The lecture has been given on Oct. 26th, 2010 by Dr. Gona.

1. BASIC AIRWAY MANAGEMENTBASIC AIRWAY MANAGEMENT

2. AirwayAirway
 Maintenance of a patent airway is anMaintenance of a patent airway is an
essential prerequisite for the safe andessential prerequisite for the safe and
successful conduct of anaesthesia.successful conduct of anaesthesia.
However, it is a skill that should beHowever, it is a skill that should be
acquired by all doctors, as duringacquired by all doctors, as during
resuscitation patients often have anresuscitation patients often have an
obstructed airway either as theobstructed airway either as the cause orcause or
result of their loss of consciousnessresult of their loss of consciousness

3. Airway anatomyAirway anatomy
 The term airway refers to the upper airwayThe term airway refers to the upper airway
consisting of the nasal and oral cavities,consisting of the nasal and oral cavities,
pharynx, larynx, trachea, and principal bronchi.pharynx, larynx, trachea, and principal bronchi.
 The laryngeal skeleton consists of nineThe laryngeal skeleton consists of nine
cartilages that together house the vocal foldcartilages that together house the vocal fold
(larynx situated C3-C6)(larynx situated C3-C6)
 Trachea in adults measures about 15 CmTrachea in adults measures about 15 Cm
starts from the C6 and end at T5 (carina) wherestarts from the C6 and end at T5 (carina) where
it bifurcates into the right and left bronchi.it bifurcates into the right and left bronchi.

4. Upper Airway AnatomyUpper Airway Anatomy

5. Upper Airway AnatomyUpper Airway Anatomy

6. Upper Airway AnatomyUpper Airway Anatomy

7.  . The right main stem bronchus is larger. The right main stem bronchus is larger
than the left and deviates from the planethan the left and deviates from the plane
of the trachea at a less acute angleof the trachea at a less acute angle
(aspirated material as well as a deeply(aspirated material as well as a deeply
placed tracheal tube is more likely to enterplaced tracheal tube is more likely to enter
the right than the left bronchus).the right than the left bronchus).

8. Airway obstructionAirway obstruction
 The majority of preventable deathsThe majority of preventable deaths
following trauma occur as a result offollowing trauma occur as a result of
airway obstruction.airway obstruction.
 Obstruction may occur at any point withinObstruction may occur at any point within
the airway, from the upper airways to thethe airway, from the upper airways to the
bronchi deep within the chest.bronchi deep within the chest.

9. Common causes of airway obstructionCommon causes of airway obstruction
Upper AirwayUpper Airway
 tongue (due to unconsciousness)tongue (due to unconsciousness)
 soft tissue swellingsoft tissue swelling
 blood, vomitblood, vomit
 direct injurydirect injury

10. Larynx (voice box)Larynx (voice box)
 foreign material, direct injury, soft tissueforeign material, direct injury, soft tissue
swellingswelling
Lower AirwayLower Airway
 secretions, edema, bloodsecretions, edema, blood
 bronchospasmbronchospasm
 aspiration of gastric contentsaspiration of gastric contents

11. Manual airway maneuvers, head tiltManual airway maneuvers, head tilt
and jaw thrustand jaw thrust‫׃‬‫׃‬
 IndicationsIndications
 -Initial management of a compromised airway.-Initial management of a compromised airway.
 -Stimulus to respiratory drive in the sedated-Stimulus to respiratory drive in the sedated
patient.patient.
 -Relief of mild anatomic airway obstruction.-Relief of mild anatomic airway obstruction.
 ..Head tilt contraindicated in suspected cervicalHead tilt contraindicated in suspected cervical
spine pathology e.g. rheumatoid arthritis so inspine pathology e.g. rheumatoid arthritis so in
these condition better to use jaw thrust only.these condition better to use jaw thrust only.

