Airway management

Med 5: Anaesthesia Module

 Summary of skills
1. Resusc. Bag:
2. Airway obstruction:
3. Bag & Mask ventilation:
4. Laryngoscope:
5. Intubation of trachea:
6. Induction sequence:
7. Verify position of tracheal tube:
Resuscitation Bag Oxygen supply
connected here
10 L/min

1. Bag - self-inflating
2. Valve – unidirectional
3. Oxygen supply / reservoir
4. Face mask
Know how to assemble!
Kept in theatre on wall
1. To transfer patients
2. Backup, if machine fails
Familiarize yourself with parts
 Old style “size 4” face masks

Note the air filled rubber seal

which is contoured to fit
the patient’s face

They are black because the rubber contains carbon.

The carbon prevents static electricity (antistatic) and sparks.
An relic of days of inflammable anaesthetic gases, such as ether.
Mask held to show contours of face

Recess angle
of mouth

Nose Cheek
Finger positions when holding a face mask

Fingers:
Thumb & Index hold mask
Middle & Ring under the jaw
Little finger at angle of jaw
Together they lift the jaw
 Airway Obstruction
 Patient cannot breath. Air cannot be
moved in and out of the lungs, despite
respiratory efforts.

 The patient may be very distressed.

 Eventually the patient will become

hypoxic, cyanosed and eventually arrest.
 Airway Obstruction &
Level of Consciousness
Conscious: Unconscious:
 Natural tone of  Tone is lost & tissues
muscles of pharynx collapse
 [airway patent]  [airway obstructs]

 Sleep:  Overdose
 Loss of coordination
 Snore / sleep apnea
 Head injury
 Stroke or MN disease  GCS < 8/15
 Bulbar palsy
 Airway Obstruction
 Functional: Patient is unconscious
 Tongue & epiglottis falling backwards
 When patient lies supine
 Tongue impinging on roof of mouth

 Mechanical: Blockage of the lumen

 Foreign bodies (vomit / blood)
 Swelling of soft tissues (infection)
 Enlarged tongue of tonsils
 Airway Obstruction
 How is functional obstruction treated?
1. Patient position (Supine to lateral)
 Recovery position (tongue falls forward)
2. Jaw (lift) / neck (extension) maneuver
 Lifts up the tongue & epiglottis
3. Airway devices that provide a patency :
 Oral airway
 Laryngeal mask airway
 Endotracheal tube (ETT)
Obstructed Airway
a. Patient lies supine
b. Head in neutral position
c. Tongue & epiglottis fall
backward onto the
posterior pharyngeal wall
 Unobstructed Airway
a a. Jaw lift / Head tilt
b. Tongue & Epiglottis
a now clear of posterior
pharyngeal wall

b
A Resuscitation Annie is used to practice bag & mask
skills, including jaw lift & head tilt and ventilation
Neutral position
Airway Obstructed
Unable to ventilate

Note position of hand on mask

Two (2) fingers hold mask
Three (3) fingers hold jaw
Mask in tight contact with face
Jaw (lift) & Neck (extended)
Airway now patent
Tongue & epiglottis lifted up
Able to ventilate lungs No resistance
when squeezing
resusc. bag
 Ventilation
 Rate: 12-15 per minute

 Volume: reasonable chest movement

 (~500 ml: Resusc. Bag 2 litres)

 It is important to observe (& auscultate)

the chest (& abdomen) to confirm that you
are ventilating the lungs and the tidal
volume is acceptable.
 Providing a patent airway
 1. Positioning of patient:
 Recovery (lateral) position
 2. Airway maneuvers:
 Jaw (lift) & Head (tilt) {neck extended}
 3. Adjuncts to the airway:
 Oral airways
 LMA (laryngeal mask airway)
 ETT (endotracheal tube)
 4. By-pass the larynx:
 Tracheostomy
Oral airways can be used to overcome obstruction
due to the tongue lying against the roof of the mouth

Oral airways come

in different sizes
Cut away model shows how an oral airway
provides a patent pathway to pharynx.
The correct size needs to be selected.

