Airway management


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Airway management

  1. 1. Airway ManagementAirway Management Augusto Torres, MDAugusto Torres, MD Department of AnesthesiologyDepartment of Anesthesiology MetroHealth Medical CenterMetroHealth Medical Center
  2. 2. OutlineOutline Review of airway anatomyReview of airway anatomy Airway evaluationAirway evaluation Mask ventilationMask ventilation Endotracheal intubationEndotracheal intubation The difficult airwayThe difficult airway
  3. 3. Airway AnatomyAirway Anatomy Ab-ductorAb-ductor – PosteriorPosterior cricoarytenoidcricoarytenoid TensorTensor – CricothyroidCricothyroid Ad-ductorsAd-ductors – All the restAll the rest
  4. 4. Airway AnatomyAirway Anatomy InnervationInnervation Vagus n.Vagus n. – Superior laryngeal n.Superior laryngeal n. External branch – motorExternal branch – motor to cricothyroid cricothyroid m. Internal branch –Internal branch – sensory larynx abovesensory larynx above TVC’sTVC’s – Recurrent laryngeal n.Recurrent laryngeal n. Right – subclavianRight – subclavian Left – Aortic arch (boardLeft – Aortic arch (board question)question) Motor to all otherMotor to all other muscles, Sensory tomuscles, Sensory to TVC’s and tracheaTVC’s and trachea
  5. 5. Airway AnatomyAirway Anatomy Innervation ofInnervation of oropharynxoropharynx – Glossopharyngeal n.Glossopharyngeal n. innervates tongueinnervates tongue base and oropharynxbase and oropharynx
  6. 6. Airway AnatomyAirway Anatomy MembranesMembranes – ThyrohyoidThyrohyoid – CricothryoidCricothryoid CartilagesCartilages – HyoidHyoid – ThyroidThyroid – CricoidCricoid
  7. 7. Airway EvaluationAirway Evaluation Take very seriouslyTake very seriously history of prior difficultyhistory of prior difficulty Head and neckHead and neck movement (extension)movement (extension) – Alignment of oral,Alignment of oral, pharyngeal, laryngeal axespharyngeal, laryngeal axes – Cervical spine arthritis orCervical spine arthritis or trauma, burn, radiation,trauma, burn, radiation, tumor, infection,tumor, infection, scleroderma, short andscleroderma, short and thick neckthick neck
  8. 8. Airway EvaluationAirway Evaluation Jaw MovementJaw Movement – Both inter-incisor gap andBoth inter-incisor gap and anterior subluxationanterior subluxation – <3.5cm inter-incisor gap<3.5cm inter-incisor gap concerningconcerning – Inability to sublux lowerInability to sublux lower incisors beyond upperincisors beyond upper incisorsincisors Receding mandibleReceding mandible Protruding MaxillaryProtruding Maxillary Incisors (buck teeth)Incisors (buck teeth)
  9. 9. Airway EvaluationAirway Evaluation ObesityObesity – Distribution, i. e. short,Distribution, i. e. short, thick neck morethick neck more concerningconcerning – Neck circumferenceNeck circumference
  10. 10. Airway EvaluationAirway Evaluation Thyromental distance:Thyromental distance: bony point onbony point on mentum (mandible) tomentum (mandible) to thyroid notchthyroid notch If short (<3FB’s orIf short (<3FB’s or 6cm), pharyngeal and6cm), pharyngeal and laryngeal axis offlaryngeal axis off
  11. 11. Airway EvaluationAirway Evaluation Oropharyngeal visualizationOropharyngeal visualization Mallampati ScoreMallampati Score Sitting position, protrude tongue, don’t saySitting position, protrude tongue, don’t say “AHH”“AHH”
  12. 12. Airway EvaluationAirway Evaluation Difficulty ventilatingDifficulty ventilating – Age >55Age >55 – BeardBeard – History of snoringHistory of snoring – Lack of teethLack of teeth – BMI >26BMI >26
  13. 13. PreoxygenationPreoxygenation Replaces the nitrogen volume of the lungsReplaces the nitrogen volume of the lungs (69% of FRC) with oxygen(69% of FRC) with oxygen Functional residual capacity (residualFunctional residual capacity (residual volume and expiratory reserve volume)volume and expiratory reserve volume) Preoxygenation with 100% oxygen viaPreoxygenation with 100% oxygen via tight-fitting mask for 5 minutestight-fitting mask for 5 minutes  up to 10up to 10 min of oxygen reserve following apneamin of oxygen reserve following apnea Four vital capacity breaths over 30Four vital capacity breaths over 30 seconds (time to desaturation quicker)seconds (time to desaturation quicker)
  14. 14. Patient PositioningPatient Positioning Sniffing positionSniffing position – Lower neck flexionLower neck flexion – Upper neck extensionUpper neck extension – Important in obesityImportant in obesity
  15. 15. Mask VentilationMask Ventilation Induction ofInduction of anesthesia producesanesthesia produces upper airwayupper airway relaxation andrelaxation and possible collapsepossible collapse DownwardDownward displacement of maskdisplacement of mask with thumb and indexwith thumb and index fingerfinger
  16. 16. Mask VentilationMask Ventilation Upward traction ofUpward traction of remaining fingersremaining fingers upwardupward Fingers on bonyFingers on bony mandiblemandible Fifth digit at angleFifth digit at angle displacing mandibledisplacing mandible anteriorlyanteriorly
  17. 17. Mask VentilationMask Ventilation Oral airwayOral airway Two-handed techniqueTwo-handed technique
  18. 18. LMA PlacementLMA Placement Carries prominentCarries 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 andDirected posteriorly and upwards towards theupwards towards the palatepalate Jaw thrust and sniffingJaw thrust and sniffing position may helpposition may help placementplacement
