Equip

1. AIRWAY EQUIPMENT
 Complied by mengistu
6/7/2023 1

2. Objectives
 Review the anatomy of respiratory tract.
 Describes the necessary equipment for successful
management.
 Presents various management techniques.
 Discuss complications of laryngoscopy, intubation,
and extubation, and
 Discuss about airway obstruction and its
management.
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3. What does it mean
airway?
airway
management?
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4. Basic anatomy of respiratory system
 Structurally the respiratory
system consist of two parts:
1. Upper respiratory system:-
parts outside the chest cavity:-
nasal cavities, mouth, pharynx,
larynx, and upper trachea
2. Lower respiratory system:–
parts found within the chest
cavity: the lower trachea and
bronchial tubes and alveoli.
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5. 6/7/2023 5

6. Functionally the RS;
a. Conducting portion :
• Mouth/nose, pharynx,
larynx, trachea,
bronchus, bronchioles
(up to the terminal
bronchioles)
• Are transporting gases
to
and from the alveoli.
• Filter, warm, and 6/7/2023 6

7. b. Respiratory portion
 Respiratory bronchioles alveolar ducts
alveolar sacs alveoli (functional
unit of respiratory system)
- is the main site of gas exchange between air and
blood.
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8. Respiratory system
 The primary function is gas exchange, it also
perform the following function
 Contains receptors for the sense of smell
 Filtration of inspired air
 Production of sound
Regulation of blood PH
Excretion of some water and gets rid of heat in exhaled air
It enables protective and reflexive non breathing air movements,
as in coughing and sneezing, to keep the air passageways clean
It assists in abdominal compression during micturition,
defecation, and parturition.
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9. Nose
Bone and cartilages-external part
Nasal cavity -for passage of air.
Has two opening(nares)
The partition of the nose is known as nasal septum
Function
Olfaction (smelling)
Respiration (breathing)
Filtration of dust
Humidification of inspired air
Reception and elimination of secretions from the
nasal mucosa, paranasal sinuses, and
nasolacrimal ducts.
Resonance of voice
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10. Anatomy of oral cavity
 Roof of the mouth is formed by the hard and soft
palate and the floor is by the tongue and the mucosa
b/n the tongue & mandible.
hard palate-bony portion
soft palate-fleshy portion
uvula - posterior edge of soft palate
 The front of soft palate faces the mouth cavity. The
posterior surface is part of the nasopharynx.
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11. 6/7/2023 11

12. Pharynx
 The pharynx is a U-shaped fibromuscular structure that
extends from the base of the skull to the cricoid cartilage
at the entrance to the esophagus.
 Nasopharynx - part above uvula and posterior to
internal nares
- lies posterior to the nasal cavity
 Oropharynx – portion visible in mirror when mouth is
wide open fauces = the opening
 Laryngopharynx – between the base of tongue & the
entrance of esophagus.
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13. Pharynx-functions
 Is a passageway for air and food
 Provides resonating chamber for speech sounds
 Houses the tonsils – which have immunological
reaction against foreign invaders.
 The mouth and pharynx are also a part of the upper
gastrointestinal tract.
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14. 6/7/2023 14

15. Larynx(voice box)
 The larynx is a cartilaginous skeleton held together by
ligaments and muscle.
 it is composed of hyoid bone and nine cartilages:
Three single cartilages
Thyroid cartilage-the largest
Cricoid
Epiglottis and
Three paired cartilages
 Arytenoid
Corniculate and
Cuneiform.
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16.  The thyroid cartilage
shields the conus
elasticus, which
forms the vocal
cords.
 The epiglottis
prevents aspiration
by covering the
glottis(the opening of
the larynx )during
swallowing. 6/7/2023 16

17. 6/7/2023 17
Mucous membrane of the larynx forms two pairs of folds;
1. superior pair called false vocal folds (ventricular folds)
2. Inferior pair called the vocal folds ( true vocal cords)

18. Trachea
 is a tubular passageway for air located anterior to the
esophagus.
 extends from the larynx (cricoid cartilage) to the
superior border of the 5th thoracic vertebra (T5)
 The trachea begins beneath the cricoid cartilage and
extends to the carina, the point at which the right and
left main-stem bronchi divide.
◦ Anteriorly, the trachea consists of cartilaginous rings.
-incomplete C shaped rings.
◦ posteriorly, the trachea is membranous.
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19. Bronchi
At the lower border of the 4th thoracic vertebra, the
trachea bifurcates into right and left primary (principal)
bronchi; which enter the respective lungs.
 The right primary bronchus is
more vertical,
shorter, and
wider than the left.
As a result, when ever there is aspiration of foreign
body, it is more likely to enter the right primary bronchus
than the left.
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20. 6/7/2023 20

