AIRWAY MANAGEMENT establishing, maintaining & removing artificial airway with complications.

Dr. Poonam Patel

AIRWAY MANAGEMENT

Assessment Mallampati score, mouth opening, thyromental distance Securing & maintenance airway devices

Artificial airway

Supraglottic airway devices

Tracheal tube

Devices for difficult airway

Management of complications

AIRWAY ASSESSMENT

Cervical spine movementT-M joint movementMouth openingModified Mallampati gradingThyromental distance

ARTIFICIAL AIRWAY

Purpose of an airway lift the tongue and epiglottis away from the posterior pharyngeal wall.

Advantage of an airway

Cervical spine movement does not occur when airway is inserted.Decreased work of breathing during spontaneous respiration using a face mask.Types

Oropharyngeal airway

Nasopharyngeal airway

AIRWAY ANATOMY

NormalObstructed airway

OROPHARYNGEAL AIRWAY

Guedel airway

Parts flange, bite portion, air channel

OROPHARYNGEAL AIRWAY (contd.)

Sizes availableColour codingSizesLength (mm)00030004005016027038049051006110

OROPHARYNGEAL AIRWAYS (contd.)

Uses

To maintain open airway

Prevent endotracheal tube occlusion

Prevent tongue bite

Facilitate suction

Conduit for passing devices into oropharynx

Obtain a better mask fit

Contraindications

Intact gag reflex

Oropharyngeal growth

OROPHARYNGEAL AIRWAY (contd.)

Pre requisite for insertionSize estimationMethods of insertionDisadvantages - Due to incorrect sizeLaryngospasm in awake patientAdvantages -

1) Simple to use, cheap.

2) Not associated with sore throat

3) Does not cause bacteremia

NASOPHARYNGEAL AIRWAY

Parts flange, airway channel, bevel.Size - inside diameter in millimeters.Size determination Method of insertion Contraindications

1) Anticoagulation

2) Basilar skull fracture

3) Nasal pathology, sepsis, or deformity of the nose or nasopharynx

4) History of epistaxis requiring medical treatment.

NASOPHARYNGEAL AIRWAY (contd.)

Uses of nasopharyngeal airway

To maintain airway in patients with intact gag reflex

To facilitate suctioning

As a guide for a fiberscope or nasogastric tube

To apply continuous positive airway pressure (CPAP)

To dilate the nasal passages in preparation for nasotracheal intubation

To maintain the airway and administer anesthesia during dental surgery.

To maintain ventilation during oral fiberoptic endoscopy.

NASOPHARYNGEAL AIRWAY (contd.)

Advantages-

1) Nasal airway is better tolerated than an oral airway if the patient has intact airway reflexes.

2) Loose or poor dentition.

3) Trauma or pathology of the oral cavity.

4) It can be used when the mouth cannot be opened.

COMPLICATIONS OF ARTIFICIAL AIRWAY

Airway Obstruction

Trauma

Tissue Edema

Ulceration and Necrosis

Central Nervous System Trauma

Dental Damage

Laryngospasm and Coughing

Retention, Aspiration, or Swallowing

Devices Caught in Airway

Equipment Failure

Latex Allergy

Gastric Distention

SUPRAGLOTTIC AIRWAY DEVICES

Supraglottic devices fill a niche between the face mask and tracheal tube in terms of both anatomical position and degree of invasiveness. These devices sit outside the trachea but provide a handsfree means of achieving a gas-tight airway.

SUPRAGLOTTIC AIRWAY DEVICES

Laryngeal Mask Airway Family

LMA ClassicLMA UniqueLMA FlexibleLMA FastrachLMA CTrachLMA Proseal

2) Other supraglottic airways similar to laryngeal mask

Soft seal laryngeal maskAmbu laryngeal maskIntubating laryngeal airway

3) Other supraglottic airway devices

Laryngeal tube airwayPerilaryngeal airwayStreamlined pharynx airway liner

LARYNGEAL MASK AIRWAY FAMILY

LMA-Classic (standard LMA, Classic LMA, LMA-C, cLMA) PARTS

Curved tube (shaft)

Elliptical spoon-shaped mask

Two flexible vertical bars.

An inflatable cuff.

An inflation tube

Self-sealing pilot balloon.

15-mm connector .

cLMA size Patient size1Neonates/infants up to 5 kg 1.5Infants between 5 and 10 kg 2 Infants/children between 10 and 20 kg 2.5Children between 20 and 30 kg3Children 30 to 50 kg4Adults 50 to 70 kg 5Adults 70 to 100 kg 6Adults over 100 kg.

