Airway Management

1. AIRWAY MANAGEMENT
By Dr Siti Salihah

2. OBJECTIVES

3. Review airway anatomy
Review basic airway maneuvers
Review blind insertion airways
Review advance airways

4. Upper and lower Airway

5. Airway Anatomy
Upper airway
• Pharynx
• Epiglottis
• Glottis
• Vocal cords
• Larynx
Lower airway
• Trachea
• Bronchi
• Alveoli
• Lung tissue,
consisting of
lobes and lobules
(3 on the right
and 2 on the left)
• Pleura

6. Basic Airway Manouvers
• These skills should be used prior to
initiating any advanced airway
technique
• Head-tilt/chin lift
• Jaw thrust
• Modified jaw thrust (for trauma
patients)
• Sellick’s maneuver

7. Airway Manouvers
.
• Oropharyngeal airway.
• Nasopharyngeal airway
• LMA
• Combitube

8. OROPHARYNGEAL
AIRWAY

9. • Size is measured
from the corner of
the mouth to the
angle of the jaw
Sizes range from
0-6
It holds the tongue
away from the
posterior pharynx,
but does not
isolate the trachea

10. - The oral airway
is inserted with
the curve
towards the side
of the mouth
- Then rotated so
that the curve of
the airway
matches the
curve of the
tongue

11. NASOPHARYNGEAL
AIRWAY

12. • Soft plastic or rubber tube that is designed
to pass just inferior to the base of the
tongue.
• Passed through one of the nares and can
be used in patients with an intact gag reflex.
• CONTRAINDICATED in cases of suspected
or possible basilar skull fracture
• Sizes range from 17-26 cm in length and 6-
9 mm internal diameter. Measured from tip
of the nose to the corner of the patients ear

13. • The nasal airway is
lubricated with a water
soluble lubricant.
The beveled tip is inserted
directed towards the
septum, with the airway
directed perpendicular to the
face
If resistance is met, rotating
the airway may help or the
other nare may be used

14. Blind Insertion Airways
• LMA
(Laryngeal
Mask
Airway)
• Combitube
1. Blind insertion
airways
considered an
alternative
airway control
device to be
used when
intubation is
unsuccessful
2. They do not
require
visualization
of the vocal
cords

15. LARYNGEAL MASK
AIRWAY

16. Sits over the glottic
opening
Available in different
sizes
Has a drain tube to
aid in gastric
suctioning. With
some versions an
endotracheal tube
may be passed
through to aid in
intubation

17. COMBITUBE

18. - It consists of a cuffed, double-lumen tube that is inserted
through the patients mouth to secure an airway and enable
ventilation.
The distal tube (tube two) enters the esophagus, where the
cuff is inflated and ventilation is provided through the proximal
tube (tube one) which opens at the level of the larynx
Inflation of the cuff in the esophagus allows a level of
protection against aspiration of gastric content similar to that
found in the laryngeal mask. It is available in two sizes: 37 Fr
(for patients 4 to 6 ft or 122 to 183 cm tall) and 41 Fr (for
patients more than 5 ft or 152 cm tall).

19. • Endotracheal intubation
• Surgical airways
ADVANCE AIRWAYS

20. Indications of
Endotracheal Intubation
1) Depressed level of consciousness:
• Stupor/ coma, status epilepticus.
• GCS < 8.
2) Hypoxemia
• paO2 < 60mmHg while breathing an inspired O2
concentration ( FiO2) of 50% or greater.
• Worsening respiratory acidosis, PaC)2 greater than
45mmHg. ( eg: AECOAD)
3) Airway Obstruction
• Eg when a foreign body becomes lodged in the airway,
or direct injury to the face or neck causing swelling and
an expanding hematoma.

21. Endotracheal intubation
procedure
1) Assemble all needed equipment, while
patient is being ventilated.
• Choose appropriate ET tube size
• Check balloon with 10cc of air
• Assemble laryngoscope and check light
• Connect and check suction
2) Position patient in “head tilt chin lift”
position. IMPORTANT-If C-spine injury is suspected have
an assistant hold the patient’s head in a neutral position.

22. 1. Usually female adults:7-8mm Male adults:8-9mm
2. Paediatric ages 1-12 using formula
Predicted Size Uncuffed Tube = (Age / 4) + 4
Predicted Size Cuffed Tube = (Age / 4) + 3
3. For children ages 12 and below , use ET tube
reference card

23. Assessment of difficult airway intubation
4D approach
Dentition: Large or loose teeth, dentures
Distortion : presence of vomitus , secretions,
blood, bone fragments obscuring airway
Disproportion – Receding chin with large
tongue, buck teeth
Dysmotility: TMJ and neck mobility.
Preoxygenation:
Always preoxygenate the patient with 100%
oxygen prior to intubation. At least for 5
minutes.)

24. “ Administration of
100% oxygen with non –
rebreathing mask for 5
minutes replaces the
nitrogen of room air in
the Functional residual
capacity ( FRC) in the
lungs with oxygen,
allowing several minutes
of apnea time. ( In a
healthy 70kg adult, up to
8 minutes of apnea
time”

25. Pretreatment
• Administration of drugs to mitigate the
adverse effects asociated with intubation.
.

26. Paralyzing agent:

27. • Paralysis with
Induction:
This is the most vital
step of the sequence.
Induction agent is given
as a rapid push followed
immediately by a rapid
push of succinylcholine

29. Positioning:
1) Sellicks manoueuvre or application of
cricoid pressure .
2) Patient is then positioned for laryngoscopy.
3) Lift straight up on the blade to expose
posterior pharynx.
4) Identify the epiglottis, straight blade should
slip over the epiglottis. With further, gentle
traction, identify trachea and arytenoid
cartilages and vocal cords
5) Insert ET tube along the blade, into the
trachea and advance the tube 1-1.5 inches
beyond the cords and inflate the cuff.
6) Attempts at intubation should not exceed 30
seconds and 2 attempts. Get expert help if you
are unable to intubate.

30. Placement and Proof:
• Chest rise.
• Bilateral breath sounds;
• Tube fogging;
• Calorimetric end-tidal carbon dioxide; and
• Continuous waveform capnography.
Post-intubation management:
• Secure endotracheal tube
• Initiate mechanical ventilation
• Do chest X-ray to ensure main stem
intubation has not occurred. (The distal tip of a
properly positioned tracheal tube should be located in
the mid-trachea, roughly 2 cm (1 inch) above the
bifurcation of the carina.)

31. SURGICAL AIRWAY

32. An emergency surgical airway is only
indicated when there is an inability to intubate
the trachea in the presence of an unrelieved
airway obstruction.
Indications for surgical airway:
• Failure of ETT insertion due to laryngeal
oedema.
• Severe maxillofacial injury that distorts the
anatomy.
• Severe oropharyngeal haemorrhage that
prevents vocal cord visualisation

33. 1. Cricothyroidotomy
2 2.Tracheostomy

34. Thank You