ANATOMY

Successful airway management requires detailed understanding of upper and lower airway structure and function. UPPER AIRWAY The human airway has two openings: the nose and the mouth. Remember: the floor of the nose is the roof of the mouth. The nose leads to the NASOP AR!N" and the mouth leads to the OROP AR!N". Separated anteriorly by the PA#AT$% these two passages &oin posteriorly in the P AR!N". At the base of the tongue% the $P'(#OTT'S separates the OROP AR!N" and the #AR!N(OP AR!N") !POP AR!N". The #AR!N" e*tends from the lower part of the pharyn* to the TRA+ $A.

$ ,$piglottis- .s/,0estibular fold 1ligament2- .#,0ocal ligamentTA,trans0erse arytenoid- +t#,cricothyroid ligament- ++,cricoid cartilage. LOWER AIRWAY

THE CONDUCTING ZONE At the CARINA, the trachea bifurcates into the RIGHT AND LEFT MAIN BRONCHI. The right and left main bronchi further branch into lobar)secondary bronchi 1one to each lobe of the lung 3 thus% two on the left and three on the right2% then di0ide again into segmental)tertiary bronchi and finally terminal bronchioles% which are the smallest airways without al0eoli. The segmental)tertiary bronchi are of particular importance because they supply each BRONCHOPULMONARY SEGMENT. These structures ma4e up the conducting airways and ser0e to lead inspired air to the gas5e*changing regions downstream. The conducting airways contain NO A#.$O#' and% thus% do not ta4e part in gas e*change. The conducting 6one of the airway constitutes the anatomical dead space 1789ml2. THE RESPIRATORY ZONE The terminal bronchioles di0ide into respiratory bronchioles which continue downstream as al0eolar ducts. :hile respiratory bronchioles ha0e occasional al0eoli budding from their walls% al0eolar ducts are completely lined with al0eoli)al0eolar sacs. There are o0er ;99 million al0eoli in the human lung and each al0eoli is co0ered in an e*tensi0e networ4 of capillaries. <The Acinus= refers to the anatomical unit formed by the portion of lung distal to a terminal bronchiole. The respiratory 6one ma4es up most of the lung 1>.85;#2.

GLOSSARY OF TERMS
NASOPHARYNX: The nasopharyn* is situated behind the nasal ca0ity% abo0e the soft palate. 't communicates with the nasal ca0ities through the nasal choanae and with the tympanic ca0ity through the eustachian tube. 't contains the pharyngeal tonsils in its posterior wall. OROPHARYNX: The oropharyn* is encompassed by the soft palate abo0e and the epiglottis below. 't communicates with the mouth through the oropharyngeal isthmus. 't contains the palatine tonsils. PALATE: The palate forms the roof of the mouth and the floor of the nasal ca0ity. The hard palate forms the anterior four5fifths of the

palate and is a bony framewor4 co0ered with a mucus membrane. The soft palate% comprising the posterior one5fifth of the palate% is a fibromuscular fold that mo0es posteriorly against the pharyngeal wall to close the oropharyngeal ca0ity when swallowing or spea4ing. PHARYNX: The pharyn* is a ?5shaped fibromuscular structure located between the oral and nasal ca0ities and posterior to the laryn*. 't is subdi0ided into the NASOP AR!N"% OROP AR!N"% and #AR!N(OP AR!N") !POP AR!N". 't e*tends from the base of the s4ull to the inferior border of the cricoid cartilage anteriorly 1at the entrance of the esophagus2 and the inferior border of the +@ 0ertebra posteriorly. The pharyn* conducts food to the esophagus and air to the laryn*% trachea and lungs. 't opens anteriorly into the nasal ca0ity% mouth and laryn* 1naso5% oro5% and laryngo5 pharyn*% respecti0ely2 and to the esophagus posteriorly. The wall of the pharyn* is composed of two layers of pharyngeal muscles: the e*ternal circular layer consists of constrictors and the internal longitudinal layer consists of muscles that ele0ate the laryn* and pharyn* during swallowing and spea4ing. EPIGLOTTIS: The epiglottis is a spoon shaped plate of elastic cartilage that lies behind the tongue. 't pre0ents aspiration by co0ering the glottis 3 the opening of the laryn* 5 during swallowing. LARYNGOPHARYNX/HYPOPHARYNX: The laryngopharyn*)hypopharyn* e*tends from the upper border of the epiglottis to the lower border of the cricoid cartilage. 't contains the piriform recesses% at each side of the opening of the laryn*% in which swallowed foreign materials may be lodged. LARYNX: The laryn* is a cartilaginous s4eleton held together by ligaments and muscles. The nine cartilages of the laryn* are the thyroid% cricoid% epiglottic and 1in pairs2 the arytenoid% corniculate and cuneiform. The laryn* ser0es as a sphincter to pre0ent the passage of food and drin4 into the trachea and lungs during swallowing% 't also contains the 0ocal cords and regulates the flow of air to and from the lungs for phonation. 't is through the abducted 0ocal cords of the laryn* that an endotracheal tube is ad0anced during endotracheal intubation TRACHEA: The trachea begins at the inferior border of the cricoid cartilage 1+@2 and continues about A578 cm in length until it bifurcates into the right and left main bronchi at the le0el of the sternal angle

1&unction of TB and T82. 't is composed of 7@5>9 incomplete cartilaginous rings that open posteriorly to pre0ent the trachea from collapsing. These incomplete rings allow for changes in caliber which can be important in changing airway resistance and in generating a cough. RIGHT AND LEFT MAIN BRONCHUS: The right and left main bronchi pass inferolaterally from the bifurcation of the trachea to the lungs. They are supported by cartilaginous rings. The right main bronchus is wider% shorter% and more 0ertical than the left% and thus is the more common side of foreign body obstruction. Coth main bronchi accompany the pulmonary arteries into the hila of the lungs and branch within the lung to form the bronchial tree. CARINA: The carina is a downward and bac4ward pro&ection of the last tracheal cartilage. 't forms a ridge that separates the opening of the right and left main stem bronchi. 't occurs at the sternal angle% the &unction of TB and T8. BRONCHOPULMONARY SEGMENT: The bronchopulmonary segment is the anatomical% functional% and surgical unit)subdi0ision of the lung and refers to the portion of the lung supplied by each segmental)tertiary bronchus and segmental)tertiary artery. 't consists of the segmental)tertiary bronchus% a segmental branch of the tertiary artery% a segment of the lung tissue% and the surrounding connecti0e5 tissue septum. The bronchopulmonary segment is important because a surgeon can remo0e one segment without seriously disrupting surrounding segments. DIAPHRAGM:The Diaphragm is the most important muscle for inspiration. :hen the diaphragm contracts% the abdominal contents are pushed downward and the ribs are lifted upwards and outwards% increasing the 0olume and decreasing the pressure in the thoracic ca0ity. Remember the pneumonic: +;%+B% +8 4eep the diaphragm ali0eE THORACIC CAGE: The muscles of the thoracic cage% the e*ternal intercostals and the accessory muscles% are used only during e*ercise)e*ertion% not during normal quiet breathing. 'n fact% use of intercostal muscles% as in retractions% often indicates increased wor4 of breathing and impending respiratory failure. SURFACTANT: Surfactant is synthesi6ed by type '' al0eolar

