Sedation Airway Management

Introduction
Basic Airway Management
Airway Anatomy
Patient Assessment
Advanced Airway Management

Introduction

The drugs used for sedation and analgesia can interfere with a patient's ventilation both by relaxing the airway muscles and suppressing
the urge to breathe. The primary risk related to sedation is respiratory complications. Ability to maintain a patent airway is an essential
prerequisite for administration of sedation. Airway obstruction can be either total or partial.

Symptoms of Partial Airway Obstruction

 Snoring
 Retraction of the sternum
 Rocking motion of the chest not in sync with respiratory effort
 Harsh, high-pitched sound upon inspiration (stridor)
 Hypoxemia
 Hypercarbia
Symptoms of Complete Airway Obstruction

 Lack of any air movement perceived by feeling with the hand over the mouth or placing the ear over the mouth
 Lack of breath sounds while listening with stethoscope to lung fields
 Retraction of the sternum and rib cage
 Rocking motion of the chest not in sync with respiratory effort
 Hypoxemia
 Hypercarbia

Normal respiration relies on a series of structures that conduct air into and out of the lungs. An understanding of the
functionalanatomy of this region is critical to airway management.

Basic airway management

Immediate action must be taken at the first signs of compromised respiratory function. If initial attempts to relieve airway obstruction
through verbal and tactile stimulation are unsuccessful, the following techniques can be employed to restore effectiveventilation.

Manual Maneuvers

When the muscles of the tongue and mouth floor relax, the tongue lies close to or on the back wall of the oropharynx. Theepiglottis may
obstruct the glottic opening or seal against the back wall of the pharynx, as well. The following positioning maneuvers can be performed
to relieve the soft tissue obstruction and improve airflow.

 Jaw thrust. This maneuver moves the tongue forward with the mandible which reduces the tongue's ability to obstruct the
airway. Standing at the head of the bed, the middle finger of the right hand is placed at the angle of the patient's jaw on the
right. The middle finger of the left hand is similarly placed at the angle of the jaw on the left. An upward pressure is applied to
elevate the mandible which will lift the tongue from the posterior pharynx.

 Chin lift. The fingers of one hand are placed under the mandible, which is gently lifted upward to bring the chin anterior. The
thumb of the same hand depresses the lower lip to open the mouth.

Pharmacologic Antagonists

Specific antagonists are available to reverse the effects of opioids and benzodiazepines. Naloxone (for opioids) or flumazenil(for
benzodiazepines) may be administered to improve patients spontaneous ventilatory efforts.

Artificial airway devices

Once a patent airway is established, it is necessary to prevent it from becoming obstructed again. Either an oropharyngeal or a
nasopharyngeal airway conduit may be used for this purpose. Both devices maintain a patent airway by preventing the tongue from
resting against the posterior pharyngeal wall.

 Oropharyngeal airway (OPA). The OPA is a curved, firm, hollow tube, usually plastic with a rectangular opening that is
used to maintain a conduit between the mouth and the glottis and to prevent obstruction by the tongue and other soft tissue.
OPAs come in sizes ranging from 50, 60, and 70 mm (nos. 0,1, and 2) for neonates and 80, 90, 100 mm (nos 3,4, and 5) for
adults. All OPAs have a straight bite section that rests against the patient’s lips and a flange on the proximal end to prevent
over-insertion. Oropharyngeal airways should be used in unconscious (unresponsive) patients as they are quite stimulating
and generate a gag reflex. In responsive patients OPAs can cause vomiting and aspiration. Incorrect insertion of an airway
can push the tongue into the back of the throat causing airway obstruction.

To select the proper size OPA, place it against the side of the face. When the tip of the OPA is at the corner of the mouth, the
phalange is at the angle of the mandible.

 Nasopharyngeal airway (NPA). The NPA, also called a "nasal trumpet," is a soft rubber or plastic hollow tube that is passed
through the nose into the posterior pharynx just above the epiglottis. Because NPAs tend to provoke less airway irritations
than oropharyngeal airways, NPAs are better tolerated by patients. NPAs can be used when OPA placement is difficult, such
as when the patient's jaw is clenched or the patient is semiconscious and cannot tolerate an OPA. NPAs come in sizes
based on their external circumference that range in size from 28 to 34.

The length of the NPA should be the same as the distance from the tip of the patient’s nose to the earlobe.

