dr.

Tjahya Aryasa,SpAn
Bagian/SMF Ilmu Anestesi dan Terapi
Intensif FK UNUD/RSUP Sanglah
 Review of airway anatomy
 Airway evaluation
 Mask ventilation
 Endotracheal intubation
 The difficult airway
 The Airway Problems:

• 40.000 deaths / year in Germany

• 200.000 deaths / year in USA
• 5-10% insidence in hospital
• Airway / respiration incidents are the highest
incidents in number in ER, ICU

• 3 mechanisms of injury:
1. Esophageal intubation
2. Failure to ventilate
3. Difficult Intubation
Anaesthesiology & Emergency
 Patent nares
 Ability to open mouth widely
with TMJ rotation and
subluxation (3 – 4 cm or two
finger breaths)
 Mallampati Class I
 Patient sitting straight up,
opening mouth as wide as
possible, with protruding
tongue; the uvula, posterior
pharyngeal wall, entire
tonsillar pillars, and fauces can
be seen
 At least 6 cm (3 finger
breaths) from tip of mandible
to thyroid notch with neck
extension
 At least 9 cm from symphysis
of mandible to mandible angle
 Upper Airway  Lower Airway
 Pharynx  Trachea
 Epiglottis  Bronchi
 Glottis  Alveoli
 Vocal cords  Lung tissue,
 Larynx consisting of lobes
and lobules (3 on
the right and 2 on
the left)
 Pleura
 Ab-ductor
 Posterior
cricoarytenoid
 Tensor
 Cricothyroid
 Ad-ductors
 All the rest
 Innervation
 Vagus n.
 Superior laryngeal n.
 External branch – motor to
cricothyroid m.
 Internal branch – sensory
larynx above TVC’s
 Recurrent laryngeal n.
 Right – subclavian
 Left – Aortic arch (board
question)
 Motor to all other muscles,
Sensory to TVC’s and
trachea
 Innervation of
oropharynx
 Glossopharyngeal n.
innervates tongue base
and oropharynx
 Membranes
 Thyrohyoid
 Cricothryoid
 Cartilages
 Hyoid
 Thyroid
 Cricoid
 Take very seriously
history of prior difficulty
 Head and neck movement
(extension)
 Alignment of oral,
pharyngeal, laryngeal axes
 Cervical spine arthritis or
trauma, burn, radiation,
tumor, infection,
scleroderma, short and thick
neck
 Jaw Movement
 Both inter-incisor gap and
anterior subluxation
 <3.5cm inter-incisor gap
concerning
 Inability to sublux lower
incisors beyond upper
incisors
 Receding mandible
 Protruding Maxillary
Incisors (buck teeth)
 Obesity
 Distribution, i. e. short,
thick neck more
concerning
 Neck circumference
 Thyromental
distance: bony point
on mentum
(mandible) to thyroid
notch
 If short (<3FB’s or
6cm), pharyngeal and
laryngeal axis off
 Oropharyngeal visualization
 Mallampati Score
 Sitting position, protrude tongue, don’t say
“AHH”
 Class I: soft palate, tonsillar fauces,
tonsillar pillars, and uvuala visualized

 Class II: soft palate, tonsillar fauces,

and uvula visualized
 Class III: soft palate and base of uvula
visualized
 Class IV: soft palate not visualized

 Class III and IV Difficult to Intubate

  MOUTHS

Component Description Assessment Activities

Mandible Length and subluxation Measure hyomental distance and
anterior displacement of mandible

Opening Base, symmetry, range Assess and measure mouth opening

in centimetres

Uvula Visibility Assess pharyngeal structures and

classify

Teeth Dentition Assess for presence of loose teeth

and dental appliances

Head Flexion, extension, rotation

of head/neck and cervical
Assess all ranges and movement

spine

Silhouette Upper body abnormalities,

both anterior and posterior
Identify potential impact on control
of airway of large breasts, buffalo
hump, kyphosis, etc.
 Difficulty ventilating
 Age >55
 Beard
 History of snoring
 Lack of teeth
 BMI >26
 ALWAYS REMEMBER THE BASICS
 These skills should be used prior to initiating
any advanced airway technique
 Head-tilt/chin lift
 Jaw thrust
 Modified jaw thrust (for trauma patients)
 Sellick’s maneuver
 Decreased level of consciousness
 GCS <9
 Cerebral injury
 Surgery
 Medical problems

