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1. LARYNGOSCOPES
Face Masks—Airways
and Endotracheal Tubes
--Dr Nisar Ahmed Arain
-------Assistant Professor
Anesthesia/Critical Care/ER

2. FACE MASK

3. INTRODUCTION
1-It is the device which allows
administration of gases to
the patient from the breathing
system without introducing
any apparatus to the patients
mouth

4. DESCRIPTION OF MASK
---A Face mask can be made
up of Black rubber, clear
Plastics, Elastomeric
material or combination
of these Parts of the
Face Mask
BODY
-It constitutes the main
part of the mask.
This Transparent
body allows observation
of Moisture, Vomitus,
and secretions etc.

5. SEAL:-
---This comes in contact with the
Face. Two types are available
a-Pad or Cushion:-Inflated with air
b-Flap:-Flexible extension of the body
CONNECTOR:- (Orifice / collar )
a-Opposite to the seal
b-Thickened fitting of 22 mm ID
c-Ring with hooks helps in strapping
the Mask

6. SPECIFIC MASKS
-This can be moulded to conform
to the Anatomy of Face
-It has slightly Malleable rubber
body, a sharp notch for the nose
and a curved chin section
-- 1-Anatomical Mask

7. 2-RANDELL-BAKER-SOUCEK
(RBS) mask
-It is designed for Pediatric
patients < then 10 years
-It has a triangular body
and Low dead space
-It is used in Tracheostomy
and Acromegaly patients

8. Size
Age group Dead space
0 preterm 3 cu.mm
1 infant 4 cu.mm
2 1 to 3 years 8 cu.mm
3 4 to 10 years 12 cu.mm

9. 3-ENDOSCOPY MASK
-Designed to allow mask
ventilation during
Endoscopy
-It has a port or Diaphragm
in the body to allow Fibro
scope insertion

10. 4-SCENTED MASK
-Scent incorporated into the Mask by the
manufacturer or Anesthetic provider
-Added for better acceptability and
pleasant experience during induction
-Its Disadvantage is Ethyl Alcohol in
some flavours may affect accuracy of
Gas monitors -

11. TECHNIQUES OF USE
-The face mask should form tight seal on the
patients face while fitting comfortably in the
user’s hands
-The smallest mask is most desirable because
It will cause least increase in dead space
-It is easy to hold and less likely to result in
pressure on Eyes
-There are several methods of holding Mask

12. ONE HAND METHOD
-The Thumb and the index finger of the Left hand
are placed on mask body on opposite sides of
connecter to push it downward to prevent Leak
-The remaining three fingers are placed on the
mandible such that middle finger is applied to
the mentum, the ring finger on the body of the
mandible and little finger at angle of the
mandible to give Jaw thrust anteriorly.

13. ONE HAND METHOD TECHNIQUE

14. TWO HANDED METHOD
TECHNIQUE
-As it requires both hands, a second person is
necessary for assisted or controlled ventilation
-Here thumbs are placed on the either side of the
body of masks, and index fingers are placed
under the angles of the Jaw, Mandible is lifted
and head is extended
-If a leak is present, downward pressure on mask
can be increased by Anesthiologist’s chin on the
mask elbow

16. TWO HANDED METHOD TECHNIQUE
Two Handed Jaw Thrust
One person stands at head end
of patient and performs jaw
thrust with his left hand at angle
of left mandible while his right
hand compresses the reservoir
bag.
The 2nd person stands at the
patients shoulder facing 1st
person. This persons Rt hand
covers the Lt hand of the 1st
person and the Lt hand
Achieves Rt sided Jaw thrust
and mask seal.

17. Claw Hand Technique
-It is useful for children undergoing short
duration procedures.
-The Anesthesiologists stands at the side of
bed facing the child.
-The face mask is applied to face by using the
Rt hand with the palmar surface facing
upwards. The ring & middle finger are
placed under the angle of jaw & the index
finger & thumb encircle the body of mask.

18. Dead space in face masks
-Face mask and its adaptor increase dead
space and it may contribute 30% or more
of tidal volume in neonates and infants.
- It can be reduced by
a- using smaller size mask
b- increasing pressure on mask
c- blowing a jet of fresh gas into the
mask
d- changing the volume of the seal
cushion

19. Advantages
-Lower incidence of sore throat
- requires less anesthetic depth
than tracheal tube or supraglottic
device
- No need of muscle relaxants
- The face mask may be the most cost
efficient method for short cases

20. Disadvantages
-Anesthesiologist`s hands are tied up
-Higher fresh gas flows are often needed
-During remote anesthesia, airway access
is difficult (CT & MRI)
-Often more episodes of oxygen
desaturation & require more
intraoperative airway manipulations

21. Complications
-Skin problems- dermatitis, pressure necrosis
- Nerve injury
-Eye injury – conjunctival chemosis, eyelid
edema & corneal injuries.
-Gastric Inflation
-Latex allergy
- Lack of co-relation between arterial & end
tidal CO2
-Environmental Pollution with anesthetic
gases
-Jaw Pain & User fatigue.

