DIFFICULT AIRWAY MANAGEMENT

1. Moderator: Dr. Atul Sharma
Speaker: Dr. Misbah Salaria

2. DIFFICULT AIRWAY:
ACCORDING TO ASA:-
 A clinical situation in which a conventionally
trained anesthesiologist experiences a difficulty
with mask ventilation, difficulty with tracheal
intubation or both !
Difficult airway: spectrum
 Difficult :- Spontaneous/mask ventilation
Laryngoscopy
Tracheal intubation
Tracheostomy.

3. DIFFICULT MASK VENTILATION –
It is not possible for the unassisted anesthesiologist to maintain
SPO2>90% using 100% O2 and positive pressure mask ventilation in
a patient whose SPO2 was > 90% before anesthetic intervention
and/0r It is not possible for the unassisted anesthesiologist to prevent
or reverse signs of inadequate ventilation during positive pressure
mask ventilation

4. SIGNS OF DIFF MASK VENTILATION
Absent or inadequate chest movement.
Absent breath sounds.
Gastric air entry or dilatation.
Cyanosis.
Haemodynamic changes due to hypoxia or
hyper carbia.
Decreasing oxygen saturation.
Absent or inadequate exhaled CO2

5. PRECICTORS OF DIFF MASK
VENTILATION (BONES)
• BEARD
• OBESITYWITHBMI > 26KG/M2
• NOTEETH
• ELDERLY> 55YEARS
• SNORERS, H/O SLEEP APNEA
PATIENTS HAVING 2 OR MORE OF THE
ABOVE PREDICTORS LIKELY TO HAVE
DIFFICULTMASKVENTILATION.

6. DIFFICULT LARYNGOSCOPY-
•It is not possible for an unassissted anaesth. to visualize
any portion of the vocal cords with conventional
laryngoscopy .
DIFFICULT ENDOTRACHEAL
INTUBATION :
•Using conventional laryngoscopy , it takes >3 attempts to
insert an ETT and/or the insertion of an ETT requires>10
min. using conventional laryngoscopy.

7. 1. Easy chin lift only
2. One person jaw thrust / mask seal.
3. As above + oropharyngeal or nasopharyngeal
airway or both.
4. Two person jaw thrust / mask seal.
5. Two person jaw thrust / mask seal + airway.
6. Impossible mask ventilation despite maximal
external effort & full use of airway
(infinite)

8.  Laryngoscopy performed by reasonably
experienced laryngoscopist with the pt in
optimal sniff position having no significant
muscle tone & the laryngoscopist has an option
of change of blade type & length.

9. 1. Easy endotracheal intubation
2. One attempt, increasing lifting force.
3. As above + use better sniff position
4. Multiple attempts,external laryngeal pressure
and multiple blades.
5. As above + multiple attempts by the
laryngoscopist.
6. Impossible to intubate despite above
maneuvers and using multiple blades.
(infinite)

10.  Intubation attempt if exceeds 30 seconds
 Cyanosis or pallor if develops
 Change in heart rate/rhythm if occurs (due to
sympathetic stimulation)
 Patient if develops significant hypoxia.

11.  Respiratory events are most common
anesthetic related injuries
 difficult face mask ventilation ~ 1:10,000
 incidence of extreme difficult intubation:
general surgery patients ~ 1:2000
 obstetrics ~ 1:300
 28% of anesthetic deaths are secondary due to
inability to mask ventilate or intubate

13.  History: previous records
 General physical examination:
(The combination of Mouth opening, jaw
protrusion n head extension is the core of airway
assessmment !)
 ASSESSMENT OF TMJ: three ways:
 Mouth opening: >3 finger breadths or >5cm is
acceptable, <3cm gap- diff intubation in 95%
 TMJ mobility
 Mandibular protrusion;
Class A :Lower incisor protrude beyond upper
incisor.
Class B :Lower incisor at same level.
Class C :Cannot protrude beyond upper incisor.
Class B & C are associated with difficult airway.

14.  Assesment of mandibular space : determine
how easily laryngeal & pharyngeal axis will fall
in line
 Thyromental Distance(Patil`s test):
>6.5cm- No problem with L & I
6-6.5cm- Difficult laryngoscopy but possible
intubation
<6cm: Laryngoscopy impossible
 Ratio of height to thyromental distance(cm)
>23.5 : easy laryngoscopy
 HYOMENTAL DISTANCE: Between mentum &
hyoid bone
 Grade I: >6cm {Easy L & I}
 Grade II: 4-6 cm {difficult L & I}
 Grade III:<4cm {impossible L & I}

15.  Sternomental distance: Head extention with
mouth closed. Normal >12.5 cm. <12.5 cm
:difficult L & I
 Modified method :
If inc. in length by 5 cm ---- easy L & I.
If <5 cm ---- difficult L & I
 Assesment of cervical & atlanto-occipital joint:
Gives indication how easily a Sniffing position
will be acheived
 Neck flexion—25-35 degree & atlanto-occipital
joint extension—85 degree
 Measurement by visual estimate or goniometer
Grade I: no reduction of extension
Grade II: 1/3rd reduction
Grade III: 2/3rd reduction
Grade IV: complete reduction
Grade III & IV are associated with difficult L & I.

16. THE EXAMINATION DESCRIBED BY
EL-GANZOURI (mouth opening,
prognathic ability, head extension,
thyromental distance and
Mallampati test) is the most
quantifiable of tests included in the
ASA guidelines.

