AIRWAY MANAGEMENT a) Nasopharynx

Rashelle Lopez-Salvatierra, MD  An upper area, separated from the lower

oropharynx by soft palate
b) Oropharynx
Airway management  Extends from the soft palate to the base of the
 Expertise in airway management is important in every tongue
medical specialty  Tongue is the principal source of airway
 Maintaining a patent airway is essential for adequate obstruction, usually due to decreased tone of the
oxygenation and ventilation genioglossus muscle
 Failure to do so, even for a brief period of time, can be life C) Laryngopharynx
threatening.
Anatomy of the Airway LARYNX
 Airway  Begins at the base of the tongue and ends at the
 Extrapulmonary air passages beginning of the trachea
( nasal and oral cavities, pharynx, larynx, trachea LARYNX (C3-C6)
and large bronchi)  Functions as:
- Open valve in respiration
- Partially closed valve during
phonation
- Closed valve during swallowing,
protecting the lower airway against
aspiration
 Its closure also insists in the development of
intrathoracic pressure associated with coughing,
defacation, micturation and lifting heavy objects
Comparative anatomy of the pediatric and adult airway
Anatomic Newborn Adult
Features

Size 4 cm 10-13 cm

Shape funnel cylindrical

Position of the C3-C4 C6

Function glottis
1. Acts as a conducting system for air to enter the lower
Narrowest point 1 cm below At vocal cords
airway the vocal cords
2. Acts as a protective mechanism to prevent foreign material (cricoid
from entering the pulmonary tree cartilage)
3. Acts as an “air conditioner” of inspired gases
4. Plays an important role in the processes of speech Vocal cords slanting Transverse or
anteriorly slightly slanting
Nose and Mouth
posteriorly
 Normal breathing: Air is warmed and humidified as it
passes through the nares Mucous Loose (swells More firmly bound
 The ophthalmic and maxillary divisions of the trigeminal membranes easily)
nerve- innervates nasal mucosa
 Palatine nerves- innervates the hard and soft palate A) Laryngeal Cartilages
 Lingual nerve- branch of the mandibular division of the  Made up of 9 cartilages to form a box-like structure at the
trigeminal nerve upper end of the trachea. There are 3 single and 3 paired
- provides sensation to the anterior 2/3 of the cartilages
tongue  Single (ETC) Paired (CAC)
 Posterior 3rd of the tongue, soft palate, oropharynx- - Epiglottis -Arytenoids
innervated by the glossopharyngeal nerve - Thyroid - Corniculate
PHARYNX - Cricoid - Cuneiform
 Serves as a common musculomembranous passage way for
the digestive & respiratory systems.

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 o Action – draws hyoid bone inferiorly &
1. Epiglottis draws thyroid cartilage superiorly (elevators
 Landmark in performing tracheal intubation of the larynx)
 Fibrous cartilage shaped like a leaf attached to the top of c. Inferior constrictors
the larynx in a hinge like fashion o A pharyngeal muscle
 Small depression - called the valleculae, which is the site o Action – solely as constrictor of pharynx
of placement of curved MAC laryngoscope blade Extrinsic Muscles of the Larynx
 During swallowing as laryngeal muscles contract,
downward movement of the epiglottis and closure &
upward movement of the glottis prevents food from
entering the larynx
 When acutely inflamed and swollen, life-threatening
airway obstruction may occur
2. Thyroid Cartilage
 Largest cartilage of the larynx
 Shield-like structure
 Consists of two laminae fused in the midline of neck to
form a subcutaneous projection termed laryngeal
prominence (Adam’s apple)
3. Cricoid Cartilage
 Shaped like a signet ring with the bulky portion placed
posteriorly
 Forms a complete ring – only tracheal ring is complete
 Narrowest portion of the upper airway in the infant and 2. Intrinsic muscles
small child  Responsible for moving the cartilages of larynx
 Smaller but thicker and stronger than thyroid one against the other
 Separated from the thyroid cartilage by the cricothyroid 3 fold function:
membrane  Open cords in inspiration
4. Arytenoid Cartilage  Close the cords and laryngeal inlet during
 Pyramidal structures located on the supero-lateral aspect of swallowing
the cricoid cartilages  Alter the tension of cords during speech
 Provide anatomic attachment for the inter-arytenoids and
vocalis muscle
5. Corniculate Cartilage
 Small conical nodules attached to superior aspect of
arytenoid
 Also known as cartilage Santorini
6. Cuneiform Cartilage
 Small and spheroidal embedded within aryepiglottic fold
on each side
 Also known as cartilage of Wrisberg