cells)pneumocytes and consists primarily of DPP+% Dipalmitoyl phosphatidylcholine. COMPLIANCE:+ompliance is the ability of the lung to stretch- its distensibility. 't represents the change in 0olume that occurs for a gi0en change in pressure. HEMOGLOBIN: emoglobin is composed of four globin subunits% each centered around a heme group 1iron containing porphyrin rings2 whose central iron atom binds re0ersibly with an o*ygen molecule. The o*ygen5hemoglobin bond is a wea4 one and can be disrupted without altering either the hemoglobin or o*ygen. Cecause there are four iron atoms in each hemoglobin molecule% each hemoglobin molecule can bind up to four o*ygen molecules. emoglobin bound to o*ygen is 4nown as o*yhemoglobin. The percent saturation of hemoglobin 1or% simply% o*ygen saturation2 refers to the percent of a0ailable binding sites that are bound to o*ygen. The o*ygen saturation of arterial blood with a PO> of 799 mm g is about AF.8G% whereas that of mi*ed 0enous blood with a PO> of B9 mm g is about F8G

LUNG VOLUMES AND CAPACITIES

Remember: C ! "#$#e% re &' (% $)e %*mm $#+, +- .+&*me%/

TIDAL VOLUME 0TV2: .olume inspired or e*pired with each normal breath.

INSPIRATORY RESERVE VOLUME 0IRV1: Ha*imum 0olume that can be inspired o0er the inspiration of a tidal 0olume)normal breath. ?sed during e*ercise)e*ertion. EXPIRATRY RESERVE VOLUME 0ERV1: Ha*imal 0olume that can be e*pired after the e*piration of a tidal 0olume)normal breath. RESIDUAL VOLUME 0RV1: .olume that remains in the lungs after a ma*imal e*piration. +ANNOT be measured by spirometry. INSPIRATORY CAPACITY 0 IC1: .olume of ma*imal inspiration: 'R. I T. FUNCTIONAL RESIDUAL CAPACITY 0FRC1: .olume of gas remaining in lung after normal e*piration% cannot be measured by

spirometry because it includes residual 0olume: $R. I R. VITAL CAPACITY 0VC1: .olume of ma*imal inspiration and e*piration: 'R. I T. I $R. , '+ I $R. TOTAL LUNG CAPACITY 0TLC1: The 0olume of the lung after ma*imal inspiration. The sum of all four lung 0olumes% cannot be measured by spirometry because it includes residual 0olume: 'R.I T. I $R. I R. , '+ I /R+ DEAD SPACE: .olume of the respiratory apparatus that does not participate in gas e*change% appro*imately ;99 ml in normal lungs. 55ANATOMIC DEAD SPACE: .olume of the conducting airways% appro*imately 789 ml 55PHYSIOLOGIC DEAD SPACE: The 0olume of the lung that does not participate in gas e*change. 'n normal lungs% is equal to the anatomic dead space 1789 ml2. Hay be greater in lung disease. FORCED EXPIRATORY VOLUME #, 2 SECOND 0FEV21: The 0olume of air that can be e*pired in 7 second after a ma*imal inspiration. 's normally J9G of the forced 0ital capacity% e*pressed as /$.7)/.+. 'n restricti0e lung disease both /$.7 and /.+ decrease % thus the ratio remains greater than or equal to 9.J. 'n obstructi0e lung disease% /$.7 is reduced more than the /.+% thus the /$.7)/.+ ratio is less than 9.J.

PRESSURE GRADIENTS: Re%!+,%#b&e -+r $)e -&+' +#r

Kust as blood mo0es through the cardio0ascular system because of the pumping action of the heart% gas flows into and out of the lungs because of pressure gradients created by the DIAPHRAGM and THORACIC CAGE. Although the abdominal and internal intercostal

muscles are used for e*piration during e*ercise or states of increased airway resistance% e*halation is usually a passi0e process% secondary to the elasticity of the lung5chest wall. Remeber that the flow of air is proportional to change in pressure o0er resistance. Thus% change in pressure dri0es 0entilation and resistance opposes it. 'nspiration occurs when the intrapulmonary pressure decreases to below atmospheric pressure 5 this can be secondary to an increase in intrapulmonary 0olume that occurs when your chest wall e*pands and your diaphragm descends towards the abdomen. $*piration occurs when the intrapulmonary pressure increases to e*ceed atmospheric pressure 1or when intrapulmonary 0olume decreases2.

ELASTICITY, COMPLIANCE, SURFACE TENSION ,3 RESISTANCE

COMPLIANCE is the ability of the lung to stretch- its distensibility. 't represents the change in 0olume that occurs for a gi0en change in pressure. 't is in0ersely related to ELASTASTICITY% the ability of the lung to recoil to its resting 0olume after the stretching force is released. $lastance depends on the elastic tissue of the lung and chest wall. SURFACE TENSION is the collapsing pressure e*erted upon the al0eoli. 't results from the attracti0e forces between molecules of liquid lining the al0eoli and follows #aPlaceLs #aw% P,>T)r% where P is the collapsing pressure% T is the surface tension and r is the radius of the al0eolus. SURFACTANT lines the al0eoli and reduces surface tension by disrupting intermolecular forces between molecules of liquid. This reduction in surface tension pre0ents al0eoli from collapsing and increases COMPLIANCE. RESISTANCE of the airway opposes the flow of gases. Air flow is characteri6ed as #aminar when it is stream5lined% low 0elocity and follows PoiseuilleMs #aw 1see below2- it is usually confined to the small peripheral airways. Air flow is characteri6ed as T?RC?#$NT when the mo0ement of molecules of gas is disorgani6ed- it occurs when 0elocity of flow e*ceeds a limiting 0alue or when irregularities in the configuration of the airway preclude laminar flow.
't follows PO'S$?'##$Ls #A:% an equation which describes laminar flow in a straight tube%

ie laminar flow.

V=Pr4/8nl where V= flow P= driving pressure r= radius of tube n= fluid viscosity l= length of tube (4 represents power of 4)
Since length and 0iscosity of the airway are usually constant% the radius 1or diameter2 of the airway is the most powerful determinant of airway resistance 1resistance and radius are in0ersely related2. The smaller the airway radius% the greater the resistance to flow. Nearly A9G of airway resistance can be attributed to the trachea and bronchi% both characteri6ed by rigid structures and together accounting for the smallest total cross5 sectional area of the airway.