17.  Patient in sitting position
 Head in neutral position
 Maximal tongue protrusion
 No phonation
SAMPSOON-YOUNG’S MODIFICATION (1987)
added Class IV and correlated b/w ability to observe
intraoral strucures and incidence of subsequent
difficult intubations.
CLASS ZERO MALLAMPATI
• Visualisation of any part of epiglottis during MMP test
• Associated with easy laryngoscopy
• Difficult airway possible  large epiglottis hinder
laryngoscopic view as well as ventilation

19.  Class III or IV: signifies that the angle between
the base of tongue and laryngeal inlet is more
acute and not conducive for easy laryngoscopy
 Limitations
 Poor interobserver reliability
 Limited accuracy
 Good predictor in pregnancy, obesity,
acromegaly

20. Grade 1:Full exposure of glottis (anterior + posterior commissure)
Grade 2: only the posterior extremity of glottis is seen
Grade3: no part of glottis n only the Epiglottis only
Grade 4: not even the epiglottis can be seen

22.  On lateral X –ray of mandible & spine.
 Effective mandibular length(EML): Length b/w tip
of lower incisor & midpoint of TMJ.
 Posterior mandibular depth(PMD) : width b/w
alveolar margin & lower border of mandible
immediately behind 3rd molar teeth.
 If EML/PMD = <3.6 ….. Difficult intubation
 Mandibular angle : Nr =110—115 deg
 If < 106 or > 120 deg = difficult intubation
 Dec. in distance b/w occiput & spinous pricess of C1
<5cm or Inc. in posterior depth of mandible > 2.5 cm
inc. chances of difficult airway.

23. RADIOGRAPHIC
PREDICTORS
1. X-Ray neck (lateral view) :
 Occiput - C1 spinous process
distance< 5cm.
 Increase in posterior mandible
depth > 2.5cm.
 Ratio of effective mandibular
length to its posterior depth
<3.6.
 Tracheal compression.

24. 2. CT Scan:
 Tumors of floor of mouth, pharynx, larynx
 Cervical spine trauma, inflammation
 Mediastinal mass
3. Helical CT (3D-reconstruction):
 Exact location and degree of airway compression
ADVANCED INDICES
• Flow volume loop
• Acoustic response measurement
• Ultra sound
• CT / MRI
• Flexible bronchoscope

25.  Weight
 Tongue protrusion
 Mouth opening
 Upper incisor length
 Mallampati class
 Head extension
Any 3 indices if present
>80kg
< 3.2cm
<5cm
>1.5cm
>1
<70 degree
~Prolonged
laryngoscopy
Group indices

26. Look at anatomy
Evaluate the airway
Mallampati
Obstructions
Neck mobility

27.  Beard
 Short, fat neck
 Morbidly obese patients
 Facial or neck trauma
 Broken teeth (can lacerate balloons)
 Dentures
 Large tongue
 Protruding teeth
 A narrow or abnormally shaped face
If present, think of difficult airway
LEM
ONS

28.  Will patients mouth open wide enough to
accommodate 3 fingers?
 Will 3 fingers fit between the mentum and
hyoid bone?
 Will 2 fingers fit between the hyoid and
thyroid notch?
 If not, expect a difficult intubation
LEM
ONS

29. LEM
ONS

30.  Laryngoscopy or intubation may
be more difficult in the presence
of an obstruction
 Anatomy
 Trauma
 Foreign body obstruction
 Edema (burns)
LEM
ONS
Neck Mobility:
Ideally the neck should be able to extend backwards
Problems:
Cervical Spine Immobilization
Ankylosing Spondylitis
Rheumatoid Arthritis

31. PARAMETER 0 1 2
Wt(Kg) <90 =90 >90
Head/neck
>90 =90 <90
movement
Interincisor
gap
>5 cm =5 cm <5 cm
Sliding
mandible
>0 =0 <0
Receeding
mandible
none moderate severe
Buck teeth none moderate severe
<5:easy laryngoscopy
6-7:moderate difficulty
8-10:severe difficulty

32. Parameter evaluated Min accepted value significance
Interincisor gap >3 cm Easy laryngoscopy
Buck teeth No overriding Wrong direction
Upper incisor length <1.5 cm easy alignment
Voluntary mandibular
Can be done Optimal TMJ fxn
protrusion
Mallampati class < grade II EASY L & I
Palate No narrowing/arching Easy L & I
TM Distance >5cm Optimally placed
larynx
Compliance of
mandibular space
soft Easy compressibility of
tongue
Neck thickness Obese neck Difficulty in aligning
axes
Neck length Should not be short Difficulty in aligning
axes
Head/neck mov Flex >35 or ext >80 3 axes best aligned

33.  1 finger breadth for subluxation of mandible.
 2 finger breadth for adequacy of mouth opening.
 3 finger breadth for hyomental distance.
In emergency situation, above test can be rapidly performed within
15sec to assess the TMJ function,mouth opening and hyomentsl
distance. Significant difficulty in 2 or more of these components
requires detailed examination.
Rule of 1-2-3-4-5
• 4 finger breath for thyromental distance
• 5 movements- ability to flex the neck upto the manubrium sterni,
extension at the AOJ, rotation of the head along with right & left
movement of the head to touch the shoulder.
RULE OF 3THREE`S
• 3 finger in the interdental space.
• 3 finger between mentum and hyoid bone.
• 3 finger between thyroid cartilage & sternum.

34.  Distance from the upper border of the manubrium
to the tip of mentum, neck fully extended, mouth
closed
 Minimal acceptable value – 12.5 cm
 Single best predictor of difficult laryngoscopy and
intubation ( Has high sensitivity & specificity).

