MBChB V

Airway management basics

A Alberts
Kalafong Provincial Tertiary Hospital
January 2022
Lethal injection vs anaesthetic induction
Who makes the difference?

Death Penalty Information Centre website

“All states and the federal government use lethal injection as their primary method
of execution. Jurisdictions use a variety of protocols typically employing one, two,
or three drugs. Most three-drug protocols use an anesthetic or sedative, followed
by a drug to paralyze the inmate, and finally a drug to stop the heart. The one and
two-drug protocols typically use an overdose of an anesthetic or sedative to cause
death.”

https://deathpenaltyinfo.org/executions/lethal-injection
https://deathpenaltyinfo.org/executions/lethal-injection/overview-of-lethal-injection-protocols
Airway management
Why is airway management during anaesthesia crucial?

Anaesthesia is loosely defined as a state of controlled, temporary loss of awareness, that is

induced for the purpose of a diagnostic, or therapeutic medical intervention

An anaesthetised person hence is a person under the effects of one or more

pharmacological agents to the point of some degree of loss of consciousness
Airway management
Why is airway management during anaesthesia crucial?

Modern day anaesthesia stands on three legs

1. Anaesthesia (loss of awareness) propofol / sevoflurane
2. Analgesia (absence of pain) opioid / NSAID / regional block
3. Immobility (loss of movement) rocuronium

Airway management skills are crucial because any one of the three components of a
modern day anaesthetic may result in upper airway obstruction and / or apnoea
Upper airway anatomy
Three pharyngeal segments form the upper airway

https://expertconsult.inkling.com/read/hagberg-airway-management-4e/chapter-41/figure-41-1
The patent upper airway
Action of the upper airway dilator muscles

https://expertconsult.inkling.com/read/hagberg-airway-management-4e/chapter-41/figure-41-1
Upper airway anatomy
Sites of obstruction during sleep apnoea

https://expertconsult.inkling.com/read/hagberg-airway-management-4e/chapter-41/figure-41-1
Airway management
Why is airway management so crucial?

Because any one of the three components of a modern day anaesthetic stationary

1. Anaesthesia
2. Analgesia
3. Paralysis

may result in upper airway obstruction due to decreased muscle tone

Post-induction upper airway obstruction
Approaches to open up the obstructed airway

▪ Clinical skills to open the obstructed airway, e.g. lifting the yaw forward

▪ Airway devices – to maintain an open airway throughout the anaesthetic

▪ Face mask (FM)
▪ Supraglottic airway (SGA)
▪ Endotracheal tube (ETT)
Airway management gadgets
To maintain an open airway during the anaesthetic

▪ Face mask (FM)

▪ Supraglottic airway (SGA)

▪ Endotracheal tube (ETT)

Oral and nasal airways
Airway adjuncts used with a Face Mask

https://psnet.ahrq.gov/web-mm/who-nose-where-airway
https://medical-dictionary.thefreedictionary.com/oropharyngeal+airway
https://fpnotebook.com/er/procedure/OrphrynglArwy.htm
Oral and nasal airways
Airway adjuncts to be used with a Face Mask
Face mask

A FM is a

▪ mask that may or may not fit neatly

▪ over (not inside) the mouth and nose,
▪ not sealing off the trachea, and
▪ not tightly enough for high ventilatory pressures to be applied, and with the risk of
▪ inflation of the stomach during positive pressure ventilation and/or
▪ obstruction of the airway, and in selected patients, with the real risk of
▪ regurgitation and pulmonary aspiration of gastric content.
Face mask
Clinical features associated with difficult FM ventilation

▪ Beard
▪ Obesity
▪ No teeth
▪ Elderly
▪ Sleep apnoea (Snoring)
Face mask
Incidence of difficulty with FM ventilation

▪ Difficult FM ventilation
▪ 1 to 2 times in every 100 surgical patients

▪ Impossible FM ventilation
▪ 1 to 2 times in every 1000 surgical patients

Benumof and Hagberg’s Airway Management

3rd Edition pg 203
SASA preoperative fasting guidelines
Elective procedures, minimum duration of fasting

