The Difficult Airway

The Difficult Airway: A Practical Guide
This page intentionally left blank
The Difficult Airway: A

Practical Guide
Edited by
Carin A. Hagberg, MD
Joseph C. Gabel Professor and Chair
Department of Anesthesiology
University of Texas Medical School at Houston
Houston, Texas
Carlos A. Artime, MD
Assistant Professor
Houston, Texas
William H. Daily, MD
Assistant Professor
Houston, Texas
3
Oxford University Press is a department of the University of Oxford.
It furthers the Universitys objective of excellence in research, scholarship,
and education by publishing worldwide.
Oxford New York
Auckland Cape Town Dar es Salaam Hong Kong Karachi
Kuala Lumpur Madrid Melbourne Mexico City Nairobi
New Delhi Shanghai Taipei Toronto
With offices in
Argentina Austria Brazil Chile Czech Republic France Greece
Guatemala Hungary Italy Japan Poland Portugal Singapore
South Korea Switzerland Thailand Turkey Ukraine Vietnam
Oxford is a registered trademark of Oxford University Press in the UK and
certain other countries.
Published in the United States of America by
Oxford University Press
198 Madison Avenue, New York, NY 10016
Oxford University Press 2013
All rights reserved. No part of this publication may be reproduced, stored in a
retrieval system, or transmitted, in any form or by any means, without the prior
permission in writing of Oxford University Press, or as expressly permitted by law,
by license, or under terms agreed with the appropriate reproduction rights organization.
Inquiries concerning reproduction outside the scope of the above should be sent to the
Rights Department, Oxford University Press, at the address above.
You must not circulate this work in any other form
and you must impose this same condition on any acquirer.
Library of Congress Cataloging-in-Publication Data
The difficult airway : a practical guide / edited by Carin A. Hagberg,
Carlos A. Artime, William H. Daily.
p. ; cm.
Includes bibliographical references and index.
ISBN 9780199794416 (alk. paper)
I. Hagberg, Carin A. II. Artime, Carlos A. III. Daily, William H.
[DNLM: 1. Airway Management. WF 145]
615.836dc23 2012035304
This material is not intended to be, and should not be considered, a substitute for medical or other professional
advice. Treatment for the conditions described in this material is highly dependent on the individual circumstances.
And, while this material is designed to offer accurate information with respect to the subject matter covered and
to be current as of the time it was written, research and knowledge about medical and health issues is constantly
evolving and dose schedules for medications are being revised continually, with new side effects recognized and
accounted for regularly. Readers must therefore always check the product information and clinical procedures
with the most up-to-date published product information and data sheets provided by the manufacturers and the
most recent codes of conduct and safety regulation. The publisher and the authors make no representations or
warranties to readers, express or implied, as to the accuracy or completeness of this material. Without limiting the
foregoing, the publisher and the authors make no representations or warranties as to the accuracy or efficacy of
the drug dosages mentioned in the material. The authors and the publisher do not accept, and expressly disclaim,
any responsibility for any liability, loss or risk that may be claimed or incurred as a consequence of the use and/or
application of any of the contents of this material.
9 8 7 6 5 4 3 2 1
Printed in the United States of America on acid-free paper
Dedicated to my family in gratitude for their love and support. Carin A. Hagberg
vii
Acknowledgments
I would like to sincerely acknowledge the scholarly efforts of all the contributors, who I consider
to be both friends and colleagues at the University of Texas Medical School at Houston, especially
my Associate Editors, Carlos Artime, MD and William Daily, MD. I would also like to thank my
publisher for her patience and my assistant, Naz Hassan, for her devoted efforts on my behalf.
Carin A. Hagberg
ix
Preface
The Difficult Airway: A Practical Guide is designed for airway managers of all specialties who want
to improve their success with modern airway devices and techniques in their clinical practice.
The approach to airway management has changed considerably in the last 20 years, and many
technological improvements have been made during this time. However, many techniques were
introduced after some clinicians completed their training. This book will fill a niche for teachers
and students alike who practice airway management.
This paperback is a unique handbook that serves as a key resource for all airway managers,
regardless of their experience and training. It is a practical, portable clinical handbook that cuts to
the chase and provides the reader with the necessary tips that will increase their understanding
and success rate in the use of the many airway devices and techniques currently available to the
clinician. These tips apply to both basic and advanced airway skills. The contributors provide a
succinct and practical structured format that encourages hands-on, active learning similar to the
workshops of most major meetings that educate those interested in airway management.
xi
Contents
Contributors xiii
Chapter 1: Airway Assessment
Ankur Khosla and Davide Cattano
Chapter 2: Preparation for Awake Intubation
Carlos A. Artime
Chapter 3: Preoxygenation Strategies and Positioning Tips

Henrique Vale and Davide Cattano
Chapter 4: Mask Ventilation
35
William H. Daily
Chapter 5: Nasotracheal Intubation
41
William H. Daily
Chapter 6: Supraglottic Airway Devices
47
William H. Daily
Chapter 7: ETTs and Laryngoscopy Techniques

William H. Daily
Chapter 8: Intubation Stylets
83
Lara Ferrario
Chapter 9: Flexible Fiberoptic Intubation

Carlos A. Artime
97
63
27
xii
Chapter 10: Retrograde Intubation
109
Katherine C. Normand and A. Paul Aucoin
Chapter 11: Percutaneous Transtracheal Jet Ventilation
117
Katherine C. Normand
Chapter 12: Cricothyrotomy
125
Contents
Katherine C. Normand
Chapter 13: Extubation Catheters
135
Lara Ferrario
Chapter 14: Combination Techniques
143
Jay R. Pinsky and Carin A. Hagberg
Chapter 15: Pediatric Airway Management
155
Ranu Jain
Chapter 16: Difficult Airway Supplies
165
William H. Daily
Chapter 17: Special Considerations for Out of the Operating

Room and Cardiopulmonary Resuscitation 169
Sam D. Gumbert
Chapter 18: Communication of the Difficult Airway and

Dissemination of Critical Airway Information
Sam D. Gumbert
Index 183
177
xiii
Contributors
Sam D. Gumbert, MD
Assistant Professor
Houston, Texas
Assistant Professor
Assistant Director, Residency Program
Medical Director, Case Western Reserve
Anesthesia Assistant Program
Houston, Texas
A. Paul Aucoin, MD
Anesthesiology Group Associates
Baton Rouge, Louisiana
Davide Cattano, MD, PhD
Assistant Professor
Medical Director, Preoperative Anesthesia Clinic
Houston, Texas
Assistant Professor
Director, Operating Rooms
Houston, Texas
Lara Ferrario, MD
Assistant Professor
Director, Neuroanesthesia
Houston, Texas
Carin A. Hagberg, MD
Joseph C. Grabel Professor and Chair
Houston, Texas
Ranu Jain, MD
Assistant Professor
Education Coordinator, Pediatric Anesthesia
Houston, Texas
Ankur Khosla, MD, MBA, MS
Houston, Texas
Contributors
xiv
Katherine C. Normand, MD
Assistant Professor,
Education Coordinator, Neuroanesthesia
Director, 3rd and 4th Year Clerkship
University of Texas Medical School
at Houston
Houston, Texas
Jay R. Pinsky, MD
Medical Anesthesia Associates
Houston, Texas
Henrique Vale, MD
Houston, Texas
Chapter 1
Airway Assessment
Ankur Khosla, MD, MBA, MS and Davide Cattano, MD, PhD
Objectives
Understand the importance of a methodical and thorough airway assessment.
Identify the key features of a patient history that have implications for a difficult airway with
respect to difficult mask ventilation, difficult laryngoscopy, difficult intubation, difficult supraglottic device placement, and difficulty with invasive techniques for airway management.
Provide an overview of the tools available for airway management with respect to airway
assessment.
Introduction
Maintaining the airway in a controlled fashion is the most critical step in the care of patients during
surgical procedures. For many years, difficulty with airway management has been the leading cause
of morbidity and mortality in the perioperative period and it maintains an important role when
planning anesthetic care. The incidence of difficult mask ventilation or difficult intubation in surgical patients has been reported to be as high as 10%. Therefore, careful assessment and planning
are critical to successful airway management. It is important that anesthesiologists become familiar
with the anatomy of the airway, patient variables that affect that anatomy, and the tools available
to help the anesthesiologist secure the airway.
A difficult airway can become apparent and problematic in four different areas of airway management. Starting from the onset of general anesthesia, there is the possibility of difficult mask
ventilation, followed by a difficult laryngeal view during laryngoscopy and difficult intubation. In
addition, if all attempts at intubation fail, then there may be difficulty with establishment of an
invasive airway.
A relatively unexplored area is that of difficult supraglottic device placement or difficult ventilation with a supraglottic device. Because their use could be primary, or secondary as a rescue
device, familiarity with the use of supraglottic airway devices in both routine and emergent airway
management is fundamental.
1 Airway Assessment
History and Physical

Emergent anesthetic inductions and intubations occur significantly less frequently than elective inductions and intubations. If time allows, conducting a formal assessment of the patient
can prove to be invaluable, as it allows for appropriate planning. A thorough history includes
current medications, allergies, last oral intake, evaluation of comorbid conditions, and prior
difficult airway management. Approaching the evaluation by organ systems helps to keep
management strategies organized and also helps in documentation for communication with
other health-care providers. For example, neurological status is an important indicator, as
an obtunded patient may not allow an in-depth airway evaluation, and protecting the airway
becomes a necessity. Confounding variables, such as prior surgeries or advanced pathology,
may affect clinical management, as in the case of cervical vertebral fusion, severe trauma,
or advanced carcinoma involving the oropharynx. Assessing the potential effects of positive pressure ventilation on each patients cardiorespiratory status is key; for example, a tiny
pneumothorax could quickly develop into a tension pneumothorax requiring invasive decompressive maneuvers. Careful consideration to these details will allow better preparation for
difficulties, if they should arise.
A difficult airway algorithm can be utilized in emergent or urgent airway management in patients
with a threatened airway, in which obstruction is imminent. The clinical assessment is pivotal in
defining a threatened airway and in the determination of possible airway collapse. Knowledge of
the anatomic and physiologic changes that occur in both normal and diseased states is critical in
the evaluation of a threatened airway. A systematic approach should assess the cause of airway
collapse, including, but not limited to, infectious, neoplastic, iatrogenic, traumatic, and neuropsychiatric etiologies, and their effects on oxygenation and ventilation.
Difficult Mask Ventilation

Although controversial among anesthesiologists, the authors feel that it is pivotal that the ability to
ventilate be assessed prior to administration of paralytics or opioids during anesthetic induction.
Difficult mask ventilation occurs when it is impossible to breathe for a patient using an airtight
facemask, as a result of inherent anatomic obstruction or traumatic injury. The presence of excessive facial hair, a lack of dentition, or the presence of facial deformities (as seen in various genetic
disorders) may prevent an airtight seal. Redundant oropharyngeal tissue may impede airflow.
Several factors have been identified as independent predictors of difficult mask ventilation and
can be summed up with the mnemonic FACESFacial hair, Age greater than 55 years, Chubby
(BMI > 26 kg/m2), Edentulous, Snoring history. A large neck circumference (male > 45 cm, female
> 40 cm) indicates the risk for sleep apnea, airway obstruction, difficult mask ventilation, and/
or difficult laryngoscopy. In obese patients, the distribution of fat (apple- vs. pear-shaped) is also
important.
Mask ventilation can be facilitated with the use of nasal trumpets or oral airways in most
causes of difficult ventilation. Because facial hair impedes a tight mask seal, options include shaving the patient or the application of occlusive dressings (e.g., Tegaderm) over the beard. The
importance of correct hand positioning, patient positioning in the sniffing position (Figs. 1.1
and 1.2), and proper jaw thrust are paramount. If these steps are unsuccessful, however, one
must consider employing a supraglottic airway device such as a laryngeal mask airway (LMA) or
a Combitube.
3
Predictors of Difcult Mask Ventilation (FACES):
Facial hair
Age > 55 years
Chubby (BMI > 26 kg/m2)
Edentulous
Snoring history
Figure 1.1 The sniffing positionflexion of the cervical spine at C6-C7 with extension at C1-C2.
Figure 1.2 A patient in whom difficult laryngoscopy could be expected. Reduced neck mobility, a Mallampati 3 airway, and a reduced laryngeal profile. The line drawings illustrate poor alignment of the oral and laryngeal axes.
Difficult Intubation
A difficult laryngoscopy (inability to obtain adequate exposure and view of the glottic opening
with conventional laryngoscopic tools) is one of the most common reasons for difficult intubation (tracheal intubation requiring multiple attempts with or without tracheal pathology). Other
factors include anatomic variants secondary to pathology or trauma that may prohibit adequate
1 Airway Assessment
Tip
1 Airway Assessment
Figure 1.3 A patient with progressive degenerative torticollis.
mouth opening, neck extension, or maneuvering of the endotracheal tube (ETT) to the glottic
opening (Fig. 1.3). Finally, the skill level of the practitioner is another variable in the determination
of difficult intubation. An unskilled practitioner is likely to experience more difficulties than an
experienced practitioner.
Several tools have been employed to evaluate the potential for a difficult airway by assessing the
patients anatomy. However, the sensitivity and specificity of these pretests do not always provide
much utility. Specifically, a pretest indicating a difficult intubation may not always correlate with
a difficult intubation. The converse also holds true: A pretest indicating an easy intubation does
not necessarily mean that the intubation will be easy. Nonetheless, the following are some of the
predictors that are more commonly used.
Tip
Pretest indicators of a difficult intubation or an easy intubation are neither 100% sensitive
nor specific and may not always be accurate.
The most obvious and reliable predictor of a difficult airway is a history of prior difficult
intubation. A large body habitus with morbid obesity is a risk factor for difficult intubation. The
most commonly used pretest scoring system (Mallampati Classification) evaluates the mouth
opening and exposure of the patients soft palate, faucial pillars, uvula, and posterior pharynx
(Fig. 1.4A1.4D). This evaluation is performed while the patient is seated upright looking directly
at the clinician. A Grade III or IV Mallampati Classification is associated with greater difficulty with
glottic exposure during laryngoscopy.
Neck extension is crucial when placing the patient in a sniffing position prior to anesthetic induction. Limited neck range of motion may indicate the possibility of a difficult laryngoscopy resulting
5
(B)
1 Airway Assessment
(A)
(D)
(C)
Figure 1.4 AD Mallampati Airway Classification Scores. From left to right(A) Class I: Full visibility of the tonsils,
uvula, and soft palate. (B) Class II: Visibility of the hard and soft palate and the upper portions of the tonsils and uvula.
(C) Class III: The soft and hard palate and base of the uvula are visible. (D) Class IV: Only the hard palate is visible.
from suboptimal positioning. Verifying that a patient can bite their top lip with their lower teeth
gives feedback regarding the ability to subluxate and overall mobility of the mandible. A thyromental distance (the distance from the superior portion of the thyroid cartilage to the anterior portion
of the mandible) of less than four fingerbreadths may correlate with an anterior or high glottis
making the laryngoscopic view difficult. A thick neck (neck circumference > 45 cm) is associated
with a short neck and poor cervical extension and has been correlated with a significant risk of
failed direct laryngoscopy.
With regards to describing the view of the glottis achieved during laryngoscopy, the most
commonly used scoring system is that described by Cormack and Lehane. Recording the view is
1 Airway Assessment
(A)
Laryngoscope
(B)
Epiglottis
(C)
(D)
Figure 1.5 AD Cormack-Lehane Score for direct laryngoscopy. (A) Grade 1 (Full view of the vocal cords),
(B) Grade 2 (Partial view of the vocal cords), (C) Grade 3 (Only epiglottis visible), and (D) Grade 4 (Neither the
epiglottis nor glottis visualized).
(From Cormack RS, Lehane J. Difficult tracheal intubation in obstetrics. Anaesthesia 1984;39:11051111; with permission.)
important as a way of communication to other practitioners in future situations that require airway management. The grades range from I to IV, starting at grade I (the best view), where there is
a complete view of the epiglottis and vocal cords, and culminating with grade IV (the most difficult
view), in which there is no visualization of the epiglottis or larynx. (Figs. 1.5A1.5D) A modified
classification scheme with five different grades based on the Cormack-Lehane scoring system was
described by Yentis. Cook has described a further modification with six grades that takes into
account difficulty of intubation.
Difficult Cricothyrotomy
When the situation arises where one cannot ventilate by facemask or LMA and intubation is not
possible, a surgical airway may need to be placed via the cricothyroid membrane (see Chapter 12).
It is rare that this anatomic point has poor exposure. Reasons for suboptimal access include morbid obesity, neck immobility, or trauma to the area. Neck assessment of the patients to identify
this critical landmark is rarely performed pre-operatively. In situations when difficult mask ventilation or difficult laryngoscopy is anticipated, it is advisable to identify the thyroid notch, cricothyroid membrane, and cricoid cartilage prior to induction. Recently, percutaneous tracheostomy
has been increasingly used rather than percutaneous needle or open cricothyrotomy. The use of
ultrasound has also been increasingly advocated as an alternative or as part of a combined assessment of external neck landmarks.
7
Tip
Supraglottic Devices
Standardized recommendations for the markers to be used for assessing proper size, proper
device, depth of insertion, and anticipation of difficulty with placement of supraglottic devices
do not currently exist. The authors (D. Cattano) have proposed the use of different external
landmarks (thyroid width, length, hyoid to cricoid distance, thyroid to cricoid distance, occipital
notch to C7 tubercle), in addition to a focused history to assess the appropriate size and type of
supraglottic device.
Tools for Success

A thorough history and plan for airway management is invaluable. Experience with various airway
management techniques is important for the development of an appropriate airway management
plan, as the experienced practitioner has insight as to which technique is most applicable to each
situation and is well-skilled at the use of various airway tools.
Positioning the patient for ease of ventilation and maximum exposure of the glottis during laryngoscopy is very useful. The sniffing position involves flexing the cervical spine at C6-C7 with extension at C1-C2 (see Chapter 15). Access to supraglottic ventilation devices (e.g., LMA, Combitube,
or King-LT) and familiarity with their function can be pivotal when mask ventilation becomes difficult. When faced with a difficult intubation secondary to a poor view of the glottis during direct
laryngoscopy, changing the size or type of blade may improve the view. Video laryngoscopes
(e.g., the Storz C-MAC, GlideScope, or McGrath) are also useful in the setting of failed direct
laryngoscopy or when the initial airway assessment portends a difficult direct laryngoscopy (see
Chapter 6). Other techniques include intubating stylets (e.g., a gum-elastic bougie), which can act
as a rigid guide over which an ETT is passed (see Chapter 7). Occasionally, these measures may
not be enough to secure the airway. Ultimately, having well-established back-up plans if the original approach fails is what saves the patienthence, the importance of the pre-operative airway
assessment and planning.
Summary
Approaching the management of a patients airway in a controlled or emergent situation cannot be a one-size-fits-all method. A methodical and thorough evaluation of the airway, along
with an appreciation of potentially complicating variables, will guide the plan to successful airway
management. If the first approach to airway management fails, then swift progression through a
pre-devised algorithm is critical for the patients safety. Thus, knowledge and familiarity with the
various tools available for ventilation and intubation are essential.
Suggested Reading
Williamson D, Nolan J. Airway Assessment. In: Benger J, Nolan J, Clancy M, eds. Emergency
Airway Management. London: Cambridge University Press; 2009:1926.
Kheterpal S, Han R, Tremper KK, Shanks A, Tait AR, OReilly M, et al. Incidence and predictors
of difficult and impossible mask ventilation. Anesthesiology 2006;105(5):885891.
1 Airway Assessment
Prior to induction, if there is the expectation of a difficult airway, locate the cricothyroid
membrane and denote the location on the skin with a marker.
1 Airway Assessment
Cattano D, Cavallone L. Airway Management and Patient Positioning: A Clinical Perspective.

Anesthesiology News 2011;37(8):1723.
Shiga T, Wajima Z, Inoue T, Sakamoto A. Predicting difficult intubation in apparently
normal patients: a meta-analysis of bedside screening test performance. Anesthesiology
2005;103(2):429437.
Koh LK, Kong CE, Ip-Yam PC. The modified Cormack-Lehane score for the grading of direct
laryngoscopy: evaluation in the Asian population. Anaesth Intensive Care 2002;30(1):4851.
Chapter 2
Preparation for Awake

Intubation
Objectives
Explain the indications and rationale for awake intubation.
Discuss premedicants and sedatives that are useful for preparation of a patient for awake
intubation.
List the various methods for topicalization of the airway with local anesthetics.
Describe the most common airway nerve blocks and their use in awake intubation.
Introduction
The ASA Task Force for Management of the Difficult Airway defines the difficult airway as a clinical situation in which a conventionally trained anesthesiologist experiences difficulty with mask
ventilation, difficulty with endotracheal intubation, or both. In a patient with a known or suspected difficult airway, awake intubation is generally regarded as the safest method for securing
the airway because of the following:
Patency of the airway is maintained through upper pharyngeal muscle tone.
Spontaneous ventilation is maintained.
The awake patient is easier to intubate, as the larynx moves to a more anterior position after
induction of anesthesia.
The patient can still protect his or her airway from aspiration.
The patient is able to monitor his or her own neurological symptoms (e.g., the patient with
potential cervical pathology).
Other indications for awake intubation include severe aspiration risk, facial or airway trauma,
severe hemodynamic instability, and unstable cervical spine pathology. A more comprehensive list
can be found in Table 2.1.
Once the decision to perform awake intubation is made, communication with the patient and
psychological preparation is of the utmost importance to maximize the odds for a successful
2 Preparation for Awake Intubation
10
Table 2.1 Indications for Awake Intubation

1. History of difficult intubation
2. Anticipated difficult airway based on physical examination:
Small mouth opening
Receding mandible/micrognathia
Macroglossia
Short, muscular neck
Limited range of motion of the neck (rheumatoid arthritis, ankylosing spondylitis, prior
cervical fusion)
Congenital airway anomalies
Morbid obesity
Pathology involving the airway (tracheomalacia)
Airway masses (malignancy of the tongue, tonsils, or larynx; large goiter; mediastinal mass)
Upper airway obstruction
3. Unstable cervical spine
4. Trauma to the face or upper airway
5. Anticipated difficult mask ventilation
6. Severe risk of aspiration
7. Severe hemodynamic instability
8. Respiratory failure
awake intubation. The practitioner should explain the specific indications for awake intubation,
as well as potential complications, including local anesthetic toxicity, airway trauma, discomfort,
recall, and failure to secure the airway. Operating room set-up should include routine monitors (electrocardiogram, noninvasive blood pressure, pulse oximetry, and capnography). Standard
emergency medications should be available, including an appropriate IV induction agent and paralyzing agent. The equipment needed for the chosen intubation technique as well as supplemental
airway equipment as delineated by the ASA Task Force should also be readily available. This
includes a range of laryngoscope blade styles and sizes, tracheal tubes of assorted sizes, tracheal
tube guides (e.g., stylets and bougies), laryngeal mask airways of various sizes, flexible pediatric
bronchoscope, retrograde intubation equipment, and equipment suitable for emergency invasive
and noninvasive airway. It is recommended that a qualified assistant be present who can help with
airway management, should the need arise.
Premedication
Prior to awake airway management, certain premedicants may be useful and should be considered. Antisialagogues can be used to dry airway secretions, facilitating indirect or fiberoptic laryngoscopy and increasing the effectiveness of airway topicalization. Nasal mucosal vasoconstrictors
should be utilized if a nasotracheal intubation is planned. In the patient at high risk for aspiration,
prophylactic medications should be administered.
Antisialagogues
One of the most important goals of premedication for awake intubation is drying of the airway.
Secretions can obscure the view of the glottis, especially when using flexible fiberoptic bronchoscopy. In addition, secretions can prevent local anesthetics from reaching intended areas, resulting
in failed sensory blockade, or can wash away and dilute local anesthetics, diminishing their potency
and duration of action. The medications most often used for their antisialagogic properties are
Table 2.2 Dosing

Intravenous (IV)
Intramuscular (IM)
Dose
Onset
Duration
of action
Dose
Onset
Duration
of action
Glycopyrrolate
Adult:
0.10.3 mg IV
Pedi:
48 g/kg IV
12
minutes
24
hours
Adult:
0.10.3 mg IV
Pedi:
48 g/kg IV
2030
minutes
68
hours
Scopolamine
Adult:
0.4 mg IV
Pedi:
6 g/kg IV
510
minutes
12
hours
Adult:
0.4 mg IV
Pedi:
6 g/kg IV
3060
minutes
46
hours
Atropine
Adult:
0.40.6 mg IV
Pedi:
10 g/kg IV
1
minute
1530
minutes
Adult:
0.40.6 mg IV
Pedi:
10 g/kg IV
1520
minutes
24
hours
Table 2.3 Pharmacologic Characteristics

Tachycardia
Antisialagogue effect
Sedation/Amnesia
Glycopyrrolate
++
+++
Scopolamine
+++
+++
+++
++
Atropine
0, no effect; +, minimal effect; ++, moderate effect; +++, marked effect

(Adapted from Morgan GE Jr., Mikhail MS, Murray MJ. Clinical Anesthesiology, 3rd edition.
New York: McGraw-Hill; 2002:208.)
Tips
Because of its pharmacologic profile, glycopyrrolate is the drug of choice in most clinical circumstances. If tachycardia is contraindicated (e.g., in patients with coronary artery
disease or severe aortic or mitral stenosis), then scopolamine should be considered, as it
is the least vagolytic.
Administer anticholinergics as early as possible for maximal effect (at least 30 minutes in
advance), as they do not eliminate existing secretions but, rather, prevent new secretion
formation.
If there is not enough time to administer an anticholinergic and for it to take effect, then
consider using a 4 4 gauze to dry the tongue.
11
the anticholinergics. These drugs inhibit salivary and bronchial secretions by way of their antimuscarinic effects. The anticholinergics used in clinical practice are glycopyrrolate, scopolamine, and
atropine. These agents should be administered at least 30 minutes in advance of the planned procedure. See Tables 2.2 and 2.3 for dosing and pharmacologic characteristics of anticholinergics.
12
Nasal Mucosal Vasoconstrictors

The nasal mucosa and nasopharynx are highly vascular. When a patient requires nasotracheal
intubation, adequate vasoconstriction is essential, as bleeding can make visualization of the larynx
extremely difficult. This is especially a concern during nasal fiberoptic intubation. Nasal mucosal
vasoconstrictors should be applied 15 minutes prior to nasal intubation. Several agents are
available.
Cocaine 4% can be applied using cotton-tipped applicators. Maximum dose is 1.5 mg/kg to 3 mg/
kg. A benefit of cocaine is that it has both vasoconstrictive and local anesthetic effects. Caution
in patients with hypertension, coronary artery disease, hyperthyroidism, pseudocholinesterase
deficiency, preeclampsia, and in patients taking MAOIs.
A mixture of lidocaine 3%/phenylephrine 0.25% can be made by combining lidocaine 4% and
phenylephrine 1% in a 3:1 ratio. This combination has similar anesthetic and vasoconstrictive
properties as cocaine and can be used as a substitute. The mixture can be sprayed intranasally
or applied with cotton-tipped applicators if viscous lidocaine is used.
Commercially available nasal decongestants containing either oxymetazoline 0.05% (Afrin) or
phenylephrine 0.5% (Neo-Synephrine) may also be applied to nasal mucosa. The usual dose is
two sprays in each nostril. Pediatric patients are especially sensitive to these drugs and require
lower concentrations.
Aspiration Prophylaxis
Routine prophylaxis against aspiration pneumonitis is no longer routinely recommended but may
be beneficial in patients at high risk for aspiration (see Indications). The goal of aspiration prophylaxis is twofold: to decrease gastric volume and to decrease gastric fluid pH. Commonly used
agents include non-particulate antacids (e.g., Bicitra), pro-motility agents (e.g., metoclopramide),
and H2-receptor antagonists. These drugs may be used alone or in combination. See Table 2.4.
Indications:
Pre-operative fasting guidelines not met (i.e., full stomach)
Symptomatic gastroesophageal reflux disease
Hiatal hernia
Morbid obesity
Diabetic gastroparesis
Pregnancy
Presence of a nasogastric tube
Table 2.4 Drugs used for aspiration prophylaxis

Route Adult dose Pedi dose
Onset
PO
Effect on
Effect on
gastric volume Gastric pH
1530 mL
0.4 mL/kg
5 min
Metoclopramide IV
10 mg
0.15 mg/kg
13 min
H2-Antagonists
Cimetidine
Ranitidine
Famotidine
300 mg
50 mg
20 mg
510 mg/kg 4560 min

0.251 mg/kg 3060 min
60120 min
0.15 mg/kg
Bicitra
IV
IV
IV
Depending on the clinical circumstance, intravenous sedation may be useful in allowing the patient
to tolerate awake intubation by providing anxiolysis, amnesia, and analgesia. Benzodiazepines, opioids, hypnotics, 2 agonists, and neuroleptics can be used alone or in combination. It is important
that these agents be carefully titrated to effect, as oversedation can render a patient uncooperative and make awake intubation more difficult. Spontaneous respiration with adequate oxygenation and ventilation should always be maintained. Care should be taken in situations with critical
airway obstruction, as awake muscle tone is sometimes necessary in these patients to maintain
airway patency. Avoidance of oversedation is also important in the patient with a full stomach, as
an awake patient can protect his or her own airway in the chance of regurgitation.
Benzodiazepines
Benzodiazepines are frequently used to achieve sedation for awake intubation in combination
with opioids or are used for their amnestic and anxiolytic effects when other sedatives (e.g.,
dexmedetomidine, ketamine, or remifentanil) are chosen as the primary agent. Three benzodiazepine receptor agonists are commonly used in anesthesia practice: midazolam, diazepam, and
lorazepam. Because of its more rapid onset and relatively short duration, midazolam is the more
commonly used agent. See Tables 2.5 and 2.6 for dosing and pharmacology.
Systemic Effects:
CNS: amnesia, sedation/hypnosis, anti-convulsive
CV: mild decrease in systemic vascular resistance and reduction in cardiac output
Respiratory: mild decrease in respiratory rate and tidal volume; effects augmented with
co-administration of opioids
Reversal:
Flumazenil 0.2 mg IV, repeated as needed to a maximum dose of 1 mg
Half-life of 0.7 hours to 1.8 hours; monitor for resedation
Table 2.5 Benzodiazepine Dosing

IV
IM
PO
Midazolam
12 mg, repeat prn

(0.0250.1 mg/kg)
0.070.2 mg/kg
0.250.5 mg/kg
Diazepam
24 mg, repeat prn

(0.050.2 mg/kg)
0.050.2 mg/kg
0.20.5 mg/kg
Table 2.6 Benzodiazepine Pharmacology

Relative potency
Time to peak onset
Duration
Midazolam
IV: 23 minutes
IM: 1530 minutes
PO: 2030 minutes
IV: 2030 minutes

IM: 2 hours
Diazepam
IV: 35 minutes
IM: 3045 minutes
PO: 6090 minutes
IV: 2030 minutes
13
Sedation
14
Opioids
Opioids, by way of their agonist effect on opioid receptors in the brain and spinal cord, provide
analgesia, depress airway reflexes, and prevent hyperventilation associated with pain or anxiety.
These properties make them a useful addition to the sedating regimen for awake intubation.
Although any opioid receptor agonist could theoretically be used for this purpose, the synthetic phenylpiperidine class of opioidsfentanyl, sufentanil, alfentanil, and remifentanilare
best-suited to the task. These drugs are particularly useful because of their rapid onset, relatively
short duration of action, and ease of titration.
Systemic Effects:
CNS: analgesia, pruritus, muscle rigidity; augmentation of sedative effects of other intravenous
agents
CV: bradycardia; little effect on myocardial contractility or afterload
Respiratory: respiratory depression characterized by increased tidal volume and decreased
respiratory rate with an overall decrease in minute ventilation; apnea with higher doses
Dosing and Pharmacology:
Fentanyl
Sedative dose: 25g to 200 g IV (0.52 g/kg)
Rapid onset within 2 to 3 minutes
Duration of a single bolus dose is roughly 30 minutes to 1 hour
Most commonly used opioid for awake intubation; usually used in combination with other
agents (e.g., midazolam, propofol)
Sufentanil
Sedative dose: 5g to 20 g IV (0.050.2 g/kg)
Is 7 to 10 times more potent than fentanyl; has a similar pharmacokinetic profile after a single
bolus dose
Alfentanil
Sedative dose: 500g to 1500 g IV (1030 g/kg)
Very rapid onset within 1.5 to 2 minutes
Rapid recovery; duration of a single bolus dose is 10 to 15 minutes
Remifentanil
Sedative dose: Bolus 0.5 g/kg IV followed by an infusion of 0.1 g/kg/min
Infusion can subsequently be titrated by 0.025 g/kg/min to 0.05 g/kg/min in 5 minutes intervals
to achieve adequate sedation
Ultrashort-acting opioid; half-life of 3 minutes
May be used as a single agent or in combination with other agents (e.g., midazolam, propofol)
Reversal:
Naloxone 0.04 mg to 0.08 mg IV, repeated every 3 minutes until restoration of spontaneous
ventilation
Onset within 1 to 2 minutes; duration of 30 to 60 minutes
Propofol
Propofol is the most frequently used intravenous anesthetic today. Its primary effect is hypnosis
as a result of an unclear mechanism; however, there is evidence that a significant portion of this
Systemic Effects:
CNS: sedation/hypnosis, antiemesis, euphoria, anti-convulsive
CV: decrease in arterial blood pressure (decreases in SV, CO, and SVR)
Respiratory: decrease in tidal volume, increase in respiratory rate; decreased respiratory responsiveness to CO2; bronchodilation
Sedative dose: Intermittent doses of about 0.25 mg/kg IV or a continuous IV infusion of
25 g/kg/min to 75 g/kg/min titrated to effect
Onset of approximately 90 seconds
Recovery of 4 minutes to 5 minutes after an induction dose; more rapid with sedative doses
Dexmedetomidine
Dexmedetomidine is a centrally acting, highly selective 2 adrenoreceptor agonist with sedative,
analgesic, anxiolytic, antitussive, and antisialagogue properties that make it well suited for use in
awake intubation. It causes minimal respiratory impairment, even at high doses. There are several
reports of dexmedetomidine sedation for awake fiberoptic intubation, including a Phase IIIb FDA
study specifically for this indication.
Systemic Effects:
CNS: sedation/hypnosis, analgesia,
CV: small reduction in minute ventilation with preservation of carbon dioxide responsiveness
Respiratory: bradycardia, decreased systemic vascular resistance, cardiac output, contractility, and arterial blood pressure; hypertension during initial loading dose resulting from direct
vasoconstrictive effect
Dose: Bolus 1 g/kg over 10 minutes, followed by a continuous infusion of 0.2 g/kg/hr to
0.7 g/kg/hr (some patients may require higher maintenance doses)
Onset of effect in approximately 15 minutes
Half-life of 2 hours to 3 hours
Consider pretreatment with midazolam to decrease incidence of recall.
Prevent bradycardia with administration of an anticholinergic.
Reduce doses in the elderly, patients with hepatic or renal impairment, or in patients with
depressed systolic function.
Ketamine
Ketamine is an NMDA antagonist that produces dissociative anesthesia, which manifests clinically
as a cataleptic state with eyes open and many reflexes intact, including the corneal, cough, and
swallow reflexes. Its use in awake intubation has been described in combination with benzodiazepines and dexmedetomidine.
Systemic Effects:
CNS: sedation/hypnosis, dissociative anesthesia, hallucinations; increase in cerebral blood flow
and intracranial pressure
15
hypnotic effect is mediated by interaction with GABA receptors. The use of propofol in awake
intubation is well described both as a single agent and in combination with remifentanil.
16
CV: increased arterial blood pressure, heart rate, and cardiac output secondary to inhibition of
norepinephrine reuptake; direct myocardial depression that may be unmasked in catecholaminedepleted states
Respiratory: no respiratory depression; bronchodilation; increased salivation
Sedative dose: 0.2 mg/kg to 0.8 mg/kg IV
Onset within 1 to 2 minutes; duration of hypnosis of 5 to 10 minutes
Pretreatment with an antisialagogue is imperative
Consider administration of a benzodiazepine to attenuate undesirable psychological effects.
Droperidol
Droperidol is a neuroleptic medication occasionally used in anesthesia practice for its sedative
and anti-emetic properties. Its mechanism of action is antagonism of dopamine receptors in the
central nervous system. In combination with fentanyl, it produces a state of hypnosis, analgesia,
and immobility classically referred to as neuroleptanalgesia. Neuroleptanalgesia can be used for
awake intubation with favorable results.
Systemic Effects:
CNS: sedation, cataleptic immobility; no anxiolysis; extrapyramidal symptoms
CV: QT prolongation, mild vasodilation, and reduction in arterial blood pressure
Respiratory: no significant effect
Sedative dose: 2.5 mg to 5 mg IV
Onset in 15 to 20 minutes; half-life of approximately 2 hours
Should be administered with a benzodiazepine for amnesia and anxiolysis
Contraindicated in patients with QT prolongation (>440 msec for males, >450 msec for
females)
ECG should be performed during and for 2 hours to 3 hours after treatment
Tips
Combining different classes of sedative medications allows for lower doses, quicker recovery,
and a lower incidence of recall. Some well-studied combinations include:
Midazolam and fentanyl
Propofol and remifentanil
Propofol, fentanyl, and midazolam
Dexmedetomidine and midazolam
Droperidol, fentanyl, and midazolam
Airway Anesthesia
Numbing of the airway with local anesthetics should, in most cases, be the primary anesthetic for
awake intubation. Topicalization is often sufficient; if supplemental anesthesia is required, then a
variety of nerve blocks may be utilized. These techniques may be used in many different combinations as long as the maximum dosage of local anesthetic is not exceeded.
Concentration
Speed of onset
Duration
Maximum dosage
Lidocaine
2%4% for topicalization;

1%2% for local
infiltration and
nerve blocks
25 minutes
3060 minutes
8 mg/kg for airway

topicalization
(5 mg/kg for local
infiltration w/o
epinephrine)
Cocaine
4% solution
3 minutes
3060 minutes
1.5 mg/kg
Benzocaine
20% spray
1 minute
3060 minutes
100 mg
Tetracaine
0.5%1% solution
3 minutes
3060 minutes
100 mg
Local Anesthetics
When using local anesthetics, it is important to be familiar with the speed of onset, duration
of action, optimal concentration, signs and symptoms of toxicity, and the maximum recommended dosage of the drug chosen. The rate and amount of topical local anesthetic absorption
vary depending on the site of application, the concentration and total dose of local anesthetic
applied, the hemodynamic status of the patient, and individual patient variation. Local anesthetic
absorption is more rapid from the alveoli than from the tracheobronchial tree, where it is more
rapid than from the pharynx. Lidocaine and cocaine are the most commonly used agents for topical anesthesia of the airway. See Table 2.7.
Signs of Local Anesthetic Toxicity:
Early symptoms: euphoria, dizziness, tinnitus, confusion, perioral numbness, metallic taste
Severe toxicity: seizures, respiratory failure, loss of consciousness, circulatory collapse
Special Considerations:
Cocaine: caution in patients with hypertension, coronary artery disease, hyperthyroidism, pseudocholinesterase deficiency, preeclampsia, and in patients taking monoamine oxidase inhibitors
Benzocaine: risk of methemoglobinemia (early symptoms of cyanosis, tachycardia, and tachypnea
leading to stupor, coma, and death) treatment with methylene blue 1 mg/kg to 2 mg/kg IV
Topicalization Techniques
Atomizers:
A standard DeVilbiss Atomizer with the bulb removed. The atomizer reservoir is filled with 2%
to 4% lidocaine. Oxygen tubing is connected from the atomizer to an oxygen cylinder with a flow
rate of 8 L/min to 10 L/min. A bleed hole is cut in the oxygen tubing, allowing for intermittent
application of the local anesthetic when a thumb is placed over the hole in the tubing.
Disposable plastic atomizer (Fig. 2.1). This device is attached to an oxygen tank with a flow rate
of 8 L/min to 10 L/min and the phalange is depressed to deliver the local anesthetic solution to
the oropharyngeal mucosa.
MADjic Mucosal Atomization Device (Wolfe Tory Medical, Salt Lake City, UT) is an inexpensive, disposable, latex-free device that, when attached to a Luer fitted syringe containing local
anesthetic, can be used to dispense a fine mist to the oropharyngeal or nasal mucosa (Fig. 2.2).
The tubing is malleable, allowing for delivery of local anesthetic to deeper pharyngeal structures
and the glottis.
17
Table 2.7 Commonly Used Local Anesthetics
18
Figure 2.1 Typical disposable atomizer.

From Hagberg CA, ed., Benumofs Airway Management, 3rd ed., St Louis: Mosby; 2012.
Figure 2.2 MADjic Mucosal Atomization Device (Wolfe Tory Medical, Salt Lake City, UT).
From Hagberg CA, ed. Benumofs Airway Management, 3rd ed., St Louis: Mosby; 2012.
Tip
Using the MADjic atomizer with a syringe instead of a standard DeVilbiss atomizer allows
for a known amount of local anesthetic to be administered. This helps to ensure that the
maximum dose is not exceeded.
Nebulizers:
A standard mouthpiece-type nebulizer (Fig. 2.3) can be used to topicalize the oropharynx and
trachea. Oxygen flow rates of 5 L/min to 8 L/min should be used to ensure that the nebulized
particle size is large enough to adequately anesthetize the upper airway.
19
Figure 2.3 Typical mouthpiece-type nebulizer.

A facemask-type nebulizer (Fig. 2.4) can be used if nasal cavity anesthesia is needed; the patient
is instructed to breathe in through the nose.
Because the patient does not cough or gag, this approach is especially advantageous in patients
with increased intracranial pressure, open eye injury, and severe coronary artery disease.
A typical dose of lidocaine used in a standard nebulizer is 4 mL of 4% lidocaine. This results in
a total dose of 160 mg of lidocaine, which is well within the safe dosage range. To aid in nasal
vasoconstriction, 1 mL of 1% phenylephrine may be added to the 4% lidocaine.
Tip
Administer nebulized lidocaine prior to other airway anesthetics (e.g., atomization, intraoral, or intranasal nerve blocks) to minimize coughing, gagging, and patient discomfort.
Direct Application:
Lidocaine lollipop: Lidocaine 5% ointment or viscous lidocaine 2% to 4% is placed on the end
of a tongue depressor and placed lidocaine-side-down onto the posterior tongue. The patient
is encouraged not to swallow but, rather, allow the lidocaine to melt and run down the base
of the tongue and pool above the glottis, where it is then aspirated.
The toothpaste method is a similar concept and involves placing a line of lidocaine 5% ointment down the middle of the tongue. The patient is instructed to place the tongue against the
roof of the mouth and is encouraged not to swallow.
Gargle and spit: The patient is administered 15 mL of viscous lidocaine 2% to 4% and instructed
to gargle the preparation for at least 15 seconds before spitting it out. Allow 4 minutes to 6
minutes for adequate anesthesia to set in.
Nasal anesthesia can be achieved by placing cotton pledgets or cotton-tipped swabs soaked in
cocaine 4%, lidocaine 4% with epinephrine 1:200,000, or a 3:1 mixture of lidocaine 4% and
phenylephrine 1% in the nares. A similar preparation using viscous 4% lidocaine can be applied
using a syringe attached to a 14-g angiocatheter.
20
Figure 2.4 Typical facemask-type nebulizer.

