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TheInternetJournalofAnesthesiology

OriginalArticle

AirwayManagement:AReviewandUpdate
J Soliz, A Sinha, D Thakar

Citation

JSoliz,ASinha,DThakar.AirwayManagement:AReviewandUpdate.The
InternetJournalofAnesthesiology.2001Volume6Number1.

Abstract

Infollowingthe'ABCs'ofresuscitation,(airway,breathing,andcirculation)
airwaymanagementisthefirstpriorityforpatientsintheemergency
department,forevaluationofpatientsbytheanesthesiologistforsurgery,and
forpatientsdecompensatinginthecriticalcaresetting.Thegoalistoventilate
adequatelyenoughtomeetthepatient'soxygendemandsandeliminate
carbondioxide.Overthepast20years,changesinairwaymanagement
techniqueshaveledtodecreasedmorbidityandmortalityinboththeacute
careandsurgicalsetting.Withdifficultintubationbeingreportedasupto3%
ofairwayemergenciesintheemergencydepartment1,andtheincidenceof
failedintubationintheoperatingroomapproximately1to3per1000
patients2,theskillfuluseofbothtraditionalandalternatetechniquesare
necessarytoprovideadequatecare.Thisreviewcoversairwayanatomy,
assessmentoftheairway,indicationsforintubation,techniques,andsomeof
thepharmacologicalissuesinairwaymanagement.

Anatomy

Knowledgeoftheanatomyofthehypopharynxisessentialforairway
management.Whenviewingthehypopharynxusingalaryngoscope,the

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epiglottisisvisualized.Theepiglottisisthestructurethatoverliesthe
laryngealinletarisingfromthevallecula(Figure1).

Figure1

Usingacurvedlaryngoscope(Macintosh),pressureappliedtothevallecula
liftstheepiglottisforvisualization,utilizingalaryngoscopewithastraight
blade(Miller),theepiglottisisdirectlyliftedforvisualizationofthelaryngeal
inlet.Thetruevocalcordsarethegraywhitecoloredstructureslocated
mediallytothevestibularfolds.Thespaceseenbetweentherelaxedvocal
cords,calledtherimaglottidisisenteredwithanendotrachealtubeduring
intubation.Anteriorly,thetruevocalcordsattachtothethyroidcartilage
(Figure2),whichmaybeexternallymanipulatedtoimprovevisualizationof
thelarynx.

Figure2

Laterally,thearyepiglotticfoldsattachtheepiglottistothecuneiform
tubercles.Medialtothesestructuresarethecorniculatetuberclesthatare
connectedbytheinterarytendoidnotch.Thecricoidcartilagelocatedbeneath
thetruevocalcordscompletelyencirclesthetrachea.Theexternal
applicationofpressuretothecricoidcartilage(Sellick'smaneuver)isa
techniqueusedtomakeaspirationlesslikelybycompressionofthe
esophagus.3
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Knowledgeoftheinnervationofthelarynx,particularlytheleftrecurrent
laryngealnerve(RLN)andthesuperiorlaryngealnerve(SLN),isimportant
withregardstoairwaymanagement.TheleftRLNcoursesaroundthearchof
theaortaattheligamentumarteriosummakingitpronetosurgicalinjury.
UnilateralinjurytotheRLNresultsinadductionoftheipsilateralvocalcord
andahoarsevoice.BilateralinjurytotheRLNcancauseadductionofboth
thevocalcordsleadingtocompleteairwayobstruction.3,4Theexternal
branchofthesuperiorlaryngealnervesuppliesthecricothyroidmuscleafter
transversingthethyrohyoidmembrane.InjurytotheSLNwillnotresultin
airwayobstruction,butmayleadtohoarsevocalizationbytensingthevocal
cords.4Inanawakepatient,bilateralSLNblocksalongwithtopicalizationof
theairwaymaybeused,allowingthepatienttobettertoleratemanipulationof
theoropharynxandintubation.Toperformthisblock,locatethegreatercornu
ofthehyoidboneandinject3mloflidocaineapproximately1cmcaudaltothis
point.5Cautionshouldbetakenwhenusingthistypeofblockbecausecough
reflexesmaybedepressedleadingtoanincreaseriskofaspiration.5

AssessingtheAirway

Withanunderstandingofairwayanatomy,athoroughpatientevaluationis
essentialinairwaymanagement.Evaluationinvolvesobtainingahistoryand
performingaphysicalexam.

