1. Airway Management: An Introduction and Overview & Massive Hemoptysis
Division of Critical Care Medicine
University of Alberta

2. Airway Management

3. Outline Overview Normal airway Difficult intubation
Structured approach to airway management
Causes of failed intubation

4. Overview of the Airway
600 patients die per year from complications related to airway management
3 mechanisms of injury:
Esophageal intubation
Failure to ventilate
Difficult Intubation
98% of Difficult Intubations may be anticipated by performing a thorough evaluation of the airway in advance

5. Indications for Intubation
Ventilatory Support
Decreased GCS
Protection of Airway
Ensuring Airway patency
Anesthesia and surgery
Suctioning and Pulmonary Toilet
Hypoxic and Hypercarbic respiratory Failure
Pulmonary lavage

6. Endotracheal Intubation Depends Upon Manipulation of:
Cervical spine
Atlanto-occipital Joint
Mandible
Oral soft tissues
Neck hyoid bone
Additionally:
Dentition
Pathology - Acquired and Congenital

7. The Normal Airway History of one or more easy intubations w/o sequelae
Normal appearing face with regular features
Normal clear voice
Absence of scars, burns, swelling, infections, tumour, or hematoma
No history of radiation of the head or neck
Ability to lie supine asymptomatically; no history of snoring or sleep apnea

8. The Normal Airway Patent nares
Ability to open mouth widely with TMJ rotation and subluxation (3 – 4 cm or two finger breaths)
Mallampati Class I
Patient sitting straight up, opening mouth as wide as possible, with protruding tongue; the uvula, posterior pharyngeal wall, entire tonsillar pillars, and fauces can be seen
At least 6 cm (3 finger breaths) from tip of mandible to thyroid notch with neck extension
At least 9 cm from symphysis of mandible to mandible angle

9. The Normal Airway
Slender supple neck w/o masses; full range of neck motion
Larynx moveable with swallowing and manually moveable laterally (about 1.5 cm each side)
Slender to moderate body build
Ability to extend atlanto-occipital joint (normal extension is 35°)

10. Risk Factors For Difficult Intubation
El-Canouri et al. - prospective study of 10, 507 patients demonstrating difficult intubation with objective airway risk criteria
Mouth opening < 4 cm
Thyromental distance < 6 cm
Mallampati grade 3 or greater
Neck movement < 80%
Inability to advance mandible (prognathism)
Body weight > 110 kg
Positive history of difficult intubation

11. Signs Indicative of a Difficult Intubation
Trauma, deformity: burns, radiation therapy, infection, swelling, hematoma of face, mouth, larynx, neck
Stridor or air hunger
Intolerance in the supine position
Hoarseness or abnormal voice
Mandibular abnormality
Decreased mobility or inability to open the mouth at least 3 finger breaths
Micrognathia, receding chin
Treacher Collins, Peirre Robin, other syndromes
Less than 6 cm (3 finger breaths) from tip of the mandible to thyroid notch with neck in full extension
< 9 cm from the angle of the jaw to symphysis
Increased anterior or posterior mandibular length

12. Signs Indicative of a Difficult Intubation
Laryngeal Abnormalities
Fixation of larynx to other structures of neck, hyoid, or floor of mouth.
Macroglossia
Deep, narrow, high arched oropharynx
Protruding teeth
Mallampati Class 3 and 4

13. Signs Indicative of a Difficult Intubation
Neck Abnormalities
Short and thick
Decreased range of motion (arthritis, spondylitis, disk disease)
Fracture (subluxation)
Trauma
Thoracoabdominal abnormalities
Kyphoscoliosis
Prominent chest or large breasts
Morbid obesity
Term or near term pregnancy
Age 50 – 59
Male gender

14. Difficult Intubation - History
Previous Intubations
Dental problems (bridges, caps, dentures, loose teeth)
Respiratory Disease (sleep apnea, smoking, sputum, wheeze)
Arthritis (TMJ disease, ankylosing spondylitis, rheumatoid arthritis)
Clotting abnormalities (before nasal intubation)
Congenital abnormalities
Type I DM
NPO status

15. Difficult Intubation - Diabetes Mellitus
Difficult intubation 10 x higher in long term diabetics
Limited joint mobility in 30 – 40 %
Prayer sign
Unable to straighten the interpharyngeal joints of the fourth and fifth fingers
Palm Print
100% sensitive of difficult airway