22. AIRWAY

23. Introduction
-A fundamental responsibility of anesthesia
providers is to maintain a patent airway
-The airway passage has a rigid posterior wall
and a collapsible anterior wall consisting of
the tongue and epiglottis
-Under anesthesia the tongue & epiglottis
falls back into the posterior pharynx
occluding the airway
-The purpose of airway is to lift the tongue
and epiglottis away from the posterior
pharyngeal wall & maintain a patent airway

25. Terminology
Artificial airway
-Any device that aims to maintain oral or
nasal air passages. It may be
-Simple supraglottic device such as
oropharyngeal or nasopharyngeal airways.
These may not be sufficient to maintain the
patency of airway on their own and may
require patients jaw to be supported as well
- Augmented supraglottic device such as LMA
and airway management
-Infraglottic devices such as Endotracheal
tubes, tracheostomy tubes, jet ventilation
catheters.

26. Oropharyngeal Airways
Description
-It extends from lips to pharynx, fitting between
tongue and posterior pharyngeal wall. Made up
of elastomeric or plastic materials. Parts are
-Flange  it is at buccal end to prevent it from
moving deeper into mouth & may also serve to
fix airway in place.
-Bite Portion  it is straight & fits between
teeth or gums
-Curved portion  extends backwards to
correspond the shape of tongue & palate.

27. size colour length(cm)
000 Violet 3.5
00 Blue 4.5
0 Black 5.5
1 White 6.5
2 Green 7.5
3 Orange 8.5
4 Red 9.5
5 Yellow 10.5
SIZES
--The American National Standard specifies that the size of
oral airways be designated by a no. i.e the length in cms.

28. SPECIFIC AIRWAYS
Most frequently used airway & has large flange &
reinforced bite portion with tubular channel for air
exchange & suctioning.
--Guedel Airway

29. Cuffed Oro-Pharyngeal Airway
-It is Guedel`s Airway with an inflatable cuff designed to seal the
oropharynx. It has an integral bite block & a 15mm connector for
attachment of the breathing circuit.
-The cuff is inflated with air to displace the base of tongue and
form a low pressure seal with the pharynx & provide an open
airway.

30. Patil-Syracuse Endoscopic Airway
-It was designed to aid fiber-optic intubation. It is
made of aluminum
- It has lateral channels & a central groove on the
lingual surface to allow passage of fiberscope. A slit
in distal end allows fiberscope to be manipulated in
antero-posterior direction but limits lateral movements.

31. Berman Intubating Airway
--It is tubular along its entire length. It is open on one
side so that it can be split & removed from around
a tracheal tube. It can be used as an oral airway or
as an aid to fiberoptic or blind oro-tracheal intubation

32. Williams Airway Intubator
-It is designed for blind tracheal intubation and can also
be used for fiberoptic intubation or as an oral airway.
-It is available in 2 sizes #9 and #10 which will admit
upto 8 and 8.5 mm tracheal tube respectively.
-The proximal half is cylindrical while distal half is
open on lingual surface

33. Ovassapian Fiberoptic Intubating Airway
-Designed for fiberoptic intubation
-Has a flat lingual surface which gradually widens at
distal end and 2 vertical sidewalls at the buccal end
between the sidewalls are a pair of guide walls that
curve towards each other which are flexible and
permit removal of airways around the tracheal tube
- The proximal half is tubular & acts as bite block. The
distal half is opened posteriorly & it can
accommodate tracheal tube upto 9 mm id

34. .
METHODS OF INSERTION
OF AIRWAYS
- Pharyngeal and laryngeal reflexes should be
depressed before an airway is inserted to
avoid coughing and laryngospasm.
- Selecting the correct size of airway is
important correct size is estimated by
holding the airway next to pts mouth & the
tip should be at the angle of mandible
-The best criteria for proper size & position is
unobstructed gas exchange

35. Oral airway may be inserted
in two ways
--The jaw opened with left
hand
--The airway is inserted
with its concave side
towards the upper
lip and when the junction
of bite portion and curved
section is near the
incisors, the airway is
rotated 180° and slipped
behind the tongue in the
final position

36. A tongue blade is used to
push forward and depress
the tongue & the airway
is inserted with concave
side towards the tongue &
is advanced.
Oral airway may be insertion

37. OTHER USES
-May be used to prevent patient
from biting and occluding ETT
-Protect the tongue from biting
-To facilitate suctioning
-To obtain better mask fit

38. NASOPHARYNGEAL AIRWAY
(nasal trumpet/ nasal airway)
-It extends from nose to pharynx, the pharyngeal
end should be below base of tongue but above
the epiglottis.
-A nasal airway is better tolerated than oral airway
if the pt has intact airway reflexes.
Description
-It resembles a shortened tracheal tube with a
flange at the outer end to prevent it from
completely passing into the naris. It is made
up of plastic or rubber and the size is
designated by the inner diameter in mm

39. --Nasopharyngeal airway

40. Nasopharyngeal airway
specific types
-It is plastic with large flange and flat
distal end and is supplied with an
introducer which has balloon on its
tip
-Before insertion, the introducer is
inserted into the airway until the tip
of balloon is just past the end
-Air is injected until the balloon tip
is inflated to approx outer diameter
of tube
-The complete assembly is lubricated
and inserted through the nostril
after it is in place, the balloon is
deflated & introducer is removed
-- Linder Nasopharyngeal Airway

41. Cuffed Nasopharyngeal Airway
It is similar to a short, cuffed tracheal tube. It is inserted
through the nose into the pharynx; cuff inflated & then is
pulled back until resistance is felt.
Binasal Airway
It consists of 2 nasal airways joined together by an adaptor
for attachment to the breathing system. Can be used to
administer anesthesia

42. INSERTION
The diameter of nasal airway should be the
same as needed to insert the tracheal tube
(0.5-1.0mm smaller than oral tracheal tube).
Before insertion it should be lubricated
thoroughly along its entire length. The airway
is held with the bevel against septum & gently
advanced posteriorly while being rotated back
& forth.