TWO GROUPS OF MUSCLES

 Extrinsic Muscles
o Moves the larynx as a whole
 Intrinsic Muscles
o Moves the various cartilages in relation to one
another
B) Laryngeal Muscles
Blood supply of laryngeal muscles
1. Extrinsic muscles
1. Superior Laryngeal Artery
a. Sternothyroid
o Branch of superior thyroid artery
o An infrahyoid muscle
o Accompanies internal branch of superior laryngeal
o Action – depressors of larynx
nerve
b. Thyrohyoid
o Pierces the thyrohyoid membrane
o An infrahyoid muscle
o Supplies the interior of larynx

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 2. Inferior Laryngeal Artery
Superior Minimal effects
o Inferior thyroid branch of the thyro cervical trunk
laryngeal nerve Hoarseness/tiring of voice
o Accompanies recurrent laryngeal nerve into larynx Unilateral
Bilateral
Innervation
1. Superior Laryngeal Nerve Recurrent Hoarseness
 Arises from ganglion nodusum laryngeal nerve Stridor, respiratory distress
Unilateral Aphonia
 Divides into an external (motor) branch to supply the
Bilateral
cricothyroid membrane; internal (sensory) branch a) Acute
pierces the thyrohyoid membrane b) Chronic

Internal branch divides into: Vagus nerve Hoarseness

o Upper branch Unilateral Aphonia
supplies mucous Bilateral
o Lower branch membrane of base of
tongue, pharynx,
epiglottis & larynx