The spray-as-you-go technique involves injecting local anesthetics through the suction port
of a fiberoptic bronchoscope (FOB). One method requires attaching a triple stopcock to the
proximal portion of the suction port to connect oxygen tubing from a regulated oxygen tank set
to flow at 2 L/min to 4 L/min. Under direct vision through the bronchoscope, targeted areas are
sprayed with aliquots of 0.2 mL to 1.0 mL of 2% to 4% lidocaine. The physician then waits 30 seconds to 60 seconds before advancing to deeper structures and repeating the maneuver. The flow
of oxygen allows higher FiO2 delivery, keeps the FOB lens clean, disperses mucous secretions
away from the lens, and aids in nebulizing the local anesthetic. A second method involves passing
a multi-orifice epidural catheter (internal diameter of 0.51.0 mm) through the suction port of an
adult FOB and intermittently administering aliquots of 0.2 mL to 1.0 mL of 2% to 4% lidocaine.
Tip
The spray-as-you-go technique is especially useful in patients who are at risk for aspirating
gastric contents because the topical anesthetic is applied only seconds before the intubation is
accomplished and allows the patient to maintain his or her airway reexes as long as possible.
Because of the multitude of nerves innervating the airway, there is no single anatomic site where
a physician can perform a nerve block and anesthetize the entire airway. Although topicalization
of the mucosa serves, in the majority of patients, to anesthetize the entire airway adequately,
some patients require supplementation to ablate sensation in the nerve endings running deep to
the mucosal surface, such as the periosteal nerve endings of the nasal turbinates and the stretch
receptors at the base of the tongue, which are involved in the gag reflex.
Sphenopalatine Nerve Block (Fig. 2.5A):
This block provides anesthesia of the nasal cavity, as well as the roof of the mouth, soft palate,
and tonsils.
Equipment: Long cotton-tipped applicators or cotton pledgets soaked in either 4% cocaine or
4% lidocaine with epinephrine 1:200,000; bayonet forceps (if using pledgets)
Technique: Apply the cotton-tipped applicator along the upper border of the middle turbinate
at approximately a 45 angle to the hard palate and directed posteriorly until the upper posterior wall of the nasopharynx (sphenoid bone) is reached. The sphenopalatine ganglion underlies
the mucosal surface at this point. The applicator is left in place for approximately 5 minutes to
10 minutes.
Alternatively, cotton pledgets soaked in the local anesthetic solution may be used and applied
to the nasal cavity in the same manner using bayonet forceps.
B
Figure 2.5 Left lateral view of the right nasal cavity, showing long cotton-tipped applicators soaked in local
anesthetic. (A) Applicator angled at 45 to the hard palate with cotton swab over mucosal surface overlying
the sphenopalatine ganglion. (B) Applicator placed parallel to the dorsal surface of the nose, blocking anterior
ethmoidal nerve.
(From University of California, Irvine, Department of Anesthesia: D.A. Teaching Aids; Reprinted with permission from Hagberg CA,
ed., Benumofs Airway Management, 2nd ed., St. Louis: Mosby; 2007.)
Tip
Because it provides anesthesia of the roof of the mouth and soft palate, a sphenopalatine
block is useful even when a transoral intubation is planned.
21
Airway Nerve Blocks
22
Anterior Ethmoidal Nerve Block (Fig. 2.5B):

This block provides anesthesia of the anterior portion of the nasal cavity.
Equipment: Long cotton-tipped applicators soaked in either 4% cocaine or 4% lidocaine with
epinephrine 1:200,000
Technique: Insert the cotton-tipped applicator into the nare parallel to the dorsal surface of the
nose until it meets the anterior surface of the cribriform plate. The applicator is held in position
for 5 minutes to 10 minutes.
Glossopharyngeal Nerve Block (Fig. 2.6):
This block primarily targets the lingual branch of the glossopharyngeal nerve (CN IX), providing anesthesia to the posterior third of the tongue and blocking the afferent limb of the gag
reflex. Some blockade of the more proximal branches of CN IX may be achieved, providing
anesthesia of the vallecula, anterior surface of the epiglottis, posterior and lateral walls of the
pharynx, and tonsillar pillars.
Equipment: Tongue blade or Mac 3 laryngoscope; 25 g spinal needle attached to a 5 mL syringe
containing 1% to 2% lidocaine
Positioning: Place the patient in the sitting position and stand facing the patient on the contralateral side of the nerve to be blocked. Instruct the patient to open his/her mouth widely and
protrude the tongue.
Technique: With the non-dominant hand, displace the tongue medially with a tongue blade or a
Mac 3 laryngoscope blade, forming a gutter or trough along the floor of the mouth between the
tongue and the teeth. The gutter ends in a cul-de-sac formed by the base of the palatoglossal
arch (also known as the anterior tonsillar pillar), which is a U- or J-shaped structure starting at
Tongue
Gutter
Figure 2.6 Glossopharyngeal nerve block, anterior approach. Tongue displaced medially forming a gutter (glossogingival groove), which ends distally in a cul-de-sac. A 25 gage spinal needle is placed at the base of the palatoglossal fold.
Tip
Consider a glossopharyngeal nerve block when planning to perform awake direct laryngoscopy, awake videolaryngoscopy, or in patients with a pronounced gag reex.
Superior Laryngeal Nerve Block (Fig. 2.7):
This block provides anesthesia of the hypopharynx and upper glottis, including the vallecula
and the laryngeal surface of the epiglottis.
Equipment: 25 g spinal needle attached to a 5 mL syringe containing 1% to 2% lidocaine
Superior laryngeal nerve

Cornu of hyoid bone
Fat
pad
Cornu of thyroid
B
C
Thyrohyoid
membrane
Figure 2.7 Superior laryngeal nerve block, external approach. (A) using the greater cornu of the hyoid bone
as landmark; (B) using the superior cornu of the thyroid cartilage as landmark; and (C) using the thyroid notch
as landmark.
23
the soft palate and running along the lateral aspect of the pharynx. Insert a 25-g spinal needle
0.25 cm to 0.5 cm deep at the base of the palatoglossal arch, just lateral to the base of the tongue,
and perform an aspiration test. If air is aspirated, the needle has been advanced too deeply (the
tip has advanced all the way through the palatoglossal arch) and should be withdrawn until no
air can be aspirated; if blood is aspirated, then the needle should be redirected more medially.
Inject 2 mL of 1% to 2% lidocaine, and repeat the procedure on the contralateral side.
24
Several different landmarks may be used: the greater cornu of the hyoid, the superior cornu of
the thyroid, and the thyroid notch.
Technique: Identify the greater cornu of the hyoid and walk a 25 g needle off the cornu of the
hyoid bone in an anterior-inferior direction. A slight resistance is felt as the needle is advanced
through the thyrohyoid membrane usually at a depth of 1 cm to 2 cm (23 mm deep to the
hyoid bone). Perform an aspiration test. If air is aspirated, then the needle has passed too deep
and entered the pharynx; the needle should be withdrawn until no air is aspirated. If blood is
aspirated, then the needle has cannulated either the superior laryngeal artery or vein or has
cannulated the carotid artery; the needle should be directed more anteriorly. When satisfactory needle placement is achieved, 2 mL to 3 mL of local anesthetic is injected as the needle is
withdrawn. The block is repeated on the opposite side.
Alternatively, identify the superior cornu of the thyroid and walk a 25 g needle off in an
anterior-superior direction. Perform an aspiration test and inject the total volume of local
anesthetic.
In some patients, the easiest landmark to identify may be the thyroid notch. Palpate the thyroid
notch, and trace the upper border of the thyroid cartilage laterally for approximately 2 cm.
Pierce the thyrohyoid ligament with a 25 g needle just above the thyroid cartilage at this location
and advance the needle in a posterior and cephalad direction to a depth of 1 cm to 2 cm from
the skin. Perform an aspiration test and inject the total volume of local anesthetic.
Transtracheal Anesthesia (Figs. 2.8 and 2.9):
This block primarily provides anesthesia of the trachea. As a result of the coughing elicited by
the block, the local anesthetic injected is nebulized and provides additional anesthesia of the
inferior larynx and vocal cords.
Equipment: Tuberculin syringe or a 25 g needle with lidocaine 1% to 2%; 20 g angiocatheter
attached to a 5 mL syringe containing 3 mL saline; syringe containing 3 mL to 5 mL of lidocaine
2% to 4%.
Hyoid
Thyroid
Thyrohyoid
membrane
Cricothyroid
membrane
midline
injection
Thyroid
gland
isthmus
Trechea
Figure 2.8 Translaryngeal anesthesia, anatomic landmarks.

(From Brown D, ed., Atlas of Regional Anesthesia, 2nd ed., Philadelphia: Saunders; 1999.)
(B)
(C)
(D)
Figure 2.9 Translaryngeal anesthesia (midsagittal view of the head and neck). (A) Angiocatheter inserted at the cricothyroid membrane, aimed caudally. Aspiration test performed to verify position of tip of needle in tracheal lumen.
(B) Needle is removed from angiocatheter. (C) Syringe containing local anesthetic attached. Aspiration test repeated.
(D) Local anesthetic is injected, resulting in coughing and nebulization of the local anesthetic (shaded area).
(From University of California, Irvine, Department of Anesthesia: The Retrograde Cookbook; Reprinted with permission from
Hagberg CA, ed., Benumofs Airway Management, 2nd ed., St. Louis: Mosby; 2007.)
Positioning: Position the patient supine, with the neck in slight extension, if possible. Stand at
the side of the patient with the dominant hand closest to the patient.
Technique: Identify the midline of the cricothyroid membrane as the needle insertion site and
raise a small skin wheal with local anesthetic using a tuberculin syringe or a 25 g needle. Advance
the 20 g angiocatheter with the attached saline-filled syringe through the skin perpendicularly
while aspirating. When air is freely aspirated, advance the sheath of the angiocatheter, remove
the needle, and attach a syringe containing 3 mL to 5 mL of 2% to 4% lidocaine to the catheter
sheath that has been left in place. Confirm the sheath position by aspiration of air, warn the
patient to expect vigorous coughing, and rapidly inject the local anesthetic during inspiration.
The sheath of the angiocatheter may be left in place until the intubation is complete in case
more local anesthetic is needed and to decrease the likelihood of subcutaneous emphysema.
Video 2.1 Transtracheal Anesthesia
Tip
Transtracheal anesthesia is especially useful when time for a neurologic exam after intubation is desired, such as in the patient with an unstable cervical spine and/or severe cervical
stenosis.
25
(A)
26
Suggested Reading
Practice guidelines for management of the difficult airway: an updated report by the
American Society of Anesthesiologists Task Force on Management of the Difficult Airway.
Anesthesiology 2003;98:12691277.
Artime C, Sanchez A. Preparation of the patient for awake intubation. In: Hagberg CA, ed.
Benumofs Airway Management. 3rd ed. Philadelphia: Mosby, 2012:243264.
Walsh M, Shorten G. Preparing to perform an awake fiberoptic intubation. Yale J Biol Med
1998;71:537549.
Atkins JH, Mirza N. Anesthetic considerations and surgical caveats for awake airway surgery.
Anesthesiol Clin 2010;28:555575.
Stoelting RK, Hillier SC. Anticholinergic drugs. In: Pharmacology and Physiology in Anesthetic
Practice. 4th ed. Philadelphia: Lippincott Williams & Wilkins, 2012:266275.
Donlon JV Jr., Doyle DJ, Feldman MA. Anesthesia for eye, ear, nose, and throat surgery.
In: Miller RD, ed. Millers Anesthesia. 6th ed. Philadelphia: Elsevier Churchill Livingstone,
2005:25272556.
White PF, Recart Friere A. Ambulatory outpatient anesthesia. In: Miller RD, ed. Millers
Anesthesia. 6th ed. Philadelphia: Elsevier Churchill Livingstone, 2005:25892636.
Fukuda K. Intravenous opioid anesthetics. In: Miller RD, ed. Millers Anesthesia. 6th ed.
Philadelphia: Elsevier Churchill Livingstone, 2005:379438. In: Miller RD, ed. Millers
Anesthesia. 6th ed. Philadelphia: Elsevier Churchill Livingstone, 2005:317378.
Strichartz GR, Berde CB. Local anesthetics. In: Miller RD, ed. Millers Anesthesia. 6th ed.
Philadelphia: Elsevier Churchill Livingstone, 2005:573604.
Simmons ST, Schleich AR. Airway regional anesthesia for awake fiberoptic intubation. Reg Anesth
Pain Med 2002;27:180192
Brown DL. Atlas of Regional Anesthesia. 4th ed. Philadelphia: Saunders, 2010.
Kundra P, Kutralam S, Ravishankar M. Local anesthesia for awake fiberoptic nasotracheal
intubation. Acta Anaesthesiol Scand 2000;44:511516.
27
Chapter 3
Preoxygenation Strategies and

Positioning Tips
Henrique Vale, MD and Davide Cattano, MD, PhD
Objectives
Learn how to optimize airway exposure during direct laryngoscopy and other airway management procedures.
Learn the basics of preoxygenation and optimization of oxygen delivery and ventilation.
Introduction
This chapter will emphasize the importance of various methods of patient positioning to optimize
direct laryngoscopy. Different positions are proposed for different patients and scenarios that can
help the anesthesiologist improve visibility when attempting to place an endotracheal tube (ETT).
The four most common laryngoscope positions will be discussed: sniffing, ramped, neutral, and
beach chair. The importance of preoxygenation and the techniques that provide the longest apnea
time before attempting airway instrumentation will also be highlighted in this chapter.
Laryngoscopy Positioning
The goal when positioning a patient for direct laryngoscopy is to achieve the best possible alignment of the three airway axes: oral, pharyngeal and laryngeal (see Fig. 3.1).
Tip
To reach the best positioning for induction of general anesthesia, the provider should achieve
the best alignment of the three airway axes: oral, pharyngeal, and laryngeal.
Sniffing Position
In 1936, Ivan Magill first proposed the sniffing position as the optimal position for direct laryngoscopy and described it as someone drinking a pint of beer or sniffing the morning air. It is
28
(A)
Oral axis (OA)
3 Preoxygenation Strategies
Pharyngeal
axis (PA)
Laryngeal
axis (LA)
OA
(B)
PA
LA
PA
LA
(C)
OA
Figure 3.1 The three airway axes (A) in the neutral position, (B) with elevation of the head, and (C) with
atlanto-occipital extension (the sniffing position).
(Reprinted with permission from Miller RD, ed. Millers Anesthesia, 6th ed., Philadelphia: Churchill Livingstone: 2004.)
considered the best position for the preparation of a non-obese patient for airway management
and endotracheal intubation. It involves the placement of a pillow under the head of the patient
to flex the neck and then extend the head, optimizing the alignment of the oral, pharyngeal, and
laryngeal axes. This allows for better visualization of the glottis and facilitates the insertion of an
ETT with direct laryngoscopy.
Tip
During mask ventilation and intubation, the snifng position is considered the best position
for the preparation of a healthy, non-obese patient.
Tip
A contraindication to the snifng position is the risk of aggravation of a cervical spine lesion
in patients with suspected or conrmed cervical spine injuries.
Ramped or Head-Elevated Position

This position is used in the obese patient to achieve the same alignment of the three axes that
is achieved in the non-obese patient with the sniffing position. It is achieved by elevation of the
patients upper body and head by placing blankets or a specialized device, such as the Troop
Elevation Pillow (Mercury Medical; Clearwater, FL) or the RAMP Device (AirPal; Coopersburg,
PA), underneath the patients torso, bringing the external auditory meatus and the suprasternal
notch into horizontal alignment (see Fig. 3.2) Alternatively, the OR table can be used to elevate
the patients upper body and lower the head, creating a wedge that facilitates visualization of the
glottis and maximizes upper airway patency.
The ramped position improves ventilation of the obese patient by downward displacement
of fat and abdominal contents via gravity, diminishing pressure on the diaphragm and decreasing
intrathoracic pressure. This reduction of lung restriction reduces work of breathing and increases
function residual capacity (FRC), allowing better preoxygenation and granting more time for the
anesthesiologist to perform endotracheal intubation with delayed desaturation.
Similarly to the sniffing position, the use of this position is contraindicated in patients with
known or suspected cervical spine injuries because of the risk of further injury.
Tip
In the head-elevated position, the reduction of intrathoracic pressure decreases work of
breathing and increases the functional residual capacity, allowing better preoxygenation in
obese patients.
Neutral In-Line Position

When placed in the neutral position, there is no pillow or blanket under the patients head or
torso. The intent is to keep the head in the most natural position, possibly in-line with the cervical spine, avoiding any degree of extension or flexion of the neck or head. This position is usually
reserved for patients with known or suspected unstable cervical spine injuries, when movement
of the neck or head can further aggravate the injury.
Unfortunately, this position does not provide alignment of the three axes (oral, laryngeal, and
pharyngeal) and creates suboptimal conditions for direct laryngoscopy and endotracheal intubation. Chin lift or jaw-thrust may be performed to help the anesthesiologist actually perform the
intubation. Alternative airway management techniques, such as video laryngoscopy, fiberoptic
29
When placing the patient in the sniffing position, the anesthesiologist flexes the lower cervical spine
and extends the upper cervical spine and atlanto-occipital joint to optimize exposure of the glottis.
Ensuring that the ears are level with the suprasternal notch helps to confirm optimal positioning.
This position is contraindicated in patients with known or suspected cervical spine injuries
because of the risk of worsening of the injury. Examples include trauma patients or patients with
anterior atlanto-axial subluxation, such as in rheumatoid arthritis or Down syndrome.
30
(A)
(B)
Figure 3.2 A morbidly obese patient placed in (A) a sniffing position and in (B) a head elevation position.
intubation, or retrograde intubation, can also be used to facilitate endotracheal intubation in this
position.
Tip
The neutral or in-line position keeps the head in line with the cervical spine, avoiding any
degree of extension or exion of the neck or head. This position is reserved for patients
with suspected or conrmed unstable cervical spine injuries.
Beach Chair Position

The beach chair position is achieved by placing the patient in the supine position with the upper
body elevated 45. This position reduces the risk of airway collapse and obstruction, permitting
the patient to maintain airway patency during airway instrumentation.
In this position, the patients head is in-line with the xyphoid process of the anesthesiologist,
and often, the anesthesiologist will need a stepstool to facilitate mask ventilation and direct laryngoscopy. This position is best for fiberoptic intubation, especially if the provider approaches the
patient from the front and has an assistant pulling the tongue and/or performing a jaw thrust.
An important consideration when using this position is that the degree of elevation may reduce
the venous return to the heart and lower blood pressure. Some shoulder surgeries are performed
in this position for surgical exposure and less bleeding. However, cases have been reported of
severe brain damage, stroke, visual loss, and death resulting from low cerebral perfusion associated with this position. The primary recommendation when using this position is to measure the
blood pressure at the level of the heart to avoid discrepancies.
Preoxygenation
Preoxygenation is considered the first step for every patient requiring any type of airway management. This technique is also called denitrogenation because of the exchange of nitrogen (N2) in
the lungs for oxygen (O2). The goal of preoxygenation is to prolong the apnea time, which is the
length of time after the onset of apnea until a patient begins to desaturate, to allow sufficient time
for airway management. To achieve adequate preoxygenation, studies have shown that the end
tidal oxygen fraction should reach levels above 90%. Because air is composed of 21% O2, 78% N2,
and 0.9% of a mix of argon (Ar) and carbon dioxide (CO2), it is easy to understand the impact of
exchanging this 78% of N2 for O2 (see Fig. 3.3).
31
Nitrogen
21%
Oxygen
Carbon Dioxide and Argon
0.9%
Figure 3.3 Air is composed of nitrogen, oxygen, and a mix of carbon dioxide and argon.
Tip
Preoxygenation is considered the rst step for every patient requiring airway management.
Physiology of Preoxygenation
In adults breathing room air, the amount of oxygen in the body is approximately 1550 mL, which
is distributed as O2 bound to hemoglobin (850 mL), O2 that remains in the lungs (480 mL), and O2
that is dissolved in blood (220 mL). Hemoglobin-bound O2 is not readily available because of the
high affinity of O2 for hemoglobin, and the O2 dissolved in the blood is such a small quantity that
the O2 in the lungs is the only real source of O2 in the body. In the setting of apnea, this amount
is insufficient to maintain life for more than a few minutes.
Oxygen consumption (VO2) in an adult can be estimated based on a patients weight in kilograms using the formula VO2 = 10(weight). This calculates to approximately 3 mLkg1min1 or
200 mL/min to 250 mL/min. The FRC is the volume of air present in the lungs at the end of passive expiration. To calculate the amount of oxygen available in the lungs during periods of apnea,
the FRC volume is multiplied by the inspiratory fraction of O2 (FiO2). A healthy adult will have
an FRC of 2300 mL and a room air FiO2 of 21%. Thus, the amount of oxygen available would be
approximately 483 mL of pure O2. If the VO2 for this same adult is 200 mL/min to 250 mL/min, the
allowable apnea time until the onset of desaturation is less than 2 minutes.
If this same adult breathes 100% O2, however, the amount of O2 available would be 2300 ml
(FRC of 2300 mL multiplied by a FiO2 of 100%), which would allow for as much as 10 minutes of
apnea before the start of desaturation. Studies have shown that the minimum expiratory fraction
of oxygen (FEO2) to ample apnea time to allow for airway instrumentation is 80%.
Tip
A healthy adult fully preoxygenated with 100% O2 will have approximately 2300 mL of oxygen in the lungs, which will assure approximately 10 minutes of apnea before desaturation.
Techniques for Preoxygenation

Methods for preoxygenation before induction of anesthesia can be divided into slow and fast
techniques. It is important to ensure that there is no leak in the circuit and/or anesthesia machine,
that 100% O2 is provided, and that rebreathing does not occur.
78%
32
For either technique, the position of the patient is important and can make a meaningful impact
on apnea time. The induction of general anesthesia decreases the FRC by 20% in a non-obese
patient and by up to 50% in an obese patient. Placing patients in a supine position will result in
greater decreases in FRC as compared to patients in the heads up or sitting position. Patients who
are obese, pregnant, or who have restrictive lung disease have an even lower FRC compared to
healthy people. Low FRC diminishes the efficacy of preoxygenation and decreases the time period
preceding desaturation. One study measuring time to desaturation after preoxygenation showed
an average apnea time of 6.1 minutes in lean patients compared to 2.7 minutes in the morbidly
obese. Thus, it is advantageous to preoxygenate obese patients in the upright position to increase
FRC and increase the apnea time. Pregnant patients showed no differences related to position
and apnea time.
Slow Technique
The slow preoxygenation technique is performed successfully by delivering 100% O2 via a facemask
with a perfect seal and asking the patient to breathe at normal tidal volumes for approximately
3 minutes. Within 3 minutes, the patients FEO2 usually reaches levels greater than 90%, ensuring
a maximal apnea time during airway management. When a perfect seal is difficult to achieve (e.g.,
because of the presence of a beard or a lack of dentition), the practitioner can attempt to create
a better seal using a two-handed technique. The anesthesia machine can be used to deliver continuous positive airway pressure (CPAP) or pressure support ventilation (PSV) to augment tidal
volumes and improve the quality of preoxygenation.
Fast Technique
The preoxygenation fast technique can be performed by providing 100% O2 by face mask with
a perfect seal and asking the patient to take vital capacity breaths. Studies have shown that it is
necessary to take approximately eight vital capacity breaths in 1 minute to be able to reach a FEO2
greater than 90%. Some studies support four deep breaths in 30 seconds to provide adequate
preoxygenation. This technique is useful during emergencies but requires patient cooperation and
can promote mild hypocapnia.
Preoxygenation Techniques Without a Face Mask

Different techniques for preoxygenation are required when a facemask cannot be applied.
In the claustrophobic patient or when it is impossible to maintain a perfect seal on the face mask
(e.g., because of a large beard or the presence of a nasogastric tube), an alternative technique may
be attempted by disconnecting the mask from the circuit and asking the patient to breath around
the 15 mm circuit connector.
Studies have demonstrated that administering oxygen via a nasal cannula after induction prolongs the apnea time even when respiratory movements are not occurring. This phenomenon,
known as apneic oxygenation, is possible because the exchange of O2 and CO2 in the alveoli creates a diffusion gradient from the pharynx (containing a higher concentration of oxygen from the
nasal cannula) to a lower concentration of oxygen in the alveoli.
Another option is to use high oxygen flow rates (3048 L/min) that permit adequate preoxygenation, even through a loose-fitting mask. This technique cannot be used in the anesthesia setting
because anesthesia machines are not able to provide such a high flow.
Morbidly Obese Patient With Obstructive Sleep Apnea

The morbidly obese patient with obstructive sleep apnea (OSA) requires special attention during preoxygenation because this population has increased oxygen consumption and a greatly
Tip
Morbidly obese patients benet from the head-elevated position during preoxygenation and
from nasopharyngeal oxygen delivery after induction. BiPAP is useful for critically ill patients
with severe atelectasis, intrapulmonary shunt, and increased A-a gradient.
Extubation Techniques and Oxygen Delivery

An important aspect of airway management and most important regarding morbidity and mortality is a safe extubation. In both cases in which the airway is challenging, as well as routine cases,
extubation should proceed smoothly, should rely on complete recovery from muscle relaxation,
and should avoid increases in intrathoracic pressure from retching or bucking, especially in situations where an increase in venous pressure or intracranial pressure could be detrimental.
When extubation is performed under deep anesthesia, one technique to optimize oxygen delivery is to utilize an oral airway and leave the ETT immediately extraglottic. Additionally, an ETT
can be substituted via the Bailey maneuver, leaving the LMA in place. With these techniques, the
continuous monitoring of ventilation, patient rate, effort and CO2 is possible, while O2 is delivered
easily through the laryngeal inlet.
In morbidly obese patients, because of a high incidence of OSA, it is recommended to extubate
patients fully awake to avoid airway obstruction and desaturation. Also, higher intra-abdominal
pressure increases the risk of aspiration if these patients are not awake enough to protect their
airway.
Final Considerations
A SpO2 of 100% does not necessarily mean that a patient is preoxygenated, because hemoglobin
reaches 100% saturation with O2 concentrations slightly above room air. Possible, but rare, side effects
from preoxygenation include increased risk of atelectasis (most commonly in the obese patient),
increased systemic vascular resistance, decreased heart rate and cardiac output, and hypocapnia
(which decreases cerebral blood flow and increases the required dose of anesthetic induction agent).
Nevertheless, preoxygenation should not be avoided simply to prevent these side effects.
In elderly patients, due to the difficulty of obtaining consistent cooperation and the potential
for leak between the mask and face (due to the absence of teeth and loss of tone of the jaw and
33
reduced FRC. The airway anatomy of an obese patient can result in difficult airway management
largely because of a low thyromental distance and a neck circumference greater than 17 inches,
requiring more time for the intubation.
Preoxygenation in the obese patient is recommended to be performed in a head-up position.
The use of a Boussignac CPAP mask is advocated by some because CPAP would increase the FRC,
but studies have shown that this increase is not significant and that the FRC returns to pre-CPAP
values once the mask is disconnected from the patient.
Apneic oxygenation via nasopharyngeal oxygen delivery following preoxygenation increases
the apnea time in morbidly obese patients. Unfortunately, this technique may not be effective
in critically ill patients because of atelectasis, increased intrapulmonary shunt, and a high A-a
gradient. For these patients, bilevel positive airway pressure (BiPAP) is recommended because
it promotes alveolar recruitment and, more specifically, decreases the intrapulmonary shunt and
A-a gradient.
Obese patients are more prone to develop atelectasis, thus a high FiO2 for prolonged periods of
time is contraindicated because of the risk of further increases via absorption atelectasis.
34
cheek muscles), the slow technique is more effective than the fast technique. Because of the
decreased minute ventilation observed in this population, the patient may require more than
3 minutes to reach adequate FEO2.
Suggested Readings
1. Weingart SD, Levitan RM. Preoxygenation and prevention of desaturation during emergency
airway management. Ann Emerg Med. 2012;59(3):165175.
2. Bein B, Scholz J. Anaesthesia for adults undergoing non-bariatric surgery. Best Pract Res Clin
Anaesthesiol. 2011;25(1):3751.
3. Leykin Y, Pellis T, Del Mestro E, Marzano B, Fanti G, Brodsky JB. Anesthetic management of
morbidly obese and super-morbidly obese patients undergoing bariatric operations: hospital
course and outcomes. Obes Surg. 2006;16(12):15631569.
4. Mort TC. Preoxygenation in critically ill patients requiring emergency tracheal intubation. Crit
Care Med. 2005;33(11):26722675.
5. Cattano D, Cavallone L. Airway management and patient positioning: a clinical perspective.
Anesthesiology News 2011;37(8):1723.
35
Chapter 4
Mask Ventilation
Objectives
Assess patient features and airway history that would predict success of mask ventilation.
Introduce devices used for mask ventilation.
Discuss mask ventilation: one handed versus two handed.
Provide detailed instructions and tips to ensure successful mask ventilation.
Outline rescue maneuvers for difficult/impossible mask ventilation.
Introduction
Mask ventilation is an essential skill for health-care workers, especially those involved with airway
management. It can provide adequate oxygenation and ventilation for the patient who is unable to
support their own respirations. With a moderate amount of instruction, most health-care providers can and should be able to perform this ventilatory technique.
Patient Airway Assessment

Evaluation of the patients physical features and obtaining a history of a difficult airway are critical
steps prior to performing airway management. It has been stated that the single most reliable
predictor of a difficult airway is a history of a difficult airway. Physical features noted in patients
with difficult mask ventilation include beard, obesity, edentulousness, history of obstructive sleep
apnea, enlarged jaw, thick tongue, poor atlanto-occipital extension, as well as facial burns and
deformities. Poor mandibular protrusion is not a risk factor for difficult mask ventilation, but it
has been associated with difficult intubation. Physical features noted in patients with impossible
mask ventilation include beard, neck radiation changes, male sex, sleep apnea, and Mallampati
III or IV.
36
4 Mask Ventilation
Predictors of Difficult Mask Ventilation Tips

A history of a difficult airway is the single most reliable predictor.
Inability to protrude the lower incisors over the upper incisors is associated with difficult
laryngoscopy but not difficult mask ventilation.
Difficult mask ventilation predictors: beard, obesity, edentulousness, history of obstructive
sleep apnea, enlarged jaw, thick tongue, poor atlanto-occipital extension, history of facial
burns.
Impossible mask ventilation predictors: (in addition to predictors of difficult mask ventilation) neck radiation, Mallampati III or IV, male gender.
Mask Ventilation Devices

The two main types of face masks are the older style, black rubber reusable masks and the newer,
clear plastic, disposable masks (Fig. 4.1). In general, the clear plastic mask is more comfortable
for the awake patient. The three main components of the mask include: (1) the body or main
component of the mask, which if clear allows observation of the exhaled moisture or secretions
during mask ventilation; (2) the seal, which is achieved with the mask covering the patients mouth
and nose, and (3) the connector, which allows the anesthesia circuit or AMBU bag to be attached
to the mask. The Rendell-Baker-Soucek Mask (Rusch Medical, Teleflex, Research Triangle Park,
NC) is triangular in shape and is designed for the pediatric population as it is associated with a
small dead space. The ErgoMask (King Systems Airway, Noblesville, IN) is a recently developed
mask that has a special finger/thumb contoured grip to facilitate one-handed mask ventilation
(Fig. 4.2). The ErgoMask improves control of mask seal and facilitates proper chin lift to assist
with opening the airway. Its ventilation port is off-center, which enables use with small hands.
Another specialized mask, the Endoscopy MaskTM, (VBM Medizintechnik GmbH, Sulz am Neckar,
Germany) can be utilized for procedures, such as upper endoscopy or fiberoptic bronchoscopy,
as these techniques can be performed through the mask without any interruption of ventilation
(Fig. 4.3). Finally, utilization of scented masks may increase acceptance by the pediatric population
during mask induction of general anesthesia.
Utilization of an oral airway is recommended if initial attempts at mask ventilation are suboptimal. The oral airway has several variants, but they all follow a basic curved design to allow the
tongue and epiglottis to be lifted away from the posterior pharyngeal wall during mask ventilation.
To avoid coughing or gagging, the patients pharyngeal and laryngeal reflexes should be suppressed
prior to their use.
Utilization of a nasopharyngeal airway is another method of assisting difficult mask ventilation.
Lubrication of the nasal airway should be performed prior to insertion. It is then placed into the
larger nostril and gently advanced posteriorly, in line with the nasal passage, until it is past the
base of the tongue but still above the epiglottis. If resistance is met during insertion, then the nasal
airway should be removed; a smaller size nasal airway should be selected or the other nostril used
for the subsequent attempt. If mask ventilation is difficult, then application of an endotracheal tube
(ETT) connector to a nasal airway and connecting this to the anesthesia circuit may aid in ventilation of a patient. With this method, it is necessary to occlude the opposite nostril, as well as the
patients mouth, to achieve adequate ventilation.
One-Handed Mask Ventilation

The face mask should be attached to the anesthesia circuit (or AMBU bag) with high-flow
(810 L/min) oxygen. In the patient undergoing anesthesia, pre-oxygenation is undertaken prior
Figure 4.1 A standard, black rubber, reusable face mask and a standard, clear plastic, disposable face mask.
Figure 4.2 Side-by-side comparison of the ErgoMask (left) and a standard face mask (right).
(Reprinted with permission from Bauman EB, et al. An evaluation of bag-valve-mask ventilation using an ergonomically designed
facemask among novice users: A simulation-based pilot study. Resuscitation 2010;81(9):11611165.)
to administration of anesthetizing drugs. The mask is held with the left hand. To create a seal, the
mask is placed snugly over the bridge of the nose and on the chin. The thumb and index finger
are held on either side of the connector. Care must be taken to avoid contact with the eyes. The
other fingers can be placed on the mandible with the little finger lifting the angle of the mandible.
Alternatively, the practitioners hand may be centered over the mask and the chin lifted. This
elevation of the mandible assists in opening the airway. Care must be taken to avoid applying
too much pressure, as this could compromise the airway. Following the loss of airway reflexes,
the right hand is used to ventilate the patient by squeezing the reservoir bag. If a leak around the
mask is observed, then counteractive pressure should be applied to the right side of the mask.
4 Mask Ventilation
37
4 Mask Ventilation
38
Figure 4.3. The Endoscopy MaskTM.

(Copyright image provided courtesy of VBM Medizintechnik GmbH, Sulz am Neckar, Germany)
Exhalation of carbon dioxide should be observed via capnography or with the Easy Cap (Nellcor,
Boulder, CO) when the AMBU bag is used.
Two-Handed Mask Ventilation

Following the preparation described above regarding oxygen supply, equipment, and drugs,
the use of one-handed mask ventilation should allow ventilation of the majority of patients. If
one-handed mask ventilation is inadequate, then two-handed mask ventilation can be performed,
which requires an assistant to provide the actual ventilation, if the patient is not spontaneously
breathing. It should be utilized if attempts at single-handed ventilation fail.
In the two-handed mask ventilation technique, the thumb is placed on the side of the mask and
the index finger is placed under the angle of the mandible. Elevation of the mandible and extension of the head should allow for a patent airway to be obtained. Similarly to one-handed mask
ventilation, exhalation of carbon dioxide should be observed via capnography or with the Easy
Cap when the AMBU bag is used.
Mask Ventilation Tips:

Elevation of the angle of the mandible along with a good mask seal are the two most
important features to ensure adequate mask ventilation. This may be accomplished with
the last two fingers elevating the mandible into the mask, while extending the neck, if not
contraindicated.
One-handed mask ventilation requires the mask to be secured with the index finger securing the mask near the chin and the thumb holding the mask near the bridge of the nose.
Two-handed mask ventilation utilizes a thumb securing each side of the mask.
Placement of an oral or nasal airway may assist with mask ventilation. In addition, changing
the position of the head and/or jaw may help improve ventilation.
Rescue Maneuvers
39
Video 4.1
Mask Ventilation Techniques
Summary
Mask ventilation is an important skill to be utilized whenever airway support is needed. Factors
to improve successful mask ventilation include airway assessment, presence of necessary supplies
including oxygen and airway masks, as well as oral or nasal airways. Elevation of the angle of the
mandible is as important as a tight mask fit to ensure adequate ventilation. Utilization of one- or
two-handed mask ventilation may be needed, depending on the skill of the practitioner or the
patients anatomy. Rescue supplies should be available if mask ventilation is inadequate.
Suggested Reading
American Society of Anesthesiologists Task Force of Management of the Difficult Airway.
American Society of Anesthesiologist Task Force on Management of the Difficult Airway.
Anesthesiology 2003; 98(5):12691277.
Matten EC, Shear T, Vender JS. Nonintubation management of the airway: airway maneuvers
and mask ventilation. In: Hagberg CA, ed. Benumofs Airway Management 3rd ed. Philadelphia,
PA: Mosby Elsevier; 2012:340345.
Dorsch JA & Dorsch SE. Face masks and airways. In: Understanding Anesthesia Equipment 5th ed,
Philadelphia, PA: Lippincott Williams and Wilkins; 2008:444450.
Langeron O, Masso E, Huraux C, et al. Prediction of difficult mask ventilation. Anesthesiology
2000;92(5):12291236.
Kheterpal S, Martin L, Shanks A, & Tremper K. Prediction and outcomes of impossible mask
ventilation: a review of 50,000 anesthetics. Anesthesiology 2009;110(4):891897.
4 Mask Ventilation
If one- or two-handed mask ventilation is unsuccessful in obtaining adequate ventilation, then the
provider should call for assistance and place either an oral or nasal airway, as previously described.
Changing the position of the head and/or mandible may improve ventilation. Additionally, a forceful mandibular lift is a helpful maneuver. Further efforts to place either a laryngeal mask airway
(LMA) or ETT may be attempted, in accordance with the ASA difficult airway algorithm.
41
Chapter 5
Nasotracheal Intubation
Objectives
Discuss indications for nasotracheal intubation.

Explain advantages and disadvantages of nasotracheal intubation.
Describe preparation for nasotracheal intubation.
Describe special equipment needed for nasotracheal intubation.
Provide guidelines for determining whether awake versus asleep intubation is indicated.
Outline rescue maneuvers if unable to successfully perform nasotracheal intubation.
Introduction
Nasotracheal intubation is indicated for operative procedures involving the oral cavity and the face
when an oral endotracheal tube (ETT) would block free access to the operative field. Numerous
advantages have been described for the patient with a nasotracheal tube, such as improved tolerance and inability of the patient to bite the ETT. Preparation of the nasopharynx prior to
intubation involves utilization of vasoconstrictive agents and water-soluble lubricants. Numerous
special items are needed for the safe placement of the nasal ETT, including but not limited to nasal
trumpets, Magill forceps and a capable assistant. Determination of awake versus asleep intubation
is influenced by multiple factors, including NPO status and an airway assessment. In the event of
inability to perform nasal intubation, a plan for either oral intubation or surgical airway must be
readily available.
Indications for Nasotracheal Intubation

Nasotracheal intubation is indicated for operative procedures involving the oral cavity or face
when an oral ETT would hinder access to the operative field. In addition, temporomandibular joint
limitation or the presence of a mandible fracture might preclude oral intubation. Other indications
include cervical spine instability, the presence of intra-oral lesions or other intra-oral pathology.
5 Nasotracheal Intubation
42
On the other hand, nasotracheal intubation should be avoided if severe coagulopathy, intranasal
abscess, polyps or other significant masses are present. Although a skull base fracture has been
previously listed as a contraindication, reports have described successful fiberoptic nasotracheal
intubation in these patients.
Advantages and Disadvantages of Nasotracheal Intubation

There are several advantages to nasotracheal intubation, including increased tolerance to the ETT,
decreased incidence of biting, and, therefore, occluding the ETT. In the awake patient, nasotracheal intubation bypasses the gag reflex; therefore, it is usually better tolerated and requires less
sedation. Disadvantages associated with nasotracheal intubation include longer time and greater
difficulty of intubation, use of a smaller sized ETT with resultant increased airway pressure, and
the possibility of bleeding. Concerns over sinusitis and bacteremia have also been raised with
nasotracheal intubation.
Preparation for Nasotracheal Intubation

The nose should be assessed pre-operatively for any signs of obstruction, including polyps or
foreign bodies. The patient may be able to inform the practitioner regarding which naris provides
better airflow. If no difference is evident, it is best to prepare the right naris, as the bevel of the
nasotracheal tube passes through the glottis more easily when introduced via the right naris.
Interestingly, determination of which nostril is best for intubation by obstruction of each nostril
and listening for the best airflow from the contralateral side has not been shown to correlate
with nasal abnormalities. Use of a vasoconstrictive agent should be applied to the both nostrils
prior to placement of a nasal airway. Preparation continues by placement of a nasal airway that
has been lubricated with lidocaine gel, if available. The ETT should be one size smaller than the
size normally used for an oral intubation. The ETT should be warmed prior to insertion to allow
it to be softer and more compliant. This can be easily accomplished by placing it in a liter bottle
of warm irrigating solution or water. The ETT should also be well lubricated with a lidocaine gel,
immediately prior to insertion. It can also be curled into a circle by inserting the distal end into the
proximal end, so that the ETT has the memory of a curvature when used for intubation.
Equipment Needed for Nasotracheal Intubation

In addition to the nasal airways mentioned above, it is important to have water-soluble lubricant,
vasoconstrictive nasal spray, a liter bottle of warm irrigating solution or water, Magill forceps, and
smaller sized ETTs.
Additional aids have been described to aid in nasotracheal intubation. Two of the more common are listed here.
1. The BAAM Whistle (Beck Airway Airflow Monitor, Great Plains Ballistics, Lubbock, TX) is a
device that consists of a plastic whistle that fits on the proximal end of the ETT (Fig. 5.1). It has
a 2 mm opening that produces a loud whistle when air passes through it in a spontaneously
breathing patient. Proximity to the tracheal air column determines the loudness of the sound.
Placement of the ETT into the esophagus will result in cessation of the sound. This intubation
aid is used primarily for blind nasotracheal intubation.
2. An alternative to blind intubation using the BAAM is to attach a capnography line to the proximal end of the ETT as it is advanced. The carbon dioxide trace will continue to display as the
ETT goes toward and enters the glottis when the patient is breathing spontaneously or when
ventilated by the practitioner. Introduction into the esophagus may exhibit carbon dioxide
if there has been entrainment of exhaled gas into the stomach or recent consumption of
carbonated beverages.
43
Figure 5.1 BAAM Whistle (Great Plains Ballistics, Lubbock, TX).
Awake versus Asleep Intubation

The determining factors as to whether to secure a patients airway following induction of general
anesthesia or awake are multifactorial. Consideration of many factors, such as a cervical spine
injury, airway assessment, NPO status, and whether a patient will be able to cooperate with the
performance of an awake intubation, must be determined.
If an awake intubation (AI) is indicated, several steps are required (see Chapters 2 and 9 for
further detail).
1. Patient preparation with a detailed pre-operative visit informing the patient of the need for AI.
2. Utilization of an antisialagogue approximately 20 minutes prior to the start of AI.
3. Titrated sedation individualized to the patient, maintaining meaningful contact at all times.
4. Administration of vasoconstrictive agent to both nares.
5. Airway anesthesia of the nasal and laryngotracheal mucosa.
If AI is chosen for nasal intubation, the use of a fiberoptic bronchoscope (FOB) to facilitate
intubation is preferable. The FOB should be inserted into the more patent nostril, which has been
properly prepared. The practitioner can either choose to place a well-lubricated, pre-warmed
ETT through the appropriate nostril first, or the FOB can be loaded with a similarly prepared ETT
and advanced through the nares after the FOB has been directed into the trachea. Advancement
of the ETT into the nostril first has the advantage of providing a pathway free of secretions for
the FOB and early determination of a tight nasal passage. Disadvantages of this technique include
increased chance of airway trauma and possible bleeding. On the other hand, if the FOB is placed
into the nostril first, there is a chance that advancement of the ETT may not be possible, although
the FOB is located in the trachea. An alternative technique to either of these procedures is to
place the FOB in one nostril while passing the ETT through the opposite nostril. The FOB simply
is used for visualization as the ETT is guided through the glottis.
Video 5.1 Fiberoptic-assisted nasotracheal intubation
If the decision is made to proceed with nasotracheal intubation after induction of general anesthesia, then fiberoptic bronchoscopy, direct laryngoscopy, or video laryngoscopy can be utilized.
44
Figure 5.2 Magill forceps.
The above steps regarding preparation (vasoconstrictive nasal spray, placement of nasal airway,
etc.) are performed and placement of the nasotracheal tube follows. An ETT one size smaller than
normal should be chosen, and as it is advanced, the tip should be directed medially and the bevel
laterally. This is to ensure that the tip of the tube does not cause trauma to the nasal turbinate.
Passage of the ETT should be performed in a gentle fashion in a posterior, caudad, medially directed
movement until it enters the oropharynx. If resistance is met, then attempt to withdraw, rotate, and
re-insert the ETT. Once the ETT enters the posterior pharynx, it can be guided between the vocal
cords by use of a Magill forceps (Fig. 5.2) with concurrent direct of video laryngoscopy. An assistant
is needed to slowly advance the ETT under the direction of the individual viewing the vocal cords.
Once tracheal intubation has been confirmed by capnography, the ETT may be secured with either
adhesive tape or a suture through the nasal septum and wrapped tightly around the ETT.
Video 5.2 Video laryngoscope-assisted nasotracheal intubation
Nasotracheal Intubation Tips

Consider nasotracheal intubation when use of an oral ETT would hinder visualization of
the operative field or if the mouth is going to be wired closed.
Avoid nasotracheal intubation if intranasal abscess, nasal polyps, or severe coagulopathy
are present.
Apply a vasoconstrictive agent to the nasal mucosa and then place a water-soluble lubricant
or lidocaine gel on the nasal trumpet and the ETT.
The ETT used should be one size smaller than normally used for orotracheal intubation.
If time permits, it is best to soften the ETT by placing it in a warm bottle of irrigating
solution or water.
Never force advancement of the ETT. If resistance is met, then consider using a smaller
size ETT, rotating the ETT or using the other nostril.
Rescue Maneuvers
When nasal intubation is necessary but unsuccessful, alternative intubation techniques should
be considered if the patient is unable to maintain their own airway, including the possibility of a
surgical airway.
Summary
Nasotracheal intubation is required when the operative procedure involves the oral cavity and an
oral ETT would block access to the operative field or the jaw is going to be wired shut following
the procedure. Successful nasotracheal intubation includes preparation of the desired nares with
vasoconstrictive agents, as well as placement of nasal airways. Special equipment includes Magill
forceps and the presence of a capable assistant. Fiberoptic intubation should always be considered
if standard techniques are not successful. Additionally, blind nasotracheal techniques such as blind
intubation or lightwand intubation may be considered.
Suggested Reading
Berry JM, Harvey S . Laryngoscopic Orotracheal and Nasotracheal Intubation. In: Hagberg CA,
ed. Benumofs Airway Management, 3rd ed. Philadelphia, PA: Mosby Elsevier; 2012:346358.
Dorsch JA, Dorsch SE. Tracheal Tubes and Associated Equipment. In: Understanding Anesthesia
Equipment, 5th ed., Philadelphia, PA: Lippincott Williams and Wilkins; 2008:585587.
45
If not contraindicated, small movements of either the head or neck or pressure on the
thyroid cartilage may facilitate tracheal intubation.
Specific problems associated with prolonged nasal intubation include sinusitis and pressure necrosis of the nostril.
If visualization via the FOB is obscured by either bleeding or secretions, then consideration can be made for a blind nasotracheal intubation technique, such as blind nasal or
lightwand-guided intubation.
47
Chapter 6
Supraglottic Airway Devices
Objectives
Discuss advantages and disadvantages of the supraglottic airway devices.
Describe the different types of supraglottic airway devices.
Describe the use of intubating supraglottic airway devices.
Introduction
The use of supraglottic airway devices (SADs) has increased dramatically over the last 25 years.
This movement was greatly influenced by the development of the Laryngeal Mask AirwayTM (LMA)
by Dr. Archie Brain in the early 1980s. The invention of the LMA has been described as the single
most important improvement in airway management over the last 50 years. Since its initial development, there have been multiple variations and improvements of the traditional classic LMA.
One of the most useful developments is use of the LMA as a conduit for endotracheal intubation. Fiberoptic intubation through SADs is an important step in the management of unexpected
difficult ventilation and/or intubation in both children and adults.
Advantages and Disadvantages of Supraglottic

Airway Devices
The LMA and other similar devices have many advantages for airway management. First, education
and instruction in the placement of these devices can be accomplished in a relatively short period
of time for most health-care professionals. Their relative low cost makes them easily obtainable
by many facilities and for use both in and out of the operating room setting. In the anesthetized
patient, a lower level of anesthesia is required as compared to endotracheal intubation, allowing
for a more rapid emergence. Notably, the LMA can be used as either a bridge to intubation or
extubation. The LMA has shown its effectiveness as a rescue device for the failed airway and is
now in the American Society of Anesthesiologists (ASA) Difficult Airway Algorithm, as well as the
American Heart Associations and European Resuscitative Councils Guidelines.
6 Supraglottic Airway Devices
48
Use of the LMA or other supraglottic devices is contraindicated if complete glottic or supraglottic obstruction is noted. Also, the risk of aspiration is a relative contraindication to its use,
and caution should be utilized in these patients at risk for aspiration. For patients with extremely
limited mouth opening or neck extension, the use of these devices is severely cautioned against.
Obtaining a proper seal may be difficult after the device is placed. Finally, there is no protection
against laryngospasm.
Insertion Techniques of Supraglottic Airway Devices

The LMA ClassicTM (LMA North America, San Diego, CA) and now the UniqueTM (disposable
LMA) are the most widely used supraglottic ventilatory devices (Figs. 6.1 and 6.2). It is listed in
the ASA Difficult Airway Algorithm as an airway ventilatory device or as a conduit for fiberoptic
intubation in five different locations. Proper insertion of the LMA is mandatory for successful use
of the device. Deflation of the cuff prior to placement allows for proper placement. Application of
a water-soluble lubricant to the dorsal surface and tip of the LMA prior to insertion aids with ease
of insertion. With the aid of the index finger, at the junction between the mask and the shaft of the
LMA, the LMA should be inserted along the hard palate directed in a cranio-posterior direction.
In the awake patient, this motion imitates the tongue during swallowing. Using the nondominant
hand to provide a proper opening of the oropharyngeal angle by head extension and neck flexion
Figure 6.1 LMA ClassicTM.

