Adult Management

of Airway
Michael BKO
 Overview

The airway management

Physiologic sequelae & complication of tracheal
Confirming tube position in the trachea
The difficult airway management
 The airway management

Providing an adequate inspired oxygen

concentration

Establishing a patent & secure airway

How to deliver positive pressure ventilation

 The airway management :
providing an adequate inspiring O2 Conc.

Facemasks
A. Anesthesia mask
B1. Simple facemask
B2. Simple facemask
with reservoir bag
C.Venturi mask
 The airway management :
providing an adequate inspiring O2 Conc.

Anesthesia-type facemask O2
concentrations approaching 100%

Simple facemask difficult in excess of

50% even with tight application & 100%
oxygen flow

Simple mask + a reservoir bag produce

O2 concentration of about 80%
 The airway management :
establishing a patent & secure airway

AIRWAY MANEUVERS
Positioning for airway management
Clearing the airway
Triple airway maneuver
Artificial airways

ADVANCED AIRWAY ADJUNCTS

TRACHEAL INTUBATION
 The airway management :
establishing a patent & secure airway

AIRWAY MANEUVERS
Positioning for airway
management

Sniffing position

Raising the head

slightly 5 -10 cm
 The airway management :
establishing a patent & secure airway

AIRWAY MANEUVERS
Clearing the airway
In the supine position secretions usually are
cleared under direct vision using a laryngoscope
& a rigid suction catheter
a flexible suction catheter introduced
through the nose & nasopharynx
A finger sweep
 The airway management :
establishing a patent & secure airway

AIRWAY MANEUVERS
Triple airway maneuver

Head tilt (neck extension), Chin lift, Jaw thrust (pulling the mandible forward),
Mouth opening.
 The airway management :
establishing a patent & secure airway

AIRWAY MANEUVERS
Artificial airways

The oropharyngeal airway (OPA) The nasopharyngeal airway (NPA)

most commonly used more contraindications
 The airway management :
establishing a patent & secure airway

ADVANCED AIRWAY ADJUNCTS

Between simple airway maneuvers and the
insertion of a tracheal tube or surgical airway
The laryngeal mask airway (LMA )
The intubating LMA (ILMA)
The Combitube
Laryngeal tube
 The airway management :
establishing a patent & secure airway

ADVANCED AIRWAY ADJUNCTS

The laryngeal mask airway (LMA )

Placed blindly
Allow ventilation with gentle
positive pressure
Difficult airway (cant
intubatecant ventilate )
 The airway management :
establishing a patent & secure airway
ADVANCED AIRWAY ADJUNCTS
The intubating laryngeal mask airway
(ILMA )
allows the passage of a specially
designed size 8.0 ET
 The airway management :
establishing a patent & secure airway

ADVANCED AIRWAY ADJUNCTS

Esophageal Tracheal Combitube

Combined esophageal
obturator & tracheal tube
Partial protection against
aspiration
May cause trauma
Contraindicated :
esophageal disease, injury,
intact laryngeal reflexes
 The airway management :
establishing a patent & secure airway

ADVANCED AIRWAY ADJUNCTS

Laryngeal Tube
 The airway management :
establishing a patent & secure airway

TRACHEAL INTUBATION
A secure, potentially long-term airway
A safe route to deliver positive-pressure ventilation
Significant protection against pulmonary aspiration
Orotracheal and nasotracheal intubation
 The airway management :
establishing a patent & secure airway

TRACHEAL INTUBATION
 The airway management :
how to deliver positive pressure ventilation

BAG-VALVE-MASK VENTILATION
PROLONGED VENTILATION USING A SEALED
TUBE IN THE TRACHEA
APNEIC OXYGENATION
 The airway management :
how to deliver positive pressure ventilation

BAG-VALVE-MASK VENTILATION

C-grip + three fingers

Squeeze the reservoir bag

A short-term measure in
urgent situations or is
used in preparation for
tracheal intubation.
 The airway management :
how to deliver positive pressure ventilation

PROLONGED VENTILATION USING A SEALED TUBE

IN THE TRACHEA
A cuffed tube in the trachea :
Orotracheal intubation
Nasotracheal intubation
Surgical cricothyrotomy
 The airway management :
how to deliver positive pressure ventilation

PROLONGED VENTILATION USING A SEALED TUBE

IN THE TRACHEA
Disposable Automatic Resuscitator
VAR (VORTRAN Automatic Resuscitator)
Hands-free Ventilatory Support
More Consistent than Manual
Resuscitators
Pressure Cycled ventilation
MRI Compatible
Use with ET Tube or Mask
 The airway management :
how to deliver positive pressure ventilation