21. Nerve supply
 The sensory supply to the upper airway is derived
from the cranial nerves(trigeminal).
 The mucous membranes of the nose are innervated
by the ophthalmic nerve.
 The vagus nerve (the tenth cranial nerve) provides
sensation to the airway below the epiglottis.
 The muscles of the larynx are innervated by the
recurrent laryngeal nerve, with the exception of the
cricothyroid muscle.
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22.  Branch of the vagus, the recurrent laryngeal nerve ,
innervates the larynx below the vocal cords and the
trachea.
Blood supply
 The blood supply of the larynx is derived from
branches of the thyroid arteries.
 The cricothyroid artery arises from the superior
thyroid artery itself, crosses the upper cricothyroid
membrane (CTM), which extends from the cricoid
cartilage to the thyroid cartilage.
 The superior thyroid artery is found along the lateral
edge of the CTM.
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23. 6/7/2023 23

24. Anatomically Pediatrics have
 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
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25. Physiologically Pediatrics have
 Increased metabolic rate, RR
 Reduced lung compliance
 Increased chest wall compliance
 Reduced functional residual capacity which limits
oxygen reserves during periods of apnea.
predisposes neonates and infants to
atelectasis and hypoxemia
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26. Routine airway management during GA
consists of:
 Airway assessment
 Preparation and equipment check
 Patient positioning
 Preoxygenation and Bag and mask ventilation (BMV)
 Intubation (if indicated)
 Confirmation of endotracheal tube placement
 Intraoperative management and troubleshooting
 Extubation
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27. Airway assessment
Why airway assessment…..
Optimal patient preparation
Proper selection of equipment and
technique, and
Participation of personnel experienced in the
difficult airway management
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28. 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
temporomandibular joints .
 Laryngeal view
Grade 1: Full aperture visible
Grade 2: Lower part of cords visible
Grade 3: Only epiglottis visible
Grade 4: Epiglottis not visible
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29.  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
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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.

30. 6/7/2023 30
Mallapati classification
Grading of the laryngeal view

31.  Thyromental distance: the distance b/n the
mentum and the superior thyroid notch. A distance
greater than 3 fingerbreadths is desirable.
 Sternomental distance: Distance from the upper
border of the manubrium to the tip of mentum, neck fully
extended, mouth closed.
 A distance <12.5 cm associated with difficulty.
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32. EQUIPMENTS
 An oxygen source
cylinder, concentrator, pipeline
 BMV capability
 Laryngoscopes (direct and video)
 Several endotracheal tubes of different sizes
 Other airway devices (eg, oral, nasal airways)
 Suction (machine and tube)
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33. Cont…
 Oximetry and CO2 detection
 Stethoscope
 Tape(plaster)
 Blood pressure and electrocardiography (ECG)
monitors
 Intravenous access
 Magill forceps
 Ambo bag
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34. Face mask ventilation
 It facilitate the delivery of oxygen or an anesthetic gas from a
breathing system to a patient by creating an airtight seal with
the patient’s face.
 Indicators of effective BMV
 chest rising
 end tidal Co2
 mist at clear facemask
 Difficult BMV
 Morbid obesity
 Craniofacial deformities
 Beard
 Edentulous
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35. Cont …
If the mask is held with the left hand, the right
hand can be used to generate positive-pressure
ventilation by squeezing the breathing bag.
The mask is held against the face by downward
pressure on the mask body exerted by the left
thumb and index finger.
The middle and ring finger grasp the mandible to
facilitate extension of the atlantooccipital joint.
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36. 6/7/2023 36
Fig One-handed face mask technique
two-handed technique

37. 6/7/2023 37

38. Uses of face mask ventilation
 Preoxygenation
 Inhalational induction of anesthesia
 Maintenance of short procedures
 Post operative ventilation
 Resuscitation (neonate, cardiac arrest, obstetric
cases…)
 Non invasive ventilation for respiratory failure
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39. Laryngeal mask airway
LMA: Is a wide bore tube whose proximal end
connects to a breathing circuit with a standard 15-mm
connector, and
whose distal end is attached to an elliptical cuff that
can be inflated through a pilot tube.
Better inserted with propofol (that depresses
laryngeal reflex) or deep inhalation anesthesia.
After adequate anesthesia, LMA is inserted to mouth
blindly without laryngoscope.
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40. 6/7/2023 40
Table : A variety of LMAs with different cuff volumes are available for
different sized patients.