Richard Lake April 2004 22

 Tongue
 Dentures
 Food stuffs
 Vomit
 Blood
 Secretions

Richard Lake April 2004 23

 Suction
 Postural airway manoeuvres
 Basic life support chocking protocol
 Up to 5 back slaps
 Up to 5 abdominal thrusts
 Only if unconscious up to 5 chest thrusts
 If unsuccessful to clear airway then Basic Life
Support

Richard Lake April 2004 24

 Check the airway
 Open the airway, place one hand on the
victims forehead and gently tilt head back
 Remove any visible obstruction from the
victims mouth, including dislodged dentures.
Leave well fitting dentures in place
 DO NOT ATTEMPT ANY FINGER SWEEPS

Richard Lake April 2004 25

Richard Lake April 2004 26
Richard Lake April 2004 27
 Downward displacement
of mask with thumb and
index finger
 Upward traction of
remaining fingers upward
 Fingers on bony mandible
 Fifth digit at angle
displacing mandible
anteriorly www.aic.cuhk.edu.hk
 Sniffing position
 Lower neck flexion
 Upper neck extension
 Important in obesity
 Semicircular, disposable and made of hard
plastic. Guedel and Berman are the frequent
types.
 Guedel is tubular and has a hollow center.
 Berman is solid and has channeled sides.
 Displaces the tongue away from the posterior
pharyngeal wall.
Guedel airway –
 Parts – flange, bite portion, air channel
INDICATIONS
 Adjunct for airway control, determines
presence of gag reflex.
 Unconscious/unresponsive
 Remove the airway if patient regains a gag
reflex
 May be inserted as a bite block after
successful intubation
SIZING
 Hold the airway next to the side of the
patient's face and measuring the length of
the airway from the corner of the mouth to
the tip of the earlobe
 Center of the mouth to the angle of the
mandible.
 Choose the appropriate size
 Open the airway
 Insert the airway:
1. Using a tongue blade. Preferred method in
children.
2. Insert upside down and rotate into place.
Not to be used in children.
•Sizes available
Sizes Length (mm)

•Colour coding 000 30

00 40
0 50
1 60
2 70
3 80
4 90
5 100
6 110
 With intact gag reflex could cause vomiting.
 Laryngospasm
 Inappropriate size:
1. To Long: may push the epiglottis closed
over the glottic opening, causing complete
airway obstruction
2. To Short: May be easily displaced, distal
opening may become obstructed by tongue
 May occur from insertion. Improperly placed
may push the tongue back into the pharynx
and cause obstruction.
 Aggressive insertion may cause trauma to the
upper airway and bleeding.
 The lumen of the tube is not large enough to
allow for suctioning. Suctioning must be
performed around the tube.
 Indications:
1. When OP is not able to be inserted
2. Airway of choice in spontaneously breathing,
but less responsive patient needing airway
control.
 Sizing
1. Proximal end of the tube at the tip of the nose
and the distal end at the earlobe
 Contraindications –
1) Anticoagulation
2) Basilar skull fracture
3) Nasal pathology, sepsis, or deformity of the nose or
nasopharynx
4) History of epistaxis requiring medical treatment.
 Advantages-
1) Nasal airway is better tolerated than an oral airway if
the patient has intact airway reflexes.
2) Loose or poor dentition.
3) Trauma or pathology of the oral cavity.
4) It can be used when the mouth cannot be opened.
 Technique of Insertion
* Needs to be lubricated.
* Proper size
* Advance with bevel toward the septum
* If patient is breathing you should feel
airflow when placed properly.
* If you meet resistance, remove and use
other nare.
 Complications
* Improper size and too long could end up
in the esophagus
* Too short could be occluded by the
tongue
* Laryngospasm
* Trauma
1) Airway Obstruction
2) Trauma
3) Tissue Edema
4) Ulceration and Necrosis
5) Central Nervous System Trauma
6) Dental Damage
7) Laryngospasm and Coughing
8) Retention, Aspiration, or Swallowing
9) Devices Caught in Airway
10) Equipment Failure
11) Latex Allergy
12) Gastric Distention
1) Laryngeal Mask Airway Family –
 LMA Classic
 LMA Unique
 LMA Flexible
 LMA Fastrach
 LMA CTrach
 LMA Proseal
2) Other supraglottic airways similar to laryngeal mask –
 Soft seal laryngeal mask
 Ambu laryngeal mask
 Intubating laryngeal airway
3) Other supraglottic airway devices
 Laryngeal tube airway
 Perilaryngeal airway
 Streamlined pharynx airway liner
cLMA size Patient size
1 Neonates/infants up to 5 kg
1.5 Infants between 5 and 10 kg

