AIRWAYS, LARYNGOSCOPES, NRVS AND CONNECTORS (I)A P

DESCRIPTION Name

Specific – Water’s airway General – Oropharyngeal airway

Material

Parts

Specific modification

Use

Sterilization/ Disposable

POSSIBLE COURSE OF VIVA Choose any one – Laryngoscope, DLT

Name of the designer, other innovations

Applications

Advantages

Disadvantages

Comparison - two laryngoscope blades

Airway Anatomy

The purpose of an airway is to lift the tongue and epiglottis away from the posterior pharyngeal wall and prevent them from obstructing the space above the larynx. Using maneuvers such as dorsiflexion at the atlanto-occipital joint and protrusion of the mandible anteriorly may still be necessary to ensure a patent airway .

An oral or nasal airway decreases the work of breathing during spontaneous breathing using a face mask.

Types

Oropharyngeal airways

Nasopharyngeal airways

Modified (a) Laryngeal mask airway (b) Cuffed oropharygeal

airway

An oropharyngeal airway

Elastomeric material or plastic The flange at the buccal end to

prevent it from moving deeper into the mouth. The flange may also serve as a means to fix the airway in place.

The bite portion is straight and fits between the teeth or gums. It must be firm enough that the patient cannot close the lumen by biting but sloghtly compressible. Wide enough to make contact wit 2 or more teeth.

The curved portion extends backward to correspond to the shape of the tongue and palate.

7Proper size

AIRWAYS

Connell’s – Holes in lateral walls

Water’s - nipple for Oxygenation

Both are metallic – Brass and chrome

More traumatic Difficult to clean,

autoclavable

The Guedel airway

Guedel’s oropharyngeal airway

Plastic with reinforced bite portion

Colour coded in six sizes has a large flange, a

reinforced bite portion, and a tubular channel.

Oval in cross section Patent airway channel Disposable

The Berman airway

Center support and open sides.

H shaped in cross section Flat – better as bite block Flange at the buccal end. The side opening can be

opened wider to engage or disengage a tracheal tube.

Modification Hinged tip Intubating airway

Insertion – Oropharyngeal airways

Rule out limiting factors

Check size Check patency Lubricate Position Direction

Modifications

Resuscitation Safar’s Brook’s

Intubation Aids Berman intubation

pharyngeal airways Patil-Syracuse Endoscopic

Airway Williams Airway Intubator Ovassapian Fiberoptic

Intubating Airway

SAFARS AIRWAY (SIZES – ADULT AND PAEDIATRIC)

In 1958, Safar and McMahon S-shaped oropharangeal airway Two Guedel’s airways soldered together Non traumatic soft rubber Use – Mainly for artificial resuscitation

BROOK AIRWAY

Artificial respiration could be performed without direct mouth-to-mouth or mouth to- nose contact

Mouth guard flap to fit snugly over the patient’s lips

Flexible rubber neck Leading to a straight

plastic tube containing a built-in spring one-way valve

Aids for intubation

Ovassapian Airway

Patil Syracuse Airway William’s Airway Intubator

Berman intubation airways Ovassapian airway

The Berman intubating/pharyngeal airway

Tubular along its entire length It is open on one side so that it can

be split and removed from around a tracheal tube

Oral airway or as an aid to fiberoptic or blind orotracheal intubation

Better than manual tongue retraction

OVASSAPIAN FIBREOPTIC INTUBATING AIRWAY

Fibreoptic intubation Description- It has a flat, narrow lingual surface

on the proximal end, which gradually widens at the distal end. At the buccal end are 2 vertical side walls. There are 2 pairs of curved guide walls between the side walls. The guide walls curve towards each other, leaving a space between them for a tracheal tube upto 9-mm ID. The guide walls are flexible so that the airway can be removed from around the tracheal tube after intubation has been completed. The proximal end is tubular so that it can function as a bite block. The distal half of the airway has no posterior wall. This provides an open space in the oropharynx in which the distal end of the fiberscope can be maneuvered. It is not necessary to remove the tracheal tube connector when using this airway for fibreoptic intubation.

Williams Airway Intubator Designed for blind orotracheal

intubations Aid fiberoptic intubations or as an

oral airway Plastic #9 and #10 - 8.0 or 8.5 (ID)

tracheal tube The proximal half is cylindrical,

while the distal half is open on its lingual surface.

A comparison of the Williams airway intubator with the Ovassapian fiberoptic intubating airway found that the Williams airway intubator provided a better view of the glottis in a significant number of patients

PATIL-SYRACUSE ORAL AIRWAY OR PATIL ENDOSCOPIC AIRWAY

Designed for aid in fibreoptic intubation.

Lateral suction channels Groove in the center of the

lingual surface to allow passage of fiberscope & guide it in the midline

A slit in the distal end allows the fiberscope to be manipulated in the anteroposterior direction.

Nasopharyngeal Airways

Better tolerated than an oral airway if the patient has intact airway reflexes.

Teeth are loose or in poor condition or there is trauma or pathology of the oral cavity

Restricted mouth opening Contraindications to using a

nasopharyngeal airway include anticoagulation; a basilar skull fracture; pathology, sepsis, or deformity of the nose or nasopharynx; or a history of nosebleeds requiring medical treatment.