43. COMPLICATIONS
1-Airway obstruction
2-Epistaxis
3-Ulceration & Necrosis
4-Dental Damage
5-CNS trauma
6-Laryngospasm & Coughing
7-Aspiration or Swallowing of
part or all of the airway
8-Latex Allergy
9-Gastric distension

44. LARYNGOSCOPES

45. --A laryngoscope is an instrument used to
view larynx and adjacent structures, most
commonly for introducing tube into the
trachea
--Laryngoscopes can be considered under two
broad headings
--Retractor type like the Macintosh laryngoscope
--Fibreoptic Laryngoscope
Two types are available
- Rigid fiberoptic laryngoscope
- Flexible fiberoptic laryngoscope
Introduction of Laryngoscopes

46. RIGID LARYNGOSCOPES
-These are manufactured either as single piece or
separate detachable blade and handle.
-For detachable handle & blade the light source is
energized when blade & handle are locked in
operating position.
A single piece laryngoscope has a switch on handle
that controls power to lamp.
Rigid Laryngoscope has 2 parts
1. Handle 2. Blade

47. Handle
-The handle is the part that is held in the hand
during use. It provides the power source for the
light. Most often this is from disposable batteries
-Fiberoptic illuminated laryngoscope may use a
remote electrically operated light source.
-The handle is fitted with a hinge pin that fits a
slot on the base of the blade

48. Handles are available in variable sizes
and have rough surface for improved grip

49. -Although most blades form right angle with
the handle when ready to use. The angle may
also be acute or obtuse.
- An adapter may be fitted between the handle
and the blade to allow angled to be altered.
Howland lock is such an example.
-The patil-syracuse handle can be positioned
and locked in four different positions
(45°, 90°, 135° and 180°)

50. Patil-syracuse handle

51. size Intended use
000 Small premature infant
00 Premature infant
0 Neonate
1 Small child
2 Child
3 Adult
4 Large adult
5 Extra large adult
Blade
-The blade is a component that is inserted into the mouth
-When a blade is available in more than one size, blades
are numbered, with the number increasing with size.

52. Parts of the blade include
1. base
2. spatula/tongue
3. heel
4. flange
5. web
6. tip
7. light source

53. Types of Blades
-There are several types of blades which may be
advantageous in some particular situations.
-- Macintosh Blade
--The Macintosh blade is one of the most popular. The tongue has a
smooth, gentle curve that extends from the base to the tip. In cross-
section, the tongue, web. and flange form a reverse 'Z'. Cervical spine
movement is greater compared to the Miller blade.

54. Left handed Macintosh Blade
-- The left handed Macintosh blade has the flange on the opposite
side from the usual Macintosh blade. This blade may be useful for
the abnormalities of right side of the face or oropharynx, left
handed persons, intubating in the right lateral position, and
positioning a tracheal tube directly on the left side of the mouth.

55. Improved Vision Macintosh Blade
The Improved Vision (IV) Macintosh blade is similar to the
standard version except that the mid portion of the tongue
is concave to allow greater visualization of the larynx

56. Polio Blade
-The blade is offset from the
handle at an obtuse angle to
allow intubation of patients in
iron lung respirators or body
jackets
- Patients with obesity, breast
hypertrophy, kyphosis with
severe barrel chest deformity,
short neck, or restricted neck
mobility.
-Disadvantages of this blade are
that little force can be applied
and control is minimal

57. Oxiport Macintosh (Mac/port)
The Oxiport Macintosh blade a conventional
Macintosh blade with a tube added to deliver
oxygen

58. Tull Macintosh
The Tull (suction) blade is a modified Macintosh that has a
suction port near the tip. The suction channel extends next
to the handle and has a finger controlled valves so that
suction can be controlled by the laryngoscopist.

59. Fink Blade
-The Fink blade is another modification of the
Macintosh
-The tongue is wider and has a sharper curve at
the distal end. The height of the flange is
reduced, especially at the proximal end The
light bulb is placed farther forward than on
the Macintosh

60. Bizarri-Guiffrida Blade
-The Bizarri-Guiffrida blade is a modified Macintosh.
The flange is removed except for a small part that
encases the light bulb.
-This was made to limit damage to the upper teeth
-The blade is useful for patients with a limited mouth
opening, prominent incisors, receding mandible, short
and thick neck or anterior larynx

61. Miller Blade
-The tongue is straight with a
slight upward curve near the
tip
-In cross-section the flange
web, and tongue form a C
with the top fattened
-The lamp may be either on
the right or left side of the
blade.