VENTILATION% which can be spontaneous 1as in breathing2 or artificial 1as in mechanical 0entilation2 is the mo0ement of AIR NAir is a mi*ture of gases. According to DaltonLs #aw% the total pressure of a mi*ture of gases is the sum of the pressures of the indi0idual gases. 'n dry air% at an atmospheric pressure of F@9 mm (% FJG of the total pressure is due to nitrogen molecules and >7G is due to o*ygen.O between the en0ironment and the al0eoli. 't is measured as the frequency of breathing multiplied by the 0olume of each breath. .entilation maintains normal concentrations of o*ygen and carbon dio*ide in the al0eolar gas and% through the process of diffusion% also maintains normal partial pressures of o*ygen and carbon dio*ide in the blood flowing from the capillaries. MINUTE VENTILATION% the 0olume of gas 0entilated in one minute% is e*pressed as H'N?T$ .$NT'#AT'ON , T'DA# .O#?H$ * CR$AT S)H'N. ALVEOLAR VENTILATION, the 0olume of gas a0ailable to the al0eolar surface per minute% is e*pressed as A#.$O#AR .$NT'#AT'ON, 1T'DA# .O#?H$3D$AD SPA+$2 " CR$AT S)H'N

VENTILATION: H+' G % 4e$% $+ $)e A&.e+&#

VENTILATION5PERFUSION RELATIONSHIPS

.entilation and perfusion are normally matched in the lungs so that gas e*change 10entilation2 nearly matches pulmonary arterial blood flow 1perfusion2. 'f mismatched% impairment of o*ygen and carbon dio*ide transfer results. The concentration of o*ygen 1PO>2 in any lung unit is measured by the ration of 0entilation to blood flow: VENTILATION/PERFUSION +r V/6 This relationship also applies to carbon dio*ide% nitrogen and any other gas present. The .entilation 3 Perfusion relationship can be measured by calculating the al0eolar 1a2 3 Arterial 1A2 PO> difference. PAO> can be calculated using the equation: PAO7 8 FIO7 0P $m 9 PH7O1 9 0P CO7/R1 at sea le0el% /'O> , .>7% P >9 , BF% Pbreath , F@9% Pa+O> measured by lab analysis% R , 9.J PAO7 8 2:; 9 0P CO7/;/<1 PaO> is measured by lab analysis. Normal PAO>5PaO> gradient , 79% increasing by 85@ per decade o0er 89.

The three basic elements of the respiratory control system are: S$NSORS% +$NTRA# +ONTRO##$RS and $//$+TORS. S$NSORS: The sensors that contribute to the control of breathing include lung stretch receptors in the smooth muscle of the airway% irritant receptors located between airway epithelial cells% &oint and muscle receptors that stimulate breathing in response to limb mo0ement% and &u*tacapillary 1or K2 receptors located in al0eolar walls which sense engorgement of the pulmonary capillaries and cause rapid shallow breathing. The most important sensors are central chemoreceptors in the medulla as well as peripheral chemoreceptors in the carotid and aortic bodies. The central chemoreceptors in the medulla respond to changes in the p of the +S/. Decreases in +S/

CONTROL OF VENTILATION

p produce increases in breathing 1hyper0entilation2 whereas increases in p result in hypo0entilation. The peripheral chemoreceptors in the carotid and aortic bodies cause an increase in 0entilation in response to decreases in arterial PO>% increases in arterial P+O> and increases in arterial hydrogen concentrations 1decrease in p 2. +$NTRA# +ONTRO##$RS:+entral control of breathing is achie0ed at the brainstem% specifically the pons and midbrain% 1responsible for in0oluntary breathing2 and the cerebral corte* 1responsible for 0oluntary breathing2. $//$+TORS:The <effectors= are the muscles of respiration% including the diaphragm% intercostal muscles% abdominal muscles and accessory muscles such as the sternocleidomastoid

GAS TRANSPORT IN THE BLOOD

The gases are carried in the blood in two forms: dissol0ed in the plasma or combined with HEMOGLOBIN. emoglobin within red blood cells is able to combine rapidly and re0ersibly with o*ygen to dramatically increase the solubility of o*ygen in blood. +onsider that the typical cardiac output is 8# blood)min and resting o*ygen consumption is >89 m#)min. Cecause of the low solubility of o*ygen in aqueous solution% only ; m# of O> will dissol0e in the plasma fraction of 7 # of arterial blood. Therefore% only 78m# of dissol0ed O> reaches the systemic circulation each minute 3 not nearly enough to meet normal metabolic demands. ?nder normal circumstances% more than AJG of the o*ygen in a gi0en 0olume of blood is transported in RC+s% bound to hemoglobin. The amount of o*ygen that binds to hemoglobin depends on the PO> of the plasma surrounding the RC+s and the number of a0ailable binding sites within the RC+. The number of potential binding sites depends largely on the total number of hemoglobin molecules in the blood. O*ygen 1O>2 forms a rapid and re0ersible combination with hemoglobin 1 b2 to gi0e o*yhemoglobin 1 bO>2. This relationship is represented by the O*ygen5 emoglobin dissociation cur0e . Note that the amount of o*ygen carried by hemoglobin rapidly increases to a

PO> of 89 mm g% but abo0e that the cur0e flattens out. This represents the o*ygen capacity% the ma*imum amount of o*ygen that can be combined with hemoglobin.

The cur0ed shape of the o*ygen dissociation cur0e confers se0eral physiologic ad0antages. The flat upper portion of the cur0e means that e0en if the PO> in al0eolar gas drops somewhat% loading of O> onto b will be little affected. 'n other words% the system can continue to operate normally with slight drops in a0ailable o*ygen. +on0ersely% the steep lower part of of the cur0e means that the peripheral tissues can e*tract large amounts of o*ygen of hemoglobin for only minute drops in capillary PO>% facilitating diffusion of o*ygen into the tissues that need it.

The o*ygen dissociation cur0e is shifted to the right 1o*ygen affinity for hemoglobin is R$D?+$D 3 harder to load o*ygen% easier to unload for a gi0en PO>2 by an increase in:

ydrogen concentration 1decrease in p 2 Pa+O> 1Cohr effect2 temperature concentration of >%;5diphosphoglycerate 1>%;5DP(2 in the red blood cells.

Opposite changes cause the cur0e to shift to the left.

CLINICAL APPROACH TO ACID5BASE PHYSIOLOGY

+arbon dio*ide is carried in the blood in three forms: dissol0ed 1although +O> is twenty times more soluble in blood than O>% the dissol0ed form for +O> accounts for less than ten percent of total body +O>2% in combination with proteins% and% chiefly% as bicarbonate. Cicarbonate is formed in blood by the following sequence: +O> I >O PQ >+O; PQ I I +O;5

The

enderson

asselbach equation is deri0ed from this chemical reaction: p , pRa I log N +O;O)N9.9;Pco>O

The 0alue of pRa is @.7 and the normal mmol)#. Thus% normal p is F.B.

