Airway Evaluation and

Management
Key Learning Objectives
•Review the anatomy relevant to airway management
•Understand the components of an airway examination
•Learn the principles of mask ventilation and intubation
 Introduction
Despite the site of surgery or the anesthetic technique
chosen, every patient receiving anesthetic care is
exposed to a varying degree of risk of airway
compromise. That is, all levels of sedation, general
anesthesia, and regional anesthesia carry with them at
least a small risk of airway obstruction and apnea.
Therefore, every anesthesia provider must examine each
patient in anticipation of a need to mechanically ventilate
and intubate, regardless of whether or not such
interventions were part of the primary anesthetic plan. A
thorough airway examination and history, combined with
expert airway management, guard against the life-
threatening risks of airway obstruction and apnea.
 Airway Anatomy
The human airway is a dynamic structure
that extends from the nares to the alveoli.
Obstruction can occur at any point because
of anatomic collapse or a foreign body
which includes liquids such as mucous,
blood, and gastric contents
 Pharynx
The pharynx is basically a wide muscular
tube forming the common upper pathway of alimentary
and respiratory tracts. It extends from the base of the skull
to the level of C6.
The pharynx lies posterior to, and communicates with,
the nose, mouth and larynx. This relationship
divides the pharynx into three sections: naso-, oro and
Laryngo pharynx. The posterior surface of the pharynx
lies on the prevertebral fascia and cervical vertebrae.
 Larynx
The larynx is a functional sphincter at the
beginning of the respiratory tree to protect
the trachea from foreign bodies. It is lined
by ciliated columnar epithelium and
consists of a framework of cartilages
linked together by ligaments which are
moved by a series of muscles.
 Cartilages of the larynx
The thyroid cartilage is said to be shaped like a
shield. It consists of two plates that join in the
midline inferiorly to form the thyroid notch (Adam’s
apple). Each plate has a superior and inferior horn
or cornua at the upper and lower limit of its
posterior border, respectively. The inferior horn
articulates with the cricoid cartilage.
The cricoid cartilage is shaped like a signet
ring, with the large laminal portion being
posterior.
Each lateral surface features a facet that
articulates with the inferior horn of the
thyroid cartilage. The upper border of the
lamina has an articular facet for the
arytenoid cartilage.
There is a pair of arytenoid cartilages, each
shaped like a triple-sided pyramid possessing
medial, posterior and anterolateral surfaces.
Each arytenoid cartilage projects anteriorly as
the vocal process and in a similar fashion
laterally as the muscular process.
The posterior and lateral cricoarytenoid muscles
are inserted into the muscular process.
The epiglottis is a leaf-shaped cartilage. It has a
lower tapered end which is joined to the thyroid
cartilage by the thyroepiglottic ligament.
The free upper end is broader and projects
superiorly behind the tongue.
The lowest part of the anterior surface of the
epiglottis is attached to the hyoid by the
hyoepiglottic ligament.
Two other minor cartilages are the corniculate and
the cuneiform.
 Ligaments of the larynx
Extrinsic ligaments are the:
thyrohyoid membrane, cricotracheal,
cricothyroid, and hyoepiglottic ligaments.

