Objectives

• To discuss the basic knowledge on airway management

• To review the different techniques used in general anesthesia

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 Introduction
• Management of the airway is paramount to safe perioperative care.
• Following a series of evaluation procedures affects outcomes in a
favourable way.

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 General Anesthesia
• Types:
• GETA
• GA-LMA
• GEN MASK
• GA-TRACH
• GA-NASOTRACH
• GEN IV/TIVA

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 Components of General Anesthesia
UNCONSCIOUSNESS AMNESIA
Awareness Sedation/Anxiety

BALANCED ANESTHESIA

ANALGESIA IMMOBILITY
Pain Muscle Relaxation

ATTENUATION OF AUTONOMIC RESPONSES

TO NOXIOUS STIMULATION
Autonomic Stabilization

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Pre-operative Assessment
• Essential for the safety of anesthesia
• Brief history and PE
• Risk Assessment (Co-morbidities, previous anaesthetic procedure, risk of MH)
• Diagnostics
• Proposed an plan suited for the planned procedure
 ASA PS Classification (October, 2014)
• ASA I
• Definition: A normal healthy patient
• Examples, including, but not limited to:
• Healthy
• Non-smoking
• No or minimal alcohol use

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 ASA PS Classification (October, 2014)
• ASA II
• Definition: A patient with mild systemic disease
• Examples, including, but not limited to:
• Mild diseases only without substantive functional limitations
• Current smoker
• Social alcohol drinker
• Pregnancy
• Obesity ( BMI: 30 to 40 kg/cm2)
• Well-controlled DM/HPN
• Mild lung disease

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 ASA PS Classification (October, 2014)
• ASA III
• Definition: A patient with severe systemic disease
• Examples, including, but not limited to:
• Substantive functional limitations
• One or more moderate to severe diseases
• Poorly-controlled DM/HPN
• COPD
• Morbid Obesity (BMI: ≥ 40)
• Active hepatitis

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 ASA PS Classification (October, 2014)
• ASA III
• Definition: A patient with severe systemic disease
• Examples, including, but not limited to:
• Alcohol dependence or abuse
• Implanted pacemaker
• Moderate reduction of ejection fraction
• ESRD undergoing regularly scheduled dialysis
• Premature infant PCA < 60 weeks
• History (> 3 months) of MI, CVA, TIA, or CAD/stents

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 ASA PS Classification (October, 2014)
• ASA IV
• Definition: A patient with severe systemic disease that is a
constant threat to life
• Examples, including, but not limited to:
• Recent (< 3 months) MI, CVA, TIA, or CAD/stents
• Ongoing cardiac ischemia or severe valve dysfunction
• Severe reduction of ejection fraction
• Sepsis
• DIC
• ARD or ESRD not undergoing regularly scheduled dialysis

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 ASA PS Classification (October, 2014)
• ASA V
• Definition: A moribund patient who is not expected to
survive without the operation
• Examples, including, but not limited to:
• Ruptured abdominal/thoracic aneurysm
• Massive trauma
• Intracranial bleed with mass effect
• Ischemic bowel in the face of significant cardiac pathology or multiple
organ/system dysfunction

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 ASA PS Classification (October, 2014)
• ASA VI
• Definition: A declared brain-dead patient whose organs are
being removed for donor purposes

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 ASA PS Classification (October, 2014)
•E
• A suffix “E” is added to denote an emergency procedure.

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 Assessment of the Airway

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 Airway Assessment
• Mouth Opening (Interincisor Distance)
• Upper Lip Bite Test
• Mallampati Classification
• Thyromental Distance
• Neck Circumference
• Atlanto-Occipital Joint Extension

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 Mouth Opening
• An incisor distance of 3 cm
or greater is desirable in an
adult

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 Upper Lip Bite Test
• Ability to Prognath
• The lower teeth are brought
in front of the upper teeth
• The degree to which this can
be done estimates the range
of motion of the
temporomandibular joints

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 Mallampati Classification

• Class I: uvula, faucial pillars, soft palate, hard palate

• Class II: faucial pillars, soft palate, hard palate
• Class III: soft and hard palate
• Class IV: hard palate
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 Thyromental Distance
• The distance between the mentum
and the superior thyroid notch.
• A distance greater than 3
fingerbreadths is desirable.

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 Neck Circumference
• A neck circumference of greater
than 27 inches is suggestive of
difficulties in visualization of the
glottic opening.