2. Recurrent Laryngeal Nerve

Trachea
 Loops around subclavian artery on right side & aortic  p  Suspended from the cricoid cartilage by the cricotracheal
arch on left side
 Innervates all intrinsic muscles of larynx except
p ligament
 Measures 15 cm in adults
cricothyroid l
 Supported by 17-18 C shaped cartilages
 Supplies sensory branch to mucous membrane of i  Cartilages are interconnected by fibroelastic tissue which
larynx below the vocal cords
e allows for expansion of the trachea with expiration or
Laryngeal Innervationv
s inspiration and flexion and extension of the thoracocervical
NERVE SENSORY MOTOR spine
 1st tracheal ring is anterior to the 6th cervical vertebrae
Superior Epiglottis, base of None m  Ends at the carina T5
laryngeal the tongue Right and Left Main Bronchus
u
(internal division) Supraglottis  Right is larger, wider and deviates from the plane of the
musoca c trachea in less acute angle
Thyroepiglottic o
joint u Airway assessment
Cricothyroid joint Why should we asses a patient’s airway preoperatively ?
s
Super laryngeal Anterior subglottic Cricothyroid
The goal of evaluating a patient's airway
(external musoca (adductor, tensor)
m -attempt to identify any possible problems with
division)
e maintaining, protecting, and providing a patent airway
during anesthesia.
Recurrent Subglottic musoca Thyarytenoid m NOTE:
laryngeal Lateral b 1) The Laryngoscope’s function is to visualize the
cricoarytenoid r mouth/Pharynx/Epiglottis
Inter arytenoids 2) With your left hand insert the Blade to the right of the tongue so
(adductors) a
that the tongue moves toward the left
Posterior n 3) Once the tip of the blade is at the base of the tongue pull the
cricoarytenoids e laryngoscope forward and upward in 45 degrees from the horizontal
(abductors) line(don’t rotate as u might damage the upper teeth).
 L
Effects of Laryngeal Nerve Injury on the Voice Assessment
o  Begins with a comprehensive history and physical
NERVE EFFECT OF NERVE INJURY w examination
e
HISTORY: History related to airway problems (aspiration risk)
r
o hx of voice changes
o Vocal cord polyps
b
Anesth: Airway Management
r
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a
n
c
 o Frequent pneumonias Pierre-Robin syndrome Micrognathia, macroglossia, cleft soft
o Coughing after eating/ drinking palate
o Acute narcotic therapy Treacher-Collins syndrome Auricular and ocular defects, malar and
o Acute trauma mandibular hypoplasia
o ICU admission (current) Goldenhar’s syndrome Auricular and ocular defects, malar and
o Pregnancy mandibular hypolasia
o Immediate postpartum Down’s syndrome Poorly developed or absent bridge of
o Systemic diseases associated with gastroparesis: DM, the nose, macroglossia
postvagotomy thyroid dysfunction, liver disease,CNS Kippel-Feil syndrome Congenital fusion of a variable number
tumors, chronic renal insufficiency, collagen vascular of cervical vertebrae, restriction of neck
disease Parkinson disease movement
Goiter Compression of trachea, deviation of
HISTORY: larynx/trachea
 difficult laryngoscopy/SGA ventilation SYNDROMES ASSOCIATED WITH DIFFICULT AIRWAY
 History of surgical manipulation in or around the MANAGEMENT
airway
 History of radiation therapy of the head/neck Acquired :
 Various congenital and acquired syndromes Infections:
Supraglottis Laryngeal edema
 obstructive sleep apnea Croup Laryngeal edema
 Body mass index > 35 kg/m2 Abscess (intraoral,
 Loud snoring retropharyngeal) ` Distortion of the airway and
 Pauses in breathing during normal sleep trismus
 Sleep interruption Ludwig’s angina Distortion of the airway and
 Daytime somnolence/napping trismus
 Airway affecting craniofacial abnormalities Arthritis:
Rheumatoid arthritis Temporomandibular joint
 lingual tonsil hyperplasia ankylosis,cricoarytenoid arthritis,
 Chronic sore throat deviation of larynx, restricted mobility
 Voice change of cervical spine
 Dysphagia Ankylosing spondylitis Ankylosis of cervical spine, less
 Obstructive sleep apnea commonly ankylosis
 Hx of tonsillectomy temporomandibular joints, lack of
 thyroglossal duct cyst mobility of cervical spine
 Asymptomatic anterior cervical mass that moves with Benign tumors:
deglutination Cystic hygroma, lipoma, adenoma, goiter
 Complications: cyst infection, fistula, spontaneous Stenosis or distortion of the airway, fixation of larynx or
rupture, voice change, dysphagia, dyspnea and snoring adjacent tissues secondary to infiltration or fibrosis from
 signs and symptoms related to airway irradiation
o Snoring Malignant tumor, facial injury, cervical spine injury,
o Changes in voice laryngeal/tracheal trauma
o Dysphagia Edema of the airway, hematoma, unstable fraction(s) of the
o Stridor maxillae, mandible and cervical vertebrae.
o Bleeding
o Cervical spine pain or limited range of motion Obesity Short thick neck, redundant tissue in the
o Upper extremity neuropathy oropharynx,sleep apnea
o TMJ dysfunction Acromegaly Macroglossia, prognathism
 sequelae of previous intubation Acute burns edema of airway
o Chipped teeth
o Significant prolonged sore throat Physical Examination:
 Patency of nares : polyps, deviated nasal septum
SYNDROMES ASSOCIATED WITH DIFFICULT AIRWAY  Teeth (edentulous)
MANAGEMENT  Palate (high arched palate or a long narrow
Congenital : mouth)
 Prognathism

