AIRWAY

MANAGEMENT
MOSTAJO, John Adriel T.
 OUTLINE

01 AIRWAY ANATOMY 03 PHYSICAL EXAMINATION

FEATURES WITH AIRWAY
MANAGEMENT IMPLICATIONS

02 CLINICAL
AIRWAY
MANAGEMENT OF 04 TRACHEAL INTUBATION
● Preoxygenation &
Bag-Mask Ventilation
● Supraglottic Airway
Devices
05 DIFFICULT
ALGORITHM
AIRWAY
AIRWAY
ANATOMY
ANATOMY
AIRWAY

● refers to the upper airway

○ Nasal & oral cavities
○ Pharynx
○ Larynx
○ Trachea
○ Principal bronchi
● for protection against aspiration of
food
● undergoes significant changes from
infancy to childhood
 LARYNX
● Consists of nine cartilages (three paired and
three unpaired)
○ Paired:
■ Arytenoid
■ Cuneiform
■ Corniculate
○ Unpaired:
■ Thyroid
■ Cricoid
■ Epiglottic
● House the vocal folds, which extend in an
anterior– posterior plane from the thyroid
cartilage to the arytenoid cartilages

+ Butterworth, Mackey, Wasnick (2018). Morgan and Mikhail’s clinical anesthesiology. 6th edition. New York: McGraw Hill Education Medical
+
 LARYNX
● Movements are controlled by
- extrinsic muscles & intrinsic
muscles
● Innervated by the superior
and recurrent laryngeal nerves
● Unilateral recurrent laryngeal
nerve injury = hoarseness
● Bilateral injury = complete
airway obstruction

+ Butterworth, Mackey, Wasnick (2018). Morgan and Mikhail’s clinical anesthesiology. 6th edition. New York: McGraw Hill Education Medical
+
CRICOTHYROID MEMBRANE
● 1 to 1.5 fingerbreadths below the thyroid
notch
● Central portion = conus elasticus + two
lateral thinner portions
● Directly beneath the membrane is the
laryngeal mucosa
● It is suggested that any incisions or
needle punctures to the CTM be made in
its inferior third and be directed
posteriorly
CRICOID CARTILAGE
● At the base of the larynx, suspended
by the underside of the CTM, has a
signet ring–shape
● Approximately 1 cm in height
anteriorly, but almost 2 cm in height
in its posterior aspect as it extends in
a cephalad direction
 TRACHEA
● Are interconnected by fibroelastic tissue
● 10-13 cm in length
● Supported circumferentially by 17 to 18
C-shaped cartilages, with a membranous
posterior aspect overlying the esophagus.
● In adults, the first tracheal ring is anterior
to the sixth cervical vertebra
● Ends at the carina which is opposite the
fifth thoracic vertebra
● Diameter of Right principal bronchus is
larger than left and deviates at a less acute
angle

+ •Barash et al. (2017). Clinical Anesthesia 8th Edition

CLINICAL
MANAGEMENT
OF AIRWAY
 PREOXYGENATION
● Replacement of the nitrogen volume of the lung with oxygen
● A healthy patient breathing room air will experience
oxyhemoglobin desaturation after 1 to 2 minutes of apnea.
● Preoxygenation with 100% O2 via a tight-fitting facemask may
support at least 8 minutes of apnea before desaturation occurs.
● Patients with pulmonary disease, obesity, or conditions
affecting metabolism frequently experience desaturation
sooner
● Apply tight-fitting mask for 5
minutes or more of tidal
volume breathing 100% oxygen
at flows of 10 to 12 L/min
● In obese patient, facilitate
bilevel positive airway pressure
and reverse-Trendelenburg
position
BAG AND MASK VENTILATION
● First step in airway management
● Most commonly used to deliver anesthetic gases and ventilate an apneic
patient
● Highly effective, minimally invasive, requires the least sophisticated
equipment
● If the airway is patent
○ squeezing the bag will result in the rise of the chest
● If ventilation is ineffective
○ No sign of chest rising, no end-tidal CO2 detected, no condensation in
the clear mask
 BAG AND MASK VENTILATION

