Airway evaluation Airway evaluation andand

ManagementManagement

By :Dr. Adel ElshimyBy :Dr. Adel Elshimy

Lecture ObjectivesLecture Objectives

Students at the end of the lecture will be able to :Students at the end of the lecture will be able to : Describe the applied anatomy of the airway.Describe the applied anatomy of the airway. Conduct a preoperative airway assessment .Conduct a preoperative airway assessment . Identify a potentially difficult airway.Identify a potentially difficult airway. Learn about management of airway obstruction.Learn about management of airway obstruction. Become familiar with airway equipment.Become familiar with airway equipment. Understand issues around aspiration Understand issues around aspiration

prophylaxis.prophylaxis. Become familiar with controlled ventilation.Become familiar with controlled ventilation. Appreciate ways of monitoring of ventilation Appreciate ways of monitoring of ventilation

and oxygenation.and oxygenation.

AIRWAY CONTROLAIRWAY CONTROLOpening the AirwayOpening the Airway

Jaw thrust Head tilt–chin lift

AIRWAY CONTROLAIRWAY CONTROLOropharyngeal AirwayOropharyngeal Airway

Mask VentilationMask Ventilation

Oral airwayOral airway Two-handed techniqueTwo-handed technique

AIRWAY CONTROLAIRWAY CONTROLOropharyngeal Airway (cont.)Oropharyngeal Airway (cont.)

AIRWAY CONTROLAIRWAY CONTROLNasopharyngeal Airway (cont.)Nasopharyngeal Airway (cont.)

OXYGENATION AND VENTILATIONOXYGENATION AND VENTILATIONBag-Valve-Mask (cont.)

With oxygen reservoir

Esophageal-Tracheal CombitubeEsophageal-Tracheal Combitube

A = esophageal obturator; ventilation into trachea through side openings = B

C = tracheal tube; ventilation through open end if proximal end inserted in trachea

D = pharyngeal cuff; inflated through catheter = E

F = esophageal cuff; inflated through catheter = G

H = teeth marker; blindly insert Combitube until marker is at level of teeth

Distal End

Proximal End

B

C

D

E

F

G

H

A

UsageUsage

Indications of intubationIndications of intubation

Resuscitation (CPR)Resuscitation (CPR) Prevention of lung soilingPrevention of lung soiling Positive pressure ventilation (GA)Positive pressure ventilation (GA) Pulmonary toiletPulmonary toilet Patent airway (coma or near coma)Patent airway (coma or near coma) Respiratory failure(CO2 retention )Respiratory failure(CO2 retention )

Airway AnatomyAirway Anatomy InnervationInnervation Vagus n.Vagus n.

Superior laryngeal n.Superior laryngeal n. External branch – motor External branch – motor

to cricothyroid m.to cricothyroid m. Internal branch – Internal branch –

sensory larynx above sensory larynx above TVC’sTVC’s

Recurrent laryngeal n.Recurrent laryngeal n. Right – subclavianRight – subclavian Left – Aortic arch (board Left – Aortic arch (board

question)question) Motor to all other Motor to all other

muscles, Sensory to muscles, Sensory to TVC’s and tracheaTVC’s and trachea

Management Management

I-History:I-History: previous history of difficulty is the best previous history of difficulty is the best

predictorpredictorInquire about:-Nature of difficultyInquire about:-Nature of difficulty -No of trials-No of trials -Ability to ventilate bet trials-Ability to ventilate bet trials -Maneuver used-Maneuver used -Complications-ComplicationsII-Snoring and sleep apnea( prdictors of II-Snoring and sleep apnea( prdictors of

DMV)DMV)

LEMONLEMON

-Look for any obvious anomaly -Look for any obvious anomaly Morbid obesity(BMI)Morbid obesity(BMI) SkullSkull FaceFace JawJaw Mouth,teethMouth,teeth Neck Neck