  19. 19. LMA PlacementLMA Placement Verify placement by ventilatingVerify placement by ventilating – Check for good chest rise, ETCO2, andCheck for good chest rise, ETCO2, and adequate tidal volumesadequate tidal volumes – Check for leak – if significant leak at aroundCheck 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 betterMay try to inflate/deflate cuff to obtain better sealseal – If difficulty passing may try inserting upsideIf difficulty passing may try inserting upside down and then flipping arounddown and then flipping around
  20. 20. Endotracheal IntubationEndotracheal Intubation Open the mouth with rightOpen the mouth with right handhand – Scissor techniqueScissor technique Gently insertGently insert laryngoscope into rightlaryngoscope into right side of mouth pushingside of mouth pushing tongue to the lefttongue to the left Careful with insertion notCareful with insertion not to hit teethto hit teeth Advance laryngoscopeAdvance laryngoscope further into oropharynxfurther into oropharynx with applied traction 45with applied traction 45 degreesdegrees
  21. 21. Endotracheal IntubationEndotracheal Intubation Look for epiglottisLook for epiglottis – If initially not foundIf initially not found insert laryngoscopeinsert laryngoscope furtherfurther – If this maneuver doesIf this maneuver does not work slowly pullnot work slowly pull laryngoscope backlaryngoscope back Once epiglottisOnce epiglottis visualized, pushvisualized, push laryngoscope intolaryngoscope into vallecula and applyvallecula and apply traction at 45 degreetraction at 45 degree angle to “push” epiglottisangle to “push” epiglottis up and out of the wayup and out of the way
  22. 22. Endotracheal IntubationEndotracheal Intubation Look for vocal cords orLook for vocal cords or arytenoid cartilages and try toarytenoid cartilages and try to optimize viewoptimize view – (i.e. lift head, apply more(i.e. lift head, apply more traction at 45 degree angletraction at 45 degree angle if necessary)if necessary) Do not move once view isDo not move once view is optimized!optimized! – Assistant will hand youAssistant will hand you ETTETT Insert ETT into far right aspectInsert ETT into far right aspect of mouthof mouth – Traction of laryngoscopeTraction of laryngoscope slightly to left may assistslightly to left may assist – Traction of laryngoscope atTraction of laryngoscope at 45 degrees will also help45 degrees will also help keep mouth openkeep mouth open
  23. 23. Endotracheal IntubationEndotracheal Intubation Insert ETT above and between arytenoidsInsert ETT above and between arytenoids and through vocal cordsand through vocal cords Try to visualize the ETT passing betweenTry to visualize the ETT passing between the vocal cordsthe vocal cords – If this is not possible, then you must visualizeIf this is not possible, then you must visualize the ETT passing above and between thethe ETT passing above and between the arytenoidsarytenoids
  24. 24. Endotracheal IntubationEndotracheal Intubation Common problems:Common problems: – ““I can’t see anything!”I can’t see anything!” Make sure tongue isMake sure tongue is swept to the leftswept to the left You are probably tooYou are probably too shallow or too deep.shallow or too deep. Even with difficultEven with difficult intubations theintubations the epiglottis can beepiglottis can be visualizedvisualized Insert laryngoscope inInsert laryngoscope in further looking forfurther looking for epiglottisepiglottis Pull laryngoscope backPull laryngoscope back if this failsif this fails
  25. 25. Endotracheal IntubationEndotracheal Intubation Common 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 isRemoving 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 bladePush 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 handLifting the patient’s head with your other hand may improve the sniffing position and bringmay improve the sniffing position and bring the vocal cords into viewthe vocal cords into view
  26. 26. Endotracheal IntubationEndotracheal Intubation Common problemsCommon problems – ““I can see the cords. But I can’t get the tubeI can see the cords. But I can’t get the tube there!”there!” – You may not be giving yourself adequateYou may not be giving yourself adequate room in the oral cavityroom in the oral cavity – Push up and to the left with the laryngoscopePush up and to the left with the laryngoscope to make sure the mouth is still fully openedto 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 theSlide the ETT in the mouth all the way to the right side, perhaps even sidewaysright side, perhaps even sideways
  27. 27. Difficult IntubationDifficult Intubation ASA Difficult Airway AlgorithmASA Difficult Airway Algorithm
  28. 28. 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
  29. 29. Other airway optionsOther airway options GlideScopeGlideScope Needle cricothyroidotomyNeedle cricothyroidotomy
  30. 30. ConclusionConclusion Airway management is an extremely importantAirway management is an extremely important aspect of the practice of anesthesiology andaspect 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, endotrachealSkills such as mask ventilation, endotracheal intubation, LMA placement are necessaryintubation, LMA placement are necessary In the case of a difficult airway, a logicalIn the case of a difficult airway, a logical algorithm and airway equipment assist thealgorithm and airway equipment assist the physician in safely managing the situationphysician in safely managing the situation