AIRWAY MANAGEMENT-INTUBATION

1. Airway
Management
Ms Tissymol Thomas

2.  Tracheal Intubation is useful to deliver
anaesthetic gases directly to trachea and
allow control of ventilation and oxygenation
and no aspiration. The airway device is
maintained in situ from the start to the end of
anaesthesia.

3. Airway Anatomy Suggesting Difficult Intubation
Protruding or receding jaw.
Prominent upper incisors.
Short Thick Neck
Disease of pharynx or larynx
Deviation of trachea from midline
Stiff joint syndrome, in the TMJ and cervical spines
• About one third of diabetics characterized by short stature,
joint rigidity, and tight waxy skin
Positive prayer sign with an inability to oppose fingers
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Prayer Sign

4. Indications of Tracheal Intubation
In the operating room
• Maintenance of patent airway
- Abnormal intraoperative positions
Airway inaccessible (eg. Head & Neck surgery)
Expected difficulty in use of face mask
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• Airway Protection
- From contamination by blood, pus, debris, etc.
• Use of controlled ventilation
- During anaesthesia

5. Indications of Tracheal Intubation
In the operating room
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Unconscious patient
Pulmonary toilet
Mechanical ventilation
During CPR

6. Time to intubate . . .
 Equipment for intubation
 Oxygen source
 ETT
 Laryngoscope
 Airways
 Magill forceps
 Suction
 Stylet

7. Oral/Nasal Airways
Moulded tubes in different sizes and shaped to curve behind the tongue lifting
it away from posterior pharynx.
Oral airways are made of hard plastic
Nasal airways are made of very soft latex and better tolerated in lightly
anaesthesised patient.
Uses:
•Keep airway patent
•Prevent falling back of tongue in unconsious patients
•Prevents semiconsoius patient from biting and occluding ETT
•Prevent biting of tongue in patient with status epilepticus

8. Oral/Nasal Airways

9. OPA
 Oropharyngeal Airway

10. NPA
 Nasopharyngeal airway

11. Laryngoscopes

12. Laryngoscope
Used for direct inspection of larynx
Has 2 separate parts; handle and interchangeable
blades

13. Laryngoscope
There are 2 types of laryngoscopes:
Macintosh: for adults, with curved blade
Miller or Magill: for children, with straight
blade

14. Laryngoscopescope
Made of flexible optical fibres. Used
mainly for difficult intubation.

15. Endotracheal Tubes
ETT for Fastrach LMA
Pediatric uncuffed ETT
ETT for blind nasal
Standard ETT
General features:
•Made of PVC with low-pressure high-
volume cuffs
•Sizes from 2.5 to 9.0 mm (internal
diameter)
•Radio-opaque incorporated to aid
placement
•Distal end is beveled

16. What Size Endotracheal Tube ?
 Adult male
 7.5-8 mm
 Adult female
 7-7.5 mm
 Pediatric
 (16 + AGE)/4
 Nasal intubation
 Size reduced 1-2 m
m

17. Types of ETTs
The Robertshaw double-lumen
tracheal tube attached to a single-
use pediatric pulse oximeter.
1. Portex tubes:
- Semirigid, with little tendency to kink. Most
commonly used.
2. Rubber tubes:
- Soft, easily kinked.
3. Reinforced tubes:
- Cuffed or non cuffed. Reinforced with wire
to prevent kinking.
4. Special tubes:
- Double lumen (Robertshaw). Used for
thoracic surgery to isolate the 2 lungs
completely.

18. TT cuff
•Most TTs have cuff inflating system consisting of
valve, balloon, inflating tube and cuff.
•Uncuffed tubes used in children to minimise
pressure injury
•Purpose of cuff is:
Airtight seal between tube and trachea
Protect from aspiration of blood, mucus or vomitus.

19. Magill Forceps
Designed for guiding tip of ETT through
larynx during nasal intubation. Also helpful
during insertion of nasogastric tubes,
removal of foreign body in mouth of putting
pharyngeal pack.

20. Malleable Stylet
Thin peace of metal of
plastic
Threaded through lumen
of ETT
Useful when exposure to
larynx is difficult
Used to change curve of
ETT.

21. Local Anaesthesia Spray
Attenuates haemodynamic response to ETT and reduce
intensity of cough reflex at light anaesthesia.

22. Position of Head & Neck
 Sniffing Position
 Flexion of lower cervical spine & extension of A-O joint
Long axes of mouth, pharynx and trachea are in straight line
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23. Orotracheal Intubation
• Place the patient in the correct position.
Grasp the laryngoscope in the left
hand.
Spread the patient's lips, and insert the
blade between the teeth, being careful
not to break a tooth.
Pass the blade to the right of the
tongue, and advance the blade into the
hypopharynx, pushing the tongue to
the left.
Lift the laryngoscope upward and
forward, without changing the angle of
the blade, to expose the vocal cords.
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24. Orotracheal Intubation
• Gently pass the tube next the laryngoscope blade through the vocal
cords into trachea, far enough so that the balloon is just beyond the
cords.
Pressing downward on the thyroid cartilage. This helps bring an
anteriorly placed larynx into view and facilitate intubation.
Once in place, inflate the cuff till airtight seal is obtained.
Confirm that the tube is properly positioned. First, listen over the
stomach with a stethoscope while ventilating the patient. If sounds
of airflow are heard or if distension of the stomach occurs, the tube
is in the esophagus. If the esophagus has been intubated instead of
the trachea, remove the tube and try again.
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25. Orotracheal Intubation
• Listen to each side of the chest, be sure that
breath sounds are equal in both sides of
the thorax. If not, reposition the tube. When
breath sounds are equal on both sides and
the thorax rises equally on both sides with
each inspiration, note the position of the tube
(mark the tube at patient's mouth).
Wrap adhesive tape around the tube where it
comes out of the mouth. Then carry the tape
over the cheek and around the back of the
head onto the other cheek. Fasten the end of
the tape around the tube.
Obtain a chest x-ray film immediately to
check tube placement, and also obtain
arterial blood gas measurements to assess
the adequacy of ventilation.
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26. Orotracheal Intubation
• Gently pass the tube next the laryngoscope blade through the vocal
cords into trachea, far enough so that the balloon is just beyond the
cords.
Pressing downward on the thyroid cartilage. This helps bring an
anteriorly placed larynx into view and facilitate intubation.
Once in place, inflate the cuff till airtight seal is obtained.
Confirm that the tube is properly positioned. First, listen over the
stomach with a stethoscope while ventilating the patient. If sounds
of airflow are heard or if distension of the stomach occurs, the tube
is in the esophagus. If the esophagus has been intubated instead of
the trachea, remove the tube and try again.
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27.  Animation of Intubation
 Actual Intubation