13. Oropharyngeal airwayOropharyngeal airway
 An oropharyngeal airway (also known as an oral airway,An oropharyngeal airway (also known as an oral airway,
OPA or Guedel pattern airway) is a medical device calledOPA or Guedel pattern airway) is a medical device called
an airway adjunct used to maintain a patent (open) airway.an airway adjunct used to maintain a patent (open) airway.
It does this by preventing theIt does this by preventing the tonguetongue from (either partiallyfrom (either partially
or completely) covering the epiglottis, which could preventor completely) covering the epiglottis, which could prevent
the patient from breathing. When a person becomesthe patient from breathing. When a person becomes
unconscious or anesthetized, the muscles in their jaw relaxunconscious or anesthetized, the muscles in their jaw relax
and may allow the tongue to obstruct the airway; in fact,and may allow the tongue to obstruct the airway; in fact,
the tongue is the most common cause of a blocked airwaythe tongue is the most common cause of a blocked airway
 The correct size OPA is chosen by measuring against theThe correct size OPA is chosen by measuring against the
patient's head (from the earlobe to the corner of thepatient's head (from the earlobe to the corner of the
mouth).mouth).
 The preferred technique is to use a tongue blade toThe preferred technique is to use a tongue blade to
depress the tongue and then insert the airway posteriorly.depress the tongue and then insert the airway posteriorly.

14.  An alternate technique is to insert the oral airway upsideAn alternate technique is to insert the oral airway upside
down until the soft palate is reached, rotate the devicedown until the soft palate is reached, rotate the device
180 degrees and slip it over the tongue, its fully inserted180 degrees and slip it over the tongue, its fully inserted
until the flange lies in front of the teeth, or gums in anuntil the flange lies in front of the teeth, or gums in an
edentulous patient.edentulous patient.
 Be sure not to use the airway to push the tongueBe sure not to use the airway to push the tongue
backward and block, rather than clear the airway.backward and block, rather than clear the airway.
 To remove the device, it is pulled out following theTo remove the device, it is pulled out following the
curvature of the tongue; no rotation is necessarycurvature of the tongue; no rotation is necessary
 This device is poorly tolerated in conscious patientsThis device is poorly tolerated in conscious patients
and may induce gagging, vomiting and aspiration.and may induce gagging, vomiting and aspiration.

17. Oropharyngeal airway insertionOropharyngeal airway insertion

18. Nasopharyngeal airwayNasopharyngeal airway
 Round, malleable plastic tubes, beveled at theRound, malleable plastic tubes, beveled at the
pharyngeal end and flanged at the nasal endpharyngeal end and flanged at the nasal end
 It inserted through a nostril and creates an airIt inserted through a nostril and creates an air
passage between the nose and thepassage between the nose and the
nasopharynx.nasopharynx.
 Any tube inserted through the nose should beAny tube inserted through the nose should be
well lubricated and use a nostril that’swell lubricated and use a nostril that’s
unobstructedunobstructed

19. The airway is inserted along the floor of the nose, withThe airway is inserted along the floor of the nose, with
the bevel facing medially to avoid catching the turbinatesthe bevel facing medially to avoid catching the turbinates
The nasopharyngeal airway is preferred to theThe nasopharyngeal airway is preferred to the
oropharyngeal airway in conscious patients because it’soropharyngeal airway in conscious patients because it’s
better tolerated and less likely to induce a gag reflex.better tolerated and less likely to induce a gag reflex.
Nasopharyngeal airways are sometimes used by peopleNasopharyngeal airways are sometimes used by people
who have sleep apnea. in a patient having epilepticwho have sleep apnea. in a patient having epileptic
seizures whose teeth are clenched shut, suction of theseizures whose teeth are clenched shut, suction of the
upper airways may also be applied via an NPAupper airways may also be applied via an NPA
Nasopharyngeal airway contraindicated in patients withNasopharyngeal airway contraindicated in patients with
severe head or facial injuries, or has evidence of a basalsevere head or facial injuries, or has evidence of a basal
skull fracture due to the possibility of direct intrusionskull fracture due to the possibility of direct intrusion
upon brain tissue, those who are anticoagulated,upon brain tissue, those who are anticoagulated,
patients with nasal infections as well as in childrenpatients with nasal infections as well as in children
(because of risk of epistaxis)(because of risk of epistaxis)