Chapter 16

Face Masks and Airways

P. 444


Face Masks
The f ace mask al l ows gas admi ni strati on t o the pat ient f rom the breathi ng system
wi thout i nt roduci ng any apparatus into the pat ient' s mouth. The abi l i ty t o hol d the
mask and to admi ni st er posi ti ve pressure venti l at ion through the mask i s a basi c
ski l l that all anest hesi a providers must master. In t he past , the face mask was of ten
been used to admi ni ster an ent i re anestheti c. More recentl y, t he i ntroducti on of
supraglott ic ai rway devices (Chapter 17) has l ed to a decrease in thi s practi ce.
Whi le some supragl ot ti c ai rway devi ces have the word mask i n t hei r ti tl es, they are
very di ff erent f rom f ace masks and are deal t wi th separat el y i n Chapter 17.
The f ace mask is al so used to admini ster noni nvasive posi ti ve pressure vent il ati on
(NPPV) f or treat ment of respi ratory fai l ure (1, 2).
Description
A f ace mask may be const ructed of a number of substances, i ncl udi ng bl ack rubber,
cl ear plast ic, an el ast omeric mat erial , or a combi nat ion of these. The maj ori t y of
anesthet ics today empl oy a di sposabl e pl ast i c mask. These masks are desi gned t o
f i t a wi de vari ety of pat ients and are not as easy to use as many ol der masks that
were si zed and anatomical ly desi gned to f i t a narrower range of pati ents.
Body
The body (shel l , dome) const i tutes t he mai n part of the mask (3). A t ransparent
body al l ows observati on for vomi tus, secreti ons, bl ood, l i p col or, and exhal ed
moi st ure. A transparent mask may be bet ter accepted by a conscious pat i ent (4).
Seal
The seal (ri m, f lap, edge) i s the part of the mask that comes i n contact wi th t he
f ace. Two general types are avai l abl e. One i s a pad (cushi on) t hat is i nf lat ed wi th
ai r or f i l l ed wi th a materi al that wi l l conform to t he face when pressure i s appl i ed.
The second t ype i s a f l ap t hat i s a f l exi bl e extension of the body that conforms t o
t he cont our of the face. I t is pressed onto the face to creat e a seal .
Connector
The connector (ori f i ce, col lar, mount) is at the opposi t e si de f rom t he seal . I t
consi sts of a thickened f i tt i ng wi t h a 22-mm i nternal di ameter. A ring wi t h hooks
(Fi g. 16.1) may be pl aced around t he connector t o al l ow a mask st rap to be
at tached.
Specific Masks
Masks come i n a vari et y of si zes and shapes (Figs. 16.1, 16.2). An assortment
shoul d be kept readi l y avail abl e, because no one wi l l f i t every f ace wel l .

View Figure

Figure 16.1 Clear, disposable masks. (A, Picture courtesy
of Kendall; B, Courtesy of Rusch, Inc.)

P. 445



View Figure

Figure 16.2 Black rubber masks. (Courtesy of Sun Med.)

Rendell-Baker-Soucek Mask
The Rendel l -Baker-Soucek (RBS) mask (Fi g. 16.3), whi ch i s desi gned for t he
pediatric pati ent , has a t ri angul ar body. I t has a l ow dead space (5,6). Some of
t hese masks are scented and may have a pacif i er (Fi g. 16. 3B). Thi s mask has been
used for the pati ent wi t h a t racheost omy (7,8, 9) and a pati ent wi t h acromegal y (10).
I t may al so be usef ul when a mask to cover onl y the nose i s needed (11).
Endoscopi c Masks
An endoscopi c mask i s desi gned to al low mask venti lat i on whi le an endoscope i s
bei ng used (12,13,14, 15). One is shown i n Fi gure 16. 4. A port /di aphragm i n the
mask body al l ows a f i berscope to be i nsert ed into the nose or mout h. A l i ght ed
st yl et (Chapter 19) may al so be used (16). A t racheal tube previousl y loaded over
t he f i berscope or l ighted styl et can t hen be advanced, i f desi red.
Scented Masks
Si nce f ace masks are of ten used f or an i nhalati on anesthesi a induct i on or f or
preoxygenati on pri or to i nducti on, ef forts have been made to make t hi s experi ence
more acceptabl e by usi ng scents to camoufl age the odors of i nhalati onal agents
(17,18,19, 20, 21,22,23, 24). The scent may be incorporated i nt o the mask by the
manuf acturer or appli ed to the mask by the anesthesi a provi der (Fi g. 16.5). Some
masks are col or coded accordi ng to the scent . The ethyl al cohol i n some appl i ed
f rui t f lavors may af f ect the accuracy of some gas moni tors (25,26). Pre-scented
masks f rom the manufacturer do not present t hi s probl em (25).
Techniques of Use
The f ace mask should f orm a ti ght seal on the pati ent ' s face whi l e f i t ti ng
comf ortabl y i n the user' s hand. A proper seal is essenti al ly f or preoxygenati on
(27,28). A poor f i t requi res the anesthesi a provi der t o mai ntai n steady pressure.
Thi s may l ead to cramped hands and ti red muscl es and l i mi ts the user' s abi l i ty t o
perf orm other t asks. Wi th spont aneous respi rat i on, a l oose seal wi l l resul t i n
P. 446

ai r di l uti on. Wi th assi sted or cont rol l ed venti l ati on, adequate gas exchange may be
i mpossible wi th a poor mask f i t . An i nadequat e seal can be compensated for some
extent by i ncreasi ng t he f resh gas f l ow, but this i s wast ef ul and cont ami nat es the
room wi t h anestheti c gases and vapors.

View Figure

Figure 16.3 Rendell-Baker-Soucek masks. A: Clear plastic
version. (Courtesy of Rusch, Inc.) B: With pacifier.
(Courtesy of Ohio Medical Products, a division of Airco,
Inc.) C: They are also available in black rubber.


View Figure

Figure 16.4 Endoscopic masks. (Pictures courtesy of VBM
Medical, Inc.)