HistoryandPhysicalExam

Takinganadequatehistoryisnecessarytoanticipatepossiblecomplications.
Withregardstoairwaymanagement,thehistoryshouldfocusonprior
intubations,anesthetichistory,drugallergies,andconfoundingillnessesthat
mayhinderairwayaccess.Ahistoryofdifficultintubationhasthehighest
positiveandnegativepredictivevalueinpredictingadifficultintubation.6The
examinationoftheairwayinvolvesinspectionofthestateofdentition
especiallylooseteeth,upperincisorsaswellasprotuberantincisors.
VisualizationoftheoropharynxisclassifiedmostcommonlybytheModified
Mallampaticlassificationsystem.Thissystemisbasedonthevisualizationof
theoropharynx(Figure3)whenaseatedpatientopenshisorhermouthand
protrudesthetongue.7,8

Figure3
FIGURE3:ViewsofthepharynxasclassifiedbyMallampatietal.7(Modified
fromSamsoonGLT,YoungJRB8:Difficulttrachealintubation:aretrospective
study.Anaesthesia.198742:487)

Inthisclassificationsystem,ClassIandIIairwaysaregenerallypredicted
easytointubate,whileClassIIIandIVaresometimesdifficult(Table1).8
Thoughthissystemlacksspecificity,8itdoesallowforpreparationofpossible
complicationsandimprovescommunicationbetweenmedicalpersonnelwith
regardstoapatient'sairway.

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Figure4

InadditiontotheMallampaticlassificationsystem,otherphysicalfindings
havebeenshowntobegoodpredictorsofadifficultairway.Wilsonetal.
usinglineardiscriminantanalysisincorporatedfivevariables:bodyweight,
headandneckmovement,jawmovement,recedingmandible,andbuckteeth
intoascoringsystemthatpredicted75%ofdifficultintubationsatarisk
criterion=2(Table2).9Otherfactorsusedtopredictadifficultintubation
include:

Largetongue

Lessthan6cmdistancefrommandibletothyroidnotch

Inabilitytoplacepatientinsniffposition

Shortneck4,10,11,12,13

IndicationsforIntubation

Establishingindicationforintubationisaprimarystepinairwaymanagement.
Ingeneral,indicationsforintubationinclude:

Protectionoftheairwayfromobstructionoraspiration

Facilitationofpositivepressureventilation

Airwaycontrolfordiagnosticandtherapeuticmeasures14

Multiplesituationsleadtooneofthesethreeindications.Forexample,
unconsciouspatientswithpoorventilatorydrive,patientswithsuspected
epiglottitis,patientswithseverelaryngealangioedema,andpatientswith
possibleforeignbodyobstructionrequireintubationforairwaymanagement.
Afterpatientevaluationandifintubationisindicated,anairwaymanagement
techniqueisselected.

AirwayManagement

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Medicalpersonnelshouldbeknowledgeableinmanagementdevicesand
techniques.Theapproachtothepatientinneedofairwayaccessbeginswith
reliefofpossibleobstruction.Sincethetongueisthemostcommoncauseof
airwayobstruction,reliefisattemptedbytiltingthehead,chinlift,andorjaw
thrust.3,15Thiswilldecreasetheamountofsofttissueobstructionaroundthe
airway.Supplementaloxygenmaythenbegivenviafacemaskornasal
canula.