(Copyright image provided courtesy of LMA North America, San Diego, CA.)
49
Figure 6.2 LMA Unique.
is another important action. Also, the jaw may be lifted by the nondominant hand to aid insertion.
Following proper placement of the LMA, inflation of the cuff is performed and the LMA is secured.
The LMA may block the esophagus depending on its position in the hypopharynx.
Video 6.1 LMA Insertion Techniques
If the LMA is going to be used as a conduit for endotracheal intubation, then there are some
technical considerations of the length and size of tracheal tubes in relations to dimensions of some
SADs that should be taken into account (see Table 6.1). The size of the LMA lumen limits the
size of the endotracheal tube (ETT) that can be passed through the device and into the trachea.
A size 6.0 mm internal diameter (ID) ETT can be passed through a size 3 and 4 LMA, and a size
7.0 mm ID through a size 5 LMA. Because a 6.0 ETT is only 28 cm in length, and projects only a
short distance into the trachea, more appropriate ETTs to consider include a size 6.0 nasal RAE
(34 cm in length) and a size 6.0 microlaryngeal tube, which is 32 cm in length.
An updated version of the reusable LMA, the LMA Classic Excel has several features that
have added benefit (Fig. 6.3). An Epiglottic Elevating Bar (EEB), a removable airway connector, and
an increased angle between the airway tube and the laryngeal cuff are designed to aid intubation.
The soft silicone cuff reduces the risk of throat irritation, and the entire device is reusable up to
60 times, providing greater cost effectiveness than the LMA Classic.
The LMA ProSealTM (LMA North America, San Diego, CA) has a second port that opens in the
distal tip of the mask (Fig. 6.4), which, when properly positioned, lies against the upper esophageal sphincter (UES). A standard gastric tube (size 16 Fr or smaller) can be placed via this port,
if needed to suction the stomach. The ProSeal LMA also allows detection of inadequate placement if the distal port is not at the UES, as airway gas will be displaced via the drain port. The
ProSeal cuff must not be overinflated (>60 cm H2O), as this can cause herniation of the gastric
port toward the glottis, which can cause blockage of the drainage tube and airway compromise.
The ProSeal also has a built-in bite block. The presence of a second seal allows positive pressure
ventilation to be performed with less likelihood of gastric insufflation. The LMA Supreme is a
disposable version of the ProSeal with similar features (Fig. 6.5).
50
Table 6.1 Relevant Dimensions of Various Supraglottic Airways
LMA ClassicTM LMA UniqueTM
AirQTM
AuraStraightTM AuraOnceTM
Supraglottic
airway size
2.5 3.5
4.5
Maximum
internal
diameter of
the ETT (mm)
6.5 7.5
8.5
5.5 6
20 20 22
Length of the
airway tube of
the supraglottic
airway* (cm)
20 20 22
16
18
20
18 18 20
17
19 22
30 30 33
30 30 33
26
28
32
28 28 31
27
29 33
Minimum
length of the
ETT** (cm)
LMA = laryngeal mask airway

* Distance between the upper end of the 15 mm connector and the mask aperture. These measures may
differ from data in the corresponding instruction manuals. For the air-QTM, the distance listed is from the
top of the tube with the connector removed to the mask aperture.
** Minimum ETT length is calculated as the sum of length of the airway tube and 10 cm (5.5 mm or 6.5 mm
ETT) or 11 cm (7 mm ETT). The latter is the sum of distance between the mask aperture and the vocal
cords and the distance between the upper border of the ETT cuff and the ETT tip.
Figure 6.3 LMA Classic Excel.

51
Figure 6.4 LMA ProSeal.
Figure 6.5 LMA Supreme.

(Copyright image provided courtesy of LMA North America, San Diego, CA)
52
Laryngeal Mask Airway Tips

The LMA is effective as a rescue device for a failed airway (ventilation and/or nasal intubation), but use of an LMA is contraindicated if complete glottic or subglottic obstruction is
present.
There is a risk of regurgitation/aspiration with the use of a supraglottic airway device.
Proper patient selection is imperative.
Select the most appropriate LMA for the surgical procedure. (e.g., a flexible LMA may be
preferred for nasal, facial, plastic, and ophthalmologic surgery).
Proper LMA insertion requires application of a water-based lubricant to its dorsal surface,
followed by LMA insertion into the oral cavity along the hard palate using a digital insertion technique. Following LMA placement, the cuff may be inflated and position verified by
noting adequate ventilation.
Secure the LMA appropriately to prevent dislodgement.
Provide adequate depth of anesthesia, especially when a patient is not paralyzed. In the
event of an inadequate seal or ventilation, slight repositioning by 3 cm to 5 cm LMA withdrawal may remedy the situation. If a proper seal is still not obtained, then use of a smaller
size LMA may solve the problem.
If cricoid pressure is necessary, it may require its temporary interruption for proper LMA
placement, followed by reapplication if ventilation is adequate.
Use of the LMA as a conduit for intubation requires use of size 6.0 mm ETT with a size 3
or 4 LMA. The same size nasal Rae or microlaryngeal tube may be considered to provide
adequate length. If a size 5 LMA is in place, a size 7.0 mm ETT may be used.
The Combitube (Covidien, Mansfield, MA) is a uniquely designed supraglottic device (Fig. 6.6)
developed by an internist, Dr. Michael Frass. It has been used extensively in emergency situations, as well as during routine surgery. Two different sizes are available: a small adult size (37 Fr,
Combitube SA) for use in patients 120 cm to 130 cm in height and a 41 Fr size for use in taller
patients. It has two cuffs; one cuff is at the distal (esophageal) end and a second (oropharyngeal)
cuff is composed of latex and is located at the middle portion of the tube. When tracheal placement occurs, insufflation of only the distal cuff is necessary. Almost 98% of the time, esophageal
placement of the device occurs, in which ventilation would be performed via the #1 (esophageal),
blue proximal lumen, which is longer than its counterpart. Its distal end is closed and it has eight
small perforations, to allow oxygenation and ventilation. When the device is placed into the
trachea, ventilation should occur via the #2 (tracheal) lumen, which is clear in color and shorter
in length. Its distal end is open. Insertion is accomplished by elevation of the mandible, anterior
displacement of the tongue, followed by insertion of the Combitube in a downward-curved
motion keeping the tongue in the midline. Insertion may be aided by prewarming the Combitube
in a bottle of warm saline or bending it for some time prior to its insertion (Lipp maneuver).
Inflation of the large oropharyngeal cuff should be performed first, followed by inflation of the
distal, esophageal cuff. Ventilation should be attempted via lumen #1 (esophageal lumen) first.
If ventilation is unsuccessful, then the device may be pulled back 1 to 2 cm and ventilation reattempted. If ventilation remains unsuccessful, then ventilation via lumen #2 (tracheal lumen) should
be attempted. If this is also unsuccessful, the device should be removed. This device is useful
in cases in which vocal cord visualization is not possible, such as the patient with regurgitation,
airway bleeding, difficult anatomy, or when there is poor access to the patient.
Video 6.2 Combitube Insertion Techniques
53
Figure 6.6 Combitube (Covidien, Mansfield, MA).
The Rusch Easytube (Teleflex Medical, Research Triangle Park, NC) is a double-lumen
rescue airway that is very similar to the Combitube, yet with some differences (Fig. 6.7). The
Easytube is latex-free and it has a narrower tip, because its esophageal lumen ends just below
the oropharyngeal balloon, unlike the Combitube, which carries the two lumens down to the
end, thus reducing the potential for trauma. The Easytube is available in two sizes: the 28 Fr
is available for patients with a height ranging from 90 cm to 130 cm and the 41 Fr is designed
for patients taller than 130 cm. The technique of Easytube insertion is very similar to the
Combitube. The Easytube also has a pathway between the two distal balloons for passing a
tube exchanger or flexible fiberoptic scope, and it is a bit shorter than the Combitube. The
distal balloons purpose is to block the esophagus. The ventilation path for gas is through
the opening between the two cuffs. As with the Combitube, if ventilation through the primary esophageal lumen is unsuccessful, then ventilation via the #2 tracheal lumen should be
attempted.
The King LT, King LT-DTM and King LTS-DTM (King Systems Corporation, Noblesville, IN)
are similar in design to the Combitube and Easytube, with a ventilation port between two
cuffs, but with several significant modifications. The King LT device is reusable and is latex free.
The King LT-D is a disposable version (Fig. 6.8). They are single-lumen devices with a tapered
distal tip, which allows easier passage into the esophagus. The distal (esophageal) portion of the
tube is occluded. The disposable King LTS-D, on the other hand, has an open distal tip and
has a secondary channel to allow suctioning of gastric contents (Fig. 6.9). There have been no
reports of tracheal placement of the King LT series, yet if it did occur, then the device should be
removed and reinserted. Insertion technique with the King LT series is best accomplished with
a lateral entry of the device into the oropharynx, followed by rotation toward the midline as it
is inserted behind the base of the tongue. The connector base should be aligned with the teeth
or gums, and both cuffs should be fully inflated. Following placement of the tube, ventilation
may proceed with gentle withdrawal of the tube until ventilation becomes easy with adequate
tidal volume and minimal airway pressure. It is important not to advance the tube with the cuffs
inflated.
Video 6.2 King LT Insertion Techniques
54
Figure 6.7 Rusch Easytube.

(Reprinted with permission from Thierbach AR, Werner C. Infraglottic airway devices
and techniques. Best Pract Res Clin Anaesthesiol 2005;19(4):595609.)
Figure 6.8 King LT-D device.
55
Figure 6.9 King LTS-D device.
Supralaryngeal, Double Cuff, Airway Devices Tips

The Combitube, Easytube, and King LT series each have a double cuff with ventilatory
openings between the cuffs.
The Combitube and Easytube are double-lumen tubes, whereas the King LTS-D has a
second lumen for suctioning of gastric contents.
The Easytube and King LT are latex free.
Placement of the distal tip of the Combitube in the esophagus occurs more than 95% of
the time.
Adequate ventilation of the lungs should be verified with exhaled carbon dioxide and
appropriate delivery of tidal volumes as endotracheal placement may occur.
Monitor for adequacy of ventilation and anesthetic plane (total compliance, capnography,
leak fraction, etc.) during anesthesia maintenance.
The King LT and King LT-D have a tapered, occluded distal tip, which allows easier placement into the esophagus. No reports of endotracheal placement have been described
with these devices.
Following insertion of the devices, slow withdrawal with ventilation is necessary to ensure
adequate tidal volume and minimal airway pressure.
Do not advance the device if the cuff(s) is inflated.
Intubating Supraglottic Airways

The Intubating LMATM (ILMA; LMA North America, San Diego, CA), known as the LMA FastrachTM,
was described by Dr. Archie Brain in 1997 in the British Journal of Anaesthesia (Fig. 6.10). Shortly
thereafter, it became available for commercial use in the United States. The ILMA provides an
alternative method of intubating the difficult airway while allowing ventilation during the process.
This airway device exhibits a moderately high success rate for blind intubation (90% to 96.2% with
3 attempts or adjusting maneuvers). When used with a FOB, however, success is even greater
(up to 100%). The ILMA comes in three adult sizes (3, 4, and 5), and all have a large enough lumen
56
Figure 6.10 LMA Fastrach.

to accommodate size 8.0 mm ID ETs. The ILMA has the basic features of a classic LMA with a few
important modifications. It has a rather acute angulation, as well as a rigid guiding handle. There is
a specific ILMA ETT that is wire-reinforced and designed with a special designed tip to allow for
atraumatic passage through the glottis. The presence of an epiglottic elevating bar is another variation from the classic LMA. This allows a clear path for the ETT to enter the trachea. A transverse
depth marker indicates the depth at which the tip of the ETT is at the level of the mask aperture.
The insertion technique allows for standard insertion of the ILMA and inflation of the ILMA cuff,
followed by insertion of the ETT through the LMA and into the trachea.
There are several maneuvers that can be performed to allow an increased chance of a successful
intubation via this device. Once the ILMA is placed, it should be repositioned by slight movements
either in or out while hand-ventilating the patient. The breathing circuits expiratory valve should
be partially closed to allow increased positive pressure within the breathing circuit. Utilization of
the Chandy (two-step) maneuver has been shown to improve the success rate of blind intubation
with the ILMA and should be performed. The guide handle is used to rotate the ILMA slightly
within the sagittal plane to the position in which there is minimal resistance to bag ventilation (step
one). By performing this maneuver, a downfolded epiglottis can be cleared. Tidal volumes can also
be noted, and the best tidal volume should coincide with the least resistance. Following this, as
the lubricated ETT is introduced, the guide handle is lifted (not tilted) slightly off the posterior
pharyngeal wall (step two). This allows for a smooth passage of the ETT.
Removal of the ILMA following endotracheal intubation is recommended, as there are reports
of mucosal injury resulting from its rigidity. The LMA stabilizer rod is used to maintain the ETT in
place while removing the ILMA. It is important to ensure proper oxygenation of the patient prior
to the following steps. First, removal of the ETT connector is performed, followed by deflation of
the ILMA cuff, but not the ETT cuff. The ILMA is gently removed while counterpressure is applied
to the proximal end of the ETT. Once the proximal end of the ILMA is even with the ETT, the
LMA stabilizer rod is inserted to keep the ETT in place until the ILMA is completely removed.
Video 6.4 Endotracheal Intubation using the Intubating LMA
Intubating Laryngeal Mask Airway Tips

The ILMA allows for passage of an ETT via its lumen. A specific ILMA ETT was designed
for this purpose; it is wire-reinforced and has a special shaped tip.
Blind placement of a polyvinyl chloride ETT can be traumatic; it should be warmed in a
bottle of irrigating solution and used in combination with a FOB.
Similarly to traditional LMA placement, the ILMA, should be passed along the hard palate,
while holding the handle.
Following proper placement of the ILMA, small advancing and withdrawing maneuvers
(5 cm) should be performed until the best ventilation is obtained. This usually clears a
downfolded epiglottis and assures proper position.
Blind tracheal tube passage via an ILMA without good ventilation will likely result in failure.
It is best to assure adequate ventilating prior to intubation attempts.
The dedicated ETT, with the vertical black line facing the operator, should be well lubricated and passed through the shaft of the ILMA.
Chandys maneuver has two steps: (1) rotate the ILMA slightly in the sagittal plane using
the handle to assist in obtaining adequate ventilation, and (2) lift the ILMA perpendicularly
by the handle away from the posterior pharyngeal wall as the ETT is advanced. A third
maneuver, such as thyroid pressure, may also be performed to allow smooth passage of
the ETT into the trachea.
If resistance to ETT advancement occurs, then it is most likely caused by a downfolded
epiglottis or impaction into of ETT against the arytenoids. Correction is achieved by slight
withdrawal of the ETT or ILMA. Alternatively, a different sized ILMA may be necessary.
57
It is important to remove the stabilizer rod prior to unthreading the ILMA over the ETT, as damage may occur to the pilot balloon. It is also important to determine that the ETT has not been
displaced during the procedure. After proper positioning is confirmed, the ETT connector is reattached to the ETT and ventilation may be resumed.
Resistance to ETT advancement may be caused by impaction of the ETT into the tracheal wall.
If this occurs, then a slight withdrawal of the ETT with rotation during subsequent advancement
should correct the problem. If this fails, then the problem might be a downfolded epiglottis and
correction of this problem may require slight withdrawal of the ILMA (no more than 6 cm) and
reinsertion or complete withdrawal. Do not deflate the cuff during this maneuver. If the ILMA is
too small, then the epiglottis will be out of reach of the epiglottic elevating bar. Attempting to
pass the ETT through the ILMA will result in obstruction about 3 cm following the transverse line
on the ETT. A larger ILMA may be required in this instance; if one is not available, then elevation
of the thyroid cartilage can improve conditions for intubation. Alternatively, if a too-large ILMA
is placed, then resistance may be noted about 4 cm to 5 cm past the depth marker. If this occurs,
then the ETT may be wedged between the mask tip and the cricoid cartilage. If an alternate sized
ILMA is not available, then caudal displacement of the larynx via mild pressure on the thyroid
cartilage may facilitate endotracheal intubation. The ILMA has been used with a great deal of
success with individuals having Mallampati 4 airways, cervical spine injuries, and other challenging
airways.
58
Following verification of proper placement of the ETT, removal of ILMA is accomplished
by deflation of ILMA cuff and removal of ILMA with the use of a stabilization rod to keep
the ETT from becoming displaced. When the pilot cuff is at the entrance of the ILMA, the
ETT should be reachable at the oropharynx. The stabilization rod is then removed, followed by removal of the ILMA. The ETT connector should be removed prior to insertion
of the stabilization rod into the ETT.
If desired, FOB may be used to aid placement of the ETT and should be considered when
blind placement fails.
Adequate lubrication of the ETT, as well as ample head and neck extension, may enhance
the success of intubation via the ILMA.
The airQ Intubating Laryngeal Airway (ILA; Cookgas, Mercury Medical, Clearwater, FL) was
invented by Dr. Daniel Cook and introduced into clinical practice in 2004. It is specially designed
with a hypercurved tube to mimic the anatomy of the oropharynx (Fig. 6.11). This helps prevent
excessive bending and kinking of the airway tube. Also, its large oval mask cavity allows intubation with standard ETTs. Another feature is the keyhole design of the airway outlet, which aids in
directing the ETT toward the laryngeal inlet. In addition, three internal ridges are located in the
distal portion of the mask, and these attempt to mimic the shape of the posterior pharynx. This
provides increased airway stability, smooth insertion, and better airway alignment. Three sizes are
available: 2.5 for 20 kg to 50 kg, 3.5 for 50 kg to 70 kg, and 4.5 for 70 kg to 100 kg patients. Prior to
insertion, deflation of the cuff is followed by application of water-based lubricant to the posterior
aspect of the ILA.
The insertion technique is similar to the LMA, with special attention to the possible need
for minor manipulation to advance the ILA past the upper pharynx. If intubation of the trachea
is desired, then proper placement of the ILA should be assured by assessing adequate ventilation, as well as relaxation of the laryngeal musculature and vocal cords with either adequate
anesthesia/muscle relaxants or adequate topicalization. To facilitate proper placement, the
Klein Maneuver, in which the air-Q is withdrawn and reinserted with a jaw thrust, can be
performed by grasping the lower incisions. The patient should be ventilated with 100% oxygen
for 3 minutes to 5 minutes prior to attempting endotracheal intubation. The ETT should also
be lubricated and its cuff deflated. Insufflation of the cuff with 4 mL to 7 mL of air should prevent the mask from being placed too deeply, which would place the keyhole aperture under
the larynx instead of proximal to it. The connector of the ILA should be removed, and the
ETT should be inserted to a depth of 12 cm to 15 cm. This should ensure that the tip of the
ETT is at the opening of the ILA tube within the mask cavity. Further advancement may be
accomplished with a FOB, a stylet, or using a blind approach. If the FOB method is used, then
the FOB is advanced into the trachea, the carina is visualized, and the ETT is advanced over
it using the FOB as a guide. The FOB is then removed and the ETT is attached to the circuit,
followed by assessment of adequate ventilation. If an intubation stylet is used, it should be
passed through the ETT into the trachea. The stylet may be felt passing over the cricoid ring,
and the ETT may be advanced over the stylet into the trachea. Following inflation of the ETT
cuff, its connector is replaced and the stylet is removed. Verification of the correct position is
determined by assessing expired carbon dioxide. If a blind technique is utilized, then the ETT is
slowly advanced through the ILA into the trachea. Capnography can be utilized throughout the
positioning either in the spontaneously ventilating patient or via position pressure ventilation in
the anesthetized and paralyzed patient.
59
Figure 6.11 airQ Intubating Laryngeal Airway (ILA).

(Copyright image provided courtesy of Mercury Medical, Clearwater, FL.)
Verification of correct position is as described above. After successful intubation of the trachea
is accomplished, the ILA Removal Stylet is placed into the ETT until a snug fit is obtained. The
stylet adapter is then rotated 90 until the adapter engages the ETT. The cuff of the ILA is then
deflated, and the ILA is slowly removed over the ETT-ILA stylet until removed from the patients
mouth. Subsequently, the ILA stylet is rotated oppositely and removed from the ETT. The ETT
connector is then replaced, and proper position of the ETT is reconfirmed. Additional tips to
successful placement include adequate lubrication, ample head and neck extension, and use of a
Parker Flex TipTM tracheal tube (Parker Medical, Highlands Ranch, CO). Advantages of the ILA
over the ILMA include its design, which facilitates reliability and ease of insertion. Additionally, it
can be left in place following intubation and is designed to accommodate standard polyethylene
ETTs. Finally, the ILA Removal Stylet is designed with grooves to allow spontaneous ventilation
through the ETT during its exchange. The ILA can remain in place, with its cuff deflated. It can be
used as a bridge to extubation, in which at the end of the procedure, the ETT can be removed
while the patient is still under deep anesthesia or awake, as in routine extubation. The ILA can
then be removed when the patient is completely awake.
Video 6.5 Fiberoptic-guided Intubation via the airQ ILA
60
Air-Q Intubating Laryngeal Airway (ILA) Tips
The hypercurved tube design of the ILA prevents bending and kinking of the airway tube.
The keyhole design of the airway outlet aids in directing the ETT toward the glottis.
No specialized ETT is necessary; a standard ETT is appropriate.
Adequate lubrication of the ETT, ample head and neck extension, and use of Parker Flex
Tip tracheal tube may be used to enhance the success of intubation via the ILA.
Physical maneuvers, such as ample head and neck extension and slight withdrawal and
reinsertion of the device, along with jaw thrust, may also enhance intubation success.
To enhance success, a FOB may be used to aid placement of the ETT.
The ILA Removal Stylet should be used for safe removal of the ILA. After removing the
ETT connector, insert the ILA Removal Stylet into the ETT and perform a 90 rotation to
engage the stylet. Following this maneuver, the ILA cuff is deflated and removal of the ILA
is performed. The ILA stylet should be rotated in an opposite fashion for its removal from
the ETT.
Figure 6.12 The Ambu Aura-iTM shown with the Ambu aScope.
(Copyright image provided courtesy of Ambu Inc., Glen Burnie, MD.)
Rescue Maneuvers
Difficulties may arise during placement of any of the SADs. Difficulty in placing an LMA is most
often caused by improper placement technique or inappropriate size of the LMA. Proper placement can be verified by performance of a leak test by partially closing the expiratory valve; 16 cm
to 20 cm water pressure should be reached prior to auscultation of a leak. Also, correction of
improper placement can be performed by 2 cm to 4 cm movement of the LMA and rechecking
for a leak, as noted. If these actions do not correct the problem, then a different size LMA (usually
smaller) is needed. Alternatively, breath holding may occur if the depth of anesthesia is insufficient. This can be corrected by administration of topical, inhalational, or intravenous anesthesia.
Difficulty with Combitube, Easy Tube, or Laryngeal Tube placement can also occur. Lifting the jaw
with the nondominant hand or insertion of the device laterally initially may facilitate placement.
Although not necessary, direct laryngoscopy can also facilitate placement of any of the supraglottic devices.
Summary
The introduction of the LMA has been described as the most important advance in airway management over the last 50 years. Since the initial Classic LMA developed by Archie Brain the 1980s,
there have been numerous advances in SADs that enable the caregiver to not only ventilate but
also to use as a conduit for endotracheal intubation.
Common problems associated with placement of a SAD include improper insertion (most often
too deep), securing the device inadequately, and cuff over-inflation. Advantages of SADs include
low cost, ease of training personnel, and a wide variety of styles suitable for different patients.
Suggested Reading
Verghese C, Mena G, Ferson D, Brain AI. Laryngeal mask airway. In: Hagberg CA, ed. Benumofs
Airway Management 3rd ed. Philadelphia, PA: Mosby Elsevier; 2012:443465.
Cook TM, Hagberg, CA . Non-laryngeal mask airway supraglottic airway devices. In:
Hagberg CA, ed. Benumofs Airway Management, 3rd ed. Philadelphia, PA: Mosby Elsevier;
2012:466507.
Dorsch JA, Dorsch SE. Supraglottic airway devices. In: Understanding Anesthesia Equipment,
5th ed, Philadelphia, PA: Lippincott Williams and Wilkins; 2008:461519.
61
The Ambu Aura-iTM (Ambu, Copenhagen, Denmark) was only recently introduced into clinical practice. It has a curved design (Fig. 6.12) that allows easy passage into the pharynx and its
desired location, like the previously mentioned intubating conduits. It has the ability to pass an
ETT through it to perform endotracheal intubation. This is accomplished by placing the appropriately sized, lubricated ETT into the Aura-i. An ETT size guide is present on the tube portion
of the Aura-i. A FOB is then placed into the ETT and guided through the glottis. The ETT is then
advanced over the FOB into the trachea and the FOB removed. Confirmation of proper placement of the ETT is determined by expired carbon dioxide and auscultation of the chest. Removal
of the Aura-I can be accomplished by the tube-to-tube method, if desired. Otherwise, the
device may be left in place and its cuff deflated. The cuff can be reinflated at the end of the surgery
and the device used as a bridge to extubation, as mentioned above. Currently, there have not
been any descriptions of blind intubations using the Aura-i.
63
Chapter 7
Endotracheal Tubes and

Laryngoscopy Techniques
Objectives
Discuss the most current, commonly used endotracheal tubes.

Describe the use of double-lumen endotracheal tubes and bronchial blockers.
Describe direct laryngoscopy using Miller and Macintosh blades.
Discuss types and use of indirect rigid laryngoscopes and video laryngoscopes.
Introduction
The use of an endotracheal tube (ETT) for ventilation of critically ill patients or patients requiring inhalational anesthesia is well documented. Several types of ETTs have been developed to
aid in anesthetic delivery for a variety of surgical procedures. Especially important is the use of
double-lumen ETTs for one lung ventilation. Until the mid-1990s, direct laryngoscopy with either
a Miller or Macintosh laryngoscopy blade was the only game in town. Since that time, new laryngoscopes have been developed, including both indirect rigid and video laryngoscopes (VLs). These
new devices have greatly improved the ability to manage difficult airways.
Endotracheal Tubes
Although there are many types of ETTs, this chapter will be limited to single-lumen ETTs,
double-lumen ETTs, and their most popular variants.
Single-Lumen ETTs
The single-lumen tube is the most commonly used ETT. It has the advantages of low cost and
availability in multiple sizes, shapes, and features (e.g., laser, reinforced, accessory port for suctioning, etc.). The most commonly used sizes of oral ETT are 7.0 mm for adult females and 8.0 mm
for adult males. Although a larger size can be tolerated, there is risk of tracheal mucosal injury as
well as damage to laryngeal structures. Using a smaller ETT is associated with increased turbulent
7 Endotracheal Tubes and Laryngoscopy

Techniques
64
airflow, which leads to increased work of breathing. In addition, blockage of the ETT with secretions or by positioning of the head or neck can compromise the internal diameter.
The Endotrol ETT (Covidien, Mansfield, MA; sizes 4.09.0 mm) has a unique design that allows
anterior displacement of the tip of the ETT by pulling on a pull ring attached to a plastic cable running on the concave surface of the ETT (Fig. 7.1). The Endotrol tube has been used for blind oral
or nasal intubations as well as in conjunction with video laryngoscopy. Following intubation, care
must be taken to ensure the pull ring is not continuing to exert pressure on the tip of the ETT.
This has been reported to cause obstruction with the ETT tip abutting the tracheal wall.
The Parker Flex-TipTM ETT (Parker Medical, Highlands Ranch, CO; sizes 2.59.5 mm) has a
flexible, curved, centered, tapered distal tip geometry that is designed to facilitate rapid, easy,
nontraumatic intubation (Fig. 7.2). When this is advanced into contact with protruding features of
the airway (such as the vocal cords or nasal turbinates), it is designed to flex and slide gently past
them, rather than impinging on them and causing trauma. The Parker Flex-Tip ETT is available in
a wide variety of formats including cuffed and uncuffed models ranging in whole and half sizes from
4.0 mm to 9.5 mm and 2.5 mm to 7.0 mm, respectively. It is also available in a reinforced model
(sizes 3.05.0 mm uncuffed, and 5.59.5 mm cuffed). Finally, it is also manufactured in preformed
oral and nasal formats, cuffed as well as uncuffed. The uncuffed run from 3.0 mm to 7.0 mm, and
the cuffed is available from 4.0 mm to 9.0 mm.
The Endoflex ETT (Merlyn Associates, Tustin, CA; sizes 4.010.0 mm) enables manipulation
of the distal tip of the ETT into proper position without the use of a stylet. A nylon cable is connected to a friction lock on the ETT near the universal connector (Fig. 7.3). Withdrawal of the
friction lock articulates the distal tip of the EndoFlex ETT. This allows easier passage of the ETT
through the glottic opening. Release of the friction lock allows the EndoFlex ETT to resume its
(A)
(B)
Figure 7.1 The Endotrol ETT in (A) neutral conformation and (B) with traction on the pull-ring resulting in anterior
displacement of the tip.
(Reprinted with permission from Cattano D, et al. Endotrol tracheal tube assisted endotracheal intubation during video laryngoscopy.
Intern Emerg Med. 2012;7(1):5963.)
Figure 7.2 Parker Flex-TipTM ETT (Parker Medical, Highlands Ranch, CO).
Figure 7.3 Endoflex ETT.

(Copyright image provided courtesy of Intersurgical, Liverpool, NY.)
initial form. The EndoFlex ETT has been used with a variety of VLs. It is also available in preformed oral and nasal as well as cuffed and uncuffed models. Finally, it has two cuff variations:
a low-volume, tapered cuff or an elongated, rounded high-volume/low-pressure cuff. Although
there are many different bronchial blockers currently available, only a few will be addressed in
this chapter.

Techniques
65

Techniques
66
If one-lung ventilation is desired yet utilization of a double-lumen tube (DLT) is impractical

because of difficult airway anatomy, decreased size of the tracheal lumen, or a need for postoperative mechanical ventilation, then placement of a bronchial blocker via a single-lumen ETT may
be indicated.
The Univent (Fuji Systems; Tokyo, Japan) is a single-lumen ETT that has a small channel within
its wall through which a bronchial blocker passes (Fig. 7.4). It underwent design modifications in
2001. The new Torque Control Blocker (TCB) Univent has a more flexible shaft made from a
softer, more compliant, medical grade material that is easier to direct. The bronchial blocker has
a lumen that allows suctioning of the collapsed lung as well as a low-pressure, high-volume cuff.
Initial placement of the Univent is the same as any single-lumen tube, with the exception that
following insertion through the glottic opening, the ETT is rotated 90o to allow passage of the
bronchial blocker into the targeted bronchus. The position of the bronchial blocker is verified by
use of a fiberoptic bronchoscope (FOB). Following placement, a locking cuff at the proximal end
of the blocker is secured. Tips for successful placement include rotation of the head, as well as
placement of the bronchoscope into the contralateral bronchus to divert the bronchial blocker
to the desired location.
The Arndt Endobronchial Blocker (Cook Critical Care; Bloomington, IN) or wire guided
endobronchial blocker has a distal snare designed to ensnare a FOB (Fig. 7.5). The FOB is then
advanced into the desired bronchus. The loop is loosened and the blocker may be advanced distal
to the FOB into the selected bronchus. This device may be utilized when the patient is already
intubated and switching to a DLT is undesired or potentially dangerous. This is available in a 5 Fr
pediatric size and a 9 Fr adult size.
The Cohen Endobronchial Blocker (Cook Critical Care; Bloomington, IN) has a rotating
wheel that easily deflects the soft tip into the desired bronchus. The blocker cuff is pear-shaped
and takes approximately 6 mL to 8 mL to seal the bronchus. The blocker size is 9 Fr with a 1.6
mm central lumen that allows limited suction and oxygen insufflation.
Double-Lumen Endotracheal Tubes

When there is a need for one-lung ventilation, a DLT may also be utilized. Indications include lung
isolation because of infection or hemorrhage, need for bronchial pulmonary lavage, and control of
distribution of ventilation. There are both advantages and disadvantages with use of a DLT. When
positioned properly, the DLT allows independent ventilation of each lung, either separately or
Figure 7.4 Univent.


Techniques
67
Figure 7.5 Arndt Endobronchial Blocker (Cook Critical Care; Bloomington, IN).
in unison. Additional advantages include treatment of desaturation, larger lumen for suctioning,
egress of gases, and, finally, more secure positioning. The DLT has a bronchial port and a tracheal
port. These are designated as left or right, depending on whether the bronchial port goes to the
left or right bronchus. The bronchial port, cuff, and connector are blue. The tracheal port, connector, and cuff are clear. The DLT comes in a variety of sizes, and most commonly a left DLT is
selected to avoid blockage of the right upper lobe bronchus. Although right-sided DLT placement
is more difficult, it may be indicated with tracheal or left mainstem bronchus abnormalities. The
ideal size results in a rear seal of the bronchial lumen with an uninflated cuff. Generally, a 37 Fr
DLT is utilized for the adult female and a 39 Fr DLT is used for the adult male, although adult
sizes also include 35 and 41 Fr. Sizes 20 Fr and 32 Fr are also available. The appropriate depth of
insertion of the DLT correlates with the height of the patient. For patients 170 cm to 180 cm tall,
the average depth for a left-sided DLT is 29 cm. The DLT should be either advanced or withdrawn
1.0 cm for every 10 cm increase or decrease in height.
The intubation technique requires the DLT to be placed in the oropharynx in an anterior-posterior orientation until the bronchial port passes through the glottis. The stylet is then removed
and the tube is rotated 90 to the side of the bronchial lumen. It is important to remove the
stylet prior to advancement to avoid damage to the laryngeal or tracheal mucosa. If resistance is
met when attempting to advance the DLT, then a smaller size should be considered. Following
placement of the DLT into the trachea, fiberoptic verification of the location of the bronchial port
should be determined. The blue bronchial cuff should be positioned just below the carina in the
appropriate bronchus. Inflation of the blue bronchial balloon under direct visualization helps verify
proper placement. Care should be taken to ensure that the bronchial cuff does not herniate over
the carina and that the tracheal cuff does not block the carina. Following verification of positioning
of the bronchial port, it is possible to isolate a lung by inflating the bronchial cuff and clamping
either the tracheal or bronchial connector. If a DLT was used for lung separation, then the risks
and benefits of changing to a single-lumen tube (SLT) must be considered. The main advantage

Techniques
68
to leaving the ETT in place is that the hazards associated with an ETT change in a difficult airway
are avoided. If the DLT is to be changed, then it should be done under direct vision, if possible. If
adequate laryngeal exposure is not possible via DL or VL, then an airway exchange catheter (AEC)
may be used to exchange a SLT for a DLT pre-operatively or a DLT for a SLT postoperatively.
The AEC by Cook specifically designed for DLT exchange is extra firm, which is stiffer, although
its distal tip is actually flexible.
One Lung Ventilation: Double-Lumen Tube and Bronchial Blockers Tips

Use of a DLT is considered the gold standard for one-lung ventilation.
To minimize the risk of tube displacement, the left mainstem bronchus should be intubated unless a left-sided DLT will interfere with surgery (e.g., a left pneumonectomy).
Right-sided DLTs are more difficult to place properly because of the risk of obstructing
the right upper lobe bronchus.
A FOB should be used to verify position of the endobronchial cuff following placement.
A Univent tube or SLT with an endobronchial blocker should be considered if a difficult
airway is anticipated, postoperative mechanical ventilation is considered, or the patient is
already intubated.
Ventilation with 100% oxygen during the use of FOB is strongly recommended when used
for DLT or SLT and bronchial blocker placement.
Generous application of lubricant to the FOB will aid with its utilization during positioning
of the bronchial blocker.
The DLT, with its larger lumen, provides better suctioning of the bronchus as well as more
rapid deflation of the desired lung.
Identify problems early. In the event of oxygen desaturation, verify proper placement of
the bronchial and tracheal tube, utilize 100% oxygen, and ensure adequate ventilation.
If DLT is used, then the nondependent lung can have CPAP applied providing partial
re-expansion of the nondependent lung. Unfortunately, if a bronchial blocker, with its
obstructive design, is used, CPAP cannot be applied to the nondependent lung.
Removal of the bronchial blocker at the conclusion of the operation will allow for continued ventilation with the in situ SLT.
CPAP = continuous positive airway pressure
Direct Laryngoscopy
Direct laryngoscopy requires direct visualization of the airway anatomy by the individual performing the intubation via the use of a laryngoscope. Preparation of any necessary equipment, as well
as adequate patient positioning, is required to ensure optimal conditions for successful endotracheal intubation.
There are two basic types of laryngoscope blades: curved, similar in design to the Macintosh
blade (Fig. 7.6), or straight, similar in design to the Miller blade (Fig. 7.7). Both are designed for
right-handed individuals; with the laryngoscope handle held in the left hand and the ETT held and
passed into the trachea with the right hand. There are numerous variations of size and shape of
these two basic designs. Insertion of the laryngoscope into the patients mouth requires prior
assessment of the patients dentition to determine existing or anticipated dental issues. In the
Figure 7.6 Macintosh blade.
Figure 7.7 Miller blade.
69
Techniques
case of obviously damaged or loose teeth, the patient must be informed of the possibility of
injury to these teeth during intubation. There are numerous brands of these preformed dental shields that reduce the force applied to the teeth and potentially reduce the probability of
tooth damage during laryngoscopy. However, the shield with the most force reduction capability,
Ormco SportsGuardTM, (Ormco Corporation, Orange, CA) is rather large and relatively expensive. Nonetheless, protection can also be accomplished with either a small gauze pad or alcohol
wipe package. These maneuvers can cause decreased visibility of the glottis if the patient has
decreased mouth opening.
Following proper patient positioning, preoxygenation, and administration of general anesthesia,
it is important to assess the ability to mask-ventilate the patient prior to the administration of a
paralytic agent. Following these steps, insertion of the laryngoscope into the mouth can follow

Techniques
70
one of two methods. The extra-oral technique requires extension of the neck by placing the right
hand on the vertex of the skull and moving it in a posterior fashion. Alternatively, the scissors
maneuver involves using the thumb of the right hand pressing downward on the lower right molar
teeth while the right index finger applies pressure to the right upper molars. This is then followed
by insertion of the blade into the mouth and retraction of the lower lip with the little finger of
the left hand. Both of these versions then require slow advancement of the Macintosh blade into
the mouth and movement of the tongue to the left. Also, special concern to keep pressure off the
lips and teeth is accomplished by lifting the laryngoscope in a 45 direction after placement into
the vallecula (where the base of the tongue meets the epiglottis.) If a straight blade is used, the tip
of the laryngoscope blade is placed at the posterior surface of the epiglottis and then elevated to
expose the glottis. It is important to lift the laryngoscope with the left shoulder and arm, as flexing
the wrist might cause damage to the upper teeth or gum. Following glottic visualization, advancement of the ETT between the vocal cords is accomplished. Verification of proper placement of
the ETT is determined by visualization of the ETT passing through the glottis, auscultation of the
lungs, and verification of expired carbon dioxide.
Curved blades are likely to be less traumatic to the teeth and epiglottis and have a lower incidence of laryngospasm than straight blades. Another advantage of the curved blades is that they
provide more space for passage of the ETT through the oropharynx. The straight blade, on the
other hand, gives a better view of the glottis in patients with a floppy epiglottis or anterior larynx.
This is beneficial in infants and children. Also, comparison of curved and straight blades shows
less force, head extension, and cervical spine movement with the straight blade. Improvement of
the view of the larynx can be accomplished via external laryngeal pressure by applying backward,
upward, and rightward pressure (BURP) to the thyroid cartilage. The individual performing the
laryngoscopy can apply the pressure initially with his right hand and then have an assistant apply
the same pressure at the time of intubation.
A common problem associated with laryngoscopy is insertion of the blade too deeply into the
pharynx, which causes elevation of the larynx and visualization of the esophageal opening. Slight
withdrawal of the blade usually corrects this issue. Also, if the tongue flips into the right side of
the oropharynx, then obstruction of the glottic view may occur. This is corrected by repositioning
the tongue in the correct position onto the left side of the laryngoscope blade. Additional space
can be created by pulling the right lip or cheek laterally.
Direct Laryngoscopy Tips

Assessment of the airway is critical prior to attempting laryngoscopy.
Following preoxygenation and induction of anesthesia, assessment of ability to ventilate
the patient is necessary prior to administration of paralytic agents.
If a Macintosh blade is used, then the tip of the blade should be placed into the vallecula.
Alternatively, if a Miller blade is used, then the blade should elevate the posterior aspect
of the epiglottis.
The blade is then lifted in a 45 angle to avoid injury to teeth or lips.
Following visualization of the glottis, the ETT may be introduced between the vocal
cords.
The number of intubation attempts should be kept to a minimum (usually < 3) to minimize
airway trauma.
If it is difficult to pass the ETT, then turn the ETT 90 counterclockwise to facilitate ETT
passage through the glottis. If difficulty continues, then an intubation stylet may be utilized.
Special ETTs, such as the Parker Flex-Tip tube, may also be considered.
The Bullard LaryngoscopeTM (BL; ACMI Corporation, Southborough, MA) was developed by
Dr. Roger Bullard and introduced into clinical practice in the late 1980s. This is an indirect rigid
fiberoptic laryngoscope that has a blade specially designed to follow the contour of the oropharynx and rest under the epiglottis (Fig. 7.8). As the blade is anatomically shaped, this allows indirect
laryngoscopy without the usually required alignment of the oral, pharyngeal, and laryngeal axes.
This is beneficial for patients with limited mouth opening or cervical spine instability. Two light
sources are available: a battery-powered handle or a flexible fiberoptic case connected to a highintensity light source (e.g., halogen or xenon). The eyepiece has an attachable diopter for correction of visual acuity. A video camera may be attached to the eyepiece.
The BL may be used in awake or anesthetized patients. If using one of the stylets, they must be
lubricated and attached to the BL in the appropriate fashion. If the older, solid stylet is used, then
the ETT adaptor should be removed and the ETT should be positioned properly over the stylet
so that the distal end of the stylet projects through the Murphy eye of the ETT. If the newer,
hollow-core stylet is used, then the ETT is simply passed over and not threaded through the
Murphy eye. A 3.7 mm channel with a Luer-Lock connection can be used for suction, oxygen insufflation, or the administration of local anesthetics. A second part accepts a nonmalleable intubating
stylet, designed to follow the contour of the laryngoscope blade.
The ETT should be warmed and lubricated prior to placement over the stylet. Anti-fog solution is applied, and the insertion of the BL into the oropharynx begins with the handle in a horizontal fashion, which is then rotated to the vertical plane upon insertion into the oropharynx.
Subsequently, the blade is moved in a slightly caudad-posterior fashion and then lifted vertically.
Once the glottis is visualized, the ETT is advanced off the stylet and into the trachea. The BL is
then moved to the horizontal position and removed from the mouth.
A common problem encountered with the BL occurs when the operator attempts to use the
eyepiece continuously during insertion. The first viewing through the eyepiece should occur when
the BL has been placed in the oropharynx behind the tongue. Occasionally, the tip of the ETT may
impact the right arytenoid. If this occurs, a slight movement of the BL to the left should correct
the problem. Alternatively, the ETT conformation may be reversed with the bevel pointing to the
right. The BL is a good tool for difficult airways in which the patient has limited mouth opening or
cervical spine movement. It is more rugged than a flexible FOB and more resistant to breakage.
Figure 7.8 Bullard LaryngoscopeTM (ACMI Corporation, Southborough, MA).
71
Techniques
Indirect Laryngoscopy

Techniques
72
Disadvantages include a limited angle of vision, problems with cleaning, a slightly longer time for
intubation than direct laryngoscopy, and possible anterior placement of the stylet with an ETT
greater than 7.5 mm. With the advent of VLs, the use of the BL has decreased.
Bullard Laryngoscope Tips

Prepare the BL by using a lens defogger on the distal tip of the BL prior to insertion. The
oropharynx should be freed of secretions either by the use of suctioning or administration
of an antisialagogue.
Use a tongue depressor to move the tongue anteriorly while placing the BL midline into
the oropharynx.
There are two different stylets (one hollow, the other solid) that can be attached to the
BL to facilitate intubation. The stylets should be lubricated with an oil-based lubricant so
that the ETT can be easily advanced. Always load the ETT so as the ETT remains behind
the distal lens. If neither stylet is utilized, then a styletted ETT may be considered.
If one of the stylets is to be used, then always keep the stylet tucked in the proper position under the blade, using the thumb of your dominant hard. The tip of the stylet should
always be visualized when viewing via the eyepiece/monitor.
Once positioned in the oropharynx, do not lift the blade until a view of the glottis is
achieved. It may not be necessary to lift the blade.
A plastic blade extender can be used to add length to the blade and lift a very floppy
epiglottis.
Remember that the ETT is advanced over the stylet from the right of the device; therefore, the glottic view should be at the 10 oclock position.
Video Laryngoscopy
Video laryngoscopy has revolutionized the practice of airway management, and its use may
become standard not only for difficult airways but for routine airways as well. In fact, VL is now
included in the ASA Difficult Airway Algorithm and should be considered for patients with a
known difficult airway. There are several advantages of these devices over direct laryngoscopy
their design often improves laryngoscopic views and increases intubation success in patients with
difficult airways. Their use may be considered for expected or unexpected difficult airways, either
as a primary device or as a rescue technique. There are several types of VLs currently on the
market that differ in terms of portability, disposability, blade angulation, channeled versus nonchanneled, direct versus indirect vision, necessity for application of lens defogger, use of a stylet,
and so forth. Although there is a steep learning curve with their use, these devices are not without
complications or failure. When using any of the VLs, the oropharynx should be free of secretions
either by suctioning or the use of an antisialagogue.
The Berci-Kaplan DCI (Direct Coupler Interface) Video Laryngoscope (Karl Storz GmbH,
Tuttlingen, Germany) uses a Macintosh blade with a video camera and light source adapter placed
into the handle. A cable from the handle attaches to a video monitor. This allows the image from
laryngoscopy to be displayed on a video monitor, which allows easier viewing of the glottic opening and less anterior lifting of the blade. The C-MAC (Karl Storz GmbH, Tuttlingen, Germany)
is a newer version of this system and has an integrated video camera in the blade. The viewing
angle is 60 to 80, much larger than the 10 to 15 seen with standard DL. Still and video images
may be stored on a memory card of the C-MAC. The D-Blade (Karl Storz GmbH, Tuttlingen,

Techniques
73
Figure 7.9 C-MAC System with D-Blade (Karl Storz GmbH, Tuttlingen, Germany).
Germany) is the newest addition to the C-MAC system (Fig. 7.9). It has an elliptically shaped blade
that curves more anteriorly than other VL blades, allowing for an easier glottic view in difficult
laryngoscopy situations. The viewing angle is also 60 to 80. It has been designed to be used when
the C-MAC has failed or difficulty is expected with direct laryngoscopy. Use of these VLs requires
application of anti-fog solution to the tip of the image light bundle. These devices allow for direct
laryngoscopy or VL, as needed. As minimal cervical spine movement is needed for use of these
devices, they are especially useful for patients with a cervical spine injury.
C-Mac, D-Mac Tips

Apply anti-fog solution to the lens prior to use.
If the epiglottis hinders the view, use the curved blade as a straight blade.
Utilization of stylet will assist in placement of ETT, although not necessary. The stylet
should be passed to the level of the Murphy eye of the ETT, and shaped as J.
GlideScope Video Laryngoscopes: The GlideScope, (Verathon Inc., Bothell, WA) was developed by Dr. John Allen Pacey and was introduced as the first commercially available VL in 2001. It
has a bend of 50 to 60 in the middle of its blade. It also has a video camera, a light emitting diode
near the tip of the blade, and a heated lens that helps to prevent fogging. The image is displayed
on a video monitor. A special stylet, the GlideRite Stylet (Verathon, Bothell, WA), which is preformed to the curve of the blade, is recommended when using the GlideScope (Fig. 7.10).