35.  Inter-incisor distance with maximal mouth
opening
 Normal value > 5-6.5 cm / admits 3 fingers.
Significance :
 Positive results: Easy insertion of a 3 cm deep
flange of the laryngoscope blade
 < 3 cm: difficult laryngoscopy
 < 2 cm: difficult LMA insertion
 Affected by TMJ and upper cervical spine mobility

36. Significance-
Class B and C: difficult laryngoscopy

37. Patient is asked to hold the head erect, facing directly
to the front maximal head extension  angle
traversed by the occlusal surface of upper
teeth(can also measured by goniometer).
Minimum 35⁰
extension is
possible at
AOJ in normal
individuals.
Attlanto.Occipital.Extension

38. Grading of reduction in A.O.Extension
Grade I : > 35°
Grade II : 22-34°
Grade III : 12-21°
Grade IV : < 12°
Grade Reduction of A.O.Extension
1 none
2 One third
3 Two third
4 complete
Grades 3 and 4 : Difficult
laryngoscopy

39. can also be done by asking the patient to look
at the floor and at wall after fully flexing and
fixing the neck as shown
• Flexion movement of the cervical spine can be assessed
by asking the patient to touch his manubrium sternii
with his chin. If done, the above maneuver assures a
neck flexion of 25- 35 degree. Flexion and the extension
movement if within the normal range ,three axis (
oral,pharyngeal & laryngeal axis) can be brought into a
straight line.

40. Place the index finger of each hand, one underneath the
chin and one under the inferior occipital prominence
with the head in neutral position. The patient is asked
to fully extend the head on neck. If the finger under the
chin is seen to be higher than the other, there would
appear to be no difficulty with intubation. If level of
both fingers remains same or the chin finger remains
lower than the other, increased difficulty is predicted.

41. Palm print sign:
Patient’s fingers and palms painted with blue ink and pressed
firmly against a white paper
 Grade 1- all phalangeal areas visible
 Grade 2- deficient interphalangeal areas of 4th and 5th digits
 Grade 3- deficient interphalangeal areas of 2nd to 5th digits
 Grade 4- only tips seen.
Prayer sign.
Limited-mobility joint syndrome(stiff-joint sydrome)
Type I diabetics positive "prayer sign“. TM joint and C-spine
(e.g.
atlanto-occipital joint) may be involved

42. A positive "prayer sign" can be elicited
on examination with the patient
unable
to approximate the palmar surfaces of
the phalangeal joints while pressing
their hands together; this represents
cervical spine immobility and the
potential for a difficult endotracheal
intubation

44.  C-spine immobilized
trauma patient
 Protruding tongue
 Short, thick neck
 Prominent upper incisors
(“buckteeth”)
 Receding mandible
 High, arched palate
 Beard
 Dentures
 Limited jaw opening
 Upper airway conditions
 Face, neck, or oral trauma
 Laryngeal trauma
 Airway edema or
obstruction
 Morbidly obese
 MONTREAL SYSTEM OF
CLASSIFICATION IN
PAEDIATRIC AGE GROUP
FOR VARIOUS CHD’S

45.  Anaesthesiologist :
Inadequate preoperative assessment
Inadequate equipment preparation
Inexperience
Poor technique
 Equipment : Malfunction / Unavailability
 Patient : Congenital & acquired causes.

46. CONGENITAL:-
Pierre Robin
Syndrome
Micrognathia, Macroglossia, Cleft soft
palate
Treacher Collins
Syndrome
Auricular & ocular defect, molar &
mandibular hypoplasia.
Goldenhar’s
Syndrome
Auricular and ocular defects, molar and
mandibular hypoplasia; occipitalization
of atlas.
Down’s Syndrome Poorly developed or absent bridge of the
nose, macroglossia
Klippel-Feil
Syndrome
Congenital fusion of a variable number
of cervical vertebrae; restriction of neck
movement, elevated scapula

47. ACQUIRED
Infections
Supraglottitis
Croup
Abscess
Ludwig’s angina
Laryngeal oedema
Laryngeal oedema
Distortion of the airway and trismus
Distortion of the airway and trismus.
Arthritis Rheumatoid
Arthritis
Ankylosing
spondylitis
TMJ ankylosis, deviation of restricted
mobility of Cervical spine.
Ankylosis of cervical spine, less
commonly ankylosis of TMJ; lack of
mobility of cervical spine.
Tumour
Benign Tumor
Malignant Tumor
Stenosis or distortion of the airway
Fixation of larynx to adjacent tissues.
Trauma Oedema of airway, unstable#,
haematoma
Obesity Short thick neck, sleep apnoea
Acromegaly Macroglossia, Prognanthism
Acute Burns Oedema of airway

48. MANAGEMENT OF DIFFICULT INTUBATION :
Correct position of the patient
- A pillow (10 cm) should be placed under the head but not under the
shoulders.
- MORTON and colleagues (1989) proposed this position as lower neck
flexion 35o and extension of the plane of face 15o (both angles relative to
horizontal plane)

50. SIMPLE TECHNIQUES : (EQUIPMENTS)
i) Pressure on cricothyroid (SELLICK’S MAN.), thyroid cartilage or External
laryngeal manipulation. - Knill postulated Backward, Upward and Rightward
pressure known as BURP to the thyroid cartilage when the larynx is
anterioly placed for improving the view.
ii) Stylet : - Elongated metal or plastic rod with a smooth surface and no
sharp edges over which an ETT can be passed.
- Should be stiff and flexible enough to change the shape and curve of the
ETT. -
Facilitate intubation by directing the tube tip towards the glottis.
iii) Guedel Airway
iv) Gum elastic Bougie or Tube Exchange Catheters.-used by Sir Robert
Macintosh (1943)
- Elongated; flexible,soft and smooth rods over which the ETT can be
passed but these can not alter the shape of ETT.
- Useful when the posterior portion of the larynx is barely visible for the
epiglottis can not be elevated. It is important to bend the distal end forward
after it has been passed through the tracheal tube. The bougie can then be
advanced blindly towards the cords and then the tube can be rail-roaded
over the bougie.
v) - Hollow bougies are also available for attachment to oxygen