41. Insertion technique
The laryngeal mask ready for insertion. The cuff
should be deflated tightly with the rim facing away
from the mask aperture.
Under direct vision, the mask tip is pressed upward
against the hard palate. The middle finger may be
used to push the lower jaw downward.
The mask is pressed forward as it is advanced into
the pharynx to ensure that the tip remains flattened.
The non intubating hand can be used to stabilize the
occiput.
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42. Cont…
By withdrawing the other fingers and with a slight
pronation of the forearm, it is usually possible to push
the mask fully into position in one fluid movement.
Note that the neck is kept flexed and the head
extended.
The laryngeal mask is grasped with the other hand
and the index finger withdrawn. The hand holding the
tube presses gently downward until resistance is
encountered. Then the cuff inflated and confirm
proper positioning then fix.
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43. LMA
 Uses
◦ In short procedures
◦ Life-saving difficult intubation
◦ Conduit for smooth emergence
◦ Way of intubation in difficult cases(95-99% success rate)
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44. Contraindications
patients with pharyngeal pathology (eg, abscess),
pharyngeal obstruction,
full stomachs (eg, pregnancy, hiatal hernia)
low pulmonary compliance(eg, restrictive airways
disease) requiring peak inspiratory pressures
greater than 30 cm H2O.
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45.  Use of LMA avoids occurrence of most TI
complication
 The major disadvantage is lack of mechanical
protection from regurgitation and aspiration. Other
problems are laryngospasm, coughing and sore
throat.
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46. 6/7/2023 46

47. Endotracheal intubation
 is the placement of a
flexible plastic or
rubber tube into the
trachea to maintain an
open airway or to
serve as a conduit
through which to
administer certain
drugs.
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48. 6/7/2023 48

49. Advantages of ETT
Airway patency
◦ Protects the airway
◦ Maintains patency during positioning
 Control of ventilation
◦ ventilation over a long period of time without intubation can
lead to gastric distention and regurgitation
Route for inhalation anesthesia and emergency
medications
◦ N – Narcan(nalozone)
◦ A - Atropine
◦ E - Epinephrine
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50. Indications for orotracheal intubation
A Medical(critical illness) indications
Disease involving the upper airway
 Upper airway edema
• Inhalation injuries
• Ludwig’s angina
• Epiglottitis
Restrictive lung disease
eg. myasthenia gravis
Chronic obstructive lung disease
eg. COPD
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51. Provide patent airway
- Protect airway
Prevent aspiration of gastric content for
unconscious pts
- GCS less than 8 is an indication for intubation
Need for frequent suctioning
eg. Bronchiectasis
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52. B Anesthesia and surgical indications
◦ Facilitate Positive pressure ventilation
◦ Operative position other than supine
◦ Operative site near or involved the upper airway
◦ Airway maintenance
◦ Prolonged surgery
◦ Thoracic and abdominal surgery
◦ Prevent aspiration of gastric content for risk pts
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53. Preparation of Equipment
Preparation for intubation includes:
 checking equipment.
 properly positioning the patient.
The TT should be examined
Endotracheal tube cuff
The tube’s cuff inflation system can be tested by
inflating the cuff using a 10-mL syringe.
Maintenance of cuff pressure after detaching the
syringe ensures proper cuff and valve function.
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54. 6/7/2023 54

55.  Tube size
• Tube length- extend
from the lower incisor
to a point midway
between the cricoid
cartilage and Louis's
angle (the sternal
angle) on the patient.
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56. Airways
 Assemble pharyngeal airways in assorted sizes
◦ Nasopharyngeal airway
◦ Oropharyngeal airway
Purpose
 avoid tongue bite
 avoid back fall of the tongue
 avoid kinking of the tube
 give space for suctioning.
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57. Laryngoscope
 Inspect laryngoscope for service ability
◦ Batteries
◦ Light bulb
 Blades; -curved(Macintosh)
-straight(Miller)
-McCoy
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58. 6/7/2023 58

