air way managment

1. Dr. Mohamed Ibrahem El said
Lecturer of Anesthesia
Zagazig university

2.  Breathing Systems delivery systems which
conduct anesthetic gases from anesthesia
machine to the patients. They include:
 Breathing tubes,
 Fresh gas inlets,
 Adjustable pressure-limiting [APL] valves
 reservoir bags) into the breathing circuit.
 The relative location of these components
determines circuit performance and is the basis
of the Mapleson classification

4.  Magill´s SystemThis system is mostly
efficient during spontaneous breathing.
 Bain System It is efficient during
controlled ventilation

5.  Type F Mapleson or Jackson Rees
SystemIt has a reservoir bag more than
Type E system, allowing assisting or
controlling ventilation. It is used mostly in
children.

6.  Difficult intubation 
 Reported as up to 3% of airway
 Failed intubation in the OR 1 to 3 per 1000
patients
 Difficult airway :
 A clinical situation in which a conventionally
trained anesthesiologist experiences difficulty
in mask ventilation, tracheal intubation or both
 The American Society of Anesthesiologists Task Force on the
Difficult Airway

8. Difficult mask ventilation
 incidence of difficult MV is approximately 1.4%,
 (ASA) defined difficult MV as a situation in which:It is
not possible for the anesthesiologist to provide
adequate ventilation because of one or more of the
following problems: inadequate mask seal, excessive
gas leak, or excessive resistance to the ingress or
egress of gas.

9. Factors affecting mask ventilation
Anesthetic factors
 the experience of the clinician and the use of
equipment.
 The use of incorrectly sized oropharyngeal or
nasopharyngeal airways
 improperly sized mask being used or faults with the
anaesthetic machine or breathing circuit.
 inadequate depth of anaesthesia and inadequate
muscle relaxation may all lead to increased muscle
rigidity, reduced chest wall compliance

10. Patient factors
Physiological reactions
 Laryngospasm
 Bronchospasm
MMMMASK
 M Male gender
 M Mask seal
 M Mallampati 3 or 4
 M Mandibular protrusion
 A Age > 55
 S Snoring and obstructive
sleep apnoea
 K Kilograms (weight)
 OBESE
 O Obese
(BMI>26kg/m2)
 B Bearded
 E Edentulous
 S Snoring
 E Elderly (>55 years)

12. Assessment of The Airway
 Taking an adequate history is necessary to
anticipate possible complications
History should focus on:
 Prior intubations
 Anesthetic history
 Drug allergies
 Confounding illnesses that may hinder airway
access
 A history of difficult intubation has the highest
positive and negative predictive value in
predicting a difficult intubation.

13. Examination
• Patency of nares:
• Mouth opening of at least 2 large finger
• Palate : A high arched palate or a long, narrow mouth
• Protrude the lower jaw beyond the upper incisors
(Prognathism).
• Temporo-mandibular joint movement : It can be restricted
ankylosis/fibrosis, tumors, etc.
• Measurement of submental space (thyromental length should
ideally be > 6 cm).
• Patient’s neck : A short, thick neck is often associated with
difficult intubation. Any masses in neck, extension of neck, neck
mobility and ability to assume ‘sniffing’ position should be
observed.

14.  Hoarse voice/stridor or previous tracheostomy may
suggest stenosis.
 Systemic or congenital disease
 Infections of airway (e.g. epiglottitis, abscess, croup,
bronchitis, pneumonia).
 Physiologic conditions: Pregnancy and obesity
=‘difficult-to mask ventilate
OBES = Obese + Beard + Edentulous + Snoring

15. Specific tests for assessment
1- Mallampatti test:
 The Mallampati classification correlates tongue size to
pharyngeal size.
 This test is performed in the sitting position,
 head in a neutral position
 The mouth wide open and the tongue protruding to its
maximum.
 Class I : Visualization of the soft palate, fauces; uvula, anterior and
the posterior pillars.
 Class II : Visualization of the soft palate, fauces and uvula.
 Class III : Visualization of soft palate and base of uvula.
 Class IV: Only hard palate is visible. Soft palate is not visible at all.