LMA CLASSIC

Insertion methods

Standard Technique

180-degree Technique

Partial Inflation Technique

Thumb Insertion Technique

LMA-UNIQUE

Disposable laryngeal mask airway, DLMA). It is made of polyvinylchloride The dimensions are identical to the standard LMA, the tube is stiffer and the cuff less compliant. Sizes It may be a better choice for out-of-hospital or ward use.Insertion and placement of the LMA-Unique is similar to the LMA-Classic. The intracuff pressure increases significantly less in the LMA-Unique when nitrous oxide is used.

LMA-FLEXIBLE

The LMA-Flexible (wire-reinforced, reinforced LMA, RLMA, FLMA, flexible LMA) has a flexible, wire-reinforced tube. The tube is longer and narrower. Not available in sizes 1 and 1.5Useful for head and neck surgeriesInsertion method Disadvantages -

1) The wire reinforcement does not prevent obstruction from biting.

2) The spiral reinforcing wire may become disrupted.

3) Only small sizes of tracheal tube or bronchoscope can pass through it.

4) Not preferred prolonged spontaneous ventilation.

5) Unsuitable for MRI scanning

6) Malposition is less easily diagnosed.

LMA-FASTRACH

The LMA-Fastrach (intubating LMA, ILMA, ILM, intubating laryngeal mask airway) designed for tracheal intubation.Parts

1) A short, curved stainless steel shaft with a standard 15-mm connector.

2) Single, movable epiglottic elevator bar

3) A V-shaped guiding ramp built into the floor of the mask.

LMA-FASTRACH

Insertion technique Uses

To facilitate tracheal intubation

It can also be used as a primary airway device.

Tracheal Intubation using LMA Fastrach

Blind,

Blind nasal

Fiberscopic guided

Light guided

LMA-FASTRACH

Disadvantages

Pharyngeal pathology or limited mouth opening may make intubation difficult.

Cannot be used for intubation in patients below 30 kg.

The LMA-Fastrach tracheal tube is expensive & prolonged use is to be avoided.

The tracheal tube may be displaced downward or dislodged.

It should not be used in the prone position

Unsuitable for use in the MRI unit.

Increased incidence of sore throat and difficulty swallowing .

In patients with immobilized cervical spine, exerts pressure on the cervical spine.

LMA-CTrach

It has two built-in fiberoptic channels with a monitor.Sizes - 3, 4, and 5Insertion techniqueAdvantages

High first intubation attempt success rate with minimal neck movement.

2) Can be used during awake intubation in the presence of an unstable cervical spine.

Disadvantages

1) Poor image quality

2) The view may be obstructed by secretions, lubricant, or blood.

3) Cannot be used easily in the patient with a limited mouth opening.

LMA-ProSeal

Parts - cuff, inflation line with pilot balloon, airway tube, and drain (gastric access) tube.Function of second dorsal cuffInsertion techniques introducer, guided, digital methodsConfirmation of proper placement

LMA-ProSeal

LMA Size Weight (kg) Max Cuff Inflation Volume (mL) Max. Fiberoptic Scope Size (mm) Max. gastric Tube Size (Fr)Length of Drain Tube (cm)Largest Tracheal Tube (ID in mm) 1.55 to 10 7-1018.2 4.0 uncuffed 210 to 20 10-1019.0 4.0 uncuffed2.520 to 30 14-1423.0 4.5 uncuffed330 to 50 20-1626.5 5.0 uncuffed450 to 70 3041627.5 5.0 uncuffed570 to 100 4051828.5 6.0 cuffed

LMA-ProSeal

Uses

Can be used for both spontaneous and controlled ventilation.

Preferred in situations where higher airway pressures are required, better airway protection is desirable, and for surgical procedures in which intraoperative gastric drainage or decompression is needed

Useful in cases where it is important to avoid airway trauma.

Safe for use in an MRI unit

LMA-ProSeal

Disadvantages -

1) The LMA-ProSeal is less suitable as an intubation device.

2) Higher resistance in spontaneously breathing patients than other devices.

3) Requires a greater depth of anesthesia for insertion.

4) Airway obstruction after insertion.

5) Gastric insufflation

6) The LMA-ProSeal has a shorter life span.

LARYNGEAL TUBE AIRWAY

Parts

The airway tube is wide, curved, color coded on the connector.

single lumen that is closed at the tip.