51. v) Magill forceps : Double angled forceps have grasping ends in the
axis of ETT and handle at the right angle.
vi) Tube bender forceps (Aillon forceps) : These have unequal
limbs which can bend the distal end of the ETT in the desired
direction.
vii) Flexible lumen finder (Flexguide) : It is designed to be used
with right hand after insertion through the ETT. It has a handle
thumb ring, inner rod and notched outer tube. The distal tip of the
tube can be manoeuvred with the help of the proximal thumb ring.
viii) Schroeder Stylet :
ix) Laryngoscope blade and handles :
Bozzoni invented first laryngoscope in 1805.
In 1907 Jackson designed a U-shaped laryngoscope with the
aim to divert force away from upper teeth.
Two commonly used designs – the curved (Macintosh) and
the straight (Miller) blades.
It is essential that the force applied to the laryngoscope
handle is directed along the long axis of handle.

52. 1. Inadequate or malfunctioning equipment.
2. Not requesting for experienced help.
3. Exaggerated idea of personal ability
4. No discussion with colleagues about proposed
management of the case .
5. Ill conceived plan (A) with no proper back up
plan (B).
6. Even poorly conducted plan (A) or sticking
extra time to the plan (A) so delaying the
rescue plan (B).
7. Inexperianced staff
8. Poor technique
9. Inadequate pre operative assesment

53.  Rigid laryngoscope blades
 Tracheal tubes
 Tracheal tube guides ( bougie, stylet,
lightwand, forceps)
 Airways (nasal & oral)
 Variety of facemasks(endoscopic masks)
 Elevation pillows
 Monitors
 Suction
 Oxygen (low & high flows)
 Pharmacological agents
 Supraglottic devices (LMA, Combitube)
 Video laryngoscope

54.  Rigid indirect laryngoscopes
 Fibreoptic intubation equipment
 Retrograde intubation kit
 Non-invasive/minimally invasive airways
 Jelly & ointment
 Defogging solution
 Fibroptic intub airways
 Other supraglottic devices
 Rigid & Flexible Broncoscope
 Local anaesthtic spray
 Difficult airway algorithm
 Airway exchange catheters
 Surgical Airway

55. Signs
...absent chest movements
…dec.SpO2
…cyanosis
…absence of exhaled Co2
…absent breath sounds
…gastric air entry or dilatation
…hemodynamic changes

56.  One person effort
 Smallest possible facemask & with jaw thrust
 Appropriate sized airway- oral or nasal
 Esmarch Heiberg Maneuver:
… involves dorsiflection at atlanto-occipital joint &
protusion of mandible anteriorly by exerting a
forward thrust on the rami of mandible”
 If both hands are needed ventilation can be
achieved by squeezing bag between elbows &
lateral abdominal wall or between knees till help
arrives

58.  Two person synergistic effort:
1st person acheives mask seal with one
hand & squeezes bag with other hand
while 2nd person provides jaw thrust or
• 1st person holds the mask with two
hands while 2nd person squeezes the bag
 Chin pressure on mask if continued leak

60.  Leave artificial dentures in place
 Packing buccal cavities with gauze
 Large mask in edentulous patients
 Employing a mask strap or tell assistant to pull
sagging cheaks
 Application of continuous +ive pressure of 5-
10cmH20 while ventillating
 Applying vaseline jelly over beard

61.  LMA.
 Combitube.
 Lightwand.
 Fibreoptic Intubation.
 Trans Tracheal Jet Ventilation
 Retrograde Intubation
 Surgical Airway
 If surgery is non emergent in nature,consider
awakening the patient or returning to
spontaneous ventilation

62. 1. Short Neck.
2. Protruding incisor teeth.
3. High arched palate.
4. Poor mobility of neck.
5. Increase in either anterior depth or Posterior
depth of the mandible.
6. Decrease in Atlanto Occipital distance.

63. Management:-

65.  Use well lubricated malleable Stylet
 Different blades of laryngoscope like
Miller, Macintosh, Bullard & McCoy.
 Gum elastic bougie
 LMA or Combitude
 Use of lightwands
 If patient is being ventilated think of
fiberoptic intubation
 Blind nasotracheal intubation
 If multiple attempts fail & case is not of
emergent nature, it is best to ventilate the
pt. until drugs can be reversed
 SURGICAL AIRWAY :FINAL RESORT

66.  …as one in which ventilation with noninvasive
techniques fails to maintain oxygenation &
tracheal intubation proves impossible
 ..this scenario may develop rapidly but often
occurs after repeated unsuccessful attempts at
intubation

67.  Call for help
 Go for emergency non invasive airway
ventilation like
Combitude/LMA
Rigid broncoscope
TTJV
 In case of failure ---EMERGENCY INVASIVE
AIRWAY ACCESS
Surgical or percutaneous
Tracheostomy or Cricothyrotomy

68. Basic preparation
~Inform
~Ascertain help
~Preoxygenation
~Supplemental
oxygenation
throughout
Portable storage unit
 Rigid laryngoscope blades
 ETTs
 ETT guides-bougie
 LMAs
 FOI equipments
 Retrograde intubation kit
 Emergency non invasive
airway ventilation device.
 Emergency invasive airway
access
 Exhaled CO2 detector

69. IN CASE OF AN UNANTICIPATED
DIFFICULT INTUBATION
 Different lengths of blades
 Different types of blades
 Different positions
 Simple Bougie or light wand guided or with a
hollow for O2
 Call for help
 Best attempt laryngoscopy

70.  Can we Ventilate with a BMV?
(Consider two NPA’s or a OPA, gentle
Ventilation)
 Two person ventilation?
 LMA an Option? Or other supraglottic
airway ?
 LMA?
 Combi -Tube?
 Retrograde Intubation?
we should have an assistant at this stage

71. Plan “C”
 Needle, Surgical or cannula
cricothyroidectomy
 TTJV
 Tracheostomy
Try to wake up the patient from the time we
fail intubation.

