynx.

 Narrowest portion: Cricoid cartilage in infant/child; vocal folds in adult.

 Relative vertical location: C3–C5 in infant/child; C4–C6 in adult.

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 Anatomic Differences Between the Pediatric &
Adult Airways

 Epiglottis: Longer, narrower, & stiffer in infant/child.

 Aryepiglottic folds closer to midline in infant/child.

 Vocal folds: Anterior angle with respect to perpendicular axis of

larynx in infant/child.

 Pliable laryngeal cartilage in infant/child.

 Mucosa more vulnerable to trauma in infant/child.

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 Anatomic Differences Between the Pediatric & Adult
Airways
 The child develops adult anatomy by the age of 10–12 years.
 The greatest anatomical differences exist in the infant (i.e. <1 year).

Figure 7 :Anatomical features of a child’s airway that differ from an

adult
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 AIRWAY ASSESSMENT
 Certain physical findings or details from the patient’s
history can be prognostic of difficulty with :
 Mask ventilation.

 Supraglottic airway placement.

 Laryngoscopy & endotracheal intubation.

 Performance of a surgical airway.

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Signs & symptoms with Airway management
implications

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 AIRWAY ASSESSMENT

Components of the Physical Examination of the Airway

 Visual inspection of the face & neck
 Assessment of mouth opening
 Evaluation of oropharyngeal anatomy and dentition
 Assessment of neck range of motion (ability of the patient to
assume the sniffing position)
 Assessment of the submandibular space
 Assessment of the patient’s ability to slide the mandible
Anteriorly (test of mandibular prognathism)

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 Techniques of common
Airway indexes measurement
 Thyromental distance: Measured along a straight line from tip of mentum
to thyroid notch in neck-extended position.

 Mouth opening: Inter incisor distance (or inter alveolus distance when
edentulous) with the mouth fully opened.

 Head and neck movement: The range of motion from full extension to full
flexion.

 Mallampati score

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 AIRWAY ASSESSMENT

Figure . Mallampati classification of the oropharyngeal view. a: Class I: uvula, faucial

pillars, soft palate visible. b: Class II: Faucial pillars, soft palate visible. C: Class III: Soft
and hard palate visible. D: Class IV: Hard palate visible only
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PHYSIOLOGIC CONCEPTS FOR AIRWAY MANAGEMENT

PREOXYGENATION
 Process of replacing nitrogen in the lungs with oxygen.

 Increased length of time before hemoglobin desaturation occurs in

patient with apnea.

 Lengthened apnea time provides an improved margin of safety until

airway secured & ventilation resumed.

 Recommended routinely before induction of general anesthesia.

Children have Lower FRC. therefore have significantly less oxygen reserve
& will desaturate much faster than adults
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PHYSIOLOGIC CONCEPTS FOR AIRWAY MANAGEMENT

PREOXYGENATION
 Via a facemask attached to either the anesthesia machine or a
Mapleson circuit.
 100% oxygen must be provided at a flow rate high enough to
prevent rebreathing (10 to 12 L/min).
 Two primary methods are used:
1. Tidal volume ventilation through the facemask for 3 minutes.
2. Vital capacity breaths:
o 4 breaths over 30 seconds is not as effective as the tidal volume
method
o 8 breaths over 60 seconds has been shown to be more effective

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PHYSIOLOGIC CONCEPTS FOR AIRWAY MANAGEMENT

PULMONARY ASPIRATION OF GASTRIC CONTENTS

 Prevention is primarily accomplished by:
 Adherence to established preoperative fasting guidelines.
 Premedication with drugs that may decrease the risk of aspiration pneumonitis,
and
 Specialized induction techniques
 Also choice of airway management patient with risk factors.