62. Oxiport Miller Blade
=The Oxiport Miller (also
called Miller/port,
oxyscope) blade has a built-
in tube that allows delivery
of oxygen or other gases
during intubation. The tube
also may be used for
suction.
=Insufflation of oxygen
during intubation using this
blade has been found to
decrease oxygen
desaturation in
spontaneously breathing
anesthetized patients

63. Tull Miller Blade
=Tull (suction) Miller blade is a standard
Miller blade with a suction tube
whose port ends near the tip of the
blade
=Near the handle is a finger-controlled
port that allows control of suction
with a finger.

64. Mathews Blade
-The Mathews blade is a straight blade with a wide and
flattened petaloid configuration tip. It is designed for
difficult nasotracheal intubations

65. Alberts Blade
=It has a cut-away flange to increase the visibility.
There is recess to facilitate tracheal tube insertion.
The blade forms a 67° angle with the handle. It is
used for pediatric pts

66. Double Angle Blade
=The spatula of double angle
blade has 2 angulations 20° and
30°, to improve lifting of the
epiglottis.
=The flange has been
eliminated. The bulb is located
at left edge of the blade
between the 2 curvatures. The
blade may be useful for the
patient with anterior larynx.

67. Flexible tip blade
=It has a hinged tip that is controlled by lever
attached to the proximal end of the blade
=When the lever is pushed towards the handle
the tip of the blade is flexed eg: Mc-Coy, flipper
flex tip etc.
=It may improve the chances of successful
intubation by elevating the epiglottis
particularly in case of difficult intubation.
=Less force and less stress response.

68. Mc Coy blade

69. Techniques of use
positioning the head
The head should be positioned so that the passage-
way to the larynx is brought into a straight line for
the best possible view of the vocal cords.
The optimal position for most patients is flexion of
35° of the lower cervical spine and extension of the
head of 85-90° at the atlanto-occipital level, the so-
called sniffing position.
In children, it may be unnecessary to flex the lower
cervical vertebrae, and in neonates it may be
necessary to elevate the shoulders because the head
is relatively larger.

70. =The laryngoscope handle is held in the left hand.
The fingers of the right hand are used to open the
mouth and spread the lips apart.
=The blade is inserted at the right side of the mouth
=This reduces the likelihood of incisor teeth damage
and helps push the tongue to the left.
=The blade is advanced on the side of the tongue
toward the right tonsillar fossa, so that the tongue
lies on the left side of the blade
=When the right tonsillar fossa is visualized, the tip of
the blade is moved toward the midline. The blade is
then advanced behind the base of the tongue
elevating it, until the epiglottis comes into view.

71. =There are two methods for elevating the
epiglottis, depending on whether a straight or
curved blade is being used.
Straight Blade Technique
=The blade is made to scoop under the epiglottis
and lift it anteriorly. The vocal cords should be
identified.
=If the blade is advanced too far, it will result in
elevation of the larynx as a whole rather than
exposure of the vocal cords.
=The straight blade can also be inserted into the
vallecula and used in the same manner as a
curved blade.

72. Curved Blade
=After the epiglottis is seen, the blade is
advanced until the tip fits into the
vallecula
=Traction is then applied along the handle
at right angles to the blade to carry the
base of the tongue and the epiglottis
forward.
=The glottis should come into view

73. The Curved and Straight Blades

74. Bullard laryngoscope
RIGID FIBEROPTIC LARYNGOSCOPES
=Description  It has a rigid metal
blade specially shaped to follow the
contour of the oropharynx.
=Fiberoptic bundles for illumination &
operatory viewing are housed in a
sheath on the posterior aspect of
blade
=A viewing arm with eye-piece extends
at a 45°angle from the handle. A
video camera can be attached to
eyepiece for remote viewing.
=A working channel extends from the
scope body to the point where the
light bundles end at the tip. It can
be used for suction, oxygen
insufflations, administration of
L.A/ Saline, or jet ventilation
catheter.

75. a-Pediatric
b-Pediatric long – for babies upto 8-10yrs of age
c-Adult version – for children more than 10yrs &
adults
Advantages
=It causes less cervical spine movement than
conventional laryngoscopy.
=Requires mouth opening of only 7mm
=Rapidity of intubation
= Low risk of failed intubation or trauma to
lips or teeth
-- SIZES
--3 sizes are available

76. Disadvantages
=Requires experience & Maintenance of
skills & is somewhat expensive
=Intubation with ETT >7.5mm may be
more difficult.
=Certain ETT & Double lumen tubes will
not fit the stylet

77. Wu-Scope
It combines a rigid, tubular
blade & a flexible fiberscope.
Flexible Fiberscope portion
The fiberscope has short light &
image transmitting fiberoptic
bundles & tip deflection
control
Blade portion
It has 3 detachable metal parts
handle, main blade & bivalve
element.
Details

78. Handle
=cone shaped tube that receives the fiberscope
at the top & connects to the main blade at
the base. The handle to blade angle is 110°
Main blade & bivalve element
are anatomically shaped
When positioned together, they form 2 passage
ways- a larger 1 for suction catheter or ETT
& a smaller 1 for fiberscope.
=An oxygen channel is alongside the slot for
fiberscope
=Different sizes of blades & bivalve element
can be used with the handle
=The adult blade can accommodate ETT upto
8.5mm

80. Advantages
=Can be used successfully to place both
tracheal & double lumen bronchial
tubes in difficult-to-intubate pts
=No forceps or stylet is needed so risk
of airway injury is low
=Suctioning & oxygen administration
can done simultaneously. Unlike
flexible fiberoptic endoscopy, one can
view ETT passing through glottis into
trachea.
=There is no need for head extension or
tongue lifting.

