Airway Devices Management Basics

1. AIRWAY DEVICES AND
THEIR SPECIFICATIONS
Dr . S.K.Varma
KG Hospital, Coimbatore

2. Classification
 Extra glottic
 Intra glottic

3. Simple Airway Devices
 Face Mask
 Oropharyngeal Airways
 Nasopharyngeal Airways

4. Face Mask
 Positive pressure
Ventilation
 Airway Patent
 Tight Fitting
 Clear and transparent
 Various sizes and flavors
 Short term airway
management with ambu
bag or anaesthetic circuit

5. Signs of successful seal and
ventilation
• the rising of the chest with delivery of positive
pressure
• breath sounds on auscultation
• a firm/taught/full bag
• return carbon dioxide on exhalation capnography
• Foggy Mask

6. Oropharyngeal Airway
 Guedel’s Airway
 Various sizes and
colour coded
 Pre hospital
emergency care or
short term airway
management
 Unconscious patient
 Stimulate gag reflex

7. Risks of use
 Patient may vomit if they have intact gag
reflex
 Too large can close glottis and obstruct the
airway
 Insertion can become traumatic and cause
bleeding

8. Nasopharyngeal airway
 Well tolerated
 Various sizes
 Length is measured
from nostril to meatus
of the ear
 Contraindicated in
basal skull fracture and
anti coaguated
patients
 Well lubricated

9. Supraglottic Airway
 Placed above the vocal cord level
 Those devices which allow hands-free
maintenance of an open airway
 Allows spontaneous or assisted
ventilation

10. General Characteristics
 Ability to be placed without direct visualization
 Better cardio vascular stability both during insertion
and removal
 Minimal IOP and ICP changes
 Provide little protection against aspiration
 Contraindicated in full stomach patients

11. 1908 to date
 1908- Hewitt Airway
 1913- Connell
 1915- Lumbard
 1933 – Guedel
 1957- Fink vallecular
 1957 – Safar Airway
 1977 – Berman intubating
 1982 – Patil Syracuse
 1983 – Laryngeal Mask – Archie Brain
 1985 – Combitube
 1997 - Intubating LMA
 2000 – Proseal LMA
 2003 - Cobra Pharyngeal lumen Airway

12. Dr. Archie Brain

13. Laryngeal Mask Airway
 Tube with an inflatable cuff
which is inserted into the
Pharynx
 Used in elective anaesthesia
 Emergency medicine for
airway management by
paramedics
 Spontaneous and controlled
 Both disposable and reusable
 Various sizes -8

14. Laryngeal Mask Airway
 Incidence of aspiration is 2 in 10000 (0.02%)
 One death attributed directly to LMA out of 2
million users
 It is included by theAmericanTask Force in
the difficult airway algorithm in 1995
C. Keller et al – Aspiration and LMA – a review of literature
BJA 93(4) 579-82: 2004
Brimacombe JR et al-The Larynfeal Mask Airway- in the
difficult airway.Anaesthesiology clin of North America
June 13(2) ; 411-37 : 1995

15. Proseal & LMA Supreme
 Has two separate tubes
 Sizes 1-5 are available
 Improved airway
protection
 Holds a better cuff seal
pressure
 Requires greater depth of
anaesthesia

16. Flexible LMA
 Flexo metallic tube
 Preformed angle
 Better placement
 Less incidence of dislodgement
once placed
 More useful in head and neck
surgery

17. Tracheo Esophageal Combitube
 Double lumen and
double balloon device
 Allows ventilation
independent of its
position
 Excellent rescue device
both in and out of
hospital emergency
situations

18. King LTD Design

19. King LTS-D Airway Design

20. INSERTION STEPS
 Use lateral approach
 Introduce the tip into corner
of mouth
 Advance behind the base of
tongue
 Without exercising excessive
force, advance until the base
of the connector is aligned
with teeth.
 Inflate the cuff

21. FINAL POSITION

22. Cobra plus tube
 Distal end has softened
openings
 Used for both spontaneous
and controlled ventilation
 Serves as a rescue airway

24.  Single use, noninflatable
 Integral gastric channel
 Various sizes
 Moulding feature

25. Streamlined liner of Pharyngeal airway -
SILPA
 Cuffless
 Lines the pharynx
 Large internal volume –
Allows collection of
secretion, minimize
aspiration
 Minimal expertise for
insertion

26. Advantages
 Speed & ease of
insertion.
 Improved
haemodynamic stability
on induction &
emergence.
 Minimal increase in IOT.
 Decrease anaesthetic
requirements for airway
tolerance.
 Decreased coughing &
sore throat.

