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airway management
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Airway ManagementAirway Management
Augusto Torres, MDAugusto Torres, MD
Department of AnesthesiologyDepartment of Anesthesiology
MetroHealth Medical CenterMetroHealth Medical Center
OutlineOutline
Review of airway anatomyReview of airway anatomy
Airway evaluationAirway evaluation
Mask ventilationMask ventilation
Endotracheal intubationEndotracheal intubation
The difficult airwayThe difficult airway
Airway AnatomyAirway Anatomy
Ab-ductorAb-ductor– Posterior Posterior
cricoarytenoidcricoarytenoid
TensorTensor– CricothyroidCricothyroid
Ad-ductorsAd-ductors– All the restAll the rest
Airway AnatomyAirway Anatomy
InnervationInnervationVagus 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 – subclavianLeft – 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
Airway AnatomyAirway Anatomy
Innervation of Innervation of oropharynxoropharynx– Glossopharyngeal n. Glossopharyngeal n.
innervates tongue innervates tongue base and oropharynxbase and oropharynx
Airway AnatomyAirway Anatomy
MembranesMembranes– ThyrohyoidThyrohyoid– CricothryoidCricothryoid
CartilagesCartilages– HyoidHyoid– ThyroidThyroid– CricoidCricoid
Airway EvaluationAirway Evaluation
Take very seriously Take very seriously history of prior difficultyhistory of prior difficulty
Head and neck Head and neck movement (extension)movement (extension)– Alignment of oral, Alignment of oral,
pharyngeal, laryngeal axespharyngeal, laryngeal axes– Cervical spine arthritis or Cervical spine arthritis or
trauma, burn, radiation, trauma, burn, radiation, tumor, infection, tumor, infection, scleroderma, short and scleroderma, short and thick neckthick neck
Airway EvaluationAirway Evaluation
Jaw MovementJaw Movement– Both inter-incisor gap and Both inter-incisor gap and
anterior subluxationanterior subluxation– <3.5cm inter-incisor gap <3.5cm inter-incisor gap
concerningconcerning– Inability to sublux lower Inability to sublux lower
incisors beyond upper incisors beyond upper incisorsincisors
Receding mandibleReceding mandible
Protruding Maxillary Protruding Maxillary Incisors (buck teeth)Incisors (buck teeth)
Airway EvaluationAirway Evaluation
ObesityObesity– Distribution, i. e. short, Distribution, i. e. short,
thick neck more thick neck more concerningconcerning
– Neck circumferenceNeck circumference
Airway EvaluationAirway Evaluation
Thyromental distance: Thyromental distance: bony point on bony point on mentum (mandible) to mentum (mandible) to thyroid notchthyroid notch
If short (<3FB’s or If short (<3FB’s or 6cm), pharyngeal and 6cm), pharyngeal and laryngeal axis offlaryngeal axis off
Airway EvaluationAirway EvaluationOropharyngeal visualizationOropharyngeal visualization
Mallampati ScoreMallampati Score
Sitting position, protrude tongue, don’t say Sitting position, protrude tongue, don’t say “AHH”“AHH”
Airway EvaluationAirway Evaluation
Difficulty ventilatingDifficulty ventilating– Age >55Age >55– BeardBeard– History of snoringHistory of snoring– Lack of teethLack of teeth– BMI >26BMI >26
PreoxygenationPreoxygenation
Replaces the nitrogen volume of the lungs Replaces the nitrogen volume of the lungs (69% of FRC) with oxygen(69% of FRC) with oxygenFunctional residual capacity (residual Functional residual capacity (residual volume and expiratory reserve volume)volume and expiratory reserve volume)Preoxygenation with 100% oxygen via Preoxygenation with 100% oxygen via tight-fitting mask for 5 minutes tight-fitting mask for 5 minutes up to 10 up to 10 min of oxygen reserve following apneamin of oxygen reserve following apneaFour vital capacity breaths over 30 Four vital capacity breaths over 30 seconds (time to desaturation quicker)seconds (time to desaturation quicker)
Patient PositioningPatient Positioning
Sniffing positionSniffing position– Lower neck flexionLower neck flexion– Upper neck extensionUpper neck extension– Important in obesityImportant in obesity
Mask VentilationMask Ventilation
Induction of Induction of anesthesia produces anesthesia produces upper airway upper airway relaxation and relaxation and possible collapsepossible collapse
Downward Downward displacement of mask displacement of mask with thumb and index with thumb and index fingerfinger
www.aic.cuhk.edu.hk
Mask VentilationMask Ventilation
Upward traction of Upward traction of remaining fingers remaining fingers upwardupward
Fingers on bony Fingers on bony mandiblemandible
Fifth digit at angle Fifth digit at angle displacing mandible displacing mandible anteriorlyanteriorly
www.aic.cuhk.edu.hk
Mask VentilationMask Ventilation
Oral airwayOral airway
Two-handed techniqueTwo-handed technique
www.aic.cuhk.edu.hk
www.haworth21.karoo.net
LMA PlacementLMA Placement
Carries prominent Carries prominent position in ASA algorithmposition in ASA algorithm
May be held like a pencilMay be held like a pencil
Balloon partially inflatedBalloon partially inflated
Directed posteriorly and Directed posteriorly and upwards towards the upwards towards the palatepalate
Jaw thrust and sniffing Jaw thrust and sniffing position may help position may help placementplacement
www.brandianestesia.it/Images/LMA-ins.jpg
LMA PlacementLMA Placement
Verify placement by ventilatingVerify placement by ventilating– Check for good chest rise, ETCO2, and Check for good chest rise, ETCO2, and
adequate tidal volumesadequate tidal volumes– Check for leak – if significant leak at around Check for leak – if significant leak at around
10cm H2O problematic10cm H2O problematic– May try size larger or smallerMay try size larger or smaller– May try to inflate/deflate cuff to obtain better May try to inflate/deflate cuff to obtain better