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  Observation of patient’s neck (short, thick)
(masses, extension, neck mobility, ability to
assume a sniffing position)
 Presence of hoarse voice/stridor or previous
tracheostomy
 Infections of the airway
 Physiologic conditions ( pregnancy and obesity)
TMJ movement
 Ask the patient to sit up with his head in the neutral
position and open his mouth as wide as possible.
 The condyle should rotate forward freely such that the
space created between the tragus of the ear and the
mandibular condyle is approximately one fingerbreadth in
width.
Mouth opening and tongue protrusion
 The aperture of the patient's mouth should admit at least 2
fingers between his teeth
Thyromental distance/ Sternomental distance
 It is measured from the lower border of the chin.
 This measurement is done with the adult patient's neck
fully extended
 Adults who have less than 3 fingerbreadths between their
mentum and thyroid notch may have either an anterior
larynx or a small mandible, which will make intubation
difficult.
SPECIFIC TEST FOR ASSESSTMENT:
Mallampati Classification
 relates tongue size to pharyngeal size
 performed with the patient in the sitting position, the head
held in a neutral position, the mouth wide open, and the
tongue protruding to the maximum.
 classification is assigned based upon the pharyngeal
structures that are visible.
 If the patient phonates, this falsely improves the view
 Class I = visualization of the soft palate, fauces,
uvula, anterior and posterior pillars.
 Class II = visualization of the soft palate, fauces and
uvula
 Class III = visualization of the soft palate and the
base of the uvula.
 Class IV = only the hard palate is visible; soft palate
is not visible at all
Direct Laryngoscopy
 Cormack and Lehane
Grades of Laryngoscopic View
 Grade I = visualization of the entire laryngeal
aperture.
 Grade II = visualization of just the posterior portion of
the laryngeal aperture.
 Grade III = visualization of only the epiglottis.
 Grade IV = visualization of just the soft palate only,
not even the epiglottis is visible
Anesth: Airway Management
Quick airway assessment
 Can the patient open the mouth widely?
 Can the patient maximally protrude the tongue?
 Patients ability to move jaw forward?
 Can the patient fully bend/ extend the head and move it
sidewards?
 Indicative of TMJ movement
 Inspects posterior aspect of mouth/pharyngeal structures
 Indicates ease to maneuver the laryngoscope
 Indicates neck movement
Management of the airway:
Preoxygenation
 “denitrogenation”
 Replacement of the nitrogen volume of the lung with
oxygen in order to provide reservoir for diffusion into the
alveolar capillary blood after the onset of apnea
 Preoxygenation for 5 minutes- furnish up to 10 minutes of
oxygen reserve following apnea
 Four vital capacity breaths of 100% oxygen over a 30 sec
period
 Eight deep breaths in a 60 second period
 Aids in prolonging the time of desaturation
Methods of supporting the airway
 Anesthesia face Mask
 Supraglottic airways
 LMA
 ET tube
Uses of face mask
 Pre-oxygenation prior to induction of anaesthesia
 Inhalational induction of anaesthesia
 Bag-mask ventilation (BMV) prior to intubation
 Maintenance of anaesthesia
 Non-invasive ventilation for respiratory failure
Techniques in using face mask:
One-handed technique
 correct sized mask over the nose and mouth
 non-dominant hand to position the facemask,
 Holding the body of the mask between thumb and
index finger
 Use remaining 3 fingers to support the jaw, with
the little finger hooked behind the angle of the
mandible
• Lift the mandible upwards, towards and into the mask to create
an air-tight seal
• Slight head extension may improve airway patency
• Ventilate the patient with dominant hand by squeezing the
bag or using bellows
• Continually assess the adequacy of the technique by observing
bilateral chest movement, listening for air leaks and assessing for
signs of inadequate facemask ventilation
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two -handed technique
 uses a similar approach to the one-handed technique
described above, with the additional hand adopting an
identical position on the other side of the mask and face
Assessment and Predictability of Difficult Mask Ventilation
 Criteria for Difficult Mask Ventilation
 Inability for one anesthesiologist to maintain
oxygen saturation > 92%
 Significant gas leak around face mask
 Need for ≥ 4 LPM gas flow ( or use of fresh gas
flow button more than twice)
 No chest movement
 Two handed mask ventilation is needed
 Changed of operator required
Patient factors associated with difficult facemask ventilation
 • Presence of facial hair/ beard
 • Lack of teeth (edentulous)
 • Patients with sunken cheeks
 • Obesity (BMI >26)
 • History of obstructive sleep apnea
 • Age >55yrs
 • History and signs of upper airway obstruction (snoring)
Problems and suggested solutions for inadequate facemask
ventilation
Poor mask seal
 Indicated by audible leak, poor chest
expansion or difficulty generating positive pressure in bag
 Solutions:
 Use two-handed technique and ensure good jaw
thrust.
 Ask assistant to support soft tissues of cheek
around rim of mask.
 Consider using an oropharyngeal or
nasopharyngeal airway to improve airway
patency.
 Ensure no leaks in equipment or circuit
 If unsuccessful, consider using laryngeal mask
airway early
Partial or complete airway obstruction
 Indicated by high airway pressures, poor chest movement,
cyanosis or low oxygen saturations
 Solutions:
 Optimize patient head position with slight head
extension.
 Use two-handed technique and ensure good jaw
thrust
 Use an oropharyngeal or nasopharyngeal airway
 Consider possibility of laryngospasm – often
giving additional intravenous anaesthetic agent
(e.g. propofol) can improve this.
 Ensure no occlusion in equipment or circuit –