Correct mask use start s wi th sel ecti on of t he appropri ate si ze and shape. This may
requi re some t rial and error. The smal l est mask that wi l l do t he job i s the most
desi rabl e because i t wi l l cause the l east i ncrease i n dead space, usuall y be easiest
t o hol d, and wi l l be l ess l ikel y t o resul t i n pressure on the eyes. If a seal is dif fi cul t
t o establ ish, reshaping the mark' s mal l eable peri meter, al teri ng t he amount of ai r i n
t he seal or selecti ng a di ff erent mask may be hel pf ul . If t here is a l eak, the mask
shoul d be checked t o make certai n there i s an adequate seal bet ween t he breat hi ng
system connector and t he mask (29).
One-hand Method
There are several methods of hol ding a mask to mai ntai n an open ai rway and a
t i ght seal . A commonl y used method i s shown i n Fi gure 16. 6. The t humb and i ndex
f inger on the l ef t hand are pl aced on the mask body on opposi te si des of the
connector. These fi ngers push downward t o hol d the mask to t he f ace and prevent
l eaks. Addi ti onal downward pressure, i f requi red, can be exert ed by the anesthesia
provi der' s chi n pushi ng down on the mask el bow. The remai ni ng t hree f i ngers are
pl aced on the mandi ble or the i nf eri or part of the mask. I t i s i mport ant that the
appli ed pressure does not decrease ai rway patency. Care shoul d be taken to
prevent pressure on t he eyes. I n some cases, i t may be necessary to extend the
f ingers t o the ri ght si de of the mask to get a good seal . It may be benef i cial to
gather part of the lef t cheek around the l ef t base of the mask wi th the pal m of the
l ef t hand.

View Figure

Figure 16.5 Adding scent to the face mask may make
inhalational inductions more pleasant.

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View Figure

Figure 16.6 Holding the mask with one hand.

Two-handed Method
A second method can be used to open any but the most di f f i cul t ai rway and obtai n a
t i ght fi t (Fi g. 16.7). It requi res t wo hands, so a second person i s necessary i f
assi sted or control led respi rati on i s needed. The thumbs are pl aced on ei ther si de
of t he mask body. The index f i ngers are pl aced under the angl es of t he jaw. The
mandible i s li f t ed and t he head ext ended. If a leak is present, downward pressure
on the mask can be i ncreased by pressing down on the mask wi th t he anesthesi a
provi der' s chi n on the mask elbow (Fi g. 16.7B). If a second person i s not avail able,
t he anesthesi a venti lat or can be used t o suppl y posi ti ve pressure whi l e the ai rway
i s hel d open by both hands (30).
Two-handed Jaw Thrust
Another method to open the ai rway i s t o have one person stand at the head of the
pati ent and perf orm a j aw thrust at t he angle of the l ef t mandi bl e whi l e the ri ght
hand compresses the reservoi r bag (31). The second person stands at t he pati ent 's
shoul der, faci ng the f i rst person. This second person' s ri ght hand covers the l ef t
hand of the fi rst person, and t he lef t hand achieves ri ght-si ded j aw t hrust and mask
seal .
Claw Hand Technique
The claw hand techni que i s useful for chi ldren undergoi ng short -durat i on
ophthal mi c procedures (32). The anesthesi a provider stands at the si de of the bed,
P. 448

f aci ng the chi ld. The f ace mask i s appl i ed to t he f ace by usi ng t he ri ght hand wi th
t he pal mer surf ace f aci ng upward. The ri ng f inger goes under the angl e of the j aw,
and the mi ddl e f i nger is pl aced under the angl e of the j aw on t he lef t . The i ndex
f inger and t humb enci rcl e the body of t he mask. The anest hesi a provi der then
t i ghtens the gri p on the mask to achieve a good f i t . The l i tt le f inger i s kept f ree.

View Figure

Figure 16.7 A: Holding the mask with two hands. Also
shown is the Esmarch-Heiberg maneuver, which involves
dorsiflexion at the atlanto-occipital joint and protrusion of
the mandible anteriorly by exerting a forward thrust on the
rami. B: The anesthesiologist's chin on the mask elbow
helps to create a better seal between the mask and the
patient's face.