59. Pre-oxygenation
 Administration of oxygen 3-5 minute prior to
induction of anesthesia with face mask.
purpose
• Oxygen reserve, is purged of nitrogen. have a 5–8
min oxygen reserve.
• Increasing the duration of apnea without
desaturation improves safety, if ventilation following
anesthetic induction is delayed.
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60.  Sniffing position
 Successful intubation often depends on correct
patient positioning. The patient’s head should be
level with the anesthesiologist’s waist to prevent
unnecessary back strain during laryngoscopy.
 Moderate head elevation (5–10 cm above the
surgical table) and extension of the atlantooccipital
joint place the patient in the desired sniffing position.
 The lower portion of the cervical spine is flexed by
resting the head on a pillow or other soft support.
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61.  The laryngoscope is held in the left hand. With the
patient’s mouth opened the blade is introduced into the
right side of the oropharynx with care to avoid the
teeth. The tongue is swept to the left and up into the
floor of the pharynx by the blade’s flange.
 The tip of a curved blade is usually inserted into the
vallecula, and the straight blade tip covers the epiglottis.
 The handle is raised up and away from the patient in a
plane perpendicular to the patient’s mandible to expose
the vocal cords.
 The TT is taken with the right hand, and its tip is passed
through the abducted vocal cords.
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62.  The “backward, upward, rightward, pressure” (BURP)
maneuver applied externally moves an anteriorly
positioned glottis posterior to facilitate visualization of the
glottis.
 The TT cuff should lie in the upper trachea, but beyond
the larynx. The laryngoscope is withdrawn, again with
care to avoid tooth damage.
 The cuff is inflated with the least amount of air necessary
to create a seal during positive-pressure ventilation to
minimize the pressure transmitted to the tracheal mucosa
and apply positive pressure ventilation while the assistant
auscultates.
 secure the endotracheal tube in position.
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63. Confirmation of ETT
 Direct visualization of the ET tube passing through the
vocal cords
 CO2 in exhaled gases(capnograph)
 Bilateral breath sounds
 Absence of air movement during epigastric auscultation
 Condensation (fogging) of water vapor in the tube on
exhalation
 Refilling of reservoir bag during exhalation
 Maintenance of arterial oxygenation
 Chest X-ray: the tip of the ET tube should be between the
carina and thoracic arc or approximately at the level of the
aortic arch.
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64. Complications of ETT
 Trauma to the lips, teeth, and soft tissues of the
airway.
◦ Awareness
Avoid by meticulous technique
 Bronchial intubation
◦ frequent complication
◦ auscultation of the chest bilaterally to detect.
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65.  Laryngospasm
◦ common when extubation is done when the patient is in a
semiconscious state
◦ extubation should be done in a relatively deep anesthesia
or when the protective laryngeal reflex has returned
 Post intubation hoarseness and sore throat
◦ due to mechanical presence of the tracheal tube
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66. Rapid sequence induction
 An established method of inducing anaesthesia with
pre calculated drug in patient who are at risk of
aspiration of gastric contents into the lungs with
application of cricoid pressure
Aim: To intubate the trachea as quickly & safely as
possible
 Employed daily especially during emergency
surgery
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67. Indications of RSI
 Patient with high risk of aspirations:
 Abdominal pathology (ileus, I/O)
Delayed gastric emptying (Pain, trauma, opioids,
alcohol, vagotomy)
Incompetent lower esophageal sphincter, hiatus
hernia, GERD
Altered conscious level Impaired laryngeal reflex
Neurological/neuromuscular disorders.
Pregnancy
6/7/2023 67

68. The Six ‘P’s of RSI
 Preparation
 Pre-Oxygenation with 100% oxygen
 Pretreatment & Induction
 Paralysis + Cricoid pressure
 Placement of the tube
 Post intubation management & strategy of failed
intubation
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69.  No ventilation b/n induction and intubation
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Administration of a potent sedative
(induction) agent and an NMBA without
interposed assisted ventilation
positive-pressure ventilation

air to pass into the stomach

gastric distention

risk of regurgitation & aspiration

70.  rapid IV push
 immediately followed by rapid administration of
intubating dose of NMBA
 wait the time the succinylcholine is given to allow
sufficient paralysis to occur.
Sellick’s maneuver
 application of firm backward-directed pressure over the
cricoid cartilage.
 Pressure is exerted by index finger while the thumb and
middle finger prevent lateral displacement of the cricoid
ring.
 minimize the risk of passive regurgitation and, hence,
aspiration.
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71. Nasotracheal intubation
 Is the TT is advancement of TT through the nose
and nasopharynx into the oropharynx before
laryngoscopy.
 Indications
• Oral Surgery
• Faciomaxillary surgery
• If mouth need to be closed after surgery
• Closed mouth
• Difficult oral intubation
• Prolonged mechanical ventilation in ICU
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72. Nasotracheal intubation technique
 topical lidocaine or phenylephrine should be applied
to the nasal passages
 0.25% - 0.5% phenylephrine and 4% Lidocaine,
mixed 1:1 should also give satisfactory results.
 generously lubricate the nares and endotracheal
tube
 ET tube should be advanced through the nose
directly towards the nasopharynx along the floor of
the nose, below the inferior turbinate, at an angle
perpendicular to the face .
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73.  loss of resistance marks the entrance into the
oropharynx.
 laryngoscope and Magill forceps can be used to
guide the endotracheal tube into the trachea under
direct vision.
 for awake spontaneous breathing patients, the blind
technique can be used.
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74. 6/7/2023 74