Small (esophageal, distal) cuff near the blind distal tip

Large (oropharyngeal, pharyngeal) cuff near the middle of the tube

LARYNGEAL TUBE AIRWAY (Cont.)

5) One inflation tube to inflate both light blue cuffs.

6) Two anterior-facing, oval-shaped openings (ventilation holes)

7) Side holes lateral to the top of the distal opening.

8) A ramp leads from the posterior wall toward the main ventilatory outlet

Reusable silicone or single-use versions made of polyvinylchloride.

LARYNGEAL TUBE AIRWAY (Cont.)

Size Patientweight (kg)Color of ConnectorMaximum Cuff Volume (mL)0neonate< 6Transparent151infant6 - 15white402child15 - 30green603Small adult30 - 60yellow1204Medium adult50 90red1305Large adult> 90violet150

LARYNGEAL TUBE AIRWAY (Cont.)

Insertion technique Advantages -

1) The LT is relatively easy to insert

2) It is well tolerated during emergence

3) Because the distal cuff fits over the esophageal inlet, the risk of gastric inflation is low

4) Can be used with both spontaneous and controlled ventilation

5) High ventilation pressures can be used.

Laryngeal Tube Airway (Cont.)

6) This device may be especially useful for resuscitation (cannot intubate, cannot ventilate situation , obstetrics after failed intubation, edentulous patients).

7) The incidence of complications such as sore throat, mouth pain, or dysphagia is low.

8) Regurgitated liquid is less likely to be aspirated with the LT

Disadvantage

Failure to ventilate if tube enters trachea contrast combitube

ENDOTRACHEAL TUBE

The tracheal tube (endotracheal tube, intratracheal tube, tracheal catheter) is a device that is inserted through the larynx into the trachea to convey gases and vapors to and from the lungs.Parts

The machine (proximal) end

The patient (tracheal or distal) end

Bevel.

ENDOTRACHEAL TUBE

4) Murphy eye

5) A radiopaque marker

6) Cuff Systems - consists of the cuff plus an inflation system, which includes an inflation tube, a pilot balloon, and an inflation valve.

ENDOTRACHEAL TUBE

Latex coated red rubber tubesPVC tubesReused multiple times DisposableNot transparentTransparentHarden and become sticky with age, poor resistance to kinking, become clogged by dried secretionsLess likely to kink than rubber tubes. They are stiff enough for intubation at room temperature but soften at body temperature, so they tend to conform to the patient's upper airway. Latex allergy in susceptible patientsNo latex allergy

ENDOTRACHEAL TUBE

Oral intubation

Direct Laryngoscopy

Blind Oral Intubation

Digital Technique

Fiberoptic guided

Retrograde intubation

Nasal intubation

Direct Laryngoscopy

Flexible Fiberoptic Laryngoscopy

Blind Nasal Intubation

EXTUBATION

The tracheal tube (extubation) is removed when it is no longer needed for airway protection. Extubation may be performed at different depths of anesthesia - awake, light, and deep Preparation for Extubation

Initial Plan

Patient position plan

Bite block in place

Throat pack removed

Preoxygenation

Secretions aspirated from the pharynx (the trachea also if indicated)

EXTUBATION

Complications at Extubation

Hypoventilation (residual effect of anesthetic drugs and neuromuscular blockade)

Upper airway obstruction

Laryngospasm and bronchospasm

Coughing (wound disruption)

Impaired laryngeal competence and pulmonary aspiration

Hypertension, tachycardia, dysrhythmias, myocardial ischemia

FLEXIBLE FIBEROPTIC BRONCHOSCOPY

Indications

Difficult intubation predicted

Congenital airway abnormalities

Acquired airway abnormalities

Trauma

Contraindications-

Lack of time

Blood & secretions in oral cavity

Edema of pharynx or tongue

Technique oral or nasal (awake or GA)

COMBITUBE

Device for difficult airwayPARTS

1) Two separate lumens (pharyngeal & tracheoesophageal) that are fused longitudinally

2) Two inflatable cuffs.

3) Each lumen is linked by a short tube to a standard 15-mm connector at the breathing system end.

4) Pharyngeal lumen - occluded distal end and eight oval-shaped perforations (ventilating eyes) between the cuffs, coloured blue.

COMBITUBE

5) Tracheoesophageal lumen - patent distal end and a clear tube.

6) The smaller distal cuff serves to seal either the esophagus or trachea, depending on its placement.

7) The larger (pharyngeal) cuff (balloon) is above the perforations.

8) The pilot balloon for the pharyngeal cuff is colored blue.