73.  Backward, Upward,
Rightward Pressure:
manipulation of the
trachea
 90% of the time the best
view will be obtained
by pressing over the
thyroid cartilage
Differs from the Sellick Maneuver

74. v) Magill forceps : Double angled forceps have grasping ends in the
axis of ETT and handle at the right angle.
vi) Tube bender forceps (Aillon forceps) : These have unequal
limbs which can bend the distal end of the ETT in the desired
direction.
vii) Flexible lumen finder (Flexiguide) : It is designed to be used
with right hand after insertion through the ETT. It has a handle
thumb ring, inner rod and notched outer tube. The distal tip of the
tube can be maneouvered with the help of the proximal thumb ring.
viii) Schroeder Stylet
ix) Laryngoscope blade and handles :
Bozzoni invented first laryngoscope in 1805.
In 1907 Jackson designed a U-shaped laryngoscope with the aim to
divert force away from upper teeth.
Two commonly used designs – the curved (Macintosh) and the
straight (Miller) blades.
It is essential that the force applied to the laryngoscope handle is
directed along the long axis of handle.

75.  Specialised curved blades
1- Left handed Macintosh blade - for left handed laryngoscopists
- For anatomical abnormalities on the right side of the face
mouth and oral cavity.
2- Improved vision Macintosh blade
3- Polio Blade – The angle between the blade and the handle is
made obtuse.
- It is useful in situations when the antero-posterior
diameter of the chest is such that insertion of the laryngoscope
into the mouth is difficult or impossible.

76. 4. Laryngoscope with “stunted” or short handle : useful in
obese patients and in patients with large breast.
5. Oxiport Macintosh : It has an oxygen port in the blade
allowing oxygen insufflation during intubation attempts.
6. Tull Macintosh : This blade has a suction port.
7. Siker blade : has stainless steel mirrored surface which
permits visualisation of an “anterior” larynx. It gives an inverted
image.
8. Huffman Prism : Images are real.
- Prism should be placed in warm water for 30 sec on anti-fog
solution to prevent fogging

78. Shucman-Pro
Levering Laryngoscope

79. 11. Upsher fibrecoptic laryngoscope – combines fibreoptic round
the corner viewing with maneuverability.
12. The tip of blade is advanced until it comes to rest close to the cords.
The tube sits in the semi-enclosed space in the blade.
- The variable focus eye piece enables the operator to obtain uninterrupted
view of the procedure. The eye piece can be attached to T.V. Camera for
teaching purposes.

80. 13. Specialised straight blades
Racz-Allen blade, Choi blade,
Belscope blade, Bainton blade, Guedel
blade, Bennett blade, Whitehead blade,
Flagg blade, Eversole blade, Snow
blade.
WU SCOPE

81. Truview evo2
Laryngoscope Glidescope L with video
intubating system

82. AIRTRACH
•Indirect rigid laryngoscopy
•Minimum mouth opening required
•Less hemodynamic stimulation
compared to conventional L
•Curvature n well designed optical
components help I visualisation of the
glottis without the need of alignment.

83. •Utilises the paraglossal technique of intubation
•BONFILS retromolar intubation fibrescope is a 5mm optical, distally curved stylet
which can accommodate a 6mm or larger ET tube
•Permits continuous oxygen insufflation
•Light supplied via remote Xenon source
•Can be attached to a module with image display

84. BLIND NASAL INTUBATION
Can be performed in anaesthetised or awake patients.
- Position - sniffing the morning air position
- A well lubricated nasal tube is gently passed through
the most patent nostril.
- The nasal mucous membrane should be
constricted by the use of vasoconstrictor
(xylometazoline or any other nasal decongestant).
-The bevel of the tube should be pointing laterally
so as to avoid trauma to choncha.
-The tube is then advanced while listening to the
breath sounds, manipulation of thyroid cartilage
and at times of head facilitates the alignment of
the tube.

85. - At times acute flexion of neck may be required if the
obstruction occurs during passage of the tube.
- The tip of the tube may get placed at five positions –
1.Into the trachea
2. Against the anterior commissure
3. may abutt In the vallecula at the base of tongue.
4. Laterally into pyriform recess.
5. In the Oesophagus.
NASOTRACHEAL INTUBATION IS INDICATED IN INTRAORAL
SURGERIES,LIMITED MOUTH OPENING, ANT LARYNX etc

86. STEPS :-
1. PSYCOLOGICAL PREP AND CONSENT
2. PREMEDICATION
3. LOCAL ANAESTHESIA OF THE AIRWAY
4. PROCEDURE

88.  DR. PETER MURPHY WAS THE FIRST TO USE
FLEXIBLE FIBERSCOPE
 Fiberoptic endotracheal intubation is a useful
technique in a number of situations. It can be used
when the patient's neck cannot be manipulated, as
when the cervical spine is not stable. It can also be used
when it is not possible to visualize the vocal cords
because a straight line view cannot be established from
the mouth to the larynx.
 Fiberoptic intubation can be performed either awake or
under general anesthesia and it can be performed
either as the initial management of a patient known to
have a difficult airway, or as a backup technique after
direct laryngoscopy has been unsuccessful.