Twoeasilyimplementednondefinitivetechniquesincludetheoralandnasal
airway.Theoralairwayisdesignedtorelieveobstructioncausedbythe
tongue,andassistinmaskventilation.3,4,15Possiblecomplicationsof
placementofanoralairwayincludeinitiationofgagreflex,vomiting,
aspiration,laryngospasm,anddamagetoteethandlips.3,16

Thecuffedoropharyngealairway(COPA)isamodifiedversionoftheoral
airwaywithaninflatablecuffanddistalportforattachmenttoananesthetic
circuit.17Whenproperlyplaced,theCOPAisdesignedtodisplacethe
tongue,provideanairtightseal,andelevatetheepiglottis.17Inadditionto
useasanondefinitiveairway,thisdevicehasbeenusedasanaidfor
trachealintubation18,andasanairwayduringanesthesiainspontaneously
breathingpatients.17,19,20WhencomparedtotheLMA,theCOPAhasbeen
showntoprovidesimilarresultsphysiologically,butdoesrequiremore
manipulationforplacement.17,19Thenasalairwaymaybepreferabletothe
oralincasessuchasinpharyngealtraumaortofacilitatenasotracheal
intubation.Liketheoralairway,thenasalairwaywillrelievesomeofthesoft
tissueobstructionoftheposteriorpharynx.3

Definitiveairwaytechniquesmostcommonlyusedincludeendotrachealand
nasotrachealintubation.Theuseofadefinitiveairwayallowsforcontrolof
ventilation,protectstheairwayfromaspiration,andallowsfordeliveryof
higherconcentrationsofsupplementaloxygen.21Beforeanairwayisplaced,
thepatientisplacedintheoptimalpositionforalignmentofthethree
anatomicaxes,theoral,pharyngeal,andlaryngeal.21Thesniffingposition
bestallowsforthis(Figure4).Alternativetechniquesforobtaininganairway
arediscussedlater.

Figure5
Figure4:Thepatientislyinginthesniffingposition.Inthisposition,the
oropharynx,pharynx,andlarynxareinalignment.

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OrotrachealIntubation

Orotrachealintubationisthemostcommonlyacceptedmethodforsecuring
anairway.Whenperformedbyaskilledclinician,ithasbeenshowntohavea
highrateofsuccesswithlowrateofcomplication.22However,similarto
manyproceduresinmedicine,orotrachealintubationisaskillthatrequires
practicetobecomeproficient.OnestudyconductedbyKonradetal
demonstrateda90%successrateafter57attemptsinfirstyear
anesthesiologyresidents.23Videotapesandanatomicalmodelshavebeen
usedtofacilitatethelearningofthisskillinmedicalstudents,residents,and
nurses.21

Whenintubationisplanned,apneumonicsuchasMSMAID(Table3)isa
helpfultoolforevaluatingyourpreparedness.Thepatientisplacedinsniffing
position,andpreoxygenatedviafacemask.Firstnarcoticsandthenan
inductionagentisgiven.Priortogivingneuromuscularblockingagent,itis
usuallynecessarytoestablishtheabilitytoventilate.Aftermusclerelaxant
takeseffect,thepatientiseithermaskventilatedbeforebeingintubated,or
immediatelyintubatediftherapidsequenceinduction(RSI)techniqueis
beingused.UsuallyinRSI,shortactingrelaxantslikesuccinylcholineare
used.14

Figure6

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Whenattemptingtointubateitisimportanttobecarefulnottousethe
patient'supperincisorsasleverageforthelaryngoscope.Damageto
dentitionisapreventablecommonsideeffectofintubation.24After
visualizationofthevocalcords,theendotrachealtubeisinserted.Correct
placementoftheendotrachealtubemaybeconfirmedby:

Directvisualizationoftheendotrachealtubecuffpassingthevocal
cords

PresenceofETCO2onthreeconsecutivebreaths

Absenceofstomachgurglingsoundmadebyairenteringthe
stomach.Itisimportanttoauscultateoverthestomachbeforethelungs
becausethestomachmayrapidlyfillwithgasesincaseofesophageal
intubation