consider reverting to self-inflating bag and mask.
Anesth: Airway Management
 If unsuccessful, consider using laryngeal mask
airway early
Presence of facial hair
 Consider using larygneal mask airway or endotracheal tube
early.
Patients with dentures, edentulous patients or sunken cheeks
 Consider leaving dentures in place if secure.
 Use oropharyngeal airway and/or nasopharyngeal airway.
 Consider placing lower pole of face mask over lower lip
itself in edentulous patients.
 Ask assistant to support soft tissue of cheeks against mask.
Obese patients
 Pre-oxygenation is essential
 Recognize that facemask ventilation and maintaining
adequate oxygenation can be difficult.
 When facemask ventilating, keep patient 5-10° head up
position, with anaesthetist standing on a platform or step if
necessary to achieve this.
 Use two-handed technique with oropharyngeal airway.
 Endotracheal intubation is often indicated for surgery.
LARYNGEAL MASK AIRWAY
 The LMA was invented by Dr. Archie Brain at the London
Hospital, Whitechapel in 1981
 The LMA consists of two parts:
 The mask
 The tube
 The LMA has proven to be very effective in the
management of airway crisis
 The LMA design:
 Provides an “oval seal around the laryngeal inlet”
once the LMA is inserted and the cuff inflated.
 Once inserted, it lies at the crossroads of the
digestive and respiratory tracts.
Contraindications of the LMA
 Risk of gastric content aspiration (full stomach, hiatal
hernia with significant gastroesophageal reflux, intestinal
obstruction, delayed gastric emptying, poor history)
Preparation of the LMA for Insertion
 Step 1: Size selection
 Step 2: Examination of the LMA
 Step 3: Check deflation and inflation of
the cuff
 Step 4: Lubrication of the LMA
 Step 5: Position the Airway
Size Selection
 Verify that the size of the LMA is correct for the patient
 Recommended Size guidelines:
 Size 1: under 5 kg (4 ml)
 Size 1.5: 5 to 10 kg (7 ml)
 Size 2: 10 to 20 kg (10 ml)
 Size 2.5: 20 to 30 kg (14 ml)
 Size 3: 30 kg to 50 kg (20 ml)
 Size 4: 50-70 kg (30 ml)
 Size 5: 70 to 100 kg (40 ml)
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LMA Insertion Technique
LMA Insertion
Step 1
 Grasp the LMA by the tube, holding it like a pen as near as
possible to the mask end.
 Place the tip of the LMA against the inner surface of the
patient’s upper teeth
Step 2
 Under direct vision:
 Press the mask tip upwards against the hard
palate to flatten it out.
 Using the index finger, keep pressing upwards as
you advance the mask into the pharynx to ensure
the tip remains flattened and avoids the tongue.
Step 3
 Keep the neck flexed and head extended:
 Press the mask into the posterior pharyngeal wall
using the index finger.
Step 4
 Continue pushing with your index finger.
 Guide the mask downward into position.
Step 5
 Grasp the tube firmly with the other hand
 then withdraw your index finger from the
pharynx.
 Press gently downward with your other hand to
ensure the mask is fully inserted.
Step 6
 Inflate the mask with the recommended volume of air.
 Do not over-inflate the LMA.
 Do not touch the LMA tube while it is being inflated unless
the position is obviously unstable.
 Normally the mask should be allowed to rise up
slightly out of the hypopharynx as it is inflated to
find its correct position.
 Choose the largest size that will fit comfortably in the oral
cavity then inflate to the minimum pressure that allows
ventilation to 20 cm water
ENDOTRACHEAL INTUBATION
IndicationS for endotracheal intubation
 Provide a patent airway
 Prevent aspiration of gastric contents
 Need for frequent suctioning
 Operative position other than supine
 Facilitate positive-pressure ventilation of the lungs
 Operative site near or involving the upper airway
 Airway maintenance by mask is difficult
Equipment for laryngoscopy
 Oxygen source and self inflating ventilation bag
 Face mask
 Oropharyngeal and nasopharyngeal airway
 Tracheal tube and stylets
Anesth: Airway Management
 Syringe for tracheal tube inflation
 Suction apparatus
 Laryngoscope handle
 Different laryngoscope blades
 stethoscope
Tracheal Tube size and length
Age Internal Diameter Length
Child 4+ age/4 14+age/4
Adult
female 7.0-7.5 21-24
male 7.5-9.0 23-24
 The height of the supine patient’s airway should be at the
level of the laryngoscopist’s xyphoid cartilage. The
clinician performing the intubation must have unobstructed
access to the head
 Extension of the head at the atlanto-occipital joint (sniffing
position) serve to align the oral, pharyngeal and laryngeal
axes such that the passage and line of vision from the lips
to the glottic opening are most nearly a straight line.
 Laryngoscope is held in the left hand
 The blade is inserted in the right side of the patient’s mouth
and the tongue is deflected to the left
 Pressure on the teeth and gums must be avoided
 Tube is advanced until the proximal end is 1-2 cm past the
vocal cords (midway between the vocal cords and carina)
 Low pressure high volume cuff that prevents leaks during
positive ventilation pressure (20 to 30 cm H2O), minimizes
the likelihood of mucosal ischemia
 Gold standard: VISUALIZATION OF THE VOCAL
CORDS AND END TIDAL CO2 DETECTION
The ASA calls a Failed/Difficult Laryngoscopy if:
 Any airway that takes more than 3 attempts
 Any airway that takes more than 10 minutes to secure
Npo status and the Rapid sequence induction
 Performed to gain control of the airway in the shortest
amount of time
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  Administration of intravenous anesthetic induction agent is
immediately followed by a rapidly acting neuromuscular
blocking drugs
 Intubation should be performed as soon as muscle
relaxation is confirmed
 Cricoid pressure (Sellick’s maneuver) is applied by an
assistant from the beginning of induction until confirmation
of the ETT placement