The intrinsic ligaments of the larynx are of

minor importance, being the capsules of
the small synovial joints
 Muscles of the larynx
• Extrinsic group:
Sternothyroid, thyrohyoid and inferior
constrictor is a constrictor of the pharynx
• Intrinsic group: These are paired, with the
exception of the (transverse arytenoid).
Cricothyroid, posterior cricoarytenoid,
lateral cricoarytenoid, aryepiglottic,
thyroarytenoid
 Nerve supply
The mucous membrane of the larynx above
the vocal cords is supplied by the internal
laryngeal nerve, that below by the
recurrent laryngeal nerve.
All muscles of the larynx are supplied by the
recurrent laryngeal nerve except for the
cricothyroid, which is supplied by the
superior (also known as external)
laryngeal nerve.
 Trachea
The trachea descends from the lower border of the cricoid
cartilage (C6) to terminate at its bifurcation into the two
main bronchi at the sternal angle (T4). The length of the
adult trachea varies between 10 and 15 cm. The walls of
the trachea are formed of fibrous tissue reinforced by 15–
20 incomplete cartilaginous rings. Internally the trachea
is lined by respiratory epithelium. The trachea may be
divided into two portions, that in the neck and that in the
thorax.
 Bronchial tree
Extrapulmonary bronchi
At the carina, the two main bronchi arise. The right
main bronchus is shorter, wider and more upright than
the left. The right pulmonary artery and azygos vein are
intimately related to the right main bronchus. The left
main bronchus passes under the aortic arch anterior to
the oesophagus, thoracic duct and descending aorta. The
structure of the extrapulmonary bronchi is very similar to
that of the trachea.
Intrapulmonary bronchi
Branching of the intrapulmonary bronchi gives rise to
functional units – the bronchopleural segments.
 Airway assessment
➢ History
• Adverse events related to prior airway
management
• Radiation/surgical history
• Burns /swelling/ tumor /masses
• Obstructive sleep apnea (snoring)
• Temporomandibular joint dysfunction
• Problems with phonation
• C-spine disease (disc dz, osteoarthritis,
rheumatoid arthritis, Down’s syndrome)
➢ Examination of the upper airway:
1. Cervical spine mobility
2. Temporomandibular mobility
3. Prominent central incisors
4. Diseased or artificial teeth
5. Ability to visualize uvula
6. Thyromental distance
 Malampatti/ Samson–Young classification of the
oropharyngeal view

• Class I: uvula, faucial pillars, soft palate

visible;
• Class II: faucial pillars, soft palate visible;
• Class III: soft and hard palate visible;
• Class IV: hard palate visible only

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 Components of the preoperative airway physical examination

Component Non reassuring finding

• Length of upper incisors------------------------- ➢ Relatively long
• Relation of maxillary and mandibular-------- ➢ Prominent “overbite” (maxillary
incisors during normal jaw closure incisors anterior to mandibular
• Relation of maxillary and mandibular-------- incisors)
incisors during voluntary protrusion of the
jaw ➢ Patient’s mandibular incisors anterior
to (in front of) maxillary incisor
• Inter-incisor distance (mouth opening)-------
• Visibility of uvula------------------------------------ ➢ <3 cm
➢ Not visible when tongue is protruded
with patient in sitting position (e.g.,
• Shape of palate------------------------------------- Malampatti class > II )
• Compliance of submandibular space—------ ➢ Highly arched or narrow
➢ Stiff, indurated, occupied by mass, or
• Thyromental distance------------------------------ non-resilient
• Length of neck--------------------------------------- ➢ <3 fingerbreadths or 6–7 cm
• Thickness of neck----------------------------------- ➢ Short
• Range of motion of head and neck------------- ➢ Thick neck (size > 17 inches)
➢ Patient cannot touch tip of chin to
chest or cannot extend neck
*
Use common cause of ceirmy obs incensuous
person: tongue pressing the phag
 Airway Devices
• Oral and nasal airways:
Typically inserted secondary to loss of upper
airway muscle tone in anesthetized patient
Airway obstruction caused by tongue falling
against posterior pharyngeal wall.
Length of nasal airway estimated by measuring
from the nares to meatus of ear, use caution
when used with patients on anticoagulants or
has basal skull fractures
↑rol
army,
Put inside edepress the bryne to than 1800
Nasalary: Chorsepolent side! (II:9.
Mask
Laryngeal mask airway (LMA)
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 Tracheal intubation
usually simply referred to as intubation, is
the placement of a flexible plastic or
rubber tube into the trachea to maintain an
open airway or to serve as a conduit
through which to administer certain drugs.
 Endotracheal tubes
Modified for variety of specialized applications:
Flexible, wired-reinforced (armored), rubber,
Microlaryngeal, oral/nasal RAE, double lumen,
cuffed non cuffed.
All endotracheal tubes has a radio-opaque line.
Airflow resistance depends on tube diameter,
curvature and length.

