AIRWAY MANAGEMENT

F. Heru Irwanto Dept. Anestesi-Reanimasi FK UNPAD-FK UNSRI

ANATOMY
Successful intubation, ventilation, cricothyrotomy, and regional anesthesia of the larynx require detailed knowledge of airway anatomy. There are two openings to the human airway: - pars nasalis - pars oralis

Anatomy of the airway

 Loss of upper airway muscle tone in anesthetized patients allows the tongue and epiglottis to fall back against the posterior wall of the pharynx Technique for opening the airway : triple airway maneuver : head tilt, chin lift, jaw trust To maintain the opening, though, an artificial airway can be inserted through the mouth or nose to create an air passage between the tongue and the posterior pharyngeal wall

 Because of the risk of epistaxis, nasal airways should not be used in anticoagulated patients or in children with prominent adenoids also, nasal airways should not be used in any patient who has a basilar skull fracture

Common indications for tracheal intubation

A. Provide patent airway. B. Protection from aspiration from gastric contents. C. Facilitate positive-pressure ventilation. D. Operative position other than supine. E. Operative site near or involving the upper airway. F. Airway maintenance by mask is difficult. G. Disease involving the upper airway. H. One-lung ventilation. I. Altered level of consciousness. J. Tracheobronchial toilet. K. Severe pulmonary or multisystem injury.

EQUIPMENT STATICS
S : scope -> stethoscope, laryngoscope T : tube A : airway equipment T : tape I : introducer , stylet, mandrain C: connector S : suction

Rigid Laryngoscopes
A laryngoscope is an instrument used to examine the larynx and to facilitate intubation of the trachea. The Macintosh and Miller blades are the most popular curved and straight designs The choice of blade depends on personal preference and patient anatomy

A rigid laryngoscope

Tracheal Tubes
TTs can be used to deliver anesthetic gases directly into the trachea and allow the most control of ventilation and oxygenation TTs are most commonly made from polyvinyl chloride The patient end of the tube is beveled to aid visualization and insertion through the vocal cords Murphy tubes have a hole (the Murphy eye) to decrease the risk of occlusion should the distal tube opening abut the carina or trachea

 TTs have been modified for a variety of specialized applications Flexible, spiral-wound, wire-reinforced TTs resist kinking and may prove valuable in some head and neck surgical procedures or in the prone patient

Oral Tracheal Tube Size Guidelines

Age

Internal Diameter (mm)

3.5

Cut Length (cm)

12

Full-term infant

Child
Adult Female

6.5-7.0

24

Male

7.59.0

24

Face Mask Design

The use of a face mask can facilitate delivery of oxygen or of an anesthetic gas from a breathing system to a patient by creating an airtight seal with the patient's face Transparent masks allow observation of exhaled humidified gas and immediate recognition of vomiting Black rubber masks are pliable enough to adapt to uncommon facial structures

 Effective ventilation requires both a gas-tight mask fit and a patent airway The mask is held against the face by downward pressure on the mask body exerted by the left thumb and index finger The middle and ring finger grasp the mandible to facilitate extension of the atlantooccipital joint The little finger is placed under the angle of the jaw and used to thrust the jaw anteriorly, the most important maneuver to allow ventilation to the patient

TECHNIQUES OF DIRECT LARYNGOSCOPY & INTUBATION Intubation is not a risk-free procedure, however, and not all patients receiving general anesthesia require it Successful intubation often depends on correct patient positioning Moderate head elevation (510 cm above the surgical table) and extension of the atlantooccipital joint place the patient in the desired sniffing position

Orotracheal Intubation
The laryngoscope is held in the left hand With the patient's mouth opened widely, the blade is introduced into the right side of the oropharynx The tongue is swept to the left and up into the floor of the pharynx by the blade's flange The TT is taken with the right hand, and its tip is passed through the abducted vocal cords

 After intubation, the chest and epigastrium are immediately auscultated If there is doubt about whether the tube is in the esophagus or trachea, it is prudent to remove the tube and ventilate the patient with a mask

Difficult Airway
Other clues to a potentially difficult laryngoscopy include :
limited neck extension (< 35) a distance between the tip of the patient's mandible and hyoid bone of less than 7 cm a sternomental distance of less than 12.5 cm with the head fully extended and the mouth closed a poorly visualized uvula during voluntary tongue protrusion (Mallampati classification)

Complications of Intubation
During laryngoscopy and intubation Malpositioning
Esophageal intubation Bronchial intubation

Airway trauma
Dental damage - Lip, tongue, or mucosal laceration - Sore throat - Dislocated mandible Hypoxia, hypercarbia Hypertension, tachycardia Intracranial hypertension , Intraocular hypertension Laryngospasm

Physiological reflexes

Complications of Intubation
While the tube is in place Malpositioning
Unintentional extubation, Bronchial intubation, Laryngeal cuff position

Airway trauma
Mucosal inflammation and ulceration

Following extubation Airway trauma

Edema and stenosis Hoarseness (vocal cord granuloma or paralysis) Laryngeal malfunction and aspiration

Laryngospasm