AIRWAY MANAGEMENT establishing, maintaining & removing artificial airway with complications.

Dr. Chetan Goyal

AIRWAY MANAGEMENTAssessment Mallampati score, mouth opening, thyromental distance Securing & maintenance airway devicesArtificial airwaySupraglottic airway devicesTracheal tubeDevices for difficult airway

Management of complications

AIRWAY ASSESSMENT Cervical spine movementT-M joint movementMouth openingModified Mallampati gradingThyromental distance

ARTIFICIAL AIRWAYPurpose of an airway lift the tongue and epiglottis away from the posterior pharyngeal wall.Advantage of an airway Cervical spine movement does not occur when airway is inserted.Decreased work of breathing during spontaneous respiration using a face mask.

Types

Oropharyngeal airwayNasopharyngeal airway

AIRWAY ANATOMYNormal

Obstructed airway

OROPHARYNGEAL AIRWAYGuedel airway Parts flange, bite portion, air channel

OROPHARYNGEAL AIRWAY (contd.)Sizes available

Colour coding

SizesLength (mm)00030004005016027038049051006110

OROPHARYNGEAL AIRWAYS (contd.)Uses To maintain open airwayPrevent endotracheal tube occlusionPrevent tongue biteFacilitate suctionConduit for passing devices into oropharynxObtain a better mask fit

Contraindications Intact gag reflexOropharyngeal growth

OROPHARYNGEAL AIRWAY (contd.)Pre requisite for insertionSize estimationMethods of insertionDisadvantages - Due to incorrect sizeLaryngospasm in awake patientAdvantages -1) Simple to use, cheap.2) Not associated with sore throat3) Does not cause bacteremia

NASOPHARYNGEAL AIRWAYParts flange, airway channel, bevel.Size - inside diameter in millimeters.Size determination Method of insertion

Contraindications 1) Anticoagulation 2) Basilar skull fracture3) Nasal pathology, sepsis, or deformity of the nose or nasopharynx 4) History of epistaxis requiring medical treatment.

NASOPHARYNGEAL AIRWAY (contd.)

Uses of nasopharyngeal airway To maintain airway in patients with intact gag reflexTo facilitate suctioningAs a guide for a fiberscope or nasogastric tubeTo apply continuous positive airway pressure (CPAP)To dilate the nasal passages in preparation for nasotracheal intubation To maintain the airway and administer anesthesia during dental surgery.To maintain ventilation during oral fiberoptic endoscopy.

NASOPHARYNGEAL AIRWAY (contd.)Advantages- 1) Nasal airway is better tolerated than an oral airway if the patient has intact airway reflexes. 2) Loose or poor dentition. 3) Trauma or pathology of the oral cavity. 4) It can be used when the mouth cannot be opened.

COMPLICATIONS OF ARTIFICIAL AIRWAYAirway Obstruction TraumaTissue EdemaUlceration and NecrosisCentral Nervous System TraumaDental DamageLaryngospasm and CoughingRetention, Aspiration, or SwallowingDevices Caught in AirwayEquipment FailureLatex AllergyGastric Distention

SUPRAGLOTTIC AIRWAY DEVICES

Supraglottic devices fill a niche between the face mask and tracheal tube in terms of both anatomical position and degree of invasiveness.

These devices sit outside the trachea but provide a handsfree means of achieving a gas-tight airway.

SUPRAGLOTTIC AIRWAY DEVICES Laryngeal Mask Airway Family LMA ClassicLMA UniqueLMA FlexibleLMA FastrachLMA CTrachLMA Proseal2) Other supraglottic airways similar to laryngeal mask Soft seal laryngeal maskAmbu laryngeal maskIntubating laryngeal airway3) Other supraglottic airway devicesLaryngeal tube airwayPerilaryngeal airwayStreamlined pharynx airway liner

LARYNGEAL MASK AIRWAY FAMILYLMA-Classic (standard LMA, Classic LMA, LMA-C, cLMA)

PARTS Curved tube (shaft) Elliptical spoon-shaped mask Two flexible vertical bars.An inflatable cuff. An inflation tube Self-sealing pilot balloon. 15-mm connector .

cLMA size Patient size1Neonates/infants up to 5 kg 1.5Infants between 5 and 10 kg 2 Infants/children between 10 and 20 kg

2.5Children between 20 and 30 kg3Children 30 to 50 kg4Adults 50 to 70 kg 5Adults 70 to 100 kg 6Adults over 100 kg.