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 & Patent airman, Ventilation, prevent aspiration.
Suctioning
Indications for orotracheal intubation
· 6cS48
1. Provide patent airway
2. Prevent inhalation (aspiration of gastric
content)
3. Need for frequent suctioning
4. Facilitate Positive pressure ventilation
5. Operative position other than supine
6. Operative site near or involved the upper
airway
7. Airway maintenance by mask difficult
8. Disease involving the upper airway
Any pations
receiving muscle relatant (LMA my be used it <II)
->

nor

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4
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-

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emergency:

-
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↑serious difficulty on tubatiy

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 Complications of tracheal intubation
• During direct laryngoscopy and intubation
of the trachea:
1. Dental and oral soft tissue trauma
2. Hypertension and tachycardia
3. Cardiac dysrhythmias
4. Myocardial ischemia
5. Inhalation (aspiration) of gastric
contents
Ventillation: Neuromuscar weakness (MG, G13S/Myopathia)
amage
· to resp-centre (stuke, meheholic, dry
* ind cold transe hor

Lung pecevelymn (fibrsis, COPD, Asthma

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↑a Resp. failure
Brain Death
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-

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 •While the tracheal tube is in place
1. Tracheal tube obstruction
2. Endobrochial intubation
3. Esophageal intubation
4. Tracheal tube cough leak
5. Barotrauma
6. Nasogastric distention
7. Accidental disconnection from breathing
system
8. Tracheal mucosa ischemia
9. Accidental extubation
 •Immediate and delayed complications after
extubation of the trachea
1. Laryngospasm
2. Inhalation of gastric content
3. Pharyngitis (sore throat)
4. Laryngitis
5. Laryngeal or subglottic edema
6. Laryngeal ulceration with or without granuloma
formation
7. Tracheitis
8. Tracheal stenosis
9. Vocal cord paralysis
10. Arytenoid cartilage dislocation
 Nasotracheal intubation
an endotracheal tube is passed through the nose
and vocal apparatus into the trachea.

Indications:
1. Intra-oral surgery
2. Anatomical abnormalities or disease of the
upper airway make direct laryngoscopy difficult
or impossible
3. When long-term intubation of the trachea is
anticipated
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 chunke
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Advantages of Nasotracheal
intubation
1. More stable tube fixation
2. Less chance for tube kinking
3. Greater comfort in awake patient
4. Fewer oropharyngeal section
 Complications unique to
Nasotracheal intubation
1. Epistaxis
2. Dislodgement of pharyngeal tonsils
(adenoid)
3. Eustachian tube obstruction
4. Maxillary sinusitis
5. Bacteremia
6. Gastric distension
 Flexible Fiberoptic Brochoscope
• Indications:
1. Difficult laryngoscopy/mask ventilation
2. Unstable cervical spines
3. Poor cervical range of motion
4. TMJ dysfunction
5. Congenital/acquired upper airway
anomalies
 Awake Flexible Fiberoptic Intubation

