183 Difficult Airway Management (Gabungan)

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KPPIA
KURSUS PENYEGAR DAN PENAMBAH ILMU ANESTESIA
5-9 AGUSTUS 2009

“QUALITY OF CARE AND
PATIENT SAFETY”

“THE AIMS OF ANESTHESIA IS SAFETY
THE SAFETY IS AN ACCIDENT PREVENTION
AN ACCIDENT PREVENTION BEGINS WITH
A GOOD PREOPERATIVE EVALUATION”

GOOD JUDGMENT comes
from EXPERIENCE.
EXPERIENCE comes from
BAD JUDGMENT.

………….AS SUCH, THE PRIMARY RESPONSIBILITY OF THE
ANESTHESIOLOGIST AS A CLINICAL IS TO SAFEGUARD THE
AIRWAY, I.E. TO PRESERVE AND PROTECT IT DURING
INDUCTION, MAINTENANCE, AND RECOVERY FROM THE STATE
OF ANESTHESIA; AND IN THE EVENT OF LOS OF THE AIRWAY, IT
SHOULD BE PROMPTLY RE-ESTABLLISH BY INTRUMENTATION OR
SURGERY BEFORE THE INDIVIDUAL SUFFERS IRREVERSIBLE
INJURY FROM INADEQUATE OR COMPROMISED
OXYGENATION…………….

SAFETY FIRST
THE CLINICAL ANESTHESIOLOGIST, AS A SPECIALIST, PLAYS A UNIQUE
ROLE IN HEALTH CARE, RENDERING PATIENTS FREE FROM PAIN
EITHER IN THE FORM OF REGIONAL ANESTHESIA OR GENERAL
ANESTHESIA TO FACILITATE SURGICAL OPERATIONS.
AS A RESULT OF RAPID-ACTING NEURODEPRESSANTS AND MUSCLE
RELAXANTS CURRENTLY USED IN CLINICAL PRACTICE, THE VARIOUS
PHYSIOLOGIC FORCES, MULTITUDE OF PROTECTIVE REFLEXES, AND
HIGHLY INTRICATE NEUROGENIC MECHANISMS THAT INTERACT WITH
EACH OTHER TO SUPPORT AND MAINTAIN THE VASTLY COMPLEX
BODILY FUNCTIONS (ACID-BASE STATUS, MAINTENANCE OF BODY
TEMPERATURE AND HEMODYNAMIC) ARE SUBDUED OR INTERFERED
WITH FROM MOMENT TO MOMENT. THESE HEMODYNAMIC AND
METABOLIC FUNCTIONS ARE APT TO SUFFER IF OXYGENATION
SHOULD BE COMPROMISED DURING INDUCTION OR MAINTENANCE
OF THE ANESTHETIZED STATE

THESE HEMODYNAMIC AND METABOLIC FUNCTIONS ARE APT TO SUFFER
IF OXYGENATION SHOULD BE COMPROMISED DURING INDUCTION OR
MAINTENANCE OF THE ANESTHETIZED STATE.
AS SUCH, THE PRIMARY RESPONSIBILITY OF THE
ANESTHESIOLOGIST AS A CLINICAL IS TO SAFEGUARD THE
AIRWAY, I.E. TO PRESERVE AND PROTECT IT DURING INDUCTION,
MAINTENANCE, AND RECOVERY FROM THE STATE OF
ANESTHESIA; AND IN THE EVENT OF LOS OF THE AIRWAY, IT
SHOULD BE PROMPTLY RE-ESTABLLISH BY INTRUMENTATION OR
SURGERY BEFORE THE INDIVIDUAL SUFFERS IRREVERSIBLE
INJURY FROM INADEQUATE OR COMPROMISED OXYGENATION.
TECHNOLOGIC INNOVATIONS (PULSE OXIMETRY, CAPNOGRAPHY) ARE
ERTAINLY HELPFUL AS MONITORS TO INDICATE THE STATE OF WELLBEING OF THE PATIENT AND ALERT THE CLINICIAN WHEN THE WELLBEING IS UNSOUND OR TREATENED.
BUT THEY ARE BY NO MEANS A SUBSTITUTE FOR CLINICAL ASSESSMENT
AND ANTICIPATION OF ANY PROBLEM, INCLUDING THE DIFFICULT AIRWAY.

