AIRWAY

MANAGEMENT

OVERVIEW
Anatomy

of the Airway
Evaluation of the Airway
Basic Airway Management
Indications for Endotracheal
Intubation
Equipment for Airway Management
Difficult Airway Algorithm

Anatomy of the Airway

Innervation of the
Nasopharynx and Oropharynx
CN V - Trigeminal Nerve
V1 - Ophthalmic Division
(anterior ethmoidal n.)
V2 - Maxillary Division
(sphenopalatine n.)
V3 - Mandibular Division
(lingual n.)

Innervation of the
Nasopharynx and Oropharynx
CN VII Facial Nerve
Taste to posterior 1/3 of tongue
CN IX Glossopharyngeal Nerve
Sensation to posterior 1/3 of
tongue, tonsils, pharynx

Nerve Supply to the Larynx

CN X Vagus Nerve
Superior Laryngeal
Nerve

- Motor to cricothyroid muscle

- Sensory to above the vocal
cords

Recurrent Laryngeal
Nerve

- Motor to all intrinsic

muscles
except cricothyroid
- Sensory to below the vocal

Clinical Significance
Acute

bilateral RLN injury stridor,

respiratory distress
Need for topical anesthetics for nasal
intubation
Nerve blocks for awake intubation

Glossopharyngeal nerve block

Superior laryngeal nerve block
Transtracheal block

Anatomy of the Larynx

C4-C6 level
3 single
cartilages

epiglottis
thyroid
cricoid

3 paired
cartilages

arytenoids
corniculates
cuneiforms

Anatomy of the Larynx

Clinical Significance
Cricothyroid

membrane puncture
during cricothyrotomy

Cricoid

cartilage signet ring,

Sellicks maneuver

Anatomy of the Airway

Trachea
15 cm long ( adult)
16-20 C shaped
cartilages
Bifurcates to R and L
bronchus at T5
R bronchus appears to
be a vertical
continuation of trachea
Aspiration more common
R mainstem intubation
more common

Evaluation of the Airway

Historical Interview

Prior difficult intubation?

Surgical history head and neck
Congenital and Acquired Syndromes

Down syndrome, Pierre Robin syndrome,

Ludwigs angina

Medical condition that may predispose

to difficult intubation
- Morbid Obesity, TMJ dysfunction, Tumors
Review of previous anesthetic records

Macroglossia

Evaluation of the Airway

Ancillary Tests
Radiographs
CT

(cervical x-ray)

Scan
MRI
Pulmonary Function Tests
Direct Fiber-optic Examination

Epiglottitis

Evaluation of the Airway

Physical Exam

General assessment

- cachexia, need for O2 support,

cyanosis, morbid obesity, VS including
SpO2

Focused Airway Exam

MALLAMPATI CLASSIFICATION

I II

I
Pharyngeal
pillars +
CLASS

Uvula +
Soft palate +
Hard palate

II

III

IV

II

III

IV

S, H

P, u, S,
H

MALLAMPATI CLASSIFICATION
Patient

sitting, mouth fully opened,

tongue fully extended, without
phonation
Significant interobserver variability
Sensitivity : 60-80%
Specificity : 53-80%

Thyromental Distance
tip of the mandible
notch of thyroid cartilage
Normal = 6.5 cm

neck fully extended

estimates the
displacement
of the tongue

Thyromental Distance
Questioned

the most re: predictive

value
Sensitivity : 60-80%
Specificity : 80-90%
Arne and El-Ganzouri : highly insensitive
but very specific (17% and 99%)
Chou and Wu : adjust this measure to
pts height

Mouth Opening/Incisor Gap

< 3 cm reduces
prevalence of easy
intubation from
95% to 62%

Neck Movement
Neck

Flexion : >80 degrees

Neck Extension : >90 degrees

Bell House and Dore

Classification

Mandible Protrusion

Multivariate Predictors of
Difficult Tracheal Intubation

1996, El-Ganzouri
Prospective analysis of 10,507 consecutive
adult patients presenting for surgery under
general anesthesia
A multivariate model for stratifying the risk
Compared to Mallampati Class I as a single
predictor. A risk index score of three
demonstrates a higher sensitivity (59 vs
44)

Multivariate Predictors of
Difficult Tracheal Intubation

Mouth opening
Thyromental
distance
Mallampati Class
Neck Movement
Ability to Protrude
the Mandible
Body Weight
History of Difficult
Intubation

Maneuvers for Opening the

Airway
Head Tilt or
Chin Lift

Maneuvers for Opening the

Airway
Jaw
Thrust

Upper Airway Obstruction

ORAL AIRWAY

NASAL AIRWAY

MASK VENTILATION

INDICATIONS FOR ENDOTRACHEAL

INTUBATION (operative)
1.
2.
3.
4.
5.
6.
7.

Need to deliver positive pressure

ventilation
Protection of the respiratory tract
Head, neck, chest surgery
GA in nonsupine position
Neuromuscular paralysis instituted
Need to treat intracranial HTN
Lung isolation

INDICATIONS FOR ENDOTRACHEAL

INTUBATION (non-operative)
1.
2.
3.