Bearded Patient Techni ques
Achievi ng a sat isf actory mask f i t i s of ten dif f icul t when the pati ent has a beard. One
solut i on is t o shave the beard (33). Thi s is usual l y not acceptable to t he pati ent .
Another sol ut ion i s t o use a supragl ot ti c ai rway devi ce (34).
I n some cases, i t may be possi bl e to pl ace the round end of the mask bet ween t he
l ower l i p and the alveol ar ri dge (35). The beard may be covered wi th a cl ear
adhesive drape, a def ibri ll ator pad wi t h a hole cut i n the mi ddl e, pl asti c cli ng wrap,
or gel and gauze (36, 37,38,39, 40, 41,42,43). A smal l mask can be pl aced over the
nose and the mouth hel d shut (44).
Mask Venti lati on of the Tracheostomy Stoma
A Rendell -Baker-Soucek mask can be used over a tracheotomy stoma to achi eve
control led or assisted vent il ati on (8,9). It i s pl aced around the stoma wi th t he nasal
port ion pointi ng i n a caudal di recti on so that t he mandibular curve rests on t he
t racheal region and the apex on the suprasternal notch.
Difficult Face Mask Ventilation
Di ff icul t mask vent il at ion i s reported t o occur i n 5% to 6% of anestheti cs (45,46,47).
A variety of f aci al characteri sti cs (fat, emaci ated, and edentul ous f aces as wel l as
t hose wi th promi nent nares, burns, f lat noses, receding j aws) or other problems
(drai nage tubes i n t he nose) wi l l be encountered in cl i ni cal practi ce. Predictors of
di ff i cul t mask vent il at i on incl ude male gender, a beard, lack of t eet h, age over 55
years, macrogl ossia, hi gh body mass index, a history of snori ng, increased
Mal lampat i score, and l ow t hyromental di stance (46,47).
A hi story of sleep apnea does not seem to be a predicti ve si gn of dif f i cul t mask
venti l ati on (48). The ai rway i n t hese pati ents may be i mproved by pl acing t he head
i n the snif f i ng posi ti on (49).
The edentul ous pati ent presents the most common problem. There is l oss of bone
of t he al veol ar ri dge, causi ng a l oss of di stance between the points where the mask
rests on the mandi ble and the nose. Furt hermore, the bucci nator muscl e l oses i ts
t one i n t hese pati ents. The cheeks sag, creat i ng gaps between them and the mask.
Al veolar process resorpti on resul ts i n shrinking at the corners of the mouth. Means
t o i mprove mask f i t incl ude i nserti ng an oral ai rway, l eavi ng the pati ent ' s dentures
i n place, packi ng t he cheeks wi th gauze sponges, and i nsert i ng t he i nf eri or margi n
of t he mask between the gingiva of the mandi bl e and the lower l i p (50,51).
Pat i ents wi t h faci al def ormi t ies are part icularl y chal l engi ng. Mask appl icati on wi th
t he nasal proj ect ion pointed i nf eri orl y has been used f or chi l dren wi t h certai n f aci al
deformi ti es (3) and for pati ents wi t h acromegal y (10).
I f the mask is t oo smal l wi th an oral ai rway i n pl ace, the oral ai rway shoul d be
removed and a nasal ai rway used. If a mask i s too l ong, t he mouth can be
el ongated by inserti ng an oral ai rway.
I f mask venti l at ion i s necessary f or t he patient who has a nasogast ri c tube in pl ace,
t here i s usual l y a l eak around the tube as i t exi ts the si de of t he mask. Thi s l eak
can be i mproved by addi ng denture adhesi ve around t he tube at the poi nt where i t
exi ts the mask (52).
Dead Space
The f ace mask and i ts adapt or normal l y const i tute the maj or part of t he mechanical
dead space. Dead space may be decreased by increasi ng t he pressure on the
mask, changi ng the vol ume of the cushi on, using a smal l er mask, extendi ng the
separati on between t he i nspi ratory and expi ratory channel s cl ose t o or i nto t he
mask, or bl owi ng a j et of f resh gas i nt o the mask. The l eak i nduced wi th a poorl y
f i t ti ng f ace mask wi l l reduce the dead space of the breathi ng system duri ng
spontaneous venti lati on (53).
Mask Straps
A mask st rap (mask hol der, inhal er retai ner, head st rap, head harness, mask
harness, mask retai ner, headband, head-restrai ni ng strap) is used to hold t he mask
f i rml y on the face. Part icul ar care needs to be paid t o maintai ni ng the ai rway when
using a mask strap because obst ructi on i s more l ikel y to go unrecogni zed t han
when t he mask i s bei ng held by t he anesthesi a provi der' s hand.
A typical mask strap (Fig. 16.8) consi sts of t hin stri ps arranged i n a ci rcle wi th t wo
or f our proj ecti ons. The head rests i n the circl e, and t he st raps attach around the
mask connect or. The st raps at the j aw may t end to pul l the j aw posteri orl y.
Crossi ng t he two l ower straps under t he chi n may resul t i n a better f i t and
counteract the pul l f rom the upper straps so t hat there i s less tendency f or t he
mask t o creep up above the bri dge of the nose (54). The best st rap appl i cati on i s a
mat ter of i ndi vi dual preference and may be t he best resul t of a tri al -and-error
process (55).
Care must be t aken that the straps are no ti ghter t han necessary to achi eve a seal
i n order to avoi d pressure damage f rom t he mask or t he st raps. They shoul d be
rel eased peri odi cal l y and the mask moved sl i ghtl y. Gauze
P. 449

sponges placed bet ween t he st raps and the ski n wi l l help t o protect the face f rom
excessive pressure. Another ri sk of usi ng a mask st rap is t hat i t wi l l take longer t o
remove the mask i f vomi t ing or regurgi t ati on occurs.

View Figure

Figure 16.8 Mask straps.

Advantages
Usi ng a f ace mask i s associ ated wi t h a l ower i nci dence of sore throat and requi res
l ess anesthet ic depth t han using a supragl ot ti c devi ce or a t racheal tube. Muscl e
rel axants do not need to be used to tol erate t he mask. The f ace mask may be the
most cost -eff i ci ent met hod t o manage the ai rway f or short cases (56).
Disadvantages
Wi th a face mask, one or more of the anesthesi a provider' s hands are i n conti nuous
use, and hi gher f resh gas fl ows are of ten needed. Duri ng remote anesthesi a
(magnet i c resonance i maging and computeri zed t omography scanning) ai rway
access i s di ff i cul t. Compared wi t h pat ients who are managed wi th a supraglott ic
ai rway devi ce, pat ients who are managed wi th a face mask have more episodes of
oxygen desaturati on, requi re more i nt raoperat ive ai rway mani pul at i ons, and present
more dif f icul t i es in mai ntai ni ng an ai rway (57, 58). I n spontaneousl y breat hi ng
pati ents, the work of breathi ng is hi gher wi t h a face mask than wi th a supragl ottic
ai rway devi ce or a t racheal tube (59). Usi ng an ai rway and/or cont i nuous posi t ive
pressure wi l l reduce t he work of breat hi ng.
Complications
Skin Problems
Dermat i t is may occur i f the pat i ent i s al lergi c to t he materi al f rom which the mask i s
made (60). The patt ern of the dermati ti s f ol l ows t he area of contact bet ween t he
mask and ski n. Chemical or gas steri l izati on of reusabl e masks can l eave a resi due
t hat can cause a ski n reacti on (61,62). Pressure necrosis under t he f ace mask has
been report ed f ol l owi ng prol onged mask appl i cat i on in t he presence of hypotensi on
(1).
Nerve I njury
Pressure f rom a mask or mask st rap may resul t i n pressure i njury t o underl yi ng
nerves. Forward j aw di spl acement may cause a stretchi ng nerve i njury. Fortunatel y,
t he sensory and motor dysfunct ions report ed have been t ransi ent
(63,64,65, 66, 67,68). If excessi ve pressure on the f ace or extreme f orward j aw
di spl acement must be exert ed, tracheal i ntubati on or a supraglott ic ai rway device
shoul d be consi dered. The mask shoul d be removed f rom t he f ace peri odi cal l y and
readj ust ed to make certain t hat cont inuous pressure i s not appl i ed to one area.
Forei gn Body Aspiration
The di aphragm of an endoscopi c mask may rupture duri ng tracheal t ube i nsert i on,
and a pi ece may be pushed int o the pat ient' s tracheobronchi al t ree (69, 70,71,72).
Ot her parts of a mask or mask st rap may be aspi rated (73,74).
Gastri c I nflation
When posi ti ve pressure venti l at ion i s used wi t h a f ace mask, gases are li kel y t o
enter t he st omach (75,76). I t i s recommended that i nspi rat ory pressure be kept
bel ow 20 cm H
2
O (75).
Eye I njury
A corneal abrasi on may be caused by a f ace mask i nadvertentl y pl aced on an open
eye (77). Chemi cals t hat enter the mask cushi on duri ng cl eani ng and di si nf ecti on
can be expel l ed f rom cracks i n the cushi on and come into contact wi th t he eye
when t he mask i s appl i ed to the f ace (78,79, 80,81). Pressure on the medi al angles
of t he eyes and supraorbi tal margi ns may resul t i n eyel i d edema, chemosis of the
conjunctiva, pressure on t he supraorbi tal or suprat rochl ear nerve, corneal i njury,
and temporary bl i ndness f rom cent ral ret i nal art ery occl usi on (82).
Mask Defects
A mask wi th a pl ast i c membrane that occluded the connect or has been reported
(83). Another mask had a met al
P. 450