COMBITUBE

Sizes:

Regular (41 [Fr])

SA (37 Fr)

Recommended for patients with a height greater than 5 feet (152 cm). Not recommended for patients younger than 12 years of age.METHOD OF INSERTION

COMBITUBE

Indications

Airway management in the difficult-to-intubate patient

Massive airway bleeding or regurgitation.

Limited access to the airway and limited mouth opening

Cervical spine injury.

Useful in entertainers in whom it is important to avoid vocal cord damage.

In cardiopulmonary resuscitation in both prehospital and in-hospital settings.

Cannot ventilate, cannot intubate situation.

Can be used during percutaneous dilatational tracheostomy or tracheotomy

COMBITUBE

ContraindicationsActive pharyngeal or laryngeal reflexesOesophageal trauma or pathologyingestion of corrosive agentsOropharyngeal, pharyngeal, or hypopharyngeal mass.

COMBITUBE

Advantages

Time needed for insertion is short and less skill is required

Can be inserted in presence of blood or secretions in the oropharynx.

Provides comparable ventilation and improved oxygenation to that of tracheal intubation

It can be used by an anesthesia provider having limited use of the left arm .

It is well tolerated by the patient during emergence from anesthesia.

Its use is not associated with high levels of trace gases.

Decreased risk of accidental extubation.

The Combitube provides good but not complete protection from aspiration

COMBITUBE

Disadvantages

Tracheal suctioning or fiberoptic bronchoscopy is not possible through the Combitube in the esophageal position

High airflow resistance

Insertion and removal of the Combitube is associated with a higher stress response

Trauma to the airway and esophagus

Sore throat and dysphagia.

Unsuitable for use in a patient with latex allergy .

The Combitube is expensive compared to other single use devices.

RETROGRADE INTUBATION

Retrograde (translaryngeal-guided, guided blind) intubation is an elective or emergency technique for securing a difficult airway, either alone or in conjunction with other techniques. Retrograde intubation is a useful option in patients who cannot be intubated by using traditional techniques. Procedure can be expected to take 5 minutes or more for completion.

Retrograde intubation set

RETROGRADE INTUBATION

RETROGRADE INTUBATION

RETROGRADE INTUBATION

RETROGRADE INTUBATION

RETROGRADE INTUBATION

Indications

Difficult intubations

Airway trauma

Oro - Pharyngeal bleed

Cervical spine injury

RETROGRADE INTUBATION

Complications

Sore throat

Trauma

Barotrauma

Pretracheal abscess

The tracheal tube may inadvertently slip out as it is advanced

CRICOTHYROTOMY

Placing a device through the cricothyroid membrane to gain control of the airway. It is part of the ASA and Difficult Airway Society difficult airway algorithms. Anatomical considerations Techniques

Needle Cricothyrotomy

Percutaneous Dilatational Cricothyrotomy

Surgical Cricothyrotomy

NEEDLE CRICOTHYROTOMY

Ventilation Techniques - Jet VentilationDevices

A number of jet ventilation devices are commercially available.

Automatic Ventilator

Manual Jet Ventilation Device

Flowmeter

Oxygen Flush

Anesthesia Breathing System

Manual Resuscitation Bag

Percutaneous Dilatational Cricothyrotomy

Indications

Upper Airway Obstruction with Inability to Ventilate or Intubate

Anticipated Difficult Intubation - Cricothyrotomy may be used as an adjunct to fiberoptic or other intubation techniques where it is anticipated that intubation may be difficult to perform.

Procedures Involving the Airway

Cervical Spine Injury

CRICOTHYROTOMY

CRICOTHYROTOMY

Contraindications

Intrathoracic Airway Obstruction

Inability to Locate the Cricothyroid Membrane

Complete Airway Obstruction

Paediatric patients

Laryngeal pathology

Decreased compliance

CRICOTHYROTOMY

Advantages

Simple, quick, easy to perform

Prevents tracheal collapse

Disadvantage-

Does not provide definitive airway

CRICOTHYROTOMY

Complications

Barotrauma

Trauma

Subcutaneous / mediastinal emphysema

Tracheal stoma granulation

Persistent stoma

Tracheal stenosis

Dysphonia

Vocal cord paresis

Wound infection

American Society of Anesthesiologists Difficult Airway Algorithm.

REFERENCES

Understanding anesthesia equipments Dorsch, 5th editionMillers text book of anesthesia 7th editionClinical anesthesia MorganCME Airway- MAMCAirway management Rashid Khan