16. 2. Atlanto occipital joint (AO) extension :
 It assesses feasibility to make sniffing position for
intubation i.e. alignment of oral, pharyngeal and laryngeal
axes into an arbitrary straight line.
 The patient is asked to hold head erect, facing directly to
the front,  extend the head maximally and the examiner
estimates the angle traversed by the occlusal surface of
upper teeth. Measurement can be by simple visual
estimate or more accurately with a goniometer. Any
reduction in extension is expressed in grades:
 Grade I : >35°
 Grade II : 22°-34°
 Grade III : 12°-21°
 Grade IV : < 12°
 Normal angle is 35° or more

17. 3. Mandibular space
 Thyromental (T-M) distance (Patil’s test): mentum to
the thyroid notch with patient’s neck is fully extended.
difficult if the T-M distance is < 3 finger breadths or < 6
cm in adults; 6-6.5 cm is less difficult, while > 6.5 cm is
normal.
 Sterno-mental distance: suprasternal notch to the
mentum with head fully extended on the neck with the
mouth closed. A value of less than 12 cm is found to
predict a difficult intubation.
 Mandibulo-hyoid distance: Measurement of mandibular
length from chin (mental) to hyoid should be at least 4
cm or three finger breadths. It was found that
laryngoscopy became more difficult as the vertical
distance between the mandible and hyoid bone
increased.

19. LEMON airway assessment method :
L = Look externally (facial trauma, large incisors, beard or
moustache, large tongue)
E = Evaluate the 3-3-2 rule (incisor distance-3 finger breadths,
hyoid-mental distance-3 finger breadths, thyroid-to-mouth
distance-2 finger breadths)
M = Mallampati (Mallampati score > 3).
O = Obstruction (presence of any condition like epiglottitis,
peritonsillar abscess, trauma).
N = Neck mobility (limited neck mobility) Patients in the difficult
intubation group have higher

20. Direct laryngoscopy and fibreoptic bronchoscopy
 Difficulty in intubation can be classified to 4 grades of
laryngoscopic views were defined by Cormack and
Lehane
 Grade I – Visualization of entire laryngeal aperture.
 Grade II – Visualization of only posterior commissure
of laryngeal aperture.
 Grade III – Visualization of only epiglottis.
 Grade IV – Visualization of just the soft palate.
 Grade III and IV predict difficult intubation.

21. Skeletal film Lateral cervical x-
ray film of the patients with
head in neutral position closed is
required for the following
measurement:
 Mandibulo-hyoid distance:
 Atlanto-occipital gap
 Relation of mandibular angle
and hyoid bone with cervical
vertebra
 Anterior/Posterior depth of the
mandible:
 C1-C2 gap

22. Predictors of difficult airway
in diabetics
Palm print: The patient is
made to sit; palm and
fingers of right hand are
painted with blue ink,
patient then presses the
hand firmly against a white
paper placed on a hard
surface. It is categorized as:
 Grade 0 – All the phalangeal areas are visible.
 Grade 1 – Deficiency in the interphalangeal
areas of the 4th and 5th digits.
 Grade 2 – Deficiency in interphalangeal areas of
2nd to 5th digits.
 Grade 3 – Only the tips of digits are seen.
 Prayer sign: Patient is
asked to bring both the
palms together as
‘Namaste’ and sign is
categorized as–
Positive – When there is
gap between palms.
Negative – When there is
no gap between palms

23. Assessment of pediatric airway
 Comprehensive history and physical examination.
 History:
 Questions regarding complaints of snoring, apnea, day time
somnolence, stridor, hoarse voice and prior surgery or
radiation treatment to face or neck should be made.
 This information may indicate hypoxemia and pulmonary
hypertension.
 History should also consist of a review of previous anesthetic
records.
 History of oropharyngeal injury, damage to teeth, awake
tracheal intubation.
 Postponement of surgery following an anesthetic.
 ildren.

24. Physical examination: It should focus on the anomalies
of face, head, neck and spine.
 Evaluate size and shape of head, gross features of the
face; size and symmetry of the mandible, presence of
sub-mandibular pathology, size of tongue, shape of
palate, prominence of upper incisors, range of motion
of jaw, head and neck.
 The presence of retractions (suprasternal/sternal/
infrasternal/ intercostal) should be sought for they
usually are signs of airway obstruction.
 Breath sounds – Crowing
 Blood gas and O2 saturation  ability to compensate
for airway problems.

25.  Size of tongue relative to oral cavity and pharynx and
laryngoscopy as determined by Cormack and Lehane.
 Mallampati with poor view of glottis during direct
laryngoscopy in pediatric patients due to lack of cooperation in
infants and young children.
 The mandibular space assessment is mainly suitable for older
children Thus values for thyromental, hyomental and
horizontal mandibular lengths do not exist for the pediatric
population.
 This places the pediatric anesthesiologist at a disadvantage and
increases the likelihood of being confronted with an
unexpected DA.