+O;5 concentration in arterial blood is >B

O: TO 'NT$RPR$T AN AC(: Often written as: p )Pa+O>)PaO>) +O;5)O> SAT

72 's the patient acidemic or al4alemic: L++=

$ $)e !H 1N# , F.;85F.B82

if the p PF.;8 then acidemic if the p is QF.B8 then al4alemic

(note: there is only one situation in which a normal pH can coexist with an acid-base disorder: chronic respiratory alkalosis. In this situation the kidneys are able to fully compensate for the respiratory alkalosis.)

>2'f there is an acidosis% is it metabolic or respiratory in origin: L++= 1N#,;85 B82

$ $)e P CO7

if the Pa+O> P ;8% then the patient has metabolic acidosis o C)e"= -+r A,#+, G !: Na 5 N+l I +O;O 'f normal 17> I)5 >2% then Non5anion gap metabolic acidosis 3#--ere,$# &: HEART CCU ypoaldosteronism)AddisonMs $*pansion with fluid Acid loading by ingestion RTA types '% ''b% '.b Tirds 1diarrhea2 +arbonic Anhydrase 'nhibitors or Spironolactone +hronic pyelonephritis ?rethral di0ersions and (' losses and TPN

'f abnormal 1PJ or Q7>2% then Anion gap metabolic acidosis 3#--ere,$# & 8 MUDPILES Hethanol% metformin ?remia DRA 1alcohol% star0ation2 Paraldehyde 'ron% 'sonia6id% 'nhalants #actic Acidosis


if

$thylene (lycol Salicylates% sol0ents 1toluene2

the Pa+O> Q B8% then respiratory acidosis o chec4 to see if acute: if acute% decrease in p by 9.9J accompanied by increase in Pa+O> by 79 #- "*$e, 3#--ere,$# & #%: /oreign body obstruction Pneumothora* ypo0entilation #- ")r+,#", 3#--ere,$# & #%: +OPD Restricti0e lung disease Obesity

;2 'f there is an al4alosis% determine if metabolic or respiratory in origin: L++= 1Nl , ;8 5 B82

$ P CO7

'f the Pa+O> is greater than B8 then metabolic al4alosis o administer Na+l to determine if +l sensiti0e or resistant 'f +l sensiti0e% differential is 0omiting nasogastric suction contraction al4alosis loop diuretics post hypercalcemia syndrome if +l resistant% differential is primary hyperaldosteronism CarterMs syndrome #iddle Syndrome blac4 licorice chronic R loss increase in glucocorticoids 1+ushings or adrenal hyperplasia2

'f Pa+O> is less than ;8% then Respiratory Al4alosis o hyper0entilation 1an*iety% +NS disease% pregnancy2 o 'ncreased altitude o Sepsis o Salicylates o #i0er failure o +ongesti0e eart /ailure o Pneumonia

yperthyroidism

INDICATIONS FOR ENDOTRACHEAL INTUBATION

'nadequate 0entilation% whether due to sedation and neuromuscular paralysis in the operating room% an obstructed or compromised airway% altered mentation% loss of consciousness% or respiratory failure can lead to brain in&ury or death within minutes. 't is% thus% of great importance to 4now how to e0aluate and address a patient who may require 0entilatory support.

INDICATIONS FOR ENDOTRACHEAL INTUBATION 'ndications for $NDOTRA+ $A# 'NT?CAT'ON in the operating room include:

the need to deli0er positi0e pressure 0entilation protection of the respiratory tract from aspiration of gastric contents surgical procedures in0ol0ing the head and nec4 or in non5supine positions that preclude manual airway support almost all situations in0ol0ing neuromuscular paralysis surgical procedures in0ol0ing the cranium% thora*% or abdomen procedures that may in0ol0e intracranial hypertension

Some non5operati0e indications are:

profound disturbance in consciousness with the inability to protect the airway tracheobronchial toilet se0ere pulmonary or multisystem in&ury associated with respiratory failure% such as sepsis% airway obstruction% hypo*emia% and hypercarbia

Ob&ecti0e measures may also be used to help determine the need for intubation:

respiratory rate Q ;8 breaths per minute 0ital capacity P 78 ml)4g in adults and 79 ml)4g in children inability to generate a negati0e inspiratory force of >9 mm g PaO> 1arterial partial pressure of o*ygen2 P F9n mm g A5a gradient 1Al0eolar5arterial2 Q ;89 mm g on 799G o*ygen Pa+O> 1arterial partial pressure of carbon dio*ide2 Q 88 m g 1e*cept in chronic retainers2

dead space Q 9.@ #

To a0oid catastrophes secondary to difficult intubations% any patient that may require intubation should first undergo a historical and physical airway e*am if the situation allows. AIRWAY HISTORY: 'f possible% attain and re0iew prior anesthesia records. As4 the patient:

about problems with prior anesthesia such as &aw pain% hoarse 0oice% dental in&ury 3 any thing that may suggest the anesthesiologist had difficulty intubating or pro0iding positi0e pressure 0entilation or that the patient has an anatomic abnormality. if they ha0e e0er been informed by an anesthesiologist that they were difficult to intubate or 0entilate. if they ha0e dentures% sleep apnea% THK problems or history of prior airway surgery or trauma 1including burns2. if they ha0e a history of head and nec4 tumors or infection.

A%%e%%#,4 $)e P $#e,$

PHYSICAL EXAM: !our physical e*am will be your most reliable tool for anticipating difficulties in airway management. Start by re0iewing 0ital signs% particularly o*ygen saturation. Then% commence your e*am with a general assessment:

is the patient obese or morbidly obeseS do they appear to ha0e a short chin or an o0er5biteS are there any signs of pre0ious head% nec4 or thora* surgeryS is the patient pale or cyanoticS is the patient able to sit upS is the patient breathing comfortablyS does the patient require supplemental o*ygenS is the patient appropriate and able to follow commandsS does the patient ha0e full range of motion of the nec4S

'n addition to a cardio0ascular and pulmonary e*am% a focused airway e*am should be conducted. De$ #&e3 e. &* $#+, ,3 3+"*me,$ $#+, +- !re5!r+"e3*re b,+rm &#$#e% #% #m!er $#.e:

e*amine the mouth and oral ca0ity 1the best combination for east airway management is a large oral ca0ity with a small mobile tongue2 e0aluate the e*tent and symmetry of mouth opening 1three finger breadths is optimal2

chec4 for loose% missing or crac4ed teeth note any prominent buc4 teeth or particularly large incisors that may interfere with laryngoscopy 1dental and oral in&uries are common complications of laryngoscopy2 note the si6e of the tongue 1large tongues may interfere with use of the laryngoscope2 note the arch of the palate 1high arched palates ha0e been 4nown to hamper 0isuali6ation of the laryn*2 e*amine the chin: the two important features of the chin include mandibular space and tissue compliance. Predicted airway ris4 is low if the thyromental space 1distance from the mandible to the thyroid2 is three finger breadths or greater and tissue compliance is high. e*amine the pharyn*. The appearance of the posterior PHARYNX may predict ease of laryngoscopy and 0isuali6ation of the #AR!N". Halampatti has classified patients in classes '5'. based on 0isuali6ation of structures during pre5operati0e e0aluation. The patient is as4ed to open the mouth wide% stic4 out the tongue% and e*tend the nec4 to allow for ma*imal 0isuali6ation of the PHARYNX/ o 'f the whole of the tonsillar pillars are 0isuali6ed% the airway is rated +lass ' and intubation is li4ely to be uncomplicated. o 'f the u0ula% but not the tonsillar pillars can be 0isuali6ed% the airway is rated as +lass ''. o +lass ''' is characteri6ed by 0isuali6ation of part of the u0ula and soft palate.