APNEIC OXYGENATION
A narrow catheter that sits in the trachea &
carries a flow of 100% oxygen.
To maintain oxygenation with a difficult
airway either at intubation or at extubation
 Physiologic sequelae & complication of
tracheal

Coughing, retching, vomiting, laryngospasm. : awake or

lightly sedated patient performed after induction of
anesthesia
in emergency situations, hypoxic and hypercarbic +
increased sympathetic nervous system activity, increase
in circulating catecholamines hypertension and
tachycardia
increase in myocardial work & myocardial oxygen
demand cardiac dysrhythmias & myocardial hypoxia/
ischemia
increases cerebral blood flow and intracranial pressure :
>> violent coughing, bucking, or breath-holding.
 Physiologic sequelae & complication of
tracheal

Dislodged structures such as teeth or dentures may be

aspirated, blocking the airway more distally

The Cuff of the ET ulceration of the tracheal mucosa,

fibrous scarring, contraction, stenosis

Pooling of saliva and other debris in the pharynx and

larynx source of respiratory infection & pulmonary
aspiration

Phonation impossible frustrated, agitated. May result

in the excessive use of sedative or psychoactive drugs
 Confirming tube position in the trachea

Failure to recognize misplacement of the ET

leading to death / brain injury
Visualizing the ET : passes between the vocal cords
into the trachea is the definitive means of assessing
correct tube
Chest wall movement : absent COPD, obesity,
decreased compliance
Condensation of water vapor the expired gas is
from the lungs
The absence of water vapor usually is indicative of
esophageal intubation
 Confirming tube position in the trachea

Auscultation of breath sounds (in both

axillae) supports correct tube positioning but
is not absolute confirmation
Inequality of breath sounds suggest
intubation of a bronchus (ET passed beyond
the carina)
Most reliable objective method :
capnography to detect end-tidal carbon
dioxide
A fiberoptic bronchoscope Visualizing the
trachea or carina
 The difficult airway management

The clinical situation in which a

conventionally trained anesthetist
experiences difficulty with mask
ventilation of the upper airway,
tracheal intubation, or both.
Difficult mask ventilation 1.4% - 7.8%

airway injury
hypoxic brain injury
death under anesthesia
Difficult laryngoscopy 1.5 % - 13 %
 The difficult airway management

Recognizing the potentially difficult airway

The airway practitioner and the clinical setting

Managing the difficult airway

 The difficult airway management :
recognizing the potentially difficult airway

Conditions associated with

difficult airway :

Abnormal facial anatomy/development ;

Small mouth or large tongue, dental abnormality,
obesity
Inability to open mouth ;
Masseter muscle spasm, facial burns, TMJ
dysfunction
Cervical immobility/abnormality ;
Short neck/obesity, poor cervical mobility
Pharyngeal/laryngeal abnormality ;
High/anterior larynx, deep vallecula, subglottic
stenosis, tumor
 The difficult airway management :
recognizing the potentially difficult airway

Conditions associated with

difficult airway :

Injury ;
Traumatic debris, fracture, bleeding, obstructing
foreign bodies
Infections ;
Epiglottitis, tetanus/trismus, abscess
Connective tissue/inflammatory disorders ;
Rheumatoid arthritis, ankylosing spondilytis
Endocrine disorders ;
Goiter (airway compression), hypothyroidism,
acromegaly : large tongue
 INTUBATION: 2 situations !

difficult Not difficult

Difficult intubation criteria
 The difficult airway management :
the airway practitioner and
the clinical setting

Common Errors Compromising

Successful Intubation :
Poor patient positioning
Failure to ensure appropriate
assistance
Faulty light source in laryngoscope
or no alternative scope
Failure to use a longer blade in
appropriate patients
Use of inappropriate tracheal tube
(size or shape)
Lack of immediate availability of
airway adjuncts
 The difficult airway management :
managing the difficult airway

THE ANTICIPATED DIFFICULT AIRWAY

Awake Intubation
Retrograde Intubation
Intubation Under Anesthesia
UNANTICIPATED AIRWAY DIFFICULTY
Bimanual Laryngoscopy
Stylet ( introducer) and Gum Elastic Bougie
Lighted Stylet
Fiberoptic Intubation
Different laryngoscope or Blade
Video Laryngoscopes
CANNOT INTUBATE CANNOT VENTILATE
 THE
The difficult airway management : ANTICIPATED
DIFFICULT
managing the difficult airway AIRWAY