31. Equipment
 Oral & Nasal Airways
 Face Mask
 Laryngeal Mask
 Combitube
 Tracheal Tube
 Laryngoscope
 Flexible Fiberopitc Bronchoscope

32. Oral & Nasal Airways
 The most common cause of airway
obstruction is the tongue
 To overcome the obstruction:
 Head tilt
 Jaw thrust
 To maintain the patency of the airway:
 Create airway passage by:
 Oral airway
 Nasal airway

33. Oral Airways
Oropharyngeal Airway
 Designed to relieve
obstruction caused by the
tongue
 Assist in mask ventilation
 Complications:
 Initiation of gag reflex
 Vomiting
 Aspiration
 Laryngospasm
 Damage to teeth and lips

34. Oral Airways
Cuffed Oropharyngeal Airway (COPA)
 It is a modified version of the
oral airway
 Displaces the tongue
 Provides an airtight seal
 Elevates the epiglottis
 When compared to the LMA,
the COPA has been shown
to provide similar results
physiologically
 Requires more manipulation
for placement

35. Nasal Airways
Nasopharyngeal Airway
 Preferable to the oral in cases such as
in
 Pharyngeal trauma
 Too facilitate nasotracheal
intubation
 Length Estimation:
 Distance from the nares to meatus
of the ears
 2-4 cm longer than the oral airway
 Insertion:
 Lubrication
 Inserted along the floor of the
nasal passage
 Contraindications:
 Patient on anticoagulant therapy
(Epistaxis)
 Prominent adenoids
 Basilar skull fracture

36. Face Mask
 Airtight seal with patient’s
face
 Delivery of oxygen and
anesthetic gas
 Attached to breathing circuit
through the orifice
 Black rubber is highly pliable
 Transparent type allows to
see:
 Humidity
 Vomiting
 Retaining hooks attached to
head strap

37. Face Mask
 Technique:
 Usually:
 The mask is held in place with the left hand
 Thumb and index finger press on the body of the mask
 Middle and ring finger grasp the bony part of the mandible
 Little finger is placed under the angle of the jaw to thrust it
anteriorly
 Right hand to squeeze the bag
 Difficult cases:
 2 hands:
 Jaw thrust (by finger tips to displace the jaw forward)
 Mask seal (by the thumbs pressing the mask)
 Assistant to squeeze the bag
 Low positive-pressure ventilation (20 cm H2O)

38. Face Mask
 Complications:
 Airway obstruction:
 Too much pressure on mask
 Ball-valve effect of jaw thrust
 Pressure injury to branches of Trigeminal or
Facial nerves
 Corneal abrasions:
 Tape the eyes shut to avoid it

39. Laryngeal Mask Airway
 High success rates (95-99%)
 Uses:
 Alternative a face mask
or ET tube
 To facilitate ventilation
and passage of ET tube
with a difficult airway
 Aid in ventilation during
fiberoptic bronchoscopy
 Partially protects the larynx
from pharyngeal secretions
 Does not protect against
gastric regurgitation

40. Laryngeal Mask Airway
 Insertion:
 Requires a slightly greater anesthetic depth than that
of the oral airway
 Lubrication of the deflated cuff
 Blind insertion until it reaches the hypopharynx
 Inflate the cuff → low-pressure seal around the
entrance of the larynx
 Secured in place by tape
 Should remain in place until patient regains airway
reflexes
 Insertion under direct visualization (laryngoscope,
fiberoptic laryngoscope) is beneficial in difficult cases
 Partial inflation before insertion may be helpful

41. Laryngeal Mask Airway
LMA vs Face Mask
 Advantages
 Hands-Free
 Better seal in bearded
patient
 Less cumbersome in
ENT surgery
 Easier to maintain airway
 Protects against airway
secretions
 Less facial nerve and
eye trauma
 Less operating room
pollution
LMA vs Tracheal Tube
 Advantages
 Less invasive
 Useful in difficult
intubation
 Less tooth and laryngeal
trauma
 Less laryngospasm and
bronchospasm
 Does not require muscle
relaxation
 Does not require neck
mobility
 No risk of esophageal or
endobronchial intubation

42. Laryngeal Mask Airway
LMA vs Face Mask
 Disadvantages
 More invasice
 More risk of airway
trauma
 Require new skill
 Deeper anesthesia
required
 Requires some TMJ
mobility
 N2O diffusion into cuff
 Multiple contraindications
LMA vs Tracheal Tube
 Disadvantages
 Increased risk of
gastrointestinal
aspiration
 Less safe in prone
position
 Limits maximum PPV
 Less secure airway
 Greater risk of gas leak
and pollution
 Can cause gastric
distention

43. Laryngeal Mask Airway
 Contraindications:
 Pharyngeal pathology (abscess)
 Pharyngeal obstruction
 Full stomachs (pregnancy, hiatal hernia)
 Low pulmonary compliance
 Requiring peak inspiratory pressure > 30 cm H2O
 Bronchospasm
 High airway resistance