An airway is characteri6ed as +lass '. if the tongue obstructs 0iew of any structures beyond the hard palate. +lass '. is associated with increased ris4 of difficult intubation.

PROVIDING SUPPLEMENTAL OXYGEN

Some patients require o*ygen supplementation% despite maintaining a patent airway and normal 0entilatory dri0e. 'n such cases de0ices such as nasal cannula% face tents and simple mas4s can be used to deli0er o*ygen 0ia positi0e pressure. The nasal cannula 1plastic tubing inserted into nares2 is the most commonly employed low5flow o*ygen deli0ery de0ice. 't pro0ides supplemental o*ygen at flows ranging from 9 to J #)min% enabling a ma*imum of B9G O> to be deli0ered. The o*ygen concentration 1/'O>2 can be estimated by adding BG per liter of O> deli0ered.

/or greater o*ygen deli0ery in a patient with a patent airway% a reser0oir systems such as a simple mas4% which co0ers the nose and mouth and can pro0ide flow rates of 79#)min and a ma*imum /'O> of 88G to be deli0ered% and a non5rebreather mas4% which uses a series of one way 0al0es and can deli0er 79578 # min and a ma*imum /'O> of J9G. igh flow systems% such as nebuli6ers% can also be used for

increased o*ygen deli0ery.

UNDERSTANDING E6UIPMENT
:atch optional 0ideo 1Tuic4time required2 F "e M %=: Deli0ery of positi0e pressure 0entilation by means of a face mas4 1or bag50al0e5 mas4 de0ice2 is an essential s4ill to de0elop. The rim of the mas4 is soft and form5fitting and by pressing it firmly against the face an airtight seal is made. The mas4 is attached to a breathing circuit including an o*ygen bag. :hen pressure in the mas4 increases by squee6ing the inflated o*ygen bag% air flows through the upper airway into the lungs. :hen the bag is empty or you stop squee6ing it% air will flow out the lungs through the nose and mouth into the mas4. Successful 0entilation requires both an air5tight mas4 fit and a patent airway. :ithout an airtight seal between the s4in of the patientLs face and the mas4% sufficient pressure to inflate the lungs 1or for that matter the 0entilation bag2 will not de0elop. #ea4 is the most common problem in deli0ering face mas4 0entilation and can be a0oided or resol0ed by proper technique. 'f you ha0e an assistant who can squee6e the 0entilation bag for you% use two hands to secure an air5tight seal. The thumbs hold the mas4 down while the fingertips or 4nuc4les displace the &aw forward and upward 1lift and protrude the &aw to pre0ent or alle0iate airway obstruction by the tongue2. The one handed technique is achie0ed by using the right hand to generate positi0e pressure by squee6ing the bag using the left thumb and inde* finger to secure the mas4 1by

pushing downward2. The middle and ring finger grasp the mandible 1and not the soft tissue of the chin2 to e*tend the atlanto5occipital &oint 1the nec42. The little finger is positioned under the angle of the &aw and thrusts it anteriorly. Signs of successful seal and 0entilation include:

a foggy mas4 the rising of the chest with deli0ery of positi0e pressure breath sounds on auscultation a firm)taught)full bag return carbon dio*ide on e*halation capnography.

Or+!) r(,4e & #r' ( 0OPA1 3 A cur0ed piece of plastic inserted o0er the tongue that creates an air passage way between the mouth and the posterior pharyngeal wall. ?seful when the tongue and)or epiglottis fall bac4 against the posterior pharyn* in anestheti6ed or unconscious patients obstructing the flow of air. The preferred technique is to use a tongue blade to depress the tongue and then insert the airway posteriorly. An alternate technique is to insert the oral airway upside down until the soft palate is reached. Rotate the de0ice 7J9 degrees and slip it o0er the tongue. Ce sure not to use the airway to push the tongue bac4ward and bloc4% rather than clear% the airway. This de0ice is poorly tolerated in conscious patients and may induce gagging% 0omiting and aspiration.

N %+!) r(,4e &

#r' ( 3 Also 4nown as trumpets% nasopharyngeal airways are inserted through one nostril to create an air passage between the nose and the nasopharyn*. The NPA is preferred to the OPA in conscious patients because it is better tolerated and less li4ely to induce a gag refle*. The length of the nasal airway can be estimated as the distance from the nares to the meatus of the ears and is usually >5B cm longer than the oral airway. Any tube inserted through the nose should be well lubricated and ad0anced at an angle perpendicular to the face 1remember: the floor of the nose is the roof of the mouthE2. ?se a nostril that is unobstructed. :hile nasopharyngeal airways are better tolerated than oropharyngeal airways in awa4e or lightly anestheti6ed patients% they are contraindicated in patients who are anticoagulated% patients with basilar s4ull fractures% patients with nasal infectios and deformities as well as in children 1because of ris4 of epista*is2. 'f the nasopharyngeal tube is 0isible in the posterior oropharyn*% it may pro0ide safe passage of an nasogastric tube 1N( tube2 in a patient with ma*illofacial fractures. L r(,4e & M %= A#r' ( 0LMA1 3 The #HA is a cuff de0ice that pro0ides sufficient seal to allow for positi0e pressure 0entilation to be deli0ered. 't is particularly useful in maintaining an airway in anestheti6ed patients when endotracheal intubation is not desired or during emergency situations in which mas4 0entilation is not possible or intubation and)or 0entilation fails. An #HA is a wide bore tube% with a connector at its pro*imal end 1that can be connected to a breathing circuit2and with an elliptical cuff at its distal end. :hen inflated% the elliptical cuff forms a low pressure seal around the entrance into the laryn*. The #HA comes in a 0ariety of pediatric and adult si6es and successful insertion requires appropriate si6e selection. L r(,4+%"+!e 3 A laryngoscope is a rigid instrument used to e*amine the laryn* and to facilitate intubation of

the trachea. 't is composed of two separate parts: the handle 1which also contains the battery2 and the blade% which is used to mo0e the tongue and soft tissues aside to re0eal a 0iew of the laryn*. To this end% an incandescent bulb can be found on the blade tip 5 it turns on when the blade is attached to the handle and loc4ed into the A9 degree position to illuminate the laryn*.