wi re st i cki ng out of i t (84). I ncorrect assembl y of a f ace mask has been report ed
(85).
Cervical Spi ne Movement
Most but not al l studi es show that mask vent i l at ion moves the cervi cal spine more
t han commonl y used methods of tracheal i nt ubat i on (86,87,88,89). Thi s may be of
si gni f icance i n the pati ent wi t h an unstabl e cervi cal spi ne i nj ury.
Latex Al lergy
I f rubber i s a component of a face mask, a seri ous reacti on can occur i n the pat ient
wi th l at ex al lergy (90,91). Thi s is di scussed more f ul l y i n Chapter 15. Because of
t he seriousness of t hi s probl em, non-l atex masks are recommended wherever
possi bl e.
Lack of Correlati on between Arterial and End-tidal Carbon
Dioxi de
The dif ference bet ween arteri al and end-ti dal carbon di oxi de l evels i s hi gher wi t h
f ace mask venti l at ion than wi t h a t racheal tube or supraglott i c devi ce, parti cul arl y
wi th smal l ti dal vol umes (92).
Environmental Poll ution
St udi es show t hat usi ng a face mask i s associ ated wi t h greater operati ng room
pol l ut ion wi t h anesthet i c gases and vapors than when a t racheal tube or
supraglott ic ai rway device i s used (93,94). Pol l ut ion can be reduced by usi ng a
cl ose acti ve scavengi ng device (95,96).
User Fatigue
Hol di ng a mask securel y ont o the f ace and at the same ti me maintai ni ng the correct
j aw posi ti on can be di f f icul t and may resul t i n operator f ati gue. Fai l ure to maintai n
t he correct j aw posi ti on may resul t i n loss of ai rway patency or gastric di stenti on.
Jaw Pain
Postoperati ve j aw pai n is more common af ter mask anesthesi a than when a
supraglott ic ai rway device i s used (97).
Airways
Purpose
A f undamental responsibil i ty of t he anesthesi a provi der i s t o maint ai n a patent
ai rway. Unl i ke other maneuvers t o mai ntai n a patent ai rway, such as chin l i f t , j aw
t hrust, and tracheal i ntubati on, cervi cal spine movement does not occur when an
ai rway i s i nsert ed (98).
Fi gure 16. 9A shows t he normal unobstructed ai rway i n a supine pati ent . The ai r way
passage has a ri gi d posteri or wal l , support ed by the cervical vertebrae, and a
coll apsible ant erior wal l , consisti ng of the tongue and epi glott i s. Fi gure 16. 9B
shows the most common cause of ai rway obst ructi on. Under anesthesi a, t he
muscles in t he f l oor of the mouth and pharynx support i ng t he tongue rel ax, and the
t ongue and epi gl ot ti s fal l back i nto the posteri or pharynx, occl udi ng the ai rway. The
purpose of an ai rway i s to l i f t the tongue and epi gl ot ti s away f rom t he posterior
pharyngeal wal l and prevent t hem f rom obstructi ng t he space above the l arynx.
Usi ng maneuvers such as dorsi f l exi on at the atl anto-occi pi tal j oi nt and prot rusi on of
t he mandi bl e anteri orl y may sti l l be necessary t o ensure a patent ai rway (99). An
oral or nasal ai rway decreases the work of breathi ng duri ng spontaneous breathing
using a f ace mask (59).

View Figure

Figure 16.9 A: The normal airway. The tongue and other
soft tissues are forward, allowing an unobstructed air
passage. B: The obstructed airway. The tongue and
epiglottis fall back to the posterior pharyngeal wall,
occluding the airway. (Courtesy of V. Robideaux, M.D.)

Types
Oropharyngeal Airways
Fi gure 16. 10 shows an oropharyngeal (oral ) ai rway i n pl ace. The bi te porti on i s
bet ween t he teeth and li ps, and the fl ange i s outsi de the l i ps. The pharyngeal end
rests bet ween the posteri or wal l of t he pharynx and the
P. 451

base of t he tongue and, by exert i ng pressure al ong t he base of the t ongue, al so
pul l s the epiglott is f orward.

View Figure

Figure 16.10 Oropharyngeal airway in place. The airway
follows the curvature of the tongue, pulling it and the
epiglottis away from the posterior pharyngeal wall and
providing a channel for air passage. (Courtesy of V.
Robideaux, M.D.)

I n addi ti on t o hel pi ng to mai ntain an open ai rway, an oropharyngeal ai rway may be
used to prevent a pat ient f rom bi ti ng and occl udi ng an oral t racheal tube, protect
t he tongue f rom bi ti ng, faci l i tate oropharyngeal suct i oni ng, obtain a bet t er mask f i t ,
or provide a pathway f or insert i ng devices into the esophagus or pharynx (100).
Oral ai rways have not been associ ated wi t h an i ncreased i nci dence of sore t hroat
or other symptoms (101,102) or bacteremi a (103).
Description
An oropharyngeal ai rway (Fi g. 16.11) may be made of el astomeri c materi al or
pl ast i c. I t has a f lange at t he buccal end to prevent i t f rom movi ng deeper i nto t he
mouth. The f l ange may also serve as a means t o f i x the ai rway i n pl ace. The bi t e
port ion i s st rai ght and f i ts bet ween t he teeth or gums. I t must be f i rm enough that
t he pat ient cannot close the l umen by bi t ing. The curved porti on extends backward
t o correspond to t he shape of the tongue and pal ate.