 Risk factors for aspiration:

 Full stomach
 Symptomatic gastro esophageal reflux disease (GERD)
 Hiatal hernia
 Presence of a nasogastric tube
 Morbid obesity
 Diabetic gastroparesis or pregnancy so on.
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PHYSIOLOGIC CONCEPTS FOR AIRWAY MANAGEMENT
AIRWAY REFLEXES AND THE PHYSIOLOGIC RESPONSE TO INTUBATION
OF THE TRACHEA
 Glottis closure reflex
 Triggered by sensory receptors in the glottic & subglottic mucosa.
 Results in strong adduction of the vocal cords.
 Exaggerated, maladaptive manifestation of this reflex, referred to
as laryngospasm, is a potential complication of airway
management.
 Treatment of laryngospasm:
o Removal of airway irritants
o Deepening of the anesthetic &
o Administration of a rapid-onset NMBD such as succinylcholine
o Bilateral pressure at the laryngospasm notch between the condyle of the
mandible and the mastoid process.
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PHYSIOLOGIC CONCEPTS FOR AIRWAY MANAGEMENT

AIRWAY REFLEXES AND THE PHYSIOLOGIC RESPONSE TO

INTUBATION OF THE TRACHEA

 Tracheobronchial reflexes
 Protect the lungs from noxious substances.

 Irritation of lower airway activates a vagal reflex–mediated

constriction of bronchial smooth muscle, resulting in bronchospasm.

 Treatment includes:
o Deepening of anesthetic
o Administration of inhaled β2-agonist or anticholinergic medications
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PHYSIOLOGIC CONCEPTS FOR AIRWAY MANAGEMENT

AIRWAY REFLEXES AND THE PHYSIOLOGIC RESPONSE TO INTUBATION

OF THE TRACHEA

Reflex autonomic activation

 Results from intense noxious stimulus via vagal & glossopharyngeal afferent due to
airway instrumentation.

 Manifested as:
o Hypertension & tachycardia in adults & adolescents.
o Bradycardia in infants & small children
o CNS activation results in increases in EEG activity, cerebral metabolic rate, & CBF,
which may result in an increase ICP in patients with decreased intracranial
compliance

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ANESTHESIA FOR AIRWAY MANAGEMENT
 Some form of anesthesia is usually required to:
 Provide comfort for the patient
 Blunt airway reflexes &
 Blunt the hemodynamic response to airway instrumentation.

 Airway management is performed after induction of general

anesthesia & Alternatively, an awake technique.

 Anesthetic drugs may not be required in obtunded or

comatose patient.

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ANESTHESIA FOR AIRWAY MANAGEMENT

Standard Intravenous Induction With

Neuromuscular Blockade
 Administration of a rapid-acting IV anesthetic, followed by a
NMBD.

 Propofol is the most frequently used IV anesthetic drug other

options include etomidate, ketamine, thiopental, and
midazolam.

 Withholding NMBDs until the ability to mask ventilate has been

established.
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ANESTHESIA FOR AIRWAY MANAGEMENT

Rapid-Sequence Induction of Anesthesia & Intubation of the

Trachea
 Used when a frequent risk for gastric regurgitation & pulmonary aspiration of
gastric contents is present.

 After adequate preoxygenation, & while cricoid pressure is applied, an induction

dose of IV anesthetic is rapidly followed by 1 to 1.5 mg/kg of IV succinylcholine.

 Trachea is intubated without attempts at PPV.

Modified RSII
 Gentle PPV (inspiratory pressure <20 cm water [H2O]) in conjunction with
cricoid pressure.

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 ANESTHESIA FOR AIRWAY MANAGEMENT

Inhalational Induction of Anesthesia

 Commonly used in pediatric to provide a painless, needle-free
experience for the child.

 In adults when IV access is not available or when the specific

advantages of the technique are desirable.

 Advantages are:
o Maintenance of spontaneous ventilation
o Potential for gradual changes in the depth of anesthesia
o Associated respiratory and cardiovascular effects.

 Also used for RSII, with a rapid-onset NMBD administered at LOC.

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 ANESTHESIA FOR AIRWAY MANAGEMENT

Intravenous Induction Without Neuromuscular

Blocking Drugs
 Commonly used for LMA placement but can be used to
achieve satisfactory intubating conditions as well.

 Useful when succinylcholine is contraindicated & prolonged

recovery time from non depolarizing NMBDs is undesirable.

