Airway management
Objectives
• Review of airway anatomy
• Airway assessment and detecting an anticipated difficult airway
• 7Ps of airway management
• Mastering bag-mask ventilation
• Understanding DAS algorithms
Goals to airway management
• Airway patency
• Ventilation
• Prevent aspiration
• Difficult intubation
• When an appropriately trained and experienced anaesthesiologist requires
more than 3 attempts or longer than 10 minutes for successful endotracheal
intubation
• Difficult ventilation
• When a trained clinician is unable to maintain an oxygen saturation of more
than 90% when a facemask is being used for ventilation, and 100% FiO2 is
used for oxygenation
Airway anatomy
Airway assessment
Predicting a difficult airway
• History
• Previous difficulty
• Trauma
• Midface, neck and mandible injury
• Bleeding into airway
• Burns
• Caustic ingestion
• Foreign body
• Pregnancy
• Congenital
7 Ds of difficult airway in patients
• Disproportion
• Distortion
• Decreased TMD
• Decreased IID
• Decreased neck ROM
• Decreased SMD
• Dental overbite
Bedside tests
• 1. Thyromental, interincisor and Sternomental distances
• 2. Mallampati classification / score
• 3. Neck mobility (extension at the atlanto-occipital joint)
• Thyromental distance:
• the distance in the midline from the mentum (chin) to the thyroid notch. This measurement is
performed with the patient's neck fully extended. A thyromental distance of < 3 finger-
breadths, or < 6 cm in adults.
• Sternomental distance:
• the distance of the lower mandible in the midline from the mentum (chin) to the sternal notch.
This measurement is performed with the patient's neck fully extended. A distance of < 12 cm
• Interincisor distance:
• is the distance between the incisors when the patient opens their mouth as widely as possible.
A distance of < 3 finger-breadths, or < 4 cm in adults
7Ps
• Preparation & Pre-treatment
• Preoxygenation
• Position
• Paralysis and induction
• Pass the tube
• Proof of placement
• Post-intubation care
Preparation and pretreatment
• Use checklists
• Roles: Airway lead, Monitors,drips & drugs, airway assistant
• Airway Plan – RSI vs modified RSI vs DSI
• Patient:
• Airway assessment
• Hemodynamic stability (Hypovolemic?, Septic?)
• Equipment & Drugs:
• monitors (Saturation, BP, ECG), ventilator setup
• drugs labelled and drawn up & adequate IV access
• equipment for intubation – 4m’s & 4s’s
• emergency trolley & defib
• 4Ms
• Machine (anesthetic/ventilator)
• Monitor
• Medicines
• Medical assistant
• 4Ss
• Suction
• Syringes
• System (IVI)
• SMALL equiment
• Mask, magill forceps
• Airway, ambu bag
• Laryngoscope, LMA
• ETT
• Stylet, syringe (air)
Pre-intubation optimization
• Pre-intubation optimization
• Haemodynamic stability – may give IV fluids prior to intubation
• Cautious fluids in patients at risk ARDS – don’t want to overload
• Aspiration risk - Sodium citrate, Ranitidine, PPI, metoclopramide
• Anxiety – low dose Ketamine 0.2mg-0.5mg/kg (DSI)
• Push dose pressors might be needed for risk of hemodynamic decompensation – Phenylephrine
100mcg, adrenaline 10ug
• Other drugs: IV lignocaine, atropine, glycopyrolate
Anesthetic equipment
• Oxygen delivery devices
• Face mask
• Guedel oropharyngeal/nasopharyngeal airway
Routine airway trolley
Oxygen therapy
Suction
• • Essential for maintaining patients airway
Soft Vs Rigid Suction Catheters
Catheter type Where to use Use for
Soft Mouth & nose • Aspiration of thin secretions oropharynx/nasopharynx
• Intratracheal suctioning
• ET tube deep suctioning, OPA, NPA
Rigid Oropharynx • Thick particulate material from oropharynx
Supraglottic airway devices
• Provide an airway for oxygenation without entering the trachea
• Lubricated LMA inserted into hypopharynx
• Inflate cuff
• MR not necessary
• Indications:
• Primary device (CPR) to oxygenate and ventilate
• Rescue device (failed intubation)
• Short anaesthetic procedures
• Contraindications:
• Risk of aspiration
• Trauma to oropharynx
• Disease of oropharynx – mucosal perforation ( Caustic ingestion, varices)
• Foreign body: risk of pushing foreign body into trachea
• Need for high peak pressures
• Patients with low lung compliance
Pre-oxygenation
• Essentially denitrogenate – 3-5min @100% FiO2
• Significantly delays the time to desaturation
• Non rebreather with nasal prongs –apnoeic ventilation (Nasal oxygen during efforts at securing a
tube (NO DESAT)
• BVM – ensure an adequate seal + PEEP
• CPAP/BIPAP well fitted mask in closed circuit
• Upright posture or reverse Trendelenburg can help