Techniques
74
Figure 7.10 GlideRite Stylet.
Under direct visualization, the blade is placed in the midline, and advanced into the oropharynx.
When the blade is beyond the soft palate, it can be advanced under videoscopic guidance. The
blade should be advanced into the vallecula but not farther, as a better view is obtained if it slightly
more proximal. The styletted ETT is introduced into the mouth and past the right palatoglossal arch under direct vision and then can be passed into the glottic opening using videoscopic
guidance. Care needs to be taken as the styletted ETT passes the base of the tongue so that it
does not cause trauma to the posterior pharyngeal wall. Advancement through the opening is
achieved by simultaneous withdrawal of the stylet and advancement of the ETT. If problems arise
with the advancement of the ETT into the glottis, then a counterclockwise rotation of the ETT
will often allow the ETT to fall into the airway. Using the GlideScope as straight blade by lifting the epiglottis provides a better view of the vocal cords but this often creates a worse angle
of entry for the ETT and should not be performed. A slight withdrawal of the laryngoscope will
reduce upward laryngeal tilting, thereby reducing the angle between the ETT and the trachea.
Use of the pediatric GlideScope has been suggested for adult patients, as this reduces the depth
of blade insertion and makes ETT advancement easier. Finally, some anesthesiologists prefer to
place the styletted ETT into the mouth prior to placement of the GlideScope, as this decreases
the likelihood of creating extra bends and encourages the operator to look at the patient and not
the monitor while inserting the ETT.
There are several GlideScope products currently available. First, the GlideScope Video
Laryngoscope (GVL) utilizes a reusable blade that connects to the video monitor. It is available
in four sizes (2, 3, 4, 5) to accommodate small children to the morbidly obese, adult patient. The
GVL (reusable) provides a clear view of the airway and tube placement, which enables quick
intubation. Next, the GlideScope Advanced Video Laryngoscope (AVL) is available in several
different configurations: reusable or single use and the AVL preterm/small child or adult-sized
laryngoscopes (Fig. 7.11). The single-use laryngoscopes utilize a reusable video baton that is
encased in a disposable hard plastic sheath when needed for intubation (Fig. 7.12). The AVL
preterm/small child is available in four sizes from 0 to 2.5. The GlideScope Ranger is also available in either a reusable or single-use design (Fig. 7.13). It is available in two sizes, 3 and 4. It
has a rugged design and is approved for military and EMS use. Finally, the GlideScope Direct
Video 7.1 Tracheal Intubation Using the Glidescope
Figure 7.11 The GlideScope AVL single-use system.

(Copyright materials provided as courtesy of Verathon, Bothell, WA.)
Figure 7.12 The GlideScope AVL reusable system.

75
Techniques
Intubation Trainer (Fig. 7.14) incorporates GlideScope video technology with the feel of a
standard Macintosh blade. This allows instruction of direct laryngoscopy, as an instructor can
observe and critique either direct or indirect intubation technique as it occurs. Both single-use
and reusable blades are available for use with this device.

Techniques
76
Figure 7.13 GlideScope Ranger.

Figure 7.14 GlideScope Direct Intubation Trainer.

GlideScope/GVL/AVL/Ranger Tips
Use an appropriately shaped stylet, such as the GlideRite Stylet, which is specially
designed for use with the GlideScope. Remember to remove the stylet once its tip has
passed through the glottis, to avoid trauma.
Alternatively, a standard, malleable stylet may be used with a 90 bend 8 cm to 10 cm from
the tip. The Truflex stylet (Truphatek International, Netanya, Israel) may also be used
with in conjunction with the GlideScope (see Chapter 7).
The size 3 blade is suitable for most adult patients.
Enter the oropharynx slightly to the right and displace tongue to the left, if possible, to
create room on the right to manipulate the ETT.
Place the tip of the blade in the vallecula and no further.
If an unacceptable view of the glottis is obtained, then slightly withdraw the blade.
McGRATH Video Laryngoscopes: Matt McGrath started work on the McGRATH (Aircraft
Medical, Edinburgh, UK) VL project in 1999, in response to a design brief issued by the Royal
Society of Arts in London. The McGRATH Series 5 VL was introduced into clinical practice in
2001. It is a fully portable VL with a 1.7-inch LCD screen on the handle that can tilt and rotate if
needed (Fig. 7.15). It has an adjustable blade, which allows its use in different sized patients. The
blade tips are disposable; however, the handle needs to be cleaned between cases. This VL can
be used in a standard direct laryngoscopy fashion. If a better view of the laryngeal anatomy is
warranted, then the practitioner can simply look at the video monitor. Insertion of the blade and
ETT is similar to the GlideScope. Enter the mouth midline and rotate toward the larynx until the
epiglottis is visible. The tip of the blade should be guided into the vallecula. The epiglottis should
clearly be visible at the top of the screen to ensure vallecular placement. Endotracheal intubation
may be enhanced by using an Endotrol ETT. First a stylet is inserted into the ETT with a 30
hockey stick bend. The stylet is inserted only three-fourths of the length of the ETT. This allows
the flexion of the Endotrol ETT to be concentrated at the tip, where it is needed. This allows the
tip of the ETT to be lifted above the posterior cartilages and placed through the glottic opening.
The McGRATH Mac is a newer model that was introduced into clinical practice in 2010. It has
an anterior camera angle that is designed to improve grade of view. Its LCD screen is also located
on the handle, but it is larger at 2.5 inches. The McGRATH Mac also has a narrower blade of
11.9 mm, which allows greater movement without damaging the patients dentition. Prior to use,
it is recommended to apply one or two drops of anti-fog solution on the tip of the blade, unless
the fog-free blades are used.
Video 7.2 Tracheal Intubation Using the McGRATH
The Pentax-AWSTM Airway Scope (Pentax Medical Co., Montvale, NJ) is a portable, batterypowered VL. It has an attached 2.4-inch color LCD screen and an L-shaped introducer blade,
which has a channel for tube loading and delivery, as well as a suction catheter (Fig. 7.16). The
LCD screen has a target to assist in alignment of the screen with the glottic opening. The tip of the
ETT is positioned just proximal to the tip of the camera cable. Like the Bullard, it is inserted into
the oropharynx and directed under the tongue. When viewing the screen, the scope is maneuvered so that there is alignment of the target signal and the glottic opening. The ETT is advanced
through the glottis and then separated laterally from the side channel. The Pentax Airway Scope
works best when the epiglottis is lifted, in a similar fashion to a straight blade laryngoscopy.
Removal of the Pentax Airway Scope is accomplished while holding the ETT in place.
The Airtraq (Prodol Meditec S.A., Guecho, Spain) is a disposable, portable, battery-powered,
optical laryngoscope. It has seven color-coded sizes ranging from infant to adult. It has a pair of
side-by-side channels, one for light and the other for passage of an ETT (Fig. 7.17). The light channels image from the distal tip is displayed on a proximal view chamber. Models have been developed to use with nasotracheal and endobronchial/double-lumen tubes. It has been recommended
that the Airtraq not be used in an anticipated difficult airway if a supraglottic airway cannot be
used (limited mouth opening), high risk of aspiration exists, apneic period cannot be tolerated, or
the patient has gross deformities of the upper airway. Fogging and secretions may also present a

Techniques
77
Keep the tip of the ETT in view by direct vision until it can no longer be visualized, then
look at the monitor to avoid soft palate or posterior pharyngeal trauma.
Only lift as necessary; a grade IIto III view may suffice; do not always try to see a grade I
view or a more difficult angle of ETT entry into the glottis may be created.
If it is difficult to pass an ETT through the glottis, then see tips under BL.

Techniques
78
Figure 7.15 McGRATH Video Laryngoscope.

(Courtesy of LMA North America, San Diego, CA.)
problem. Suctioning the oropharynx or administration of an antisialagogue is encouraged prior to

its use. Application of anti-fog solution is not necessary, as there is a built-in anti-fogging system
for the optics that is activated by turning on the LED light. The Airtraq should be turned on for
3 minutes to 5 minutes to prep the electronic defog system.
The Airtraq should be inserted in similar fashion as the Bullard and Pentax-AWS. Once the
glottis is visualized, the ETT should be advanced. The ETT is then separated laterally from the
channel, and the Airtraq is removed from the mouth. Although visualization of the larynx is easily
obtained with the Airtraq, problems include difficulty changing direction of the ETT during insertion into the glottis. Additional problems may arise if the Airtraq is situated close to the larynx,
as the ETT is often directed into the right aryepiglottic fold. This can be corrected with an initial
leftward turn of the ETT in the channel, followed by an immediate turning of the tip to the right,
which lines up the tip of the ETT with the larynx. Alternatively, ensure that the tip of the Airtraq
is not too deep and close to the glottic opening.
For optimal results, the glottis should be centered in the screen and not above the midline for
successful intubation. If difficulty is encountered in advancing the ETT, then a bougie may be used

Techniques
79
Figure 7.16 Pentax-AWSTM Airway Scope.

(Copyright image provided courtesy of Ambu, Glen Burnie, MD.)
Figure 7.17 Airtraq.

(Copyright image provided courtesy of Prodol Meditec S.A., Guecho, Spain.)
to direct the ETT through the glottic opening. As a completely disposable device, it may be too
costly for routine use. A newer version, the Airtraq Avant, features a reusable optic core with a
disposable blade and eyecup. This system currently has two sizes, small (6.07.5 mm) and regular
(7.08.5 mm). Utilization of a docking station allows for recharging and display of the remaining
service life of optics. A wireless camera and display recorder may be utilized if desired. It is compatible with all Airtraq models.
80
Techniques
Video 7.4 Tracheal Intubation with the Airtraq
The King Vision Video LaryngoscopeTM (King Systems, Noblesville, IN) is another system that
has a disposable blade with a 2.4-inch LED screen attached to the handle (Fig. 7.18). It is available
in two sizes and has both a channeled and a nonchanneled (regular) blade. Lubrication of the ETT
is recommended prior to use to ensure it passes easily within the channeled blade. The channeled
blade has a special design with a soft outer edge that allows easy removal of the ETT from the
blade following correct placement. No other channeled VL has this feature.
Video 7.5 Tracheal Intubation Using the King Vision Video Laryngoscope
Pentax, Airtraq, King Vision Tips
Generously lubricate the ETT prior to loading it in the tube guide.

Load the ETT in the guide until the tip of the ETT is proximal to the distal lens.
Advance the blade in the midline of the oropharynx behind the tongue.
Place the tip of the blade in the vallecula and do not advance further.
Once positioned in the oropharynx, only lift the blade if lifting is necessary to achieve a
view of the glottis.
Remember that the ETT is advanced from the right side of the device; therefore, it may
be necessary to move the blade slightly off-center to the left.
(A)
(B)
Figure 7.18 King Vision Video LaryngoscopeTM.

Techniques
81
Figure 7.19 Truview EVOTM 2.
The Truview EVOTM 2 (Rusch Medical, Teleflex, Research Triangle Park, NC) is an optical
laryngoscope that shows a 42 anterior refraction in line of sight (Fig. 7.19). The Truview is
an optical laryngoscope blade that is designed to provide indirect laryngoscopy with continuous
oxygen insufflation. It is indicated for use in both standard and difficult intubation. It illuminates
and expands the angular view of the larynx and adjacent structures, thereby facilitating endotracheal intubation. The Truview uses an optical system view-tube, which consists of prisms
and lenses that extend vision beyond the distal end of the blade. The Truview is designed to
decrease pharyngeal trauma and reduce the amount of force needed to successfully intubate a
patient by greater than 30%. This helps protects against dental injury, reduces post-intubation
sore throat, and minimizes risk of esophageal intubation. Also notable is the distal angulation of
the distal blade. These features allow around the corner visualization. Following insertion of the
Truview (via the midline approach), a styletted ETT is passed between the vocal cords. Care
must be taken not to advance the Truview too deeply, as this will make endotracheal intubation
more difficult to achieve.
The newest generation of the Truview is the Truview PCDTM video and optical laryngoscope.
It is fully portable, lightweight, and has interchangeable laryngoscope blades in five sizes (pediatric:
0, 1, 2; regular adult: 3; large adult: 4). Video output and recording is available using the Truview
PCDTM Monitor.
Truview EVO Tips

Less force is required to intubate patients with the Truview EVO 2.
Avoid too-deep insertion of the device, as this will decrease the chance of successful
endotracheal intubation.
Protection against dental injury and post-intubation sore throat is reported with the
Truview EVO 2.
Another video option for the Truview PCDTM is to connect the device to the Storz Video
System (Karl Storz Endoscopy, Tuttlingen, Germany).

Techniques
82
Rescue Maneuvers
The ASA Difficult Airway Algorithm should be adhered to when failure to intubate utilizing these
laryngoscope techniques occurs. Ventilation must be maintained, utilizing any of the following
techniques: ventilation via mask, supraglottic airway, jet ventilation, or, if necessary, a surgical
airway.
Summary
The use of VLs has increased over the last decade. Multiple systems are now available, with a
wide variety of advantages unique to each particular laryngoscope. Successful use of these devices
requires practice, as a good view of the vocal cords is often easily obtained but difficulty occurs
with ETT advancement. Tips for successful use of these devices include pre-operative administration of glycopyrrolate, availability of suction, use of anti-fog solution on selected devices, and use
of a properly sized ETT with a stylet in place (if indicated). If the practitioner is unable to see the
vocal cords, then an assistant can apply laryngeal pressure or perform a mandibular lift. Once the
vocal cords are visualized, advancement of the ETT may be performed while an assistant removes
the stylet.
Suggested Reading
Berry JM, Harvey S. Laryngoscopic Orotracheal and Nasotracheal Intubation. In: Hagberg CA,
ed. Benumofs Airway Management, 3rd ed. Philadelphia, PA: Mosby Elsevier; 2012:346358.
Levitan RM, Hagberg CA. Upper airway retraction: new and old laryngoscope blades. In:
Hagberg CA, ed. Benumofs Airway Management, 3rd ed. Philadelphia, PA: Mosby Elsevier;
2012:508535.
Marasigan B, Sheinbaum R, Hammer GB, Cohen E. Separation of the two lungs: double-lumen
tubes, bronchial blockers, and endobronchial single-lumen tubes. In: Hagberg CA, ed.
Benumofs Airway Management, 3rd ed. Philadelphia, PA: Mosby Elsevier; 2012:549568.
Dorsch JA, Dorsch SE. Laryngoscopes. In: Understanding Anesthesia Equipment, 5th ed,
Dorsch JA, Dorsch SE. Tracheal Tubes and Associated Equipment. In: Understanding Anesthesia
Equipment, 5th ed, Philadelphia, PA: Lippincott Williams and Wilkins; 2008:561632.
Dorsch JA, Dorsch SE. Lung Isolation Devices. In: Understanding Anesthesia Equipment, 5th ed.,
Monaca E, Fock M, Doehn M, Wappler F. The Effectiveness of Preformed Tooth Protectors
During Endotracheal Intubation: An Upper Jaw Model, Anesth and Analg 2007;
105(5):13261332.
Savoldelli GL, Ventura F, Waeber JL, Schiffer E. Use of the Airtraq as the primary technique to
manage anticipated difficult airway: a report of three cases. J Clin Anesth 2008; 20(6):474477.
83
Chapter 8
Intubation Stylets
Lara Ferrario, MD
Objectives
Explain the differences between the most commonly used commercially available intubation
stylets.
List the advantages and disadvantages of intubation stylets.
Describe the techniques for using intubation stylets.
Introduction
Over the past 60 years, a number of intubation stylets have been described, tested, and introduced
into clinical practice. The aim of these devices is to aid either direct or indirect laryngoscopy in
those situations when an unexpected poor visualization of the airway structures would otherwise
compromise successful endotracheal tube (ETT) placement. The two major kinds of stylets are
endotracheal tube guides and lighted stylets.
Endotracheal Tube Guides

There are several commercially available endotracheal tube guides, which have similar characteristics (see Table 8.1). These are often shaped with a degree of angulation at the distal tip (coud
tip), can be solid or hollow, and share similar indications and handling techniques.
Coud-Tip Stylets
The Frova Intubating Introducer (Cook Critical Care; Bloomington, IN) is an ETT guide introduced into clinical practice in 1998 (Fig. 8.1). It is available in 8 and 14 Fr, and is angulated 65 at
the distal tip. It is supplied with a stiffening cannula that allows it to maintain a desired curvature,
and two Rapi-Fit adapters. These adapters allow for oxygenation/ventilation by attaching the
introducer to a ventilator circuit, an Ambu bag, or a jet ventilator, and allow for confirmation of
tracheal placement via capnography.
The Portex Tracheal Tube Introducer (PTTI), which became available in 1997 but is no
longer being manufactured, the more recent Portex Single-Use Bougie (PSUB) (Smiths
84
Table 8.1 Endotracheal Tube Guides

Solid stylets
Hollow stylets
Portex Tracheal Tube Introducer
Frova Intubating Introducer
Muallem ET Tube Stylet
Portex Single-Use Bougie
Radlyn R-100 Stylet
Muallem ET Tube Introducer
8 Intubation Stylets
GlideRite Rigid Stylet
Aintree Intubation Catheter
Medical International; Ashford, Kent, UK), and the Muallem ETT Introducer (METTI) (VBM
Medizintechnik GmbH; Sulz am Neckar, Germany) are 15 Fr stylets (Fig. 8.2). Graduation marks
for accurate depth insertion are present on the PSUB and METTI. The Muallem ETT Stylet
(METTS) (VBM Medizintechnik GmbH; Sulz am Neckar, Germany) also offers the advantage of
three different diameters (8, 12, and 14 Fr). All of these stylets are malleable and designed with
a coud tip. With the exception of the PTTI (also known as the gum-elastic bougie), which was
a reusable device that could be disinfected in cold-water solutions, the stylets described above are
non-sterilizable, single-use introducers.
Video 8.1 Tracheal intubation using Direct laryngoscopy and an Intubating Stylet
Figure 8.1 Frova Intubating Introducer.

(Permission for use granted by Cook Medical, Bloomington, IN.)
Figure 8.2 Portex Single-Use Bougie.

(Copyright image provided as courtesy of Smiths Medical North America, Rockland, MA.)
Intubation Catheter Tips

Prepare two different size ETTs in the eventuality of an unexpectedly narrow airway.
Use a sterile, petroleum gel-based ointment to lubricate the stylet.
Shape the stylet to a degree of curvature to best fit the patients anatomy (usually
J-shaped).
Maintain the stylet in midline position, aligned with the right side of the patients nose.
Ensure that the coud tip is facing upward prior to advancing the stylet to feel for the
tracheal clicks.
Make sure that proper anesthetic technique is used (open cords). If muscle relaxation
is adequate and the stylet is caught under the epiglottis, then other possible structural
abnormalities may be the cause.
Never force a stylet over obstacles that are not properly visualized or identified.
If when advancing the ETT over the introducer, the ETT is caught on the laryngo-pharyngeal
structures, then slightly retract and rotate the ETT counterclockwise so that the bevel is
turned posteriorly prior to further advancement.
Failure to successfully pass the ETT over the introducer may also indicate the use of a
smaller size ETT.
Radlyn R-100 Stylet

The Radlyn R-100 Stylet (Radlyn LLC; Cincinnati, OH) is a single-size, semi-rigid, coud-tip
stylet that fits into a 7.0 mm ETT. It is equipped with a built-in tapered balloon at the distal tip
that, upon inflation, creates a close fitting of the stylet within the ETT (Fig. 8.3). This feature is
particularly helpful in the presence of swollen, redundant laryngo-pharyngeal tissues, as well as
in those anatomic abnormalities characterized by the presence of a steep curvature at the larynx
(i.e., ankylosing spondylitis). These situations typically are problematic because the stylet advances
through the cords, but the ETT gets hung up on the arytenoids and is unable to advance forward. This stylet presents similar handling requirements as the previously described coud tip
stylets with the exception of the ETT advancement over the stylet.
Radlyn R-100 Stylet Tips

Because the presence of the cuff adds bulk and friction, lubricate the proximal portion of
the stylet with a sterile, petroleum gel-based ointment.
Position the tip of stylet at the level of the Murphy eye of the ETT.
85
Coud-tip intubating stylets are easy to use and have a steep learning curve. They have
proven to be useful and potentially life-saving devices during unexpected difficult intubations
when only a portion of the laryngeal structures, such as just the tip of the epiglottis, can be
visualized. The operator can shape the introducer prior to positioning the tip under the epiglottis and blindly advance the stylet into the trachea. Correct placement of the stylet is indicated
by the perception of tracheal clicks as the coud tip passes along the tracheal rings and by
a distal hold-up as it reaches the small bronchi. Coughing in an unparalyzed patient is also
indicative of tracheal placement. An ETT is subsequently advanced over the introducer into
the correct position.
86
Inflate the stylet cuff to the ETT internal diameter.

Because the provided ETT stopper may present some difficulty at repositioning, the ETT
can be secured in position by bending the stylet at the top of the ETT.
If the stylet tip is caught at the tracheal rings and cannot advance further, then slightly
rotate the stylet counterclockwise.
Figure 8.3 Radlyn R-100 Stylet shown loaded in a standard ETT.
Aintree Intubation Catheter

The Aintree Intubation Catheter (AIC; Cook Critical Care; Bloomington, IN) is a 19 Fr, hollow,
single-use guide designed to exchange a supralaryngeal airway device for an ETT (Fig. 8.4). It is a
straight introducer with an atraumatic blunt tip and graduation markings. The internal diameter
(4.7 mm) is designed to accept a standard fiberoptic bronchoscope (FOB). The external diameter
is 6.5 mm and fits in a 7.0 mm or larger ETT. It is also packaged with Rapi-Fit adapters to allow
either jet ventilation or ventilation through the anesthesia circuit or the Ambu bag. The presence
of sideports on the distal end facilitates adequate airflow.
The ability of the AIC to accommodate a FOB allows for a unique employment of this introducer in cannot intubate, cannot ventilate (CICV) scenarios. In these situations, a supraglottic
airway device, such as a laryngeal mask airway (LMA) should be placed in accordance with the
ASA Difficult Airway Algorithm. Once ventilation is achieved, the FOB loaded with an AIC is
guided through the LMA and advanced into the patients trachea. Under fiberoptic visualization,
the AIC is positioned approximately 1 inch above carina. The FOB is subsequently removed,
followed by removal of the LMA by carefully sliding it over the AIC. Next, the ETT is advanced
over the AIC. If necessary, oxygenation can be provided through the AIC by either jet ventilation
or manual ventilation by attaching the AIC to the ventilator circuit. This intubating technique has
been extensively described in literature and it can also be applied to nonemergent difficult airways
as a technique for asleep fiberoptic intubation. Not uncommonly, a planned asleep fiberoptic
intubation is rendered difficult by the loss of airway tone and redundancy of oropharyngeal tissue.
Placement of an LMA will provide a clear passage for the FOB by displacing the oropharyngeal
87
Figure 8.4 Aintree Intubation Catheter (AIC).

structures. The AIC technique provides the advantage that a larger sized ETT can be placed as
compared to when an ETT is placed with fiberoptic guidance directly through an LMA.
Aintree Intubation Catheter Tips

Optimize the position of the LMA to achieve the maximum tidal volume ventilation with
the best seal. This maneuver usually guarantees the proper placement of the LMA over
the pharyngeal structures and provides better FOB visualization.
Lubricate the FOB as well as the proximal portion of the AIC with a petroleum gel-based
ointment to facilitate passage of the AIC over the FOB, as well as of the ETT over the AIC.
This will also help to prevent accidental displacement or removal of any of these devices
secondary to friction and adhesiveness.
Use a lens defogger on the lens of the FOB.
Securely fasten the AIC at the distal end of the FOB to facilitate maneuverability of the
scope.
Observe the AIC graduation markings to prevent trauma by excessive advancement of the
catheter into the trachea.
Once removed, keep the LMA clean and available, should intubation fail.
Verify correct ETT position by FOB.
Videolaryngoscope Stylets
The GlideRite Rigid Stylet (Verathon Medical; Bothell, WA) is part of a range of rigid, stainless
steel, reusable stylets, particularly designed to aid intubation with the GlideScope video laryngoscopes as it conforms to the unique configuration of the GlideScope blades. See Chapter 6 on
video laryngoscopes for intubation technique and tips.
The TruFlex Stylet (Truphatek International; Netanya, Israel) is a reusable, stainless steel
stylet with a controllable tip. Depressing the lever provides anterior flexion of the distal tip of the
stylet, facilitating ETT placement during videolaryngoscopy (Fig. 8.5).
88
Figure 8.5 TruFlex Stylet shown loaded in a standard ETT.

(Copyright image provided as courtesy of Truphatek International, Netanya, Israel.)
Lighted Non-Optical Stylets

The lighted stylets such as the Surch-Lite, (Bovie Medical Corporation; Clearwater, FL), the
Vital Signs Light WandTM Illuminating Stylet (Vital Signs; Totowa, NJ), and the Tube-Stat Lighted
Stylet (Medtronic; Jacksonville, FL) are more recent versions of the Trachlight, which is
no longer manufactured. These stylets make use of the transillumination technique to blindly
intubate the trachea and have been described in the literature as an alternative or as an aid to
direct laryngoscopy, particularly in airways predicted to be difficult (e.g., high Mallampati score).
In addition, they may be helpful at times when the presence of blood or heavy secretions limits
visualization of the airway. However, because lighted stylet insertion is a blind technique, it may
not be appropriate in patients with certain anatomical abnormalities, such as an intra-oral tumor.
A combination technique with either direct or indirect laryngoscopy may be more appropriate.
Because increased soft tissue leads to difficulty with transillumination, this technique is less useful
in the morbidly obese patient. In general, these stylets are portable and inexpensive and are less
stimulating than direct laryngoscopy.
89
An ETT is preloaded onto the stylet. The left hand of the operator lifts the supine patients jaw
by gently grasping the mandible and displacing it anteriorly to facilitate the insertion of the stylet
under the tongue. The stylet should be inserted using a retro-molar approach. Once inserted, the
stylet should be kept midline and advanced under the tongue. A well-circumscribed glow (about
the size of a half dollar) should appear in the midline of the patients neck at the level of the cricoid
cartilage (Fig. 8.6). This indicates correct positioning of the stylet within the trachea. Subsequently,
the ETT can be advanced over the stylet into proper position.
Video 8.2
Intubation with a Lighted Non-Optical Stylet
Figure 8.6 Orotracheal intubation using a lighted non-optical stylet.

(Reprinted from McGill J. Airway management in trauma: an update. Emerg Med Clin North Am 2007;25:603622.)
Lighted Non-Optical Stylet Tips

Hold the lighted stylet in the dominant hand and advance it into the patients mouth by
keeping the tip pointing upward.
Advance the stylet by keeping it behind the patients molars.
To assist visualization, the room lights should be dimmed.
If no light appears anteriorly, then the tip may be in the esophagus. If the light is present
laterally, then the epiglottis may not be lifted adequately.
Technique
90
Table 8.2 Lighted Stylets

Non-optical stylets
Optical stylets
Surch-Lite
Shikani Optical Stylet
Vital Signs Guided Intubation Stylet
Levitan FPS stylet
Tube-Stat Lighted Stylet
Bonfils Retromolar Intubation Fiberscope

Brambrink Intubation Endoscope
SensaScope
Video RIFL Scope
Lighted Optical Stylets

Originally designed as an aid to difficult intubations, optical stylets have some advantages over
endotracheal tube guides and non-optical lighted stylets. There is a substantial body of evidence
that supports the use of these optical stylets in patients with limited neck mobility, small mouth
opening, and redundant oropharyngeal soft tissue (e.g., large tonsils, large tongue, and floppy epiglottis). Different kinds of optical stylets are commercially available (see Table 8.2).
High-Resolution Optical Stylets

The Shikani Optical Stylet (Clarus Medical; Minneapolis, MN) is a high-resolution malleable
fiberoptic stylet that comes in a preformed hockey-stick shape consisting of several illumination
fibers and a fiberoptic bundle arranged in a coherent pattern (Fig. 8.7). With a length of 38.5 cm,
the completely sealed stainless steel sheath can be sterilized in cold solutions (such as ethylene
oxide or by immersion in a glutaraldehyde solution). Two different sizes are available: the adult
version fits into a 5.5 mm ETT, and the pediatric shaft fits into 3 mm ETTs. An adjustable tube
stop with an oxygen port allows the ETT to be firmly connected to the stylet and deliver oxygen.
This stylet can be connected to different light sources, such as a fiberoptic cable or a fiberoptic
laryngoscope handle through an adapter. The device offers two options for airway visualization:
direct vision through an eyepiece or indirect vision via a camera, allowing the image to be shown
on a monitor. The Clarus Video System (Clarus Medical, Minneapolis, MN) is similar to the Shikani
Optical Stylet, except with digital camera at the tip and an attached LCD screen (Fig. 8.10).
Video 8.3
Tracheal Intubation with the Clarus Video System
The Levitan FPS Stylet (Clarus Medical; Minneapolis, MN) is a shorter, streamlined version of
the Shikani. With a length of 30 cm to closely mimic a standard malleable stylet, it requires that the
ETT to be trimmed to 27.5 cm to 28 cm to achieve the correct standard stylet position (Fig. 8.8).
It can be inserted into a 6.0 mm or larger ETT. The malleable steel portion of the device encloses
optical and light-transmitting fiberoptic fibers that connect to an eyepiece and a removable light
source. On the side of the stylet, a small hole is present that permits oxygen insufflation. The
Levitan is intended for use with laryngoscopy, replacing a standard stylet for shaping and placement of the ETT.
The Bonfils Retromolar Intubation FiberscopeTM (Karl Storz Endoscopy; Tuttingen, Germany)
is a 40 cm long, rigid optical stylet with an external diameter of 5.0 mm and is designed with a
preformed anterior tip curvature of 40 (Fig. 8.9). The adult stylet accommodates an ETT as small
as 6.5 mm, whereas the pediatric stylet allows for 2.5 cm to 6.0 mm ETTs. The fiberoptic cable
is encased in a stainless steel tube and connected to either a video monitor or to an eyepiece,
91
Figure 8.7 Shikani Optical Stylet.

(Copyright image provided as courtesy of Clarus Medical, Minneapolis, MN.)
Figure 8.8 Levitan FPS Stylet.

(Copyright image provided as courtesy of Clarus Medical, Minneapolis, MN.)
92
allowing for visualization of the airway. As with the Shikani, the ETT is preloaded on the stylet.
There is an adaptor slide cone for fixation of the ETT. This adaptor has a side port that allows
oxygen insufflation or instillation of local anesthetic; thus, it can be used for awake intubation, if
indicated. A similar device is the Brambrink Intubation Endoscope (Karl Storz Endoscopy;
Tuttingen, Germany). It is different from the Bonfils in that it is semi-flexible.
Video 8.4
Tracheal Intubation with the Bonfils Retromolar Intubation Fiberscope
Intubation Technique With High-Resolution Optical Stylets

These optical stylets allow for intubation either with direct/indirect laryngoscopy or without (solo
technique). The left hand of the operator lifts the supine patients jaw by gently grasping the
mandible and displacing it anteriorly to facilitate the insertion of the stylet (with a preloaded
ETT) under the tongue to facilitate placement (Fig. 8.10). The tip of the scope should be visualized directly until it passes under the tongue. After visualizing the tip of the stylet pass through
the cords (through the eyepiece or the monitor), the ETT can be advanced over the stylet into
proper position.
Insufflation of oxygen through the appropriate delivery system allows for the lens to remain
clear from fogging and secretions, as well as to provide oxygenation. The advantage of performing
direct laryngoscopy with these optical stylets is that there is no need for extreme head extension
or forced traction of the laryngoscope blade to achieve a satisfactory view. All can be used for
awake intubation.
Advantages of these optical stylets over the conventional flexible FOB have been attributed to
the preformed shape of these tools allowing for an easier maneuverability around the oropharyngeal structures, including a large, floppy epiglottis. This has been described for the nonmalleable
Bonfils (fixed anterior tip curvature of 40), as well as the malleable Shikani and Levitan (suggested
straight-to-cuff shape of 35 bend angle). This shape also permits simultaneous visualization of the
tube tip and target (glottic opening) under direct vision.
Figure 8.9 Bonfils Retromolar Intubation FiberscopeTM in various sizes.

(Copyright image provided as courtesy of Karl Storz Endoscopy, Tuttingen, Germany.)
93
Figure 8.10 Intubation technique with the Clarus Video System using a jaw lift.
Lighted Optical Stylet Tips

As for any airway device, skill should be obtained before their use.
Optimize visualization by suctioning the mouth and the posterior pharynx.
Pretreat the patient (whenever medically feasible) with an antisialagogue to reduce the
production of secretions.
Avoid fogging of the lens by applying an anti-fogging agent or simply by dipping the tip of
the stylet into warm water/saline.
To improve visualization of the glottis, the tongue may be gently pulled out of the mouth
by grasping the tip with a piece of gauze. Neck extension and external jaw thrust can also
help to increase the retromandibular space.
If the epiglottis is obstructing the view of the glottis, try inserting the tip of the stylet into
the esophagus and withdrawing until the glottis comes into view.
To facilitate advancement of the ETT off the stylet, always ensure adequate lubrication
and load the ETT onto the stylet with the beveled end facing medially. Use a twisting
motion when sliding the ETT off the stylet.
94
Hybrid Fiberoptic Video Stylets

The SensaScope (Acutronic; Hirzel, Switzerland) was first introduced into clinical practice in
2006 (Fig. 8.11). Described as a new hybrid guidable semi-rigid video stylet with a novel S-shaped
curvature, the SensaScope is 45 cm long. A unique feature of this stylet is the 3 cm long steerable
tip, which by operating a lever at the proximal end of the device can be flexed 75 in both directions on the sagittal plane. In addition, the proximal end holds a standard 15 mm shaft over which
the ETT can be secured, an eyepiece that can be also connected to a video camera, and a light
source connector. Although it does not have a working channel, oxygen can be supplied via the
adapter that holds the ETT in place.
Like the SensaScope, the Video RIFL Scope (AI Medical Devices, Williamston, MI) has a rigid
portion and a flexible, steerable tip that can bend to 135. An actuation lever that is grasped by
the operators right hand allows steering of the tip (Fig. 8.12). It fits ETTs size 6.5 mm or larger.
Powered solely by batteries, it provides a clear image that is displayed on the LCD monitor
attached to the handle portion. Despite the overall structure of this stylet being quite bulky and
heavy, the fact that the monitor for visualization is attached to the stylet could be an advantage in
those situations when a difficult intubation is encountered outside of the operating room.
Intubation Technique With Hybrid Fiberoptic Video Stylets

The SensaScope is intended to facilitate intubation providing continuous vision of the anatomical structures during conventional direct laryngoscopy. The intubating technique with the
SensaScope requires the operator to first perform direct laryngoscopy with a Macintosh blade in
the left hand and then to proceed to hold the stylet (with a preloaded ETT) in the right hand. The
scope should be carefully advanced along the palate. Just as with the flexible FOB, the tip should
be kept, at first, in a neutral position. Once the cords are visualized, the operator should lower
the scope prior to advancing it into the trachea. Ultimately, under direct vision, the ETT can be
positioned properly once the carina has been visualized.
The Video RIFL, like the SensaScope, can be used as an aid to direct laryngoscopy. In this
scenario, it shares the same technical points. Similarly to the high-resolution optical stylets, it also
allows for intubation with a direct laryngoscope-free technique (refer to high-resolution optical
stylets for intubation technique).
In addition to providing continuous visualization of the airway structures during direct or indirect laryngoscopy, these stylets provide optimal visualization without the need for extreme head
extension or forced traction of the laryngoscope blade.
Because the utilization of SensaScope is linked to direct laryngoscopy, one might presume
that this stylet would also share some of the limitations of direct laryngoscopy, including the
Figure 8.11 SensaScope.

(Copyright image provided as courtesy of Acutronic, Hirzel, Switzerland.)
95
Figure 8.12 Video RIFL Scope.

(Copyright image provided as courtesy of AI Medical Devices, Williamston, MI.)
need for a satisfactory mouth opening as well as a certain degree of cervical spine motion.
Although this concept holds true to some extent, the SensaScope has been successfully utilized
to perform awake intubation in a limited number of patients presenting with a variety of difficult
airway scenarios, including cervical spine instability. As these optical stylets are relatively recent
and studies reporting their clinical application during difficult airway are still limited, flexible FOB
remains the gold-standard technique in those patients who present with cervical spine instability or those who require awake intubation secondary to predicted difficult mask ventilation/
intubation.
Video RIFL Tip

Make sure that the actuation lever of the Video RIFL Scope is relaxed before removing
the scope from the ETT.
96
Suggested Reading
Hodzovic I, Wilkes AR, Stacey M, Latto IP. Evaluation of clinical effectiveness of the Frova
single-use tracheal tube introducer. Anaesthesia 2008;63:189194.
Hodzovic I, Latto IP, Wilkes AR, Hall JE, Mapleson WW. Evaluation of Frova, single-use
intubation introducer, in a manikin. Comparison with Eschmann multiple-use introducer and
Portex single-use introducer. Anaesthesia 2004;59:811816.
Hagberg CA. Current concepts in the management of the difficult airway. Anesthesiology News.
2009;35(10):85104.
Cook TM, Seller C, Gupta K, Thornton M, OSullivan E. Conventional uses of the Aintree
Intubating Catheter in management of the difficult airway. Anaesthesia 2007;62:169174.
Higgs A, Clark E, Premraj K. Low-skill fibreoptic intubation: use of the Aintree Catheter with the
classic LMA. Anaesthesia 2005;60:915920.
Rhee KY, Lee JR, Kim J, Park S, Kwon WK, Han S. A comparison of lighted stylet (Surch-Lite)
and direct laryngoscopic intubation in patients with high Mallampati scores. Anesth Analg
2009;108:12151219.
Shikani AH. New seeing stylet-scope and method for the management of the difficult airway.
Otolaryngol Head Neck Surg1999;120:113116.
Levitan RM. Design rationale and intended use of a short optical stylet for routine fiberoptic
augmentation of emergency laryngoscopy. Am J of Emerg Med 2006;24:490495.
Abramson SI, Holmes AA, Hagberg CA. Awake insertion of the Bonfils retromolar intubation
fiberscope in five patients with anticipated difficult airways. Anesth Analg 2008;106:12151217.
Kovacs G, Law AJ, Petrie D. Awake fiberoptic intubation using an optical stylet in an anticipated
difficult airway. Ann Emerg Med 2007;49:8183.
Biro P, Battig U, Henderson J, Seifert B. First clinical experience of tracheal intubation with the
SensaScope, a novel; steerable semirigid video stylet. Br J Anesth 2006;97:255261.
Greif R, Kleine-Brueggeney M, Theiler L. Awake tracheal intubation using the SensaScope in
13 patients with an anticipated difficult airway. Anaesthesia 2010;65:525528.
Davis L, Cook-Sather SD, Schreiner MS. Lighted stylet tracheal intubation: a review. Anesth
Analg. 2000;91(3):745756.
Langeron O, Birenbaum A, Amour J. Airway management in trauma. Minerva Anesthesiol.
2009;75(5):307311.
97
Chapter 9
Flexible Fiberoptic Intubation
Objectives
Discuss the indications and advantages of flexible fiberoptic intubation.
Outline the steps that should be taken to prepare for a flexible fiberoptic intubation.
List the different steps involved in flexible fiberoptic intubation and how to troubleshoot when
difficulties arise.
Introduction
Fiberoptic-guided intubation of an anesthetized patient was first described in 1967 using a flexible
fiberoptic choledochoscope. Since that time, fiberoptic technology has been developed specifically
for the purpose of bronchoscopy and tracheal intubation, and the flexible fiberoptic bronchoscope
(FOB) has become an invaluable tool in the airway management of both awake and anesthetized
patients. There are countless clinical scenarios where fiberoptic intubation (FOI) provides a superior technique for airway management and it is well accepted that FOI of the awake, spontaneously ventilating patient is the gold standard for management of the difficult airway.
Indications for FOI essentially include any indication for tracheal intubation. There are several
clinical scenarios, however, where FOI may be the airway management technique of choice:
Known or anticipated difficult airway (cannot intubate/cannot ventilate [CICV])
Extension of the neck is undesirable (e.g., unstable cervical fracture, severe cervical stenosis,
vertebral artery insufficiency, or Chiari malformation)
High risk of dental damage (e.g., poor dentition or fragile dental work)
Mouth opening is limited (e.g., TMJ disease, mandibular-maxillary fixation, severe facial burns)
There are no specific contraindications for FOI; however, in certain clinical situations, successful FOI is unlikely. Severe airway bleeding can obscure anatomical landmarks and soil the tip of
the FOB with blood, making visualization of the larynx extremely difficult. Obstruction or severe
stenosis of the airway such that a FOB cannot be passed can also make FOI impossible.
9 Flexible Fiberoptic Intubation
98
Fiberoptic intubation provides several advantages over standard airway management techniques:
Allows for visual examination of the airway prior to intubation
Provides confirmation of tube placement, avoiding esophageal and endobronchial intubation
Eliminates the need for three-axis alignment; least likely method to result in cervical spine
movement
Well-tolerated in awake patients (less tachycardia and hypertension)
Less potential for airway and dental trauma
Can be performed in multiple positions
Equipment
The standard FOB (Fig. 9.1) consists of thousands of flexible glass fibers approximately 8 m
to 10 m in diameter that are capable of transmitting reflected light along their length. Light is
transmitted via from an external light source to the distal end of the FOB; the light reflecting off
the object to be viewed is transmitted back along the length of the FOB to an eyepiece or video
camera at the proximal end of the scope. In recent years, FOBs have been replaced by modern
bronchoscopes that use video chip technology.
The Ambu aScope 2 (Ambu, Copenhagen, Denmark) is a disposable, single-use flexible intubation scope that shares a similar design to video chip bronchoscopes (Fig. 9.2). The scope itself
has a length of 63 cm, a 0.8 mm working channel (suitable for drug instillation but not suctioning),
and can accommodate a 6.0 mm or larger endotracheal tube (ETT). The image is displayed on
the portable aScope monitor. Specific advantages include the lack of cross-contamination risk
and a decreased cost basis as compared to traditional FOBs, which incur maintenance and repair
costs.
Prior to its use, one must ensure that the FOB, light source, and video monitor (if being utilized)
are in proper working condition and that all components have been fully prepared for use. This
includes focusing the FOB, ensuring proper view orientation if using a video camera, lubricating
the distal third of the FOB, applying anti-fogging solution to the tip of the FOB, and connecting a
suction line or oxygen source to the suction port.
The ETT should be prepared by placing it in a warm water bath. This softens the plastic, easing
passage into the trachea and minimizing airway trauma. The ETT should then be lubricated prior
to being loaded onto the FOB and secured with tape (Fig. 9.3). All other ancillary equipment
needed for the planned technique, such as intubating airways, medications (e.g., lidocaine), and
airway exchange catheters, should be readily available.
Working channel
Light bundles
Epidural catheter
Lens convering viewing bundle
Diopter ring
Tracheal tube Flexible insertion cord
Eye piece
Control lever
Light cable Venting connector
Bending section
To light source
Figure 9.1 A standard FOB.

(From Miller RD, ed. Millers Anesthesia. 7th ed. 2009.)
99
Figure 9.2 The Ambu aScope 2.

