Jutarat Luanpholcharoenchai Airway management Jutarat Luanpholcharoenchai

Topic modules Anatomy of airway Evaluation of airway Airway equipments Intubation & ventilation techniques (-> W : Airway Management)

Respiratory tract UPPER TRACT

Anatomy of larynx

Trachea& Lungs Trachea : Adult 12-15 cm , Newborn 4 cm Right mainstem : larger, shorter and less angle Endobronchial intubation RUL atelectasis

Evaluation of airway History Physical examination

History Disease & Underlying disease mass/ tumor infection trauma contracture obesity Congenital& variation

History History of previous anesthesia general anesthesia history of difficult intubation

Physical examination Airway examination Airway investigation

Airway examination General contour Oral cavity Inter incisor distance Mallampati classification Thyromental distance Neck circumference Range of motion of neck

Mallampati classification Laryngoscopic view

Difficult intubation Suspected inter incisor < 3 cm TMD < 6 cm Mallampati class >3 neck circumference > 40 cm limited TM joint or neck AO axis movement

Investigation X-ray Neck Chest CT

Airway Equipments Artificial airway devices : supraglottic airway & endotracheal tube Anesthesia mask Laryngoscope etc……..

Artificial airway Endotracheal tube Orotracheal tube Nasotracheal tube Double lumen tube Semirigid tube :armored, anode tube RAE tube Supraglottic airway LMA (laryngeal mask airway) Laryngeal tube Oropharyngeal / nasopharyngeal airway

Endotracheal tube Less mucosal damage Sore throat Aspiration Spontaneous extubation More mucosal damage!

Endotracheal tube Nasotracheal tube Cuff RAE tube Double lumen tube Uncuff

Endotracheal tube sizes Age Internal diameter (mm.) Length (cm.) Full term child 3.5 10-12 Child Age(yr)/4 +4 Age(yr)/2 +12 Adult -Female -Male 7.0-7.5 7.5-8.0 20-22 21-24

Supraglottic airway LMA LARYNGEAL TUBE

Oral airway: oropharyngeal airway Vomitting Gag reflex Airway obstruction!!!

Nasal airway : nasopharyngeal airway Too long enter esophagus Mucosal injury/bleeding Better tolerance

Anesthesia mask

Rigid laryngoscope Bulb Curve blade “Macintosh” Electrical contact Handle Straight blade

Lever-Tip Laryngoscope Blade

Etc….. Self inflating bag stylet

Intubation & ventilation techniques

Indications for Definitive Airway Airway Protection Ventilation 1.Unconscious 1.Apnea Neuromuscular Paralysis Unconscious 2.Severe Maxillofacial fracture 2.Inadequate Respiratory Effort Tachypnea Hypoxia or Hypercarbia 3.Risk for aspiration Bleeding Vomiting 3.Severe closed head injury with need for hyperventilation 4.Risk for obstruction Neck hematoma Laryngeal, tracheal injury/burn

Equipments for endotracheal intubation Rigid laryngoscope Endotracheal tube Anesthesia mask Airway : oral, nasal Syringe 10 cc Stylet Suction Stethoscope Anesthesia machine, breathing system ,self inflating bag Monitoring : pulse oximeter, capnograph Other : Plaster, lidocaine jelly

Techniques for routine intubation Preoxygenation with 100% oxygen Administration of induction agent Loss of eyelash/verbal reflex Mask ventilation Administration of neuromuscular block Intubation Confirm ETT in trachea

Airway maneuvers Head-tilt chin-lift Jaw-thrust maneuver

Face mask ventilation One hand two hand the two-hand mask hold is most effective KEYS SUCCESS a patent airway an adequate mask seal proper ventilation

Sniff position 10 cm.

Intubation Techniques Valeculla

Complication of intubation During laryngoscope & intubation Malpositioning : esophageal intubation Airway trauma : injury to tongue, lip etc. Physiological reflexs : hypoxia, HT, tachycardia, laryngospasm Tube malfunction : cuff perforation While tube is in place Malpositioning :bronchial intubation Airway trauma : injury to mucosa Tube malfunction : obstruction Following extubation Airway trauma : hoarseness, edema/stenosis of subglottic, trachea Negative pressure pulmonary edema laryngospasm

Questions ?