An Introduction to Anaesthesia 201

Airway
Dr Mark Lambert
Consultant in Anaesthesia
Royal National Throat Nose and Ear
Hospital

Scary things in anaesthesia

1 - Bad airways
2 Sick kids
3 Sick kids with bad airways

Airway

Because it all starts with A

Any hint of an airway problem means that
anaesthetist gets called
Most airways are easy

Learning outcomes
Recognise airway anatomy
Prepare a framework for managing the airway in
theatres
Discriminate easy and difficult airways
Outline plans for failed airway management

Anatomy

The Glottis

Why do anaesthetists need to manage the

airway?
Anaesthetic drugs
Depress/abolish airway reflexes
Cause relaxation of upper airway muscle tone
Cause respiratory depression / apnoea

In an emergency
Acute airway obstruction
Failure to oxygenate/ventilate

Pharyngeal structures

A typical anaesthetic...

Jeremy H, 49 from London, needs his broken

hand fixed
You give your best anaesthetic
5 seconds later : hes asleep
15 seconds later : apnoea
What are you going to do next?

Ventilate with facemask

Put in an LMA
Tracheostomy
Intubate

Ask your
ODA/ODP/anaesthetic
nurse to bail you out

Call for help

Fibreoptic laryngoscopy
Go for coffee

Change specialty

Get out iPhone

Always think about.

Oxygenation

Preoxygenation

Minimal oxygen stores in the body

Functional residual capacity 2500ml
Oxygen demand 250ml/min
Allows time before desaturation
But rising CO2

Beyond preoxygenation
THRIVE :
High flow oxygen
Apneoic mass transfer
of O2 to alveoli
Prolonged apnoea time
without desaturation

Facemask ventilation

The most important anaesthetic skill ???

Harder than it looks
One person / two person
Adjuncts

Know where your facemask is

Back up self inflating bag location

Facemask ventilation adjuncts

Oropharyngeal airway

Size : Incisor to angle of jaw (or ask your ODA)

Facemask ventilation adjuncts

Nasopharyngeal airway
Size :
Women
Men

6
7

Use plenty of lube (and go carefully if you suspect

basal skull fracture)

Back to Jezza
Hes easy to facemask ventilate
Will we hold a mask on his face for the entire
case?
Other airway options include
Laryngeal mask airway
Endotracheal tube

Laryngeal mask airway (LMA)

Blind insertion
Cuff to improve seal
Hands free
Sits above the glottis

Variety of second generation devices available but

all work on a similar principle

Second generation SADs (LMAs)

LMA position

Like a facemask over

the larynx
Doesnt protect against
aspiration of gastric
contents
May be helpful in
difficult facemask
ventilation

Endotracheal tube

A secure airway is a cuffed

tube in the trachea
Allows ventilation
Protects against aspiration

Normally placed under direct

vision (laryngoscopy)

Direct Laryngoscopy
Uses a metal blade with a light
source to create a direct line of
sight to the glottis
Can be stressful (for you and
the patient)
Laryngoscopes come in a
variety of shapes and sizes

Video-laryngoscopy
Uses a camera and screen to
allow visualisation of the glottis
without direct line of sight

Fibre-optic Laryngoscopy
Fibreoptic scope used
to provide an indirect
view of the
glottis/trachea
Scope then used as a
guide to pass ETT into
trachea

The view from a laryngoscope

The Glottis

Recognising when airway management is

going to be difficult
History
Previous anaesthetic problems
Congenital disorders associated with difficult airway (Anatomy)
Co-morbid conditions (Pathology)
Examination
General appearance
Specific tests
Special investigations
Rarely used (nasal endoscopy/CT)

Specific airway tests

Mallampati
Mouth opening
C la s s 1

Neck movement
Thyromental distance

Jaw protrusion

f0 1 -0 1 -1 0 4 5 1 3 7

C la s s 2

C la s s 3

C la s s 4

Oral / tracheal axis

Sometimes its obvious

But.
Tests are notoriously unreliable and focus on
difficult intubation
Difficult facemask ventilation is more worrying
than difficult intubation
Beards / big neck / high BMI / Elderly

Trust your instincts!

Ask for senior advice or help early

Planning for failure

Always have a plan B for managing the airway
(and communicate this to the rest of the team)
If not possible to place an endotracheal tube what next?
Plan B LMA (and call for help)
Plan C Facemask ventilation + Guedel (+/- wake up)
Plan D Emergency cricothyroid puncture

Guidelines exist to help plan for the unexpected

but its much easier if youve identified trouble
beforehand

Extubation
Taking the airway device out can be as risky as
putting the device in
Increasing recognition of this
Improved training / support
Guidelines (Difficult airway society)

If you had difficulties at intubation then extubation

also likely to be troublesome

Key Points
Always think oxygenation
Consider whether mask ventilation or intubation
(or both) will be a problem
Trust your instincts
Ask for help early

Have a back-up plan ready and make sure

everyone else knows what it is

Learning outcomes
Recognise airway anatomy
Prepare a framework for managing the airway in
theatres
Discriminate easy and difficult airways
Outline plans for failed airway management

Please ask your questions now.

Thanks!