ExaminationExamination

I-The 3 joints movementsI-The 3 joints movements A-O joint(15-20 degrees)A-O joint(15-20 degrees)

Presence of a gap bet the Presence of a gap bet the

Occiput and C1 is essentialOcciput and C1 is essential The cervical spine(range>90)The cervical spine(range>90) T.M joint:T.M joint: -subluxation (1 finger)-subluxation (1 finger)

ExamineExamine Airway Airway

The 3 – 3 – 2 ruleThe 3 – 3 – 2 rule Mouth open: 3 fingersMouth open: 3 fingers Mentum to hyoid: 3 fingersMentum to hyoid: 3 fingers Floor of mouth to thyroid Floor of mouth to thyroid

cartilage: 2 fingerscartilage: 2 fingers

ExamineExamine Airway Airway

Mouth openMouth open: 3 fingers: 3 fingersAllows insertion of tube, Allows insertion of tube,

laryngoscopelaryngoscopeMentum to hyoidMentum to hyoid: 3 fingers: 3 fingers

Predicts ability to lift tongue Predicts ability to lift tongue into mandibleinto mandible

MallampattiMallampatti

Mallampatti test:Mallampatti test:

Based on the hypothesisBased on the hypothesis

That when the base of theThat when the base of the

Tongue is disproportionallyTongue is disproportionally

Large it will overshadow theLarge it will overshadow the

larynxlarynx

-Simple easy test,correlates with what is seen during -Simple easy test,correlates with what is seen during laryngoscopy or Cormack-Lehene grades ,butlaryngoscopy or Cormack-Lehene grades ,but

1-moderate sensitivity and specificity(12% false +ve)1-moderate sensitivity and specificity(12% false +ve)

2-Inter observer variation2-Inter observer variation

3-Phonation increases false negative view3-Phonation increases false negative view

II-Wilson testII-Wilson test

-Consists of 5 easily assessed factors-Consists of 5 easily assessed factors Body wight(n=0 ,>90=1,>110=2)Body wight(n=0 ,>90=1,>110=2) Head and neck movementHead and neck movement Jaw movementJaw movement Receding jawReceding jaw Buck teethBuck teeth

Each factor assigned as o ,1 ,2 max is Each factor assigned as o ,1 ,2 max is 1010

ObstructionObstruction

Apparent cause e.g. goitreApparent cause e.g. goitre OSAOSA Noisy breathing or stridorNoisy breathing or stridor Signs of upper airway obstructionSigns of upper airway obstruction Other causesOther causes

NeckNeck Mobility Mobility

Prior conditionPrior condition SurgerySurgery Rheumatoid Rheumatoid

arthritisarthritis OsteoarthritisOsteoarthritis OthersOthers

Proper EquipmentProper Equipment

-Bag and mask,oxygen source-Bag and mask,oxygen source

-Airways oro and nasopharyngeal-Airways oro and nasopharyngeal

-Laryngosopes different blades-Laryngosopes different blades

-ETT different sizes-ETT different sizes

-suction on-suction on

Airway gadgetsAirway gadgets

Mask VentilationMask Ventilation

Induction of Induction of anesthesia anesthesia produces upper produces upper airway relaxation airway relaxation and possible and possible collapsecollapse

Downward Downward displacement of displacement of mask with thumb mask with thumb and index fingerand index finger

Requirement of successful Requirement of successful intbatinintbatin

1-Normal roomy 1-Normal roomy mandiblemandible

2-Normal T-M, A-O 2-Normal T-M, A-O , and C-spine, and C-spine

Positioning for successful Positioning for successful intubationintubation

3-Alignment of 3 axes or3-Alignment of 3 axes or

Assuming sniffing positionAssuming sniffing position

-Any anomaly in these 3 joints-Any anomaly in these 3 joints

A-O, T-M or C-spine can resultA-O, T-M or C-spine can result

In difficult intubationIn difficult intubation

Endotracheal IntubationEndotracheal Intubation Look for epiglottisLook for epiglottis

