1. Perform a thorough airway assessment to evaluate any anatomical variations or difficulties that may be encountered. This includes evaluating mouth opening, neck mobility, Mallampati score, and other tests. 2. Prepare all necessary airway equipment like laryngoscopes, endotracheal tubes, stylets, laryngeal mask airways etc and have them checked and ready to use. 3. Pre-oxygenate the patient with 100% oxygen for 3-5 minutes to denitrogenate the lungs. 4. Induce anesthesia and provide muscle relaxation while maintaining oxygenation with a facemask or other device. 5

1. Dr Ramprasad Gorai
PGT-Dept of Anaesthesiology
R.G.Kar Medical College,Kolkata

2. AIRWAY ANATOMY
UPPER AIRWAY
(Part above cricoid cartilage)
1. Nose & Paranasal sinuses
2. Oral cavity
3. Pharynx
4. Larynx
LOWER AIRWAY
1. Trachea
2. Lt & Rt Principal Bronchi
3. Secondary (Lobar) bronchi
4. Segmental (Tertiary) bronchi
5. Terminal bronchiole
6. Respiratory bronchiole
7. Alveolar duct & Sacs

3. NOSE
INTERNAL NOSE
1. Lt & Rt Nasal Cavities
2. Nasal Septum
Collumeller Septum
Membranous Septum
Septum Proper
a. Cartilage 1/3
b. Bone 2/3
NASAL CAVITITY
1. Vestibule
2. Respiratory Segment
3. Olfactory Segment
EXTERNAL NOSE
1. Osteo-Cartilagenous
2. Ala Nasi
3. Nasal Skin

4. 1.Vestibule
Strat column epithelium.
Vestibular hair (Vibrissae) filter large particulate matter.
Lamina propria
a. Hair follicle
b. Ecrine gland
c. Sebaceous gland
2. Respiratory Segment
Ciliated Pseudo strat Column
Contains
Goblet,Basal,Brush,
Neuro -endocrine cell
3. Olfactory Segment
Olfactory epithelium
Contains:
Bipolar neurosensory cell
supporting cell
regenerative basal cells

5. NASAL SEPTUM
• Consist of-
1. Septal Cartilage
2. Perpendicular plate(Ethmoid)
3. Vomer
4. Crest of Nasal bone
5. Nasal Spine of Frontal bone
6. Rostrum of sphenoid bone
7. Crest of Palatine bone
8. Crest & Ant nasal spine of
Maxilla

6. PARANASAL SINUS
Blind ended air containing
Cavity in certain skull bones.
2 groups—
Anterior Group
1. Maxillary
2. Frontal
3. Ant Ethmoidal
Posterior Group
1. Posterior Etmoidal
2. Sphenoid
Functions
1.Warm & Humidify Inspired Air
2.Resonance to Voice

7. PHARYNX
• Musculo-membranous tube extend from base of
skull to 6th Cerveical Vertebra.
• Length-12-14 cm
• Width- Max 3.5 cm(Naso Pharynx)
- Min 1.5 cm(Pharyngo esophageal Jn)
* 3 Part----
1. Naso/Epi-Pharynx
2. Oro/Meso-Pharynx
3. Laryngo/Hypo-Pharynx
At the base of tongue EPIGLOTTIS functionally separate
Oropharynx from Laryngopharynx.

8. LARYNX LARYNX
Lies- in front of hypopharynx &
opposite to 3rd to 6th Cerveical vertebra.
Composition-
1.CARTILAGE-3 Unpaired & 3 Paired(Total 9)
UNPAIRED—Thyroid, Cricoid , Epiglottis
PAIRED ---Aretenoid, Corniculate, Cuneiform
2.MUSCLES---Intrinsic & Extrinsic.
3.JOINTS—Cricothyroid & Cricoarytenoid
4.MEMBRANE-Intrinsic & Extrinsic
5.CAVITY- Inlet. Vestibule. Sinus of Lrynx. Infraglottic part.
6.MUCOSA-Ciliated Pseudostratified Columnar except VC--Strat squamnous.