Awake intubation
 Maintenance of spontaneous ventilation in the event that
the airway cannot be secured rapidly
 Confers maintenance of upper and lower esophageal
sphincter tone, thus reducing the risk of reflux

Transtracheal Techniques
DIFFICULT EXTUBATION
 LARYNGOSPASM- can be triggered by respiratory
secretions, vomitus, blood, or foreign body in the airway
 Contraction of the lateral
criciarytenoid,thyroarytenoid and cricothyroid
muscles
 Tx: removal of the offending stimulus,
administratyion of O2, small dose of short acting
muscle relaxants
DIFFICULT AIRWAY
 ‘Difficult airway’
 one in which there is a problem in establishing or
maintaining gas exchange via a mask, an artificial
airway or both.
 Recognizing before anaesthesia the potential for a
difficult airway (DA) allows time for optimal
preparation, proper selection of equipment and
technique and participation of personnel
experienced in DA management.
ASA defines…
 difficult airway as “the situation in which the
conventionally trained anesthesiologist experiences
difficulty with intubation, mask ventilation or both”.
 Cricothyrotomy
 Transtracheal jet ventilation
 Needle cricothyrotomy— involves passing an over-the-
needle catheter through the cricothyroid membrane
 Surgical cricothyroidotomy — is an emergent airway
approach in which the clinician makes an incision in the
cricothyroid membrane and passes a tracheostomy or
endotracheal tube into the trachea.
 Percutaneous transtracheal ventilation — involves
oxygenation and ventilation via a needle or surgical
cricothyroidotomy using an improvised ventilation device.
 Transtracheal jet ventilation — refers to high frequency,
low tidal volume ventilation provided via a laryngeal
catheter by specialized ventilators that are usually only
available in the operating room or intensive care unit .This
procedure is occasionally employed in the operating room
when a difficult airway is anticipated

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