The two most commonly used blades in the ?nited States are the Hacintosh% which is cur0ed% and the Hiller% which is straight. Coth blades come in a 0ariety of si6es. The choice of blade depends on personal preference and patient anatomy. The laryngoscope is held in your NON5DOH'NANT AND 1if you are right handed% resist the temptation to hold the laryngoscope in your right handE2. +arefully introduce the blade into the right side of the mouth. Regardless of which blade is used% 'T H?ST N$.$R PR$SS A(A'NST T $ T$$T or dental trauma will result. The tongue is then swept to the left and up into the floor of the pharyn* by the bladeLs flange.

The cur0ed Hacintosh blade is inserted past the tongue into the 0allecula 1at the base of the tongue2. Pro0iding sufficient lifting force in parallel with the handle% yet a0oiding posterior rotation that causes the blade to press against the teeth% pressure is applied deep in the 0allecular space by the tip of the blade immediately anterior to the epiglottis% which flips out of the 0isual field to e*pose the laryngeal opening.

The straight Hiller blade is inserted deep into the oropharyn*% PAST the epiglottis. Pro0iding sufficient lifting force in parallel with the handle% yet a0oiding posterior rotation that causes the blade to press against the teeth% under direct 0ision% the blade is slowly withdrawn. 't will slip o0er the anterior laryn* and come to a position at which it holds the epiglottis flat against the tongue and anterior pharyn*% e*posing a 0iew of the laryn*.

:ith either blade% the handle is raised up and away from the patient in a plane perpendicular to the patientLs mandible. A0oid trapping a lip between the teeth and the blade and A.O'D using the teeth as le0erage.

E,3+$r ")e & T*be 3 $ndotracheal tubes are most commonly made from poly0inyl chloride% with a radiopaque line from top to bottom% standard si6e connectors 1for anesthesia machines% 0entilators% or bag5 mas4 de0ices% a high pressure)low 0olume inflatable balloon% and a hole at the be0eled% distal end 14nown as HurphyLs eye2. Tubes come in a number of si6es% usually designated in millimeters of internal diameter. The choice of $TT si6e is always a compromise between choosing the largest si6e to ma*imi6e flow and minimi6e airway resistance and the smallest si6e to minimi6e airway trauma. Once a 0iew of the laryn* is obtained 0ia laryngoscopy% the $TT is introduced with the dominant hand through the right side of the mouth. Directly obser0e the tip of the tube passing into the laryn*% between the abducted cords. Pass the tube 7 cm through the cords. Double lumen endotracheal tubes are designed so that one lung may be isolated from the other to facilitate selecti0e 0entilation of one lung or surgery within a hemithora*.

S$(&e$ 3 A stylet is a long% bendable rod that can be inserted into an endotracheal tube to facilitate intubation. 't is placed into the tube prior to laryngoscopy and then the tube 1with the stylet in it2 is bent to

resemble a hoc4ey stic4. After insertion of the tube into the trachea% the stylet is remo0ed.

B+*4#e 3 The Cougie is a straight% semi5rigid stylette5li4e de0ice with a bent tip that can be used when intubation is 1or is predicted to be2 difficult. During laryngoscopy% the bougie is carefully ad0anced into the laryn* and through the cords until the tip enters a mainstem broncus. :hile maintaining the laryngoscope and Cougie in position% an assistant threads an $TT o0er the end of the bougie% into the laryn*. Once the $TT is in place% the bougie is remo0ed.

HOW TO INTUBATE
:atch airway anatomy 0ideo :atch intubation procedure 0ideo 1Tuic4time required2 Prior to intubation% always chec4 equipment and ma4e sure e0erything you might need is not only within your reach% but also properly wor4ing. 'f in the operating room% a complete chec4 of the anesthesia equipment at the start of each day as well as a modified chec4 before each new case is imperati0e. 'f in the emergency room or the hospital wards% ma4e sure you 4now where all of your equipment is and% also% that you ha0e the necessary resources to support the patient once intubated. Prior to positioning the patient:

Ha4e sure that your laryngoscope is loc4ed into position and that the incandescent light on the blade tip functions. Also ma4e sure that you

ha0e se0eral alternate blades a0ailable in case the one you ha0e chosen does not allow for 0isuali6ation of the cords. $*amine the endotracheal tube. Ha4e sure that the cuff inflates by using a 795m# syringe to inflate the cuff and then detach the syringe to ensure that the cuff pressure is maintained. Ce sure to deflate deflate the cuff after testing it. Attach the connector to the pro*imal end of the tube. Push it in as far as possible to lessen the li4elihood of disconnection. 'f you are going to use a stylet% it should be inserted into the $T tube and bent to resemble a hoc4ey stic4 to facilitate intubation of an anteriorly positioned laryn*. $0en if you do not plan on using a stylet% one should be within easy access in case the intubation pro0es to be more difficult than anticipated. $nsure a functioning suction unit to clear the airway in case of une*pected blood% emesis or secretions. $nsure that you ha0e tape within your reach to secure the tube once it is in place.

Proper patient positioning can be the difference between a successful and failed intubation.

The patientLs head should be le0el with the physicianLs *iphoid process. To achie0e the sniff position 1which allows for optimal 0isuali6ation of the glottic opening2% ele0ate the patientLs head and e*tend the atlanto5occipital &oint. This can be achie0ed by sliding your free hand 1right hand if you are right handed% left hand if you are left handed2 beneath the patientLs head and gently lifting it up and towards you. Or% you can gently position the chin up and mouth open before attemting laryngoscopy. The Uscissor techniqueU can also be used to further open the patients mouth. +ross your right forefinger and thumb and insert into the right side of the patientMs mouth. Apply pressure to the upper teeth with your forefinger and the lower teeth with your thumb to open the mouth. Ce sure to position your hands so as NOT to obstruct your 0iew.

M %= Ve,$#& $#+, is often used in the operating room after induction% prior to intubation. 'f you are able to achie0e signs of 0entilation using this technique% you are afforded the 4nowledge that% if intubation fails% you are able to achie0e 0entilation using the bag5mas450al0e de0ice. /urther% it allows for pre5o*ygenation. Preparation for induction and intubation in the operating room also in0ol0es pre5o*ygenation with se0eral 1eight2 deep breaths of 799G o*ygen. Preo*ygenation pro0ides an e*tra margin of safety in case the patient is not easily 0entilated after induction. After preo*ygenating the patient and positioning the patient in the