16. Difficult Intubation - Physical Exam
General:
LOC, facies and body habitus, presence or absence of cyanosis, posture, pregnancy
Facies:
Abnormal facial features
Pierre Robin
Treacher Collins
Klippel – Feil
Apert’s syndrome
Fetal Alcohol syndrome
Acromegaly
Nose:
For nasal intubation
Patency

17. Pierre Robin

18. Treacher Collins

19. Difficult Intubation - Physical Exam
TMJ Joint – articulation and movement between the mandible and cranium
Diseases:
Rheumatoid arthritis
Ankylosing spondylitis
Psoriatic arthritis
Degenerative join disease
Movements: rotational and advancement of condylar head
Normal opening of mouth 5 – 6 cm

20. Difficult Intubation - Physical Exam
Oral Cavity
Foreign bodies
Teeth:
Long protruding teeth can restrict access
Dental damage 25% of all anesthesia litigations
Loose teeth can aspirate
Edentulous state
Rarely associated with difficulty visualizing airway
Tongue:
Size and mobility

21. Mallampati Classification
Class I: soft palate, tonsillar fauces, tonsillar
pillars, and uvuala visualized
Class II: soft palate, tonsillar fauces, and uvula
visualized
Class III: soft palate and base of uvula visualized
Class IV: soft palate not visualized
Class III and IV Difficult to Intubate

22. Mallampati Classification

23. Structured Approach to Airway Management
MOUTHS
Component
Description
Assessment Activities
Mandible
Length and subluxation
Measure hyomental distance and anterior displacement of mandible
Opening
Base, symmetry, range
Assess and measure mouth opening in centimetres
Uvula
Visibility
Assess pharyngeal structures and classify
Teeth
Dentition
Assess for presence of loose teeth and dental appliances
Head
Flexion, extension, rotation of head/neck and cervical spine
Assess all ranges and movement
Silhouette
Upper body abnormalities, both anterior and posterior
Identify potential impact on control of airway of large breasts, buffalo hump, kyphosis, etc.

24. Bag/Valve/Mask Ventilation
Always need to anticipate difficult mask ventilation
Langeron et al patients reported a 5% incidence of difficult mask ventilation
5 independent risk factors of difficult mask ventilation:
Beard
BMI > 26
Edentulous
Age > 55 years of age
History of snoring (obstruction)
Two of these predictors of DMV
Sensitivity and specificity > 70%
DMV Difficult Intubation in 30% of cases

25. Intubation Technique Preparation: Equipment Check
100% oxygen at high flows (> 10 Lpm) during bask/mask ventilation
Suction apparatus
Intubation tray
Two laryngoscopic handles and blades
Airways
ET tubes
Needles and syringes
Stylet
KY Jelly
Suction Yankauer
Magill Forceps
LMA’s

26. Pre - oxygenation Traditional: Rapid
3 minutes of tidal volume breathing at 5 ml/kg 100% O2
Rapid
8 deep breaths within 60 seconds at 10 L/min
Always ensure pulse oximetry on patient

27. Positioning Optimal Position – “sniffing position”
Flexion of the neck and extension of the antlanto-occipital joint

28. Mandible and Floor of Mouth
Optimal position:
flexing neck and extending the atlantooccipital joint

29. Positioning

30. Positioning

31. Factors that Interfere with Alignment
Large teeth or tethered tongue
Short mandible
Protruding upper incisors
Pathology in floor of mouth
Reduced size of intra and sub mandibular space
Practical Note: Thyromental distance 6 cm or 3 finger breaths should show Normal mandible

32. Visualization

33. Visualization Insert blade into mouth
Sweep to right side and displace tongue to the left
Advance the blade until it lies in the valeculla and then pull it forward and upward using firm steady pressure without rotating the wrist
Avoid leaning on upper teeth
May need to place pressure on cricoid to bring cords into view

34. Visualization

35. Visualization

36. Laryngoscopy Grade Grade I - 99% Grade II - 1% Grade III - 1/2000
Grade IV - 1/ 10,000

37. Insertion Insert cuff to ~ 3 cm beyond cords
Tendency to advance cuff too far
Right mainstem intubation
Cuff Inflation
Inflate to 20 cm H2O
Listen for leak at patients mouth
Over inflation can lead to ischemia of trachea

38. Confirmation ETT Position
Continuous CO2 monitoring or capnometry
Gold standard
Must have at least 3 continuous readings without declining CO2