LMA CLASSICInsertion methods Standard Technique180-degree TechniquePartial Inflation TechniqueThumb Insertion Technique

LMA-UNIQUE

Disposable laryngeal mask airway, DLMA). It is made of polyvinylchloride The dimensions are identical to the standard LMA, the tube is stiffer and the cuff less compliant. Sizes It may be a better choice for out-of-hospital or ward use.Insertion and placement of the LMA-Unique is similar to the LMA-Classic. The intracuff pressure increases significantly less in the LMA-Unique when nitrous oxide is used.

LMA-FLEXIBLE

The LMA-Flexible (wire-reinforced, reinforced LMA, RLMA, FLMA, flexible LMA) has a flexible, wire-reinforced tube. The tube is longer and narrower. Not available in sizes 1 and 1.5Useful for head and neck surgeriesInsertion method Disadvantages - 1) The wire reinforcement does not prevent obstruction from biting. 2) The spiral reinforcing wire may become disrupted. 3) Only small sizes of tracheal tube or bronchoscope can pass through it.4) Not preferred prolonged spontaneous ventilation.5) Unsuitable for MRI scanning 6) Malposition is less easily diagnosed.

LMA-FASTRACH

The LMA-Fastrach (intubating LMA, ILMA, ILM, intubating laryngeal mask airway) designed for tracheal intubation.Parts 1) A short, curved stainless steel shaft with a standard 15-mm connector. 2) Single, movable epiglottic elevator bar3) A V-shaped guiding ramp built into the floor of the mask.

LMA-FASTRACH

Insertion technique

UsesTo facilitate tracheal intubationIt can also be used as a primary airway device.

Tracheal Intubation using LMA Fastrach Blind, Blind nasal Fiberscopic guidedLight guided

LMA-FASTRACH

DisadvantagesPharyngeal pathology or limited mouth opening may make intubation difficult.Cannot be used for intubation in patients below 30 kg.The LMA-Fastrach tracheal tube is expensive & prolonged use is to be avoided.The tracheal tube may be displaced downward or dislodged.It should not be used in the prone positionUnsuitable for use in the MRI unit.Increased incidence of sore throat and difficulty swallowing .In patients with immobilized cervical spine, exerts pressure on the cervical spine.

LMA-CTrach

It has two built-in fiberoptic channels with a monitor.Sizes - 3, 4, and 5Insertion technique

Advantages High first intubation attempt success rate with minimal neck movement. 2) Can be used during awake intubation in the presence of an unstable cervical spine.

Disadvantages1) Poor image quality2) The view may be obstructed by secretions, lubricant, or blood. 3) Cannot be used easily in the patient with a limited mouth opening.

LMA-ProSeal

Parts - cuff, inflation line with pilot balloon, airway tube, and drain (gastric access) tube.

Function of second dorsal cuff

Insertion techniques introducer, guided, digital methods

Confirmation of proper placement

LMA-ProSeal

LMA Size Weight (kg) Max Cuff Inflation Volume (mL) Max. Fiberoptic Scope Size (mm) Max. gastric Tube Size (Fr)Length of Drain Tube (cm)Largest Tracheal Tube (ID in mm) 1.55 to 10 7-1018.2 4.0 uncuffed 210 to 20 10-1019.0 4.0 uncuffed2.520 to 30 14-1423.0 4.5 uncuffed330 to 50 20-1626.5 5.0 uncuffed450 to 70 3041627.5 5.0 uncuffed570 to 100 4051828.5 6.0 cuffed

LMA-ProSeal

UsesCan be used for both spontaneous and controlled ventilation.Preferred in situations where higher airway pressures are required, better airway protection is desirable, and for surgical procedures in which intraoperative gastric drainage or decompression is needed Useful in cases where it is important to avoid airway trauma.Safe for use in an MRI unit

LMA-ProSealDisadvantages -1) The LMA-ProSeal is less suitable as an intubation device. 2) Higher resistance in spontaneously breathing patients than other devices.3) Requires a greater depth of anesthesia for insertion.4) Airway obstruction after insertion.5) Gastric insufflation6) The LMA-ProSeal has a shorter life span.