Potential Hazards Involved in the Use of Airway Conduits

Oropharyngeal airways Nasopharyngeal airways

 Increasing airway obstruction by pushing tongue backward  Using an airway that is too long; this may cause the tip to
 Using an incorrectly-sized devise. A device that is too enter the esophagus.
small is ineffective and can be lost in the oropharynx. A  Injuring the nasal mucosa causing bleeding. This can lead
device that is too large can press against the epiglottis and to aspiration of blood or clots.
obstruct the larynx.  If nasal airway doesn’t have flange at the nasal end can
 Causing trauma to soft tissue by catching the tongue or lose airway in nose and the airway.
lips between the airway and the teeth.
 Inducing vomiting by using the device in a patient with
intact gag reflex.

Bag-mask ventilation

Bag-mask ventilation is a basic but critical airway management skill. It enables clinicians to provide adequate ventilation for patients
requiring airway support and allows enough time to establish a more controlled approach to airway management, such as endotracheal
(ET) intubation. Because the technique can be difficult to perform correctly, clinicians performing the procedure should continually
practice and monitor their technique.

Successful bag-mask ventilation depends on three things:

 Patent airway. Airway patency can be established using airway maneuvers and airway conduits described above.
 Adequate mask seal. In order to secure a good seal, the mask must be placed
and held correctly. Disposable bag-mask units are often packaged with one large
adult-sized mask. Even though facial anatomy differs for eachpatient, one sized
face mask is usually sufficient for positive pressure ventilation with the bag mask.
The nasal portion of the mask should be spread slightly and placed on the bridge
of the patient's nose. The body of the mask is then placed onto the patient's face
covering the nose and mouth. The provider's wrists or the mask cushion should
not rest on the patient's eyes during bag-mask ventilation. There are two methods
for holding the mask in place. The two-hand mask hold is most effective, however
it requires a second clinician. Therefore, the clinician should be comfortable with
both techniques.
 Proper ventilation (ie, proper volume, rate, and cadence). The three key
errors to avoid when performing bag-mask ventilation are:
 Excessive tidal volumes: A volume just large enough to cause chest
rise (no more than 8 to 10 cc/kg) should be used. During cardiopulmonary resuscitation (CPR), even smaller tidal
volumes are adequate (5 to 6 cc/kg) due to the reduced cardiac output of such patients.
 Forcing air too quickly: The bag should not be squeezed explosively. It should be squeezed steadily over
approximately one full second.
 Ventilating too rapidly. The ventilatory rate should not exceed 10 to 12 breaths per minute.

Airway Anatomy
Upper airway

The upper airway consists of the structures above the vocal cords. It is divided into the following regions:

 Nose and oral cavity. Conduit for air entry into the pulmonary system. The nose, which is composed of bone cartilage, is the
primary pathway for normal breathing. The resistance through the nasal passage accounts for more than 50% of the total
respiratory resistance during normal breathing. This is more than twice the resistance during mouth breathing. The oral cavity
consists of the upper and lower teeth, the tongue and floor of the mouth, the hard palate and the openings of the major
salivary glands. The floor of the mouth is supported by the mylohyoid muscles.
 Pharynx. In normal size adult males, an approximately 13-cm long muscular tube located behind the oral and nasal cavities.
It conducts food to the esophagus and air to the larynx, trachea and lungs. The pharynx is divided into three sections:
 Nasopharynx: extends from the back of the internal nasal cavity to the soft palate. Contains the adenoids.
 Oropharynx: Begins at the soft palate and continues to the level of hyoid bone. Serves as both respiratory and
food passage. Contains the tonsils. The tongue is the principal source of obstruction, usually because of
decreased muscle tone related to sedation drugs such that the tongue falls backward in a supine patient.
 Laryngopharynx: Begins at the level of the hyoid bone and extends downward where it branches into two
passages: the larynx at the front which leads to the lungs; the esophagus at the back which leads to the stomach.
 Larynx. Enlargement at the top of the trachea which houses the vocal cords. The structure contains muscles, ligaments, and
cartilages. The epiglottis is a fibrous leaf-like cartilage that hangs over the laryngeal inlet that closes during swallowing to
prevent aspiration of gastric contents into the trachea. The triangular opening between the vocal cords is called the glottic
opening and is the entry point to the larynx, It is the adult airway’s narrowest point. Patency of the glottic opening is
dependent upon muscle tone.

Lower airway

The lower airway encompasses the structures of the respiratory system below the larynx.

 Trachea. Rigid tube approximately 10-15 cm length in the midline of the neck that provides a passage for air into the lungs.
 Bronchial tree. Branched tree-like tube system leading from the trachea that conducts air into the lungs. It is made up of
increasingly smaller tubes terminating in the alveoli.
 Lungs. Paired organs consisting of millions of small sacs (alveoli) gas exchange occurs. The lungs occupy most of the
space of the thoracic cavity.