Sniff position% with the patientLs mouth widely open% carefully introduce the blade% held in your #$/T AND% into the right side of the mouth. Regardless of which blade is used% 'T H?ST N$.$R PR$SS A(A'NST T $ T$$T or dental trauma will result. The tongue is then swept to the left and up into the floor of the pharyn* by the bladeLs flange. The cur0ed Hacintosh blade is inserted past the tongue into the 0allecula 1at the base of the tongue2. Pro0iding sufficient lifting force in parallel with the handle% yet a0oiding posterior rotation that causes the blade to press against the teeth% pressure is applied deep in the 0allecular space by the tip of the blade immediately anterior to the epiglottis% which flips out of the 0isual field to e*pose the laryngeal opening. The straight Hiller blade is inserted deep into the oropharyn*% PAST the epiglottis. Pro0iding sufficient lifting force in parallel with the handle% yet a0oiding posterior rotation that causes the blade to press against the teeth% under direct 0ision% the blade is slowly withdrawn. 't will slip o0er the anterior laryn* and come to a position at which it holds the epiglottis flat against the tongue and anterior pharyn*% e*posing a 0iew of the laryn*. :ith either blade% the handle is raised up and away from the patient in a plane perpendicular to the patientLs mandible. A0oid trapping a lip between the teeth and the blade and A.O'D using the teeth as le0erage and a0oid posterior rotation of the blade. Once a 0iew of the laryn* is obtained 0ia laryngoscopy% the $TT is introduced with the R'( T AND through the right side often mouth. Directly obser0e the tip of the tube passing into the laryn*% between the abducted cords. Pass the tube 7 cm through the cords. The $TT should lie in the upper trachea but beyond the laryn* 1; to B cm pro*imal to the carina2. 'f the patient is going to be repositioned% the cuff should be closer to > cm beyond the cords.

Remo0e the laryngoscope% careful not to displace the $T tube and not to cause trauma to the teeth% lips or mucosa. 'nflate the cuff with the least amount of air necessary to create a seal during positi0e pressure 0entilation 1usually B5J m# of air2. Remo0e the mas4 from the bag50al0e de0ice and attach the 78 mm connector on the pro*imal end of the $T tube to the bag50al0e de0ice 1into which o*ygen is flowing and to which the carbon dio*ide detector is attached2. Pro0ide positi0e pressure and immediately 1and quic4ly2:

ausculatate the chest for breath sounds chec4 the capnoraphic tracing on the monitor to ensure end tidal +O> chec4 the connector for fog loo4 at the chest for e*pansion with each breath

'f there is any question as to whether the tube is in the esophagus or trachea% remo0e the tube% 0entilate with a mas4 and try again% this time attempting to ad&ust anything that may ha0e interfered with your first attempt. !ou might reposition the patient% use a different blade% decrease tube si6e% or add a stylet. 'f you are sure that your intubation is successful% turn on the mechanical 0entilator. +ontinuously pro0ide positi0e5pressure 0entilation at a 0olume of ;895F99 H# per F9 4g 18579 m#)Rg2 and at a sufficient rate to maintain normal end tidal +O> 1J57> respirations per minute2. Proceed to tape or tie the tube to secure its position. Do not tape or tie the cuff. To pre0ent the patient from biting and occluding the $TT during emergence from anesthesia% a roll of gau6e can be placed between the teeth or an OPA can be inserted. Document the 0iew of the laryn* obtained during laryngoscopy using the following criteria:

(rade (rade (rade (rade ': full 0iew of the cords '': partial 0iew of the cords ''': 0iew of the epiglottis '.: No 0iew of the cords or epiglottis

OTHER WAYS TO INTUBATE N %+$r ")e & I,$*b $#+,: Nasal intubation is similar to oral

intubation e*cept that the $TT is ad0anced through the nose into the oropharyn* before laryngoscopy. 'f the patient is awa4e% local anesthetic drops and ner0e bloc4s can be used. A lubricated $TT is introduced along the floor of the nose% below the inferior nasal turbinate% perpendicular to the face. Often% a nasopharyngeal airway can be used. The tube is ad0anced until it can be 0isuali6ed in the oropharyn*. .ia laryngoscopy% the tube is then ad0anced in between the abducted 0ocal cords. Nasal instrumentation 1with $TTs% NPOs% or nasal catheters2 is contraindicated in all patients with se0ere midfacial trauma. B+*4#e: The Cougie is a straight% semi5rigid stylette5li4e de0ice with a bent tip that can be used when intubation is 1or is predicted to be2 difficult 3 often helpful when the tracheal opening is anterior to the 0isual field. During laryngoscopy% the bougie is carefully ad0anced into the laryn* and through the cords until the tip enters a mainstem broncus. :hile maintaining the laryngoscope and Cougie in position% an assistant threads an $TT o0er the end of the bougie% into the laryn*. Once the $TT is in place% the bougie is remo0ed.

L#4)$ W ,3: #ightwands% when inserted into an endotracheal tube% may be useful for blind intubations of the trachea 1when the laryngeal opening cannot be 0isuali6ed2. The end of the $T tube is at the entrance of the trachea when light is well transilluminated through the nec4 1the &ac4 oLlantern effect2. The tube can then be threaded off the light wand and into the trachea in a blind fashion.

F&e>#b&e F#ber+!$#" Br+,")+%"+!(: #aryngoscopy may be contraindicated in a patient who requires intubation and mechanical 0entilation. This is often the case in trauma patients who may ha0e an unstable cer0ical spine or in patients with poor range of motion of the temporo5mandibular &oint. 'n such patients% fle*ible fiberoptic bronchoscopy allows for indirect 0isuali6ation of the laryn*. The endoscope is introduced through the mouth or nose. Once anatomic structures are recogni6ed% and the laryn* or trachea are entered under direct 0isuali6ation. COMPLICATIONS OF INTUBATION +omplications of laryngoscopy and intubation are most frequently secondary to airway trauma% tube malpositioning% tube malfunction or physiologic responses to airway instrumentation. Trauma such as tooth damage% lip)tongue)mucosal laceration% sore throat% dislocated mandible% retropharyngeal dissection can occur during laryngoscopy and intubation. Hucosal inflammation and ulceration and e*coriation of nose can occur while the tube is in place. #aryngeal malfunction and aspiration% glottic% subglottic or tracheal edema and stenosis% 0ocal cord granuloma or paralysis during e*tubation. Halpositioning of the endotracheal tube can result in esophageal

intubation and unintentional e*tubation. Physiologic responses to intubation include hypertension% tachycardia% intracranial hypertension% and laryngospasm. #aryngospasm% which occurs during induction and reco0ery from anesthesia or% rarely% in an awa4e patient% is a forceful in0oluntary spasm of the laryngeal musculature caused by sensory stimulation of the superior laryngeal ner0e. Treatment includes positi0e pressure 0entilation 0ia a bag5 mas4 de0ice using 799G o*ygen or administration of '. lidocaine.