+ Butterworth, Mackey, Wasnick (2018). Morgan and Mikhail’s clinical anesthesiology. 6th edition. New York: McGraw Hill Education Medical
+
SUPRAGLOTTIC AIRWAY
● Devices that isolate the airway above the vocal cords
● Associated with lower incidence of sore throat, coughing, and
laryngospasm on emergence and with decreased reversible
bronchospasm that is seen in tracheal intubation
● Less effect on heart rate, blood pressure, and intraocular
pressure
LARYNGEAL MASK AIRWAY CLASSIC
● Perilaryngeal mask + airway barrel
● It sits in the hypopharynx with an anterior surface
aperture overlying the laryngeal inlet
● Has an inflatable cuff that fills the hypopharyngeal space,
creating a seal
● LMAs come in varying sizes, from neonatal to large adult
● It is recommended to choose the largest size that will fit
comfortably within the oral cavity
LARYNGEAL MASK AIRWAY CLASSIC
● LMA is inflated with the minimum amount of pressure that allows ventilation to
20 cm H2O without an air leak
● Intracuff pressure maintained under 60 cm H2O
● Light anesthesia and laryngospasm also may contribute to poor seal
● With inflation, observe rising of the cricoid and thyroid cartilages and lifting of
the barrel out of the mouth by approximately 1 cm as the mask expands
● If a midline position is not possible due to the patient’s position or the surgical
procedure, use flexible LMA
+ Butterworth, Mackey, Wasnick (2018). Morgan and Mikhail’s clinical anesthesiology. 6th edition. New York: McGraw Hill Education Medical
+
 ADVANTAGES AND DISADVANTAGES
ADVANTAGES DISADVANTAGES

Compared with tracheal ● Less invasive ● Increased risk of

intubation ● Very useful in gastrointestinal
difficult intubation aspiration
● Less tooth and ● Less safe in prone
laryngeal trauma or jackknife
● Less laryngospasm position
and bronchospasm ● Less secure airway
● Does not require ● Can cause gastric
muscle relaxation distention
● Does not require
neck mobility
● No risk of
esophageal or
endobronchial
intubation.
+ Butterworth, Mackey, Wasnick (2018). Morgan and Mikhail’s clinical anesthesiology. 6th edition. New York: McGraw Hill Education Medical
+
 LMA FLEXIBLE
Designed to be paired with a tonsillar
mouth gag commonly used in oral
and pharyngeal surgery

Useful when:

● heavy drapes are placed over the

airway
● movement of the head during
surgery
● the LMA barrel cannot be
secured in the midline
+ •Barash et al. (2017). Clinical Anesthesia 8th Edition
 KING LARYNGEAL TUBE
Single-lumen tube with distal and proximal
low-pressure cuffs that are inflated via a
common pilot valve

The distal cuff sits within and obstructs the

upper esophageal sphincter and the proximal
cuff seals the oral and nasal pharynx

Inserted either blindly or with the aid of a

laryngoscope

Improved oxygenation and facilitated drainage

of gastric contents
+ •Barash et al. (2017). Clinical Anesthesia 8th Edition
 COOKGAS AIR-Q
● Air-Q perilaryngeal airway can function
both as an elective SGA and a conduit
for blind or flexible scope-aided
intubation
● Seals the perilaryngeal space and has
airway seal pressures of 25 to 30 cm
H2O
● Comes in sizes 0.5 to 4.5 and is inserted
using a technique similar to that
recommended for the LMA
● Recommended that the cuff should be
filled with less than 10 mL of air
+ •Barash et al. (2017). Clinical Anesthesia 8th Edition
 I-GEL
Has a solid elastomer gel body mounted
on a plastic barrel without an inflatable
cuff

A drain tube runs from the distal tip

that sits over the esophageal inlet, to an
outlet lateral to the airway circuit
connector.

A gastric tube may be placed via this

drain which also serves as a passage for
passively regurgitated gastric contents
+ •Barash et al. (2017). Clinical Anesthesia 8th Edition
LMA ProSeal
● It was the first SGA with a gastric port and thus the first “second-generation” SGA
● The gastric port also allows passive (regurgitation) and active (gastric tube insertion)
emptying of the stomach
● Improves airway seal during positive-pressure ventilation
PHYSICAL
EXAMINATION
FEATURES WITH
AIRWAY
MANAGEMENT
IMPLICATIONS
+ •Barash et al. (2017). Clinical Anesthesia 8th Edition
+ •Barash et al. (2017). Clinical Anesthesia 8th Edition
+ •Barash et al. (2017). Clinical Anesthesia 8th Edition
+ •Barash et al. (2017). Clinical Anesthesia 8th Edition
+ •Barash et al. (2017). Clinical Anesthesia 8th Edition
TRACHEAL
INTUBATION
DIRECT LARYNGOSCOPY
● GOAL: to produce a direct line of sight from the operator’s eye to the larynx
○ Alignment of the laryngeal, pharyngeal, and oral axes would result in adequate glottic
view
○ Explains the rationale of the intubation sniffing position (SP) in which the neck is
flexed by 35 degrees and the head extended by 15 degrees
○ It is achieved by placing a support (around 7 cm in the adult) under the patient’s
occiput.
 MALLAMPATI CLASSIFICATION