81. Disadvantages
=Requires experience or
Maintenance of skills & high
initial cost
=Time required to assemble or
disassemble the device is more
=Application of cricoids pressure
decreases the ease of intubation
while using this device.

82. Upsher-Scope
Details
=It consists of C-shaped metal
blade, shaped to approximate
curve of oropharynx.
=The distal part has an
upward curve. To the left are 2
tubes that carry fiberoptic
bundles
Proximally the viewing bundle
terminates in the eye piece
while the light bundle makes
contact with the light source at
the handle.. It is presently
available only in adult size

83. Advantages
=It can be used with all size of adult ETT
=Useful to intubate pts with difficult
airways in a reasonable time
Disadvantages
=Not suitable for naso-tracheal intubation
=In routine intubation this scope has
demonstrated no advantages over the
conventional laryngoscopes

84. VIDEO LARYNGOSCOPE
=It can be created by attaching video system to a
flexible laryngoscope or an optical stylet. It has
many advantages
=The displayed anatomy is magnified & a larger
viewing angle is provided
=In addition to allowing laryngoscopy & intubation to
be visualized, it can be used to observe vocal cord
movements after thyroid surgery, verify tracheal
tube position & aid in tracheal tube exchange
= Results in less neck movement than conventional
laryngoscopy
=By projecting the image it makes a good teaching
tool
=Limitations of these device is the need for a video
endoscopy monitoring system

85. =It has Macintosh blade
attached to the handle
= The image- light bundle
is threaded through a
small guide in the blade
& advanced 2/3 of the
length of the blade
=Provides better view
than traditional
Macintosh Laryngoscope
VIDEO MACINTOSH
INTUBATING LARYNGOSCPE

86. GLIDE SCOPE
Description
=It has a miniature digital camera
underside of a plastic blade.
A light emitting device( LED)
mounted beside the camera
provides illumination
=Blade has a 60° bend at the
midpoint The Glide Scope is
available in adult & pediatric
sizes
=Studies shows this scope yields
a comparable or superior glottis
view compared to direct
laryngoscopy
=It causes less cervical
movements than Macintosh
blade

87. FLEXIBLE FIBEROPTIC
LARYNGOSCOPE
Introduction
=The 1st use of flexible fiberoptic technology in the
airway management can be credited to Dr P Murphy
who in 1967 invented Choledochoscope for intubation
of trachea
=The flexibility of these devices means that they can
be made to follow virtually any anatomical space to
return an image of the objective. The technique of
flexible fibreoptic intubation has become a gold
standard for management of difficult laryngoscopy.
=This has tended to create the impression that the
technique is solution to all difficult airways, but this
is patently not so.

88. Principles & Design
=The pathway through which the illumination &
the image pass consists of thousands of very fine
glass fibers, each typically of 10µm in diameter
Each fiber consists of a central glass core surrounded
by a thin cladding of another type of glass with
different refractive index. As a result of difference
in refractive indices, light entering the glass fiber
undergoes total internal reflection along the length
of the fiber to emerge at the other end
For image transmission, the arrangement of fibers
relative to one another must be identical at either
end of the bundle, as each fiber carries tiny portion
of the overall image. This is called a COHERENT
BUNDLE.

90. Parts
=It is composed of several parts, a light source, handle &
flexible insertion portion.
The handle is the part to be held in hand during use. It
includes the eyepiece, focusing ring, working channel port &
the tip control lever.
The insertion tube carries
2 light bundles
1 image bundle
1 working or biopsy channel
2 angulation wires, which control the more flexible tip of
device

91. = These are held together with a
stainless steel spiral wrap followed
by a stainless steel braid & covered
by waterproof material, to give a
rigid cross section while allowing
overall flexibility. The fiberscope is
axially rigid to twisting forces thus
rotation of the control handle results
in similar rotation of the tip.
=The fiberscope uses a powerful
external cold light source so that the
tissues are not damaged by radiant
heat.

92. Usage
=The intubating fiberscopes are
available with insertion tubes ranging
in size from 2.5mm external diameter
to over 6mm with proportionately
larger working channels
=A device with external diameter of
3.5mm is optimal for use in adults.
The advent of the miniature video
camera has revolutionized fiberoptic
endoscopy

93. Fiberoptic Intubation
=It can be performed via oral or nasal route
=The fiberscope is inserted & advanced behind
the tongue & into the larynx. Once in the
trachea, a tracheal tube which has been
previously loaded onto the fiberscope is
advanced off the scope into the trachea &
then the fiberscope is removed.
=Oral intubation is considered more difficult
than nasal intubation

94. Advantages
=Reliable approach to the difficult airway management.
=Facility to record images for review & documentation.
=Improvements in teaching techniques.
Disadvantages
=More expensive & fragile & difficult to use than rigid
laryngoscope.
=Requires more time than rigid laryngoscopy.
=Requires considerable experience & skill Maintenance
=Laryngeal trauma may occur.