Patient assessment

Before the initiation of sedation, patients should be evaluated for anatomical characteristics and relevant medical history that could
increase the risk of airway management problems.

Medical history

The following factors may contribute to a potentially higher risk for airway difficulties. If any of these conditions are present, the clinician
will determine the patient’s level of risk on an individual basis.

 Previous problems with anesthesia, sedation or airway management

 Stridor, snoring, or sleep apnea
 Advanced rheumatoid arthritis
 Abnormal anatomy in head/neck such as tumors
 Obese patients
 Congenital syndromes that involve the airway
 Radiation therapy or previous surgery to head/neck may distort airway and complicate airway manipulations
 Large beard such that mask ventilation is more difficult
 A short, thick, muscular neck

Physical assessment

The pre-procedure physical examination should include the following assessments to evaluate the patient’s airway and uncover physical
traits that could contribute to respiratory complications.

 Oral cavity inspection. The patient's oral cavity should be carefully inspected for the following abnormalities prior to
sedation. Findings should be documented in the patient's record.
 Small mouth opening (less than 3 cm in an adult)
 Protruding incisors
 Loose or capped teeth
 Missing teeth
 Dental appliances such as crowns, bridges, and dentures
 Enlarged tonsils
 Non-visible faucial pillars, which are vertical folds of tissue created by muscles that surround the palatine tonsils
(See Mallampati Class III and IV)
  Non-visible uvula
 Tumor that could obstruct air flow

 Temporomandibular joint examination. Pain or limited range of motion in the temporomandibular joint can be assessed by
palpating the joint while the patient's mouth is open to the widest point. In an adult, the normal mouth opening is 4 to 6 cm.
Patients with temporomandibular joint disease who have an opening of less than 4 cm (approximately 2 finger breadths) may
have limited airway mobility if mechanical devices are needed to treat respiratory distress.

 Thyromental distance evaluation. The thyromental distance should be at least 5-7 cm as measured from the thyroid
cartilage to the point of the chin when the neck is extended fully and the mouth closed. A distance less than 7 cm can
indicate difficulty with intubation should the need develop.

 Neck mobility. Assessment of the movement of the atlanto-occipital joint through flexion, extension, and side to side is
necessary before sedation is initiated. Ability to align the oral, pharyngeal, and laryngeal axes is required for successful
endotracheal intubation.

 Physical characteristics. Patients should be examined for physical traits that can indicate a potential for airway
complications.
 Significant obesity especially in the region of the neck and face
 High, arched palate
 Enlarged tongue
 Short, immobile neck
 Protruding teeth
 Recessed or protruding jaw

 Mallampati Airway Classification System. This system is a method for quantifying the degree of difficulty of endotracheal
intubation based on amount of posterior pharynx that can be visualized. The exam is performed with the patient sitting with
the head in a neutral position and the mouth open as wide as possible

Illustration with permission from UF Airway Evaluation Tutorial

http://www.anest.ufl.edu/

Class I: soft palate, fauces, uvula, pillars visible. No difficulty.

Class II: soft palate, fauces, portion of the uvula visible. No difficulty.
Class III: soft palate, base of uvula visible. Moderate difficulty.
Class IV: hard palate only. Severe difficulty.
Advanced airway management

Cases where non-invasive means are insufficient to provide adequate oxygenation and ventilation, a clinician may need to use one of
the following advanced airways.

 Endotracheal tube (ETT). An endotracheal tube is indicated for airway protection in a comatose patient for example, for
mechanical ventilation, and if pulmonary toilet is necessary. It is the definitive method to secure a compromised airway,
prevent aspiration, and initiate mechanical ventilation. Placement typically requires laryngoscopy.
 Laryngeal mask airway (LMA). A laryngeal mask airway can be inserted into the lower oropharynx after general anesthesia
has been induced. Some models also have a channel that can guide an endotracheal tube into the trachea. This device
does not require laryngoscopy for insertion.

Sources

2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 4: Adult
Basic Life Support. Circulation 2005;112: IV-19-IV-34 and Part 7.1: Adjuncts for Airway Control and Ventilation. Circulation2005;112: IV-
51-IV-57.

Euliano TY, Gravenstein JS. Essential Anesthesia: From Science to Practice. Cambridge, UK. Cambridge University Press. 2004: 24-27

Field, John M. Advanced Cardiovascular Life Support Provider Manual, American Heart Association 2006: 27-28.

Kost M. Moderate Sedation/Analgesia: Core Competencies for Practice, 2nd Ed. St. Louis, MO: Saunders, St. Louis; 2004:171-184