44. Tracheal Tubes
 Uses
 Deliver anesthetic gases
to the trachea
 Control ventilation &
oxygenation
 Made of polyvinyl chloride
 Murphy tubes have Murphy
eyes → decrease risk of
occlusion
 Resistance:
 Tube diameter
 Tube length
 Tube curvature

45. Tracheal Tubes
 Cuffs
 Valve, pilot baloon, inflating tube
 Creats a tracheal seal
 allowing PPV
 Deacrease likelihood of aspiration.
 Pressure
 High pressure
 more ischemic damage
 Low pressure
 sore throat
 Aspiration
 Spontaneous extubation
 Difficult insertion (floppy cuff)
 More commonly used

46. Tracheal Intubation
 Correct placement is confirmed by:
 Direct visualization of the ET tube cuff passing the
vocal cords
 Presence of ETCO2 on three consecutive breaths
 Absence of stomach “gurgling” sound made by
air entering the stomach
 Equal bilateral breath sounds over the lungs
 Fogging of the ET tube
 Refilling of the ventilatory bag with expiration
 Chest x-ray may be used to confirm placement of
tube

47. Combitube
 Consists of 2 fused
tubes
 The longer tube:
 Occluded distal tip
 Side perforations
 The shorter tube:
 Open tip
 No side perforations
 2 inflatable cuffs:
 100 ml proximal cuff
 15 ml distal cuff

48. Combitube
 Technique:
 Blindly inserted through the mouth
 Black rings have to be between the upper & lower
teeth
 Both cuffs should be fully inflated after insertion
 The distal part of the tube will lie in the esophagus 95%
of the time:
 The longer tube forces air to the larynx through
perforations
 The shorter tube acts as a gastric decompressor
 If it entered the trachea:
 Gas will be directed into the trachea through the
perforations

49. Combitube
 Uses:
 Managing difficult airway in ACLS
 It is rarely used
 LMA and others are preferred

50. Laryngoscope
 Uses in general:
 Examine the larynx
 Facilitate intubation of the trachea
 Rigid Laryngoscope:
 Composed of:
 Handle
 Flange
 Blade
 Bulb
 Different Types
 Choice depends on preference
and patient anatomy

51. Laryngoscope
 Specialized Laryngoscope:
 Bullard Laryngoscope
 Wu Laryngoscope
 Both have:
 Fiberoptic light sources
 Curved blades with elongated tips
 Uses & Advantages:
 Visualize glottic opening in patients
with large tongues
 Visualize very anterior glottic
opening
 Anticipated difficult intubation
 Trauma settings
 Easy portability
 Disadvantages:
 Unfamiliarity
 Cost
Bullard
Laryngoscope
Wu
Laryngoscope

52. Alternative Airway
Techniques

53. Transtracheal Jet Ventilation
 Placing a large bore catheter (14-gauge) through the
cricothyroid membrane into the trachea
 Confirmed by aspiration of air before connecting to
the ventilation system
 Provides a temporary airway until an alternate airway
is established
 Complications:
 Aspiration
 Bleeding
 Pneumothorax
 Subcutaneous emphysema
 Inadequate ventilation

54. Fiberoptic Bronchoscopy
 The bronchoscope may facilitate the placement of an ET tube
both nasally and orally
 The scope is passed through the glottis for indirect visualization
of the vocal cords, at which time the trachea is entered
 The bronchoscope may identify causes of acute hypoxia, and
may help to remove secretions in the airway
 Indications:
 History of difficult intubation
 Upper airway abnormality
 Poor range of motion of TMJ
 Cases of impossible neck extension (unstable cervical
spine)
 Awake intubation

56. Lightwand
 A malleable stylet with a small light bulb on the end
 An ET tube is placed over the lightwand and is
inserted into the mouth
 Once at the tip of the larynx, the ET tube is slipped
into the larynx
 If the ET tube happens to enter the esophagus, the
light dims
 The ET tube may then be withdrawn, and another
attempt at placement is attempted
 This technique must be practiced in a darkened
room, limiting its use to a controlled setting

57. Surgical Airway
 Indications:
 When other means of establishing an airway fail
 Laryngeal trauma
 Facial injuries
 Long term need of ventilatory support
 Technique:
 Cricothyroidotomy is the preferred method of a surgical airway
 It involves the opening of the cricothyroid membrane for placement of a tracheal
tube
 Complications:
 Bleeding
 Infection
 Vocal cord damage
 Tracheal stenosis
 Contraindications:
 Age <12 years
 Laryngotracheal disruption
 Coagulopathy
 Tracheostomy:
 Indicated when cricothyroidotomy is contraindicated
 Percutaneous dilational tracheostomy is a faster procedure with fewer
complications than a surgical tracheostomy

58. THANK
YOU