89. FFI;- Bronchoscopes : Both rigid and fibreoptic
bronchoscopes have been used as an aid to intubation.
Flexible fibreoptic intubation. It consists of –
A. Insertion tube – Flexible part extending from control
section to distal tip of scope.
B. Control section – Contain the tip control knob which
controls movement of insertion tube.
C. Eye piece section.
D. Light transmission cord – from external light source to
hand of fiberscope.
E. Light source.
Principle
• Internal reflection - Beam of light entering one
end of glass rod will repeated internally reflex off the
walls of rod, eventually emerging from other end.
• Optical lenses – Light that is internally reflected
is completely blurred. it is focused with a series of
optical lenses.
• (Gold standard for anticipated difficult intubation)
– any age, any position.
• Requires good experience.

91. 91
 Lack of expertise (most common)
 Secretion and blood
 Fogging of lenses
 Poor topical anesthesia
 Distorted anatomy
 Fiberoscope malfunction
 Inadvertent passage of fiberoscope through
Murphy’s eye

92. ADJUNCTS TO DIFFICULT AIRWAY MANAGEMENT –
1. Nasopharyngeal airway
Connell’s Nasopharyngeal Airway
Esophageal Obturator Airway
2. Oesophageal Obturator Airway –By Don Michael and Gordon in 1968.
Consist of two parts first 30 cms plastic oesophageal tube occluded at distal
end.
- There are perforations in the tube which are intended to be located in
hypopharynx. A large balloon is located at distal end to create a seal in the
oesophagus.
- Second part of the device is face mask with an inflatable cuff designed to
make a tight seal with the face. After lubrication tube is inserted blindly
without laryngoscope.

93.  Purpose ___ maintain a patent airway
 Adv. ___ dec. the work of breathing
 How ?___lifts the tongue & epiglottis
away from the posterior
pharyngeal wall and prevent
them from obstructing the space
• USES PATENCY OF AIRWAY
prevent biting/occluding of ETT
facilitating suctioning
obtains better mask fit
inserting devices into oesophagus

94. 3. Patils syracuse oral airway- allows fibreoptic intubation
4. Ovassapian fiberoptic intubating airway – Accommodates
tracheal tube upto 9 mm diameter.
5. COPA (Cuffed Oropharyngeal airway )-
Disposable device that combines a guided airway with an
inflatable distal high volume lowpressure cuff and a proximal
15mm adapter. - distal tip should be behind base of tongue

95. 6. Pharyngo-tracheal lumen airway - it is double lumen tube
consisting of a long tube with a distal cuff (15 cc) designed to be
inflated in esophagus and shorter tube that protrudes through the
larger tube and past alarge proximal cuff (100 cc) to ventillate
the lungs.

96. 7. Oesophageal tracheal combi tube (OTC) :
- Disposable double lumen tube with a low volume inflatable distal
cuff and a larger proximal cuff.
- Distal cuff => Oesophagus Proximal cuff => Oropharynx
- Ventilation is possible with either tracheal or esophageal intubation.
If it enters oesophagus (common) – Ventilation is through multiple
proximal apertures situated above distal cuff. Both cuffs have to be
inflated. - If it enters trachea –ventillation is through distal lumen as
with a standard tracheal tube.
4.

98. 10. I GEL
• Is a non cuffed
supraglottic device with the
shape of the LMA
• Disposable
• Made of gel ,softer
• Has a gastric drain
(ProSeal LMA-like)
• Bite block
• And an epiglottis blocker

99. “Pharyngeal Express” Airway

100. 12.

101. Plastic disposable uncuffed
device
Anatomically shaped to fit
pharynx & forms a seal with the
pharynx
Hollow boot with toe, heel &
bridge with opening anteriorly
Available in 6 sizes(47,49,51,
52,55 &57 mm)
Match with the width of thyriod
cartilage

102.  Bridge fits in pyriform
fossa
 Heel connects to airway
tube(rectangular) , stablize
it & has color coded
connector
 Large chamber for storing
regurgitated fluids
 Toe has lateral bulges

103.  Easy to insert & high first high attempt success rate
 But more resistance to insertion
 Used for both spontaneous & controlled ventilation
 Well tolerated during recovery
 PERILARYNGEAL AIRWAY (COBRAPLA)

104.  Easy to insert & high successful first
attempt rate
 Used for percutaneous cricothyroidotomy
 In difficult to ventilate & intubate scenario
 In LMA failure as in neck contractures
DISADVANTAGE
 Does not protect against aspiration

105.  Nebulizers—entire airway {5ml of 4% lidocaine}
 Topical sprays—upper airway {10%lidocaine}
 Viscous gels_ upper airways {4% lidocaine }
 Trans tracheal injection —larynx and trachea {2-
3 ml of 2% lidocaine}
 “SAYG”—larynx and trachea
 Nerve blocks —distribution of the nerve supply
 Combinations of the above
 Generally speaking, vocal cord and its vincity is
the most sensitive site and the most common
barrier to successful awake fiberoptic intubation;
others are usually tolerable under the spray of
local anesthetics.