View Figure

Figure 16.11 Oropharyngeal airway. All oral airways have
a flange to prevent overinsertion, a straight bite block
portion, and a curved section.

The Ameri can nati onal standard (104) speci f i es that the si ze of oral ai rways be
designated by a number that i s the l engt h in centi meters (Fi g. 16.11).
Specific Airways
Guedel Airway
The Guedel ai rway (Fi g. 16. 12) has a l arge f lange, a rei nf orced bi te porti on, and a
t ubul ar channel . Modi f i cat i ons to aid f lexible f iberopti c i ntubati on have been
descri bed (105,106,107,108).
Berman Airway
The Berman ai rway (Fi gs. 16. 10, 16.11) has a center support and open si des. The
center support may have openi ngs. There i s a f l ange at the buccal end. The si de
openi ng can be opened wi der t o engage or di sengage a t racheal tube.
Patil-Syracuse Endoscopic Airway
The Pati l -Syracuse endoscopi c ai rway was desi gned t o aid f i beroptic i nt ubat ion
(109). I t has l ateral channel s and a central groove on the l i ngual surface to al l ow a
f iberscope wi th a t racheal tube to pass. A sl i t i n the di stal end al l ows the f i berscope
t o be mani pul ated in t he anteropost erior di recti on but
P. 452

l i mi ts l at eral movement (110). I t i s made f rom al umi num. The ai rway must be
removed f rom t he oropharynx bef ore a tracheal t ube can be advanced over t he
f iberscope and i nt o the glot t is.

View Figure

Figure 16.12 Guedel airways. The bite portions are color
coded to provide easy identification of size. (Courtesy of
Mercury Medical.)


View Figure

Figure 16.13 Williams airway intubators. (Courtesy of
Mercury Medical.)

Williams Airway Intubator
The Wi l l i ams ai rway i nt ubat or was desi gned f or bl i nd orotracheal i ntubati ons
(111, 112,113). It can also be used t o ai d f i beropt ic i ntubat i ons or as an oral ai rway
(114).
The ai rway, shown i n Fi gure 16.13, i s plasti c and avai lable i n two si zes, #9 and
#10, whi ch wi l l admi t up to an 8.0 or 8. 5 i nternal di ameter (I D) t racheal tube,
respecti vely. The t racheal tube connect or shoul d be removed duri ng i ntubati on,
because i t wi l l not pass through the ai rway unl ess the ai rway i s modif i ed (115). The
proxi mal half is cyl i ndri cal , whi l e t he di st al half i s open on i ts l i ngual surf ace.
A compari son of the Wi l l i ams ai rway i nt ubator wi t h t he Ovassapi an f i beroptic
i ntubat ing ai rway f ound that the Wil l iams ai rway i ntubator provi ded a bett er vi ew of
t he gl ott i s i n a si gni f i cant number of pati ents (116).
Ovassapian Fiberoptic Intubating Ai rway
The Ovas-sapi an f i beropti c i ntubati ng ai rway (Fi g. 16.14) was desi gned t o del i ver a
f iberscope as cl ose to t he larynx as possible (110). It has a f l at l i ngual surface that
graduall y wi dens at the di st al end. At the buccal end are two vert ical si dewal l s.
Bet ween the si dewal l s is a pai r of gui de wal l s that curve toward each other. The
gui de wal l s are f lexi bl e and permi t t he ai rway to be removed f rom around the
t racheal tube. The proximal hal f i s tubular so that i t can f uncti on as a bi te bl ock.
The dist al hal f is open posteri orl y. I t wi l l accommodate a tracheal tube up to 9.0
mm I D. Pl aci ng a bl ack l i ne al ong the mi ddle of the ai rway hel ps to i denti f y t he
mi dl i ne and f aci l i tates advancing t he f lexible endoscope (117,118,119).

View Figure

Figure 16.14 Ovassapian fiberoptic intubating airway.
(Courtesy of A. Ovassapian, M.D.)


View Figure

Figure 16.15 Berman intubation pharyngeal airways.

A compari son of thi s ai rway wi t h the Wi l l i ams ai rway i nt ubator and the Berman
i ntubat ing ai rway (see bel ow) f ound that both other ai rways provi ded a good view of
t he gl ott i s (116,120).
Berman Intubating/Pharyngeal Airway
The Berman i nt ubat i ng/pharyngeal ai rway (Berman I I) (Fi g. 16.15) is tubul ar al ong
i ts enti re l ength. I t i s open on one si de so that i t can be spli t and removed f rom
around a t racheal tube. I t can be used as an oral ai rway or as an ai d to f i beroptic
or bl i nd orotracheal i ntubati on (121). When t he f i berscope is i n the ai rway, t he t ip
cannot be bent , l i mi ti ng scope maneuverabi l i t y. Part i al l y wi thdrawi ng t he ai rway wi l l
i mprove maneuverabi l i t y (110).
One study f ound t hat the Berman ai rway of fered an advant age over t ongue
retracti on for f i beroptic i nt ubati on (122). Compari son wi th t he Ovassapi an
i ntubat ing ai rway f ound that the Berman ai rway off ers somewhat easi er
vi suali zati on of t he cords (120). However, if the t racheal tube impi nges on the
ai rway, i t i s more di ff i cul t to compl ete t he i ntubat ion wi t h t he Berman ai rway.
Mani pulat i ng the Berman ai rway i n pl ace can lead to successf ul t racheal intubat ion
(120).
Use
Pharyngeal and l aryngeal ref l exes shoul d be depressed before an oral ai rway i s
i nsert ed to avoid coughing or l aryngospasm.
Sel ecti ng the correct si ze is i mportant . Too smal l an ai rway may cause the tongue
t o kink and f orce part of
P. 453

i t agai nst the roof of t he mout h, causi ng obstructi on. Too l arge an ai rway may
cause obstruct i on by di spl aci ng the epi gl ot ti s post eriorl y and may t raumati ze the
l arynx. The correct si ze can be esti mated by holdi ng the ai rway next t o the pati ent' s
mouth. The ti p shoul d rest cephal ad to the angl e of t he mandi bl e. The best cri teri a
f or proper si ze and posi t i on are unobst ructed gas exchange. I f the ai rway
repeatedl y comes out of the mouth, i t should be removed and a smal l er si ze tri ed.