Rnowing when to e*tubate is also an important 4nowledge set. 'n general% it is best to e*tubate when a patient is still deeply anestheti6ed 1but with adequate spontaneous respirations2 or when the patient is awa4e and responsi0e with stable 0ital signs% good grip and sustained head lift. Adequate re0ersal of neuromuscular bloc4ade must be established. A patient must also demonstrate adequate spontaneous respiratory function with a 0ital capacity of greater than 78 m#)4g and a negati0e inspiratory force of greater than >9 mm g. $*tubation while the patient is in a light plane of anesthesia or still emerging from anesthesia is a0oided because of an increased ris4 of laryngospasm% the most dreaded complication of e*tubation. Regardless of whether a patient is e*tubated while deeply anestheti6ed or awa4e% begin by thoroughly suctioning the patientLs pharyn* and mouth in order to decrease the ris4 of aspiration or laryngospasm. Also% <preo*ygenate= the patient with 799G o*ygen in case it becomes difficult to establish an airway after the $TT is remo0ed. ?ntape the $TT and deflate its cuff. Apply a small degree of positi0e pressure on the air bag to help blow out any secretions you may ha0e missed on first suctioning and suction again. :ithdraw the tube on end5 inspiration or end5e*piration in a single% smooth motion. Apply a face mas4 to deli0er 799G o*ygen.

HOW TO EXTUBATE

?e%*&#$ , I,$*b %#
The American Society of Anesthesiologists telah mengembang4an algoritma dalam mengatasi 4esulitan intubasi. :alaupun setiap pasien harus die0aluasi secara indi0idual% secara umum 4ondisi yang

berhubungan dengan 4esulitan intubasi sebagai beri4ut :

Tumor oral)faring% hemagOral)pharyngeal tumors% hemangiomas or hematomas 'nfections such as submandibular or peritonsillar abscesses or epiglottitis +ongenital Anomalies such as Pierre Ronin Syndrome% #aryngeal atresia or craniofacial dysostosis /oreign body /acial trauma such as laryngeal% ma*illary or mandibular fracture% +er0ical spine in&ury 'nhalational burn Obesity 'nadequate nec4 e*tension due to rheumatoid arthritis% cer0ical stenosis or an4ylosing spondylitis Anatomic .ariations such as micrognathia% prognathism% macroglossia% arched palate% short nec4% prominent incisors or buc4 teeth.

+lic4 here to 0isit the American Society of AnesthesiologistMs Difficult Airway (uidelines.

APPROACH TO THE AIRWAY IN TRAUMA PATIENTS: T)e A +- ABC

The most immediately life threatening complication of any trauma is loss of airway patency. Haintaining o*ygenation and pre0enting hypercarbia are critical in managing the trauma patient% especially if the patient has sustained a head in&ury. Thus% the first step in e0aluating and treating any trauma patient is to assess airway patency and% if compromised% restore it: the A of A 1airway2% C 1breathing2% + 1circulation2. Any patient who is awa4e% alert and able to tal4 has a patent airway. :hether they need supplemental o*ygen can be determined by 0itals and physical e*am. Patients who are unconscious or ha0e signs suggesti0e of respiratory compromise% howe0er% require immediate attention. All patients should be immobili6ed due to increased ris4 of spinal in&ury. Assessment of the patient should be done while maintaining the cer0ical spine in a stable% neutral position. Cegin the primary sur0ey by rapidly assessing airway patency: rapidly assess for obstruction. Haintain an airway with &aw thrust or the chin lift maneu0er. +lear the airway of foreign bodies. 'f the patient is li4ely to 0omit% position them in a lateral and head down position to pre0ent

aspiration. All trauma patients should be administered supplemental o*ygenE Determine the patientLs needs. Signs and symptoms suggesti0e or airway or 0entilatory compromise include:

ma*illofacial trauma nec4 trauma laryngeal trauma 1with hoarseness or subcutaneous emphysema2

#OOR for:

obtundation agitation 1which may suggest hypercarbia2 cyanosis retractions)accessory muscle use symmetrical rise and fall of the chest wall

#'ST$N for:

abnormal breath sounds snoring stridor crac4les dysphonia symmetrical breath sounds o0er both hemithoraces tachypnea

/$$# for:

a de0iated trachea subcutaneous emphysema

The ladder of tools a0ailable for respiratory support in order of increasing in0asi0eness are:

Nasal cannula /ace mas4% nonrebreather face mas4 Nebuli6er Oral5pharyngeal airway)Nasoparyngeal airway Cag5mas4 0entilation 'ntubation 3 Any patient e*hibiting airway symptoms 1stridor% hoarseness% se0ere cough% 0oice change2 and all unconscious patients should be intubated. $ndotracheal intubation is far superior to bag5mas4 0entilation because it pro0ides larger tidal 0olumes and pre0ents aspiration. Particularly in the trauma

patient population 3 often time obtunded or unconscious% with loss of or diminished gag refle*es 3 the pre0ention of aspiration is of 4ey importance. $mergency +ricothroidotomy 3 Two large bore needles 17B guage2 needles are inserted into the cricothyroid membrane

THE DEFINITIVE AIRWAY: A definiti0e airway can be: an endotracheal tube% an nasotracheal tube% or a surgical airway 1cricothroidotomy2.

The need for a definiti0e airway is based upon a number of clinical findings: the presence of apnea inability to maintain a patent airway by less in0asi0e means need to protect the lower airway from aspiration of blood or 0omitus impending or potential airway compromise 1following inhalational in&ury% facial fractures% retroparygeal hematoma or sustained sei6ure acti0ity2 presence of a closed head in&ury requiring assisted 0entilation inability to maintain adequate o*ygenation by face mas4 o*ygen supplementation any patient with a (lasgow coma score of J or less

'n the trauma situation% the decision whether to proceed with orotracheal or nasotracheal intubation is based upon the e*perience and discretion of the super0ising attending or chief resident. Coth techniques are safe and effecti0e when performed properly. 1All apneic patients should be intubated orally2. 'f the decision is made to proceed with orotracheal intubation% the two person technique with in5line cer0ical spine immobili6ation should be used. N %+$r ")e & I,$*b $#+,: Nasal intubation is similar to oral intubation e*cept that the $TT is ad0anced through the nose into the oropharyn* before laryngoscopy. 'f the patient is awa4e% local anesthetic drops and ner0e bloc4s can be used. A lubricated $TT is introduced along the floor of the nose% below the inferior nasal turbinate% perpendicular to the face. The tube is ad0anced until it can be 0isuali6ed in the oropharyn*. .ia laryngoscopy% the tube is then ad0anced in between the abducted 0ocal cords. VVNasal instrumentation 1with $TTs% NPOs% or nasal catheters2 is contraindicated in all patients with se0ere midfacial trauma.

S*r4#" & Cr#"+$)(r+#3+$+m( : Surgical cricothyroidotomy is performed by ma4ing a s4in incision that e*tends through the cricothyroid membrane. The incision is dilated using a cur0ed hemostat and small endotracheal tube or trachesotomy tube can be inserted. because of potential damage to the cricoid cartilage 1the only circumferential support to the upper trachea% this procedure is not recommended in children under the age of 7>.

American +ollege of Surgeons Airway Decision Scheme 3 designed to foster rapid decision ma4ing in patients who are apneic 1in acute respiratory distress2 and in need of immediate airway AND in whom cer0ical spine in&ury is suspected.