1. Dr. Mahmoud Abdel-Khalek
Airway Management
Prepared by
Dr. Mahmoud Abdel-Khalek

2. Introduction
In order to ensure adequate oxygenation and ventilation throughout the insults of anesthesia and surgery, the anesthesiologist must take active measures to maintain the patency of the airway as well as ensuring its protection from aspiration

3. Airway Anatomy The airways can be divided into 2 parts namely:
The upper airway.
The lower airway.

4. Anatomy of the Upper Airway
Airway structures above the vocal chords
Oral, nasal cavities& pharynx
Lower airway
Trachea, bronchi, bronchioles& alveoli

5. Upper and Lower Airway

6. Upper Airway

7. Anatomy of the Upper Airway

8. Oral Cavity
Adenoids and tonsils may become swollen and infected may cause upper airway obstruction

9. Larynx Marks where the upper airway ends and lower airway begins
Thyroid cartilage
Formed by two plates that form the laryngeal prominence (Adam’s apple)
Cricoid cartilage is the first ring of the trachea
Cricothyroid membrane: ligament between the thyroid and cricoid cartilage site for emergency airway(cricothyrotomy)

10. Larynx Glottis: Space between the vocal cords Vallecula
Pocket between base of tongue and epiglottis
Important landmark for ET intubation
Arytenoid cartilages
Posterior attachment of the vocal cords
Valuable guides for ET intubation
Laryngospasm: spasmodic closure of the vocal cords seals off the airway

11. Trachea Begins below the cricoid cartilage About 12cm length in adults
Adult 1st tracheal ring anterior to C6
Supported by C-shaped cartilages (open posteriorly; membranous aspect overlies esophagus
Trachea ends at level of carina at T5
Divides into right and left mainstem bronchi
Right mainstem bronchus larger in diameter and deviates at less acute angle than left (therefore aspiration or endobronchial intubation usu. to right side)

12. Routine airway management
Routine airway management associated with general anesthesia consists of:
Airway assessment
Preparation and equipment check
Patient positioning
Preoxygenation
Bag and mask ventilation (BMV)
Intubation (if indicated)
Confirmation of endotracheal tube placement
Intraoperative management and troubleshooting
Extubation

13. Airway Assessment: Mouth opening
Inter-incisor distance of 3 cm or greater is desirable in an adult

14. Thyromental Distance: Thyromental distance
Thyromental distance: the distance between the mentum and the superior thyroid notch
A distance greater than 3 fingerbreadths is desirable

15. Airway Assessment: Mallampati Classification
Examines the size of the tongue in relation to the oral cavity
Large sized tongue obstructs the view of the pharyngeal structures and may add difficulty to intubation

16. Conditions Associated with Difficult Intubation

17. Preparation and equipment check

18. Preparation

19. Laryngoscopes

20. Oral artificial airway sizes
Correct size by measuring from corner of mouth to bottom of earlobe
Adult oral airways typically come in small (80 mm [Guedel No. 3]), medium (90 mm [Guedel No. 4]), and large (100 mm [Guedel No. 5]) sizes.

21. Endotracheal tubes

22. The face mask

23. Patient Positioning Relative alignment of the oral and
pharyngeal axes is achieved by having the patient in the “sniffing” position

24. Preoxygenation
When possible, preoxygenation with face mask oxygen should precede all airway management interventions
Oxygen is delivered by mask for several minutes prior to anesthetic induction.
The FRC, the patient’s oxygen reserve, is purged of nitrogen.
Up to 90% of the normal FRC of 2 L following preoxygenation is filled with O2
Considering the normal oxygen demand of 200–250 mL/min, the preoxygenated patient may have a 5–8 min oxygen reserve.
Thus improving safety by allowing more time before desaturation in if ventilation following anesthetic induction is delayed.
Conditions that increase oxygen demand (e.g., sepsis, pregnancy) and decrease FRC (e.g. morbid obesity, pregnancy) reduce the apneic period before desaturation ensues.

25. The use of face mask In current practice the face mask is only used
In preoxygenation before tracheal intubation or insertion of the laryngeal mask
During short non-invasive procedures, e.g. Orthopedic manipulations and dental anaesthesia

26. Technique of face mask
Selection of the correct fit is important to provide a gas-tight seal
For children, a mask with excessive dead space should be avoided (Rebreathing)
The mandible is held ‘into’ the mask by the anesthetist and forward to prevent obstruction of the airway by the tongue
The importance of observation of the airway during mask anesthesia cannot be overemphasized
Maintenance of the airway may be assisted further by the use of an oropharyngeal (Guedel) airway in anesthetized patients

27. Technique….

28. Disadvantages It “ties up” the anesthesiologist’s hands
It does not protect against aspiration or laryngospasm (closure of the cords in response to noxious stimuli at light planes of anesthesia)
Upper airway obstruction may occur, particularly in obese patients or patients with very large tongues

29. Laryngeal Mask Airway (LMA)
LMA consists of a wide bore tube whose proximal end connects to a breathing circuit with a standard 15-mm connector, and whose distal end is attached to an elliptical cuff that can be inflated through a pilot tube.
The deflated cuff is lubricated and inserted blindly into the hypopharynx so that, once inflated, the cuff forms a low-pressure seal around the entrance to the larynx.
This requires anesthetic depth and muscle relaxation slightly greater than that required for the insertion of an oral airway.