LARYNGEAL TUBE AIRWAY

Parts The airway tube is wide, curved, color coded on the connector. single lumen that is closed at the tip.Small (esophageal, distal) cuff near the blind distal tip Large (oropharyngeal, pharyngeal) cuff near the middle of the tube

LARYNGEAL TUBE AIRWAY (Cont.)5) One inflation tube to inflate both light blue cuffs. 6) Two anterior-facing, oval-shaped openings (ventilation holes)7) Side holes lateral to the top of the distal opening.8) A ramp leads from the posterior wall toward the main ventilatory outlet Reusable silicone or single-use versions made of polyvinylchloride.

LARYNGEAL TUBE AIRWAY (Cont.)

Size Patientweight (kg)Color of ConnectorMaximum Cuff Volume (mL)0neonate< 6Transparent151infant6 - 15white402child15 - 30green603Small adult30 - 60yellow1204Medium adult50 90red1305Large adult> 90violet150

LARYNGEAL TUBE AIRWAY (Cont.)Insertion technique

Advantages -

1) The LT is relatively easy to insert2) It is well tolerated during emergence 3) Because the distal cuff fits over the esophageal inlet, the risk of gastric inflation is low 4) Can be used with both spontaneous and controlled ventilation 5) High ventilation pressures can be used.

Laryngeal Tube Airway (Cont.)6) This device may be especially useful for resuscitation (cannot intubate, cannot ventilate situation , obstetrics after failed intubation, edentulous patients).7) The incidence of complications such as sore throat, mouth pain, or dysphagia is low.8) Regurgitated liquid is less likely to be aspirated with the LT

Disadvantage Failure to ventilate if tube enters trachea contrast combitube

ENDOTRACHEAL TUBE The tracheal tube (endotracheal tube, intratracheal tube, tracheal catheter) is a device that is inserted through the larynx into the trachea to convey gases and vapors to and from the lungs.Parts The machine (proximal) end The patient (tracheal or distal) end Bevel.

ENDOTRACHEAL TUBE4) Murphy eye5) A radiopaque marker 6) Cuff Systems - consists of the cuff plus an inflation system, which includes an inflation tube, a pilot balloon, and an inflation valve.

ENDOTRACHEAL TUBE

Latex coated red rubber tubesPVC tubesReused multiple times DisposableNot transparentTransparentHarden and become sticky with age, poor resistance to kinking, become clogged by dried secretionsLess likely to kink than rubber tubes. They are stiff enough for intubation at room temperature but soften at body temperature, so they tend to conform to the patient's upper airway. Latex allergy in susceptible patientsNo latex allergy

ENDOTRACHEAL TUBEOral intubation Direct LaryngoscopyBlind Oral IntubationDigital TechniqueFiberoptic guidedRetrograde intubation

Nasal intubation Direct LaryngoscopyFlexible Fiberoptic LaryngoscopyBlind Nasal Intubation

EXTUBATION The tracheal tube (extubation) is removed when it is no longer needed for airway protection.

Extubation may be performed at different depths of anesthesia - awake, light, and deep

Preparation for Extubation Initial Plan Patient position planBite block in placeThroat pack removedPreoxygenationSecretions aspirated from the pharynx (the trachea also if indicated)

EXTUBATIONComplications at ExtubationHypoventilation (residual effect of anesthetic drugs and neuromuscular blockade)Upper airway obstructionLaryngospasm and bronchospasmCoughing (wound disruption)Impaired laryngeal competence and pulmonary aspirationHypertension, tachycardia, dysrhythmias, myocardial ischemia

FLEXIBLE FIBEROPTIC BRONCHOSCOPYIndications Difficult intubation predictedCongenital airway abnormalitiesAcquired airway abnormalitiesTraumaContraindications-Lack of timeBlood & secretions in oral cavityEdema of pharynx or tongue

Technique oral or nasal (awake or GA)

COMBITUBEDevice for difficult airway

PARTS 1) Two separate lumens (pharyngeal & tracheoesophageal) that are fused longitudinally 2) Two inflatable cuffs. 3) Each lumen is linked by a short tube to a standard 15-mm connector at the breathing system end.4) Pharyngeal lumen - occluded distal end and eight oval-shaped perforations (ventilating eyes) between the cuffs, coloured blue.

COMBITUBE5) Tracheoesophageal lumen - patent distal end and a clear tube. 6) The smaller distal cuff serves to seal either the esophagus or trachea, depending on its placement. 7) The larger (pharyngeal) cuff (balloon) is above the perforations. 8) The pilot balloon for the pharyngeal cuff is colored blue.