Decreased consciousness
Tracheobronchial toilet
Severe pulmonary and multi-system
injury associated with respiratory
failure

Severe sepsis
Airway obstruction
Hypoxemia/hypercarbia of various
etiologies

Objective Measures
(FOR ENDOTRACHEAL INTUBATION)

RR > 35/min
Vital Capacity < 15 ml/kg
Inability to generate a negative inspiratory
force of 20 mm Hg
PaO2 < 70 mm Hg on 40% FiO2
A-a gradient > 350 mm Hg on 100% O2
PaCO2 > 55 mm Hg
Dead Space (Vd/Vt) > 0.6

LARYNGOSCOPY

Alignment of the Axes

Alignment of the Axes

Neck Flexion

Alignment of the Axes

Neck Flexion + Atlanto-Occipital Extension

Sniffing Position

Cormack - Lehane
Classification

Entire
glottic
aperture

Posterior aspect
of glottic aperture
Tip of epiglottis

Soft palate

LARYNGEAL MANIPULATION
Bbackward
U - upward
Rrightward
P - pressure
BURP
Maneuver

Equipment for Airway

Management

ORAL AIRWAYS
Relieves obstruction
due to tongue
falling backward
Initially inserted
towards hard palate
then rotated 180
degrees
Can cause gag
/vomit reflex

NASAL AIRWAYS

Equipment for Airway

Management

Anesthesia Face Mask

Should fit over the bridge
of the nose cheeks and
chin to produce AIRTIGHT
SEAL
Increased dead space
therefore larger TV
required
Clear mask preferable to
see vomitus/secretions
and color

Equipment for Airway

Management

Laryngoscopes
Consist of handle and blade
Handle has the batteries.
Usually rough for better grip
Blades are designed to
enter mouth, displace the
tongue, elevate epiglottis
and expose the Vocal cord
STRAIGHT BLADE- MILLER
CURVED BLADE- MACINTOSH

Equipment for Airway

Management

Endotracheal tube
Increases resistance
to gas flow
Increases dead space
IT or Z 79 (indicates
lack of tissue toxicity)
High volume-low
pressure cuff
preferred (<25 torr) :
prevents tracheal
mucosa ischemia

Equipment for Airway

Management

Endotracheal tube
Very flexible thus a
STYLET maybe needed
Can be inserted orally,
nasally or thru the
tracheostomy stoma
With Murphys eye
( allows ventilation even
if main port is occluded

Stylet
Malleable metal inserted
thru the tube for
difficult intubation

Equipment for Airway

Management

LMA (Laryngeal Mask

Airway)

Relatively new device

Alternative to ETT
Aspiration?
Easier to insert

ILMA (Intubating LMA)

An ETT may be inserted
thru the LMA

Equipment for Airway

Management

COMBITUBE

Equipment for Airway

Management

GLIDESCOPE

Equipment for Airway

Management
Fiberoptic

Bronchoscope

Equipment for Airway

Management
Cricothyrotomy

Kit

Equipment for Airway

Management

Retrograde

Intubation Kit

Equipment for Airway

Management
Tracheostomy

Set

Difficult Airway
the

clinical situation in which a

conventionally trained
anesthesiologist experiences
difficulty with mask ventilation,
difficulty with tracheal intubation, or
both.

Prediction of the Difficult

Airway
Recent

data from the Closed Claims

Project of the American Society of
Anesthesiologists (ASA)
Adverse respiratory events largest
source of injury
inadequate ventilation (38%)
esophageal intubation (18%)
difficult intubation (17%)

Prediction of the Difficult

Airway
Of

these respiratory events

death or brain damage - 85%
substandard care - 12.5%
preventable - 12.5%

Better

prediction and anticipation of

the difficult airway - lead to reduction
in these numbers

Definition of Terms Four

concepts

Difficult

Mask Ventilation
Difficult Laryngoscopy
Difficult Intubation
Failed Intubation

Difficult Mask Ventilation

No universally acceptable classification

(1) inability of unassisted anesthesiologist

to maintain SpO2 > 90% using 100%
oxygen and positive pressure mask
ventilation in a patient whose SpO2 was
90% before anesthetic intervention; or

(2) inability of the unassisted

anesthesiologist to prevent or reverse
signs of inadequate ventilation during
positive pressure mask ventilation.

Difficult Laryngoscopy

difficult laryngoscopy = not being able to see any

part of the vocal cords with conventional
laryngoscopy

Cormack and Lehane Classification

Four grades of laryngoscopy based on structures

visualized

Grade three and four or grade four alone as

correlating with a potentially difficult intubation

Difficult Intubation
Less straightforward
In 1993, The ASA Committee on
Practice Guidelines for Management of
the Difficult Airway defined it as
intubation when the proper insertion
of the ET tube with conventional
laryngoscopy requires more than
three attempts and/or more than 10
minutes

Failed Intubation
The

inability to place the endotracheal tube

into the airway

0.05% or 1:2230 of surgical patients

0.13% to 0.35%, or 1:750 to 1:280 of

obstetric patients

LMA in the Difficult Airway

Algorithm

Techniques for Difficult

Ventilation

two-person

mask ventilation
oral and nasopharyngeal airways
laryngeal mask airway
esophageal-tracheal combitube
transtracheal jet ventilation
rigid ventilating bronchoscope
surgical airway access

Techniques for Difficult

Intubation

alternative laryngoscopic blades

intubating stylet
gum elastic bougies
awake intubation
fiberoptic intubation
blind intubation (oral or nasal)
retrograde intubation
surgical airway access

ASA Difficult Airway Algorithm

Take-Home Messages

If suspicious of trouble secure the airway

awake

If you get into trouble awaken the patient

Have a plan B and C immediately available or

in place think ahead

Intubation choices do what you do best

THANKS GUYS!