39. False Negative Results
Tube in Trachea, Capnogram Suggests Tube in Esophagus
Concurrent PEEP with ETT cuff leak
Severe Airway obstruction
Low Cardiac Output
Severe hypotension
Pulmonary embolus
Advanced pulmonary disease

40. False Positive Results
Tube NOT in trachea, capnogram suggests tube in trachea
Bag/valve/mask ventilation prior to intubation
Antacids in stomach
Recent ingestion of carbonated beverages
Tube in pharynx

41. False Positive Results

42. Other Methods to Determine Placement of ETT tube
Auscultation
Visualization of tube through cords
Fiberoptic bronchoscopy
Pulse oximetry not improving or worsening
Movement of the chest wall
Condensation in ET tube
Negative Pressure Test
CXR

43. Airway Maneuvers BURP – Improves visualization of airway
Posterior pressure on the larynx against cervical vertebrae (Backward)
Superior pressure on the larynx as far as possible (Upward)
Lateral pressure on the larynx to the right (Right)
With pressure (Pressure)

44. Causes of Failed Intubation
Poor positioning of the head
Tongue in the way
Pivoting laryngoscope against upper teeth
Rushing
Being overly cautious
Inadequate sedation
Inappropriate equipment
Unskilled laryngoscopist

45. Summary
600 patients die per year from complications related to airway management
3 mechanisms of injury:
Esophageal intubation
Failure to ventilate
Difficult Intubation
Indication for intubation:
Ventilatory Support
Decreased GCS
Protection of Airway
Ensuring Airway patency
Anesthesia and surgery
Suctioning and Pulmonary Toilet
Hypoxic and Hypercarbic respiratory Failure
Pulmonary lavage

46. Massive Hemoptysis

47. Massive Hemoptysis More than 300 to 600 ml of blood in 12 to 24 hours.
Difficult to assess the actual amount.
Life threatening bleeding into the lung can occur without actual hemoptysis.

48. Causes of Hemoptysis and Pulmonary Hemorrhage
Localized bleeding
Diffuse Bleeding

49. Localized Bleeding Infections Tumors Cardiovascular Bronchogenic
Bronchitis
Bacterial Pneumonia
Streptococcus and Klebsiella
Tuberculosis
Fungal Infections
Aspergillus
Candida
Bronchiectasis
Lung Abscess
Leptospirosis
Tumors
Bronchogenic
Squamous
Necrotizing parenchymal cancer
Adenocarcinomas
Bronchial adenoma
Cardiovascular
Mitral Stenosis

50. Localized Bleeding Pulmonary Vascular Problems Trauma Others
Pulmonary AV malformations
Rendu-Osler-Weber Syndrome
Pulmonary embolism with infarction
Behcet syndrome
Pulmonary artery catheterization with pulmonary artery rupture
Trauma
Others
Broncholithiasis
Sarcoidosis (cavitary lesions with mycetoma)
Ankylosing spondylitis

51. Diffuse Bleeding Drug and chemical Induced Hemosiderosis
Anticoagulants
D-penicillamine (seen with treatment of Wilson’s disease)
Trimellitic anhydride (manufacturing of plastics, paint, epoxy resins)
Cocaine
Propylthiouracil
Amiodarone
Phenytoin
Hemosiderosis
Blood dyscrasias
Thrombotic thrombocytopenic purpura
Hemophilia
Leukemia
Thrombocytopenia
Uremia
Antiphospholipid antibody syndrome
Pulmonary – Renal Syndrome
Goodpasture syndrome
Wegener granulomatosis
Pauci-immune vasculitis

52. Diffuse Bleeding Vasculitis Pulmonary capillaritis
With or without connective tissue disease
Polyarteritis
Churg-Strauss syndrome
Henoch-Schonlein Purpura
Necrotizing vasculitis
Connective Tissue diseases
Systemic lupus erythematosus
Rheumatoid arthritis
Mixed connective tissue disease
Scleroderma (rare)

53. Key Major Etiologies Tuberculosis Bronchiectasis Cancer Mycetoma
Iatrogenic causes
Alveolar Hemorrhage
Trauma
Vascular malformation
Pulmonary embolism
Other Infectious Causes

54. Pathophysiology Bronchial circulation Pulmonary circulation
High (systemic) pressure circulation
Drains into the right atrium (extrapulmonary bronchi)
Also drains into pulmonary veins (intrapulmonary bronchi)
Anterior spinal artery may originate from bronchial artery (5% of cases)
Pulmonary circulation
Low-pressure circulation
Multiple anastomoses exist between bronchial and pulmonary circulations

55. Clinical Findings Hemoptysis, Dyspnea, Cough, Anxiety
Fever, weight loss
Smoking and Travel history
Bloody sputum
Frothy blood – sputum mixture
Bright red
Alkaline
Tachypnea, respiratory distress
Localized wheezing, rales, poor dentition
Digital clubbing
Hematuria

56. Differential Diagnosis
Upper GI Bleeding
Dark blood
Food particles
Acid pH
Consider endoscopy
Upper airway bleeding
Examine mouth, nose, and pharynx.