The key questions

1. Should the patient be kept awake or be
anesthetized for intubation?
2. Which technique should be used for intubation?

Awake Intubation
May have to be abandoned patients inability to
cooperate.
Significantly safer spontaneous breathing and
pharyngeal or laryngeal muscle tone is maintained,
For a difficult airway
 THE
The difficult airway management : ANTICIPATED
DIFFICULT
managing the difficult airway AIRWAY

Algorithm for managing the difficult airway

(Adapted from Practice guidelines for management of the difficult airway: An updated report by the American Society of
Anesthesiologists Task Force on Management of the Difficult Airway. Anaesthesia 2003;98:1269.)
 Algorithm for managing the difficult airway
THE
ANTICIPATED
DIFFICULT
AIRWAY

(Adapted from Practice guidelines for management of the difficult airway: An updated report by the American
Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anaesthesia 2003;98:1269.)
 Algorithm for managing the difficult airway
THE
ANTICIPATED
DIFFICULT
AIRWAY

A four-component algorithm for managing the difficult airway. (From Difficult Airway Society:
Difficult Airway Society Composite Plan. Anaesthesia 2004;59:675-694.
 THE
The difficult airway management : ANTICIPATED
DIFFICULT
managing the difficult airway AIRWAY

Fiberoptic Intubation
Flexible endoscope with a tracheal tube
Nasotracheal route >>
Nasal vasoconstrictors, nebulized local anesthetic via
facemask, sedation may be given
Remain breathing spontaneously & responsive to verbal
commands
Indications : anticipated difficult intubation, avoidance of
dental damage, direct laryngeal trauma, other need for
awake intubation
 THE
The difficult airway management : ANTICIPATED
DIFFICULT
managing the difficult airway AIRWAY

Retrograde Intubation

The cricothyroid membrane is punctured by a needle through which a

wire or catheter is passed upward through the vocal cords.
When it reaches the pharynx, the wire is visualized, brought out through
the mouth, then used to guide the ET through the vocal cords before it is
withdrawn.
 THE
The difficult airway management : UNANTICIPATED
managing the difficult airway DIFFICULT
AIRWAY

Short period to solve the problem

Maintain oxygenation and avoid hypercarbia
By mask ventilation with 100% O2
The four-handed technique often is used
If the practitioner is inexperienced, let recover
consciousness An awake intubation
 THE
The difficult airway management : UNANTICIPATED
managing the difficult airway DIFFICULT
AIRWAY

Bimanual Laryngoscopy
 THE
The difficult airway management : UNANTICIPATED
managing the difficult airway DIFFICULT
AIRWAY

Stylet (introducer)

Inside an ET to adjust the curvature

To allow the tip of the ET to be directed through a
poorly visualized or unseen glottis
 THE
The difficult airway management : UNANTICIPATED
managing the difficult airway DIFFICULT
AIRWAY

Gum Elastic Bougie

At direct laryngoscopy may be

passed through the poorly or
nonvisualized larynx keeping the
laryngoscope in the same position
in the pharynx
The ET can be rail-roloaded
over the bougie, which is then
withdrawn.
First-choice adjunct in the DA
situation
 THE
The difficult airway management : UNANTICIPATED
managing the difficult airway DIFFICULT
AIRWAY

Lighted Stylet

A malleable fiberoptic
light source can be
passed along the lumen
of an ET to facilitate
blind intubation by
transillumination

The preferred
alternative airway
device in the difficult
intubation scenario.
 THE
The difficult airway management : UNANTICIPATED
managing the difficult airway DIFFICULT
AIRWAY

Different Laryngoscope or blade

Macintosh blade, size 4

a large lower jaw /
deep pharinx
Ensures the tip of the
blade can reach the base
of the vallecula to lift
the epiglottis
McCoy may be
advantageous in specific
situations
 THE
The difficult airway management : UNANTICIPATED
managing the difficult airway DIFFICULT
AIRWAY

Video laryngoscopes

Storz, Glidescope, McGrath,

and Pentax airway scope
Provide superior views of the
glottis compared to direct
laryngoscopy
Useful in patients with cervical
instability, either by providing
a better glottic view or by a
reduction in upper cervical
movement
 THE
The difficult airway management : UNANTICIPATED
managing the difficult airway DIFFICULT
AIRWAY

Video laryngoscopes
 CANNOT
INTUBATE
CANNOT
VENTILATE
 Take Home Message

Anticipate the possibility of difficult airway

management by performance a thorough by airway
assesment
Secure the airway awake if difficulty is suspected
Have the back up plan(s) if the initial plan to secure
airway fails
Algorithms serve only as guideline
Equipment must be available