sealseal– If difficulty passing may try inserting upside If difficulty passing may try inserting upside
down and then flipping arounddown and then flipping around
Endotracheal IntubationEndotracheal IntubationOpen the mouth with right Open the mouth with right handhand
– Scissor techniqueScissor technique
Gently insert laryngoscope Gently insert laryngoscope into right side of mouth into right side of mouth pushing tongue to the leftpushing tongue to the left
Careful with insertion not Careful with insertion not to hit teethto hit teeth
Advance laryngoscope Advance laryngoscope further into oropharynx further into oropharynx with applied traction 45 with applied traction 45 degrees degrees
Endotracheal IntubationEndotracheal IntubationLook for epiglottisLook for epiglottis– If initially not found insert If initially not found insert
laryngoscope furtherlaryngoscope further– 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 traction vallecula and apply traction at 45 degree angle to at 45 degree angle to “push” epiglottis up and out “push” epiglottis up and out of the wayof the way
www.int-med.uiowa.edu/Research/TLIRP/Bronchos
Endotracheal IntubationEndotracheal IntubationLook for vocal cords or arytenoid Look for vocal cords or arytenoid cartilages and try to optimize viewcartilages and try to optimize view– (i.e. lift head, apply more (i.e. lift head, apply more
traction at 45 degree angle if traction at 45 degree angle if necessary)necessary)
Do not move once view is Do not move once view is optimized!optimized!– Assistant will hand you ETTAssistant will hand you ETT
Insert ETT into far right aspect of Insert ETT into far right aspect of mouthmouth– Traction of laryngoscope Traction of laryngoscope
slightly to left may assistslightly to left may assist– Traction of laryngoscope at 45 Traction of laryngoscope at 45
degrees will also help keep degrees will also help keep mouth openmouth open
Endotracheal IntubationEndotracheal Intubation
Insert ETT above and between arytenoids Insert ETT above and between arytenoids and through vocal cordsand through vocal cords
Try to visualize the ETT passing between Try to visualize the ETT passing between the vocal cordsthe vocal cords– If this is not possible, then you must visualize If this is not possible, then you must visualize
the ETT passing above and between the the ETT passing above and between the arytenoidsarytenoids
Endotracheal IntubationEndotracheal IntubationCommon problems:Common problems:– ““I can’t see anything!”I can’t see anything!”
Make sure tongue is Make sure tongue is swept to the leftswept to the left
You are probably too You are probably too shallow or too deep. Even shallow or too deep. Even with difficult intubations with difficult intubations the epiglottis can be the epiglottis can be visualizedvisualized
Insert laryngoscope in Insert laryngoscope in further looking for further looking for epiglottisepiglottis
Pull laryngoscope back if Pull laryngoscope back if this failsthis fails
Endotracheal IntubationEndotracheal IntubationCommon problemsCommon problems– ““I can’t see the cords!”I can’t see the cords!”– Epiglottis is visualized, vocal cords are notEpiglottis is visualized, vocal cords are not– Removing the epiglottis partly from view is Removing the epiglottis partly from view is
necessary to visualize the vocal cords belownecessary to visualize the vocal cords below– Push the end of the laryngoscope blade Push the end of the laryngoscope blade
further into the vallecula and “toe up”further into the vallecula and “toe up”– Lifting the patient’s head with your other hand Lifting the patient’s head with your other hand
may improve the sniffing position and bring may improve the sniffing position and bring the vocal cords into viewthe vocal cords into view
Endotracheal IntubationEndotracheal IntubationCommon problemsCommon problems– ““I can see the cords. But I can’t get the tube I can see the cords. But I can’t get the tube
there!”there!”– You may not be giving yourself adequate You may not be giving yourself adequate
room in the oral cavityroom in the oral cavity– Push up and to the left with the laryngoscope Push up and to the left with the laryngoscope
to make sure the mouth is still fully opened to make sure the mouth is still fully opened and the tongue adequately swept awayand the tongue adequately swept away
– Slide the ETT in the mouth all the way to the Slide the ETT in the mouth all the way to the right side, perhaps even sidewaysright side, perhaps even sideways
Difficult IntubationDifficult Intubation
ASA Difficult Airway Algorithm ASA Difficult Airway Algorithm
www.metrohealthanesthesia.comwww.metrohealthanesthesia.com
Fiberoptic IntubationFiberoptic Intubation
Oral or nasal routesOral or nasal routes
Topicalization is keyTopicalization is key– Aerosolized lidocaine 4%Aerosolized lidocaine 4%– Airway blocksAirway blocks
Thin bronchoscope inserted into tracheaThin bronchoscope inserted into trachea
Other airway optionsOther airway options
GlideScopeGlideScope
Needle cricothyroidotomyNeedle cricothyroidotomy
ConclusionConclusion
Airway management is an extremely important Airway management is an extremely important aspect of the practice of anesthesiology and aspect of the practice of anesthesiology and critical carecritical care
A firm basis in airway anatomy is neededA firm basis in airway anatomy is needed
Skills such as mask ventilation, endotracheal Skills such as mask ventilation, endotracheal intubation, LMA placement are necessaryintubation, LMA placement are necessary
In the case of a difficult airway, a logical In the case of a difficult airway, a logical algorithm and airway equipment assist the algorithm and airway equipment assist the physician in safely managing the situationphysician in safely managing the situation