75. Contraindications
• Coagulopathy
• Severe intranasal pathology
• Fracture of skull base
• CSF leak
• Midface instability
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76. Complications
 Epistaxis
 Damage to nasal cavity (avulsion of nasal polyps,
fracture of the turbinates, septal abscesses)
 Aspiration
 Vagal stimulation
 Laryngospasm
 Vocal cord damage
 Bacteremia from introduction of nasal flora to the
trachea
6/7/2023 76

77. Extubation
 ensure that the patient is recovering is breathing
spontaneously with adequate volumes.
 evaluate the patient's ability to protect his airway by
observing whether the patient responds appropriately to
verbal commands.
 Oxygenate patient with 100 percent high flow O2 for 2
to 3 minutes.
 if secretions are suspected in the tracheobronchial tree,
remove them with a suction catheter through the lumen
of the endotracheal tube.
 ensure that the patient is not in a semiconscious state.
6/7/2023 77

78.  turn the patient onto his side if he is still
unconscious
 unsecure the endotracheal tube from the patient's
face.
 deflate the cuff and remove the endotracheal tube
quickly and smoothly during inspiration.
 continue to give the patient O2 as required.
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79. Awake extubation
Associated with coughing(bucking) on TT tube
increases
• heart rate
◦ central venous pressure
◦ arterial blood pressure
◦ intracranial pressure
◦ intraabdominal pressure, and
◦ Intraocular pressure.
 It may also cause wound dehiscence and increased
bleeding.
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80. Difficult airway
ASA definition of difficult airway:
“The clinical situation in which a conventionally trained anaesthetist
experiences difficulty with mask ventilation, difficulty with tracheal
intubation or both.”
Difficult ventilation: The inability of a trained anesthetist to maintain
the oxygen saturation > 90% using a face mask for ventilation and
100% inspired oxygen, provided that the pre-ventilation oxygen
saturation level was within the normal range.
Difficult intubation: More than 3 attempts
Longer than 10 minutes
Failure of optimal best attempt unable to intubate.
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81.  Difficult laryngoscopy: can not see any portion of the
vocal cords after multiple attempts at conventional
laryngoscopy.
Difficult airway specific groups
 Predicted difficult airway patients (from airway
assessment)
 Pediatrics
 Obstetrics
 Obesity
 Systemic diseases with airway implications, e.g.
rheumatoid arthritis, diabetes, ankylosing spondylitis.
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82. Assessment of Difficult Airway
 History
 General physical examination
 Specific tests for assessment
◦ Difficult mask ventilation
◦ Difficult laryngoscopy
◦ Difficult surgical airway access
 Radiologic assessment
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83. History
 Congenital airway difficulties: e.g. Pierre Robin, Down’s
syndromes
 Acquired
◦ Rheumatoid arthritis, Acromegaly, Benign and
malignant tumors of tongue, larynx etc.
 Iatrogenic
◦ Oral/pharyngeal radiotherapy, Laryngeal/tracheal
surgery, TMJ surgery
 Reported previous anaesthetic problems
◦ Dental damage, Emergency tracheostomy
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84. General Examination
 Adverse anatomical features: e.g. small mouth,
receding chin, high arched palate, large tongue,
morbid obesity
 Mechanical limitation: reduced mouth opening, post-
radiotherapy fibrosis, poor cervical spine movement
 Poor dentition: Prominent/loose teeth
 Orthopaedic/neurosurgical/orthodontic equipment
 Patency of the nasal passage
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85. Down’s Syndrome
 Atlanto-axial instability
 Macroglossia
 Sleep apnea
 Associated multisystem anomalies
 Subglottic stenosis
 Hypotonia
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86.  Prepare equipments for difficult intubation
- alternative size laryngoscopes
- stylet
- bougie
- combitube
- Magill forceps
- fiberoptic laryngoscopes
- invasive airway management equipments
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87. 6/7/2023 87
Difficult Airway Algorithm

88. 6/7/2023 88

89.  Intubation attempt fail
Call for help
 Maintain oxygenation and ventilation via mask
 LMA, esophageal combitube
 Emergency invasive airway management
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91. THANK YOU!!!
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