106. AIRWAY BLOCKS:-
Glossopharyngeal Nerve Block
26# spinal needle
Advance 0.5 cm
into mucosa
2 BRANCHES : MOTOR N
SENSORY
2ml of 1~2% lidocaine
each side into tonsillar
pillors
Aspiration before injection
May have the patient in
sitting or back-up position
Block post 3rd of tongue &
oropharynx

107. Superior Laryngeal Nerve Block
Locate the hyoid bone
• 1cm below each greater cornu
(where the internal branch of the
superior laryngeal nerve
penetrates the thyrohyoid
membrane)
• Infiltrate 3ml 2% lignocaine
• Feel a ‘pop’ as the needle
penetrates the membrane

108. TTJI can provide o2 on a short term basis until definitive airway can b placed or the
patient resumes spontaneous breathin or wakes up.
 The patient’s neck is slightly hyperextended.
108
 Drug : 4% Lidocaine 2 ml of 10% at end
expiration (2% needs longer onset time, maybe 10
min)
 22G IVcath, through cricothyroid membrane,air
bubbles after aspiration confirmcorrectplacement
 Ask pt to cough

109. 85
 An oral bite is a must unless very good topical
anesthesia (which is a rarity.)
 Advance the tip of the scope(ETT mounted) till
the posterior part of the tongue base then bend
downwards nearly 90°; epiglottis will appear in
view.
 Advance between epiglottis and posterior wall
of larynx. Glottic opening would be found.
 Now advance the ETT on the scope & remove
the scope

110. 110
 A more curved pathway compared with
nasal passage
 Less convenient in distorted anatomy
 Prone to deviate from midline position
(an intubating airway is helpful.)
 Easy to cause fiberoscope damage

111. ~RI INVOLVES A PUNCTURE OF
THE CRICOTHYROID MEMBRANE
AND THE THREADING OF A WIRE
RETROGRADE THROUGH THE
VOCAL CORDS INTO THE MOUTH
OR THE NOSE, WHICH GUIDES AN
ETT THROUGH THE GLOTTIS.
~THIS IS TYPICALLY USED IN THE
CANT VENTILATE, CANT
INTUBATE SCENARIO!

112. IN CASE FIBEROPTIC TNTUBATION TOO FAILS, WE GO FOR
{RETROGRADE INTUBATION}:-
EQUIPMENTS:-
~SELF CONTAINED RI KITS ARE AVAILABLE
~HOWEVER EQUALLY EFFECTIVE ASSEMBLY OF THE
EQUIPMENT CAN BE DONE BY PROCURING A WIDE BORE
NEEDLE OR TUOHY’S NEEDLE OR AN 18-16G INTRACATH, AN
EPIDURAL CATHETER, A 5ML SYRINGE N A STERLISED
MOSQUITO FORCEPS
~EVEN A REAUTOCLAVED LONG LENGTH >50 CMS J-WIRE OF
A CVP CAN BE USED OVER WHICH ET IS RAILROADED!
COMPLICATIONS:-
TRACHEAL LACERATION, INFECTION AND MEDIASTINITIS

113. ~ The retrograde technique of intubation consists of percutaneously
passing a narrow flexible guide into the trachea from a site below the
vocal cords and advancing this guide through the larynx and out the
mouth or nose. In the basic technique, the tracheal tube is then passed
over the guide through murphy’s eye into the upper part of the trachea,
the guide is removed, and the tube is advanced into the trachea.
~Guides may emerge from the mouth or nose. If nasal intubation is
planned and the guide comes out of the mouth, a soft catheter can be
passed through the nose, retrieved from the mouth, and then used to
bring the guide out through the nose.
~Passage of an epidural catheter through the larynx has been
successful after failure with a guidewire, and it is easier to retrieve a
plastic guide than a steel guidewire from the mouth. Guidewires are a
better choice for use with the FFL. The technique can be performed
under topical anesthesia in a sedated patient.
~The guides are inserted through a needle or cannula that is inserted
horizontally (so that the vocal cords are not damaged) with the bevel
directed cephalad. The intratracheal position of the initial needle should
be confirmed by aspiration of air. Jaw thrust and tongue traction can
facilitate passage of the guide behind the tongue.

114. ADVANTAGES
 CERVICAL SPINE FRACTURE PTS
 SAFE ALTERNATIVE IF INTUBATION IS
ANTICIPATED DIFFICULT OR IMPOSSIBLE
 EFFECTIVE IN CASES OF FAILED INTUBATION
WHERE BAG & MASK VENTILLATION IS
ADEQUATE & TIME IS AVAILABLE
 CAN BE DONE AWAKE OR IN ANAESTHTISED PTS
contraindications
 INFECTED NECK
 NEOPLASTIC LARYNGEAL LESIONS

116.  Injection of high velocity gas into the
airway through a narrow cannula without
a seal—60cyc/min
 HFJV- >60 cyc/min
 Jet acts to inc volume delivered
 Needle cricothyrotomy
 In children peak pressure is set at 5psi-increased
by 5psi increments until
adequate chest expansion
 In adults-preset pressure 25psi, then dec
or inc depending clinically
 Keep airway patent-sniff position & jaw
thrust
 If obstruction persists-go for tracheostomy
 Inspired 02 conc depends on structure of
catheter & ratio of catheter to trachea

117.  Automatic ventilators
 Manual jet ventilation
 Auxilary flometer
 Oxygen flush
 Anaesthesia breathing system
 Manual resuscitation bag

118.  Indications (only if >10 years old)
 Failed airway
 Failed ventilation
 Predictors of difficulty
 Previous neck surgery
 Obesity
 Hematoma or infection

120. - Minitracheostomy is preferred. A single vertical incision 3-5 mm in
length over cricothyroid membrane is made and then through
obturator the 4 mm uncuffed tracheal tube is guided.
-Compared with I.V. cannula the minitrach has larger diameter and is
better for jet ventilation and even for assisted spontaneous
respiration for a short period.
MINI TRACHEOSTOMY

