Airway Management

Department of Anesthesiology
 Outline
. Review of airway anatomy
. Airway evaluation
. Mask ventilation
. Endotracheal intubation
. The difficult airway
 Airway Anatomy
. Ab-ductor
Posterior cricoarytenoid
. Tensor
Cricothyroid
. Ad-ductors
All the rest
 Airway Anatomy
. 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
 Airway Anatomy
. Innervation of
oropharynx
Glossopharyngeal n.
innervates tongue base
and oropharynx
 Airway Anatomy
. Membranes
Thyrohyoid
Cricothryoid
. Cartilages
Hyoid
Hn
Cricoid
 Airway Evaluation
. 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
 Airway Evaluation
. 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)
 Airway Evaluation
. Obesity
Distribution, i. e. short,
thick neck more
concerning
Neck circumference
 Airway Evaluation
. Thyromental distance:
bony point on mentum
(mandible) to thyroid
notch
. If short (<3FB’s or
6cm), pharyngeal and
laryngeal axis off
 Airway Evaluation
. Oropharyngeal visualization
. Mallampati Score
. Sitting position, protrude tongue, don’t say “AHH”
 Airway Evaluation
. Difficulty ventilating
Age >55
Beard
History of snoring
Lack of teeth
BMI >26
 Preoxygenation
. Replaces the nitrogen volume of the lungs
(69% of FRC) with oxygen
. Functional residual capacity (residual volume
and expiratory reserve volume)
. Preoxygenation with 100% oxygen via tight-
fitting mask for 5 minutes  up to 10 min of
oxygen reserve following apnea
. Four vital capacity breaths over 30 seconds
(time to desaturation quicker)
 Patient Positioning
. Sniffing position
Lower neck flexion
Upper neck extension
Important in obesity
 Mask Ventilation
. Induction of anesthesia
produces upper airway
relaxation and possible
collapse
. Downward
displacement of mask
with thumb and index
finger

www.aic.cuhk.edu.hk
 Mask Ventilation
. Upward traction of
remaining fingers
upward
. Fingers on bony
mandible
. Fifth digit at angle
displacing mandible
anteriorly

www.aic.cuhk.edu.hk
 Mask Ventilation
. Oral airway
. Two-handed technique

www.aic.cuhk.edu.hk
www.haworth21.karoo.net
 LMA Placement
. Carries prominent position
in ASA algorithm
. May be held like a pencil
. Balloon partially inflated
. Directed posteriorly and
upwards towards the palate
. Jaw thrust and sniffing
position may help placement

www.brandianestesia.it/Images/LMA-ins.jpg
 LMA Placement
. Verify placement by ventilating
Check for good chest rise, ETCO2, and adequate
tidal volumes
Check for leak – if significant leak at around
10cm H2O problematic
May try size larger or smaller
May try to inflate/deflate cuff to obtain better seal
If difficulty passing may try inserting upside down
and then flipping around
 Endotracheal Intubation
. 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
 Endotracheal Intubation
. 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
 Endotracheal Intubation
. 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
 Endotracheal Intubation
. Insert ETT above and between arytenoids and
through vocal cords
. Try to visualize the ETT passing between the
vocal cords
If this is not possible, then you must visualize the
ETT passing above and between the arytenoids
 Endotracheal Intubation
. Common problems:
“I can’t see anything!”
. Make sure tongue is
swept to the left
. You are probably too
shallow or too deep. Even
with difficult intubations
the epiglottis can be
visualized
. Insert laryngoscope in
further looking for
epiglottis
. Pull laryngoscope back if
this fails
 Endotracheal Intubation
. Common problems
“I can’t see the cords!”
Epiglottis is visualized, vocal cords are not
Removing the epiglottis partly from view is
necessary to visualize the vocal cords below
Push the end of the laryngoscope blade further
into the vallecula and “toe up”
Lifting the patient’s head with your other hand
may improve the sniffing position and bring the
vocal cords into view
 Endotracheal Intubation
. Common problems
“I can see the cords. But I can’t get the tube
there!”
You may not be giving yourself adequate room in
the oral cavity
Push up and to the left with the laryngoscope to
make sure the mouth is still fully opened and the
tongue adequately swept away
Slide the ETT in the mouth all the way to the right
side, perhaps even sideways
 Difficult Intubation
. ASA Difficult Airway Algorithm
. www.metrohealthanesthesia.com
 Fiberoptic Intubation
. Oral or nasal routes
. Topicalization is key
Aerosolized lidocaine 4%
Airway blocks
. Thin bronchoscope inserted into trachea
 Other airway options
. GlideScope
. Needle cricothyroidotomy
 Conclusion
. Airway management is an extremely important aspect
of the practice of anesthesiology and critical care
. A firm basis in airway anatomy is needed
. Skills such as mask ventilation, endotracheal
intubation, LMA placement are necessary
. In the case of a difficult airway, a logical algorithm
and airway equipment assist the physician in safely
managing the situation