• Equipment: airway, topical anesthesia,

vasoconstrictors, antisialogogue, suction,
fiberoptic scope with lubricated ETT
• Indications: Cervical spine pathology,
obesity, head and neck tumors, history of
difficult airway
• Premedication: Sedation (midazolam,
Fentanyl, Ketamine)
Light wand
Retrograde Tracheal Intubation
Airway Bougie
Cricothyroidotomy
 Oxygen therapy
Oxygen therapy administered as increased
inhaled concentration of oxygen is
indicated for a PaO2 lower than 60 mmHg.
Supplemental inspired oxygen is often
routinely provided in the post operative
period regardless of the duration or type of
surgery.
In the presence of chronic obstructive
pulmonary disease associated with carbon
dioxide retention, graded doses of
supplemental oxygen administered via an
air entrainment (Venturi) mask increase
the patient’s PaO2 to acceptable level
 Nasal Cannula
Supplemental oxygen can be administered
through a nasal cannula with minimal
patient discomfort.
A nasal cannula incorporates two prongs
that extend about 1 cm into the patient’s
nares and is held in place by an adjustable
elastic head strap
↓ 5 L/min otherwise becomes uncomfortable
 pt is conformable, can ear ad speak, good for longterm use
-
Cheap 2 CIP1)
-

Disadvanes:80% of the this expirited

for to his fixe or blume

Inspired oxygen concentrations achieved

with nasal cannula depends on:
1. The flow rate of oxygen through the flow
meter (L/min)
2. Patient’s tidal volume
3. breathing frequency
4. Volume of nasopharynx
& Imn proves & 4Y but this is not fixed
-

2. 98%
3 =
3 2 Y.
 ↑7) SLImgien -> Use humidifier) Discoiled water used

Oxygen flow rate 6L/min gives inhaled oxygen

concentrations about 44%
Excessive flow rates of oxygen may result in air
swallowing and gastric distension without
increasing inhaled oxygen concentration
Mouth breathing does not decrease the
effectiveness of oxygen therapy delivered by
nasal cannula because inspiratory airflow
through the posterior pharynx entrains oxygen
from the nose
 Face Mask
Face masks used for oxygen therapy are
categorised as:
• Simple
• Partial rebreathing
• Nonrebreathing
• Air-entrainment
 Simple Face mask
• It does not include a valve or oxygen
reservoir bag
• can provide inhaled concentration of
oxygen between 35% and 50% with O2
flow rate of 5-8 L/min (6 1) -

• Provides little advantage over nasal

cannula in term of delivering constant
inhaled concentrations of oxygen
Adranba: Leos disbigement. More fit a volume can be given, gets
rid of CO2

admins

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-
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-
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More CO2

Venturi or nebulizer
 Partial Rebreathing
Its valveless system that includes an O2
resrvoir bag
With O2 flow10L/min the inhaled
concentration of oxygen are between 50-
60%
 Non rebreathing
It includes a unidirectional valve plus an
oxygen reservoir bag
Inhaled concentration of O2 can reach 100%
if the mask was fixed tight on the patient
face to completely eliminate entrainment
of room air
The flow rate of oxygen into this system
should be sufficient to maintain an inflated
reservoir bag
10 +4 C/min
Cor severe hypoxia
 Air-Entrainment (Ventimask)
Venturi Face mask
It employs the Bernolli principle to entrain large
volumes of room air to mix with oxygen flowing
through an injector the resultant mixture of
gases produces stable inhaled concentrations of
oxygen(24-50%) depending on the bore of the
O2 injector
The high flow of gas into the face mask result in
constant inhaled concentrations of O2 despite of
changes in the patient ventilation

High flow BasVenturi Gaya

3
-
is needed (>19L/m.)
Exact of fifa is
pt dependanc
->
fixed amour gien. Nor
amount given
Amany perion High flow did a exact fits cannorbegian
 & xygen therapy
postop- 8 a giron: Resp-muscle weakness

cound hypoxin from doves

A
Lelecmsy

Continuous Posuave Airway pressure

prevent collapse by controllin PEEP

physioloadPEEN: 9-5 mmify This is modire accords to

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w when we believe they's perfusion/renulation mismatch or low obat

perfusion whole prospecting adequate fixed volume of ta

eg LowPaOa despise 80% frea

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& PEEP -
imple U/R mismath (Collapse (x)
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PEEP & Furthouse pressure bVenous

↑

o much return
F
- ->

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- -
--

MAP is the mostimp I3N 60-80 walls is normal

tidalblume: 8-Dmm/ky

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