Airway Management

Recognition of Airway
Obstruction

Systematic method of detecting airway

obstruction :

Look, listen and feel

Look for chest and abdominal movement
Listen and feel for airflow at the mouth and
nose.

Recognition of Airway
Obstruction

Characteristic sounds in airway obstruction :

Gurgling : liquid or semisolid foreign material in the

main airway.
Snoring : pharyng is partially occluded by soft
palate or epiglottis.
Crowing : sound of laryngeal spasm.
Inspiratory stridor : obsruction at laryngeal level or
above.
Expiratory wheeze : obstruction of the lower airway.

Patient Assessment

Level of consciousness
Spontaneous efforts vs. apnea
Airway and cervical spine
injury
Chest expansion
Signs of airway obstruction
Signs of respiratory distress
Protective airway reflexes

Opening the Airway the Triple

Airway Maneuver

Slightly extend neck

(when cervical spine
injury not suspected)
Elevate mandible
Open mouth

Hand Positioning the Triple

Airway Maneuver

Reassess Spontaneous Breathing

(Ventilation) When Airway Open

Adequate
oxygen supplementation

Inadequate
manual assisted
ventilation

Manual Assisted Ventilation

Apply face mask

Oro-/nasopharyngeal
airway adjuncts
Mouth opening
Hand positioning
Elevate mandible and chin
Resuscitation bag
compression volume and
frequency

Single-Hand Method
of Facemask Application

Base of mask placed

over chin and mouth
opened
Apex of mask over
nose
Mandible elevated,
neck
hyperextended (no
cervical spine injury),
and downward
pressure by mask hand

Two-Hand Method of
Facemask Application

Indications

Demonstration

Inadequate Mask-to-Face Seal

Identify leak
Reposition face mask
Improve seal along cheek(s)
Slightly increase downward
pressure over face or neck
extension (if no cervical spine
injury)
Use two-hand technique

Preparation for Endotracheal

Intubation

Continue adequate ventilation and

hyperoxygenation

Decompress stomach

Assess degree of difficulty for

intubation

Analgesia, sedation, amnesia,

neuromuscular blockade as needed

Degree of Difficulty

Micrognathia
Cervical spine status
Facial injury, surgery, scarring
Thyromental distance (short neck)
Mouth opening and Mallampati classification

Mallampati Classification

Analgesia, Sedation, Amnesia,

Neuromuscular Blockade

Analgesia topical, nerve blocks, sedation

Sedation/amnesia rapid acting, short
duration, reversible

Fentanyl: 25100 g iv, titrated to effect

Midazolam: 12 mg iv, titrated to effect
Etomidate: 0.30.4 mg/kg iv, titrated
to effect

Analgesia, Sedation, Amnesia,

Neuromuscular Blockade

Neuromuscular blockers assess need

Succinylcholine: 11.5 mg/kg iv

bolus; depolarizing agent

Vecuronium: 0.10.3 mg/kg iv

bolus;nondepolarizing agent

Orotracheal Intubation
Preparation

Appropriate monitoring oximetry, ECG, BP

Assemble equipment
Laryngoscope test light, select blade
Endotracheal tube test cuff, lubricate
Stylet insert, angulate
Suction test
Magill forceps

Orotracheal Intubation
Preparation

Don protective garb

Elevate occiput with pad if no cervical

spine injury suspected

Provide anesthesia, sedation, amnesia,

and neuromuscular blockade as
required

Orotracheal Intubation
Technique

Proper operator position

Holding the
laryngoscope handle
Application of cricoid
pressure
Mouth opening methods

Orotracheal Intubation
Technique

Insertion of
laryngoscope blade
tongue control

Tongue displacement
medially visualize
epiglottis

Orotracheal Intubation
Technique

Advance laryngoscope
into position (vallecula
for curved blade;
under epiglottis for
straight blade)
Elevate base of tongue
and expose glottic
opening

Orotracheal Intubation
Technique

Elevate base of tongue

further to fully expose
glottic opening and
surrounding anatomy

Orotracheal Intubation
Technique

Insert endotracheal tube under direct

vision to 2325 cm at lip
Remove stylet and laryngoscope, inflate
tube cuff
Confirm tube position breath sounds,
CO2 detector
Secure endotracheal tube
Obtain chest radiograph

Orotracheal Intubation
Technique

Straight blade
position, elevating
the epiglottis
Be aware of
laryngospasm when
epiglottis is
touched

Pediatric Considerations

Infections commonly cause airway

obstruction in young children

Because infants are obligate nose

breathers until ~ age 6 months,
suctioning nares may establish an open
airway

When possible, allow child to assume

position of comfort in early respiratory
compromise

Pediatric Considerations

Face mask may agitate child several delivery

devices should be available

If obtunded or unable to assume a

comfortable position, sniffing position is
preferred in infants and young children to
minimize airway obstruction from soft tissues
(when no cervical spine injury is suspected)

Overextension of neck may cause airway

obstruction

Pediatric Considerations

Positive pressure during bag-mask

ventilation may cause gastric distention;
a nasogastric tube may be needed

Tongue in infants and children up to ~

age 2 yrs occupies relatively large portion
of oral cavity and is likely to cause
obstruction during spontaneous breathing
and manually assisted ventilation

Pediatric Considerations for

Orotracheal Intubation

Secure patient for procedure

Pad or towel under shoulders of infant may be
better than elevation of occiput
Endotracheal tube size approximates size of
patients small finger
Uncuffed endotracheal tubes usually used when
patient < 8 yrs old
Straight laryngoscope blade usually used

Pediatric Considerations for

Orotracheal Intubation

Observe cervical spine precautions

as needed

Relatively larger tongue, angle of

attachment of epiglottis, anterior
and more cephalad position of
larynx make exposure of glottic
opening more difficult

Pediatric Considerations for

Orotracheal Intubation
Cricoid pressure may improve

visualization of glottis
Trachea relatively short so mainstem
intubation may occur more easily
Depth of insertion estimated by
multiplying internal diameter of
endotracheal tube by 3
(e.g., 4.0 tube 3 = 12 cm insertion
depth)

Key Points