View Figure

Figure 16.16 Insertion of oral airway. The airway is
inserted 180 from the final resting position.

Wet ti ng or l ubri cati ng the ai rway may facil i tat e i nserti on. The jaw i s opened wi th
t he l ef t hand. The teeth or gums are separat ed by pressi ng t he thumb agai nst the
l ower t eet h or gum and t he i ndex or thi rd f i nger agai nst the upper t eet h or gum.
One met hod t o i nsert an ai rway i s shown i n Fi gure 16. 16. The ai rway i s i nsert ed
wi th i ts concave si de f aci ng the upper l ip. When t he junct ion of the bi te porti on and
t he curved sect ion i s near the i nci sors, the ai rway i s rotated 180 and sli pped
behind t he tongue i nto the f i nal posi ti on. If resi stance i s met duri ng i nserti on, i t can
usual l y be overcome by a jaw t hrust .
An al ternate met hod of i nsert i on is shown i n Fi gure 16.17. A tongue bl ade i s used
t o push f orward and depress t he tongue. The ai rway i s inserted wi t h t he concave
si de t oward t he t ongue. As i t is advanced, i t i s rotated to sli de around behi nd the
t ongue.
I f the ai rway has been used to faci l i tate f i beropti c i ntubat ion, i t may be bet ter to
remove the ai rway af t er t he f i berscope has entered t he trachea because the ai rway
mi ght prevent t he tracheal tube f rom passi ng i nto the trachea (123).
Bite Block
A bi te bl ock (gag, mout h prop, bi te protect or) i s pl aced bet ween the mol ar teeth or
gums but not the i nci sors (124). It is i nt ended to prevent the teet h f rom bi t i ng on a
t racheal tube, supraglott i c ai rway device, f iberscope, or other devi ce. Not onl y wi l l
i t protect t hese devi ces, but i t may al so avoi d dental i nj ury (125). A bi te bl ock is
al so used during el ectroconvul si ve t herapy and i n unconsci ous indi vidual s to
protect t he tongue and li ps. An oral ai rway shoul d not be used f or t hese purposes
(124, 126,127). It i s ineff ecti ve and may be harmf ul to the pati ent in t hi s rol e
because al l the power of t he bi te i s concentrated on t he i nci sors, whi ch are not
designed f or this pressure and are l i abl e to break or l oosen. Because a bi te bl ock
does not extend i nto t he pharynx, i t is usual l y l ess i rri tati ng than an oral ai rway.

View Figure

Figure 16.17 Alternative method of inserting an oral
airway. A tongue blade is used to displace the tongue
forward.

A variety of bi t e bl ocks have been developed (Fi gs. 16. 18,16.19, 16.20). Some have
a channel for gas to pass. Many have an attached st ri ng that can be pinned to the
P. 454

pati ent 's gown or t aped to the skin so t hat i t can be easi l y ret rieved. The curved
port ion of an oral ai rway can be removed, leavi ng the remai ni ng port i on as a bi te
bl ock (128,129). A gauze rol l is sof t and al lows pressure to be di st ri buted over
several teeth (127). A bi t e block may be part of a devi ce used t o secure a t racheal
t ube.

View Figure

Figure 16.18 Bite block. This is placed between the teeth or
gums (preferably in the molar area) to prevent occlusion of
a tracheal tube or damage to a fiberoptic endoscope or to
keep the mouth open for suctioning.


View Figure

Figure 16.19 This bite block is designed to be placed
between the molar teeth with the flat portion extending
toward the side of the face. The flat portion is used to grip
for insertion and removal. (Picture courtesy of Hudson
RCI.)

A bi te bl ock may become deformed so that i t does not prevent bi t i ng (130). A bi te
bl ock may be aspi rated (130).
Nasopharyngeal Airways
A nasopharyngeal ai rway (nasal ai rway, nasal t rumpet ) is shown i n posi ti on i n
Fi gure 16. 21. When f ul l y i nsert ed, the pharyngeal end shoul d be bel ow the base of
t he tongue but above the epi gl ot tis (131).
A nasal ai rway is bett er t ol erat ed t han an oral ai rway i f the pati ent has i ntact ai rway
ref l exes. I t i s pref erabl e to use a nasal ai r way i f the pat i ent' s teeth are l oose or i n
poor condi t i on or t here i s t rauma or pathol ogy of the oral cavi ty. It can be used
when t he mout h cannot be opened.

View Figure

Figure 16.20 Oberto mouth prop, which is used for
protecting the teeth during electroconvulsive therapy.
(Courtesy of Rusch, Inc.)


View Figure

Figure 16.21 The nasopharyngeal airway in place. The
airway passes through the nose and extends to just above the
epiglottis. (Courtesy of V. Robideaux, M.D.)