95. Complications of laryngoscopy
1. Dental injury
2. damage to soft tissue and
nerves
3. Injury to cervical spinal cord
4. Circulatory changes
5. Swallowing or aspiration of
foreign body.
6. Shock or Burns
7. Laryngoscope malfunctions
8. Disease transmission
9. TMJ Dislocation.

96. Endotracheal tubes

97. DESCRIPTION
=An endotracheal tube is one
through which anesthetic
gases and respiratory gases
are conveyed into and out of
the trachea.
=It has tracheal & machine
end
=The bevel is defined as the
slanted part of the tube at
the tracheal end.
=When, an opening in the
tube is present on the
opposite side of the bevel
it is designated as Murphy’s
tip endotracheal tube.

98. REQUIREMENTS
OF AN IDEAL ET TUBE
1) Inertness
2) Smoothness of outer surface to avoid
damage to mucosa
3) Inner surface should be smoothed and
non-wettable to prevent building of
secretions.
4) Non-inflammable
5) Transparent
6) Easily sterilized
7) Non kinking

99. 8) Sufficient strength to allow thin wall
construction
9) Thermo plasticity to confirm to anatomic
passage and to be self centering within the
trachea.
10) Non reactive with lubricants or anesthetic
agents
11) Latex free
12) Non injurious catheter tip
Currently used tubes are manufactured from
synthetic rubber, plastic materials and
silicone.

100. GENERAL PRINCIPLES
RESISTANCE AND WORK OF BREATHING
=A tracheal tube places a mechanical burden on
spontaneously breathing patient. It is a source of more
resistance and is an important factor in determining the
work of breathing. The factors determining the
resistance include:
1) Internal diameter: The tube with thick wall
decreases the ID and thereby increases the resistance
and vice-versa.
2) Length: Decreasing the length of the tube decreases the
resistance.
3) Configuration: Abrupt change in the diameter and
direction increases the resistance. Gentle curve
connectors offer less resistance than right-angled ones as
there will be increased resistance because of turbulent
flow of gases.

101. DEAD SPACE
=The volume of tracheal tube and connector is
usually less than that of the natural passage.
=Dead space is normally reduced by intubation.
=In pediatric patients long tubes and
connectors may increase the dead space
considerably.

102. STANDARD MARKING OF ETT
=The markings are situated on the
bevel side above the cuff & are
read from pt end to machine end
=Type of the tube: Oral or nasal or
oral/nasal Size: ID in mm
=External diameter may also be
indicated.
=Manufacturer's name or trade
mark

103. =Tube has Graduated markings, showing the
distance in cms from the patient end.
=Precautions are usually noted: Disposable/Do
not reuse
=Implantation tests (IT) or Z-79 indicating the
tube has been tested for tissue toxicity &
accomplish ANSI standard.
=Opaque lines may also be included at the
patient end or along full length.

104. CUFF SYSTEM
=A Cuff system consists of the cuff & inflation
system.
=The purpose of cuff system is to provide a
seal between tube & tracheal wall to
prevent passage of pharyngeal contents into
the trachea & ensure no gas leaks past the
cuff.
=The cuff also serves to center the tube in
trachea.

105. INFLATION SYSTEM
1)Inflation valve: When a syringe tip is inserted, a
plunger is displaced from its seat & gas can be
injected into the cuff. Upon removal of the syringe
the valve seals and gas cannot escape.
2) Pilot balloon: Its function is to give an indication of
inflation or deflation of the cuff and a rough idea of
the cuff pressure.

106. 3) External inflation tube: The standard
specifies ,
a)The external diameter should not
exceed 2.5mm
b) The inflation tube should be attached
to the ETT at a small angle.
c) The tube should extend at least 3cm
beyond the machine end of the ETT
before a pilot balloon or inflation
valve is incorporated.
4) Inflation lumen: This connects the inflation
tube to the cuff. It is located within the wall
of the tracheal tube.

107. CUFF
The cuff is a inflatable sleeve near
the patient end of ETT.
The cuff material should be strong
and tear resistant but thin, soft
and pliable.
Cuffs are usually made of the
same material as the ETT.

108. CUFF PRESSURE
Intracuff pressure and pressure
on tracheal wall
=It is desirable that cuff seals the airway
without extending so much pressure on the
trachea so that its circulation is not
compromised or trachea is dilated.
=When cuff is inflated in the trachea, there
is a linear decrease in the perfusion. It is
reduced when the lateral pressure on the
tracheal wall attains 30cm of H20 (22mmHg)
and ceases completely at 50cm of H20
(42mmHg).
=So it is recommended that the pressure on the
lateral tracheal wall should be kept between
25-34cm of H20.