Positioning
Paralysis and induction
• RSI – Push drugs fast – should be able to intubate @ 30-45sec
• Delayed sequence intubation – agitated patient – aggressive – often mislabelled as difficult patient –
hypoxic – Low dose ketamine 0.20.5mg/kg
• Preinduction agents
• Fentanyl 1-3mcg/kg (opioid)
• Iv lignocaine – 1-1.5mg/kg (Blunting of airway response)
• Induction agents:
• Propofol – onset rapid 30-45sec, duration of action 5-10 min
• -Dose 1.5-2.5mg/kg – reduced dose in elderly and those at risk hypotension
• -Supress airway reflexes and produce apnea, dose dependant venodilation/arteriodilation &
decreased cardiac contractility
• Ketamine – 1-2mg/kg Onset 1 min, (length 10 to 20 minutes)
• -intact autonomic nervous system- ↑sympathetic tone(↑BP, P, CO) - Direct cardiac depressant
(Profound hypovolemic, depleted sympathetic reserves)
• Induction agents:
• Etomidate: 0.2-0.4mg/kg, (rapid onset 30-45sec)
• Does not vasodilate or cause myocardial depression – cardio stable so not cause
hypotension
• Does have adrenal suppression and prevent cortisol response within first 12hours - pt unable
to respnd to stress (single dose not affect mortality rate)
• Midazolam: 0.2mg/kg (Onset 30 to 60 seconds)
• Duration 15-30 min
• causes moderate hypotension – 10-25% resp depression common with opiods
• Amnesic effect, supplements sedation
• Muscle relaxants:
• Suxemethonium – 1.5mg/kg – 30-60sec
• Duration 7-12min
• Contraindication – Hyperkalemia, Burn Patients, extensive tissue
trauma, anaphylaxis
• Fasciculations occur
• Bradycardia – have atropine ready
• Rocuronium: 1.2mg/kg – length of block is 30-70 minutes
• Caution in the difficult airway
• Emergency drugs:
• Adrenalin 10mcg boluses
• Phenylephrine – 100mcg boluses (beware bradycardia)
• Ephedrine 5-10mg boluses
• Atropine – 200-500mcg bradycardia
Pass the tube
• Step 1: Open the mouth sufficiently to allow blade insertion without traumatizing the teeth
• Step 2: Insert the blade and control the tongue
• Step 3: Carefully advance the blade toward the epiglottis in a controlled manner, gently lifting the
blade tip every few millimetres
• Step 4: Advance the tip of the blade into the vallecula, the recess between the base of the tongue
and the epiglottis
• Step 5: Identify the best spot for elevating the epiglottis (hyoepiglottic ligament (HEL)
• Step 6: Lift the laryngoscope in the direction of the handle, thereby exposing the glottis; do not lever
back on the teeth with the laryngoscope handle
• Step 7: Optimize the glottic view as needed with external laryngeal manipulation, head elevation,
and neck flexion
• Step 8: Place the tracheal tube
Proof of placement
• Waveform capnography is the most accurate means of confirming ETT placement
• capnometry or colorimetric ETCO2 devices can be used
• visualization of the ETT through the cords
• Auscultation of breath sounds over the lung fields 5 point
• misting of the tube with ventilation
• Chest radiograph
• Ultrasound
• Flexible intubation scope (FIS)
Bag mask ventilation
• Successful bag-mask ventilation depends on three things:
• Patent Airway
• Adequate mask seal
• Proper ventilation (Volume, rate)
• Core anesthetic skill
• Head and neck should be maintained with lower C-spine flexed and
upper C-spine extended (sniffing position)
• Use C-grip – thumb and index finger are used to hold the mask,
pushing downwards, remaining three fingers pull the chin and jaw
(with fingers holding the bony elements of the mandible) and soft
tissues up into the mask and also maintain head and neck positions
• Manual ventilation performed with anesthetist’s other hand
• May need to use two people
• Mask seal is problematic:
• Edentulous
• Bearded
• Morbidly obese (require high ventilation pressures)
Ventilation, volumes, rates and
cadence
• Three critical errors should be avoided:
• Giving excessive tidal volumes
• Forcing air too quickly
• Ventilating too rapidly
• Volume large enough to visualise chest rise (6-8ml/kg)
• Give breath over 1 second at rate not exceeding 10-12/bpm (CPR30:2)
• Excessive ventilation avoided: Gastric insufflation (aspiration), ↑ intrathoracic pressure, ↓ venous
return, ↓ CO & survival
Troubleshooting problems with BMV
• Inadequate mask seal – facial hair, edentulous?
• Improper mask size: Corners of mouth & all adjuncts inside the body of the mask
• Lack of airway adjuncts: OPA/NPA
• Inadequate airway manoeuvres: Head tilt/Jaw thrust
• Inexperienced healthcare worker: seek help if not comfortable
Thank you
• Questions
• Comments