Insertion – Nasopharyngeal airways

Rule out limiting factors

Check size Check patency Lubricate Vasoconstrictor Position Direction

MODIFICATIONS

The Linder nasopharyngeal (bubble-tip) airway

Plastic with a large flange

The distal end has no bevel

Introducer, which has a balloon on its tip

No latex

ADVANTAGES OF NASOPHARYNGEAL AIRWAYS Nasal airways are better tolerated in a semi-

awake patient than an oral airways & are less likely to be accidentally displaced or removed.

They offer an alternative to the oral airway when the patient has limited mouth opening, awkward or fragile dentition, trauma or pathology of the oral cavity, or where oral airways are frequently displaced by a marked overlapping bite.

They have also been used to aid in pharyngeal surgery, to apply CPAP, to facilitate suctioning, to reduce trauma while passing a fibreoptic bronchoscope & to help in management of Pierre Robin syndrome.

Bite block Bite blocks should be placed between the teeth or gums (preferably

in the molar area) to prevent occlusion of a tracheal tube or damage to a fiberoptic endoscope or to keep the mouth open for suctioning

This bite block is designed to be placed between the molar teeth with the flat portion extending toward the side of the face. The flat portion is used to grip for insertion and removal.

“Around the tube" bite block For short-term intubation or bronchoscopy Fits 5-9 mm tubes May lead to crimping of ETT or occlusion of pilot balloon tube

LARYNGOSCOPES Laryngoscopes are devices that have been

designed to visualize the interior of the larynx including the vocal cords so as to aid endotracheal intubation

Direct Laryngoscopy “Line of Sight”

Indirect Laryngoscopy “Around the corner” Optic device – mirror, prism Fiberoptics – rigid or flexible

LARYNGOSCOPE

1880 MacEwen – digital intubation 1895 - First direct-vision instrument -Alfred

Kirstein (German laryngologist) 1907 - Chevalier Jackson (US laryngologist

1865-1958) 1940s - Ivan Magill and Robert Reynolds

Macintosh 1970s - FOB 1980s - Bullard Laryngoscope 1990s – Rigid fiberoptic scopes Fiberoptic stylets Video-assisted devices

Types Direct Laryngoscope

Curved blades -Macintosh

Straight blades – MillerAngulated blades –

McCoy, Belscope, FlexiSpecific modifications

Reduced step- Bizzari Guffrida, Racz Allen

Polio blades, handles, Small infraoral cavity- Bainton

Flexible Fiberoptic Bronchoscope

Rigid Indirect Laryngoscope and styletsOptically assisted –

prisms, mirrorsFiberoptic - Bullard, WuStylets – Bonfils,

ShikaniVideo assisted -

Glidescope

Parts Handle

1. Contains battery power source.2. Fibreoptic scopes contain a fibreoptic bundle in the blade.

Blade1. Base: attaches to handle2. Tongue: usually perpendicular to the handle, can be either straight (for placement posterior to the epiglottis) or curved (for anterior placement); most are interchangeable.3. Web: contains electrical connections and bulb.4. Flange: forms proximal third of the blade.

Blades

Macintosh Miller WisconsinPolio

McCoy

Better laryngeal visualisationEasier intubation

MACINTOSH Robert Reynolds Macintosh (1897-1989), New

Zealand-born anaesthetist, became the first British Professor of Anaesthetics in Oxford in 1937. He designed his laryngoscope, spray, endobronchial tube and vaporiser.

The tongue, web and flange form a reverse Z shape in cross-section. It is the most commonly used blade in the UK. The curvature of the blade allows the tip to fall naturally into position in the vallecula of the patient and the wide flange assists in holding the tongue safely aside during intubation. A ‘left-sided’ version is available. It is used in patients with right-sided facial deformities making the use of the right-sided blade difficult.

POLIO MACINTOSH BLADE The blade is mounted at 135 degrees to the

handle. This equipment was originally designed to facilitate intubation in patients encased within iron lung ventilators during the polio epidemic. It is also useful in patients with barrel chest, restricted neck mobility or breast hypertrophy. These blades are more popularly used in conjunction with a short ‘stubby’ handle.

IVAN WHITESIDE MAGILL (1888-1986) Irish-born anaesthetist,

responsible for much of the innovation and development of modern anaesthesia.

Helped found the Association of Anaesthetists

Professional exams in anaesthesia

U-shaped in cross section Most commonly used

straight blade.

WISCONSIN BLADE

Larger than the Magill blade. Features a more open rear profile, allowing even greater visualisation than the Miller blade. Also popular in USA. (Also available for paediatric patients)

Lighting considerations

Better illumination – distal bulbs, not fiberoptic blades

Larger area of illumination

Fiberoptic blades – cool and secure light source

Washing and 90deg C disinfecton

Steam sterilsation at 134deg C 200-300 cycles

Lux meter

ALIGNING THE AXES

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IDEAL POSITIONING

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o Neck - Flexiono Atlanto occipital joint -

Extension

Sniffing position

Laryngoscopy

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Laryngoscope Blade Position