(Image courtesy of Ambu USA, Glen Burnie, MD.)
Flexible Fiberoptic Laryngoscopy Tips

Use a silicone-based lubricant for lubricating the FOB. Water-based lubricants can become
sticky as they dry, whereas petroleum-based lubricants can damage the outer coating of
the FOB.
Petroleum based-lubricants, such as lidocaine ointment or ophthalmic lubricant, can be
used for lubricating the ETT.
Avoid getting lubricant on the tip of the FOB, as this can obscure the view.
To secure the ETT to the FOB, remove the 15 mm connector and tape the ETT directly
to the scope (Fig. 9.3A). It is important to always place the connector in a safe place; the
best location is attached to the circuit.
Alternatively, use the pilot balloon to tape the ETT onto the FOB (Fig. 9.3B).
100
Figure 9.3 Use of the pilot balloon to tape the ETT onto the FOB.
Awake versus Asleep Fiberoptic Intubation

Before proceeding with FOI, the decision must be made whether to perform the procedure
before or after the induction of general anesthesia (GA). Indications for an awake FOI are generally those situations where mask ventilation is anticipated to be difficult, when there is a need for
a postintubation neurologic exam, or when induction of GA could cause adverse hemodynamic
or respiratory consequences. A comprehensive list of indications can be found in Chapter 2. The
major technical disadvantage to performing FOI under GA is the loss of pharyngeal muscle tone,
which can lead to upper airway collapse and difficult fiberoptic laryngoscopy.
Preparation of the Patient

Prior to FOI, certain premedicants should be considered. Unless contraindicated, an antisialagogue, such as glycopyrrolate 0.2 mg IV, should be administered to dry airway secretions. In the
patient at high risk for aspiration, prophylactic medications should be administered. For awake
FOI, topical anesthesia of the airway is necessary, and in some circumstances, IV sedation may be
appropriate. (See Chapter 2 for details.)
Patient positioning for FOI primarily depends on the preference of the physician. Successful FOI
can be accomplished in the supine or sitting/beach-chair positions. Emergency FOI in the lateral
decubitus and prone positions have also been described. When performing FOI in the supine
position, the physician stands at the head of the patient. Advantages to this position are that the
laryngeal view through the FOB is in the same orientation as during direct laryngoscopy, and the
patient and physician are already in the optimal position to perform mask ventilation or other airway maneuvers, if necessary. When performing FOI with the patient in the sitting or beach-chair
position, the physician should stand facing the patient at the patients side. This position may be
the position of choice in awake, non-sedated FOI because of improved ventilation and greater
patient comfort. In addition, the sitting position optimizes airway anatomy and prevents airway
collapse in obese patients, in patients with obstructive sleep apnea, and in patients with anterior
extrinsic airway obstruction.
101
When performing a FOI in the sitting position, stand on the side of the patient such that
the hand that controls the insertion cord is closest to the patient. The fiberoptic cart
should be positioned to the left of the physician (on the opposite side of the patient, if
necessary).
Technique
One of two approaches can be utilized for FOI: orotracheal and nasotracheal. While weighing the
advantages and disadvantages, the clinician should determine which approach is best-suited for the
clinical situation (Table 9.1).
There are various techniques for FOIwhich technique to use depends on whether the patient
will be awake, sedated, spontaneously ventilating under GA, or under GA with muscle paralysis
and whether the plan is for orotracheal or nasotracheal intubation. Whichever route the physician
chooses, however, there are essentially two steps to FOI:
1. Performing fiberoptic laryngoscopy and endoscopy (obtaining a view of the glottis with the
FOB and maneuvering the FOB through the vocal cords into the trachea).
2. Advancing the ETT over the FOB into its proper position in the trachea and removing
the FOB.
These steps will be discussed separately to address the specific issues that frequently arise
during the procedure.
Table 9.1 Advantages and Disadvantages of Oral and Nasal Fiberoptic Intubation
Advantages
Disadvantages
Orotracheal
Less traumatic and lower risk of

bleeding
Preferable for long-term intubation
Usually allows for placement of
a larger ETT
Can be performed in patients with
maxillary or skull base fractures
More difficult fiberoptic technique

Stimulates the gag reflex; requires
dense airway anesthesia
Risk of damage to the FOB by biting
Potentially less comfortable for the
patient
Nasotracheal
Easier view of the larynx

Bypasses the gag reflex
Does not require mouth opening
Prevents damage to the FOB by biting
Potentially more comfortable for the
patient
Allows for intra-oral surgical
procedures
Usually requires a smaller ETT

Risk of trauma to nasal mucosa and/
or nasal turbinates
Risk of submucosal tunneling in the
nasopharynx
Risk of epistaxis
Relatively contraindicated in setting
of maxillary or skull base fractures
Flexible Fiberoptic Laryngoscopy Tip
102
It is best to suction the oropharynx prior to inserting the FOB.

Use a lens defogger or insert the tip of the FOB in warm saline prior to its use.
If fogging occurs, touch the tip of the FOB to the airway mucosa to clear the view.
If necessary, use O2 via the suction channel, but use low flows (23 L/min) and be able
to identify where the tip of the FOB is at all times. Avoid this in pediatric patients and
patients with severe airway obstruction, as this can lead to a build-up of pressure and
potential barotrauma.
Supplemental O2 can also be administered over the patients nose or mouth, depending
on the route of intubation.
Oral Fiberoptic Laryngoscopy

One major challenge in oral FOI is navigating the FOB around the base of the tongue to achieve
a satisfactory view of the larynx. The FOB has a tendency to stray off the midline and frequently
there is little to no airspace between the tongue and the palate through which to navigate the
FOB. To mitigate this issue, there are several devices or techniques that can be utilized.
Specialized intubating oral airways are useful for several reasons: to protect the FOB from
damage by biting, to prevent the tongue from falling back into the pharynx and obstructing the
airspace, and to keep the FOB midline while guiding it to the larynx. There are several types available, each with unique design differences. They include the Ovassapian, Berman, and Williams
airways (Figs. 9.4 and 9.5). A disadvantage of these devices is that they place pressure on the base
of the tongue, potentially causing gagging in awake patients.
ROTIGS (Rapid OroTracheal Intubation Guidance System; Hanu Surgical Devices, Honolulu,
HI) is a novel device that has been developed to replace the endoscopic oral airway during awake
oral FOI. ROTIGS is comprised of a mouthpiece, bite block, and guidance tube (Fig. 9.6). The
mouthpiece and bite blocks keep the device centered and allow a midline approach to the larynx.
Figure 9.4 Berman, Williams, and Ovassapian airways.
103
Figure 9.5 A flexible FOB inserted through a Bermann airway.

(From Miller RD, ed. Millers Anesthesia. 7th ed. 2009.)
Figure 9.6 ROTIGS (Hanu Surgical Devices, Honolulu, HI).
104
Because the device does not rest on the tongue, it does not cause gagging, making it well-suited
for use in awake and minimally sedated patients.
Video 9.1
Awake Fiberoptic Orotracheal Intubation using ROTIGS
In both awake patients and those under GA, gentle traction on the tongue anteriorly is helpful
in preventing the tongue from falling back into the pharynx if an intubating airway is not used. This
can easily be accomplished by hand with the aid of 4 4gauze pads for traction or with Magill
forceps. Care should be taken to not injure the tongue on the bottom teeth.
Laryngeal mask airways (LMAs) and intubating LMAs can both be used as conduits for oral FOI.
(See Chapters 6 and 14 for details on these techniques.)

When using an intubating oral airway, it is usually best to load the ETT in the oral airway
first, as opposed to loading the ETT directly on the FOB. Insert the ETT to a depth of 5 cm
into the oral airway.
When performing oral FOI on an awake patient without the use of an intubating oral
airway, instruct the patient to phonate as you advance the FOB along the palate around
the base of the tongue. This elevates the soft palate, lifting it off the tongue and providing
more space through which to navigate the FOB.
A 4 4 gauze may be used to gently retract the tongue to open more space in the
oropharynx, facilitating FOI. Care should be taken to not cause a laceration on the tongue
with the bottom teeth.
When performing a FOI in a patient under GA, a jaw lift can be used to open the airway
and generate more airspace in the hypopharynx through which to navigate the FOB. This
requires the assistance of a second person. This technique is useful in oral or nasal FOI
and can be performed with an intubating oral airway in place.
Alternatively, a jaw lift can be accomplished using the JED (LMA North America, San
Diego, CA). JED (Jaw Elevation Device) is a noninvasive, hands-free device that maintains a patent airway by lifting the jaw and extending the neck. See Fig. 9.7.
Video 9.2
Asleep Fiberoptic Orotracheal Intubation using JED
Nasal Fiberoptic Laryngoscopy

Obtaining a laryngeal view during nasal FOI is often easier as compared to the oral approach,
because the FOB stays midline and the tip of the FOB is usually directed at the glottis as it enters
the oropharynx. The challenge in the nasal approach is usually related to placement of the ETT
through the nasal passage into the nasopharynx. There are several steps that can be taken to
increase the chances of success.
1. Select the more patent nostril. This can be accomplished by occluding each nostril separately
and having the patient inhalethe patient will usually be able to inhale much more effectively
through one of the nares. Alternatively, one can use the FOB to visualize the nasal passages and
determine which is more patent.
2. Administer a nasal mucosal vasoconstrictor. Cocaine, phenylephrine, and oxymetazoline are
acceptable agents. (See Chapter 2.)
Mallinckrodt Nasal RAE or Hi-Lo ETT*
Nasopharyngeal airway
Size/ID (mm)
OD (mm)
Size (French)
8.0
10.9
34
11.3
7.5
10.2
32
10.7
7.0
9.6
30
10.0
6.5
8.9
28
9.3
6.0
8.2
26
8.7
OD (mm)
*Nellcor Puritan Bennett; Boulder, CO

ID = internal diameter; OD = outer diameter
3. Gage the degree of patency of the nasal passage. Soft plastic nasopharyngeal airways (nasal
trumpets) can be used to determine the ETT size that will pass easily. A nasopharyngeal airway one size larger than the desired ETT should be used. For example, placement of a 32 Fr
nasopharyngeal airway predicts easy passage of a 7.0 mm ID ETT. Table 9.2 lists the outer
diameters of various ETT and nasopharyngeal airway sizes.
4. Place the ETT into the nasopharynx before the FOB. Insert the warmed, softened, lubricated
ETT through the prepared nostril into the nasopharynx first, rather than placing the FOB
first and attempting to insert the ETT over it. This avoids the situation where one has successfully navigated the FOB into the trachea but cannot intubate because the nasal passage is
inadequate.
The FOB can then be placed through the ETT into the oropharynx, taking care to ensure that
the tip of the FOB goes through the distal end of the ETT and not through the Murphy eye. Once
the FOB is in the oropharynx, the glottic structures should be visible in a majority of patients. If
not, the ETT may have been advanced too far into the oropharynx; withdraw the ETT slightly and
look anteriorly. In heavily sedated patients or patients under GA, airway collapse may obscure
the view of the glottis; the previously described techniques of tongue traction, jaw thrust, or neck
extension can open the airway.
Flexible Fiberoptic Laryngoscopy Tip

It is important to not advance the ETT too far into the oropharynx, as this can make
visualization of the vocal cords more difficult. A depth of 13 cm to 15 cm from the naris is
usually adequate.
Fiberoptic Endoscopy
Once the FOB has been successfully positioned in the oropharynx, the epiglottis and vocal cords
can usually be visualized with a slight anterior deflection of the tip of the FOB. If only the epiglottis
is visible, then maneuver the FOB below the epiglottis and flex the tip anteriorly to visualize the
vocal cords. Aim for the anterior commissure of the vocal cords and flex posteriorly to enter into
the trachea. The trachea is easily identifiable by the presence of the cartilaginous tracheal rings.
105
Table 9.2 Outer Diameters of Various ETT and Nasopharyngeal

Airway Sizes
106
Figure 9.7 JED (LMA North America, San Diego, CA) can be used to facilitate asleep FOI.
(Image courtesy of LMA North America, San Diego, CA.)
Advance the FOB distally until a point just above the carina. In some cases, glottic visualization is
possible, but the FOB is unable to be advanced through the vocal cords despite all the tricks
described because of abnormal anatomy or an obstructing lesion in the airway. In these situations,
a guide wire can be utilized. In this technique, the FOB tip is moved as closely as possible to the
vocal cords. A guide wire (such as one from a retrograde intubation kit) can then be fed into the
working channel of the FOB and inserted through the vocal cords in an anterograde fashion. The
FOB is then advanced over the guide wire into the trachea.

Do not hesitate to use external laryngeal manipulation to bring the glottis into view.
In case of a long, floppy epiglottis, use neck extension, jaw lift, or traction on the tongue
to bring the vocal cords into view.
Sometimes, insertion of a laryngoscope blade is necessary to open the airspace and lift the
epiglottis off the posterior pharyngeal wall.
Another trick for difficult fiberoptic laryngoscopy is to advance the FOB into the esophagus, flex the tip of the FOB anteriorly about 75, and retract slowly. As soon as the FOB
Advancing the Endotracheal Tube Over the Fiberoptic Bronchoscope

Once the FOB has been positioned just above the carina in the trachea, the ETT is advanced over
the FOB while continuously visualizing the trachea through the FOB. This provides confirmation
that the FOB and ETT have not been accidentally dislodged into the oropharynx or esophagus.
Frequently, especially with orotracheal intubation, resistance is met as the tip of ETT reaches the
glottic inlet. Studies have shown that this usually results from the bevel of the ETT impinging on
the right arytenoid. A slight withdrawal of the ETT and a 90 turn counterclockwise, orienting
the bevel posteriorly, usually resolves this issue. For nasotracheal intubation, a clockwise 90
turn such that the bevel is oriented anteriorly can prevent the tip of the ETT impinging on the
epiglottis. Alternatively, the Parker Flex-TipTM ETT (Parker Medical, Englewood, CO), which has a
bull-nosed tip directed toward the center of the distal lumen, can be utilized (Fig. 9.8). This ETT
has been shown to have a higher first-pass success rate when being advanced over a FOB.
Parker Flex-Tip
Tube
No gap between
tip of Parker tube
and FOB.
Figure 9.8 The Parker Flex-TipTM ETT.
(Image courtesy of Parker Medical, Highlands Ranch, CO.)
Standard ETT
Gap between leading

edge of stardard ETT
and FOB. This gap
allows the projecting
tube edge to catch
on the arytenoid cartilage
as the tube is advanced
into the glottis.
107
exits the esophagus, the tip of the FOB should be underneath the epiglottis, and some
slight maneuvering should bring the vocal cords into view.
If the patient is awake, then changing position to sitting or lateral can improve glottic
visualization. One can also ask the patient to sniff, swallow, or inhale deeply to aid in
maneuvering the FOB through the vocal cords.
If the patient is spontaneously ventilating (either awake or under GA), spray 2 mL of
4% lidocaine through the working channel of the FOB prior to advancing through the
vocal cords to avoid laryngospasm. Laryngotracheal anesthesia can also be administered
through an epidural catheter inserted through the working channel of the FOB. (These
techniques are usually unnecessary if a transtracheal block has been performed.)
108
Upon successful passage of the ETT, proper depth (23 cm from the carina) is confirmed during
withdrawal of the FOB. If indicated, a neurologic examination is performed. After confirmation of
the presence of end-tidal CO2 on the capnogram, anesthesia is induced with a rapid intravenous
agent. On rare occasion, the FOB may prove difficult to remove from the ETT. This may result
from the FOB having passed through the Murphy eye rather than the distal lumen or could be
a result of inadequate lubrication of the FOB. In these situations, forceful removal may damage
the instrument; therefore, the FOB and ETT should be removed as a unit and the procedure
repeated.
Flexible Fiberoptic Intubation Tips

NEVER use force when advancing the ETT over the FOB.
A warmed, softened ETT will usually pass through the vocal cords more easily and with
less trauma.
A flexometallic ETT or the tapered-tip ETT for use with the intubating LMA can be used
for FOI to increase the chance of first-pass success when railroading over a FOB if a Parker
Flex-TipTM ETT is not available.
Many times, the gap between the FOB and the larger ETT is a factor when difficulty is
encountered advancing the ETT into the trachea. An Aintree catheter loaded in between
the FOB and the ETT can minimize this gap and increase success in advancing the ETT
over the FOB.
Summary
Flexible fiberoptic intubation is a valuable technique for airway management and the gold standard
for management of most difficult airways. All practitioners involved in airway management should
be familiar with the difficulties that may arise during the procedure and the steps that can be taken
to overcome them.
Suggested Reading
Gil KSL, Demunsch PA. Fiberoptic and flexible-endoscopy aided technique. In: Hagberg CA, ed.
Benumofs Airway Management, 3rd ed. Philadelphia, PA: Mosby; 2012:365411.
Popat M. Practical Fibreoptic Intubation. Oxford: Butterworth Heinemann; 2001.
Ovassapian A. Fiberoptic Endoscopy and the Difficult Airway. Philadelphia, PA: Lippincott-Raven;
1996.
Benumof JL. Management of the difficult adult airway. Anesthesiology 1991;75:10871110.
Asai T, Shingu K. Difficulty in advancing a tracheal tube over a fibreoptic bronchoscope:
incidence, causes and solutions. Br J Anaesth. 2004;92(6):870881.
109
Chapter 10
Retrograde Intubation
Katherine C. Normand, MD and A. Paul Aucoin, MD
Objectives
Discuss the indications and contraindications for retrograde intubation.
Review the relevant anatomy for retrograde intubation.
Learn the different techniques for retrograde intubation.
Introduction
Retrograde intubation (RI) is a well-described technique that involves several methods of translaryngeal guided nonsurgical airway access to assist in endotracheal or nasotracheal intubation.
It can be used successfully in awake, sedated, obtunded, or apneic patients who have either an
anticipated or unanticipated difficult airway. Butler and Cirillo reported the first case of RI in 1960.
They passed a red rubber catheter cephalad through a patients existing tracheostomy. After the
catheter exited the patients mouth, it was tied to an endotracheal tube (ETT), which was then
pulled into the patients trachea. The term retrograde intubation is a misnomer; the technique is
actually a translaryngeal-guided intubation.
The ASA Practice Guidelines on Management of the Difficult Airway describe RI as an alternative approach to difficult intubation. Retrograde intubation is included in the ASA Difficult Airway
Algorithm in the nonemergent pathway, when unable to intubate but able to ventilate. The ASA
Difficult Airway Task Force suggests that equipment for RI be included in a portable storage
unit for difficult airway management. Retrograde intubation can take several minutes to accomplish; therefore, it is not appropriate to use in an emergent cannot ventilate, cannot intubate
scenario.
Indications
Retrograde intubation has been used in a variety of airway pathologies. It can be employed in
both adult and pediatric patients and has even been used in neonates as young as 1 day old.
Indications include: failure of direct laryngoscopy; obstruction of a view of the vocal cords by
blood, secretions, or anatomic derangement; and difficult intubation scenarios such as unstable
cervical spine, ankylosing spondylitis, maxillofacial trauma, or trismus. Retrograde intubation is
also an alternative to fiberoptic intubation in developing countries where the availability of flexible
fiberoptic bronchoscopes is limited.
10 Retrograde Intubation
110
Retrograde Intubation Tips

Retrograde intubation can be performed in an awake patient when spontaneous ventilation is necessary. Proper anesthetizing of the airway must be performed before the RI is
initiated.
Retrograde intubation is beneficial in the unexpected difficult airway in which multiple
direct laryngoscopies have caused trauma and fiberoptic intubation may be difficult to
perform secondary to bleeding.
Retrograde intubation can be performed during bag mask ventilation or with an LMA in
place. The LMA should be removed as the wire is advanced.
Contraindications
This technique is contraindicated if ventilation (spontaneous or positive pressure) is not possible.
Additional contraindications to RI are mostly relative and can be divided into four categories: difficult anatomy, laryngotracheal disease, coagulopathy, and infection.
Difficult anatomy: RI is performed at or below the level of the cricoid cartilage; therefore, this
anatomy should be accessible. A severe flexion deformity of the cervical spine can make RI
unfeasible. Patients with nonpalpable anatomical landmarks, overlying malignancy, or a goiter
should be approached cautiously.
Laryngotracheal disease: Narrowing of the trachea or larynx can be made worse by needle
puncture or catheter insertion. Retrograde intubation should be avoided when tracheal stenosis
exists directly under the puncture site.
Coagulopathy: Although the cricothyroid membrane (CTM) is a relatively avascular structure,
preexisting bleeding diathesis should be considered a relative contraindication.
Infection: An infection over the puncture site or the path of the puncture can result in spread
of the bacteria into the trachea and should be avoided.
Complications
1.
2.
3.
4.
5.
6.
7.
Bleeding (usually minimal)

Subcutaneous emphysema
Pneumomediastinum
Pneumothorax
Pretracheal abscess (late complication, more common in diabetic patients)
Hypercapnia secondary to periods of apnea
Injury to posterior trachea and esophagus
Anatomy
The performance of RI requires knowledge of the anatomy of the cricoid cartilage and surrounding structures (Fig. 10.1). The cricoid cartilage is a ring-shaped structure inferior to the thyroid
Thyroid
cartilage
Cricothyroid
membrane
Cricoid
cartilage
Figure 10.1 Relevant anatomy for retrograde intubation. The puncture site is the lower third of the CTM, just above
the cricoid cartilage.
(From Walls RM, Murphy MF, eds. Manual of Emergency Airway Management. Philadelphia, PA: Lippincott Williams & Wilkins; 2000.)
cartilage that can be palpated on the anterior neck as a firm, rounded structure 1.5 to 2 fingerbreadths inferior to the laryngeal prominence (Adams apple or thyroid notch). The CTM is a
relatively avascular, elastic tissue extending from the thyroid cartilage superiorly to the cricoid
cartilage inferiorly. It is approximately 1 cm in height and 2 cm in width. It can be identified as a
shallow groove between the cricoid cartilage and the inferior border of the thyroid cartilage. The
cricothyroid artery runs along the anterior surface of the CTM, close to the thyroid cartilage.
Retrograde Intubation Tip

Because of the location of the cricothyroid artery and the proximity of the CTM to the
vocal folds, puncture of the CTM should be made in the inferior third of the membrane
and directed posteriorly.
Technique
1. Positioning: Ideally, the patient should be in the supine sniffing position with the neck in
hyperextension, allowing easier palpation of the cricoid cartilage and surrounding structures.
Retrograde intubation can also be performed with the patient in the sitting position or with the
neck in a neutral position (e.g., in a patient with cervical spine injury or limited range of motion
of the neck).
2. Skin preparation: The anterior neck should be cleansed prior to puncture. Retrograde intubation should be performed using aseptic technique. It has been suggested that prophylactic antibiotics be administered to diabetic or immunocompromised patients prior to the performance
of an elective RI.
111
112
3. Anesthesia: For the patient undergoing awake or sedated RI, several different techniques can be
used to prevent discomfort during the procedure, including transtracheal anesthesia, superior
laryngeal nerve block, and topicalization of the airway mucosa with atomized or nebulized local
anesthetic (see Chapter 2). For the patient under general anesthesia, instillation of translaryngeal local anesthetic after CTM puncture can reduce the incidence of sympathetic stimulation
and laryngospasm.
4. Entry site: The translaryngeal puncture site can be performed superior or inferior to the cricoid
cartilage. The CTM (superior to the cricoid cartilage) has the advantage of being relatively avascular; however, a puncture at this site allows only 1 cm of space below the level of the vocal
cords for the tip of the ETT. A puncture site inferior to the cricoid cartilage, at the cricotracheal
ligament, allows the ETT to travel in a straighter path with a longer length of the ETT below the
vocal cords; however, this site is associated with a greater potential for bleeding.

Retrograde intubation can take several minutes to perform (depending on operator experience and patient anatomy), so ventilation of a patient is necessary while the procedure is
being performed. Patients with a reduced FRC (e.g., the morbidly obese) may not be good
candidates for RI secondary to a limited ability to withstand periods of apnea.
Classic Technique
This technique requires a standard 17 g Tuohy needle, a syringe half-filled with saline, a hemostat,
and a standard epidural catheter.
1. After the patient has been positioned and the skin has been properly cleansed, a
right-hand-dominant person should stand on the patients right side.
2. Use the left hand to stabilize the trachea by placing the thumb and the third digit of either side
of the thyroid cartilage. The index finger of the left hand identifies the midline of the CTM and
the upper border of the cricoid cartilage.
3. With the right hand, grasp the Tuohy needle with the saline-filled syringe like a pencil, and
puncture the CTM, aspirating to confirm placement in the lumen of the airway. The bevel of
the Tuohy needle must be directed cephalad.
4. Once the Tuohy needle is in the trachea, remove the syringe and insert an epidural catheter
through the needle until it exits the oral or nasal cavity. It is important to pull the tongue anteriorly to prevent the catheter from coiling in the oropharynx.
5. Clamp the epidural catheter with a hemostat at the neck skin line to prevent further movement
of the epidural catheter.
6. Thread the epidural catheter through the Murphy eye (outside to inside) or through the distal
lumen of the ETT.
7. Advance the ETT over the epidural catheter into the trachea.
8. Verify that the ETT is below the vocal cords before removing the epidural catheter by the
presence of bilateral breath sounds and by capnography. Fiberoptic bronchoscopy can also be
utilized to confirm proper ETT positioning.
113
Because the Tuohy needle is blunt, make a small incision with a blade or a large-bore cutting needle at the selected puncture site to facilitate advancing the Tuohy through the skin.
A skin incision may not be necessary if the neck skin is very thin.
Rather than saline, fill the syringe with 1% to 2% lidocaine and inject the local anesthetic after placement of the tip of the needle in the lumen of the trachea is confirmed.
This provides additional anesthesia to blunt the sympathetic response and prevent
laryngospasm.
Guidewire Technique
Performing a RI with a J-tip guidewire rather than an epidural catheter provides the following
advantages: the J-tip of a guidewire is less traumatic to airway; there is less tendency for the guidewire to coil or kink; retrieval of the guidewire from the oral or nasal cavity is easier; the guidewire
can be used in conjunction with a fiberoptic bronchoscope; and it is a faster technique. This
technique requires an 18 g angiocatheter, a syringe half-filled with saline, a J-tip guidewire, a guide
catheter (e.g., an Arndt Airway Exchange Catheter), and a hemostat. The discrepancy in diameter
between the guidewire and ETT predisposes the ETT to catch on the arytenoids or vocal cords
rather than sliding smoothly into the trachea. The guide catheter reduces this discrepancy in diameter and can prevent this from occurring.
1. After the patient has been positioned and the skin has been properly cleansed, a
right-hand-dominant person should stand on the patients right side.
2. Use the left hand to stabilize the trachea by placing the thumb and the third digit of either
side of the thyroid cartilage. The index finger of the left hand identifies the midline of the
CTM and the upper border of the cricoid cartilage.
3. Attach the saline-filled syringe to the angiocatheter and advance at a 90 angle to the CTM,
aspirating for air to confirm the position inside the trachea. (See Fig. 10.2A.)
4. Lower the angle to 45, again aspirating air to confirm the position within the trachea. Remove
the needle.
5. Advance the guidewire through the angiocatheter until it exits the mouth or nose
(Fig. 10.2B).
6. Clamp the guidewire with a hemostat at the neck skinline.
7. Place the guide catheter over the portion of the guidewire exiting the oral or nasal cavity and
advance it to the CTM (Fig. 10.2C).
8. Remove the wire. The guide catheter is now situated in the trachea.
9. Place the ETT over the guide catheter and advance the ETT through the vocal cords
(Fig. 10.2D).
10. Remove the guide catheter and confirm proper endotracheal tube placement (Fig. 10.2E).
Video 10.1
Guidewire-assisted Retrograde Intubation
Tips
114
(A)
(B)
(C)
(D)
(E)
Figure 10.2 The guidewire technique for retrograde intubation.

(Courtesy of Cook Critical Care; Bloomington, IN).
115
This technique ideally requires two individuals, one to place the transtracheal wire and another
to mask ventilate and retrieve the guidewire. It is also helpful for one individual to maintain
traction on the guidewire while the other individual advances the exchange catheter.
In patients with normal upper airway anatomy, the guidewire generally exits via the nose.
If oropharyngeal placement is desired, then a hemostat may be needed to grasp and
retrieve the guidewire from the oral cavity. Direct laryngoscopy during wire insertion can
be helpful in guiding the wire toward the oral cavity.
One can add fiberoptic bronchoscopy to the guidewire technique by feeding the guidewire through the suction port of a fiberoptic bronchoscope. The ETT can then be loaded
on the bronchoscope and advanced through the glottis after visual confirmation of guidewire placement in the trachea.
Push the wire in from the skin instead of pulling it once it is out of the mouth/nose. Pulling
the wire can cause a slicing injury to the pharynx or tongue.
Tension must be maintained on the guidewire when removing it so that the exchange
catheter does not pop out of the airway.
If the patient is hypoxic, then jet ventilation can be performed through the exchange
catheter before placement of the ETT.
Commercially Available Kit

Cook Medical currently has a commercially available retrograde intubation set. This is a complete
set with all of the equipment necessary to perform a RI over a guidewire. It is available in two
sizes (6 Fr and 14 Fr) and includes an Arndt Airway Exchange Catheter, which facilitates placement
of an ETT, along with two Rapi-Fit adapters, which allow for patient oxygenation through the
exchange catheter if necessary.

If using the Cook retrograde intubation kit, the guidewire is marked with two black lines
that indicate the length of the exchange catheter. The guidewire should be advanced
through the CTM until the second black line has reached the skin. The wire should be
advanced one more centimeter and clamped with a set of hemostats. This will allow for
visualization of the first black line 1 cm past the exchange catheter.
Suggested Reading
Sanchez A. Retrograde Intubation Techniques. In: Hagberg CA, ed. Benumofs Airway
Management, 3rd ed. Philadelphia, PA: Mosby; 2012:412429.
Rosenblatt W. Airway Management. In: Barash PG, Cullen BF, Stoelting RK, eds. Clinical
Anesthesia, 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2005:595642.
Retrograde Intubation Tips
116
Bagam K, Murthy SGK, Vikramaditya C, Jagadeesh V. Retrograde intubation: An alternative in

difficult airway management in the absence of a fiberoptic laryngoscope. Indian J Anaesth
2010;54(6):585.
Bowes WA, Johnson JO. Pneumomediastinum after planned retrograde fiberoptic intubation.
Anesth Analg 1994;78:795797.
Hagberg CA. Current concepts in the management of the difficult airway. Anesthesiology News
2009;35(10):85104.
117
Chapter 11
Percutaneous Transtracheal
Jet Ventilation
Objectives
Discuss the indications and contraindications for transtracheal jet ventilation.
Review the relevant anatomy for transtracheal jet ventilation.
Learn the techniques for transtracheal jet ventilation.
Introduction
Percutaneous transtracheal jet ventilation (TTJV) is a relatively safe, quick, and effective method
of oxygenation and ventilation in the cannot intubate, cannot ventilate (CICV) scenario when
more conservative measures fail. The ASA Difficult Airway Algorithm lists TTJV as an emergent
nonsurgical technique to be used in patients who cannot be conventionally ventilated or intubated. Transtracheal jet ventilation is widely regarded as a lifesaving procedure that can provide
adequate, temporary oxygenation and ventilation with less training and complications than a surgical airway, a last resort for obtaining an airway in the algorithm.
Flory et al. introduced TTJV in the 1950s, and by the 1970s, TTJV was being used as an airway
management tool during routine surgical procedures of less than 2 hours. Currently, its primary
use is as an emergency airway and, occasionally, for laryngeal surgery. The recommended time
that this technique should be used is less than 30 minutes.
Mechanism of Transtracheal Jet Ventilation

Inspiration during TTJV is achieved by insufflation of pressurized oxygen through a cannula.
Expiration is passive because of the elastic recoil of the lungs and the chest wall. It is imperative
that sufficient time is allowed for the passive expiration to avoid barotrauma from breath stacking. Expiration occurs through the glottis and depends on a nonobstructed upper airway, which is
imperative to avoid barotrauma and resulting pneumothorax. The egress of air through the glottic
aperture can also provide bubbles to facilitate placement of an endotracheal tube (ETT) when the
11 Percutaneous Transtracheal Jet
118
glottic opening had not previously been able to be visualized. In fact, several case reports have
demonstrated that after initiation of TTJV in an airway with little or no visualization of the glottis,
successful intubation occurred because of opening of the glottis and guidance from bubbles with
jet ventilation.
Indications for Transtracheal Jet Ventilation

As previously mentioned, TTJV is indicated as an emergency technique for the establishment of
oxygenation and ventilation in the CICV scenario. Other clinical situations where TTJV might be
utilized include:
1. Combative or uncooperative patients with upper airway, facial, or head and neck trauma.
Transtracheal jet ventilation can provide a quick, relatively painless airway to proceed with
sedation to allow for a surgical airway.
2. Patients with copious oropharyngeal secretions that would render fiberoptic intubation difficult. Transtracheal jet ventilation can force the secretions out of the proximal trachea.
3. Patients with foreign bodies in the proximal trachea, in which placement of an ETT would cause
further migration of the foreign body into the airway. Transtracheal jet ventilation in this situation may result in expulsion of the foreign body from the trachea.
4. Anatomic abnormalities that make an oral approach to airway management difficult, such as
tumors of the glottis or base of the tongue.
5. Emergency airway in children less than 12 years old. Because of the small caliber of the
trachea at the level of the cricoid membrane in this population, cricothyrotomy can be
dangerous.
6. For inexperienced physicians, TTJV may be preferred over more difficult maneuvers (such as
cricothyrotomy or fiberoptic intubation) in an already hypoxic patient because of the length of
time involved.
Contraindications to Transtracheal Jet Ventilation

Transtracheal jet ventilation should not be performed in patients who have sustained direct damage to the cricoid cartilage or larynx or in patients with complete upper airway obstruction.
Surgical cricothyrotomy is preferred in these situations.
Relative contraindications to TTJV include:
1. Partial airway obstruction in which air egress might not be possible. A smaller-sized catheter
may be considered.
2. Distorted or difficult airway anatomy in which catheter placement might be difficult.
3. Uncorrected coagulopathy.
4. Obstructive pulmonary diseases, such as chronic bronchitis, asthma, or emphysema, which may
increase the risk of barotrauma and pneumothorax. One recent study, however, showed that
patients with chronic obstructive disease did not, in fact, have a higher incidence of barotrauma
as a result of TTJV.
Complications of Transtracheal Jet Ventilation

Although TTJV is considered a safe procedureespecially in comparison to the risks of a surgical airwaythere does exist a risk of life-threatening complications. A major concern for TTJV is
barotrauma with resulting pneumothorax from the use of high-pressure oxygen. To prevent this
Transtracheal Jet Ventilation Tip

If possible, use a kink-resistant catheter. Because of their thin walls, standard IV angiocatheters are highly prone to kinking, which can result in subcutaneous emphysema.
Be highly aware of the possibility for pneumothorax and have a low threshold for chest
tube placement once TTJV is initiated.
Anatomy
To perform TTJV safely, a firm understanding and knowledge of the anatomy is essential. The jet
ventilation catheter is placed through the cricothyroid membrane (CTM) located in the anterior
neck (Fig. 11.1). It is a ligament that is generally 8 mm to 12 mm in height with a width of 20 mm to
24 mm. It is avascular, made up of mostly elastic tissue. It is located between the thyroid cartilage
superiorly and the cricoid cartilage inferiorly. To locate it, palpate the laryngeal prominence of the
thyroid cartilage (Adams apple), then follow this down until an indentation is felt, which is the
CTM. Commonly, small cricothyroid arteries cross the upper CTM, so it is important to perform
TTJV in the lower third of the membrane, if possible.
Transtracheal Jet Ventilation Tip

If the laryngeal prominence cannot be located because of distortion of the airway, the
suprasternal notch may be identified and, by walking up the trachea, the CTM may then
be located. The CTM is generally located 3 fingerbreadths above the suprasternal notch
with the neck in the neutral position.
119
complication, it is an absolute necessity to ensure that a path for air egress exists and that there
is adequate time for passive expiration. The lowest possible pressure that will provide adequate
oxygenation and ventilation should be used.
Other complications associated with TTJV include:
1. Subcutaneous or mediastinal emphysema resulting from catheter misplacement. It is critical
to confirm catheter placement after needle removal to ensure correct placement. Initiation of
high-pressure jet ventilation in a space other than the trachea will result in air being forced into
the surrounding tissues.
2. Perforation of the posterior wall of the trachea or esophagus. Care must be taken when
advancing the needle after puncture of the cricothyroid membrane to avoid lacerations and
injuries to these structures.
3. Kinking of the catheter. Regular angiocatheters are prone to kinking because of their thin wall.
It is best to use a kink-resistant catheter for TTJV.
4. Hemorrhage at the insertion site. This is generally rare if the cricothyroid membrane is properly identified, as it is avascular and no surgical incisions are performed.
5. Aspiration. Transtracheal jet ventilation does not prevent airway aspiration of secretions,
blood, or gastric contents.
120
Hyoid
Thyroid
Thyrohyoid
membrane
Cricothyroid
membrane
puncture site
Thyroid
gland
isthmus
Trachea
Figure 11.1. Anatomic landmarks for TTJV.

(From Brown D, ed. Atlas of Regional Anesthesia, 2nd ed. Philadelphia, PA: Saunders; 1999.)
Technique
Prior to initiating TTJV, all necessary equipment should be assembled and ready. Pre-assembled
kits that contain the equipment are available, but in general the following items should be available:
high-pressure non-collapsible tubing, a 12 g to 16 g kink-resistant catheter, a fluid-filled syringe, an
oxygen source with a flow of 10 L/min to 15 L/min, and a manual jet ventilator/insufflator device.
1. Whenever possible, sterile techniques should be utilized.
2. Identify the CTM.
3. Attach a syringe containing partially filled saline to the large bore needle. Using the dominant
hand, aim the needle caudally at a 30 to 45 angle at the skin. Stabilize the cricoid cartilage
with the nondominant hand (Fig. 11.2A).
4. While aspirating, insert the needle through the skin, soft tissue, and CTM (Fig. 11.2B).
5. When air is freely aspirated, advance only the cannula and remove the needle. The needle
should not be advanced, as it can perforate the posterior trachea or esophagus.
6. Reconfirm catheter placement by reattaching the fluid-filled syringe to the cannula and
aspirating.
7. Secure the cannula with sutures or ties or, preferably, have someone dedicated to manually
hold the cannula in place.
8. Connect the oxygen source to the cannula.
9. Administer oxygen via intermittent bursts (<50 psi) of 1-second duration, with 3 seconds of
pause to allow for exhalation (Fig. 11.3).
10. Plans for establishment of a more permanent airway should be immediately considered.
Pressure Required for Adequate Jet Ventilation

The minimum pressure required to drive a jet ventilator is 15 psi. The pipeline pressure for oxygen in hospitals in the United States is approximately 55 psi. Commercially available jet ventilators
(B)
121
(A)
Figure 11.2. Placement of a transtracheal catheter.

(From Patel RG, Norman JR. The technique of transtracheal ventilation. J Crit Illness 1996;11:803808.)
Oxygen Outlet (50 psi)
Manual Trigger
Angiocath
Figure 11.3. The TTJV setup.

(From Patel RG, Norman JR. The technique of transtracheal ventilation. J Crit Illness 1996;11:803808.)
Transtracheal Jet Ventilation Tips

When performing TTJV, ideally there should be three dedicated individuals to perform
safe execution of jet ventilation. One individual must strictly hold the catheter to assure
it does not dislodge and watch for signs of dislodgement. The second individual provides
a jaw lift and similar maneuvers to ensure the egress of air. The third individual is responsible for actual performance of the jet ventilation.
Ideally, the neck should be fully extended, with the exception of a patient with any suspected or known cervical spine injuries.
122
Using a larger syringe (e.g., 20 mL) can help to more easily identify entrance into the
trachea, as the larger cross-sectional area of the plunger prevents drawing back when the
needle is in soft tissue.
Transtracheal jet ventilation can facilitate subsequent direct laryngoscopy and intubation
by allowing visualization of the airway because of the high pressure to open the airway.
Using 2% to 4% lidocaine when placing the catheter/needle may help to anesthetize the
airway.
A small nick in the skin may facilitate passage of the catheter through the dermis.
A small bend in the distal part of the needle may facilitate advancement of the catheter
once the trachea has been cannulated.
It is of the utmost importance to recheck catheter placement in the trachea before initiating TTJV by reconnecting a syringe and aspirating air.
generally contain pressure regulators to lower the pipeline pressure to provide successful jet ventilation, while avoiding higher pressures that might result in barotrauma. In most instances in the
OR, adequate pressure for jet ventilation can be achieved by connecting straight to the pipeline
supply. Difficulty usually arises in locations outside of the OR where TTJV may be needed but
adequate driving pressure is not available.
Generally, most anesthetic machines have connections for commercial jet ventilator kits. If
this is not available, then the oxygen flush value on most anesthetic machines has been shown to
provide sufficient pressure to achieve adequate jet ventilation, averaging 18 psi. Wall-mounted
oxygen flowmeters and anesthesia machine auxiliary oxygen flowmeters will not provide sufficient
pressure at their highest flow rates for jet ventilation, as the highest possible pressure achieved
is about 5.5 psi. Similarly, manual resuscitation bags connected to oxygen flowmeters cannot
provide adequate pressures to provide adequate jet ventilation.
Commercially Available Transtracheal Jet Ventilation

Devices
1. Manujet III (VBM Medizintechnik GmBH; Sulz am Neckar, Germany): A reusable set that contains a pressure hose, Luer lock tubing, bronchoscope adapter with catheter, and a jet ventilation catheter.
2. Manual Jet Ventilator (Instrumentation Industries; Bethel Park, PA): A complete set with tubing
and a pressure regulator.
3. Enk Oxygen Flow Modulator Set (Cook Medical; Bloomington, IN): A disposable set that
includes a kink-resistant catheter, syringe, tubing, and the Enk oxygen flow modulator with
connector.
Summary
Percutaneous TTJV is a temporary maneuver used in the difficult airway to achieve oxygenation
and ventilation. It has the benefit of being able to be performed quicker and with fewer complications by less experienced physicians in comparison to a cricothyrotomy. It provides some degree
of airway protection by upward gas flow to blow secretions away from the larynx. Nonetheless,
TTJV has to be performed in the right patient, under the appropriate circumstances, and using
proper technique and equipment.
Suggested Reading
McHugh R, Kumar M, Sprung J, Bourke D. Transtracheal jet ventilation in management of the difficult airway. Anaesth Intensive Care 2007;35:406408.
Fassl J, Jenny U, Nikiforov S, Murray WB, Foster PA. Pressures available for transtracheal jet
ventilation for anesthesia machines and wall-mounted oxygen flowmeters. Anesth Analg
2010;110:94100.
Hooker EA, Danzl DF, OBrien D, et al. Percutaneous transtracheal ventilation: resuscitation
bags do not provide adequate ventilation. Prehosp Disaster Med 2006;21:431435.
Gulleth Y, Spiro J. Percutaneous transtracheal jet ventilation in head and neck surgery. Arch
Otolaryngol Head Neck Surg 2005;131:886890.
Patel RG. Percutaneous transtracheal jet ventilation: a safe, quick, and temporary way to
provide oxygenation and ventilation when conventional methods are unsuccessful. Chest
1999;116:16891694.
Hagberg CA. Current concepts in the management of the difficult airway. Anesthesiology News.
2009;35(10):85104.
Cook TM, Woodall N, Frerk C. Fourth National Audit Project. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal
College of Anaesthetists and the Difficult Airway Society. Part 1: anaesthesia. Br J Anaesth.
2011;106(5):617631.
123
Early use of TTJV can allow sufficient time for more invasive maneuvers, such as cricothyrotomy
or tracheostomy. It has been shown to facilitate a once-difficult direct laryngoscopy by opening
the airway via a relatively high pressures technique. The most significant complications from TTJV
arise from incorrect placement of the catheter resulting in subcutaneous air and from high pressures during ventilation producing barotrauma.
125
Chapter 12
Cricothyrotomy
Objectives
Discuss the indications and contraindications for cricothyrotomy.
Review the relevant anatomy for cricothyrotomy.
Learn the techniques for percutaneous and surgical cricothyrotomy.
Introduction
Cricothyrotomy is an invasive technique that provides access to the airway in situations when
either noninvasive maneuvers have failed or it is clinically indicated as a primary plan to secure the
airway. It is included in the ASA Difficult Airway Algorithm in both the emergent and nonemergent pathway after other rescue maneuvers have failed or are not feasible. Cricothyrotomy equipment should be included in all emergency airway storage units and readily available. It is estimated
that emergency cricothyrotomy is performed in approximately 1% of all emergency airway cases
in the ED, with a higher rate in the pre-hospital setting.
Because of fears of subglottic stenosis, a common complication in the early 1900s, cricothyrotomy was generally avoided for most of the twentieth century in favor of formal tracheostomy.
With the development of modern surgical techniques, biocompatible endotracheal tubes (ETTs),
and antibiotics, however, cricothyrotomy developed renewed interest as a safe, acceptable surgical airway in the 1970s. With the specialization of emergency medicine, use of cricothyrotomy in
the ED and pre-hospital setting for those who could not be conventionally intubated increased.
For anesthesiologists, cricothyrotomy provides an option in the difficult airway algorithm for the
cannot intubate, cannot ventilate scenario as hypoxemia develops.
Nonetheless, there is a high failure rate for this technique when performed emergently (60%
according to a recent national audit performed in the United Kingdom). A root cause analysis was
not performed but numerous mechanisms are most likely involved. This study emphasizes the
point that this technique needs to be taught and performed to the highest standards to maximize
the chance of success.
126
Cricothyrotomy is a not considered a permanent airway, and after placement, plans should be
made for either removal of the cricothyrotomy catheter or conversion to a formal tracheostomy.
12 Cricothyrotomy
Indications for Cricothyrotomy

As mentioned, patients with a difficult airway may be considered candidates for cricothyrotomy.
There are predisposing factors that would increase the likelihood a patient would require a cricothyrotomy for immediate airway control. These include:
1. Non-reassuring findings on airway examination (long incisors, overbite, <3 cm mouth opening, Mallampati class 3 or 4, <3 fingerbreadth thyromental distance, short/thick neck, reduced
range of motion of neck)
2. Maxillofacial trauma
3. Pharyngeal and laryngeal trauma
4. Cervical spine trauma
5. Previous radiation/surgery to airway structures
6. Infections of the head and neck
Contraindications
Cricothyrotomy is a life-saving technique and used only in an emergency setting. Because of this,
there are few absolute contraindications for this procedure, which include:
1. Children younger than 12 years of age: The isthmus of the thyroid gland reaches the level of
the cricothyroid membrane in children and the larynx is smaller with the cricoid cartilage being
the narrowest portion. Needle cricothyrotomy with transtracheal (jet) ventilation is indicated
in this pediatric population.
2. Laryngeal fractures: Damage to the osseocartilagenous framework of the larynx with mucosal
damage.
Relative Contraindications for Cricothyrotomy
1. Patients with laryngeal disease: cancer or inflammation
2. Patients who have been intubated translaryngeally for more than 3 days (increased risk of subglottic stenosis)
3. Distorted or unidentifiable neck anatomy
4. Bleeding disorders
5. Inexperienced physicians who are unfamiliar with the technique
Complications
Complication rates range from 10% to 40% for emergency cricothyrotomy. Generally, the complications
are divided into those that are acute problems related to the procedure and those that develop postoperatively. Higher complication rates are seen in the pre-hospital setting and in the pediatric population.
Early Complications:
1. Hemorrhage from laceration of a neck vein or a small cricothyroid artery
2. Improper insertion of the catheter, generally in the subcutaneous tissue, resulting in subcutaneous or mediastinal emphysema
3. Posterior tracheal wall laceration and esophageal perforation
4. Possible laceration of the thyroid gland (and corresponding vessels) when anatomical landmarks are poorly identified
5. Vocal cord injury
6. Aspiration, as patients are frequently full stomach and the airway is not protected during the
procedure
Anatomy
The cricothyroid membrane (or ligament) is located in the anterior neck between the thyroid
cartilage and cricoid cartilage (see Fig. 12.1). The cricothyroid space is identified by palpation of
an indentation below the laryngeal prominence (Adams apple or thyroid notch). The size of
cricothyroid membrane (CTM) can vary, but on average it is 2 cm to 3 cm wide and 1 cm in length.
Arterial structures surrounding the airway typically lie deep in the neck, with the exception of
the cricothyroid artery, which lies on the anterior surface of the CTM and typically traverses the
upper portion of the membrane.
Thyroid cartilage
Access Point
Cricoid cartilage
Figure 12.1 Midsagittal anatomy of the larynx and trachea. The access point for percutaneous cricothyrotomy is in
the lower third of the cricothyroid membrane.
(Courtesy of Cook Critical Care; Bloomington, IN)
Percutaneous Cricothyrotomy Tip

Because of the location of the cricothyroid artery and the proximity of the CTM to the
vocal folds, puncture or incision of the CTM should be made in the inferior third of the
membrane and directed posteriorly.
127
12 Cricothyrotomy
Late Complications:
1. Tracheal stenosis with an incidence of approximately 2% to 8% in adults. This is more likely if
preexisting trauma or infection is present.
2. Swallowing dysfunction
3. Voice changes: hoarseness, early fatigue
4. Infection
5. Bleeding
128
Techniques
The two most common techniques for performing a cricothyrotomy are the percutaneous dilational cricothyrotomy and the surgical cricothyrotomy. Both require a thorough knowledge of the
cricothyroid anatomy as well as the surrounding structures.
12 Cricothyrotomy
Percutaneous Dilational Cricothyrotomy (Seldinger Technique)

A number of commercially available kits utilize this concept. The basis for this procedure is the
insertion of an airway catheter over a dilator that has been inserted over a guidewire. The guidewire is placed initially through a needle using the Seldinger technique.
1. Whenever possible, extend the patients neck and use aseptic technique.
2. Identify the cricothyroid groove. Over the CTM, make a 1 cm to 1.5 cm vertical incision through
the skin.
3. Pass an 18 g needle-catheter attached to a fluid-filled syringe (time permitting) through the incision
at a 45 angle in the caudal direction with continuous aspiration. Aspiration of free air confirms passage through the CTM. Advance the catheter over the needle into the trachea (see Fig. 12.2A).
4. Detach the needle and leave the catheter in place (if time permits, re-aspirate through the
catheter to confirm maintenance of correct placement).
5. Insert the guidewire caudally to a depth of approximately 2 cm to 3 cm. Remove the catheter
(Fig. 12.2B).
6. Thread the curved dilator with the airway cannula over the guide wire while maintaining stabilization of the guidewire. Advance both the dilator and the cannula through the CTM while
maintaining control of the guidewire to avoid loss of the wire (Fig. 12.2C).
7. Remove the dilator and guidewire together with the cannula in place, inflate cuff and ventilate
(Fig. 12.2D).
8. Confirm proper placement by capnography and secure the catheter in place.
Percutaneous Cricothyrotomy Tips

Position yourself on the right side of the patient to perform the procedure.
Time permitting; fill the syringe with 2% or 4% lidocaine to anesthetize the airway prior to
inserting the tube.
Do not use excessive force when passing the needle-catheter, as it may penetrate the
posterior wall of the trachea.
In obese patients, consider keeping the needle in place while threading the guidewire to
avoid kinking of the catheter.
Lubrication of the dilator should facilitate placement.
Video 12.1 Percutaneous Dilational Cricothyrotomy (Seldinger Technique)
Surgical Cricothyrotomy
Equipment needed: #11 blade scalpel, tracheal hook, hemostat or dilator, size 6.0 mm ETT.
1. Whenever possible, extend the patients neck, infiltrate with local anesthetic, and use aseptic
technique.
2. Identify the CTM. Stabilize the larynx by placing the nondominant thumb and middle finger over
the thyroid cartilage.
129
12 Cricothyrotomy
(A)
(B)
Figure 12.2 Technique for percutaneous dilational cricothyrotomy (Seldinger technique).

