Airway Management

Herwin B. Bautista Department of Anesthesia

Anatomy
Two openings of the airway

1. nasopharynx 2. oropharynx Hypopharynx - comprises your larynx - composed of nine cartilages

sagittal-section of Trachea

 9 Cartilages

a. thyroid (paired) b. cricoid (paired) c. epiglottic (paired) d. aretynoid e. corniculate f. cunieform

Nerve supply
Sensory
Mucuos membrane

- anterior ethmoidal nerve (anteriorly) - sphenopalatine nerve (posteriorly Hard and soft palate - palatine nerve

 Tongue

- lingual nerve (anterior 2/3) - glossopharyngeal nerve (posterior 3rd) Roof of the pharynx, tonsils, soft palate - glossopharyngeal nerve Larynx between epiglottis and vocal cords - internal laryngeal nerve

 Larynx below vocal cords to the trachea

- recurrent laryngeal nerve Motor

All muscles of the larynx (except cricothyroid)

- recurrent laryngeal nerve Cricothyroid - external laryngeal nerve

Nerve injuries
Bilateral superior laryngeal nerve

- hoarseness or easy tiring of the voice Unilateral recurrent laryngeal nerve - ipsilateral paralysis of the vocal cords - deterioration of voice quality Bilateral recurrent laryngeal nerve - stridor and respiratory distress

Blood supply
Branches of the carotid artery

thyroid artery superior thyroid artery cricothyroid artery

Equipment
Oral and Nasal airway
Face Mask Laryngeal mask airway (LMA)

Endotracheal tubes
Rigid laryngoscopes Flexible fiberoptic bronchoscopes

Intubation techniques
Orotracheal intubation
Nasotracheal intubation Flexible fiberoptic intubation

Retrograde intubation

Complications
During laryngoscopy and intubation

I. Malpositioning a. esophageal intubation b. endobronchial intubation c. laryngeal cuff position

II. Airway trauma a. tooth damage b. lip, tongue, or mucosal laceration c. dislocated mandible d. sore throat e. retropharyngeal dissection

III. Physiologic reflexes a. hypertension, tachycardia b. intracranial hypertension c. intraocular hypertension d. laryngospasm IV. Tube malfunction a. cuff perforation

 While the tube is in place

I. Malpositioning a. unintentional extubation b. endobronchial intubation c. laryngeal cuff position II. Airway trauma a. mucosal inflammation and ulceration b. excoriation of nose

III. Tube malfunction a. ignition b. obstruction

Following extubation

I. Airway trauma a. edema and stenosis (glottic, tracheal) b. hoarseness (vocal cord paralysis) c. laryngeal malfunction and aspiration

II. Physiologic reflexes a. laryngospasm

Techniques of extubation
When to extubate?

deep or awake effects neuromuscular blocking agents role of lidocaine Thorough suctioning is mandatory 100 % oxygen after extubation

Difficult airway
Mallampati scoring

Class I - uvula, hard and soft palate, pillars Class II - hard and soft palate, pillars Class III - hard and soft palate Class IV - hard palate

Conditions associated with Difficult intubation

Tumors
Infection Congenital anomalies

Foreign body
Trauma Obesity

Inadequate neck extension

Anatomic variations

Difficult airway algorithm

1. Assess the likelihood and clinical

impact of basic management problems A. difficult intubation B. difficult ventilation C. difficult with patient cooperation and consent

 2. Consider the relative merits and

feasibility of basic management choices A. initial approach to intubation - surgical vs. non-surgical B. level of consciousness - awake vs. anesthetized C. spontaneous ventilation - spontaneous vs. paralyzed

 3. Develop primary and alternative strategies

A. Awake intubation
Airway approach by Non-surgical intubation airway secured by surgical access

Succeed

Fail

Cancel case

consider feasibility of other options

surgical airway

 B. Intubation after induction of General

Anesthesia
Initial intubation attempts successful initial intubation attempts unsuccessful
consider the advisability of 1. return to spontaneous ventilation 2. awakening the patient 3. calling for help

NON-EMERGENCY PATHWAY
Patient anesthetized, intubation unsuccessful MASK VENTILATION ADEQUATE Alternative approaches to intubation Succeed FAIL after multiple attempts Surgery under awaken mask anesthesia patient

Surgical airway

EMERGENCY PATHWAY
Patient anesthetized, intubation unsuccessful MASK VENTILATION IS INADEQUATE

Call for help

One more intubation attempt

Emergency non-surgical airway ventilation

Succeed

FAIL

FAIL

Succeed definitive airway

Emergency surgical airway