27. Intraglottic devices-History
 1864- First endotracheal anaesthesia using
tracheotomy cannula by German surgeon
 1880- SirWilliam Macewen – Glasgow
surgeon was the first to introduce
orotracheal intubation
 1921- Sir Ivan Magill endotracheal rubber
tubes
 1928- Cuffed endotracheal anaesthesia

28. Indications for endotracheal
intubation
 Airway Protection
 Pulmonary toileting
 Applications of positive pressure
ventilation
 Maintenance of adequate oxygenation

29. Endotracheal tubes
 NonToxic,Non allergic
 PVC tubes –
inexpensive most
compatible with
tissues
 Red rubber tubes not
used nowadays

30. Endotracheal tube

31. Endotracheal tube

32. ETT -Cuff
 HighVolume Low
pressure cuffs- PVC
tubes- less prone for
pressure necrosis
 LowVolume high
pressure cuffs –red
rubber tubes- more
prone

33. Endotracheal tube

34. Endotracheal tube

35. Endotracheal tube

36. RAE Tubes
 Ring , Adair ElvinTube
 Orosurgical, ENT,
Maxillofacial surgeries
 Preformed Bend
 Problem with
suctioning

37. Paediatric tubes
 Uncuffed tubes
 Varoius sizes available
 Formulas are available
to guide tube selection
 Pediatric airway is
more susceptible
 Black mark indicates
depth of insertion

38. Armoured or Reinforced ETT

39. Laser Resistant tubes

40. Laser Resistant Tubes

41. Micro laryngeal trachealtubes
 Standard tube length
and cuff size with
smaller ID and OD
(4,5,6mm)
 Smaller diameter is
helpful if there is tumor
in the airway.
 Used in microlaryngeal
surgery

42. Hi Lo Evac ETT with evacuation
Lumen
 Designed to reduce
Ventilator Associated
Pneumonia(VAP)
 Lumen in the
supraglottic region
allows suctioning and
thereby reduce
aspiration.
 Silver impregnation of
PVC tubes

43. Double Lumen Tubes

44. Bronchial Blockers
 UniventTube
 Arndt wire guided
endobronchial blocker
 Single lumen ETT with
movable bronchial
blocker in the second
lumen
 Used when long term
post op ventilation is
needed

45. Intubating Aids
 Direct laryngoscopes
 Gum elastic bougie
 Flexible fibre optic bronchoscopes
 Intubating laryngeal mask airway (Fastrach)
 Light wand
 Video laryngoscopes
 Indirect fibreoptic laryngoscopes(Bullard)

46. Direct Laryngoscopes
 First introduced by
Alfred Kirstein in 1895
 Jackson used it for
intubation and
modified it with distal
light source
 Janeway introduced
batteries and made it
portable

47. Various Blades of Laryngoscopes

48. Gum elastic Bougie
 Flexible
 Narrow diameter
tracheal tube introducer
or exchanger
 Length is approximately
60cm and the distal tip
can be curved or straight
 Pediatric and adult sizes
available

49. Video Laryngoscopes

50. ILMA & LMA C Trach
 Allows intubation with
minimal head and neck
manipulation
 Recommended in both
difficult airway and
Resuscitation algorithm
 CTrach allows intubation
under direct vision

51. Flexible fibreoptic bronchoscopy
 Used for either
diagnostic or
therapeutic procedures
 Used often in difficult
airway situation
 Blood or secretion in
the airway can make
the procedure difficult

52. Light wand and intubating
Stylet
 Used in anticipated
difficult intubation
 Trans illumination of
anterior neck used as a
guide
 Well circumscribed glow
indicates laryngeal
placement
 Used both in awake and
anaesthetized patients

53. Indirect Fibre optic laryngoscope-
Bullard
 Rigid fibreoptic
laryngoscope
 Adult and paediatric
scopes
 Difficult intubation
 Multifunctional stylet
 Minimal head
manipulation

54. Case Scenario
 40 year old -180 kg man with history of sleep
apnoea and EF 25% has Strept .pneumonia
in his left lower lobe and progressive resp
insufficency
 O/E he has 50degree neck extension and
Mallampati 2
 How will you proceed?

55.  Patient airway anatomy is not suggestive of
difficulty.
 Supine position – subcutaneous tissues may
impair your ability to ventilate
 Use reverseTrendlenburg position, shoulder
roll to make ventilation better-gravity
 Have some accessory airway equipment
ready – like fibreoptic , ILMA , LMA

56. Difficult airway algorithm

57. Conclusion
 Wide variety of airway armamentarium available
 Provides great margin of safety
 Ask for senior help early
 Always have plan B and plan C available in case
plan A fails in difficult airway situations

58. Thank you