2 Infants/children between 10
and 20 kg

2.5 Children between 20 and 30

kg
3 Children 30 to 50 kg
4 Adults 50 to 70 kg
5 Adults 70 to 100 kg
6 Adults over 100 kg.
 Developed as an alternative to the face mask
for achieving and maintaining control of the
airway during routine anesthetic procedures
in the operating room.
 Found to be useful in the emergency
situation when intubation is not possible and
you can’t ventilate with a BVM
 May prevent doing a surgical procedure to
open the airway
 Not designed to seal the esophagus and was
not originally meant for emergency use.
 It is not equal to the ET and should only be
used when efforts to intubate the trachea
have been unsuccessful and ventilation is
compromised.
 Use only in patients who are unresponsive and
without protective reflexes.
 Do not use in any patient with injury to the
esophagus
 Lubricate only the posterior surface of the LMA
to avoid blockage of the aperture or aspiration
of the lubricant
 Patients should be adequately monitored
 Never force the device to avoid trauma to the
airway
 Never overinflate the cuff. May cause
malposition, loss of seal, or trauma.
 If airway problems persist, it should be removed
and reinserted.
 Does not prevent aspiration if the patient vomits
 If
the patient regains consciousness, you
must remove it.
 Ventilate with mouth-to-mask or BVM, and
suction
 Remove the valve tab and check the integrity of
the LMA cuff by inflating with maximum volume
 Cuff should be tightly deflated using the
enclosed syringe so that it forms a flat oval disk
with the rim facing away from the aperture.
 Lubricate the posterior surface
 Preoxygenate the patient
 If no danger of spinal injury, position the patient
with the neck flexed and the head extended,
otherwise neutral position.
 Hold the LMA like a pen and insert.
 Use the index finger to guide the LMA, pressing
upwards and backwards toward the ears
 Without holdings the tube, inflate the cuff
with just enough air to obtain a seal. The
tube will “bob” when properly placed.
 Connect the LMA to the BVM and check
position.
 Ventilatory Support
 Decreased GCS
 Protection of Airway
 Ensuring Airway patency
 Anesthesia and surgery
 Suctioning and Pulmonary Toilet
 Hypoxic and Hypercarbic respiratory
Failure
 Pulmonary lavage
 Cervical spine
 Atlanto-occipital Joint
 Mandible
 Oral soft tissues
 Neck hyoid bone

 Additionally:
 Dentition
 Pathology - Acquired and
Congenital
 The tracheal tube (endotracheal
tube, intratracheal tube, tracheal
catheter) is a device that is inserted
through the larynx into the trachea
to convey gases and vapors to and
from the lungs.
 Parts –
1) The machine (proximal) end
2) The patient (tracheal or distal) end
3) Bevel.
4) Murphy eye
5) A radiopaque marker
6) Cuff Systems - consists of
the cuff plus an inflation
system, which includes an
inflation tube, a pilot
balloon, and an inflation
valve.
Oral intubation –
1. Direct Laryngoscopy
2. Blind Oral Intubation
3. Digital Technique
4. Fiberoptic guided
5. Retrograde intubation

Nasal intubation –
1. Direct Laryngoscopy
2. Flexible Fiberoptic Laryngoscopy
3. Blind Nasal Intubation
 Preparation:
 Equipment Check
 100% oxygen at high flows (> 10 Lpm) during bask/mask
ventilation
 Suction apparatus
 Intubation tray
 Two laryngoscopic handles and blades
 Airways
 ET tubes
 Needles and syringes
 Stylet
 KY Jelly
 Suction Yankauer
 Magill Forceps
 LMA’s
 Traditional:
 3 minutes of tidal volume breathing at 5 ml/kg
100% O2