Note the pharynx lies in same vertical plane as the

ear and auditory canal. Thus the ideal length of an
oral airway is from the corner of the mouth to ear hole.
1. The correct sized oral airway is selected

Note that the airway is orientated

in the position it will take up when
inserted into the mouth
2: This one (size 3) is the correct size
3: The head is tilted to open the jaw and the airway
is inserted towards the hard palate to avoid the tongue

Note that for insertion the

airway has been rotated 180o
4: The airway is rotated back to its correct
orientation as advanced into the mouth
 The LMA (laryngeal mask airway)

2 3 1

1. Inflatable cuff (25-30 ml air)

2. Stalk with universal (15 mm) connector
3. Pilot balloon (with syringe)
4. Plastic / reused < 40 times
 LMA with cuff inflated

The LMA is a relatively new innovation

in anaesthesia, introduced in the late 1980s
 Placement of an LMA in an anaesthetized patient

The LMA is inserted into the mouth of the unconscious patient

and advanced into the pharynx until it will go no further. Then
the cuff is inflated with 25-30 ml of air. It is then checked for
patency and the ability to ventilate both lungs.
Cut away model showing how
the LMA is positioned over the
laryngeal opening in pharynx
when its cuff is inflated
Design of ETT (endotracheal tube)
Plastic:
a
Clear, disposable & non-allergy
Cuff with Pilot balloon (5-10 ml air)
Seal to keep air (in) / vomit (out)
Connector (a):
Universal size 15 mm
Markings:
Size, length & position
Cut away model showing
position of ETT in airway

Mark on ETT to help

position it at level of
vocal cords
Close up view of the inflated cuff & pilot balloon
and the markings (a) that denote the placement
level with respect to the vocal cords

a
 Some more unusual airway tubes
Armoured non-kinking tube

Old style red rubber double lumen tube used for lung surgery

Armoured preformed tracheostomy tube for intra-operative use

Latex nasal airway

Machintosh Laryngoscope:

Upper scope is ready for use with light switched on.

Lower scope is in off position. The light is housed in
the handle with an optical conduit in the blade.
Disassembled Laryngoscope

Identify:
Handle, blade, light source (a) & batteries with housing
Note that the blade has a optical conduit to transfer light source
Older style scopes had a screw in light bulb on the blade
Laryngoscope held in LEFT hand,
Person intubating stands at head end of patient
Note (a) how the handle is grasped and
(b) The orientation of blade in the mouth

Note:
Too much pressure
on upper teeth
View of larynx from above:
Be able to identify:

Base of tongue

Epiglottis

Vocal cords

Trachea

Arytenoids

Oesophagus
Identify structures
Identify structures

Note nodule on closed vocal cords

Identify structures
Laryngoscope blade is positioned at the valecula
(base of tongue) superior to the epiglottis

Note that the blade is inserted

carefully into the mouth and
walked down the tongue to be
positioned at its base.
However much he tries you cannot see the larynx!!
 Outline of upper airway

TONGUE

Posterior tongue & epiglottis

obstruct view of larynx.
During laryngoscopy they
are displaced forward by
scope blade
A: The pathway from the mouth to larynx is
a right angle in the neutral position
B: But when the neck is extended
The pathway becomes a straight line

The tongue & epiglottis

remain a problem and
have to be displaced
by using a laryngoscope
A: Neutral position:
Laryngoscope blade only reveals
posterior wall of pharynx
B: With neck extended
and scope blade used
to displace tongue forward,
the larynx is visualized
 Induction of anaesthesia

