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Airway Management
Airway Management
ANATOMY
Successful intubation, ventilation, cricothyrotomy, and regional anesthesia of the larynx require detailed knowledge of airway anatomy. There are two openings to the human airway: - pars nasalis - pars oralis
Loss of upper airway muscle tone in anesthetized patients allows the tongue and epiglottis to fall back against the posterior wall of the pharynx Technique for opening the airway : triple airway maneuver : head tilt, chin lift, jaw trust To maintain the opening, though, an artificial airway can be inserted through the mouth or nose to create an air passage between the tongue and the posterior pharyngeal wall
Because of the risk of epistaxis, nasal airways should not be used in anticoagulated patients or in children with prominent adenoids also, nasal airways should not be used in any patient who has a basilar skull fracture
EQUIPMENT STATICS
S : scope -> stethoscope, laryngoscope T : tube A : airway equipment T : tape I : introducer , stylet, mandrain C: connector S : suction
Rigid Laryngoscopes
A laryngoscope is an instrument used to examine the larynx and to facilitate intubation of the trachea. The Macintosh and Miller blades are the most popular curved and straight designs The choice of blade depends on personal preference and patient anatomy
A rigid laryngoscope
Tracheal Tubes
TTs can be used to deliver anesthetic gases directly into the trachea and allow the most control of ventilation and oxygenation TTs are most commonly made from polyvinyl chloride The patient end of the tube is beveled to aid visualization and insertion through the vocal cords Murphy tubes have a hole (the Murphy eye) to decrease the risk of occlusion should the distal tube opening abut the carina or trachea
TTs have been modified for a variety of specialized applications Flexible, spiral-wound, wire-reinforced TTs resist kinking and may prove valuable in some head and neck surgical procedures or in the prone patient
Age
Full-term infant
Child
Adult Female
6.5-7.0
24
Male
7.59.0
24
Effective ventilation requires both a gas-tight mask fit and a patent airway The mask is held against the face by downward pressure on the mask body exerted by the left thumb and index finger The middle and ring finger grasp the mandible to facilitate extension of the atlantooccipital joint The little finger is placed under the angle of the jaw and used to thrust the jaw anteriorly, the most important maneuver to allow ventilation to the patient
TECHNIQUES OF DIRECT LARYNGOSCOPY & INTUBATION Intubation is not a risk-free procedure, however, and not all patients receiving general anesthesia require it Successful intubation often depends on correct patient positioning Moderate head elevation (510 cm above the surgical table) and extension of the atlantooccipital joint place the patient in the desired sniffing position
Orotracheal Intubation
The laryngoscope is held in the left hand With the patient's mouth opened widely, the blade is introduced into the right side of the oropharynx The tongue is swept to the left and up into the floor of the pharynx by the blade's flange The TT is taken with the right hand, and its tip is passed through the abducted vocal cords
After intubation, the chest and epigastrium are immediately auscultated If there is doubt about whether the tube is in the esophagus or trachea, it is prudent to remove the tube and ventilate the patient with a mask
Difficult Airway
Other clues to a potentially difficult laryngoscopy include :
limited neck extension (< 35) a distance between the tip of the patient's mandible and hyoid bone of less than 7 cm a sternomental distance of less than 12.5 cm with the head fully extended and the mouth closed a poorly visualized uvula during voluntary tongue protrusion (Mallampati classification)
Complications of Intubation
During laryngoscopy and intubation Malpositioning
Esophageal intubation Bronchial intubation
Airway trauma
Dental damage - Lip, tongue, or mucosal laceration - Sore throat - Dislocated mandible Hypoxia, hypercarbia Hypertension, tachycardia Intracranial hypertension , Intraocular hypertension Laryngospasm
Physiological reflexes
Complications of Intubation
While the tube is in place Malpositioning
Unintentional extubation, Bronchial intubation, Laryngeal cuff position
Airway trauma
Mucosal inflammation and ulceration
Laryngospasm