CLINICAL ASSESSMENT OF THE
AIRWAY

INTRODUCTION
AIRWAY ANATOMY
THE SUPRAGLOTTIC AIRWAY
SUBGLOTTIC AIRWAY
MANAGEMENT OF PATIENTS WITH NORMAL AIRWAY
ANATOMY
MANAGEMENT OF PATIENT WITH THE DIFFICULT AIRWAY
PREDICTION
PREPARATION
PRACTICE
TOOLS FOR MANAGEMENT OF THE DIFFICULT AIRWAY

INTRODUCTION
VARIOUS STUDIES REPORT THAT BETWEEN 1% AND 18% OF
PATIENTS HAVE DIFFICULT AIRWAY ANATOMY. OF THESE, 0.050.35% ARE NOT INTUBATED SUCCESSFULLY; AND A
SIGNIFICANT PORTION MAY BE DIFFICULT TO VENTILATE BY
MASK. IT IS LIKELY THAT THE PRACTITIONER WILL ENCOUNTER
BETWEEN ONE AND 10 PATIENTS PER YEAR IN WHOM
INTUBATION OF THE TRACHEA WILL BE DIFFICULT OR
IMPOSSIBLE.
WILL BE DISCUSS, THE BASICS OF AIRWAY ANATOMY AND
NORMAL AIRWAY MANAGEMENT, AND TO HIGHLIGHT SOME OF
THE FACTORS THAT CONTRIBUTE TO THE SAFE MANAGEMENT
OF THE PATIENT WITH A DIFFICULT AIRWAY

ANATOMY AIRWAY
AIRWAY ANATOMY
THE SUPRAGLOTTIC AIRWAY
SUBGLOTTIC AIRWAY
MANAGEMENT OF PATIENTS WITH NORMAL AIRWAY ANATOMY
MANAGEMENT OF THE DIFFICULT AIRWAY
PREDICTION
PREPARATION
PRACTICE

TAKEN AS A SYSTEM, THE AIRWAY BEGINS AT THE EXTERNAL OPENINGS OF THE MOUTH
AND NOSE AND ENDS IN THE ALVEOLAR UNITS.
AIRWAY ANATOMY WILL BE DISCUSSED IIN TERMS OF THE SUPRAGLOTTIC AIRWAY, THE
LARYNX AND THE SUBGLOTTIC AIRWAY.
THE SUPRAGLOTTIC AIRWAY
THE NOSE
THE NOSE SERVES TO WARM AND HUMIDITY AIR AS IT ENTERS THE BODY. THE NASAL
PASSAGE MAY BE LIMITED BY THE SIZE OF THE TURBINATES, WHICH ARE HIGHLY
VASCULAR. PASSAGE OF ENDOTRACHEAL TUBES OR BRONCHOSCOPES THROUGH THE
NOSE MAY BE ASSOCIATED WITH PROFUSE BLEEDING. THE NASAL SEPTUM IS OFTEN
DEVIATED, GIVING A SMALLER PASSAGE ON ONE SIDE THAN THE OTHER. THE
NASOPHARYNX OPENS INTO THE OROPHARYNX BRANCHES OF THE FIFTH CRANIAL
NERVE PROVIDE SENSORY INNERVIATION TO THE NOSE

THE PHARYNX
THE SPACE IN THE POSTERIOR PORTION. THE NASOPHARYNX,
AND HYPOPHARYNX. LYMPHOID TISSUE AROUND THE PHARYNX
MAY HINDER PASSAGE OF AN ENDOTRACHEAL TUBE.
THE INTERNAL MUSCLES OF THE PHARYNX SERVE TO ELEVATE
THE PALATE DURING SWALLOWING.
THE EXTERNAL MUSCLES OF THE PHARYNX ARE
CONSTGRICTORS AND SERVE TO PUSH FOOD INTO THE
ESOPHAGUS, BUT MAY IMPAIR PASSAGE OF AN ENDOTRACHEAL
TUBE OR BRONCHOSCOPE IN AWAKE OR LIGHTLY ANESTHETIZED
PATIENTS.
THE INNERVATION OF THE PHARYNX IS FROM THE NINTH
CRANIAL NERVE FOR SOMATIC SENSORY AND MOTOR FUNCTION.
THE LEVATOR VELI PALATINI, WHICH IS INNERVATED BY THE
FIFTH CRANIAL NERVE

THE PHARYNX
THE TONGUE MAY MOVE POSTERIORLY IN THE PHARYNX AND OBSTRUCT
THE AIRWAY BY CONTRACTING THE POSTERIOR WALL OF THE
OROPHARYNX.
THIS CONDITION OCCURS IN ANESTHETIZED AND SEDATED PATIENTS
BUT MAY ALSO OCCUR IN SLEEPING PATIENTS.
THE OBSTRUCTION OCCURS AS MUSCLE TONE DECREASES AND A
DECREASE IN THE FUNCTIONAL LUMEN OF THE PHARYNX ENSUES.
WITH SPONTANEOUSLY BREATHING PATIENTS, A DECREASE IN
FUNCTIONAL AIRWAY LUMEN MAY BE ASSOCIATED WITH AN INCREASED
RESPIRATORY EFFORT AND RESULTANT GREATER NEGATIVE PRESSURE
BELOW THE LEVEL OF OBSTRUCTION.
THIS CAN LEAD TO A WORSENING OF THE OBSTRUCTION AS THE
NEGATIVE PRESSURE PULLS MORE SOFT TISSUE INTO THE AREA OF
COLLAPSE.
A SIGNIFICANT FROM OF THIS PROBLEM IS OBSTRUCTIVE SLEEP APNEA