Equalbilateralbreathsoundsoverthelungs

Foggingoftheendotrachealtube

Refillingoftheventilatorybagwithexpiration

Rarely,achestxraymaybeusedtoconfirmplacementoftube14,25

Nasotrachealintubation

Nasotrachealintubationprovidesanotherdefinitiverouteofsecuringan
airway.Incasessuchasoralsurgery,thisrouteofintubationispreferred.The
choiceofnostrildoesnotappeartobeafactorintherateofperioperative
complications.26Thenostrilthatthepatientbreathesmoreeasilythroughis
usuallychosenforintubation.21Afterpreparationofthenasalmucosawith
vasocontrictingnosedropsanddilationofthenostrilwithprogressivelylarger
nasaltrumpets,thetubeisinsertedintothenoseuntilvisualizedinthe
oropharynx.WiththeaidofalaryngoscopeandMagillforceps,thetubeis
thenadvancedintothetrachea.Alternatively,thenasaltubemaybeinserted
overafiberopticscope.21,27Complicationsthatcanoccurwiththisrouteof
intubationincludebleeding,infection,laryngospasm,anddamageofthe
turbinates.28

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RapidSequenceInduction

RapidSequenceInduction(RSI)isacommonlyusedtechniqueofintubation
inemergentcasesandinsurgicalpatientsatriskforaspiration.29RSI
consistsofpretreatment,preoxygenation,administeringofashortacting
inductionagent,andtheadministeringofaneuromuscularblocker.
Pretreatmentalsoinvolvestheadministeringofdrugstodecreasethe
cardiovascularresponsetointubation.Lidocainehasbeenshowntobluntthe
cardiovascularresponsetothestimulationoftheairway.30Common
inductionagentsarethiopental,propofol,andetomidate.29,31Paralysisis
commonlyachievedwitheithersuccinylcholineorrocuronium.32,33Many
cliniciansprefertointubatewithoutconfirmingtheabilitytomaskventilatethe
patient.Sellick'smaneuver,continuouspressureonthecricothyroidcartilage,
isemployedtodecreaseaspirationrelatedcomplicationssuchas
Mendelson'sSyndrome.3Afterplacementoftheendotrachealtube,
confirmationofitsplacementisperformedasinstandardorotracheal
intubation.

TheDifficultAirway

Inmanysituationsconventionalmethodsofmanaginganairwaymaybe
inadequateandfail.Alternativestotheseconventionaltechniques(oraland
nasalintubation)mustbepracticedandwellunderstoodforoptimumairway
management.TheAmericanSocietyofAnesthesiologistsTaskForceonthe
DifficultAirwaydefinesadifficultairwayasaclinicalsituationinwhicha
conventionallytrainedanesthesiologistexperiencesdifficultyinmask
ventilation,trachealintubationorboth.34Managementofadifficultairway
hasbeenreviewedextensivelyandiswellsummarizedbytheASADifficult
AirwayAlgorithm(Figure5).34

Figure7
Figure5:DifficultAirwayAlgorithm.ModifiedfromCaplanRA,BenumofJL,
BerryFAetal:Practiceguidelinesformanagementofthedifficultairway:A
reportbytheAmericanSocietyofAnesthesiologistsonManagementofthe
DifficultAirway.Anesthesiology.199378:57859734

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Thealgorithmbeginswiththerecognitionofadifficultairwaybyaclinician.
Theclinicianwillthenconsiderthenonsurgicalvssurgicalapproach,awake
intubationvs.intubationafterinduction,andtheneedforspontaneousvs.
mechanicalventilation.Oncethesechoicesareconsidered,thealgorithmis
followedbasedononeoftwostrategies:awakeintubationvs.intubation
followinginduction.Thechoicetointubatemustbeginwiththepatientin
properpositionwhilemaintainingoxygensaturation.4Techniquesavailable
includeoralandnasalintubation,retrogradeintubation,fiberopticintubation,
cricothyroidotomy,andtracheostomy.34Intubationafterinductionfollowsan
emergentornonemergentpathway.Bothpathwaysforintubationhavea
commonendpoint,topromptlyandsafelysecureanairway.Inaddition,the
availabilityofadifficultairwayequipmentcartismandatoryforthesecases.
Itemstobeincludedallowforalternativetechniquestobeimplementedmore
readily(TABLE4).34