Contrai ndi cat ions to using a nasopharyngeal ai rway i nclude ant icoagul ati on; a
basi l ar skul l f racture; pathol ogy, sepsis, or deformi t y of t he nose or nasopharynx;
or a hi st ory of nosebl eeds requi ri ng medi cal t reat ment . There is no evidence that
nasal ai r ways cause si gnif icant bacteremia (103, 132).
Nasopharyngeal ai rways have been used duri ng and af t er pharyngeal surgery
(133, 134), i n inf ants wi th Pi erre Robin syndrome (135), t o appl y conti nuous posi t i ve
ai rway pressure (CPAP) (136), to f aci li t ate suct ioning (137), as a gui de f or a
f iberscope (137), t o t reat si ngul tus (hi ccups), as a gui de f or a nasogast ri c tube
(138, 139), t o di l ate the nasal passages i n preparat ion f or nasot racheal i ntubati on
(138) and as a means to maintai n the ai rway and administer anesthesi a duri ng
dental surgery (140).
A nasopharyngeal ai rway can be fi tt ed wi th a tracheal tube connector and used wi t h
an anest hesi a breat hi ng system (141,142,143,144,145,146,147, 148). These devices
have been used to mai ntai n vent i l ati on during oral fi beropt ic endoscopy (109) and
t o administer cont i nuous posi ti ve pressure (136). Envi ronmental gas contami nat ion
may be a probl em wi t h thi s t echnique (149).
Description
A nasopharyngeal ai rway resembles a shortened tracheal tube wi th a f l ange at t he
outer end to prevent i t f rom compl etel y passing i nt o the nari s. Some ai r ways come
wi th a saf et y pi n that can be i nsert ed into the fl ange or ai rway wal l (150). The
f lange is movabl e on some models. The Ameri can standard (104) requi res that the
si ze of a nasopharyngeal ai rway be desi gnated by the i nsi de di ameter i n
mi ll i meters.
P. 455



View Figure

Figure 16.22 Nasopharyngeal airways. The one on the right
does not contain latex.

Specific Airways
A variety of nasopharyngeal ai rways are avai l abl e. Some are shown i n Fi gure
16.22.
Linder Nasopharyngeal Airway
The Li nder nasopharyngeal (bubbl e-ti p) ai rway i s shown i n Figure 16. 23. It i s
pl ast i c wi t h a l arge f l ange (151,152). The di stal end has no bevel . The ai rway i s
suppl ied wi t h an int roducer, whi ch has a bal l oon on i ts ti p. The bal l oon can be
i nf l ated and def l at ed by at tachi ng a syringe to t he one-way v alve at the other end of
t he i ntroducer.

View Figure

Figure 16.23 Linder nasopharyngeal airway. (Courtesy of
Polamedco, Inc.)

Bef ore i nsert i on, the i ntroducer i s inserted i nt o the ai rway unt i l the t i p of the
bal l oon i s just past the end. Ai r i s injected unti l t he bal l oon t ip i s i nf l ated to
approxi matel y the outsi de di amet er of the tube. The compl et e assembl y i s
l ubricated and then inserted through the nostri l . Af ter i t i s i n place, t he bal l oon i s
defl ated and the int roducer removed.
Cuffed Nasopharyngeal Airway
The cuff ed nasopharyngeal (pharyngeal ) ai rway i s si mi l ar t o a short cuf fed t racheal
t ube (147, 148, 153). I t i s inserted t hrough the nose i nt o the pharynx, the cuff i s
i nf l ated, and then is pul l ed back unt i l resistance i s f el t.
Binasal Airway
The bi nasal ai rway (Fi g. 16.24) consi sts of two nasal ai rways joined together by an
adapt or f or at tachment to the breathing system
(154, 155,156,157, 158, 159,160, 161). I t can be used to admini ster anest hesi a or to
provi de CPAP t o babi es.
Insertion
The di ameter of the nasal ai rway shoul d be the same as needed to i nsert a t racheal
t ube (0.5 t o 1 mm smal ler than for an oral tracheal tube).

View Figure

Figure 16.24 Binasal airway. (Courtesy of Rusch, Inc.)

P. 456



View Figure

Figure 16.25 Insertion of a nasal airway. A: Correct
method. The airway is inserted perpendicularly, in line with
the nasal passage. B: Incorrect method. The airway is being
pushed away from the air passage and into the turbinates.

Bef ore i nsert i on, the nasal ai rway should be l ubri cated thoroughl y al ong i ts enti re
l ength. Each si de of t he nose shoul d be i nspected f or si ze, patency, and the
presence of pol yps. A vasoconst ri ct or may be appl ied bef ore i nsert ion t o reduce
t rauma.
The nasopharyngeal ai rway should be i nsert ed as shown i n Fi gure 16.25A. The
ai rway i s held wi th t he bevel against t he septum and gentl y advanced posteri orl y
whi l e bei ng rot ated back and fort h. I f resistance i s encountered duri ng i nsert ion,
t he other nostri l or a smal l er si ze ai rway shoul d be used. Figure 16.25B shows an
i ncorrect met hod f or i nsert i ng t he ai rway. The ai rway i s bei ng pushed toward t he
roof of the nose.
The ai rway may be adj usted to fi t t he pharynx by sl i di ng i t in or out . If t he t ube i s
i nsert ed too deepl y, l aryngeal ref l exes may be sti mulated; if too short , ai rway
obstruct i on wi l l not be rel i eved. Al though t he correct nasal ai rway l engt h for a
pati ent correl ates wi t h si mpl e external measurements of t he f ace and neck, st udi es
i ndi cate a correl at ion onl y wi t h the pati ent ' s hei ght (131).
Complications
Airway Obstruction
The t ip of an ai rway can press the epi gl ott i s or tongue against t he posteri or
pharyngeal wal l and cover t he l aryngeal apert ure (162,163). Wi th a nasopharyngeal
ai rway, neck movement i n rotat ion or anteroposteri orl y may resul t i n the l umen
becomi ng obst ructed (164). The use of a f enest rat ed ai rway may overcome thi s
probl em. The nasopharyngeal ai rway l umen may be compressed i nsi de the nose
(131).
A f orei gn body can enter an ai rway and cause compl ete or parti al obst ructi on
(165, 166). I n one case, the pl ast ic packagi ng became stretched over t he end of the
ai rway, causi ng obstruct i on (167).
I f a nasopharyngeal ai rway perforat es t he retropharyngeal space, the space may
expand and cause ai rway obstruct i on (168).
Trauma
I njury t o t he nose and posteri or pharynx is a potenti al compl icati on of nasal
ai rways. Epistaxi s i s usual ly self -l i mi t ing but can present a seri ous problem i n some
pati ents. To cont rol severe nasal and nasopharyngeal bleedi ng, an epistaxis ai rway
(Fi g. 16.26) can be used. Pharyngeal perforat ion and ret ropharyngeal abscess
f ormati on can occur (168). The l i p or tongue may be caught bet ween the teeth and
an oral ai rway.
Tissue Edema
Faci al , neck, or t ongue edema, ei t her uni lateral or bil ateral , can occur f ol lowi ng
surgery, especi al l y i n the si t ti ng posi ti on, and can resul t in ai rway obstructi on
(169, 170,171,172, 173). Pressure f rom an oral ai rway may be a
P. 457