 Propofol is the best suited because of its unique ability to

suppress airway reflexes & to produce apnea.

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 ANESTHESIA FOR AIRWAY MANAGEMENT

AIRWAY MANAGEMENT IN AN AWAKE PATIENT

 Advantages:
o Preservation of pharyngeal muscle tone & patency of the
upper airway.
o Maintenance of spontaneous ventilation.
o An ability to obtain a quick neurologic examination.
o Safeguard against aspiration attributable to the preservation of
protective airway reflexes.

 In general used , when difficult mask ventilation & difficult

intubation are expected.

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 AIRWAY MANAGEMENT

 VENTILATION VIA A MASK

 SUPRAGLOTTIC AIRWAY

 ENDOTRACHEAL INTUBATION

 PERCUTANEOUS AIRWAYS

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Difficult airway

 Clinical situation in which a conventionally trained

anesthesiologist experiences difficulty with ventilation of the
upper airway via a mask, difficulty with tracheal intubation, or
both.

Difficult Airway Algorithm

 Guide clinical decision making when an anesthesiologist is
faced with a known or potential difficult airway.

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 Difficult Airway management

1. Assess the likelihood and clinical impact of basic management

problems:
 Difficulty with patient cooperation or consent
 Difficult mask ventilation
 Difficult supraglottic airway placement
 Difficult laryngoscopy
 Difficult intubation
 Difficult surgical airway access

2. Actively pursue opportunities to deliver supplemental oxygen

throughout the process of difficult airway management.
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 Difficult Airway management

3.Consider the relative merits & feasibility of basic management

choices:
 Awake intubation vs. intubation after induction of GA.
 Noninvasive technique vs. invasive techniques for the initial
approach to intubation.
 Video-assisted laryngoscopy as an initial approach to
intubation.
 Preservation vs. ablation of spontaneous ventilation.

4. Develop primary and alternative strategies.

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Figure 5. The American Society of Anesthesiologists’ “Difficult Airway Algorithm.”
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2013
 EXTUBATION OF THE TRACHEA
 Is critical component of airway management.
 Failed extubation can result from:
o Failure of oxygenation
o Failure of ventilation
o Inadequate clearance of pulmonary secretions or
o loss of airway patency

 Anesthesia practitioner needs to stratify the extubation risk

preemptively & establish an extubation plan.

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 GENERAL CONSIDERATIONS FOR
EXTUBATION OF THE TRACHEA
 Extubation technique:
o Awake Extubation
o Deep extubation
o Bailey maneuver

 General preparations for extubation should include:

o Ensuring adequate reversal or recovery from neuromuscular blockade.
o Hemodynamic stability
o Normothermia &
o Adequate analgesia

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 GENERAL CONSIDERATIONS FOR
EXTUBATION OF THE TRACHEA
 Sniffing position is the standard position for extubation

 Suctioning of the pharynx (and the trachea, if indicated).

 Removal of throat packs .

 Placement of a bite block.

 Inspection of the pilot balloon to ensure complete cuff deflation
before extubation.

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 Factors Associated With Increased
Extubation Risk
Airway Risk Factors
o Known difficult airway
o Airway deterioration (bleeding, edema, trauma)
o Restricted airway access
o Obesity and obstructive sleep apnea
o Aspiration risk

General Risk Factors

o Cardiovascular disease
o Respiratory disease
o Neuromuscular disease
o Metabolic derangements
o Special surgical requirements

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Complications Associated With Extubation
 Laryngospasm & bronchospasm
 Upper airway obstruction
 Hypoventilation
 Hemodynamic changes (hypertension, tachycardia)
 Coughing and straining, leading to surgical wound dehiscence
 Laryngeal or airway edema
 Negative-pressure pulmonary edema
 Paradoxical vocal cord motion
 Arytenoid dislocation
 Aspiration

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 Reference
 Miller’s Anesthesia 8th edition/chapter 55/page no 1923-
1955/.

 Clinical Anesthesia 7th edition/Paul Barash/chapter 27/page

no 765 -799/.

 Emergency air way management/ Beneger/chapter 11.

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THANK YOU . . .

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