Basic Airway Management

By Tan Yee Wen

Supervisor Dr Johny Kiu
 QUESTION
1. Use of a laryngeal mask airway would
be most appropriate for airway
management in the following patient:
A. An obese patient with acute appendicitis
who, after rapid sequence induction, cannot be
intubated
B. An elderly patient with restrictive lung
disease scheduled for inguinal hernia repair
C. An obese male patient with a hiatal hernia
and GERD scheduled for umbilical hernia repair
D. A full-term parturient brought to the OR for
emergent cesarean section because of fetal
bradycardia
2. One of the following is a primary risk
factor for difficult mask ventilation:
A. Limited mouth opening
B. Thyromental distance less than 3
fingerbreadths
C. High arched palate
D. Inability to bring mandibular incisors
anterior to the maxillary incisors
Definition :American society of Anesthesiologist (ASA)
 The difficult airway is “the clinical situation in which a
conventionally trained Anesthesiologist experiences difficulty
with facemask ventilation, difficulty in supraglottic device
ventilation, difficulty in tracheal intubation or all three”

 difficult to ventilate: difficulty with facemask ventilation is the

inability of an unassisted anesthesiologist:
a) to maintain oxygen saturation, measured by pulse oximetry,
92%; or
b) to prevent or reverse signs of inadequate ventilation during
positive-pressure mask ventilation

 difficult to intubate: if a trained Anaesthetist using

conventional laryngoscope take’s more than 3 attempts or
more than 10 minute are required to complete tracheal
intubation
 Steps
To intubate or not?
Evaluation of airway/ aspiration risks
Informed consent/ Explanation to patient/family
members
Check Equipment – MARBLES and difficult airway trolley
Ensure appropriate number of staff present
Prepare drugs for RSI/ Resuscitation
Position
Preoxygenate / ventilation
Induce
Intubate (Difficult airway management)
Confirm and secure airway
Sign of Description Quantitative Acceptable
difficulty or qualitative findings not
findings usually associated
reported to with difficulty
be
associated
with
difficulty
1. Increased
Disproportion size of Mallampati class I or
tongue in Mallampati II
relation to class III or IV
pharyngeal
size
Possibly
Airway
difficult to
swelling
assess
Blunt or
Airway penetrating
Midline trachea
trauma Tracheal
trauma
Sign of Description Quantitative Acceptable
difficulty or qualitative findings not
findings usually
reported to associated
be associated with difficulty
with difficulty

2. Distortion Neck mass Voice changes

Neck Subcutaneous
haematoma emphysema
Neck abscess Laryngeal Mobile
immobility laryngeal
anatomy
Arthritis in the Non palpable Easily palpated
neck joint thyroid thyroid
cartilage cartilage
Previous Non palpable Easily palpated
surgical history cricoid cricoid
cartilage cartilage
Sign of Description Quantitative Acceptable
difficulty or qualitative findings not
findings usually
reported to be associated
associated with difficulty
with difficulty

3. Decreased Anterior larynx Thyromental Thyromental

thyromental and decreased distance <7cm distance >7cm
distance mandibular or3 finger or 3 finger
space breadths) breadths

Receding chin No receding

chin
4. Dysmobility Restricted ROM
of Atlanto-
occipital Joint
5. Dentition Prominent
Upper incisors
 Airway considerations
Recognise objective signs of airway
obstruction/difficult airway
Trauma (cervical immobilization)
Burn (NB inhalational injury)
Signs of airway compromise
Tachypnoea/ability to talk
Altered GCS
Anticipation of vomiting/Aspiration
Prepare suction/ NG standby
Difficult intubation =
Difficult LMA = RODS
LEMON Restricted mouth
Look externally
opening
Evaluate 3-3-2 rule Obstruction
Mallampati score Distorted airway
Obstruction Stiff lungs or c-spine
Neck Mobility

Difficult BVM = BONES Difficult surgical airway =

Beard SHORT
Surgery
Obese
Hematoma
No teeth
Obesity
Elderly
Radiation distortion or
Sleep Apnea / Snoring other deformity
Tumor
LEMON LAW
Occiput able to extend below the lower jaw

Mouth Opening > 3 Finger

breaths
What to prepare for intubation
M - Mask
A – Airways (Nasal or
Oropharyngeal), Aspiration
(NG tube)
R – Resus Drugs and RSI drugs
B – Bag valve Mask/ Bougie
L - Rigid laryngoscope blade of
alternate design and sizes
E – ETT, Emergency invasive
airway access.
S - Suction, Stylet, Secure,
Syringe, Stethoscope
 ETT sizes
 Ages 1-8 yr old
Uncuffed endotracheal tube size = 4 + (Age / 4)
Cuffed endotracheal tube size = 3.5 + (Age / 4)

• <1 year of age uncuffed tube 3.5 mm

• Infants more than 3.5 kg and <1 year cuffed ETT 3.0 mm
MAY BE used

Adults
Female 6.5-7.5mm cuffed
Males 7-8mm cuffed
 Anchoring
Paediatrics
ETT size x 3
Age/2 + 12 (Oral)

Adults
Females 18-21 (oral)
Males 21-24 (oral)

Nasal depth = Oral depth +3cm

Positioning
Mask ventilation
Head tilt
Chin lift
Jaw thrust
Cormack Lehane Grades
 Confirming ETT position
Observed
Direct visualization
Observed chest rise
Auscultation
Absence of gastric
sounds/gastric content in
tube
Exhaled tidal volume
Absence of air escape
Tube Condensation
Measured
EtCO2
SPO2
Complications of intubation
Malpositioning (Oesophageal/
Bronchial/Cuff position)
Airway Trauma(Dental injury/ dislocated
mandible, retropharyngeal dissection/
airway edema/stenosis, sore throat )
Physiological – laryngospasm/
hypertension, tachycardia, hypoxia,
hypercarbia
Aspiration
Tube malfunction - obstruction/ cuff
perforation
 QUESTION
1. Use of a laryngeal mask airway would
be most appropriate for airway
management in the following patient:
A. An obese patient with acute appendicitis
who, after rapid sequence induction, cannot be
intubated
B. An elderly patient with restrictive lung
disease scheduled for inguinal hernia repair
C. An obese male patient with a hiatal hernia
and GERD scheduled for umbilical hernia repair
D. A full-term parturient brought to the OR for
emergent cesarean section because of fetal
bradycardia
2. One of the following is a primary risk
factor for difficult mask ventilation:
A. Limited mouth opening
B. Thyromental distance less than 3
fingerbreadths
C. High arched palate
D. Inability to bring mandibular incisors
anterior to the maxillary incisors
THANK YOU

Questions?
References
American society of Anaesthesiologists
Difficult Airway Society Guidelines 2015
Manual for TLS course PKPK Pulau Pinang
Lippincott’s Anesthesia Review: 1001 Questions
and Answers
Author(s): Paul Sikka, Edward A. Bittner, Thomas
Halaszynski, Thoha Pham, Ashish Sinha

https://
www.merckmanuals.com/medical-calculators/Ped
iatricETTubeSize.htm
Morgan and Mikhail Clinical Anaesthesiology 5 th
edition Chapter 19 Pg309-341