▪ 8 hours
▪ meal that includes meat or fried or fatty foods
▪ 6 hours
▪ light meal (e.g. toast and a clear fluid) or infant formula or non-human milk
▪ 4 hours
▪ breast milk (no additions to pumped breast milk are allowed)
▪ 2 hours
▪ clear fluids
▪ unless contraindicated, adults and children should be encouraged to drink clear fluids
(including water, pulp-free juice, and tea or coffee without milk) up to two hours before
elective surgery
Supraglottic airway

R
iGel
An SGA is a

▪ mask that fits neatly

▪ over (not inside) the opening (glottis) of the trachea, but
▪ not sealing off the trachea, and
▪ not tightly enough for high ventilatory pressures to be applied, and with the risk of
▪ inflation of the stomach during positive pressure ventilation and/or
▪ obstruction of the airway, and in selected patients, with the risk of
▪ pulmonary aspiration of gastric content even while the cuff remains inflated.
Supraglottic airway

An SGA is a

▪ mask that fits neatly

▪ over (not inside) the opening (glottis) of the trachea, but
▪ not sealing off the trachea, and
▪ not tightly enough for high ventilatory pressures to be applied, and with the risk of
▪ inflation of the stomach during positive pressure ventilation and/or
▪ obstruction of the airway, and in selected patients, with the risk of
▪ pulmonary• aspiration of gastric content even while the cuff remains inflated.
A = King LT
• B = i-Gel
• C = air-Q
• D = Aura-I
Source: Clinical Anesthesia 8th Edit; Barash et al. Wolters Kluwer
Supraglottic airway
Clinical features associated with difficulty in the use of an SGA

▪ Limited mouth-opening

▪ Intra-oral abnormalities
▪ Anatomical (syndromic)
▪ Pathological (tumour / bleeding)
Supraglottic airway
Incidence of difficulty with an SGA

The failure rate for the LMA to establish a patent airway is approximately 1 to 2 per 100 surgical patients

Benumof and Hagberg’s Airway Management

3rd Edition pg 207
Supraglottic airways
Two generations of SGA

▪ 1st generation SGA

▪ Classic LMA
▪ Simple airway conduit

▪ 2nd generation SGA

▪ Proseal LMA
▪ Features to reduce risk of aspiration

▪ Intubating LMA (ILMA)

▪ Fastrach
▪ Conduit for placement of an ETT
Endotracheal tube

An ETT is a

▪ tube that fits snugly

▪ into (not against over) another tube (the trachea)
▪ sealing off the trachea
▪ tightly so that high ventilatory pressures can be applied, without the risk of
▪ inflation of the stomach or
▪ obstruction of the airway, and without the risk of
▪ pulmonary aspiration of gastric content while the ETT remains in position and the cuff
inflated.
SGA vs ETT

The ETT passes through

the glottic opening into
The SGA does not the trachea!
pass through the
glottic opening into
the trachea!
Endotracheal tube
Clinical features associated with difficult Direct Laryngoscopy (DL)

▪ D isproportion

▪ D istortion

▪ D ysmobility

▪ D entition
Direct laryngoscopy (DL)
Light travels down a straight line
Optimal positioning for DL
‘Sniffing the morning air’ position
Video assisted laryngoscopy (VAL)
VAL has revolutionized laryngoscopy
Three groups of airway management gadgets
CVCI

▪ Face mask (FM)

The inability to oxygenate / ventilate a patient

with the use of all three these groups of airway
▪ management
Supraglottic gadgets, is defined as a CVCI scenario
airway (SGA)

▪ Endotracheal tube (ETT)

Can’t Intubate, Can’t Ventilate (CVCI)

▪ Incidence of the CVCI* is 0.01 to 2 cases per 10 000 patients

*CICV = Can’t Intubate Can’t Ventilate

Benumof and Hagberg’s Airway Management
3rd Edition pg 205
Thank You