COMBITUBESizes: Regular (41 [Fr]) SA (37 Fr)

Recommended for patients with a height greater than 5 feet (152 cm). Not recommended for patients younger than 12 years of age.

METHOD OF INSERTION

COMBITUBEIndications

Airway management in the difficult-to-intubate patient Massive airway bleeding or regurgitation. Limited access to the airway and limited mouth openingCervical spine injury. Useful in entertainers in whom it is important to avoid vocal cord damage. In cardiopulmonary resuscitation in both prehospital and in-hospital settings. Cannot ventilate, cannot intubate situation.Can be used during percutaneous dilatational tracheostomy or tracheotomy

COMBITUBEContraindications

Active pharyngeal or laryngeal reflexesOesophageal trauma or pathologyingestion of corrosive agentsOropharyngeal, pharyngeal, or hypopharyngeal mass.

COMBITUBEAdvantages

Time needed for insertion is short and less skill is requiredCan be inserted in presence of blood or secretions in the oropharynx.Provides comparable ventilation and improved oxygenation to that of tracheal intubationIt can be used by an anesthesia provider having limited use of the left arm .It is well tolerated by the patient during emergence from anesthesia. Its use is not associated with high levels of trace gases. Decreased risk of accidental extubation.The Combitube provides good but not complete protection from aspiration

COMBITUBEDisadvantages

Tracheal suctioning or fiberoptic bronchoscopy is not possible through the Combitube in the esophageal position High airflow resistanceInsertion and removal of the Combitube is associated with a higher stress response Trauma to the airway and esophagus Sore throat and dysphagia. Unsuitable for use in a patient with latex allergy .The Combitube is expensive compared to other single use devices.

RETROGRADE INTUBATION

Retrograde (translaryngeal-guided, guided blind) intubation is an elective or emergency technique for securing a difficult airway, either alone or in conjunction with other techniques. Retrograde intubation is a useful option in patients who cannot be intubated by using traditional techniques. Procedure can be expected to take 5 minutes or more for completion.

Retrograde intubation set

RETROGRADE INTUBATION

RETROGRADE INTUBATION

RETROGRADE INTUBATION

RETROGRADE INTUBATION

RETROGRADE INTUBATIONIndications

Difficult intubationsAirway traumaOro - Pharyngeal bleedCervical spine injury

RETROGRADE INTUBATIONComplications Sore throatTraumaBarotraumaPretracheal abscess The tracheal tube may inadvertently slip out as it is advanced

CRICOTHYROTOMY

Placing a device through the cricothyroid membrane to gain control of the airway. It is part of the ASA and Difficult Airway Society difficult airway algorithms.

TechniquesNeedle CricothyrotomyPercutaneous Dilatational CricothyrotomySurgical Cricothyrotomy

NEEDLE CRICOTHYROTOMYVentilation Techniques - Jet VentilationDevicesA number of jet ventilation devices are commercially available.Automatic VentilatorManual Jet Ventilation DeviceFlowmeterOxygen FlushAnesthesia Breathing SystemManual Resuscitation Bag

Percutaneous Dilatational Cricothyrotomy

IndicationsUpper Airway Obstruction with Inability to Ventilate or IntubateAnticipated Difficult Intubation - Cricothyrotomy may be used as an adjunct to fiberoptic or other intubation techniques where it is anticipated that intubation may be difficult to perform.Procedures Involving the AirwayCervical Spine InjuryCRICOTHYROTOMY

CRICOTHYROTOMY

Contraindications Intrathoracic Airway ObstructionInability to Locate the Cricothyroid Membrane Complete Airway Obstruction Paediatric patientsLaryngeal pathologyDecreased compliance

CRICOTHYROTOMY

Advantages Simple, quick, easy to performPrevents tracheal collapse

Disadvantage-Does not provide definitive airway

CRICOTHYROTOMY

ComplicationsBarotraumaTraumaSubcutaneous / mediastinal emphysemaTracheal stoma granulationPersistent stomaTracheal stenosisDysphoniaVocal cord paresisWound infection

American Society of Anesthesiologists Difficult Airway Algorithm.

REFERENCES Understanding anesthesia equipments Dorsch, 5th editionMillers text book of anesthesia 7th editionClinical anesthesia MorganCME Airway- MAMCAirway management Rashid Khan

Berman airway, Patil endoscopic airway, Ovassapian intubating airway, Berman intubating airway*