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 Atlanto-Occipital Joint
Extension
• “Sniffing” Position
• Assesses the feasibility to make
the optimal intubation position
with alignment of oral, pharyngeal
and laryngeal axes into a straight
line

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 Practical Approach to the OR

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 What can I do when the patient arrives to the
operating room?
• ALWAYS ACCOMPANY THE PATIENT FROM WARDS TO OR TABLE
• Establish a working and patent intravenous line
• Baseline vital signs
• Monitors attached including an ECG, NIBP, and pulse oximeter

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 Pre-anesthetic Check List
• “SAMMM”
• SUCTION: Suction tip connected to a suction tubing and suction
machine functioning.
• AIRWAYS: Laryngoscope, blades, ETT, syringe, stylet, oral and
nasal airways, tape, mask, and manual resuscitation bag.
• MACHINE: Wall-source medical gas pipelines connected, N2O &
O2 cylinder and pipeline pressures OK, machine turned-on flow-
meters functioning, O2 flush functioning, N2O and O2
proportioning device functioning, oxygen pipeline disconnect
whistle functioning
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 Pre-anesthetic Check List
• “SAMMM”
• MONITORS: Capnograph connected to circuit and
functioning. ECG, BP cuff, pulse oximeter, peripheral nerve
stimulator, and temperature probe monitors available and
working.
• MEDS: Intravenous fluids and equipment for starting i.v.
prepared. Emergency medications as per staff
anaesthesiologist where appropriate, (e.g. Atropine,
Ephedrine, etc.).
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 Anatomy of the Airway

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 Department of Anesthesia – Ospital ng Maynila Medical Center - Department of Anesthesia – Ospital ng Ma
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 Airway Anatomy
• LARYNX
• The laryngeal skeleton consists of nine
cartilages:
• PAIRED: Arytenoid, Corniculate, Cuneiform
• UNPAIRED: Thyroid, Cricoid, Epiglottic
• Together, these house the vocal folds, which
extends in an anterior-posterior plane from the
thyroid cartilage to the arytenoid cartilages

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 Airway Anatomy
• LARYNX, two groups of muscles:
• Extrinsic Muscles, which move the larynx as a
whole
• Intrinsic Muscles, which move the various
cartilages in relation to one another

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 Airway Anatomy
• EPIGLOTTIS
• Located at the base of the tongue
• Functionally separates the oropharynx from the
laryngopharynx (or hypopharynx)
• Prevents aspiration by covering the glottis
during swallowing

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 Airway Anatomy
• TRACHEA
• Inferiorly, it is suspended from the cricoid
cartilage by the cricotracheal ligament
• Measures approximately 15 cm in adults and is
circumferentially supported by 17 to 18
C-shaped cartilages, with a membranous
posterior aspect overlying the esophagus
• In the adult, first tracheal ring is anterior to the
C6 vertebra
• It ends at the CARINA, opposite the T5 vertebra

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 Airway Anatomy
• Anatomic differences between the Pediatric and Adult
airways:
ADULT PEDIATRIC
SIZE Bigger Smaller
NARROWEST Vocal Folds/Glottic Opening Cricoid Cartilage
LEVEL OF THE LARYNX C4 to C6 C3 to C5
EPIGLOTTIS Shorter; Broad Longer; Narrower; Stiffer
ARYEPIGLOTTIC FOLDS Far Closer
LARYNGEAL CARTILAGE Stiffer Pliable
PATENCY More resistant to trauma More vulnerable to trauma

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 Pediatric
Airway

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 Adult
Airway

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 Three Phases of General Anesthesia
• Induction
• Maintenance
• Emergence

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 5 Steps in Tracheal Intubation
• Patient positioning
• Opening the patient’s mouth
• Performing laryngoscopy
• Insertion of the endotracheal tube (ETT) through the vocal
cords and removing the laryngoscope
• Confirmation of correct placement, and securing the ETT

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 Patient Positioning
• Relative alignment of the oral, pharyngeal and laryngeal axes
is achieved by having the patient in the “sniffing” position
• When cervical spine pathology is suspected, the head must
be kept in a neutral position during airway manipulations
• IN-line stabilization of the neck must be maintained during
airway management in these patients

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 Opening the Patient’s Mouth
• Take the laryngoscope in your LEFT HAND as you stand
directly behind the patient’s head
• The right hand is used to open the patient’s mouth and,
later, to advance the ETT

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 Opening the Patient’s Mouth

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 Opening the Patient’s Mouth

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Macintosh vs Miller
Cormack-Lehane Classification
 Laryngoscopy

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 ETT Insertion
• LEFT HAND: Controlling the laryngoscope blade
• RIGHT HAND: Opens the mouth and then passes the ETT tip
through the laryngeal inlet
• When the epiglottis partially obscures the view of the
glottis, an assistant may be used to apply cricoid pressure

•BURP
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 ETT Insertion
• ETT cuff is inflated with enough air to create a seal around
the ETT during positive pressure ventilation
• Cuff leak may be detected by listening at the patient’s
mouth, or over their larynx

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 Confirmation of Correct ETT Placement
• GOLD STANDARD: ETCO2
• Other Techniques:
• Visualization through the ETT using a fiberoptic scope
• Using the 5-point auscultation by listening to the epigastrium for
the absence of breath sounds and lung fields for breath sounds
with ventilation
• Observing the chest to rise and fall with positive pressure
ventilation
• Direct visualization by laryngoscopy
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 Confirmation of Correct ETT Placement
• Points of Auscultation

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 Department of Anesthesia – Ospital ng Maynila Medical Center - Department of Anesthesia – Ospital ng Ma
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 Hope You Learned Something!

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