109. Intracuff pressure and
use of nitrous oxide
The resting intracuff pressure
and volume of the cuff inflated
with air rise during nitrous oxide
anesthesia, which results in
ischaemia of the tracheal
mucosa or compression of the
tube, and increase in volume
may lead to cuff herniation.

110. to prevent the increasing pressure
includes the following
a) Filling the cuff with gas mixture to be used for
anesthesia or saline
b) Fitting the cuff system with pressure relief
valve or pressure regulating devices.
c) Use of special system e.g. Lanz pressure
regulating valve, sponge cuff and special tubes
like Brandt tubes.
d) Monitoring cuff pressure and deflating the cuff
as needed.
--Steps

111. Types of cuffs
Low volume high pressure cuff
= They have a small diameter at rest and low residual
volume.
=It requires a high intra-cuff pressure to achieve a
seal
with the trachea.
=It has a small area of contact with the trachea and
distends and deforms the trachea to a circular
shape.
=The intra-cuff pressure and lateral pressure on the
tracheal wall increase sharply as increments of air
are added to the cuff. For this reason use of largest
ETT has been advised, so that the cuff will be
minimally inflated when a seal is created
a) Low volume high pressure
b) High volume low pressure

112. Advantages
=Usually reused,
=Less expensive
=Offers better protection against aspiration
=Better visibility during intubation than low
pressure cuffs.
=There is also low incidence of sore throat.
Disadvantages
=The most serious risk associated with
these cuffs is ischemic damage to the
trachea following prolonged use.

113. High volume low pressure cuffs
=They have a high resting volume, large diameter
and a thin competent wall.
=As it is inflated, it first touches the trachea at its
narrow point. As cuff inflation continues the area
of contact become larger and the cuff adopts
itself to irregular tracheal surface.
=If the cuff inflation is continued the area in
contact will be subjected to increasing pressure
and trachea will be distorted to a circular cross
section similar to high pressure cuff.

115. Advantage
=It is relatively easy to pass devices such as esophageal
stethoscope, temperature probes, nasogastric tubes
around a low pressure cuffs
Disadvantage
=These tubes are more difficult to insert,
=Obscure the view of the tube tip and larynx
=The cuff is more friable and thus more likely to
be torn during intubation.
=Incidence of sore throats is greater with these
tubes.
=It may not effectively prevent fluid leakage into
lower airway.

116. THE GUIDELINES TO DETERMINE
THE SIZE OF ETT
Ideal tube in average Adult male = 8.5mm ID
Ideal tube in an average Adult female = 7.5mm ID.
Age is recognized as the most reliable indicator of
appropriate ETT size for children.
3 months & less ------ 3 mm ID
3 - 9 months ------ 3.5 mm ID
Older than 1 year ------ ID in mm
= (16 + age in years)/4

117. Younger than 6 years ---3.5 + age in years/3
= ID in mm
Older than 6years ---- 4.5 + age in years / 4
= ID in mm
Infants below 1kg ----- 2.5mm
Infants 1-2 kg ------ 3.0 mm
Infants 2-3 kg ------ 3.5 mm
Infants 3 kg ---------- 4.0 mm
Choosing a tube whose external diameter is
same width as the patient's distal little finger

118. Patients age Size( mm ID)
Premature neonate 2.5 to 3.0
Full term neonate 3.0 to 3.5
3 months to 1 year 4.0
2 years 4.5
4 years 5.0
6 years 5.5
8 years 6.0
10 years 6.5
12 years 7.0
Other recommendations for size of ET tubes

119. DEPTH OF INSERTION
The tube should be in the middle third of the
trachea with the head in natural position.
The following calculations can be used.
1) Length in cm = age/2 + 12
2) Length in cm = weight in kg/5 + 12
3) Length in cm = height in cms/10 + 5
4) Length in cm = 3 × ID (mm)

120. In adults, the tube should be passed until the
cuff is 2.25 to 2.5cm below the vocal cord
In average size adult patients, securing the
tube at the anterior incisor at 23cm in males
and 21cm in females will usually avoid
endobronchial intubation.
For nasal intubation 5cm should be added to
these length for positioning at the nares.

121. SPECIFIC ET TUBES
Cole tube
=It is uncuffed ETT, designed for
pediatric patients. The patient end is
smaller in diameter than the rest of
the tube
=They are sized according to the
internal diameter of the tracheal
portion. It ranges from 2mm to 5mm..
=It is recommended for neonatal
resuscitation but not for long term
intubation.
=Disadvantage of this tube is that it
cannot be used nasally

122. Spiral embedded tubes
=Also known as Armored tube.
=These tubes have a metal or
nylon spiral woven reinforcing
wire covered both internally
and externally by rubber, PVC
or silicone.
=A stylet is often needed for
intubation.
=These tubes are esp useful in
situations where the tube is
likely to be bent or compressed
as in head & neck surgery

123. Advantages
----Primary advantage of tube is resistance to
kinking and compression.
--The portion of the tube outside the patient
can be easily angled away from the surgical
field without kinking
-- Can be used for patients with Tracheostomies
Disadvantages
----Tube may rotate on the stylet during intubation.
-- Insertion through nose & intubating LMA is difficult.
-- Fixation of these tubes are more difficult.
--If the patient bites the tube it will cause permanent
deformity resulting in obstruction of the tube.