contri but ing f actor. To prevent this compl icati on, the oral ai r way shoul d not be l ef t
i n place for an ext ended period. A bi te bl ock shoul d be used i nstead. Excessive
head or neck fl exi on shoul d be avoi ded, and t he head and neck shoul d be checked
f requent l y duri ng l ong cases f or edema or ecchymoses. Uvul ar edema possi bl y
caused by t he uvula becomi ng ent rapped bet ween the hard palat e and an
oropharyngeal ai rway has been report ed (174). Another pati ent developed
t emporary deaf ness secondary to edema of the uvul a and sof t palate f ol l owi ng
prol onged nasopharyngeal ai rway use (175). Transi ent sal i vary gl and swel l ing may
occur wi t h oral ai r way use (176,177).

View Figure

Figure 16.26 Epistaxis airway. This is inserted into the nose
and inflated to provide local pressure on the bleeding site. It
is available in several sizes. (Courtesy of Rusch, Inc.)

Ulceration and Necrosis
Ul cerat ion of the nose or t ongue can occur i f an ai rway remai ns i n pl ace f or a long
peri od of t ime (178).
Central Nervous System Trauma
The use of a nasal ai rway i n a pati ent wi t h a basi lar skul l f racture can resul t i n i ts
entering the anteri or crani al f ossa (179,180).
Dental Damage
Teeth can be damaged or avulsed if t he pati ent bi t es down hard on an oral ai rway
(181, 182,183). An oral ai rway shoul d be avoided i f there is evidence of periodont al
di sease, t eet h weakened by cari es or restorat ions, crowns, f ixed parti al dent ures,
pronounced procl i nati on (t he f ront teeth havi ng a f orward i ncl i nat ion and
overl apping the l ower f ront t eet h), or isol ated teeth. In t hese cases, the use of a
nasopharyngeal ai rway and/or a bi te bl ock between the back t eeth may be
pref erabl e.
Laryngospasm and Coughi ng
I nserti ng an ai rway bef ore adequate anest het i c depth is establ i shed may cause
coughi ng or l aryngospasm, especi al l y i f the ai rway contacts the epiglott is or vocal
cords.
Retenti on, Aspirati on, or Swallowing
Part or al l of an ai rway may become displaced i nto t he pharynx, t racheobronchi al
t ree, or esophagus (184, 185,186,187, 188, 189,190,191). Pl aci ng a saf et y pi n
t hrough the nasal ai rway f l ange may prevent i t f rom sl ipping i nto the nose (192).
Devices Caught in Airway
I n one case, a cuf f became detached when an esophageal st ethoscope was
removed f rom a pat i ent wi t h an oral ai rway i n pl ace (193). It was postul ated that t he
cuff became caught i n t he si de grooves of the ai rway. Another case was reported
where a fi berscope inadvert ent l y t raversed a f enestrated oral ai rway, maki ng i t
i mpossible t o pass a tracheal tube (194).
Equipment Failure
An oral ai rway may f racture at the connection between the bi te porti on and the
curved sect i on (195,196,197). A def ect in the Wi l li ams i ntubat ing ai rway t hat coul d
t ear t he tracheal t ube cuff has been report ed (198).
Latex Al lergy
I f an ai rway contai ns latex, a severe react i on may occur i f the pati ent is sensi t ive t o
l atex (90). Non-l atex oral and nasal ai rways are readi l y i denti f ied and avai l abl e.
Chapter 15 provi des more det ai l s on l atex al l ergy.
Gastri c Distention
A nasopharyngeal ai rway t hat i s too l ong may enter the esophagus wi t h resul tant
gastri c distenti on (131).
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P. 460


Questions
For the f ol lowing quest ions, answer
i f A, B, and C are correct
i f A and C are correct
i f B and D are correct
i s D i s correct
i f A, B, C, and D are correct .
1. Compli cations associated wi th use of a face mask incl ude
A. Movement of the cervi cal spi ne
B. Faci al nerve i nj ury
C. Chemical i rri t ati on of the eyes
D. Si nusi ti s
Vi ew Answer2. Which maneuvers can be used to secure a patent ai rway?
A. Jaw t hrust
B. Posteri or prot rusion of the mandi bl e
C. Chi n l if t
D. Posteri or f l exi on of t he atl anto-occi pi t al j oi nt
Vi ew Answer3. Airways developed to ai d in fi beroptic i ntubati on i ncl ude
A. Pati l -Syracuse
B. Wi l l i ams
C. Ovassapi an
D. Guedel ai rway
Vi ew Answer4. Contraindications to nasal ai rways i nclude
A. Hemorrhagi c di sorders
B. Sepsi s
C. Basi l ar skul l f racture
D. Sei zure di sorders
Vi ew Answer5. Which external measurements correlate wi th the proper
l ength of a nasal airway?
A. Ti p of nose to 2 cm above the t hyroi d carti l age
B. The distance f rom the ti p of the t humb t o the t ip of the i ndex f i nger measured t o
t he hand and back
C. Ti p of the earl obe to cri coi d carti l age
D. The pati ent' s hei ght
Vi ew Answer6. Complications associated wi th the use of oral ai rways
i ncl ude
A. Swel l i ng of t he tongue
B. Edema of t he uvul a
C. Ul cerat ion of the tongue
D. Swal l owi ng of the ai rway
Vi ew Answer7. Predictors of diffi cul t mask venti lati on include
A. Hi gh body mass i ndex
B. Age over 65 years
C. Hi story of snori ng
D. Hi story of sl eep apnea
Vi ew Answer8. Techniques to improve mask fit i n the edentulous pati ent
i ncl ude
A. Packi ng the cheeks wi th gauze sponges
B. Not removi ng the dentures
C. I nsert i ng t he i nferi or margi n of the mask bet ween t he gi ngi va of the mandible
and the l ower l i p
D. Using a nasal ai rway
Vi ew Answer