9. LARYNX

11. SENSORY NERVE SUPPLY
NASAL CAVITY
ANT-Anterior ethmoidal N
(br of Ophthalmic div-V1)
POST-Sphenopalatine
(br of Maxillary div -V2)
TONGUE(GEN SENSATION)
ANT 2/3—Lingual Nerve
(br of Mandibular div of
Trigeminal)
POST 1/3-Glossopharyngeal
nerve.
PHARYNX
Glossophayngeal nerve also
innervate -
Roof of pharynx
Tonsil
under surface of soft palate.
LARYNX
Below the epiglottis --VAGUS.
Above vocal cord-
Internal Laryngeal branch
Below vocal cord-
Recurrent laryngeal branch

12. NERVE SUPPLY

13. TRACHEA
Membrano cartilaginous tube
Lower border(Carina)
T4 vertebra- supine & cadaver
T6 vertebra- standing & living
Length- 10-11 cm
Breadth-12 mm in adult. (int diameter)
3 mm (newborn –upto 3 yr)
increase by 1mm/year till 12 yr of age.
Structure-16-20 C-shaped hyaline cartilage connected by
strong fibroelastic memb & posterior deficit part contain
involuntary trachealis muscle
Relation-Thyroid Isthmus-2nd.3rd .4th Ring

15. ZONE OF AIRWAY
(23 generation)
Conducting zone-(First 14 gen)
Trachea
Principal Bronchi
Segmental bronchi-upto Terminal
bronchiole
Transitional zone-(15th gen)
Terminal bronchiole(3-4 generation)
Respiratory zone-(Last 8 gen)
Respiratory bronchiole
Alveolar ducts
Alveolar sacs.

17. Def- The portion of the lungs aerated by each tertiary
or segmental bronchus.
Features-
- an independent respiratory district.
- covered by inter-segmental septa through which br of
pulmonary vein runs.
- the largest sub-divisions of the lobe and is surgically
resectable.
- supplied independently by segmental brochus and a
tertiary branch of pulmonary artery.

18. Bronchopulmonary segments
Right Lung :
Superior Lobe :
Apical
Posterior
Anterior
Middle Lobe :
Lateral
Medial
Inferior Lobe:
Superior
Anterior basal
Posterior basal
Medial basal
Lateral
Left Lung :
Superior Lobe :
Apico-posterior
Anterior
Lingular Lobe :
Superior
Inferior
Inferior Lobe:
Superior
Anterior basal
Posterior basal
Lateral

19. Left main bronchus and its divisions

20. Rt Bronchous
RIGHT BRONCHUS IS
WIDER ,SHORTER AND
MORE VERTICAL THAN
LEFT BRONCHUS
 IT IS WIDER B/C IT
SUPPLIES MORE
VOLUMINOUS RT LUNG
 IT IS MORE VERTICAL
B/C AT ITS BIFURCATION
TRACHEA DEVIATES MORE
TO THE RT SIDE

21. Right main bronchus and its divisions

22. At a glance…

24. ACINUS V/S TERMINAL RESPIRATORY UNIT
• ACINUS-The ultimate lung unit from
each terminal bronchiole.
• TRU-all alveolar duct & their
accompanying alveoli,that stem from
the most proximal (first) respiratory
bronchiole.
• 1 Acinus contain 10-12 TRU.
• Anatomist & Pathologist –Acinus.
• Physiologist & Pulmonologist-TRU.

31. ANATOMICAL VARIATION &
IMPLICATION IN ANAESTHESIA
Conventional Laryngoscopy – done in
-supine position
-a slight Neck flexion of 25-35 deg
-Head extension of 85deg at atlanto-
occipital joint
to align oral,pharyngeal & Laryngeal axes.
In adult a head elevation of 10 cm with a
pillow is appropriate for neck flexion.
No such elevation required in pediatric age
gr (<8yr age) d/t their large head size.
This position is called OPTIMAL SNIFFING
POSITION.

32. AIRWAY ASSESSMENT
• Mouth opening: an incisor distance of 3 cm or
greater is desirable in an adult.
• Upper lip bite test: the lower teeth are brought in
front of the upper teeth. The degree to which this
can be done estimates the range of motion of the
tempero-mandibular joints .
• Mallampati classification: examines the size of
the tongue in relation to the oral cavity. The
greater the tongue obstructs the view of the
pharyngeal structures, the more difficult
intubation

33. Cont…
• ■ Class I: the entire palatal arch, including the
bilateral faucial pillars, are visible down to their
bases.
• ■ Class II: the upper part of the faucial pillars and
most of the uvula are visible.
• ■ Class III: only the soft and hard palates are visible.
• ■ Class IV: only the hard palate is visible.
• Thyromental distance: the distance between the
mentum and the superior thyroid notch. A distance
greater than 3 finger breadths is desirable.
• Neck circumference: a neck circumference of greater
than 27 inch is suggestive of difficulties in
visualization of the glottic opening.