(Courtesy of Cook Critical Care; Bloomington, IN.)
(C)
12 Cricothyrotomy
130
(D)
Figure 12.2 (Continued)
3. Perform a vertical incision over the CTM through the skin and fascia only. The index finger can
be left in the wound to act as a guide.
4. Perform a horizontal incision into the CTM of approximately 1 cm to 2 cm wide. It helps to
perform the initial incision from the midline outward and then turn the blade around and repeat
on the other side rather than slashing across the membrane.
5. Again, the index finger can be left in the incision to maintain location of the airway. Insert
the tracheal hook cephalad at the inferior border of the thyroid cartilage and maintain gentle
traction.
Percutaneous Cricothyrotomy Tips

If infiltrating the skin with local anesthetic, use a small amount to avoid obscuring the surgical field.
Always have suction available.
Keep incisions midline to avoid laterally lying vessels.
Do not use excessive downward force with the scalpel, as it may penetrate the posterior
tracheal wall.
Although it is debatable whether to use a vertical or horizontal skin incision, a vertical
incision may be preferable, as it can be extended if above or below the CTM.
Commercially Available Cricothyrotomy Kits

1. Emergency Transtracheal Airway Catheter (Cook Critical Care; Bloomington, IN): Needle cricothyrotomy catheter composed of kink-resistant fluorinated ethylene propylene.
2. Melker Emergency Cricothyrotomy Catheter Set (Cook Critical Care; Bloomington, IN): Kit
designed with all necessary components for Seldinger cricothyrotomy. Set includes syringe,
introducer needles with Teflon catheter, extra-stiff guidewire with flexible tip, scalpel,
curved dilator and PVC airway catheter. Sizes available: 3.8 cm, 4.2 cm, and 7.5 cm uncuffed
catheters.
3. Melker Cuffed Emergency Cricothyrotomy Catheter Set (Cook Critical Care; Bloomington, IN):
Same kit as above but with a cuffed 9.0 cm catheter (Fig. 12.3).
4. Melker Universal Emergency Cricothyrotomy Catheter Set (Cook Critical Care; Bloomington,
IN): Same kit as above with additional equipment for surgical technique (tracheal hook, safety
scalpel, Trousseau dilator, and blunt curved dilator) (Fig. 12.4).
5. Quicktrach Emergency Cricothyrotomy Device (VBM Medizintechnik GmbH, Sulz am
Neckar, Germany): Full set containing preassembled airway catheter, stopper, needle, and
syringe.
Summary
Cricothyrotomy is used in a life-saving situation for a patient that cannot be intubated or ventilated through noninvasive measures. Failure to provide adequate ventilation and oxygenation is
the primary cause of cardiac arrest for patients undergoing general anesthesia. Cricothyrotomy is
the final step for securing an airway in those patients where conventional measures to secure the
airway have failed. The success of cricothyrotomy depends on two main factors: thorough knowledge of the neck and airway anatomy and previous training or experience with the technique.
Simulation and anatomy labs (animals or human) have been shown to be highly beneficial for
131
12 Cricothyrotomy
6. Dilate the CTM with a Trousseau dilator or hemostat. To avoid trauma, only insert the dilator
a few millimeters into the airway.
7. With the dilator in place, remove the tracheal hook and insert the ETT into the airway. The
dilator must be opened horizontally to allow insertion of the ETT. If the dilator is vertical,
then it will interfere with the ETT placement.
8. Alternatively, the tracheal hook can remain in place and the dilator removed. The ETT can be
inserted with the hook maintaining traction on the airway.
9. Inflate the cuff and ventilate.
10. Confirm proper placement by capnography and secure the airway.
12 Cricothyrotomy
132
Figure 12.3 Melker Cuffed Emergency Cricothyrotomy Catheter Set (Cook Critical Care; Bloomington, IN).
(From Metterlein T, Frommer M, Ginzkey C. A Randomized Trial Comparing Two Cuffed Emergency Cricothyrotomy Devices Using
a Wire-Guided and a Catheter-Over-Needle Technique. J Emerg Med 2011;41(3):326332.)
Figure 12.4 Melker Universal Emergency Cricothyrotomy Catheter Set (Cook Critical Care; Bloomington, IN).
teaching proper technique and confidence in the practitioner. For the anesthesiologist, the percutaneous technique appears to be the more successful, less complicated technique as compared
to a surgical cricothyrotomy because of the familiarity of using the Seldinger technique for other
procedures. It should be remembered that a cricothyrotomy is a temporary airway, and plans for
conversion to a formal tracheotomy should be immediately considered.
Hagberg CA. Current concepts in the management of the difficult airway. Anesthesiology News
2009; 35(10):85104.
Eisenburger P, Laczika K, List M, et al. Comparison of conventional surgical versus Seldinger
technique emergency cricothyrotomy performed by inexperience clinicians. Anesthesiology
2000;92:687690.
Hatton KW, Price S, Craig Lo, Grider JS. Educating anesthesiology residents to perform
percutaneous cricothyrotomy, retrograde intubation, and fiberoptic bronchoscopy using
preserved cadavers. Anesth Analg 2006;103:12051208.
Gulsen S, Unal M, Dinc AH, Altinors N. Clinically Correlated Anatomical Basis of
Cricothyrotomy and Tracheostomy. J Korean Neurosurg Soc 2010;47:174179.
Gibbs MA, Mick NW. Surgical Airway. In: Hagberg CA, ed. Benumofs Airway Management,
3rd ed. Philadelphia, PA: Mosby; 2012:640656.
Brock G, Gurekas V. The occasional poor mans cricothyrotomy. CJRM 1999;4:149151.
Melker RJ, Kost KM. Percutaneous Dilational Cricothyrotomy and Tracheostomy In: Hagberg
CA, ed. Benumofs Airway Management, 2nd ed. Philadelphia, PA: Mosby; 2007:640677.
133
12 Cricothyrotomy
Suggested Reading
135
Chapter 13
Extubation Catheters
Lara Ferrario, MD
Objectives
Discuss extubation criteria and the need for a detailed extubation plan in the difficult airway
patient.
Define the role of airway exchange catheters in an extubation plan.
List the different types of airway exchange catheters and their use.
Introduction
Although great strides in airway related morbidity and mortality have been made in the past few
years, analysis of the ASA Closed Claims Database has shown that extubation-related complications have not significantly decreased. The decision to proceed with extubation is a complex part
of the overall anesthetic management, particularly when one is faced with a known or suspected
difficult airway. Reintubation of the trachea in the patient with a difficult airway is laden with
complications, particularly in the postoperative period. Post-extubation upper airway obstruction, many times resulting from laryngeal edema, may lead to rapid development of hypoxia. In
this emergency scenario, the anesthesiologist must quickly re-establish an airway. However, the
presence of soft tissue edema and, at times, postsurgically altered anatomy may limit access to the
airway, hindering success. Repeated intubation attempts have been associated with high morbidity
and mortality rate.
Although the standard criteria for prediction of successful extubation are primarily based on
pulmonary function, none of the extubation criteria are specifically designed to predict patency of
the airway once the endotracheal tube (ETT) is removed.
136
13 Extubation Catheters
Extubation Criteria
Patient must be awake and alert to ensure airway protection.

Respiratory rate less than 30 breaths per minute
Hemodynamically stable with no significant inotropic support
Adequate gas exchange (baseline O2 saturation 93%; no significant acidosis by arterial
blood gas, if applicable)
Adequate neuromuscular block reversal (sustained head lift)
Negative inspiratory force greater than 20 mmHg
Vital capacity greater than 15 mL/kg
A common maneuver that has been shown to have a high specificity and negative predictive
value for post-extubation obstruction is the cuff leak test. This noninvasive, simple test can
qualitatively assess the presence or absence of an air leak around an in situ ETT. To determine
whether an air leak is present, the spontaneously breathing patient is disconnected from the ventilator circuit and the ETT cuff is completely deflated. After occlusion of the end of the ETT, the
patient with minimal or no laryngeal edema will be able to breathe around the ETT. Alternatively,
a quantitative evaluation of the leak volume can be performed by subtracting the end-tidal volume
measured with the ETT cuff deflated from the end-tidal volume obtained when the cuff is inflated.
A low cuff leak volume (<12%) is useful at identifying a patient with the potential to develop
post-extubation stridor. It should be considered that this test is more specific for laryngeal, rather
than oropharyngeal, edema. Although some authors have questioned the value of the cuff leak test
to predict extubation success in patients with an uncomplicated airway, there is general agreement that such a simple and noninvasive maneuver is very valuable when facing the decision to
extubate a known or suspected difficult airway.
Once the decision to proceed with extubation has been made, the ASA Task Force on Difficult
Airway Management recommends development of an extubation strategy, including maintenance of
access to the suspected or known difficult airway to facilitate reintubation. To this goal, extubation
over an airway exchange catheter (AEC) has been described as part of a staged extubation strategy.
Airway exchange catheters are commercially available devices that, when inserted through an ETT
prior to extubation, may facilitate the reintubation of the trachea. They are long, hollow, semi-rigid
catheters with a small internal diameter. Some may also allow oxygenation/ventilation. Specialized
AECs have been developed to exchange supraglottic airways for an ETT (see Chapter 14 for details).
Indications
Extubation over an AEC is recommended in the following situations:
In patients who, at intubation, presented with a difficult airway
In patients whose airway, intra-operatively, may have progressed to a difficult airway
Types of Airway Exchange Catheters

Currently, the AECs manufactured by Cook Medical (Bloomington, IN), are the most commonly
used and considerably more studied. Refer to Table 13.1 for a detailed description of the different
catheters.
The Cook AECs share several characteristics. The Cook AEC (C-AEC) is a semi-rigid polyurethane catheter (yellow in color) with a blunt, smooth tip to decrease the potential for trauma
during insertion and removal (Fig. 13.1). Two Rapi-Fit adapters, which allow either jet ventilation
or ventilation with a 15 mm connection to a ventilator or Ambu bag, are included in the package.
137
Table 13.1 Airway Exchange Catheters

Fr; ID (mm); ETT fit size
Catheter length (cm)
Cook Airway Exchange

Catheter (C-AEC)
8; 1.6; 3.0
11; 2.3; 4.0
14; 3.0; 5.0
19; 3.4; 7.0
45
83
83
83
Cook Airway Exchange

Catheter- EF (C-AEC-EF)
11; 2.3; DLT

14; 3.0; DLT
100
100
Soft-Tipped Cook Airway

Exchange Catheter
11; 2.3; 4.0

14; 3.0; 5.0
100
100
Arndt Airway Exchange Catheter Set
14; 3.0; 5.0
70
Aintree Intubation Catheter (AIC)
19; 4.7; 7.0
56
Figure 13.1 Cook Airway Exchange Catheter (C-AEC) shown with a Rapi-Fit adapter.
Distal side ports are provided to ensure adequate airflow. The Arndt AEC is characterized by a
tapered end (Fig. 13.2). Packaged with a stiff guide wire and Rapi-Fit adapters, it is recommended
for the exchange of laryngeal mask airways (LMAs) and ETTs using a fiberoptic bronchoscope
(FOB). Similarly to the C-AEC, the Arndt AEC is a semi-rigid, polyurethane catheter. The Aintree
Intubation Catheter (AIC), an adaptation of the C-AEC, is also a semi-rigid, polyurethane catheter (powder blue in color) with a blunt, smooth tip, and side ports on the distal end (Fig. 13.3).
The unique feature of the AIC is the width of its internal diameter (ID 4.7 mm), which is designed
to be large enough to accept a standard 4 mm FOB. As a consequence, its external diameter is
quite large as well (6.5 mm). Therefore, only ETTs greater than 7.0 mm. should be used with this
device. It is also packaged with two Rapi-Fit adapters.
Because depth of insertion of any AECs beyond the tip of the ETT (>26 cm for an orotracheal adult AEC) increases the risk of tracheobronchial tree perforation and barotrauma with
jet ventilation, these devices are manufactured with centimeter markings to allow for proper
depth determination. Whenever an AEC is used for either of its two purposes(1) extubation/
reintubation or (2) oxygenation/ventilationconfirmation that the AEC is indeed in the trachea
should be performed.
Device
138
Figure 13.2 Arndt Airway Exchange Catheter.

Figure 13.3 Aintree Intubation Catheter (AIC) shown with a Rapi-Fit adapter.
Uses of Airway Exchange Catheters

Once the ETT is removed over the AEC, the AEC should remain in place as a conduit allowing
for: (1) oxygen administration by insufflation, manual ventilation, or jet ventilation; (2) intermittent
measurement of end-tidal CO2 from the trachea; and (3) reintubation, using the AEC as a stylet. It
is highly recommended that laryngoscopy (direct or indirect) be performed to facilitate passage of
the ETT over the AEC, not so much to visualize the glottis, but rather to displace the tongue and
the other soft tissues so as to allow the ETT to advance more easily through the glottic opening
and into the trachea.
Both the pediatric and the adult C-AECs can be used as stylets through which the ETT can be
inserted if reintubation is necessary. Therefore, prior to extubation, a decision must be made on
the proper size of C-AEC to be used. A relatively small diameter C-AEC (8 or 11 Fr) will be better
tolerated by the spontaneously breathing and conscious patient. It also is the size of choice when
the C-AEC is used to exchange for a nasal REA. On the other hand, the adult C-AEC allows for
manual or jet ventilation. Independently from the size of AEC chosen, an important consideration
is the patients comfort and ability to tolerate such a device while awake. Although routine use
of lidocaine is unnecessary, topicalization of the trachea can be achieved by injecting 4% lidocaine
through either the ETT or the AEC, particularly in patients with reactive airway disease or traumatic cervical spine injury. It is recommended that this maneuver, aimed at increasing tolerance
of the AEC, be performed while the patient is still anesthetized to prevent forceful coughing. If
a pediatric C-AEC is chosen (11 Fr), then one must consider the potential difficulty of advancing
an appropriately sized adult ETT over the device. If there is a significant discrepancy between the
external diameter of the C-AEC and the internal diameter of the ETT, then the gap may potentially cause impingement of the ETT on the arytenoid cartilages (usually the right side secondary
Airway Exchange Catheter Tips

When a nasotracheal tube is exchanged for a C-AEC (particularly sized 11 Fr), make sure
that the C-AEC is clearly labeled to ensure it is not mistaken for a nasogastric feeding
tube. (The DobbhoffTM nasogastric tube is the same color and a similar diameter.)
Whenever a patient with a difficult airway is extubated, communication among hospital
personnel who will be in charge of the patients care is crucial, especially if a C-AEC is left
in place as an airway rescue device.
Prior to reintubation or oxygenation/ventilation through an AEC, reconfirm its correct
placement by either FOB or ETCO2 analysis.
When reintubating over an AEC, use a petroleum gel-based lubricant on the AEC and use
laryngoscopy (direct or indirect) to elevate the tongue to enhance ETT passage.
Securely tape the C-AEC at the side of the nose or mouth and label the distance at which
it should be kept.
The AIC, being significantly shorter than the C-AEC (56 vs. 83 cm in length in the adult versions)
but considerably wider in ID to allow the passage of the FOB, is very useful when the exchange
of a supraglottic airway device for an ETT is required. This intubating technique, referred to as
fiberoptic-assisted endotracheal intubation through the LMA-AIC, is described in Chapter 14.
Airway Exchange Catheters and Double-Lumen

Endotracheal Tubes
The C-AEC-EF is specifically designed to aid in the exchange of a double-lumen tube (DLT) for a
standard ETT (Fig. 13.4). EF stands for extra firm for adequate stiffness for use with a DLT. The
most recent model incorporates a softer plastic for the distal 7 cm to decrease the risk of bronchial
trauma or perforation. The C-AEC-EF is normally used at the end of a surgical procedure when the
DLT is no longer needed, but the patient still requires assisted ventilation through an ETT. Because
in these clinical situations the patients are usually in a critical and delicate state of health, it is important to be able to provide oxygenation through the catheter while the tube exchange is performed,
should the patient require it. The C-AEC-EF comes with two Rapi-Fit adapters to allow this.
139
to the bevel orientation). To obviate this potentially harmful inconvenience, a laryngoscope can be
used to lift the soft tissues and facilitate the passage of the ETT over AEC. Additionally, the Parker
Flex-TipTM tracheal tube (Parker Medical; Englewood, CO) is a specially designed ETT with a soft,
curved, and anteriorly located bevel. This particular design allows for the tip to flex and slide past
any protruding feature of the patients anatomical structures and minimizes the gap between the
AEC and the lumen of the ETT. There is a substantial body of evidence in the literature that this
specifically designed ETT is particularly helpful in those situations characterized by a swollen or
anatomically distorted airway.
Alternatively, a second AEC, such as the AIC, can be used to bridge the gap between the pediatric C-AEC and larger diameter ETT. After inserting the shorter and larger AIC over the pediatric
C-AEC, the latter can be removed and the adult ETT may be advanced over the AIC. This maneuver offers the additional advantage of determining with FOB the correct placement and depth
of insertion of the AIC prior to proceeding with jet ventilation. On the other hand, it must be
considered that this bridging technique is not without hazard. An additional step in the process
to secure a patients airway by removing a C-AEC to place another AEC inevitably increases the
odds of losing the airway. Therefore, it is necessary that the above risks and benefits be carefully
considered when determining what size C-AEC may be better in a given airway scenario.
140
Figure 13.4 Cook Airway Exchange CatheterExtra Firm (C-AEC-EF). The purple tip is blunt, soft, and flexible and
is designed to prevent trauma to the airway.
Double Lumen Tube Exchange Tips
Make sure that the DLT bronchial cuff is deflated.

Use a sterile, petroleum gel-based ointment to lubricate the proximal portion of the catheter.
Insert the C-AEC-EF through the tracheal lumen of the DLT.
Deflate the tracheal cuff of the DLT before sliding it over the C-AEC-EF.
The opposite exchange has also been described and is useful in patients with a known or
unexpected difficult airway who require DLT placement. At first, the airway can be secured with
a conventional single-lumen ETT, which can subsequently be exchanged for a DLT or a Univent
tube (Fuji Systems; Tokyo, Japan) by using a C-AEC-EF.
Double Lumen Tube Exchange Tips
Choose the appropriate size C-AEC-EF to fit in the DLT required.

Use a sterile, petroleum gel-based ointment to lubricate the proximal portion of the catheter.
Exchange the ETT for the C-AEC-EF.
Slide the tracheal lumen of the DLT over the C-AEC-EF.
With a laryngoscope blade, gently lift the soft tissue and displace the tongue over to the
left to allow the DLT to advance easily without the cuffs rubbing over the patients teeth.
Advance the DLT tip just past the cords and remove the C-AEC-EF.
Properly position the DLT by performing fiberoptic bronchoscopy through the bronchial lumen.
Solid Intubating Stylets

Solid intubating stylets such as the Portex Tracheal Tube Introducer (Smiths Medical International;
Ashford, Kent, UK) and the Muallem ETT Introducer (METTI; VBM Medizintechnik GmbH;
141
Figure 13.5. Muallem ETT Introducer (METTI).
Sulz am Neckar, Germany) have been described as having a high success rate during ETT exchange
(Fig. 13.5). However, when used as reintubation devices, solid stylets present some clear disadvantages over the AECs. The degree of rigidity, which may facilitate the ETT exchange, is more likely to
cause tracheal or bronchial perforation when they are left in the extubated patient for a given period
of time. Additionally, they do not allow depth determination, oxygenation/ventilation, or fiberoptic
bronchoscopy through a lumen. Therefore, solid intubating stylets, although easy to use and with
a high success rate as tube exchangers, are not recommended for the purpose of assisting in the
extubation of the patient with difficult airway in the described staged extubation strategy.
Summary
Extubation, particularly of the difficult airway, is not without risk and should be taken seriously,
as reflected in the last ASA Closed Claims Analysis. The clinician needs to consider many factors,
including the ease of the initial intubation, the patients medical status, the surgical procedure, the
setting in which the extubation is going to occur, and, finally, the practitioners skills and preferences. The ASA Task Force on Management of the Difficult Airway has developed an extubation
strategy that should be followed, as there is always the potential need for reintubation.
Any strategy chosen by the clinician should be of low risk and optimize oxygenation and ventilation. Among the various techniques, the use of an AEC allows the most reliable securing of the airway
and often the advantage of the ability to provide oxygenation during the tube exchange and even
after extubation, especially of patients with reduced residual capacity and limited oxygen reserve.
Suggested Reading
Biro P. Staged Extubation Strategy: Is an Airway Exchange Catheter the Answer? Anesth Analg
2007;105:11821185.
Benumof JL. Airway Exchange Catheters. Simple concept, potentially great danger. Anesthesiology
1999; 91:342344.
Mort TC. Continuous Airway Access for the Difficult Extubation: The Efficacy of the Airway
Exchange Catheter. Anesth Analg 2007;105:13571362.
Higgs A, Swampillai C, Dravid R, Mitchell V, Patel A, Popat M. Re-intubation over airway
exchange cathetersmind the gap. Anaesthesia 2010; 65:859860.
Wittekamp B, van Mook W, Tjan D, Zwaveling JH, Bergmans D. Clinical review: Post-extubation
laryngeal edema and extubation failure in critically ill adult patients. Critical Care 2009;13:233.
Miller RL, Cole RP. Association between reduced cuff leak volume and postextubation stridor.
Chest 1996;110:10351040.
Jaber S, Chanques G, Matecki S, Ramonatxo M, Vergne C, Souche B, et al. Post-extubation
stridor in intensive care unit patients. Risk factors evaluation and importance of the cuff-leak
test. Intensive Care Med 2003;29:6974.
Practice guidelines for the management of the difficult airway: an updated report by the
Sanuki T, Son H, Kishimoto N, Kotani J. Utility of the Portex Introducer, Ivory Type, as a Tube
Exchanger. J Oral Maxillofac Surg 2009;67:16151618.
Peterson SN, Domino KB, Caplan RA, Posner KL, Lee LA, Cheney FW. Management of the
Difficult Airway: A Closed Claims Analysis. Anesthesiology 2005;103:3339.
(Copyright image provided as courtesy of VBM Medical, Sulz am Neckar, Germany.)
143
Chapter 14
Combined Airway Management

Techniques
Jay R. Pinsky, MD and Carin A. Hagberg, MD
Objectives
Be familiar with combination techniques to optimize successful airway management.
Understand situations in which combined airway management techniques can be useful.
Be prepared to use combination techniques when difficulty in airway management is encountered.
Introduction
Management of the difficult airway remains one of the most relevant and challenging tasks of anesthesia care providers. A common factor preventing successful tracheal intubation is the inability
to visualize the vocal cords during the performance of direct laryngoscopy. Most airway problems
can be solved with relatively simple devices and techniques, but clinical judgment born of experience is crucial to their application. Whether the patient is awake or anesthetized, there are a
variety of devices/techniques that can be combined to accomplish successful intubation. In many
of these combination techniques, physical maneuverssuch as lingual traction, chin lift, or jaw
thrustare very advantageous and should be utilized. Additionally, placement of pressure on the
thyroid cartilage, (backward, upward, rightward, pressure; BURP maneuver) or utilization of special endotracheal tubes (e.g., Endotrol, Parker Flex-Tip, etc.) may enhance tracheal intubation
when using any combination technique. Before undertaking any of these procedures, the clinician
should be prepared by having the appropriate personnel, monitoring equipment, and emergency
airway equipment readily available. This chapter focuses on using various combinations of devices/
techniques to increase the success of tracheal intubation.
Direct Laryngoscopy Combination Techniques

Direct Laryngoscopy/Flexible Fiberoptic Laryngoscopy
Many different airway instruments and methods have been shown to be adequate for securing an
airway in which the vocal cords cannot easily be visualized by direct laryngoscopy (DL) alone. The
flexible fiberoptic bronchoscope (FOB) is the most well-known airway device utilized for difficult
14 Combined Airway Management
144
intubation, but its use may be limited in certain situations and conditions, such as a posteriorly
displaced epiglottis, upper airway edema, or an oropharyngeal mass, which can create difficulty
in passing the FOB into the glottic opening. Although many maneuvers, such as jaw thrust, lingual
traction, and optimal external laryngeal manipulation have been suggested to facilitate the use of
the FOB, DL has also been demonstrated to be useful in facilitating this technique. Direct laryngoscopy can be considered in combination with flexible FOB when either method is unsuccessful
alone. This combination technique has been shown to be useful not only for intubation but for
tracheal extubation and reintubation as well (Fig. 14.1). Using a FOB to facilitate an exchange can
provide a more controlled method of extubation. This combination technique does have a drawback in its requirement of two individuals, but management of a difficult airway often necessitates
that at least two individuals be involved. Both the clinical situation and the skill of the individuals
should dictate who performs which (DL or FOB).
During FOB use, DL can expand the space available in the oral cavity to manipulate the scope
by displacing pharyngeal tissue, and the epiglottis can be elevated, allowing the scope to be more
easily directed underneath the epiglottis toward the glottic opening. This may be especially helpful in the morbidly obese patient or patients with soiled airways (e.g., with blood, secretions, or
vomitus). Following induction of general anesthesia, one individual should perform laryngoscopy
until the best view is obtained. While holding the laryngoscope in place, a second individual should
direct the tip of the FOB under the epiglottis and advance it toward the glottic opening. The FOB
should then be directed until the tip of the scope is approximately 2 cm to 3 cm above the carina.
The ETT should then be advanced over the FOB until in proper position and the laryngoscope, as
well as the FOB, is removed. Even in the event of a soiled airway, this technique may be useful.
Direct Laryngoscopy/Intubation Catheter

In addition to the use of the FOB, there are other tools that can assist DL when the view is less
than optimal. An intubation stylet, such as the bougie (Fig. 14.2), has been used for years to assist
laryngoscopy in difficult intubations. When a Cormack-Lehane grade III view is encountered, its
coud tip can be passed underneath the epiglottis, and tracheal positioning confirmed by the
sensation of clicks as the bougie tip passes the tracheal rings. The Cormack-Lehane grade III view
is described when only the epiglottis is visualized and can be subdivided into grades IIIA and IIIB.
Grade IIIA represents the DL view when the epiglottis can at least be lifted up and away from the
Figure 14.1 Use of two-person technique with DL/FOB in nasal to oral ETT exchange in patient with a
difficult airway.
145
Figure 14.2 Use of a bougie combined with direct laryngoscopy.
posterior pharyngeal wall, whereas the grade IIIB view shows the epiglottis either pointing posteriorly or closely related to the posterior pharyngeal wall. The epiglottis cannot be visualized at all
in the grade IV view. The distinction between these different anatomic views is important because
an intubation catheter is more likely to assist laryngoscopy in successful tracheal intubation in a
grade IIIA or better but is much less likely to result in successful intubation when a grade IIIB or
IV view is encountered upon DL.
Direct Laryngoscopy/Fiberoptic Stylet

Another airway tool that can be used in combination with DL is the fiberoptic stylet (Fig. 14.3).
These devices have shafts (either rigid, semi-rigid, or malleable) that transmit light and image via
optical fibers, a proximal eyepiece, and an ETT holder located proximally. An ETT is placed over
the stylet with the tip of the ETT positioned just past the distal end of the stylet. While using the
fiberoptic stylet as an adjunct to DL, the tip of the stylet can be guided just beneath the tip of
the epiglottis under direct vision. While holding the ETT/fiberoptic stylet securely, the clinician
transfers his/her vision to the eyepiece or monitor where the glottic opening can be visualized,
Figure 14.3 Use of the fiberoptic stylet in combination with direct laryngoscopy.
146
and the ETT can be advanced through the vocal cords and into the trachea. Because the curved
fiberoptic stylet is a more rigid device than the bougie and allows indirect visualization around
certain anatomic barriers (i.e., the epiglottis, pharyngeal tissue, etc.), it may be a more appropriate
adjunct to DL, especially with grade IIIB views.
Direct Laryngoscopy/Retrograde Intubation

Retrograde-guided intubation is yet another alternative method for difficult intubation for either a
rescue or as the preliminary technique in situations in which ventilation is preserved. Retrograde
intubation, by itself, is a blind procedure, as there is no visualization of the glottis as the ETT
is advanced. To improve the success of retrograde intubation, it can be combined with direct
or fiberoptic laryngoscopy. Direct laryngoscopy can be used as an adjunct to improve success
during retrograde guided intubation. During the classic technique of retrograde intubation, after
a catheter is placed in the inferior cricothyroid membrane, the J-tip of a guidewire is directed
upward until it can be retrieved from the mouth or nares. If orotracheal intubation is desired,
then DL can aid the clinician in opening the oropharynx and visualizing the wire so that it may be
retrieved more easily through the mouth prior to entering the nasopharynx. In addition, after the
guiding catheter is advanced anterograde over the wire until tenting is noted at the cricothyroid
access point, DL may be used to lift the epiglottis, pharyngeal tissue, and facilitate the passage of
an ETT through the vocal cords. When using any DL combination technique, it should be kept in
mind that the basic maneuvers to improve DL, including optimal patient positioning and external
laryngeal manipulation, remain vitally important in improving the success of tracheal intubation.
Additionally, in many combination techniques, physical maneuvers (lingual traction, chin lift and
jaw thrust) are very advantageous.
Video Laryngoscopy Combination Techniques

Video Laryngoscopy/Intubating Catheter
Just as the bougie has been demonstrated to be an invaluable adjunct to DL, it may be used in
combination with video laryngoscopy (VL) to improve the success of tracheal intubation, and
may offer additional advantages. The bougie has been well described as a useful ETT introducer
because of its small diameter and angulated tip. This can prove useful when mouth opening/size
is limited and difficulty is encountered advancing the ETT. This can occur because of the difficulty
in aligning the tip of the ETT with the glottis, even when the glottis is well visualized. The bougie
can be advanced into the glottis and trachea when attaining only a minimal view of the glottic
opening because of the ability to rotate its angulated tip. Also, although certain VLs, such as the
Pentax-AWS Airway Scope (Pentax, Tokyo, Japan), have been shown to reduce cervical spine
movement during endotracheal intubation, the combination use of the bougie in addition to VL
has been shown to cause further reduction of cervical spine angulation during intubation, making
this combination of techniques a useful option for patients with unstable cervical spine injuries.
Video 14.1 Combination Techniques: Videolaryngoscopy/Intubating catheter
Video Laryngoscopy/Flexible Fiberoptic Laryngoscopy

Video laryngoscopy has been used effectively for many years now, and there are many VLs currently available, including, but not limited to, the C-MAC (Karl Storz Endoscopy, Tuttlingen,
Germany/Culver City, CA), GlideScope GVL (Verathon Medical, Bothell, WA), and McGRATH
(Aircraft Medical, Edinburgh, UK) VLs. These devices provide electronic images projected onto a
screen originating from a video camera at the distal end of a conventional-like laryngoscope blade.
Although each device offers its own unique advantages, VLs in general provide several advantages
Video 14.2 Combination Techniques: Videolaryngoscopy/Flexible FOB
Videolaryngoscopy/Fiberoptic Stylet
A fiberoptic stylet, such as the Bonfils Retromolar Intubation Fiberscope (Karl Storz Endoscopy,
Tuttlingen, Germany/Culver City, CA), can also assist VL in difficult airway management. Similarly
to the use of a bougie, a fiberoptic stylet can be guided underneath the epiglottis, as visualized
on the VL screen, and used as an ETT introducer with the ability to indirectly visualize the glottic inlet either through the eyepiece or on a separate monitor. This can be a very useful adjunct
when a posteriorly displaced epiglottis or other anatomic barriers present using VL by itself
and has been demonstrated to be faster than the combined use of VL/FOB (although not more
successful).
Just as optimal positioning and external laryngeal manipulation are extremely important in the
success of DL combination techniques, the clinician should keep in mind that these maneuvers can
still be (and should be) used for VL techniques to further improve intubation success.
Supraglottic Airway Device Combination Techniques

Supraglottic airway devices (SADs) are effective and convenient methods to ventilate patients
both in minor elective surgery and in difficult airway situations (both anticipated and unanticipated) in children and adults. The Laryngeal Mask AirwayTM (LMA; LMA North America, San
Diego, CA) has proved to be very effective in situations of the difficult airway and is part of the
ASA algorithm for difficult airway management. When properly positioned, both the LMA and
Intubating Laryngeal Mask airway (ILMATM or Fastrach LMATM) serve as excellent conduits for
intubation. Once either device is placed, other methods/devices may be used in combination
with these devices to either effectively ventilate the patient or secure a more definitive airway. Also, additional SADs can be used, as such, including the air-Q Laryngeal Mask (Cookgas,
St. Louis, MO; distributed by Mercury Medical, Clearwater, FL) or the Ambu Aura-iTM (AMBU,
Glen Burnie, MD), which were specifically designed as intubation conduits, or alternative SADs
such as the i-gel (Intersurgical, Berkshire, UK) and other laryngeal masks. An advantage with any
of these devices is that the laryngeal area may be sealed off from blood/secretions and accomplish ventilation in a patient who may be difficult to mask ventilate, difficult to intubate, or has
significant intra-oral bleeding.
147
to the clinician managing the airwaynamely, an improved view of the glottis, decreased cervical
spine motion, and the ability to improve instruction to a trainee. Video laryngoscopy, however,
does not have a 100% success rate and can be combined with other methods/devices to improve
success. Certain circumstances may arise in which a combination of VL/FOB may be very beneficial. A patient with severely limited mouth opening and/or unstable cervical spine injury (possibly
in a halo) may preclude the use of DL to assist in fiberoptic intubation, but using VL in addition
to FOB in this situation may provide the ability to view the glottic opening and better guide the
FOB into correct position. The procedure for VL/FOB is identical to the DL/FOB technique. If a
channeled VL is used, then the FOB may be inserted either within the lumen of the ETT or next
to the device. If possible, direct the FOB toward the glottis and, if not, use the DL/FOB techniques
previously detailed.
Video laryngoscopy can also diagnose FOB problems, as this combination technique provides
the advantage of visualizing of the passage of the ETT over the FOB into the glottis and identifies, as well as helps to resolve any passage difficulties. This technique also facilitates instruction
of FOB, as the instructor can observe FOB manipulation by the trainee, thus maximizing their
learning experience.
148
Supraglottic Airway Device/Intubation Catheter/Lightwand

If DL fails because of conditions that preclude techniques that require glottic visualization, then
intubation via the LMA or ILMA may be most appropriate. Blind passage of an ETT through one
of these devices may fail or result in trauma. To improve intubation success of the LMA/ILMA,
the bougie has been used; however, this technique is not much better than blind intubation
through the LMA. The use of the lightwand, on the other hand, is likely to improve the accuracy
of ETT placement through transillumination. It can be used either with or without its internal
stylet for this purpose. When performing lightwand-guided intubation through the LMA/ILMA,
the tip should project 1.5 cm from the aperture of the distal LMA lumen. Alternatively, the ILMA
can first be inserted, and after ventilation is established, the ETT and lightwand can be placed
through its lumen. In either method, the anterior neck should be observed for transillumination.
If a discrete circle of light is not visualized over the cricothyroid membrane, then the LMA should
be repositioned, depending on the location of the LMA/ILMA light, by advancing, withdrawing, or
rotating the device. If unsuccessful, an alternative size may be necessary. Contraindications to this
technique include inability to ventilate via the LMA/ILMA, upper airway obstruction, and laryngeal
fracture or tumor.
Supraglottic Airway Device/Flexible Fiberoptic Laryngoscopy/Airway

Exchange Catheter
Although the FOB can be used simply as an adjunct to simple SAD placement and positioning,
it is more often utilized as an aid to intubation. This combination of devices has been discussed
in Chapter 6; it will also be described here for completeness. The LMA /ILMA is an excellent
conduit for the FOB, especially when properly positioned. For the procedure, the patient should
be positioned in the neutral or sniffing position and can be performed in either the awake or
anesthetized patient.
Indications for this technique include failed ventilation, as the LMA/ILMA can be inserted as a
rescue device for ventilation with subsequent FOB intubation; failed laryngoscopy and intubation;
and, finally, failed blind intubation via LMA/ILMA. Also, the FOB can be combined with a SAD for
troubleshooting device intubation problems (high airway pressures, leak, etc.). The combination
can actually be used even for the initial placement of the SAD by having the FOB just recess within
the airways bowl as the SAD is advanced into the oropharynx. When using this combination
technique for intubation, the practitioner needs to make sure that the ETT is able to pass both
through the device and the trachea. Keep in mind that because the length of a standard size 6.0
ETT may not be long enough in males, either a nasal RAE ETT or a MicroLaryngeal Tube (MLT;
Covidien, Mansfield, MA) may be better suited. To facilitate ETT passage, the bevel of the ETT can
be placed in a traverse plane or the epiglottic aperture bars of the LMA may be cut beforehand.
Intubating laryngeal masks have been specially designed to better facilitate endotracheal intubation
via an LMA and afford the advantage of the ability to place larger ETTs. Also, the appropriately
sized FOB needs to be utilized (adult vs. pediatric size).
Video 14.3 Combination Techniques: Supraglottic Airway Device/FOB
Additional SADs can be used in combination with the FOB, either through the shaft of the airway device, such as the air-Q laryngeal mask, or adjacent to the device, such as the Esophageal
Tracheal Combitube (Covidien) or King LT (King Systems/VBM Medizintechnik GmbH,
Noblesville, IN).
Using an LMA as a conduit for FOB to facilitate use of an airway exchange catheter to achieve
orotracheal intubation is an attractive option because it allows unhurried instrumentation of the
Video 14.4 Combination Techniques: LMA/Aintree/FOB Intubation
Extubation of alternative SADs such as the Combitube or the King LT laryngeal tube (LT) can
also be performed in combination with other devices. Often, a combination technique is recommended because these alternative SADs are placed after a number of failed intubation attempts,
thus in patients with a difficult airway, which has possibly been traumatized. The exchange of the
Combitube (esophageal placement) for an ETT can be performed with several techniques, including DL or VL. The LT can also be exchanged with the help of the Arndt Airway Exchange Catheter
(Cook Critical Care, Bloomington, IN) with DL or a VL, such as the Airtraq or King Vision, both
of which are channeled devices. Using this combination technique, the cuffs of the LT should be
partially deflated, and while maintaining ventilation, the channeled device is inserted between
the tongue and the LT. Once the vocal cords are visualized, the ETT should be advanced and its
position confirmed before removal of the LT.
149
airway while permitting ventilation and oxygenation around the FOB via a dedicated airway. This
technique may be performed in patients who are either spontaneously breathing (sedated or
deeply anesthetized, or ventilated with or without paralysis). Preoxygenation should be performed
for 10 minutes, if possible. While administering 100% oxygen, the SAD should be disconnected
from the circuit, and a FOB loaded with an ETT is then passed through the SAD and through the
glottic opening until the carina is visualized. The ETT is then advanced over the FOB and positioned 1 cm to 3 cm above the carina. The FOB is then removed and ETT placement is confirmed
with capnography. The SAD can remain in place or be removed. If the patient is to remain supine,
the procedure is short, postoperative ventilation is not necessary, and/or the patient has a difficult
airway, then the clinician may elect to leave the SAD in placesimply deflate the cuff and ventilate via the ETT. If the supraglottic device is to be removed, then either another ETT (smaller in
size), a stabilizing device (LMA FastrachTM; LMA North America), or Magill forceps can be utilized
to perform the removal, while keeping the ETT in proper position. The 15 mm ETT connector is
removed, and then any of the aforementioned devices can be used to stabilize the ETT while the
supraglottic device is removed. Once the ETT can be grasped within the oropharynx, both the
stabilizing device and supraglottic device can be removed.
Many different devices can be utilized using this combination technique, including the Aintree
intubation catheter (AIC; Cook Critical Care, Bloomington, IN), the wire and catheter from a
retrograde intubation kit, a transtracheal tube introducer and guidewire, and a pre-packaged
catheter exchange kit. There are limitations to each device, but this combination technique is
one of the most commonly performed in the anticipated or unanticipated difficult airway. After
inserting an appropriately sized LMA, a bronchoscopic adapter may be placed between the
anesthesia circuit and the LMA connector. While ventilating through the LMA, the FOB can
then be advanced through the adapter, the LMA, and into the patients trachea. After correctly
identifying the carina, the clinician should advance the AIC over the FOB into the airway or
advance a guidewire through the working channel of the fiberscope until noted to exit the distal
end of the FOB in the trachea, depending on which device/technique is employed. The LMA is
deflated, and the ETT can then be passed over the AIC after the FOB is removed, leaving the
ETT in place.
Additionally, the AIC can be used at the conclusion of surgery if there is concern regarding
extubation (possible airway edema). It can be placed over the FOB in an existing ETT and the
vocal cords can be visualized upon FOB and ETT removal. It can then be left in place as an airway
stent and used if the patient fails the extubation trial. The ETT fitted FOB would then be reinserted down the AIC for intubation.
150
Supraglottic Airway Device/Retrograde Intubation

Certain situations can arise in which neither the glottic aperture nor any airway structures
may be visualized despite optimal DL attempts, including prominent lingual tonsils, tonsillar
tissue, and excessive soft tissue at the glottic opening. If an LMA can be successfully placed
in this situation, and the lungs ventilated adequately, then a combination retrograde/LMA
technique may be easily performed to establish a more secure airway with an ETT, with or
without the use of the FOB. The use of an LMA in this situation allows ventilation throughout
the execution of a retrograde intubation. Certain limitations of this combination approach
include the wire getting caught up on the LMA itself; however, simply removing the LMA
at that time can alleviate the problem. Obviously, conditions that would preclude this technique include inadequate ventilation via the LMA, lack of access to the cricothyroid membrane (severe neck deformity, obesity, mass), laryngotracheal stenosis/malignancy/infection,
or severe coagulopathy.
Supraglottic Airway Device/High Frequency Jet Ventilation

