Airway Basics Matt Hallman, MD

Disclosures I’m an anesthesiologist I’m an intensivist

Objectives Provide an overview Impart some respect for the airway Of anatomy Of airway evaluation Of basic equipment Of technique Impart some respect for the airway

Indications for Artificial Airway Ventilation Oxygenation Protection Secretions Everything is relative, nothing absolute!!

Dictims All patients must always have an airway The most important airway in the unconscious patient is the bag and mask airway It’s much harder to kill a breathing patient than a non-breathing patient Calling for help early is always the right thing to do

Upper Airway Anatomy Nasopharynx Oropharynx Pharynx Plate Hypopharynx Epiglottis Glottis Larynx

Your Goal: the glottic opening Epiglottis Vocal Cords Arytenoids

Step 1: Prepare, prepare, prepare Call for help Gather equipment and medications Have a plan(s)…A, B, C, D

Equipment Working Suction Catheter Bag & mask Oral & nasal airways Laryngoscope Handle and Blade Endotracheal Tube

The Airway Exam Mallampati Good Bad

Teeth Buck Teeth Loose Teeth Fancy Teeth No Teeth

C-Spine Mobility

Thyromental Distance Distance >6 cm indicates less likely to be difficult to intubate

Mouth Opening Distance > 4 cm indicates less likely to be difficult intubation

Other Concerning Features Beards Obesity TMJ dysfunction Kids (every single one of them) “Facies” History of difficulty with intubation Trauma

Step 2: Position, preoxygenate and induce At least 3 minutes if possible Highest FiO2 possible OK to combine modalities (e.g. NC & FM) Monitors

Position in the “Sniffing” position

Aligning the Axes

Step 3: Mask Ventilation Requires a mask and self-inflating reservoir bag (Ambu) Supplemental airways and FiO2 are optional

Pull the face into the mask—don’t push the mask onto the face

If it’s difficult… Reposition the patient Place oral airway Place nasal airway 2-person ventilation Call for help! There are “advanced” options Prepare to intubate

Oral Airways

Nasal Airways

Step 4: Laryngoscopy & intubation Goal: line up the axis’ and place tube through larynx

Aligning the Axis’ Direction of force Be careful of teeth, lips, eyes!

Your goal

It’s not always perfect…

What size endotracheal tube? General Rules Men: 7.5 – 8.0 mm internal diameter Women: 6.5 – 7.0 mm internal diameter Kids: Age/4 + 4 Insertion depth: internal diameter x 3

Step 5: Confirm and Secure ETT cuff pressure <20-25 mmHg No sounds in the stomach? Bilateral breath sounds? Misting in ETT? Direct visualization? Persistent EtCO2? CXR

Pediatric vs Adult Airway Head: Infant’s is proportionately larger compared to body Tongue: Infant’s is proportionately larger compared to the mouth Infant tongue lacks muscle tone Larynx: Infant’s is higher level in relation to C-spine Cords:Infant’s anteroinferior incline Airway diameter: Infant’s is smallest at cricoid cartilage, adults smallest at glottis Epiglottis: infant’s is omega shaped, longer, less flexible Infants have much higher oxygen consumption and less FRC = desaturations occur quickly