30. Advantages and disadvantages

31. Indications Contraindications
To provide a clear airway without the need for the anesthetist’s hands to support a face mask.
To avoid the use of tracheal intubation during spontaneous ventilation.
In a case of unanticipated difficult intubation
Contraindications
‘Full stomach’
A patient in whom the risk of regurgitation of gastric contents into the esophagus is increased (e.g. hiatus hernia).
Oral operations as it may prevent surgical access

32. Size selection& Technique

33. Technique of LMA insertion

35. Tracheal Intubation

36. ET tube Most commonly made of PVC
The shape and rigidity of TT’s can be altered by inserting a stylet
The patient end of the tube is beveled to aid visualization and insertion through the vocal cords
Murphy eye to decrease the risk of occlusion
Most adult TT’s have a cuff inflation system consisting of a valve, pilot balloon, inflating tube, and cuff

37. Indications
Provision of a clear airway, e.g. anticipated difficulty in using mask anesthesia in the edentulous patient
An ‘unusual’ and prolonged position, e.g. prone or sitting. A reinforced non-kinking tube may be necessary.
Operations on the head and neck, e.g. ENT, dental A nasotracheal tube may be required
Protection of the respiratory tract against aspiration e.g. from blood during upper respiratory tract or oral surgery and from inhalation of gastric contents in emergency surgery or patients with oesophageal obstruction.
During anesthesia using IPPV and muscle relaxants
To facilitate suction of the respiratory tract
During thoracic operations

38. Contraindications for Intubation
Patients with an intact gag reflex
Patients likely to react with laryngospasm to an intubation attempt. e.g. Children with epiglottitis
Basilar skull fracture – avoid naso-tracheal intubation and nasogastric/pharyngeal tube

40. Technique
Position the patient supine, open the airway with a head-tilt chin-lift maneuver.(Suspected spinal injury, attempt naso-tracheal intubation, spine in neutral position.)
Open mouth by separating the lips and pulling on upper jaw with the index finger.
Hold laryngoscope in left hand, insert scope into mouth with blade directed to right tonsil

41. Technique
Once right tonsil is reached, sweep the blade to the midline keeping the tongue on the left
This brings the epiglottis into view.” DO NOT LOOSE SIGHT OF IT!”
Advance the blade until it reaches the angle between the base of the tongue and epiglottis( vallecular space)
Lift the laryngoscope upwards and away from the nose – towards the chest. This should bring the vocal cords into view. It may be necessary for a colleague to press on the trachea to improve the view of the larynx

42. Technique
Place the ETT in the right hand. Keep the concavity of the tube facing the right side of the mouth
Insert the tube watching it enter through the cords Insert the tube just so the cuff has passed the cords and then inflate the cuff
Listed for air entry at both apices and both axillae to ensure correct placement using a stethoscope.

43. Technique

44. Confirmation of Tube Placement
End Tidal Carbon Dioxide Monitor
Stethoscope

45. Complications

46. Nasotracheal Intubation

47. Nasotracheal intubation
Advantages:
Comfortable for prolong intubation in postoperative period
Suitable for oral surgery : tonsillectomy , mandible surgery
For blind nasal intubation
Can take oral feeding
Resist for kinking and difficult to accidental extubation
Disadvantages
Trauma to nasal mucosa
Risk for sinusitis following prolonged intubation
Risk of bacteremia
Smaller diameter than oral route

48. Contraindication for nasoendotracheal intubation
Fracture base of skull
Large adenoids
Coagulopathy
Nasal cavity obstruction
Retropharyngeal abscess

50. Case Presentation
A 28-year-old, 100-kg, term primigravida presented in labor requesting regional anesthesia. On preoperative assessment, the patient’s past medical history was unremarkable. Examination revealed she had a short stature and was morbidly obese and Mallampati grade III airway
Which Mallampati grading is accompanied with more difficult intubation:
Grade I
Grade II
Grade III
Grade IV

51. Predictors of difficult intubation include:
Technical difficulties in treating patients with morbid obesity include:
Difficult venous access
Difficult intubation
Difficult airway maintenance with mask
All of the above
Predictors of difficult intubation include:
Short muscular neck
Prominent upper incisor
Protruding mandible

52. Thank You