Combining high frequency jet ventilation (HFJV) with the use of an LMA can be beneficial for rescue oxygenation in a patient who is unable to be intubated or ventilated after induction of anesthesia. Additionally, this combination technique can be used in elective surgical procedures, such
as extracorporeal shock wave lithotripsy. This technique affords the benefit of reducing urinary
calculi movement, which may potentially decrease the incidence of renal trauma and subcapsular
hematomas in these patients, in addition to avoiding longer sessions and repeat treatments. This
technique can be accomplished by using a standard semi-closed circle breathing system with a
carbon dioxide absorber used to deliver a low flow of oxygen and air through an LMA via a swivel
Y connector. Then, the distal end of a 14 g suction catheter is placed within the airway portion of
the LMA, via the swivel Y connector, thus being in an entirely supraglottic position. The proximal
end of the suction catheter is then cut (cutting off the hole occlusion segment) and placed over
the Luer lock outlet of the jet ventilator.
Transtracheal Jet Ventilation/Flexible Fiberoptic Intubation

In the cannot intubate, cannot ventilate scenario, transtracheal jet ventilation is considered an
important option, especially when supraglottic airway devices are contraindicated or fail. Once
jet ventilation is established, the FOB can be used to secure a definitive airway. The benefits of
this technique include a splinting open of the airway, facilitating FOB, and permitting ongoing
ventilation while the procedure is being performed.
Retrograde Intubation Combination Techniques

Retrograde/Flexible Fiberoptic Laryngoscopy
Retrograde wire-guided intubation consists of guiding an ETT into the trachea using a wire or catheter that has been passed blindly into the trachea, larynx, hypopharynx, pharynx, and out of the
mouth or naris via a percutaneous piercing through the cricothyroid membrane. This technique
has been used in many clinical situations, most commonly in the unstable cervical spine, upper
airway malignancy, mandibular fracture, or when the vocal cords cannot be visualized because of
blood, secretions, or anatomic variations. Once the guidewire is retrieved from either the mouth
or naris, it is passed through the working channel of the FOB from distal to proximal. The FOB
is then passed over the guidewire and into the glottis until resistance is met at the cricothyroid
membrane. The hemostat that held the guidewire in place internally may now be released and the
guidewire removed. The FOB may then be advanced until the carina is visualized and the ETT is
Retrograde/Fiberoptic Laryngoscopy/Supraglottic Airway Device

The retrograde technique can be utilized in combination with the FOB and a SAD. A long wire
(110145 cm length, 0.038 inch diameter) can be threaded through the SAD and then into the
working channel of the FOB. The FOB is then guided into the trachea, and both the FOB and SAD
are removed. Subsequently, the wire is once again threaded through the working channel of the
FOB, which is now loaded with an ETT. The FOB is then guided over the airway and intubation is
completed, as previously discussed (FOB/retrograde).
Retrograde/Direct Laryngoscopy
See the previous section on this combination technique (DL/Retrograde).
151
passed into the trachea. In this fashion, the FOB reduces the likelihood that the ETT will become
dislodged and the airway can be visualized throughout the procedure. Contraindications to retrograde intubation are almost all relative (see Chapter 10). There are several advantages to passing
a FOB antegrade over a retrograde placed wire:
The outer diameter of the guidewire and the internal diameter of the fiberoptic suction port
form a tight fit that allows the FOB to follow a straight path through vocal cords without impinging on anatomic structures.
The FOB acts as large antegrade guide catheter and allows easy passage of the ETT.
This technique allows placement of the ETT under direct vision.
The FOB may be advanced to carina freely (past the puncture site), which eliminates the problem of the short distance between vocal cords and puncture site.
Oxygen can be continuously delivered via the FOB while the guidewire is still in place.
These advantages of using the FOB over the retrograde wire to place an ETT makes this combination technique easier to use than any of the retrograde intubation techniques. The main disadvantage to this combination technique would be the requirement of more equipment and more
preparation time that may not be available in emergency cases as well as the fact that use of the
FOB may not be suitable for certain situations such as when there is a large amount of blood or
secretions within the airway.
152
Tips for Combination Techniques

The oropharynx should be free of secretions, either by use of a Yankauer suction or
administration of an antisialagogue.
To prevent fogging, when using either the FOB or a fiberoptic stylet, dip the tip into
a warm bottle of saline or sterile water immediately prior to use, or use a lens defogger.
To improve visibility, plug device into a xenon light source, if available, rather than using
a battery-powered source.
If given a choice between a FOB with or without a video monitor, select the ability to
perform and view the procedure from a monitor.
To prevent excessive glare when viewing through a FOB when using the VL/FOB technique, dim the brightness of the VL, if possible. If not possible, simply power off the VL
intermittently during the course of the procedure.
When using a FOB or fiberoptic stylet directed technique, use the naked eye (direct) view
until the tip of the scope can no longer be visualized in this manner, then the clinician
should redirect his/her vision to the eyepiece or monitor (indirect).
If a large, floppy epiglottic causes difficulty in FOB passage under the epiglottis, then consider passing the ETT past the tip of the FOB until the FOB can be successfully advanced.
Proper patient positioning and physical maneuvers, such as lingual traction, chin thrust, jaw
lift and thyroid pressure may facilitate tracheal intubation if difficulty occurs.
If surgical access is anticipated as a backup procedure, consider identifying cricothyroid
membrane access, applying antiseptic solution and sterile draping of the neck.
If a grade IV Cormack-Lehane view is obtained with DL, avoid use of blind attempts at
a bougie or stylet placement. A SGA combination technique may be most appropriate.
Summary
Each airway device has unique properties that may be advantageous in certain situations, yet limiting in others. Specific airway management techniques are greatly influenced by individual disease
and anatomy, and successful management may require combinations of devices and techniques.
Combining multiple approaches to manage the difficult airway is another illustration of the general
concept of multimodal therapy in contrast to monotherapy. Indeed, anesthesia practitioners
are accustomed to the use of multimodal therapy in clinical practicefor example, different
classes of drugs for balanced anesthesia, nausea, and pain control. This multimodal approach to
the airway is necessary, as there are disadvantages to individual airway devices and techniques.
No device is foolproof. Thus, practitioners should gain the knowledge of the combination strategies, many of which are outlined in this chapter, to increase their success in the use of these
airway devices/techniques. As with any intubation technique, practice and routine use will improve
performance and may reduce the likelihood of complications.
Suggested Reading
Joffe AM, Arndt GA, Willmann K . Wire-Guided catheter exchange after failed direct
laryngoscopy in critically ill adults. Journal of Clin Anesthesia 2010; 22: 9396.
Kovacs G, Law JA, McCrossin C, Vu M, Leblanc D, Gao J. A Comparison of a Fiberoptic Stylet
and a Bougie as Adjuncts to Direct Laryngoscopy in a Manikin-Simulated Difficult Airway. Ann
Emerg Med 2007;50:676685.
153
Hagberg CA, Westhofen P. A Two-Person Technique for Fiberscope-Aided Tracheal

Extuabtion/Reintubation in Intensive Care Unit (ICU) Patients. J Clin Anesth 2003;15:467470.
Arndt GA, Topp J, Hannah J, McDowell TS, Lesko A . Intubation via the LMA using a Cook
retrograde intubation kit. Can J Anaesth 1998;45(3):257260.
Canty DJ, Dhara SS. High frequency jet ventilation through a supraglottic airway device: a
case series of patients undergoing extra-corporeal shock wave lithotripsy. Anaesthesia
2009;64:12951298.
Kim SH, Woo SJ, Kim JH. A comparison of Bonfils intubation fiberscopy and fiberoptic
bronchoscopy in difficult airways assisted with direct laryngoscopy. Korean J Anesthesiol
2010;58(3):249255.
Takenaka I, Aoyama K, Iwagaki T, Ishimura H, Takenaka Y, Kadoya T . Approach Combining
the Airway Scope and the Bougie for Minimizing Movement of the Cervical Spine during
Endotracheal Intubation. Anesthesiology 2009;110:13351340.
Burbulys D, Kiai K. Retrograde Intubation. Emerg Med Clin N Am 2008;26:10291041.
Murdoch JAC. Emergency tracheal intubation using a gum elastic bougie through a laryngeal
mask airway. Anaesth 2005;60:626627.
Ahmed AB, Nathanson MH, Gajraj NM. Tracheal intubation through the laryngeal mask airway
using a gum elastic bougie: the effect of head position. J Clin Anesth 2001;13:427429.
Benumof JL. Laryngeal mask airway and the ASA difficult airway algorithm. Anesthesiology 1996;
84:686699.
Asai T, Murao K, Tsutsumi T, Shingu K. Ease of tracheal intubation through the intubating
laryngeal mask during manual in-line head and neck stabilization. Anesthesiology 2000;55:8285.
Agr F, Brimacombe J, Carassiti M, Morelli A, Giampalmo M, Cataldo R. Use of a lighted stylet
for intubation via the laryngeal mask airway. Can J Anaesth 1998;45:556560.
Niijima K, Seto A, Aoyama K, Takenaka I, Kadoya T . An illuminating stylet as an aid for tracheal
intubation via the intubating laryngeal mask airway. Anesth Analg 1999;88:470471.
Dimitriou V, Voyagis GS, Brimacombe JR. Flexible lightwand-guided tracheal intubation with the
intubating laryngeal mask Fastrach in adults after unpredicted laryngoscope-guided tracheal
intubation. Anesthesiology 2002;96:2969.
Agro FE, Antonelli S, Cataldo R. Use of Shikani flexible seeing stylet for intubation via the
intubating laryngeal mask airway. Can J Anaesth 2005;52:657658.
Benumof JL, Scheller MS. The importance of transtracheal jet ventilation in the management of
the difficult airway. Anesthesiology 1989;71:769778.
Baraka A. Transtracheal jet ventilation during fiberoptic ventilation under general anesthesia.
Anesth Analg 1986;65:10911092.
Benumof JL. Use of the laryngeal mask airway to facilitate fiberoptic bronchoscopic intubation.
Anesth Analg 1992;74:313315.
Benumof JL. Laryngeal mask airway and the ASA difficult airway algorithm. Anesthesiology
1996;84:686699.
Heath ML, Allagain J. Intubation through the laryngeal mask. Anesthesiology 1991;76:545548.
Orebaugh SL. Airway obstruction secondary to prolonged shoulder arthroscopy. Anesthesiology
2003;99:14561458.
Frass M. Mechanical ventilation with the esophageal tracheal Combitube in the intensive care
unit. Arch Emerg Med 1987;4:219223.
155
Chapter 15
Pediatric Airway Management
Ranu Jain, MD
Objectives
Discuss the relevant differences between the pediatric and adult airway.
List the conditions most commonly associated with a difficult airway in the pediatric population.
Describe the most useful techniques for management of the pediatric difficult airway.
Introduction
The pediatric patient presents special challenges with regards to airway management. Data from
the ASA Pediatric Closed Claims Database show a greater frequency of adverse respiratory events
in the pediatric population as compared to adults. Although the proportion of adverse outcomes
resulting from respiratory events has decreased over the last 30 years, respiratory events still
account for a significant fraction of all adverse events. The most recently analyzed data from 1990
to 2000 shows that respiratory events accounted for 23% of adverse events in pediatric patients
and that greater than 50% of those adverse respiratory events resulted from airway obstruction,
inadequate ventilation, esophageal intubation, or difficult intubation (DI). In analysis of data from
the Pediatric Perioperative Cardiac Arrest (POCA) registry performed in 2000, 20% of all cardiac
arrests were attributed to the respiratory system. Airway obstruction and DI were responsible
for 27% and 13% of these events, respectively. Most of the patients who experienced arrests from
airway obstruction or DI had underlying diseases or syndromes. The incidence of difficult mask
ventilation in non-obese children is 2.1%.
Knowledge of the differences between adult and pediatric anatomy, as well as a familiarity with
congenital syndromes and different disease states seen in the pediatric population, is required for
the safe management of the difficult airway (DA) in pediatric patients. Management of a known
or suspected DA in the pediatric population may require induction of general anesthesia prior
to intubation attempts, whereas in a cooperative adult patient, a practitioner might choose to
attempt intubation prior to induction of general anesthesia in this circumstance.
15 Pediatric Airway Management
156
Anatomy and Physiology of the Pediatric Airway

The pediatric airwayparticularly in infantshas significant differences from the adult airway.
Understanding these differences is important when managing the pediatric airway.
The pediatric tongue lies closer to the palate and more easily apposes it, resulting in airway
obstruction during induction or emergence from anesthesia. Elevating the head, as in the sniffing
position, only moves the larynx into a more anterior position. Infants should be positioned with
their head and shoulders on a flat surface with the head in a neutral position and the neck neither
flexed nor extended (see Fig. 15.1).
The infant epiglottis is long, stiff, and often described as omega or U-shaped. The infant larynx
is funnel-shaped with a narrow cricoid cartilage, whereas the adult airway is cylindrical. The larynx
is more cephalad at the level of C3 to C4 in the infant and migrates to the adult level of C5 by
age 6 years. The cricoid cartilage is the narrowest portion of the infants airway (about 5 mm in
diameter), whereas the vocal cords are the narrowest in the adult airway.
The infants nares are smaller. The nares can offer significant resistance to airflow, especially
when they are narrowed by secretions, edema, or bleeding, which can significantly increase
the work of breathing. The infants are obligate nasal breathers in the first 6 months of life. An
improperly placed facemask in an infant can compress the external nares and cause respiratory
obstruction. The upper airway has adult-like characteristics by age 10 years.
The newborn ribcage is oriented parallel, and the intercostal muscles are not as effective
at increasing intrathoracic volume with inspiration. The work of breathing for each kilogram
of body weight is similar in infants and adults. The oxygen consumption of a full-term newborn (6 mL/kg/min) is twice that of an adult (3 mL/kg/min), which results in an increased
respiratory rate.
The infants tidal volume is relatively fixed. Minute alveolar ventilation is more dependent on
increased respiratory rate than on tidal volume. Functional residual capacity (FRC) of an infant
is similar to an adult when normalized to body weight; therefore, the ratio of alveolar minute ventilation to FRC is doubled by comparison. As a result, under circumstances of hypoxia,
apnea, or under anesthesia, the infants FRC is relatively diminished and desaturation occurs more
precipitously.
Figure 15.1 Optimal positioning for airway management in the infant.
157
Total lung capacity is smaller in infants
FRC is comparable on a per kilogram basis
Closing capacity (CC) differs with age (CC is larger than FRC in infants; therefore, during
exhalation small airways start to collapse and trap air.)
The Difficult Pediatric Airway

Conditions that may lead to an increased incidence of DA in the pediatric patient may be broadly
classified into congenital syndromes and acquired diseases. A summary of the most common
conditions associated with DA management in pediatric patients is presented below. Many of the
congenital syndromes are associated with more than one malformation of the head and neck that
affects airway management.
Congenital/Hereditary:
Congenital Malformations:
Micrognathia/mandibular hypoplasia, macroglossia, maxillary hypoplasia, choanal atresia, tracheoesophageal fistula, tracheomalacia, laryngomalacia, tracheal stenosis, laryngeal stenosis,
and laryngeal web
Congenital Masses
Dermoid cyst, teratoma, cystic hygroma, and hemangioma
Congenital Syndromes:
Pierre Robin, Treacher Collins, Aperts, Downs, and Goldenhars syndromes
Metabolic Syndromes:
Beckwith-Wiedemann syndrome, glycogen storage diseases, congenital hypothyroidism,
mucopolysaccharidosis
Acquired:
Infectious:
Epiglottitis, tonsillitis, peritonsillar abscess, retropharyngeal abscess, laryngotracheobronchitis
(croup), laryngeal papillomatosis
Trauma
Facial or cervical
Neoplasm
Facial, airway, or anterior mediastinal neoplasm
Obstructive
Foreign body (esophageal, tracheal, or bronchial), obesity, obstructive sleep apnea, subglottic
stenosis (post-traumatic or secondary to long-term intubation)
Evaluation of the Pediatric Airway

Physical examination to predict the potentially DA should be guided by knowledge of normal airway anatomy and familiarity with syndromes associated with a DA. Many criteria used to predict a
DA in adults have not been extrapolated to the pediatric population. Cooperation of the patient
is necessary for precise evaluation. In the young or uncooperative child, appropriate evaluation is
limited. Pediatric anesthesiologists are at a disadvantage because they are anesthetizing patients
with less objective airway information available.
Airway Physiology Tips (Infants vs. Adults)
158
A recent retrospective analysis of more than 11,000 pediatric anesthetics by Heinrich et al. demonstrated that a Mallampati score of III or IV (when able to be assessed) and patient age younger
than 1 year were associated with a significantly higher incidence of difficult intubation. Patients
presenting for cardiac and oromaxillofacial surgery were also at increased risk.
Evaluations should focus on the size and shape of the mandible, size of the mouth and tongue,
absence or prominence of teeth, presence of loose teeth, and the neck length and range of motion.
Much of the examination is subjective, and clinical experience should improve the ability to predict
a DA. A review of previous anesthetic records should be performed, if possible. In the event a DA
is encountered, a description of events and documentation of the ability to mask ventilate is helpful
for future caregivers. A prior uneventful anesthesia does not guarantee success the next time.
Magnetic resonance imaging (MRI) and computed tomography (CT) may be extremely helpful
in the evaluation of airway pathology. Flexible fiberoptic endoscopy may be beneficial prior to
intubation when visualization of vocal cords is thought to be difficult or when airway pathology
is suspected. Radiographs have high sensitivity (>86%) for the diagnosis of airway foreign body,
exudative tracheitis, and innominate artery compression. For laryngomalacia and tracheomalacia,
they have a much lower sensitivity (5% and 62%, respectively).
Pediatric Airway Equipment

To manage the pediatric DA successfully, all necessary equipment should be immediately available. The author recommends the creation of a difficult pediatric airway cart stocked with equipment appropriate for patients ranging from premature infants to small adults. In addition, the
American Academy of Pediatrics Section on Anesthesiology recommends a DA cart be present in
all locations where children are anesthetized. This should be a dedicated cart for use only in a DA
or a cannot intubate, cannot ventilate (CICV) scenario.
Face Mask
When managing the DA, the ability to ventilate with a mask is more important than endotracheal
intubation. When dealing with the pediatric airway, and especially the difficult pediatric airway, it
is important to have a selection of masks readily available. Disposable clear plastic masks with an
inflatable rim are typically used. These masks should extend from the chin to the bridge of the
nose. A leak-free seal should be obtained, with minimal pressure applied to the face or mandible.
Transparent masks allow visualization of secretions or vomitus during induction.
The Rendell-Baker-Soucek Mask (Rusch Medical, Teleflex, Research Triangle Park, NC) is a
non-disposable mask with a triangular shape that minimizes dead space, making it well-suited for
use in pediatric patients.
Oropharyngeal Airway
Upper airway obstruction may occur during induction of anesthesia because the infants tongue
is large in relation to the oropharynx. Appropriately sized oropharyngeal airways are necessary
for air exchange. By holding the airway next to the childs face, the correct size can be estimated.
If the airway is too short, then obstruction may be worsened. If the airway is too long, then the
epiglottis or uvula may be damaged.
Nasopharyngeal Airway
Nasopharyngeal airways are available in sizes from 12 Fr to 36 Fr. They must be used with caution
in pediatric patients with hypertrophied adenoids. The modified nasal trumpet was first described
by Beattie, and its use in pediatric airway management was described by Holm-Knudsen in 2005
(see Fig. 15.2). It is a nasal airway with an endotracheal tube (ETT) connector wedged into the
flared end. The patient can be ventilated with the anesthesia circuit through this modified nasal
trumpet by closing the mouth, lips, and the other naris.
159
Figure 15.2 Modified nasal trumpet as described by Beattie.
Endotracheal Tube
Endotracheal tubes in a variety of sizes (2.57.0 mm internal diameter [ID]) should be available for
the pediatric patient. Laser-resistant, nasal/oral Ring-Adair-Elwyn (RAE), and wire-reinforced ETTs
are available for use depending on the surgical requirement. Determination of the correct ETT
size is based on the patients age and weight. Traditional teaching advocates the use of uncuffed
ETTs in patients younger than age 8 years, although the use of cuffed ETTs in newborns and children younger than age 8 years has been studied. Pediatric ETTs with low-pressure, high-volume
cuffs are available for use in patients with low lung compliance or those who are at risk for aspiration. For cuffed ETTs, one half-size smaller tube should be used because the outer diameter (OD)
of the tube is larger as a result of the cuff. Maintenance of a leak at less than 25 cm of H2O with or
without a cuff is recommended to minimize the occurrence of postintubation croup.
Tip: Choosing the Correct ETT Size

Age
Preterm (>1000 g)
Preterm (10002500 g)
Newborn to 6 months
12 years
>2 years
Size (mm ID)

2.5
3.0
3.03.5
4.04.5
(Age in years)/4 + 4 = ID
ETT Size and Depth Tips

For cuffed ETTs, subtract 0.5 mm from the ID.
For proper insertion depth for an orotracheal intubation, use the following formula:
(Age in years)/2 + 12 or
3 ID (mm)
Add 2 cm to the orotracheal insertion depth for a nasotracheal intubation.
160
Double-lumen tubes are not available for use in pediatric patients younger than ages 6 years to
8 years. The Arndt Endobronchial Blocker (Cook Critical Care, Bloomington, IN) has been used
to provide one-lung ventilation in infants.
Some complications of endotracheal intubation include airway trauma, bleeding, and postintubation croup (incidence of 0.1%1%). Subglottic stenosis can result from prolonged intubation
because of mucosal ischemic injury secondary to the lateral wall pressure from the ETT; granulation tissue forms within 48 hours leading to scarring and stenosis.
Endotracheal Tube Exchangers

Endotracheal tube exchangers have multiple uses; they can be used to exchange damaged ETTs
and provide a conduit for reintubation, if necessary. The Frova Intubating Introducer (Cook
Critical Care, Bloomington, IN) is available in a pediatric size (8 Fr) that allows placement of a
3.0 mm ETT. Cook also manufactures airway exchange catheters in four sizes. These catheters are
hollow, blunt-tipped, and have distal side ports. The 8 Fr size is 45 cm in length and can be used
in ETTs 3.0 mm or larger.
Laryngoscope Blades
Straight laryngoscope blades are often recommended for use in neonates and infants to lift the
epiglottis. The most common straight blades include the Miller, Wisconsin, Wis-Hipple, and
Wis-Foregger blades. Curved blades are also available for use; they are more suitable for older
children.
Bullard Laryngoscope
The Bullard laryngoscope (ACMI Corporation, Southborough, MA) is an indirect laryngoscope
that utilizes fiberoptic and mirror technology to visualize the larynx. Use of fiberoptics and a
curved blade enable visualization of the larynx around the corner of the blade, thus eliminating the need to align the oral, pharyngeal, and laryngeal axes. A standard laryngoscope handle
or a flexible fiberoptic cable connected to a light source powers the fiberoptic light source.
This laryngoscope is manufactured in three sizes: adult, pediatric, and pediatric long. The adult
size, with a blade that is 2.5 cm wide, is suitable for children older than age 10 years. The pediatric version has a blade 1.3 cm wide that extends 0.6 cm beyond the fiberoptics. This blade is
recommended for use in neonates, infants, and smaller children. The pediatric long version is
available for use in infants and small children up to age 10 years; it has a longer blade (1.4 cm)
and a wider flange (1.6 cm). In the pediatric long version, a multifunctional stylet is attached to
the fiberoptic bundle between the eyepiece and handle and aligns the tip of the ETT beneath
the flange of the blade. The smallest ETT that passes over the stylet in the pediatric long version
is 4.5 mm. The Bullard laryngoscope requires minimal mouth opening for its insertion (0.64 cm
in cephalad-caudad axis). It has been used to intubate patients with unstable cervical spine or
with Pierre-Robin, Treacher-Collins, Noonans, and Klippel-Feil syndrome, among others. The
adult Bullard laryngoscope has been used successfully to intubate patients older than 12 months
with normal airways.
Truview PCD
The Truview PCD (Truphatek International, Netanya, Israel) is a recently introduced rigid laryngoscope that has an angulated tip and an optical assembly that provides an illuminated and magnified
view of the larynx (see Fig. 15.3). It has been shown to improve laryngoscopic views in infants and
children when compared to direct laryngoscopy with a Miller blade.
Figure 15.3 The Truview PCD (Truphatek International, Netanya, Israel).
Laryngeal Mask Airway

Pediatric versions of the Laryngeal Mask Airway (LMA) ClassicTM, as well as the disposable LMA,
are available for use and are part of the pediatric DA algorithm. This device requires minimal training and has been shown to be useful in neonatal resuscitation. The LMA has been described as a
conduit for blind intubation as well as a conduit for fiberoptic intubation.
Induction and Airway Management Techniques

The principles outlined in the ASA Guidelines for DA Management apply to the pediatric patient
as well. Evaluation, recognition, and preparation are key elements. A surgeon capable of establishing a surgical airway and emergency airway equipment should be in the operating room before
induction of anesthesia of the pediatric patient with a documented DA. A capable assistant should
be available for help to induce anesthesia, insert an intravenous line, and help secure the airway.
Infants and children are not as cooperative as adults; most alternative strategies are not successful in the awake pediatric patient. The history and physical examination may indicate situations in
which direct laryngoscopy will be unsuccessful, and one should proceed directly to an alternative
strategy for managing the airway. If an intravenous line is present, then intravenous induction can
be performed after appropriate pre-oxygenation. Once the child is unconscious and the ability
to mask ventilate is confirmed, neuromuscular blockade can facilitate direct laryngoscopy and
intubation. If the infant or child does not have an intravenous line, inhalational induction should
be performed with sevoflurane and oxygen. As soon as the child is unconscious, an intravenous
line should be established. If it is easy to ventilate the infant or child with a mask, neuromuscular
blockers might make laryngoscopy and intubation easier. Often, a properly placed shoulder roll
can facilitate direct laryngoscopy and intubation.
If the practitioner is unable to mask ventilate, then he/should call for immediate help and, if possible, insert an LMA or another supraglottic airway device. If unable to oxygenate with the LMA,
then it may be necessary to awaken the patient or proceed with a surgical airway.
An LMA should always be available when attempting to manage the airway of any pediatric
patient, particularly one with a DA. An LMA may provide a way to successfully ventilate and
oxygenate the patient at any time during intubation attempts to intubate and can provide an
excellent channel for fiberoptic intubation. It may also be the only way to maintain an airway until
a surgical airway is established or until the patient awakens. Fiberoptic intubation at this point may
be difficult if there is already blood in the airway from multiple attempts at direct laryngoscopy.
If blood or edema has made it difficult to intubate the patient and the surgery is elective, then it
161
162
may be better to awaken the patient, reschedule the surgery, and plan for an alternative strategy
for intubation from the beginning.
Many other options are available to manage the difficult pediatric airway, such as the Bullard
laryngoscope, transtracheal jet ventilation, retrograde intubation, and transcutaneous cricothyrotomy. Cannula cricothyrotomy in infants and children has high incidence of complications
and, therefore, should not be used as an emergency adjunct in patients younger than age 5 to
6 years. The trachea of infants and small children is pencil-sized, elastic, flaccid, mobile, difficult to locate, and collapses if transcutaneous insertion is performed. Anatomically, the close
approximation of the cricoid and the thyroid cartilages makes it difficult as well; however, the
technique may be successful under rigid bronchoscopic guidance and splinting of the airway.
Neonates and infants lack a functional cricothyroid membrane. In neonates, it is important to
appreciate that the gap between the cricoid and the thyroid cartilage does not allow passage
of a 2.0 mm ID ETT.
The traditional approach to the difficult pediatric airway has been maintenance of spontaneous ventilation under inhalational anesthesia. Premedication with oral or intravenous atropine
(0.010.02 mg/kg) is indicated for its vagolytic and antimuscarinic effects. Another important
aspect for successful airway management is topicalization of the airway with local anesthesia. In
pediatric patients, this may be obtained via nebulization.
Airway topicalization can be performed by spraying or swabbing local anesthetic solution or
by applying viscous gel to a gloved finger. Also, the spray-as-you-go technique can be performed by application of local anesthesia on the vocal cords under direct vision. The maximum
dose of local anesthetic allowed should be calculated before topicalization technique. The drug
of choice is lidocaine because it has the best safety profile; it has a maximum dose of 5 mg/kg.
Agents containing benzocaine, such as Cetacaine spray, Americaine ointment, and Hurricaine
ointment, gel, or spray, should be avoided in infants and young children because of the risk of
methemoglobinemia.
Extubation of the Difficult Airway

Extubation of the infant or child with a DA should be orchestrated as carefully as intubation of
the infant or child with a DA. The management of the difficult pediatric airway does not end until
successful extubation has been performed. If the safety of extubation is questionable, it may be
performed over an airway catheter or guidewire. Extubation may be postponed until an air leak
develops, as in the case of epiglottitis or airway edema. If airway edema is suspected, administration of a corticosteroid such as dexamethasone may be beneficial. Postoperative ventilation
may be indicated as well until the edema resolves. The infant or child with a DA should only be
extubated when personnel capable of reintubating them are available. Extubation itself should be
performed in the operating room or in the ICU, where appropriate equipment for reintubating
the infant or child is immediately accessible. Generally, if there is doubt or debate as to whether
the infant or child with a DA is ready for extubation, then it is usually better to leave them
intubated.
Summary
Unexpected difficulties with airway management in otherwise healthy children after exclusion of
predictors of difficult intubation such as mandibular hypoplasia, limited mouth opening, and facial
asymmetry including abnormalities of the ear, syndromes, obstructive sleep apnea, and stridor
are very rare. If they occur, they are probably a result of inexperience, inadequate supervision,
and lack of pediatric airway training. Thorough pre-operative assessment and anticipation of airway difficulties as well as education, continuous training, and regular practice in basic airway
Suggested Reading
Jain RR, Rabb MF . The difficult pediatric airway. In: Hagberg CA, ed. Benumofs Airway
Management. 3rd ed. Philadelphia: Mosby, 2012:723760.
163
management are necessary to reduce the incidence of pediatric airway difficulties. Apart from
inexperience with the pediatric airway, a majority of morbidity and mortality in pediatric airway
management is attributed to a failure to recognize and overcome functional airway problems
because of insufficient depth of anesthesia or inadequate muscle paralysis rather than failure to
intubate.
165
Chapter 16
Difficult Airway Supplies
Objectives
Provide suggested supply lists for difficult airway wall-mounted boxes.
Provide suggested supply lists for portable difficult airway mobile carts.
Provide suggested supply lists for portable difficult airway tackle boxes.
Introduction
As the variability of difficult airways continues to expand in the operating room, as well as external
locations, the practitioner is faced with many challenges. Although the practitioner may be able to
handle the majority of these experiences, it is imperative that difficult airway supplies are readily
available when needed. With this in mind, a list of suggested supplies for these eventualities is
presented in this chapter.
Operating Room Airway Supply Box

At the authors institution, there is an emergency airway box attached to the wall of every operating room. (Fig. 16.1) The opening hinge to the box is secured with a plastic tie to prevent pilfering
of supplies. The box has a plexiglass cover to allow easy visualization of the following contents.
Individual contents may be changed for your practice patterns.
Adult Emergency Airway Inventory List
Cricothyrotomy kit (6.0 mm) cuffed

Bougie (15 Fr)
Cook Airway Exchange Catheter (19 Fr)
LMA #3, #4
Emergency transtracheal airway catheter
Aintree intubation catheter
16 Difficult Airway Supplies
166
Figure 16.1 Wall-mounted emergency airway box containing a cricothyrotomy kit, bougie, 19F Cook AEC, disposable LMA, Aintree intubation catheter, and a transtracheal airway catheter.
Pediatric Emergency Airway Inventory List
Cricothyrotomy kit (4.0 mm)

Bougie (10, 15 Fr)
Cook airway exchange catheter (8, 11, 19 Fr)
LMA #1, #2, #3
Emergency transtracheal airway catheter
Aintree intubation catheter
Portable Difficult Airway Tool Box

A portable fishing tackle box is also used at the authors institution; it has two levels and is easily
secured with a plastic tie on the closing hinge (Fig. 16.2). This allows a sealed, well-supplied box
to be available without anyone borrowing the contents. Contents can be adjusted for individual
practice patterns.
Drawer 1
Miller Blade #2, #3

Mac Blade #3, #4
Video laryngoscope
Magill forceps
Laryngoscope handle 2
Tongue blade 4
Oral airways 80 mm, 90 mm, 100 mm 2 ea.
ETT 7.0, 7.5, 8.0 mm with stylets and 10 mL syringes
Drawer 2
ETT sizes 6.0 mm to 8.5 mm
Intubation stylet
167
Figure 16.2 Portable fishing tackle box containing emergency airway equipment, including direct laryngoscopes, oral
and nasal airways, ETTs of various sizes, LMAs, and drugs (e.g., induction agents, paralytics, and local anesthetics).
Airway exchange catheter (19 Fr)

Aintree intubation catheter (19 Fr)
Bougie (15 Fr)
LMA #3, #4, #5
Exhaled CO2 detector
Nasal trumpets size 28, 30 2 ea.
20 mL syringes 4
10 mL syringes 6
18 G needles 10
10 mL saline filled syringes 6
Emergency drug pack from pharmacy (includes water-based lubricant, propofol, etomidate, succinylcholine, rocuronium, Bicitra, and phenylephrine)
Difficult Airway Cart

An alternative to a difficult airway box is a mobile cart, which has the advantage of being easily
transported to different locations, as needed. If several carts are needed because of the number of
locations, then each cart should be set up in an identical fashion. This allows the user to be familiar
with the location and operation of the equipment on each cart. These supplies should be customized to meet the specific needs, preferences, and skills of the practitioner and the health-care
facility. Suggested set-up is:
Drawer 1
Airways: One each of all sizes (oral and nasal)

Laryngoscopes: Miller, Macintosh: (one each of all size blades); video laryngoscope of some type
Lidocaine 4% solution (one bottle), lidocaine ointment, lidocaine jelly
Atomizer, nebulizer, gloves, 4 4 gauze pads, 1 plastic tape, tongue depressors
Water-based lubricant, benzoin swabs, anti-fog solution
168
Magill forceps
Cricothyrotomy kit
Bronchoscope-ETT adapter (Bodai connector)
Exhaled CO2 detector
Intubation catheter
Retrograde intubation kit
Drawer 2
Endotracheal tubes: Two of each size 2.5 mm to 6.5 mm (uncuffed). Two of each size 3.5 mm
to 8.5 mm (cuffed)
Intubating LMA (one set all sizes, 15)
LMA UniqueTM, ProsealTM (one set all sizes, 15)
ETT stylet: adult and pediatric
3 mL, 5 mL, and 10 mL syringes and assorted sized needles
Drawer 3
Oxygen masks (simple and non-rebreather), nasal cannula, oxygen tubing
Face masks
Combitube/Laryngeal Tube (adult and pediatric)
Drawer 4
ETT exchange catheters
Jet ventilation system
Lightwand
Top of the Cart

Fiberoptic bronchoscope: adult and pediatric, video monitor, light source
Summary
Preparation and practice are key elements for dealing with the difficult airway. Utilization of
standard, readily available supplies are an invaluable aid whenever the difficult airway presents.
Depending on the patient population, the practitioners level of expertise, and practice parameters, differences in supplies utilized are expected. The key factor is that a standard set of emergency airway supplies be readily available when the difficult airway presents. The presence of
trained assistants (nurses, anesthesia technicians or respiratory technicians, or even another
anesthesiologist or surgeon, if necessary) can make the difference in the critical airway case.
Suggested Reading
Dunn S, Connelly NR, Robbins L. Resident Training in Advanced Airway Management. J Clin
Anesth 2004;16:472476.
American Society of anesthesiologists Task Force on Management of the Difficult Airway.
Anesthesiology 2003;64(6):1319.
Jain RR, Rabb MF . The difficult pediatric airway. In: Hagberg CA, ed. Benumofs Airway
Management. 3rd ed. Philadelphia: Mosby, 2012:723760.
169
Chapter 17
Special Considerations for Out

of the Operating Room and
Cardiopulmonary Resuscitation
Sam D. Gumbert, MD
Objectives
Outline Basic Life Support guidelines and management.

List the options for initial airway management during CPR.
Evaluate the successful placement and usages of the different airways.
Discuss alternative methods of oxygen delivery during CPR.
Recognize airway challenges during emergency resuscitation.
Introduction
The need for a secured airway does not always occur in the controlled setting of the operating
room. Often, emergency scenarios present themselves in less-than-ideal circumstances. In fact,
out-of-hospital cardiac arrest is a common problem in the United States, affecting between 235,000
and 325,000 people each year. Recently, the American Heart Association (AHA) has revised its
Basic Life Support (BLS) and cardiopulmonary resuscitation (CPR) guidelines to reflect data that
recommend good quality chest compressions over initial airway management and breathing. Even
so, endotracheal intubation still remains the gold standard for securing the airway during emergency resuscitative procedures. Although there are varying success rates to this practice, there are
several methods and alternatives to basic and advanced airway management that can be employed
for any given scenario. Proper application of these guidelines and tools may reduce complications
and improve outcomes during airway management and CPR outside of the operating room.
Guidelines for Adult Cardiopulmonary Resuscitation

Adult Basic Life Support and Cardiopulmonary Resuscitation Guidelines
In 2010, the AHA revised the recommended CPR process from the traditional Airway-BreathingCirculation (A-B-C) to Circulation-Airway-Breathing (C-A-B). During low blood flow states such
as cardiac arrest, oxygen delivery to the brain and heart is limited primarily by blood flow as
17 Special Considerations for Out of OR

and CPR
170
opposed to arterial oxygen content. It has been shown that in the absence of a hypoxic etiology,
the oxygen content of the lungs is enough to maintain a sufficient PaO2 for the few minutes of
CPR. Cardiac-only resuscitation and minimizing delays or interruptions in chest compressions
have been shown to improve survival. Current evidence does not show any difference in survival
rates between chest compressions delivered alone and chest compressions combined with positive pressure ventilation. The AHA now recommends that chest compressions be initiated before
rescue breaths or advanced airway placement. Rescue breaths are now provided after the first
cycle of chest compressions. The exception to the cardiac-centered BLS approach is in infants
and children where cardiorespiratory arrest is usually secondary to hypoxia rather than a primary
cardiac event. As a result, initial resuscitation in this patient population is directed toward respiratory support.
Goals of Managing a Collapsed Patient in a Hospital Setting

Recognition of cardiorespiratory arrest or emergency and activation of emergency response
team
Early, high-quality CPR
Early defibrillation with an automated external defibrillator (AED)
Early advanced life support followed by post-resuscitation care by health-care professionals
CPR Tip
The updated 2010 AHA CPR guidelines recommend beginning chest compressions before
initial airway management (Circulation-Airway-Breathing).
Patient Assessment
Turn the patient onto his/her back and confirm the patient is unconscious.
Check patients pulse (<10 seconds), and if pulse is absent, then continue with CPR.
Occasional gasps or slowed labored breathing is indicative of actual or impending cardiac
arrest.
Chest Compressions
Cardiac output can approach 25% to 35% of spontaneous circulation

Give cycles of 30 compressions followed by two ventilations.
Rate of at least 100 compressions per minute
Compress the chest, at lower half of sternum, with elbows locked.
Compressions should be a firm controlled vertical depression of sternum at least 2 inches deep.
Allow complete chest recoil after each compression.
Minimize pauses in chest compressions to less than 10 seconds (changing providers or preparing
for shock).
Interposed abdominal compressions (IACs) with CPR have been shown to improve coronary perfusion by maintaining aortic diastolic pressure and are an AHA-approved adjunct to standard CPR.
Application of Defibrillation Pads

Analyze the rhythm using adhesive pads as quickly as possible.
Apply defibrillator pads over sternum and vertically in the mid-axillary line.
Initial Airway Management During Cardiopulmonary

Resuscitation
Rescue Breathing
Ensure the airway is open (head tilt/chin lift or head tilt/jaw thrust in a suspected cervical spine
injury).
Rescue breathing during CPR should be provided via mouth-to-mouth, mouth-to-barrier device,
or bag-mask ventilation (if available).
Each rescue breath should be given over 1 second with enough volume for chest rising in 30:2
compression-to-ventilation ratio.
Excessive force or tidal volume can cause gastric inflation.
Trained providers should initiate rescue breathing with an untrained lay rescuer designated to
perform chest compressions only.
Add supplemental oxygen as soon as possible.
Once airway is secured, give uninterrupted compressions at 100 compressions/minute and
simultaneously ventilate the lungs at a rate of 10 breaths/minute.
CPR Tip
Evidence suggests that excessive ventilation has been shown to increase intrathoracic pressures, lower coronary perfusion, and impair venous return, leading to decreased survival.
Airway Adjuncts
Oropharyngeal airways can be used in the unconscious patient to prevent airway occlusion by
the tongue and facilitate bag-mask ventilation.
Nasopharyngeal airways assist ventilation by relieving nasopharyngeal obstruction and are better tolerated in conscious patients than oral adjuncts. Caution should be used with a patient
with a basilar skull fracture or suspected coagulopathy.
Advanced Airway Management During Cardiopulmonary Resuscitation

Trained health care providers should perform endotracheal intubation during CPR.
Interruptions to chest compressions should be minimized, and prolonged attempts at tracheal
intubation should be avoided.
Placement of an endotracheal tube (ETT) or other advanced airway device has not been associated with any improvement in return of spontaneous circulation (especially with cessation of
chest compressions during attempts).
Endotracheal intubation attempts by inexperienced providers may result in complications, such
as failed intubation or esophageal intubation.
After ETT placement, ventilations should be delivered without interruption of chest compressions at a rate of 1 breath every 6 seconds to 8 seconds.
171
and CPR
Minimize interruptions to chest compressions for rhythm analysis and pad placement.
Defibrillation is indicated for ventricular fibrillation and tachycardia.

and CPR
172
CPR Tip
The following resuscitation medications can be delivered via endotracheal tube if intravenous access is unavailable: lidocaine, epinephrine, atropine, vasopressin, and naloxone.
Administer two to three times the intravenous dosage diluted in 10 mL of normal saline.
Use of Cricoid Pressure During Cardiopulmonary Resuscitation

The 2010 guidelines recommend against the routine use of cricoid pressure as part of airway
management during CPR.
Evidence suggests cricoid pressure may impede ventilation and interfere with the placement of
advanced airway devices or intubation.
Confirmation of Endotracheal Tube Placement During Cardiopulmonary

Resuscitation
The 2010 CPR guidelines recommend the use of continuous waveform capnography for confirmation of ETT placement during CPR.
Continuous waveform capnography may have decreased specificity and sensitivity with prolonged resuscitation and decreased perfusion.
Rise and fall of chest and auscultation of lungs can be misleading during CPR.
Qualitative exhaled CO2, PETCO2, and esophageal detector devices are still considered acceptable if waveform capnography is unavailable.
Low cardiac output limits the usefulness of qualitative exhaled CO2 and PETCO2 detectors.
Esophageal detectors are best used in combination with capnography.
Supraglottic Airway Devices

Both the 2005 and 2010 AHA CPR guidelines support the use of a supraglottic airway device
(SAD) as an alternative to endotracheal intubation.
SAD placement should be considered if endotracheal intubation fails.
SADs do not require glottic visualization, allowing the airway to be secured faster than endotracheal intubation, and may minimize low flow states.
Ventilations are delivered in the same ratio (1 breath every 68 seconds) without interruption
of chest compressions.
Intubating SADs may provide an effective conduit for endotracheal intubation with preliminary
evidence supporting their use in the pre-hospital environment, especially if a difficult intubation
is encountered.
Role of Advanced Airway Devices

Advanced airway management techniques, such as fiberoptic intubation and video laryngoscopy,
have not been widely studied for airway management during CPR.
Preliminary evidence suggests that video laryngoscopy may be an acceptable alternative, especially in difficult intubation, but their use may not be practical (absent electricity) or available in
the pre-hospital environment.
Oxylator
The Oxylator (CPR Medical Devices, Ontario, Canada) is a fixed-flow automatic resuscitation
management system with an adjustable pressure limit.
The Oxylator delivers oxygen flow at 30 L/min until an adjustable maximum pressure (up to
45 cm H2O) is reached, at which point passive exhalation occurs to an airway pressure of 2 cm
to 4 cm H2O.
The device allows both manual (rescuer initiated) and automatic inhalation modes.
The Oxylator works via hospital air supply, tank, or compressor; does not require electricity;
and can be connected to a facemask, supraglottic airway, or ETT.
Potential advantages of the Oxylator over bag-mask ventilation include consistent ventilation
and oxygenation to a set pressure; possible avoidance of hyperventilation, excessive ventilation,
or gastric insufflation; and early detection of airway obstruction.
Use of the Oxylator in the automatic mode can free the CPR provider to focus on other
resuscitation tasks. The Oxylator may be useful in austere environments where access to the
patients head and airway may be limited.
Res-Q-Pod
The Res-Q-Pod (Advanced Circulatory Systems, Roseville, MN), an impedance threshold device,
has been found to increase survivor rates and is an AHA Class 2A recommendation for patients
in cardiac arrest.
It is placed proximal to a facemask/airway and connects to the source of ventilation, preventing
excess air from entering the thorax, and increases thoracic negative pressure.
By regulating thoracic pressure during ventilation, the device increases blood flow to the heart
and brain, increases systolic blood pressure, and increases the success rate of defibrillation.
The Res-Q-Pod also contains timing assist lights to guide proper ventilation rates and prevent
hyperventilation.
Passive Oxygen Insufflation

Oxygen can be delivered passively via oropharyngeal airway, facemask, supraglottic airway, or
modified ETT (Boussignac endotracheal tube; Vygon Corporation, Montgomeryville, PA).
The Boussignac tube contains capillaries through which oxygen is delivered via continuous
insufflation, generating a constant positive alveolar pressure with the proximal end open for
exhalation.
The changes in intrathoracic pressure during chest compressions trigger passive inhalation and
active exhalation, allowing adequate gas exchange.
This technique does not require the rescuer to deliver ventilations, minimizes interruptions in
chest compressions, and may reduce the risk of barotrauma.
Evidence demonstrates passive oxygen delivery to be as effective as bag-mask ventilation or
mechanical ventilation via an ETT.
Passive oxygen delivery is described as an alternative but not a replacement for ventilation during CPR in the 2010 AHA CPR guidelines.
173
and CPR
Alternative Methods of Oxygen Delivery During

