Airway management-what is new?

1. Dr Alpa Sonawane
Divisional Medical Officer
Department of Anaesthesia and Pain Management
Jagjivanram Railway, Hospital, Mumbai
Recent Advances In Airway
Management

2. Airway Management
 cardiopulmonary resuscitation (CPCR)
 Intensive care medicine
 Emergency medicine
 First aid
 ANAESTHESIA-
anaesthesia is nothing,but airway management or
anaesthesia is nothing without airway management !!!!

3. Airway
 passage through which air passes during respiration
Nasal and oral cavities
pharynx
larynx
trachea and large bronchi

5. Difficult airway
 American society of anaesthesiologist (ASA) suggest…
Difficult mask ventilation,
difficult tracheal intubation
or
both

7. Worry…….
Hypoxia !
Death
Brain injury
Cardiopulmonary arrest
Unnecessary surgical airway
Airway trauma
Damage to teeth
Managing difficult airway is always challenging !!!

8. Management has become simple….
Advent of
 New devices
 New concepts
 Increased awareness
 Airway management guidelines
Appropriate knowledge of using these devices,
airway assessment and planning is the key to
success!
Airway manager should suitably modify
(CUSTOMIZE) the guidelines for his set up

9. Recent Advances
Airway assessment –methods and tools
Stress on oxygenation rather than only
ventilation
New devices
Topical techniques
CICO by scalpel cricothyroidotomy

10. Why airway examination?

11. Purpose of airway assessment
 Identify areas of anticipated difficulties
 Formulate strategy based on available recourses and
expertise
 Focused history
 Focused general physical examination
 Airway examination

12. Mallampati classification
Class-I
Class-II
Class-III
Class-IV
soft palate, fauces;
uvula, anterior and
the posterior pillars.
the soft palate, fauces
and uvula
soft palate and base of uvula Only hard palate

13. Specialized evaluation
 Indirect laryngoscopy
 Radiological imaging
X –ray
CT scan
MRI
USG

14. USG in Airways
 Assessment-Bedside
-OT
 Pre, intra and postoperatively
 Relatively easy and quick
 Noninvasive
 Cheaper than CT and MRI
 Radiation free

15. USG in Airways

16. 3D Reconstruction of Airways

17. Stess on oxygenation rather than
ventilation-
Most dreaded situation in difficult airway management is
can not intubation can not ventilate(CICV)
“Patients do not die from lack of intubation they die
from lack of oxygenation”
CICO-separated oxygenation from ventilation!
-patient can remain reasonably well oxygenated
even when apneic !

18. Preoxygenation
 Increases oxygen reserve and delays onset of hypoxia
 Duration of apnia without desaturation--1-2 minutes
With preoxygenation—8 minutes !!!

19. Paraoxygenation
 Oxygenation during airway management !
while securing airway
 Awake or spontaneously breathing- 4-6 L/minute
through nasal cannula
 Apnic-15L/minutes nasal cannula
 THRIVE- Transnasal humidified rapid insufflation
ventilatory exchange

21. THRIVE

22. Airway devices
 Endotrcheal tubes
 Larygoscopes –direct
-indirect -Bullard
-videolaryngoscope
 Alternate airway divices -
Bougie and stylets guided
Supraglottic devices
Flexible fiberoptic devices
 Surgical airway

23. Endotracheal tubes

24. Tube with camera at the end

26. Bullards laryngoscope

27. Gum elastic bougie

28. Lighted stylates

29. Supraglottic devices
 1982-Dr Archie Brain
 Maintain airway patency
 Placed just above the glottis
 Outside trachea, hands free
 Face mask and tracheal tube
 LMA Classic- first LMA

30. Based on evolution
• First generation devices- simple airway tubes
 Classic LMA
 Flexible LMA
• Second generation- with addition of drainage channel
 Proseal LMA
 I-Gel
 LMA supreme
• Third generation- cuffless, two drain tubes, small bowl
 Baska mask.

31. Classic LMA

32. Proseal LMA
Developed basically for more better sealing
pressure and access to oesophaeous
Modifications over classic LMA-
Drainage tube

33. I-Geltm
 Single-use non-inflatable mask made of a gel-like
thermoplastic elastomer.
 Epiglottic rest to prevent epiglottic downfolding

34. Baska mask
 3rd generation supraglottic device
 Smaller bowel compared to other LMAs- less risk of
including oesophageal opening
 Adjustable tab in shaft to increase angulation to allow
easy negotiation of oropharyngeal curve

36. Supraglottic airway guided ET intubation
and fibre optic laryngoscopy
 LMA fastrach
 LMA proseal
 I-gel

38. videolaryngoscope
 Images transmitted to LCD display through video
system
 Indirect laryngoscope –Handle
Blade
Micro video chip camera
at end of the tube
Classification-with integrated tube chhannel
-without integrated tube channel

40. Kings Vision

43. video

44. Flexible Fiberoptic intubation
 Indication-
• Anticipated difficult airway
• Suspected cervical spine injury
• Failed intubation
• Congenital airway abnormality

47. Fiberless fiberoptic bronchoscope

49. Surgical airway -CICV
 Tracheostomy -surgical
-percutanious tracheostomy
 Needle cricothyroiditomy
 Scalpel cricothyrodotomy

50. Scalpel cricothyrodotomt

52. Robotic intubation

54. Topicalization techniques
 Mucosal Atomizing Devices (MAD)
Deliver consistent, fine atomized spray to almost all
parts of upper airway easily
 MADgicWand-pharyngeal tissue atomizer
 MADNasal

55. MADgic laryngotracheal mucosal
atomization device

56. CONCLUSION
 Impact on health system- reduced morbidity and
mortality mainly SAFETY HAS INCREASED
 Cost– quality should be maintained.
 There is no optimum solution for managing difficult
airway
 Each device has unique advantage in certain situation
 Clinical judgment
 Practice and routine use will improve performance
 A commitment to education and maintenance of skills

57. Bag mask ventilation

58. THANK YOU