If initially not found If initially not found insert laryngoscope insert laryngoscope furtherfurther

If this maneuver does If this maneuver does not work slowly pull not work slowly pull laryngoscope backlaryngoscope back

Once epiglottis visualized, Once epiglottis visualized, push laryngoscope into push laryngoscope into vallecula and apply vallecula and apply traction at 45 degree traction at 45 degree angle to “push” epiglottis angle to “push” epiglottis up and out of the wayup and out of the way

Confirm tube positionConfirm tube position

Direct visualization of ETT between Direct visualization of ETT between cordscords

Bronchoscopy ;carina seenBronchoscopy ;carina seen Continuous trace of capnographyContinuous trace of capnography 3 point auscultation3 point auscultation Esophageal detector deviceEsophageal detector device Other as bilateral chest Other as bilateral chest

movement,mist in the tube,CXRmovement,mist in the tube,CXR

Rapid sequence Rapid sequence inductioninduction

IndicationsIndications Technique: Technique:

-Preoxygenation-Preoxygenation

-IV induction with sux-IV induction with sux

-Cricoid pressure-Cricoid pressure

-Intubate, inflate the cuff ,confirm -Intubate, inflate the cuff ,confirm positionposition

-Release cricoid and fix the tube-Release cricoid and fix the tube

Cricoid pressureCricoid pressure

Cricoid Pressure

Complications of Complications of intubationintubation

1-Inadequate 1-Inadequate ventilationventilation

2-Esophageal 2-Esophageal intubationintubation

3-Airway obstruction3-Airway obstruction

4-Bronchospasm4-Bronchospasm

5-Aspiration5-Aspiration

6- Trauma6- Trauma

7-Stress response7-Stress response

Difficult airwayDifficult airway

CausesCauses

-Congenital-Congenital

-Acquired-Acquired

Airway gadgetsAirway gadgets

Rigid Fiberoptic ScopeRigid Fiberoptic Scope

Bullard Bullard Wu ScopeWu Scope

Rigid Fiberoptic ScopeRigid Fiberoptic Scope

Upsher Upsher GlideScopeGlideScope

Difficult airwayDifficult airway

Expected from history,examinationExpected from history,examination

Secure airway while awake under LASecure airway while awake under LA

Unexpected different optionsUnexpected different options

Priority for maintenance of patent Priority for maintenance of patent airway and oxygenationairway and oxygenation

Transtracheal Jet Transtracheal Jet VentilationVentilation

VentilationVentilation

Spontaneous ventilationSpontaneous ventilation Controlled ventilationControlled ventilation Minute volume dividerMinute volume divider

-Tidal volume 10 mls/kg-Tidal volume 10 mls/kg

-Respiratory rate to maintain -Respiratory rate to maintain normocarbianormocarbia

-I:E ratio -I:E ratio

RecommendationsRecommendations

Adequate airway assessment to pick up Adequate airway assessment to pick up expected D.A to be secured awakeexpected D.A to be secured awake

Difficult intubation cart always readyDifficult intubation cart always ready Pre oxygenation as a routinePre oxygenation as a routine

Maintenance of oxygenation not the Maintenance of oxygenation not the intubation should be your aimintubation should be your aim

Use the technique you are familiar withUse the technique you are familiar with Always have plan B,C,D in unexpected D.AAlways have plan B,C,D in unexpected D.A

ReferencesReferences

Anesthesia and resuscitationAnesthesia and resuscitation Dr. H .BradenDr. H .Braden chapters 1,2 Airway and ventilationchapters 1,2 Airway and ventilation

Lecture notes on clinical anesthesiaLecture notes on clinical anesthesia Carl Gwinnutt Carl Gwinnutt 22ndnd edition edition Chapter 2 page 18-29Chapter 2 page 18-29

DrDr. Adel Elshimy. Adel Elshimy

Date: 18/10/2011Date: 18/10/2011

TThank You hank You