57. Laboratory Tests No specific tests CBC, diff, INR, PTT, platelet count
Electrolytes, BUN, Cr
Sputum culture and AFB
Urinalysis
ECG
ABG’s
Type and Screen

58. Imaging Studies Chest X-ray CT scan
Normal suggests endobronchial or extrapulmonary source.
Potentially misleading
Aspiration from distant source
Chronic changes unrelated to acute event
CT scan
Useful in stable patients
Can detect bronchiectasis

59. Stabilization Ensure adequate ventilation and perfusion.
Most common cause of death is asphyxia.
Place patient in Trendelenburg position to facilitate drainage.
Lateral decub – Bleeding side down
Prevent contamination of good lung.

60. Treatment General Measures:
Place bleeding lung down to prevent aspiration into good lung
Supplemental oxygen
Avoid Sedation
Correct coagulopathy and thrombocytopenia
Consult pulmonary, critical care, and thoracic surgery
Consider early involvement of anesthesia and interventional radiology

61. Primary Goal is Airway Control
Asphyxiation, not blood loss, is the cause of death.
Only stable patients with ability to protect and clear their own airway should be managed without intubation.
Intubation:
Performed by experienced personnel.
Large bore tube for bronchoscopy and suctioning.
Consider bronchial blocker or double lumen tube if bleeding site is known.

62. Secondary Goal is Localization of Bleeding
Bronchoscopy required.
Intubate prior to bronchoscopy.
Rigid bronchoscopy
May facilitate better suctioning.
Inability to visualize beyond main stem bronchi and need thoracic surgeon.

63. Bronchoscopic Interventions
Bronchial blocker or Fogarty balloon catheter to occlude bleeding lung, lobe, or segment.
Topical coagulants:
Fibrin or fibrinogen-thrombin solution.
Topical transexamic acid
Consider Nd:YAG laser coagulation, electrocautery, or argon plasma coagulation.
Lavaged iced saline
Topical epinephrine

64. Unilateral Lung Ventilation
Single lumen tube advanced into main stem bronchus.
Double lumen tube:
Protects non-bleeding lung.
Use left sided tube to prevent occlusion of Right upper lobe.
May be difficult to position.
Individual lumens too small for standard bronchoscope.
Airway obstruction frequent problem.
Displacement can lead to sudden asphyxiation.
Patient should be therapeutically paralyzed and not moved.

65. Bronchial Arteriography and Embolization
Favored initial approach if facilities and expertise available.
High success rate: approximately 90% when a bleeding vessel is identified.
Recurrence rate: 10 – 27%
10% of patients bleed from the pulmonary circulation (TB or mycetoma).
Serious complications:
Occlusion of the anterior spinal artery with paraplegia.
Embolic infarction of distal organs.

66. Early Surgical Treatment
Offers definitive treatment.
Indicated for lateralized massive life-threatening hemoptysis, or failure or recurrence after other interventions.
Contraindications:
Poor baseline respiratory function.
Inoperable lung carcinoma.
Inability to localize bleeding site.
Diffuse lung disease (relative) eg. CF.
Mortality is higher if bleeding is acute

67. Late Surgical Treatment
Indicated for definitive treatment of underlying lesion, once bleeding subsided.
Indications:
Mycetoma
Resectable carcinoma
Localized bronchiectasis

68. Prognosis Factors likely affecting outcome Mortality
Etiology of hemoptysis
Underlying co-morbid illnesses
Surgical vs. medical treatment
Mortality
Medical mortality: 17 – 85%
Estimated early surgical mortality: 0 – 50%
Most case series reports preceded the development of angiographic embolization.

69. Conclusion More than 300 to 600 ml of blood in 12 to 24 hours.
Major causes:
Tuberculosis
Bronchiectasis
Cancer
Mycetoma
Iatrogenic causes
Alveolar Hemorrhage
Trauma
Vascular malformation
Pulmonary embolism
Primary goal is airway control followed by bleeding localization.