34. Mallampati Classification of oral opening
Laryngoscopic grade of Cormac & Lehane

35. Airway of Neonates and infants
• Relatively larger head and tongue
• Narrower nasal passages
• Anterior and cephalad larynx
• Relatively longer epiglottis
• Shorter trachea and neck
• More prominent adenoids and tonsils
• Weaker intercostal and diaphragmatic
muscles
• Greater resistance to airflow
• Adult larynx is cylindrical but
• Childs larynx is Conical.

36. Cont…..
narrowest point of the airway-
cricoid cartilage (children younger than 5 years of age)
glottis ( in Adult)
One millimeter of mucosal edema will have a
proportionately greater effect on gas flow in children
because of their smaller tracheal diameters.
The presence of fewer, smaller airways produces increased
airway resistance.The alveoli are fully mature by late
childhood(about 8 years of age). The work of breathing is
increased and respiratory muscles easily fatigue.

37. Pediatric Airway

38. Anatomical change during Pregnancy.
• Most of the changes during pregnancy are
Physiological.
• Capillary engorgement of the respiratory
mucosa during pregnancy predisposes the
upper airways to trauma, bleeding, and
obstruction.
• Gentle laryngoscopy and smaller endotracheal
tubes (6–6.5 mm) should be employed during
general anesthesia.

40. EMERGENCY TRACHEOSTOMY
• 4 Step
• Horizontal skin incision
• Expose investing layer
of Deep Fascia
• Divide/Displace
Isthmus.
• Vertical incision in
trachea.

43. Aspiration, pneumonia and lung abscess
Right lung is most frequently involved
as the right main bronchus directly takes
off from principle bronchus.
In the recumbent position,
superior segment of the right lower lobe
and posterior segment of the right upper
lobe are the most dependent segment of
the lung &
in standing position,
basilar segment of the lower lobe is most
dependant.
Aspiration pneumonia involving
apical segments of the lower lobe is
known as mendelson’s syndrome

44. Postural Drainage
It consist of positioning the patient to allow
gravity to assist the drainage of secretions
from specific areas of the lungs
Segments receiving drainage should be
uppermost
Treat the lower lobe segments first and
upper lobe last
Aerosol therapy with humidification prior
to PD
Worst area should be drained first
On average 15-20 mins is spend in each
position
During PD :
Chest manipulations
like(Vibration,
clapping/percussion,
shaking )-Tappotment
massage are performed in
postural drainage position.
Should be done in order.
 Vibrations and clapping
first .
Shaking next

45. Upper lobe-apical segments
(bilateral)
Half lying

46. Upper lobe-posterior segment-right
left side lying 45 degree turn towards face side

47. Upper lobe-posterior segment-Left
Right side lying
45 degree turn towards face side
Three pillow

48. Middle lobe –lateral and medial
segments right
From supine 45 degree turn towards left
pillow from shoulder to hip
foot end raised 14”

49. Left Lingula –superior and inferior
segments
From supine 45 degree turn towards right
pillow from shoulder to hip
foot end raised 14”
14”

50. Lower lobe-apical
segments(bilateral)
Prone lying
pillow under hip

51. Lower lobe-anterior basal
segments(bilateral)
supine lying
pillow under hip
foot end elevated to 18”
18”

52. Lower lobe-posterior basal
segments(bilateral)
prone lying
pillow under hip
foot end elevated 18 inches
18”

53. Lower lobe- Medial basal of right&
lateral basal of left
Right Side lying
pillow under hip
foot end elevated 18”
18”

54. Lower lobe-lateral basal segment-
right
Left side lying
pillow
18”

55. Technique for airway management of a patient with
suspected spinal cord injury.
One individual holds the head firmly
with the patient on a backboard, the
cervical collar left alone if in place,
ensuring that neither the head nor neck
moves with direct laryngoscopy.
A second person applies cricoid
pressure and
The third performs laryngoscopy and
intubation.
BUT
Gold standard is
FLEXIBLE FIBEROPTIC INTUBATION .
laryngoscopy with in-
line stabilization

56. •
Thank you