 You need to learn how to bag

& mask ventilated a patient’s
lungs and then successfully
intubate the patient following
the induction of anaesthesia.
 Sequence of events
1. Have the correct equipment
2. Pre-oxygenate & Induce anaesthesia
3. Bag & mask the patient (± oral airway)
4. Laryngoscopy
5. Intubation (+ inflate cuff)
6. Check position of tube
An Airway Trainer is used
1: It is important to have all the equipment you need
ready and checked before you start
 Equipment required
 Ventilation:  Intubation:
 Resuscitation bag  Laryngoscope
 Face mask  Endotracheal tube
 Stylet
 10 ml syringe

 Airway obstruction:  Tube position:

 Selection of airways  Stethoscope
 ETCO2 monitor
2: The patient is pre-oxygenated before induction
This provides a store of oxygen in the lungs
that will last up to 3-5 minutes if any problem
is encountered during ventilation & intubation
Anaesthesia & unconsciousness are induced.
Intravenous anaesthetic is injected and it takes
30-60 seconds for the drugs to reach the brain and
the patient to fall asleep. (Muscle relaxation follows)
One must check that the patient is fully
anaesthetized and not rousable before continuing
3: The patient’s lungs are ventilated using a bag &
mask to assure oxygenation. This is usually done for
3 minutes to allow muscle relaxants to take full effect

Rate = 12-15 breaths per min

Occasionally difficulty (obstruction) is encountered
whilst ventilating and an oral airway is needed
4: When you are ready (after 3 min) you can attempt
laryngoscopy. Remember to visualize the cords first
5: Now intubate the trachae. You may experience
difficulty with the trainer when passing the tube
You should use a metal stylet to make the tube firmer
The stylet is passed through the lumen of the tube
You can also spray silicone lubricant on the tube tip

After using silicone lubricant

your hands may feel sticky!
Wash them afterwards
The endotracheal tube should be inserted to ~22 cm
at the lips. This co-insides with the mark at the cords
If you insert tube is insert to far (>22 cm),
you end up ventilating one lung
Only the right side lung is being ventilated.
This leads to lung collapse (left) and hypoxia
The cuff is inflated with 5-10 ml of air. This
prevents air leakage during ventilation

Balloon feels firm

Note the valve that has to

be depressed to admit
air into the system
6: You must check that the tube is in the trachea.
Auscultate both lungs & stomach (oesophagus)
Also check that CO2 is detected in the expired gas
 Oesophageal Intubation
 The tube is easily put in the oesophagus:
 This is a potential disaster!!!
 The patient receives no oxygen
 However, hypoxic is delayed (pre-O2)
 Problems become manifest later, after 3-5 min
 The patient’s stomach is blown up with gas
 The patient is likely to regurgitate / vomit
 Lungs are unprotected from aspiration
 If uncorrected the patient will arrest & die.
An oesophageal Intubation:
Note the position of ET tube

By checking the position of the tube after

intubation, oesophageal intubations can be
identified and the tube correctly positioned
An Oesophageal Intubation:

ET tube in oesophagus
 Workshop
 You will practice these skills at an
airway management workshop and
on patients in the operating theatre
during this attachment

 Thanks to Eric Ng (Elective Student) who

helped with the photographs
Appendix
 Cricoid Pressure (Slide 1)
 In some cases presenting for anaesthesia the
stomach is not fully empty and there is a risk
during induction of anaesthesia that the patient
may regurgitate and stomach contents will be
aspirated into the lungs leading to pneumonia,
lung abscess and even death.

 Patients at risk tend to be emergency cases who

have not been adequately fasted.
 Cricoid Pressure (Slide 2)
 To prevent aspiration in such cases induction of
anaesthesia is modified:
 A rapid sequence of induction followed by
intubation, without lung ventilation, is performed.
 To prevent regurgitation a procedure called
cricoid pressure is done during intubation.
 Cricoid pressure involves pressing on the
patient’s larynx (cricoid) with the objective of
closing off the oesophagus.
Larynx showing thyroid cartilage (a) and cricoid (b).
Notice the position with respect to the oesophagus

a
b
Downward pressure is applied to the cricoid
which is transferred to the oesophagus

Oesophagus is closed off

Demonstration of Cricoid Pressure on a model