AlternativeAirwayTechniques

LaryngealMaskAirway

Whencomparedtoorotrachealintubation,theLMAisconsideredeasierand
fastertoplacecorrectly.25,26ThelubricatedLMAisinsertedintothe

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hypopharynxuntilthetipmeetstheupperesophagealsphincter.1,26,27The
cuffistheninflated.Thislowpressurecuffincreasestheriskofaspirationif
vomitingoccursduringventilation.2,27,35,36WhenusingtheLMAinthis
mannertheuseofmusclerelaxantsdonotnecessarilyimprovethesuccess
rateofintubation,butdecreasetheincidenceofcoughingandmovement.1
Therefore,musclerelaxantsaregenerallygivenbeforeLMAplacement.
ContraindicationstotheLMAincludetheneedforpeakpressuregreaterthan
20cmsH20,patientsatriskforaspiration,andpatientswithlowlung
compliancenecessitatingtheneedforhighpressureventilation.1

Intheemergentsituation,orincasesofadifficultairway,theintubatingLMA
Fastrachcanbeusedasaconduitforplacementofanendotracheal
tube.2,27,37,38Fersonetal.demonstratedhighsuccessratesforblindand
fiberopticallyguidedintubations(96.5%and100%respectively)usingthe
LMAFastrachinpatientswithdifficultairways.39TheLMAFastrachisa
modifiedversionofthestandardLMAwithalargeboremetaltube,ametal
handle,andanepiglottiselevatingbar.TheLMAFastrachisplacedinside
themouthandtheendotrachealtubeispassedthroughthedeviceand
blindlyinsertedintothetrachea.Itcanacceptuptoan9.0mmendotracheal
tube.2Levitanetalfoundthataftera60secondinstructiontoexperienced
LMAusers,asuccessfulairwayusinganintubatingLMAFastrachwas
established97%ofthetimeinamediantimeof35s.2

TheProSealLMAisanewerLMAmodel.Itsmodifiedcuffhasbeenshownto
provideamoreeffectivesealthanthestandardLMA,anditcomeswitha
drainagetubeforgastrictubeplacement.36Becauseofthebetterseal
providedbytheProSealLMAascomparedtothestandardLMA,theProSeal
LMAmaybesaferforuseinpatientsatriskforaspirationandintheemergent
difficultairwayscenario.36

TranstrachealJetVentilation

Transtrachealjetventilationisperformedbytheplacementofalargebore
catheter(14gauge)throughthecricothyroidmembraneintothe
trachea.4,14,35Theplacementofthecatheterisconfirmedbyaspirationof
airbeforeconnectingtotheventilationsystem.Thismethodcanprovidea
temporaryairwayuntilanalternateairwayisestablished.35Complications
withthistechniqueincludeaspiration,bleeding,pneumothorax,
subcutaneousemphysema,andinadequateventilation.4,15

Fiberopticintubation

Theuseofabronchoscopemayfacilitatetheplacementofanendotracheal
tubebothnasallyandorally.Thescopeispassedthroughtheglottisfordirect
visualizationofthevocalcords,atwhichtimethetracheaisentered.An
endotrachealtubemaythenbepassedoverthebronchoscopeintothe
trachea.35Thebronchoscopemayidentifycausesofacutehypoxia,andmay
helptoremovesecretionsintheairway.Indicationsforfiberoptictracheal
intubationincludeahistoryofdifficultintubation,acompromisedairway,in
casesaswhereextensionoftheneckisnotpossible,orforawakeintubation
withtopicalanesthesia.40AnOvassapianintubatingairwayisanfiberoptic
intubatingairwayusedtofacilitatepassageofaflexiblebronchoscopeand
placementofanendotrachealtube.40Becauseofthetimeandskillneeded
toperformthisprocedure,thistechniqueisnotoftenusedinanemergent
situation.15Limitationstothistechniqueincludesecretionsobstructingview,
operatorinexperience,andneedforpatientcooperation.35