+ •Barash et al. (2017). Clinical Anesthesia 8th Edition

 DIRECT LARYNGOSCOPE BLADES
Macintosh (curved) Blade

It is used to displace the epiglottis out of the line of

sight by placement of the distal tip in the vallecula
and tensing of the glossoepiglottic ligament

Miller (Straight) Blade

Reveals the glottis by compressing the epiglottis

against the base of the tongue

+ •Barash et al. (2017). Clinical Anesthesia 8th Edition

DIRECT LARYNGOSCOPE
● SPECIAL CONSIDERATIONS:
● Hyperextension at the atlanto-occipital joint
○ done in adults
○ may cause airway obstruction
● The comparatively short neck of a child gives the impression of an anterior position of the
larynx and external laryngeal manipulation is often required to move the laryngeal inlet into
view
○ A straight blade - helpful in displacing the stiff, omega shaped epiglottis
○ Cricoid cartilage - most rigid portion of the airway until 6 to 8 years of age
○ Due to the short length of the trachea
■ higher risk of endobronchial intubation or accidental extubation with head
movement.
 DIRECT LARYNGOSCOPE

Laryngeal View Scoring

Grade 1: entire glottic aperture

Grade 2: posterior aspects of the glottic aperture

Grade 3: tip of the epiglottis

Grade 4: no more than the soft palate

+ •Barash et al. (2017). Clinical Anesthesia 8th Edition

+ •Barash et al. (2017). Clinical Anesthesia 8th Edition
 BACKWARD-UPWARD-RIGHTWARD PRESSURE
MANEUVER
In this maneuver, the larynx is displaced
backward (B) against the cervical vertebrae,
upward (U, superiorly) and to the patient’s
right (R), using pressure (P) over the
thyroid cartilage

It has been shown to improve the laryngeal

view.
PARAGLOSSAL APPROACH
● A straight-blade laryngoscope is
introduced into the right side of the
mouth and advanced between the
tongue and palatine tonsil.
● The blade passes below the epiglottis,
which is then elevated.
● This approach subjects the tongue to
less compressive forces and may
improve the view of the larynx in the
presence of lingual tonsil hyperplasia
DIFFICULT AIRWAY
ALGORITHM
+ •Barash et al. (2017). Clinical Anesthesia 8th Edition
+ •Barash et al. (2017). Clinical Anesthesia 8th Edition
 EXCEPTION TO THE AAA

● Unable to cooperate owing to mental

disability
● Language barriers
● Intoxication
● Anxiety
● Depressed level of consciousness
● Young age

+ •Barash et al. (2017). Clinical Anesthesia 8th Edition

● If two to three attempts at laryngoscopy fail, mask ventilation should be instituted
○ if adequate, the ASA-DAA non-emergency pathway is entered
● Most convenient and appropriate technique for establishing tracheal intubation
○ Use of a flexible intubation scope
○ an SGA or intubating SGA
○ lighted stylet
○ retrograde wire
○ Surgical approach
● When mask ventilation fails, the algorithm suggests supraglottic ventilation via an
SGA
AWAKE AIRWAY MANAGEMENT
● Provide maintenance of spontaneous ventilation
● Benefits include:
○ Increased size and patency of the pharynx,
○ Relative forward placement of the base of the tongue
○ Posterior placement of the larynx
○ Ability of the patient to cooperate with procedures
● In the event of regurgitation, the patient can expel aspirated foreign bodies
by cough
● Patients at risk for neurologic sequelae) may undergo active sensory—motor
testing after tracheal intubation and positioning
AWAKE AIRWAY MANAGEMENT
● In an emergent situation:
○ Cardiovascular stimulation
■ cardiac ischemia or ischemic risk
■ Bronchospasm
■ increased intraocular or intracranial pressure
● Contraindications
○ patient refusal
○ inability to cooperate
○ allergy to local anesthetics.
 THANK YOU!!!
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+ Barash et al. (2017). Clinical Anesthesia 8th Edition

+ Butterworth, Mackey, Wasnick (2018). Morgan and Mikhail’s clinical anesthesiology. 6th edition. New York: McGraw Hill Education Medical