 Rapid
 8 deep breaths within 60 seconds at 10 L/min

 Always ensure pulse oximetry on

patient
 Optimal Position – “sniffing position”
 Flexion of the neck and extension of the antlanto-
occipital joint
 Auscultation
 Visualizationof tube through cords
 Fiberoptic bronchoscopy
 Pulse oximetry not improving or
worsening
 Movement of the chest wall
 Condensation in ET tube
 Negative Pressure Test
 CXR
 Open the mouth with right
hand
 Scissor technique
 Gently insert laryngoscope
into right side of mouth
pushing tongue to the left
 Careful with insertion not to
hit teeth
 Advance laryngoscope
further into oropharynx
with applied traction 45
degrees
 Look for epiglottis
 If initially not found insert
laryngoscope further
 If this maneuver does not
work slowly pull
laryngoscope back
 Once epiglottis visualized,
push laryngoscope into
vallecula and apply traction
at 45 degree angle to
“push” epiglottis up and out
of the way

www.int-med.uiowa.edu/Research/TLIRP/Bronchos
 Look for vocal cords or arytenoid
cartilages and try to optimize
view
 (i.e. lift head, apply more
traction at 45 degree angle if
necessary)
 Do not move once view is
optimized!
 Assistant will hand you ETT
 Insert ETT into far right aspect
of mouth
 Traction of laryngoscope
slightly to left may assist
 Traction of laryngoscope at 45
degrees will also help keep
mouth open
 Poor positioning of the head
 Tongue in the way
 Pivoting laryngoscope against upper teeth
 Rushing
 Being overly cautious
 Inadequate sedation
 Inappropriate equipment
 Unskilled laryngoscopist
 El-Canouriet al. - prospective study of
10, 507 patients demonstrating difficult
intubation with objective airway risk
criteria
 Mouth opening < 4 cm
 Thyromental distance < 6 cm
 Mallampati grade 3 or greater
 Neck movement < 80%
 Inability to advance mandible (prognathism)
 Body weight > 110 kg
 Positive history of difficult intubation
 Trauma, deformity: burns, radiation therapy, infection,
swelling, hematoma of face, mouth, larynx, neck
 Stridor or air hunger
 Intolerance in the supine position
 Hoarseness or abnormal voice
 Mandibular abnormality
 Decreased mobility or inability to open the mouth at least 3
finger breaths
 Micrognathia, receding chin
 Treacher Collins, Peirre Robin, other syndromes
 Less than 6 cm (3 finger breaths) from tip of the mandible to
thyroid notch with neck in full extension
 < 9 cm from the angle of the jaw to symphysis
 Increased anterior or posterior mandibular length
 Laryngeal Abnormalities
 Fixation of larynx to other structures of neck,
hyoid, or floor of mouth.
 Macroglossia
 Deep, narrow, high arched oropharynx
 Protruding teeth
 Mallampati Class 3 and 4
 Neck Abnormalities
 Short and thick
 Decreased range of motion (arthritis, spondylitis, disk
disease)
 Fracture (subluxation)
 Trauma
 Thoracoabdominal abnormalities
 Kyphoscoliosis
 Prominent chest or large breasts
 Morbid obesity
 Term or near term pregnancy
 Age 50 – 59
 Male gender
 Previous Intubations
 Dental problems (bridges, caps, dentures, loose
teeth)
 Respiratory Disease (sleep apnea, smoking,
sputum, wheeze)
 Arthritis (TMJ disease, ankylosing spondylitis,
rheumatoid arthritis)
 Clotting abnormalities (before nasal intubation)
 Congenital abnormalities
 Type I DM
 NPO status
 Difficultintubation 10 x higher in long term
diabetics
 Limited joint mobility in 30 – 40 %
 Prayer sign
 Unable to straighten the interpharyngeal joints
of the fourth and fifth fingers
 Palm Print
 100% sensitive of difficult airway
 General:
 LOC, facies and body habitus, presence or absence of cyanosis,
posture, pregnancy
 Facies:
 Abnormal facial features
 Pierre Robin
 Treacher Collins
 Klippel – Feil
 Apert’s syndrome
 Fetal Alcohol syndrome
 Acromegaly
 Nose:
 For nasal intubation
 Patency
 Oral Cavity
 Foreign bodies
 Teeth:
 Long protruding teeth can restrict access
 Dental damage 25% of all anesthesia litigations
 Loose teeth can aspirate
 Edentulous state
 Rarely associated with difficulty visualizing airway
 Tongue:
 Size and mobility
 TMJ Joint – articulation and movement
between the mandible and cranium
 Diseases:
 Rheumatoid arthritis
 Ankylosing spondylitis
 Psoriatic arthritis
 Degenerative join disease
 Movements: rotational and advancement
of condylar head
 Normal opening of mouth 5 – 6 cm
TERIMA KASIH