124. =It is preformed to facilitate the
head & neck surgeries.
=The tubes are available in cuffed
uncuffed ,nasal and oral version
=There is a preformed bend in the
tube that may be temporarily
straightened for suctioning.
=Each tube has a rectangular mark
at the center of the bend.
=Distance from this mark to the
distal tip is printed on each tube.
Preformed tubes/Ring-Adair-Elwyn (RAE)

125. =Oral RAE tubes are shorter than the nasal ones. The external
portion is bent at an acute angle so that when in place it rests
on patients chin & the connector over the pts chest.
=Nasal RAE has a curve opposite to the curvature of the oral
tube, so that when in place the outer portion of the tube is
directed towards patient's forehead

126. Advantages
=Easy to secure and reduce the risk of
unintended extubation.
=Breathing system remains away from
surgical field
Disadvantages
=It offers more resistance than conventional
tubes.
=Suctioning is difficult

127. Laryngectomy tube
=Designed for insertion into a
tracheostomy site.
=The tube is preformed in a J
configuration at the pt end
=This allows the part of the
tube external to the patient
to be directed away from
the surgical field.
=The tip may be short and/or
without a bevel to avoid
inadvertent advancement
into a bronchus.

128. Injectoflex Tube
=It is used for laryngeal microsurgery.
=It is a short cuffed silicone tube designed to
be placed below the vocal cords.
=The tube has an embedded wire spiral to
prevent kinking and compression. The cuff
inflation lumen and the inflation tube are
integrally joined in a sheath with a malleable
introducer.

129. Microlaryngeal tracheal surgery tube
It is available with an ID of 4, 5 or 6mm,
each of which has the same length and cuff
diameter as a standard 8mm ID tube.
Designed for microlaryngeal tracheal
surgery.
The small diameter provides better surgical
access
The problems with this tube are incomplete
exhalation & occlusion.

130. Endotrol tubes
A tip control system is incorporated
in this tracheal tube to change the
direction of the tip.
This tube has a ring loop at the
machine end that is connected to
the tip with a cable
Pulling the ring causes the tip of the
tube to move anteriorly.
This is useful when laryngoscopy is
difficult and only epiglottis is seen.

131. Tubes with extra lumens
Tubes are available with one or more separate lumens terminating near
the tip.
They are useful for respiratory gas sampling, airway pressure
monitoring, injection of fluids and drugs & jet ventilation.

132. The LITA (Laryngotracheal
Instillation of Topical anesthesia)
Has additional small bore channel
within the concave surface of the
tube.
10 small holes at the distal 13cm
of the tube allows the injected
medication to be spread both
above & below the cuffs.
This can provide a smooth
emergence from anesthesia
without coughing in most cases.

133. EMG Reinforced Tube
This tube is designed to
monitor recurrent laryngeal
nerve electromyogram
activity during surgery.
The tube is wire-reinforced &
has 4 stainless steel
electrodes above the cuff.
The electrodes are connected
to a monitor.

134. Laser-shield II Tracheal Tube
It is designed for use with CO2 and
KTP lasers.
Made from silicone with an inner
aluminium wrap and a smooth Teflon
outer coating.
The cuff is not laser resistant &
contains methylene blue crystals.
It should be inflated with water or
saline solution.

135. Cottonoids for wrapping around the cuff are supplied
with each tube. These must be moistened and kept
moist during the entire procedure
Disadvantage
Exposure of unprotected parts of the tube proximal &
distal to cuff can result in rapid combustion.
The methylene blue crystals may not fully dissolve &
may obstruct the pilot tube, making it impossible to
deflate.

136. Laser-Flex Tubes
Laser flex tube is a flexible
stainless steel tube with a smooth
surface designed for used with
C02 and KTP
(potassium-titanyl-phosphate)
lasers.
Adult version has two PVC cuffs
and PVC tips with Murphy eye.
The tube cuffs are inflated by two
separate inflation tubes. The
distal cuff can be used if proximal
one is damage by laser.

137. The cuff should be filled with saline. The distal
cuff should be filled first until sealing occurs,
then the proximal cuff is filled with saline
coloured with methylene blue.
Problems
with the laser flex tube include
stiffness, roughness, cannot be trimmed.
The double cuff adds to the time of intubation
and extubation.

138. Laser-tubes
This is made of white rubber & has
a cuff-within-a cuff design.
If the outer cuff is perforated by a
laser beam, the trachea will still be
sealed by inner cuff. The inner cuff
is filled with air & outer with water
or saline.
The shaft above the cuff is covered
by a corrugated silver foil, which is
covered by merocel sponge that
should be moistened with saline
before use.
It is recommended for use with
argon, NdYAG, CO2 lasers.

139. Hi-Lo Evac Tube
It incorporates dedicated
channel which can be used to
clear secretions below the
vocal cords but above the
cuff.
The lumen may be blocked by
secretions.

140. Hi-Lo Jet Tube
It is an uncuffed tube with
additional lumen that can be
used for Jet ventilation,
monitoring airway pressure,
sampling respiratory gases or
administering local
anesthetics.

141. THANK YOU