28. Nasotracheal Intubation
 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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29. Nasotracheal Intubation
 Contraindications
Coagulopathy
Severe intranasal pathology
Fracture of skull base
CSF leak
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30. Nasotracheal Intubation
 Technique
Apply vasoconstrictor nasal drops
Lubricate tube wall. Length should be 2 cm longer and 1-2 mm
smaller diameter
Guide the tube slowly but firmly into the nasal passage, going up
from the nostril (to avoid the large inferior turbinate) and then
backward and down into the nasopharynx
Proceed with the procedure as an orotracheal intubation, guiding
the tube through the vocal cords with a Magill’s forceps

31. Nasotracheal Intubation
 Technique (blind intubation)
Blind nasal intubation is tried if laryngoscopy isn’t
feasible
The patient is allowed to breathe during induction of
anaesthesia to facilitate intubation
Tube is inserted till maximun breath sounds are heard
Tube is then blindly inserted into glottis during
inspiration

32. Methods of Anaesthesia for TI
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General Anaesthesia (GA) by rapid IV agent
In children, induction is done by inhalational
agent
ETI can be done without muscle relaxant under
deep anaesthesia
Intubation through tracheal stoma can be done
without GA, muscle relaxant or laryngoscope
Awake intubation using only topical anaesthesia.
Indicated in patients whom induction is unsafe
unless airway is secured first
ETI can be done without anaesthesia in
comatose patients or during CPR
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33. Extubation
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Muscle relaxant fully reversed
Patient awake & responsive, sable vital signs 100% oxygen at high
flow 2-3 min
Remove secretion in trachea or pharynx Turn patient to lateral
position
Defkate cuff and remove ETT during inspiration
Continue 100% oxygen by facemask
Extubation in semiconscious patient can provoke laryngospasm

34. Complications of Laryngoscopy & ETI
A) During Intubation
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Prologned attempt: hypoxia – hypercapnia – risk of aspiration
With inadequate anesthesia: Coughing – Laryngospasm - Bronchospasm
Trauma
Bruising lips,tongue,pharynx Fracture,chipping,dislogement of teeth Perforation
trachea,esophagus
Fracture or dislocation cervical spine
Dislocation arytenoid cartilages or mandible
Endobronchial intubation Oesophageal intubation Nasal
Intubation
Epistaxis Mucosal damage
Displaced polyp or adenoid
Bacteraemia from nasal obstruction
Haemodynamic response to laryngoscopy
*Hypertension, tachycardia, arrhythmia (bradycardia in children)
*Common at light anesthesia, dangerous to cardiacs
*Minimized by deep anesthsia, propofol induction
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35. Complications of Laryngoscopy & ETI
B) With tube in situ
-Accidental extubation
-Endobronchial intubation
-Tube malfunction
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Obstruction / kinking
Ignition of tube by laser device
Cuff perforation
-Bronchospasm
-Aspiration
-Sinusitis
-Excoriation of nose or mouth

36. Complications of Laryngoscopy & ETI
C) After extubation
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Haemodynamic response
Hypoxia
Laryngospasm
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Common in semiconscious
Better extubate in deep anesthesia or awake patient
Treated with giving oxygen via facemask
• Pulmonary Oedema: dt. Prolonged powerful inspiratory effort against
closed epiglottis – require re-intubation
Stridor or croup due to oedema in subglottic region in children.
Hoarsness and sore throat
VC paralysis – Granuloma of cords – Laryngeal or
tracheal Stenosis
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Watch demo

37. The Laryngeal Mask Airway (LMA)

38. The Laryngeal Mask Airway (LMA)
•New device to maintain airway during
anesthesia when TI is not desired.
•It’s easier in insertion and has high
rate of success
•It’s made in 8 sizes to suite neonates,
children and adults.
•Better inserted with propofol (that
depresses laryngeal reflex) or deep
inhalation anesthesia.
•After adequate anesthesia, LMA is
inserted to mouth blindly without
laryngoscope and pushed downward
till resistance is felt. The cough is then
inflated.

39. The Laryngeal Mask Airway (LMA)
•Video of insertion of an LMA

40. Laryngeal Mask Airway
 Uses
 In short procedures
 Life-saving difficult intubation
 Conduit for smooth emergence
 Way of intubation in difficult cases
 Contraindications
 Increased risk of aspiration
 Full stomach

41. Laryngeal Mask Airway
 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.
Ms Tissymol Thomas