122. Indications
1. Upper Airway Obstruction.
2. Pulmonary Ventilation.
3. Pulmonary Toilet.
4. Elective Procedure

123.  Patient placed in supine
position with pillow under
shoulders & a head ring.
 Prepare the area & drape.
 Under local or general
anaesthesia.
 Give a transvrse insicion
favouribly
 Gentle dissection

124.  After retracting isthmus
of thyriod gland
upwards ,trachea is
exposed
 NS filled syringe is
introduced & aspirate to
confirm position
 Window created in 3rd -
5th tracheal rings
 Tracheostomy tube
inserted & secured

125. Intraopertaive Complications.
 Bleeding and injury to big vessels
 Injury to tracheoesophageal wall
 Pneumothorax
Early Complications
 Bleeding
 Tracheostomy tube obstruction
 Tracheostomy tube displacement
 Infection
Late Complications
 Tracheal Stenosis
 Granulation tissue
 Tracheocutaneus fistula
 Tracheo - inominate fistula

126. Cricothyrotomy creates a percutaneous airway through the
cricothyroid membrane. Its advantages over tracheostomy are that
the membrane is superficial and relatively avascular and cartilage
incision is not necessary because the height of the membrane is
greater than the distance between the tracheal rings. Cricothyrotomy
can be performed with a surgical or cannula (needle) technique, and
appropriate use can prevent anesthetic-related deaths. It is a core
skill for the anesthesiologist
Equipments:
Quicktrach I
Standard-Set
Available for adults (I.D. 4mm
 children (I.D. 2mm) and
 infants (I.D. 1.5mm)
Quicktrach II

127. METHODS OF
CONFIRMATION
Technology Based
• ETCO2 (monitor)
• Pulse Ox change
Traditional
• Direct
Visualization
• Lung Sounds
• Tube
Condensation

128. 1….. MMP Class 3 or 4
2….Supraglottic and glottic areas oedema.
3….Large breasts.
4….Full dentition.
5….Mucosal congestion of nose, pharynx,etc.
6….Enlargement of tongue.
7….Fat deposition in oropharyngeal region.
8….Elevation of hyoid bone.
9…..Weight gain.
10…Improperly applied cricoid pressure.
11…Improperly applied hip wedge causes decreased chin –
chest distance.

130.  Difficult spontaneous ventilation in obstructive
sleep apnea
 BMI > 26 – predicts difficult mask ventilation
 Difficult intubation predictors-
MMP Score >3
Neck circumference >16inches

133.  RSI involves 4 experienced personnel
 AMPLE history
 Allergies
 Medication
 Past medical history
 time of Last meal
 Events leading
 safe cervical spine movement
 Equipment option depending on operator experience & skill
4.CERVICAL SPINE INJURY: MANAGEMENT OPTIONS
• Manual in-line stabilization(MILS)
• Airway interventions requiring less neck movement
– Jaw-thrust (ventilation)
– Adjunctive device  ILMA, combitube
– Cricothyrotomy
• Least movement (0.1 mm) with fibre optic nasal intubation

135. • Micrognathia is a common feature of difficult intubation in children
• The most important consideration is whether ventilation by facemask will be
possible.
• Always have a plan A, B and C.
• Whenever possible use an inhalational technique and keep the child breathing
spontaneously
• Repeated attempts using a technique which has failed has little logic. Alternative
techniques should be considered.
• Familiarize yourself with one technique of indirect laryngoscopy by practicing it
in children with normal airways.

136. Cuff leak test, visual inspection n imaging of airway swelling!
 LEAK TEST is performed in a spontaneously ventilating patient at
risk of obstruction after extubation. Circuit disconnected 
occlusion of ETT end and deflation of cuff  ability to breath
around the ETT.
METHODS:-
1.Conventional awake extubation
2.Extubation over a bougie.
3.Extubation over a fibreoptic bronchoscope.
4. Endotracheal ventilation and exchange catheters
e.g.
– Cook’s airway exchange catheter
– Tracheal tube exchanger

137. -THE LARSONS MANEUVER :- Pressure on the laryngospasm notch is a non
invasive, safe n often effective technique in the management of
laryngospasm on extubation. Suxamethonium(0.5mg/kg) IS USED IN
EXTUBATION INDUCED LARYNGOSPASMS.
- Also it is a useful stimulant whenever there is respiratory depression after
extubation.
-Helium is of proven value in the management of post extubation stridor.
-CROUP N LARYNGOSPASMS CONTRIBUTE A HIGHER RATE IN PAEDIATRIC
DIFFICULT EXTUBATIONS.
-EXTUBATION RISK PATIENT:
-Awaken the patient and wait for complete reversal of NMB
-Should remain intubated in the intensive therapy until there is an evidence that
airway swelling has resolved
-Extubate over a ventilating stylet/tube exchange catheter
-Factors such as altered neurological status may affect extubation n trachaeostomy
may be needed
-Extubation should not be performed in a patient at risk of vomitting or
regurgitation.
-It should b performed in an awake patient after breathing 100% oxygen to max o2
stores
-Helium, non invasive ventilation and CPAP may reduce the need for reintubation!

139. • Use antisialogue in premedication.
• Aspiration prophylaxis.
• ET of assorted size.
• LMA of assorted size.
• Tracheostomy set.
• Check special airway equipment.
• Keep help of senior anaesthesiologist.
• Preoxygenate patient / End tidal CO2 device.

140. • Dont produce deep plane of anaesthesia.
• Dont use technique that you are not familiar.
• Avoid multiple attempts.
• Dont render the patient apnoeic, unless you are
certain that mask ventilation can be maintained

141. THANK
YOU!