1. Airway Basics
Matt Hallman, MD

2. Disclosures
I’m an anesthesiologist
I’m an intensivist

3. 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

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

5. 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

6. Upper Airway Anatomy Nasopharynx Oropharynx Pharynx Plate Hypopharynx
Epiglottis
Glottis
Larynx

7. Your Goal: the glottic opening
Epiglottis
Vocal Cords
Arytenoids

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

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

10. The Airway Exam
Mallampati
Good
Bad

11. Teeth
Buck Teeth
Loose Teeth
Fancy Teeth
No Teeth

12. C-Spine Mobility

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

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

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

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

17. Position in the “Sniffing” position

19. Aligning the Axes

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

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

22. 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

23. Oral Airways

24. Nasal Airways

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

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

27. Your goal

28. It’s not always perfect…

29. 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

30. 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

31. 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