Cardiopulmonary Resuscitation

and CPR
174
Challenges of Airway Management During Cardiopulmonary

Resuscitation
Communication
One of the biggest challenges in any emergency is communication. Maureen Dunn, MD, MIPP,
from the University of Pennsylvania Department of Anesthesiology and Critical Care developed
the ABCDE Communication Tool (Fig. 17.1) to facilitate rapid transfer of vital medical data following traumatic injury for patients requiring emergent surgery.
In the pre-hospital setting, medical history or intubation history is often unavailable to guide
airway management.
Patient Access
Access to the airway during CPR outside of the hospital may be limited by the outside environment or the accident scene, and vital equipment for resuscitation may be limited.
Department of
Anesthesiology
& Critical Care
ABCDE Communication Tool
Airway Airway plan
(intubated [yes/no, any difficulty], Intubate in Bay, Intubate in OR)
Breathing Oxygenation (Nasal cannula, face mask, FiO2)
Ventilator settings (if not standard)
Pulmonary Injuries
Circulation Hemodynamic status
Access (# peripheral IVs, trauma line)
Blood given/availability
Uncrossmatched (2-pack or 5-pack to come with pt?)
Crossmatch (underway?)
Exsanguination Protocol or cell saver activated?
Disability/Drugs C-spine status/neurological injuries
All known (or suspected) injuries
Medications (drugs) received in ED, including antibiotics
Allergies if known
Extremity/Exposure/Everything Else Patient name, alert or response #
Procedure(s) planned
Operating room number
Give your name
Obtain name of Anesthesiology resident and attending
The ABCDE Communication Tool developed by Maureen McCunn, MD, MIPP,
University of Pennsylvania, Department of Anesthesiology and Critical Care.
Figure 17.1 ABCDE Communication Tool (Maureen Dunn, MD, MIPP, from the University of Pennsylvania
Department of Anesthesiology and Critical Care.)
Cervical Spine Injury

Cervical spine injury has been reported in 2% to 5% of patients after traumatic injury.
Manual in-line cervical spine stabilization is recommended for airway management in patients
with a suspected or known cervical spine injury.
The presence of a cervical collar has been reported to increase the difficulty of intubation. If
necessary, the collar may be removed for airway management, provided that manual in-line
stabilization is maintained.
No single best intubation method has been proven to be safest, and rapid sequence intubation
via direct laryngoscopy is the most commonly reported method.
Suspected or Known Cervical Spine Injury Tips

Rapid sequence intubation is most often recommended.
Manual in-line stabilization of the cervical spine should be performed during intubation to
minimize movement.
No safe amount of cervical spine movement has been defined.
A selection of laryngoscope blades and sizes should be available.
Supraglottic airway devices can be used as an airway adjunct.
No specific intubation method is recommended. All airway maneuvers or techniques may
cause cervical spine motion.
(Adapted from Ollerton JE, Parr MJA, Harrison K, et al. Potential cervical spine injury and
difcult airway management for emergency intubation of trauma adults in the emergency
department: a systemic review. Emerg Med J 2006;23:311.)
Summary
Recently, the AHA revised the recommended CPR process from the traditional Airway-BreathingCirculation (A-B-C) to Circulation-Airway-Breathing (C-A-B). Cardiac-only resuscitation and minimizing delays or interruptions in chest compressions have been shown to improve patient survival.
Supplemental oxygen and advanced airway management by trained personnel should be implemented as quickly as possible. Alternative methods of oxygen delivery such as the Res-Q-Pod, the
Oxylator, and passive oxygen insufflation techniques may be an effective alternative to bag-mask
ventilation or mechanical ETT ventilation.
Suggested Reading
Otto CW. Cardiopulmonary Resuscitation. In: Barash PG, Cullen BF, Stoelting RK, Cahalan M,
Stock MC, eds. Clinical Anesthesia, 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins;
2009:15321558.
McGlinch BO, White RD. Cardiopulmonary Resuscitation: Basic and Advanced Life Support.
In: Miller RD, ed. Millers Anesthesia, 7th ed. Philadelphia, PA: Churchill Livingstone;
2010:29713002.
175
and CPR
Within the hospital setting, access to the patients airway may be limited by equipment, invasive
lines or monitors, or the small size of the rooms or intensive care suite.
During mass casualty disasters, personal protective equipment or chemical protection gear may
cause airway management to be more difficult.

and CPR
176
Thierbach AR, Murphy MF. Prehospital Airway Management. In: Hagberg CA, ed. Benumofs
Airway Management, 2nd ed. Philadelphia: Mosby; 2007:731755.
Murray MJ. Disaster Preparedness. In: Barash PG, Cullen BF, Stoelting RK, Cahalan M, Stock MC,
eds. Clinical Anesthesia, 6th ed. Philadelphia: Lippincott Williams & Wilkins; 2009:15591578.
Nichol G, Aufderheide TP, Eigel B, Neumar RW, Lurie KG, Bufalino VJ, et al. Regional systems
of care for out-of-hospital cardiac arrest: a policy statement from the American Heart
Association. Circulation 2010;121:709729.
American Heart Association Web site. Available at http://www.heart.org/. Accessed October 30,
2012.
177
Chapter 18
Communication of the Difficult

Airway and Dissemination of
Critical Airway Information
Sam D. Gumbert, MD
Objectives
Understand the importance of communicating difficult airway/intubation management to future
providers.
Know the options for the dissemination of critical airway information.
Learn more about the MedicAlert Foundation Registry and its benefits.
Introduction
This chapter focuses on how critical airway information can be effectively distributed to future
health care providers to improve patient safety. The Anesthesia Advisory Council created the
MedicAlert Foundation National Difficult Airway/Intubation Registry to facilitate the uniform
documentation and dissemination of critical airway management information to practitioners. As
of 2010, this registry contained nearly 11,700 patients with an identified difficult airway/intubation.
Enhanced awareness and better communication can lead to improved recognition of the difficult
airway and prevent recurrent airway management difficulties.
Consequences of Difficult Airway Management

The consequences of a difficult airway/intubation may include adverse medical events and professional liability to the practitioner, as well as direct and indirect costs to the patient and health-care
system. The rate of complication is increased by 70% with prolonged airway management.
In 1988, the ASA Committee on Professional Liability Closed Claims Project found that respiratory events were the most common cause of brain damage and death during anesthesia, with
difficult intubation being the likeliest category for risk reduction. A study of the American Society
of Anesthesiologists Closed Claims database from 1985 to 1999 revealed that 67% of claims of difficult airway liability were associated with intubation. Most complaints initiated against physicians
18 Communication of the Difficult Airway
178
are unrelated to the physicians technical skill but arise because of inadequate records or poor
communication.
Difficult Airway/IntubationDocumentation
of Critical Information
Tip
The communication of successful and unsuccessful airway management techniques consists
of two parts: (1) documentation at the time of the event (pre-anesthesia, anesthesia, postanesthesia) for concurrent care providers during that episode of care, and (2) dissemination
of that information to future care providers during subsequent episodes of care.
Documentation in Medical Records

In the past, a standardized, readily available document did not exist to precisely record airway
events. Traditionally, critical airway/intubation information was recorded in the paper anesthesia
record as a non-standardized, handwritten, free text entry. This information was not included in
the operative report or on the face sheet of the medical record. Additionally, this information was
often department-specific and not shared within the health care system.
In 1993 and 2003, the ASA practice guidelines recommended that the anesthesiologist document more fully in the medical record, including a description of the nature of the airway difficulties, the various airway management techniques that were employed, and the extent to which
each of these techniques were beneficial or detrimental in managing the difficult airway.
Documentation in In-House Electronic Medical Records

A patient with a history of difficult airway/intubation should be recorded in an electronic medical
record with automatic triggers for facesheet and difficult airway/intubation wristband alerts. An
electronic medical record system can ensure that a difficult airway/intubation patient is recognized
for the remainder of the hospital stay and subsequent hospital admissions.
Difficult Airway/IntubationDissemination of Critical

Information
American Society of Anesthesiologists Recommendations
for Dissemination of Information
In 1993, the ASA Guidelines for Difficult Airway Management recommended that anesthesiologists inform patients and caregivers that a difficult airway was encountered. These guidelines
encourage notifications systems, such as a written report and direct communication with the
patients surgeon/primary caregiver, be undertaken. The 2003 and 2013, ASA practice guidelines
further recommended the use of an identification bracelet or equivalent that can be worn to alert
care providers of a potential high-risk airway/intubation.
Dissemination of Information via Paper Medical Records

Difficult airway/intubation information has traditionally been a part of the patients paper medical
or anesthetic records. Even when this written documentation is adequate, its dissemination to
medical care providers is often lacking, particularly in the event of an emergency.
Most anesthesiologists inform the patient of a difficult airway/intubation in the post-anesthesia

care unit (PACU). Verbal communication of difficult airway information can often be hindered
by a patients postoperative pain, sedation, or continued intubation. One study found that 50%
of patients who were informed verbally did not recall or were unsure about ever having had
a postoperative conversation with their anesthesiologist. Difficult airway/intubation information
relayed verbally can be miscommunicated because of patients lack of understanding of medical
terminology or anxiety related to their medical condition. Providers may also underrepresent
the severity of the difficult airway/intubation because of fear of personal liability exposure or
to alleviate patient anxiety. When these patients re-enter the health-care system, previous verbal communication may be minimized, vague, or not remembered by a potential at-risk patient.
Additionally, patients in emergence situations may not be able to convey their risk in part because
of medication, stress/anxiety, or injury.
Dissemination of Information via Letters

In 2000, the Department of Anesthesiology at Mayo Clinic Scottsdale began providing written
notification to patients about their difficult airway in the form of letters mailed 1 week postoperatively. In a follow-up survey performed 2 years later, 20% of patients could not recall receiving the
letter. To improve communication, the Mayo Clinic followed up with a telephone call to confirm
receipt of the letter, a MedicAlert Foundation brochure was incorporated, and the nature of the
difficult airway /intubation was emphasized to the patient.
Following these measures, the survey found 41% had informed their primary care physician of
their difficult airway and 95% who had surgery notified their surgeons and/or anesthesiologist of
their airway risk. A standard written notification system or airway alert form should be distributed
to the patient, primary care provider, and surgeon with follow-up communication stressing the
importance of their airway risk.
Dissemination of Information via Difficult Airway/Intubation Registries

In a limited number of facilities, patients identified with a difficult airway/intubation are incorporated into a hospital-wide difficult airway/intubation registry system. The purpose of an in-house
registry is to disseminate critical airway information during subsequent episodes of care at that
facility. A review of 119 patients in the Beth Israel Deaconess Medical Center Difficult Airway
Registry from 1995 to 1997 found that 31 (26%) returned for surgery one or more times and that
the registry provided valuable information for airway management. However, in-house difficult
airway/intubation registries are not common, even at tertiary-level institutions, and the information they contain is available only within that institution.
Dissemination of Information via Electronic Medical Records

and Electronic Health Records Systems
In 2009, the Health Information Technology for Economic and Clinical Health (HITECH) Act
was passed in an effort to improve the health of Americans and the performance of the healthcare system. Some of its programs included supporting state initiatives for health information
exchange (HIE) and creating a common platform for HIE across the country: the National Health
Information Network (NHIN). The hope is state programs can be expanded to form an envisioned NHIN. The emergence of an electronic health records system in the United States is in its
infancy and cannot provide an answer to the immediate need for national access to emergency
medical information. However, a solution that is already in place and fully operational can be
found with the MedicAlert Foundation.
179
Verbal Dissemination of Information
180
The MedicAlert Foundation

The MedicAlert Foundation pioneered and is the foremost national and international emergency
medical information and identification services system that provides immediate access to critical
medical information.
Services Provided by the MedicAlert Foundation

The MedicAlert Foundations core services are comprised of a four-part system: a personalized and custom-made MedicAlert medical ID worn as a bracelet or necklace, a personalized
MedicAlert wallet card, an Emergency Medical Information Record (EMIRSM), and the MedicAlert
live 24/7 Emergency Response Service Center. The MedicAlert medical ID and MedicAlert wallet card immediately alert a provider that the patient has a specific medical condition, such as a
difficult airway/intubation history. Engraved on the medical ID and printed on the wallet card is
a toll-free emergency contact phone number (18006072565) that provides the health care
provider the details of the patients airway management history. For members who travel internationally, MedicAlert provides an international collect call number 2096344917. The Emergency
Response Center accepts all international collect calls and is staffed by medically trained personnel
24 hours a day, 7 days a week, in more than 140 languages.
Membership in the MedicAlert Foundation

A MedicAlert Foundation membership allows its members to manage their own personal
Emergency Medical Information Record (EMIRSM). Extended service features provide the consolidation of paper records (including lab reports, immunization records, radiology reports, EKG
results, etc.) in an electronic format.
The MedicAlert Foundation National Difficult Airway/Intubation Registry

The major objectives of the Anesthesia Advisory Council for the National Difficult Airway/
Intubation Registry were to:
Develop and implement mechanisms for uniform documentation and dissemination of critical
information.
Establish a central database of airway management information for research purposes.
Conduct long-term tracking of patients to assess implications of adverse outcomes for future
management.
Determine whether rapid and economical dissemination of critical airway information could have
a positive impact on the future care of patients and overall costs to the healthcare system.
The components of the National Difficult Airway/Intubation Registry include:
Information for health-care providers and patients
Specialized enrollment form
Secure database
Supporting services of the MedicAlert Foundation (MedicAlert medical ID, MedicAlert wallet
card, MedicAlert Emergency Medical Information Record, and the 24/7 Emergency Response
Service Center)
Follow-up letter sent to the primary care physician or specialist
The specialized registry enrollment form documents critical information, including the hospital
name, patients medical record number, surgical procedure, date of procedure, clinical anesthesia
profile, nature of difficulty encountered, reasons for difficulty, successful and unsuccessful techniques, best visualization of airway anatomy, clinically applied algorithm, and clinical outcome.
Tip
Benets of the National Difcult Airway/Intubation Registry include patient safety, practitioner
security, and nancial savings.
With enrollment in the Registry, the patients primary care physician and specialists are notified
of the patients difficult airway/intubation status to facilitate care. A 2010 survey of more than
700 members in the MedicAlert Foundation National Difficult Airway/Intubation Registry found
that 11.2% had had another episode in which a difficult airway/intubation was encountered. The
registry provides a chronology of the patients airway events over time, reflecting changes in
pathophysiology and airway management. This chronology assists future care providers in their
decision-making process and preparation for patients care and has the potential to reduce cancellations and cost of operating room time, supplies, and equipment.
A MedicAlert medical ID and/or wallet card provide a visible reminder of the patients difficult
airway status and allows health care providers a toll-free phone number to access details of the
patients previous airway management.
Summary
Information is the lifeblood of modern medicine. Quality improvements in the process of managing difficult airway/intubation (methods to identify patients, algorithms, equipment, airway teams)
should be vigorous and performed concurrently with improvements in how airway information is
documented and disseminated. Once a difficult airway/intubation patient is identified, documentation of the specifics of their airway management is critical. The ASA recommendations for the
dissemination of difficult airway/intubation include informing the patient/guardian of the presence
of a difficult airway and the reasons for difficulty with (1) a written report or letter to the patient,
(2) a report in the medical record, (3) a chart flag, (4) communication with the patients surgeon
or primary caregiver, and (5) notification bracelet or equivalent identification device.
Tip
The ASA recommendation of a notication bracelet or equivalent identication device is
a visual warning of the presence of a difcult airway/intubation. To be most effective, this
medical ID should be linked to a database such as the MedicAlert Foundation, which provides patient-specic difcult airway/intubation information on demand, around the clock,
anywhere in the world.
Suggested Reading
1. Practice guidelines for management of the difficult airway: an updated report by the
2. Mark L, Foley LJ. Effective Dissemination of Critical Airway Information: The MedicAlert
National Difficult Airway/Intubation Registry. In: Hagberg CA, ed. Benumofs Airway
Management, 3rd ed. Philadelphia, PA: Mosby; 2012:10981105.
181
Benefits of the Registry
182
3. Koenig, HM . No more difficult airway, again! Time for consistent standardized written
patient notification of a difficult airway. Anesthesia Patient Safety Foundation Newsletter
2010;25(2).
4. Mark LJ, Beattie C, Ferrell CL, et al. The difficult airway: mechanisms for effective
dissemination of critical information. J Clin Anesth. 1992;4(3):247251.
5. MedicAlert Foundation Web site. Available at: http://www.medicalert.org/. Accessed
December 17, 2012.
183
Index
A-B-C. See Airway-Breathing-Circulation
ABCDE Communication Tool, 174
adult CPR guidelines, 16971
advanced initial airway management, during CPR,
171, 172
AEC. See airway exchange catheter
Afrin. See oxymetazoline 0.05%
AHA. See American Heart Association
Aintree Intubation Catheter (AIC), 84t, 8687, 87f,
137, 137t, 138f, 149
air composition, 3031, 31f
airQ Intubating Laryngeal Airway (ILA), 5860,
59f, 147
Airtraq, 7780, 79f, 149
airway
anatomy of, 1
anesthesia for, 1625
airway nerve blocks, 2125
direct application of, 1920
local, 17
topicalization techniques for, 1720
assessment of
difficult cricothyrotomy for, 6
difficult intubation for, 1, 36, 3536, 155
difficult mask ventilation for, 1, 23, 3f, 3536
history and physical for, 2
introduction to, 12
objectives of, 1
summary of, 7
supraglottic devices for, 12, 7
axes of, 28f
laryngeal, 27
oral, 27
pharyngeal, 27
collapse of, 2
Airway-Breathing-Circulation (A-B-C), 169,
175
airway exchange catheter (AEC), 68, 135, 13640,
137t, 14849
airway management challenges, 17475
airway management combined techniques
direct laryngoscopy
DL/fiberoptic stylet, 14546, 145f
DL/FOB, 14344, 144f
DL/intubation catheter, 14445, 145f
DL/RI, 146
introduction to, 143
objectives of, 143
RI, 15052
SADs, 14750
summary of, 152
TTJV/FOI, 150
VLs
VL/fiberoptic stylet, 147
VL/FOB, 14647
VL/intubating catheter, 146
airway nerve blocks, 2125
alfentanil, 14
Ambu aScope 2, 98, 99f
Ambu Aura-i, 60f, 61, 147
American Heart Association (AHA), 169, 170,
172, 175
anatomy
of airway, 1
for cricothyrotomy, 127, 127f
of pediatric airway, 15657, 156f
for RI, 11011
for TTJV, 119, 120f
Index
184
anesthesia/anesthetics. See also airway

induction of, 2
local, 17
transtracheal, 2425, 24f, 25f
anterior ethmoidal nerve block, 21f, 22
anticholinergics, 11
antisialagogues, 1011
Arndt Airway Exchange Catheter, 115, 137, 137t,
138f, 149
Arndt Endobronchial Blocker, 66, 67f
ASA Closed Claims Analysis, 141
ASA Closed Claims Database, 135
ASA Committee on Professional Liability Closed
Claims Project, 177
ASA Difficult Airway Algorithm
adherence to, 82
LMA in, 47, 48, 86
RI in, 109
TTJV in, 117
ASA Pediatric Closed Claims Database, 155
ASA Task Force for Management of the Difficult
Airway, 9, 10, 39, 136, 141
asleep flexible fiberoptic intubation, 100
asleep nasotracheal intubation, 4344
aspiration prophylaxis, 12, 12t
assessment, of airway, 18
atomizers, 1718, 18f
atropine, 11, 11t
AVL. See GlideScope Advanced Video
Laryngoscope
awake intubation. See intubation
awake nasotracheal intubation, 4344.
See also intubation
awake patients, RI in, 110
BAAM Whistle, 42, 43f
beach chair position, 30
benzocaine, 17
benzodiazepines, 13
Berci-Kaplan DCI, 72
Berman airway, 102, 102f, 103f
Bicitra, 12t
bilevel positive airway pressure (BiPAP), 33
BL. See Bullard Laryngoscope
blades
D-Blade, 72, 73f
laryngoscope, 160
Macintosh, 6870, 69f, 75, 94
Miller, 68, 69f, 70
Bonfils Retromolar Intubation Fiberscope,
90, 90t, 92f, 147
Boussignac CPAP, 33, 173

Brambrink Intubation Endoscope, 90t, 92
bronchial blockers, 66, 67f, 68
Bullard Laryngoscope (BL), 7172, 71f, 78, 160
C-A-B. See Circulation-Airway-Breathing
C-AEC. See Cook Airway Exchange Catheters
C-AEC-EF. See Cook Airway Exchange CatheterExtra Firm
cannot intubate, cannot ventilate (CICV), 86, 117,
118, 158
cardiopulmonary resuscitation (CPR)
A-B-C, 169, 175
adult guidelines for, 16971
airway management challenges during
cervical spine injury, 175
communication, 174
patient access, 17475
C-A-B, 169, 175
ETT during, 171, 172, 173
initial airway management during
advanced, 171, 172
airway adjuncts, 171
cricoid pressure, 172
rescue breathing, 171
SADs, 172
objectives of, 169
oxygen delivery methods during
Oxylator, 173, 175
passive oxygen insufflation, 173, 175
Res-Q-Pod, 173, 175
summary of, 175
cart, for difficult airway, 16768
catheters. See also extubation catheters
AEC, 68, 135, 13640, 137t
AIC, 84t, 8687, 87f, 137, 137t, 138f, 149
Arndt Airway Exchange Catheter, 115, 137, 137t,
138f, 149
C-AEC, 136, 137, 137t, 13840, 140f
C-AEC-EF, 13940, 140f
Emergency Transtracheal Airway Catheter, 131
for intubation, 14445, 145f, 146, 148
Melker Cuffed Emergency Cricothyrotomy
Catheter Set, 131, 132f
Melker Emergency Cricothyrotomy Catheter
Set, 131
Melker Universal Emergency Cricothyrotomy
transtracheal, 121f
cervical spine injury, 175
indications for, 126

kits for, 131
objectives of, 125
summary of, 13132
techniques for
percutaneous dilational cricothyrotomy, 128,
129f
surgical cricothyrotomy, 12831
CTM. See cricothyroid membrane
cuff, of ETT, 136, 159
cuff leak test, 136
DA. See difficult airway
D-Blade, 72, 73f
defibrillation pads, 17071
degenerative torticollis, 4f
denitrogenation, 30
devices. See also supraglottic airway devices
MADgic Mucosal Atomization Device, 1718,
18f
of mask ventilation, 36, 37f, 38f
RAMP, 29
dexmedetomidine, 15
DI. See difficult intubation
diazepam, 13, 13t
difficult airway (DA), 155, 157, 162
objectives of, 165
summary of, 168
supplies for
difficult airway cart, 16768
emergency airway inventory list, 16566
operating room airway supply box, 16566,
166f
portable difficult airway tool box, 16667,
167f
difficult airway cart, 16768
difficult airway/intubation critical information
dissemination of, 17879
documentation of, 178
difficult airway/intubation registries, 179
difficult airway management communication
consequences of, 17778
through difficult airway/intubation registries, 179
through electronic health records systems, 179
through letters, 179
MedicAlert Foundation for, 177, 179, 18081
through medical records
documentation for, 177, 178
185
Index
chest compressions, 170

CICV. See cannot intubate, cannot ventilate
cimetidine, 12t
Circulation-Airway-Breathing (C-A-B), 169, 175
classic technique, for RI, 11213
C-MAC, 7273, 73f, 146
cocaine, 12, 17, 17t, 19, 21, 22, 104
Cohen Endobronchial Blocker, 66
collapsed patient hospital management
assessment of, 170
chest compressions, 170
defibrillation pads, 17071
Combitube, 52, 53f, 55, 149
communication
during CPR, 174
of difficult airway management, 17781
complications
of cricothyrotomy, 12627
of RI, 110
of TTJV, 11819
continuous positive airway pressure (CPAP), 32,
33, 68
contraindications
for cricothyrotomy, 126
for RI, 110
to TTJV, 118
Cook Airway Exchange Catheter-Extra Firm
(C-AEC-EF), 13940, 140f
Cook Airway Exchange Catheters (C-AEC), 136,
137, 137t, 13840, 140f
Cook retrograde intubation set, 115
Cormack-Lehane scoring system, 56, 6f, 144
Coud-Tip stylets, 8385
Frova Intubating Introducer, 83, 84f, 84t
METTI, 84, 84t
METTS, 84, 84t
PSUB, 8384, 84f, 84t
PTTI, 83, 84t
CPAP. See continuous positive airway pressure
CPR. See cardiopulmonary resuscitation
cricoid cartilage, 11011, 111f, 112, 127, 127f
cricoid pressure, 172
cricothyroid membrane (CTM)
in cricothyrotomy, 127, 128, 13031
in RI, 110, 111, 111f, 112
in TTJV, 119, 120
cricothyrotomy, 6
anatomy for, 127, 127f
complications of, 12627
contraindications for, 126
CTM with, 127, 128, 13031
Index
186
difficult airway management communication (Cont.)

electronic, 179
paper, 177, 178
objectives of, 177
summary of, 181
through verbal dissemination, 177, 179
difficult cricothyrotomy, 6
difficult intubation (DI), 1, 36, 3536, 155
difficult mask ventilation, 1, 23, 3f, 3536
dimensions, of SADs, 50t
direct laryngoscopy (DL), 6870
direct laryngoscopy combination techniques,
14346, 145f
direct laryngoscopy/fiberoptic stylet, 14546, 145f
direct laryngoscopy/flexible fiberoptic laryngoscopy
(DL/FOB), 14344, 144f
direct laryngoscopy/intubation catheter
(DL/intubation catheter), 14445, 145f
direct laryngoscopy/retrograde intubation
(DL/RI), 146
dissemination, of critical information, 177, 17879
DL. See direct laryngoscopy
DL/fiberoptic stylet. See direct laryngoscopy/
fiberoptic stylet
DL/FOB. See direct laryngoscopy/flexible fiberoptic
laryngoscopy
DL/intubation catheter. See direct laryngoscopy/
intubation catheter
DL/RI. See direct laryngoscopy/retrograde
intubation
DLT. See double-lumen tube
documentation
of critical information, 178
of medical records, 177
double-lumen tube (DLT), 63, 6668, 13940
droperidol, 16
Easy Cap, 38
Easytube. See Rusch Easytube
EEB. See Epiglottic Elevating bar
electronic health records systems, 179
electronic medical records, 179
emergency airway inventory list
adult, 165
pediatric, 166
Emergency Transtracheal Airway Catheter, 131
EndoFlex ETT, 64, 65f
Endoscopy Mask, 36
endotracheal intubation, 49
endotracheal tubes (ETT), 7, 36, 39
during CPR, 171, 172, 173
cuff of, 136, 159

with DL/fiberoptic stylet, 14546, 145f
with DL/FOB, 144
with DL/RI, 146
DLT, 63, 6668
with extubation catheters, 135, 136, 137, 13841
FOB with, 60, 61, 66, 1078
with ILMA, 5658
laryngoscopy techniques and
direct, 6870
indirect, 7172
introduction to, 63
objectives of, 63
rescue maneuvers for, 82
video, 63, 7282
for nasotracheal intubation, 41, 42, 43, 44, 45
oral, 41
for pediatric airway management, 15960
for RI, 109, 112, 113, 114f
RI/FOB, 150
RI/FOB/SAD, 151
with SAD/FOB/AEC, 14849
with SAD/RI, 150
single-lumen, 6366, 6768
size of, 49
tolerance to, 42
with TTJV, 117
types of, 6368
with VL/fiberoptic stylet, 147
with VL/FOB, 147
with VL/intubating catheter, 146
endotracheal tube (ETT) guides, 8388
AIC, 84t, 8687, 87f
Coud-Tip stylets, 8385
Radlyn R-100 Stylet, 84t, 8586, 86f
Videolaryngoscope Stylets, 87
Endotrol ETT, 64, 64f
Enk Oxygen Flow Modulator Set, 122
Epiglottic Elevating bar (EEB), 49
epinephrine, 19, 21, 22
equipment
for FOI, 98100, 98f
for nasotracheal intubation, 42, 43f
for pediatric airway management, 158
ErgoMask, 36
ETT. See endotracheal tubes
ETT exchangers, 160
extubation
criteria for, 136
of difficult airway, 162
techniques for, 33
face mask, 32, 158

famotidine, 12t
fentanyl, 14
fiberoptic bronchoscope (FOB), 95
with AIC, 86
for awake intubation, 43
with BL, 71
with DLT or SLT, 68
with ETT, 60, 61, 66, 1078
for FOI, 9799, 100, 100f, 101
ILMA with, 55, 5758
with TTJV, 150
fiberoptic endoscopy, 1056
fiberoptic intubation. See flexible fiberoptic
intubation
FiO2. See fraction of inspired O2
flexible fiberoptic intubation (FOI)
advantages of, 98
Ambu aScope 2, 98, 99f
asleep, 100
awake, 100
equipment for, 98100, 98f
FOB for, 9799, 100, 100f, 101
indications for, 97
LMA with, 104
objectives of, 97
patient preparation for, 100
summary of, 108
techniques for, 1018, 101t
fiberoptic endoscopy, 1056
nasal fiberoptic intubation, 101, 101t
nasal fiberoptic laryngoscopy, 1045
oral fiberoptic intubation, 101, 101t
oral fiberoptic laryngoscopy, 1024
flumazenil, 13
FOB. See fiberoptic bronchoscope
FOI. See flexible fiberoptic intubation
fraction of inspired O2 (FiO2), 31, 33
FRC. See functional residual capacity

Frova Intubating Introducer, 83, 84f, 84t, 160
functional residual capacity (FRC), 29, 31, 3233,
15657
GlideRite Stylet, 7374, 74f, 76, 87
GlideScope, 7377
GlideScope Advanced Video Laryngoscope (AVL),
74, 75f
GlideScope Direct Intubation Trainer, 7475, 76f
GlideScope Ranger, 74, 76f
GlideScope Video Laryngoscope (GVL), 74, 146
glossopharyngeal nerve block, 2223, 22f
glycopyrrolate, 11, 11t
guidewire technique, for RI, 11315, 114f
GVL. See GlideScope Video Laryngoscope
H2-Antagonists, 12, 12t
head-elevated position, 28f, 29, 30f
Health Information Technology for Economic and
Clinical Health (HITECH) Act, 179
high-resolution optical stylets, 9091
HITECH Act. See Health Information Technology
for Economic and Clinical Health Act
hybrid fiberoptic video stylets insertion, 9495
ILA. See airQ Intubating Laryngeal Airway
ILA Removal Stylet, 5960
ILMA. See Intubating LMA
indications
for awake intubation, 10t
for cricothyrotomy, 126
for extubation catheters, 136
for nasotracheal intubation, 4142
for RI, 10910
for TTJV, 118
indirect laryngoscopy, 7172
induction
of anesthesia, 2
with pediatric airway management, 16162
initial airway management, during CPR, 17172
insertion techniques, of SADs, 4855
Intubating LMA (ILMA), 5558
intubation. See also flexible fiberoptic intubation;
nasotracheal intubation; retrograde intubation
awake
airway anesthesia for, 1625
FOB for, 43
FOI for, 100
indications for, 10t
187
Index
extubation catheters
airway exchange catheters
double-lumen endotracheal tubes and, 13940
types of, 13638
uses of, 13839
ETT with, 135, 136, 137, 13841
objectives of, 135
solid intubating stylets and, 14041
summary of, 141
Index
188
intubation (Cont.)
nasotracheal, 4344
objectives of, 9
premedication for, 1012
sedation for, 1316
catheters for, 14445, 145f, 146, 148
difficult, 1, 36, 3536, 155
endotracheal, 49
with SADs, 5561
stylets for
ETT guides, 8388
introduction to, 83
lighted non-optical, 8890
lighted optical, 9095
objectives of, 83
translaryngeal-guided, 109
invasive airway, 1
JED, 104, 106f
ketamine, 1516
King LT, 53, 54f, 55, 149
King LT-D, 53, 54f, 55
King LTS-D, 53, 55, 55f
King Vision Video Laryngoscope, 80, 80f, 149
Klein Maneuver, 58
laryngeal airway axis, 27
Laryngeal Mask Airway (LMA), 47, 52, 5758, 147
with AIC, 8687
with FOI, 104
invention of, 47, 61
pediatric, 16162
use of, 2, 39
laryngoscope blades, 160
laryngoscopes. See also video laryngoscopes
Bullard Laryngoscope (BL), 7172, 71f, 78, 160
Macintosh blade, 6870, 69f, 75, 94
Miller blade, 68, 69f, 70
laryngoscopy, 1, 3, 4, 5, 7. See also specific
laryngoscopies
indirect, 7172
nasal fiberoptic, 1045
oral fiberoptic, 1024
positioning for, 2730, 28f, 30f
rescue maneuvers with, 82
techniques for, 6382
laryngospasm, 48
letters, communication through, 179
Levitan FPS Stylet, 90, 90t, 91f
lidocaine, 12, 17, 17t, 19, 20, 21, 22, 24
lighted non-optical stylets, 8890

Surch-Lite, 88
technique for, 89, 89f
Tube-Stat Lighted Stylet, 88, 90t
Vital Signs Light Wand Illuminating Stylet,
88, 90t
lighted optical stylets
Bonfils Retromolar Intubation Fiberscope, 90,
90t, 92f
Brambrink Intubation Endoscope, 90t, 92
high-resolution, 9091
Levitan FPS Stylet, 90, 90t, 91f
SensaScope, 90t, 9495, 94f
Shikani Optical Stylet, 90, 90t, 91f, 93f
Video RIFL Scope, 90t, 94, 95f
LMA. See Laryngeal Mask Airway
LMA Classic, 48, 48f, 61
LMA Classic Excel, 49, 50f
LMA Fastrach, 55, 56f
LMA ProSeal, 49, 51f
LMA Supreme, 49, 51f
local anesthetics, 17
lorazepam, 13
Macintosh blade, 6870, 69f, 75, 94
MADgic Mucosal Atomization Device, 1718, 18f
Magill forceps, 41, 42, 44, 44f, 45, 149
Mallampati Airway Classification, 4, 5f
Manual Jet Ventilator, 122
Manujet III, 122
mask. See also Laryngeal Mask Airway
face, 32, 158
mask ventilation, 28
devices
components of, 36
Endoscopy Mask, 36, 38f
ErgoMask, 36, 37f
Rendell-Baker-Soucek Mask, 36
types of, 36, 37f
difficult, 1, 23, 3f, 3536
Easy Cap, 38
impossible, 35
introduction to, 35
objectives of, 35
one-handed, 3638
patient airway assessment with, 35
rescue maneuvers with, 39
summary of, 39
two-handed, 38
McGrath Mac, 77
McGrath Video laryngoscopes, 77, 78f, 146
naloxone, 14
nasal fiberoptic intubation, 101, 101t
nasal fiberoptic laryngoscopy, 1045
nasal mucosal vasoconstrictors, 10, 12
nasopharyngeal airway, 105t, 15859, 171
nasotracheal intubation
advantages of, 42
asleep, 4344
awake, 4344
disadvantages of, 42
equipment for
BAAM Whistle, 42, 43f
capnography, 42
ETT for, 41, 42, 43, 44, 45
introduction to, 41
objectives of, 41
preparation for, 42
summary of, 45
National Health Information Network (NHIN), 179
nebulizers, 1819, 19f, 20f
Neo-Synephrine. See phenylephrine
nerve blocks, 2125
neutral in-line position, 2930

NHIN. See National Health Information Network
non-optical stylets. See lighted non-optical stylets
non-particulate antacids, 12
obese patient, 29, 30f
morbidly, with OSA, 3233
obstructive sleep apnea (OSA), 3233
one-handed mask ventilation, 3638
one lung ventilation, 63, 6668
operating room airway supply box, 16566, 166f
opioids, 2, 14
optical stylets. See lighted optical stylets
oral airway axis, 27
oral endotracheal tube, 41
oral fiberoptic intubation, 101, 101t
oral fiberoptic laryngoscopy, 1024
Ormco SportsGuard, 69
oropharyngeal airway, 158, 171
OSA. See obstructive sleep apnea
Ovassapian airway, 102, 102f
oxygen delivery, 33
CPR methods of, 173, 175
Oxylator, 173, 175
oxymetazoline (Afrin), 12, 104
paper medical records, 177, 178
paralytics, 2
Parker Flex-Tip ETT, 64, 65f, 107, 107f
passive oxygen insufflation, 173, 175
patients. See also collapsed patient hospital
management
access of, 17475
airway assessment of, 35
awake, RI in, 110
FOI preparation of, 100
with OSA, 3233
pediatric airway management
anatomy of, 15657, 156f
Bullard laryngoscope for, 160
difficulty of, 157
with airway, 155
extubation for, 162
with intubation, 155
equipment for, 158
ETT exchangers for, 160
ETT for, 15960
evaluation of, 15758
face mask for, 158
induction with, 16162
189
Index
mechanism, of TTJV, 11718

MedicAlert Foundation, 177, 179, 18081
membership in, 180
services provided by, 180
MedicAlert Foundation National Difficult Airway/
Intubation Registry, 18081
medical records
documentation of, 177
electronic, 179
paper, 177, 178
Melker Cuffed Emergency Cricothyrotomy
Melker Emergency Cricothyrotomy Catheter Set,
131
Melker Universal Emergency Cricothyrotomy
membership, in MedicAlert Foundation, 180
metoclopramide, 12t
METTI. See Muallem ETT Introducer
METTS. See Muallem ETT Stylet
midazolam, 13, 13t
Miller blade, 68, 69f, 70
modified nasal trumpet, 15859, 159f
morbidly obese patient, with OSA, 3233
Muallem ETT Introducer (METTI), 84, 84t, 140, 141f
Muallem ETT Stylet (METTS), 84, 84t
Index
190
pediatric airway management (Cont.)

laryngoscope blades for, 160
LMA for, 16162
nasopharyngeal airway, 15859
objectives of, 155
oropharyngeal airway, 158
physiology of, 15657, 156f
summary of, 16263
Truview PCD for, 160, 161f
Pediatric Perioperative Cardiac Arrest (POCA), 155
Pentax-AWS Airway Scope, 77, 78, 79f, 80, 146
percutaneous dilational cricothyrotomy, 128, 129f
percutaneous tracheostomy, 6
percutaneous transtracheal jet ventilation. See
transtracheal jet ventilation
pharyngeal airway axis, 27
phenylephrine, 12, 19, 104
physiology
of pediatric airway management, 15657, 156f
of preoxygenation, 31
POCA. See Pediatric Perioperative Cardiac Arrest
portable difficult airway tool box, 16667, 167f
Portex Single-Use Bougie (PSUB), 8384,
84f, 84t
Portex Tracheal Tube Introducer (PTTI),
83, 84t, 140
position/positioning. See preoxygenation
premedications, for awake intubation
anticholinergics, 11
antisialagogues, 1011
aspiration prophylaxis, 12, 12t
atropine, 11, 11t
dosing for, 11t
glycopyrrolate, 11, 11t
nasal mucosal vasoconstrictors, 10, 12
pharmacologic characteristics of, 11t
scopolamine, 11, 11t
preoxygenation
final considerations for, 3334
introduction to, 27
for morbidly obese patient, with OSA, 3233
objectives of, 27
oxygen delivery for, 33
physiology of, 31
positioning for
beach chair position, 30
for laryngoscopy, 2730, 28f, 30f
neutral in-line position, 2930
ramped or head-elevated position, 28f, 29, 30f
sniffing position, 2729, 28f, 30f
strategies for, 2734
techniques for, 3132

extubation, 33
without face mask, 32
fast, 32
slow, 32
pressure. See also bilevel positive airway pressure;
continuous positive airway pressure
for TTJV, 12022, 121f
pro-motility agents, 12
propofol, 1415
PSUB. See Portex Single-Use Bougie
PTTI. See Portex Tracheal Tube Introducer
Quicktrach Emergency Cricothyrotomy
Device, 131
Radlyn R-100 Stylet, 84t, 8586, 86f
RAMP Device, 29
ramped or head-elevated position, 28f, 29, 30f
Ranitidine, 12t
Rapi-Fit adapters, 115, 136, 137, 139
remifentanil, 13, 14
Rendell-Baker-Soucek Mask, 36, 158
rescue breathing, 171
rescue maneuvers
for laryngoscopy, 82
with mask ventilation, 39
for nasotracheal intubation, 45
for SADs, 61
Res-Q-Pod, 173, 175
retrograde/direct laryngoscopy, 151
retrograde/fiberoptic flexible laryngoscopy,
150
retrograde/fiberoptic flexible laryngoscopy/
supraglottic airway device, 151
retrograde intubation (RI), 146, 150
anatomy of, 11011
in ASA Difficult Airway Algorithm, 109
in awake patients, 110
contraindications for, 110
CTM with, 110, 111, 111f, 112
ETT for, 109, 112, 113, 114f
objectives of, 109
technique for, 11115
classic, 11213
Cook retrograde intubation set, 115
guidewire, 11315, 114f
translaryngeal-guided intubation, 109
SAD/HFJV. See supraglottic airway device/high

frequency jet ventilation
SAD/intubation catheter/lightwand. See
supraglottic airway device/intubation
catheter/lightwand
SAD/RI. See supraglottic airway device/retrograde
intubation
SADs. See supraglottic airway devices
scopolamine, 11, 11t
sedation, 1316
SensaScope, 90t, 9495, 94f
services, of MedicAlert Foundation, 180
Shikani Optical Stylet, 90, 90t, 91f, 93f
single-lumen tube (SLT), 6366, 6768
size, of ETT, 49
SLT. See single-lumen tube
sniffing position, 2, 3f, 7, 2729, 28f, 30f
solid intubating stylets, 14041
sphenopalatine nerve block, 21, 21f
stylets. See specific stylets
sufentanil, 14
superior laryngeal nerve block, 2324, 23f
supraglottic airway devices (SADs), 12, 7, 172
advantages of, 4748
dimensions of, 50t
disadvantages of, 4748
insertion techniques of, 4855
introduction to, 47
intubation with, 5561
objectives of, 47
summary of, 61
supraglottic airway device (SAD) combination
techniques, 14750
SAD/FOB/AEC, 14849
SAD/HFJV, 150
SAD/intubation catheter/lightwand, 148
SAD/RI, 150
supraglottic airway device/flexible fiberoptic
laryngoscopy/airway exchange catheter
(SAD/FOB/AEC), 14849
supraglottic airway device/high frequency jet

ventilation (SAD/HFJV), 150
supraglottic airway device/intubation catheter/
lightwand, 148
supraglottic airway device/retrograde intubation
(SAD/RI), 150
Surch-Lite, 88
surgical cricothyrotomy, 12831
thyroid cartilage, 11010, 111f, 119, 127, 127f
tolerance, to ETT, 42
topicalization techniques, 1720
Torque Control Blocker (TCB) Univent, 66
translaryngeal-guided intubation, 109
transtracheal anesthesia, 2425, 24f, 25f
transtracheal catheter, 121f
transtracheal jet ventilation (TTJV)
anatomy of, 119, 120f
commercially available devices of, 122
contraindications to, 118
CTM with, 119, 120
Enk Oxygen Flow Modulator Set, 122
ETT with, 117
FOB with, 150
Manual Jet Ventilator, 122
Manujet III, 122
mechanism of, 11718
objectives of, 117
pressure for, 12022, 121f
summary of, 12223
technique for, 120
Troop Elevation Pillow, 29
TruFlex Stylet, 76, 87, 88f
Truview EVO 2, 81, 81f
Truview PCD, 81, 160, 161f
TTJV. See transtracheal jet ventilation
Tube-Stat Lighted Stylet, 88, 90t
Tuohy needle, 11213
two-handed mask ventilation, 38
UES. See upper esophageal sphincter
ultrasound, 6
Unique, 48, 49f
Univent, 66, 66f, 140
upper esophageal sphincter (UES), 49
ventilation. See also mask ventilation
one lung, 63, 6668
191
Index
retrograde intubation (RI) combination

techniques
retrograde/DL, 151
retrograde/FOB, 150
retrograde/FOB/SAD, 151
RI. See retrograde intubation
Ring-Adair-Elwyn, 159
Rotigs, 1024, 103f
Rusch Easytube, 53, 54f, 55
Index
192
verbal dissemination, of information, 177, 179

video laryngoscopes (VLs), 63, 7281
Airtraq, 7780, 79f
Berci-Kaplan DCI, 72
C-MAC, 7273, 73f, 146
D-Blade, 72, 73f
GlideScope, 7377
GlideScope Advanced Video Laryngoscope
(AVL), 74, 75f
GlideScope Direct Intubation Trainer, 7475, 76f
GlideScope Ranger, 74, 76f
GlideScope Video Laryngoscope (GVL), 74, 146
King Vision Video Laryngoscope, 80, 80f, 149
McGrath Mac, 77
McGrath Video laryngoscopes, 77, 78f, 146
Pentax-AWS airway scope, 77, 78, 79f, 80
Videolaryngoscope Stylets, 87
video laryngoscopy combination techniques, 14647

video laryngoscopy/fiberoptic stylet, 147
video laryngoscopy/flexible fiberoptic laryngoscopy
(VL/FOB), 14647
video laryngoscopy/intubating catheter
(VL/intubating catheter), 146
Video RIFL Scope, 90t, 94, 95f
Vital Signs Light Wand Illuminating Stylet, 88, 90t
VL/fiberoptic stylet. See video laryngoscopy/
fiberoptic stylet
VL/FOB. See video laryngoscopy/flexible fiberoptic
laryngoscopy
VL/intubating catheter. See video laryngoscopy/
intubating catheter
VLs. See video laryngoscopes
Williams airway, 102, 102f

The Difficult Airway

Enviado por

Dados do documento

Direitos autorais

Formatos disponíveis

Compartilhar este documento

Compartilhar ou incorporar documento

Opções de compartilhamento

Você considera este documento útil?

Este conteúdo é inapropriado?

Direitos autorais:

Formatos disponíveis

The Difficult Airway

Enviado por

Direitos autorais:

Formatos disponíveis

The Difficult Airway: A Practical Guide

This page intentionally left blank