RetrogradeIntubation

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Thistechniqueofintubationinvolvestheplacementofaguidewirethrough
thecricothyroidmembraneandintothepharynxinaretrogradefashion.The
guidewireisthenusedtoaidplacementofanendotrachealtube.4,15

Bullardlaryngoscope/WuScope

TheBullardlaryngoscopeisarigidfiberopticdevicethathasbeenusedin
patientswithadifficultairway.Becausevisualizationofthelarynxis
performedwhilethepatientisintheneutralposition,itsuseinthetrauma
settinghasincreased.15,35,41Otheradvantagesofthisdeviceincludeits
easyportabilityandtimetosuccessfulintubation.42LiketheBullard
laryngoscope,theWuscopeisalsousedwiththepatientintheneutral
position.1Unfortunately,theunfamiliarityandcostofthesedeviceslimittheir
use.

Lightwand

Thelightwandisamalleablestyletwithasmalllightbulbontheend.An
endotrachealtubeisplacedoverthelightwandandisinsertedintothemouth.
Onceatthetipofthelarynx,theendotrachealtubeisslippedintothelarynx.If
theendotrachealtubehappenstoentertheesophagus,thelightdims.The
endotrachealtubemaythenbewithdrawn,andanotherattemptatplacement
isattempted.Thistechniquemustbepracticedinadarkenedroom,limitingits
usetoacontrolledsetting.10,35

Combitube

Thecombitubeisadoublelumentubewithonetubeservingasan
esophagealairway,andtheotherasatrachealairway.35Itsblindplacement
intothehypopharynxmakesitanimportantdeviceinemergencyairway
management.Afterplacement,thelongeresophagealtube,tube1,is
ventilated.IfnoCO2isdetectedwithventilation,thetubeiscorrectlyplacedin
theesophagus.Theventilatoristhenattachedtotheother,tube2,for
ventilationintothetrachea(Figure6A).Threepercentoftheblindcombitube
intubationsleadtotrachealplacementoftheesophagealtube.Whenthisis
thecase,tube1isventilatedinsteadoftube2(Figure6B).35Placementof
thecombitubewhilethepatient'sneckisintheneutralpositionallowsan
advantageforuseinthetraumapatient.1Themajorcontraindicationtouseof
thecombitubeisesophagealpathology.1,10,43,44

CheckthearticlewrittenbytheinventoroftheCombitubetoreadmoreabout
thisdevice(http://www.ispub.com/ostia/index.php?
xmlFilePath=journals/ija/vol5n2/combi.xml)

Figure8
Figure6:AThecombitubeiscorrectlyplacedintheesophagus.Tube#2is
usedtoventilatethetrachea.B.Thecombitubeisplacedinthetrachea.Tube
#1isusedtoventilatethetrachea.

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SurgicalAirway

Asurgicalairwayisindicatedwhenothermeansofestablishinganairway
fail,orincasesoflaryngealtrauma,facialinjuries,orlongtermneedof
ventilatorysupport.15,34Cricothyroidotomyisthepreferredmethodofa
surgicalairway.Itinvolvestheopeningofthecricothyroidmembranefor
placementofatrachealtube.45Complicationstothistechniqueinclude
bleedinginfection,vocalcorddamage,andtrachealstenosis.15Casesin
whichacricothyroidotomyiscontraindicatedincludeage<12years,
laryngotrachealdisruption,orcoagulopathy.15Whenacricothyroidotomyis
contraindicated,atracheostomyisthepreferredapproach.45Inthesecases,
Freidmanetaldemonstratedthatapercutaneousdilationaltracheostomyisa
fasterprocedurewithfewercomplicationsthanasurgicaltracheostomy.45

AirwayPharmacology

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