THE LARYNX
THE LARYNX IS A COMPLICATED STRUCTURE THAT SERVES TO PROTECT THE
LOWER AIRWAYS, AS THE ORGAN OF PHONATION AND AS THE CONDUIT FOR
RESPIRATION.
THESE FUNCTIONS DEPEND ON THE INTERATCTION OF THE CARTILAGINOUS,
BONY AND SOFT TISSUE COMPONENTS OF THE LARYNX AND PHARYNX.
THERE ARE 9 CARTILAGES OF THE LARYNX. THE MUSCLES OF THE LARYNX ARE
BOTH EXTRINSIC AND EXTRINSIC.
CARTILAGES OF THE LARYNX
 THYROID CARTILAGE
 CRICOID CARTILAGE
 ARYTENOID CARTILAGES
 EPIGLOTTIS
SUBGLOTTIC AIRWAY
 TRACHEA
 LOBAR BRONCHI

MANAGEMENT OF PATIENTS WITH NORMAL AIRWAY ANATOMY
MASTERING VENTILATION BY BAG AND MASK IS CRITICAL FOR SAFE PRACTICE.
THE BASIC MANEUVERS USED TO FACILITATE AIR EXCHANGE IN SPONTANEOUSLY
BREATHING OR PARALYZED PATIENTS ARE DIRECTED TO OPENING THE AIRWAY
ABOVE THE GLOTTIS.
MOTIONS THAT MOVE THE TONGUE AND OTHER SOFT TISSUES OF THE
SUPRAGLOTTIC AIRWAY ANTERIORLY WILL GENERALLY IMPROVE AIR EXCHANGE.
THESE MANEUVERS INCLUDE CHIN LIFT, JAW THRUST, HEAD TILT AND
INTRODUCTION OF ORAL OR NASAL AIRWAYS.
DIFFICULT WITH MASK VENTILATION MAY BE PREDICTED IN SOME PATIENTS.
FACTORS REPORTED TO CORRELATE TO DIFFICULT MASK VENTILATION INCLUDED
 PRESENSE OF A BEARD
 BODY MASS INDEX GREATER THAN 26
 LACK OF TEETH
 AGE OVER 55 YEARS
 HISTORY OF SNORING

MOTIONS REQUIRED FOR INTUBATION IN THE NORMAL PATIENT ARE PERFORMED TO
ALLOW VISUALIZATION OF THE LARYNX FROM THE OPENING OF THE MOUTH.
IN PATIENTS WITH NORMAL AIRWAY ANATOMY, THE MAJOR COMPONENTS OF THIS
POSITIONING ARE FLEXION OF THE NECK, PARTICULARLY IN THE LOWER CERVICAL SPINE
AND EXTENSION OF THE AT THE ATLANTOOCCIPITAL JOINT.

THIS POSITION IS REFERRED TO AS THE “SNIFFING POSITION”

MANAGEMENT OF THE DIFFICULT AIRWAY
IDEALLY ALL PATIENTS WOULD HAVE NORMAL AIRWAY
ANATOMY.
ANY PATIENT REQUIRING A CONTROLLED AIRWAY WOULD
HAVE NO ADDITIONAL RISK.
THE ANESTHESIOLOGIST MUST HAVE A WAY TO IDENTIFY AND
CARE FOR PATIENTS WITH ABDNORMAL AIRWAY ANATOMY.
SAFE MANAGEMENT OF PATIENTS WITH A DIFFICULT AIRWAY.
 PREDICTION
 PREPARATION
 PRACTICE

MANAGEMENT OF THE DIFFICULT AIRWAY

PREDICTION
THERE ARE SEVERAL POPULAR METHODS OF PREDICTING EASE OR
DIFFICULTY OF INTUBATION USING A PHYSICAL EXAMINATION.
DIFFICULT IN INTUBATING THE TRACHEA CAN BE SAID TO OCCUR
WHEN AN EXPERIENCED PRACTITIONER IS UNABLE TO PASS AN
ENDOTRACHEAL TUBE IN THE NORMAL TIME AND FASHION, IT MAY
BE DEFINED AS AN INTUBATION THAT REQUIRES MORE THAN ONE
ATTEMPT.
HOWEVER, MORE DIFFICULT INTUBATIONS CAN BE RELATED TO THE
GRADE OF LARYNGOSCOPIC.
DIFFICULTY DURING INTUBATION IS LIKELY WITH A GRADE III OR IV
VIEW.
 GRADE I
: VOCAL CORDS ARE VISIBLE
 GRADE II
: VOCAL CORDS ARE ONLY PARTLY VISIBLE
 GRADE III
: ONLY THE EPIGLOTTIS IS SEEN
 GRADE IV
: NOT EVEN THE EPIGLOTTIS IS SEEN

A

C

B

D

MANAGEMENT OF THE DIFFICULT AIRWAY
THERE ARE VARIOUS FACTORS TO EVALUATE WHEN ASSESSING A PATIENTS
FOR ENDOTRACHEAL INTUBATION


HISTORY; HOWEVER, PATIENTS WHO GIVE A HISTORY OF PRIOR
DIFFICULT INTUBATION HAVE A VERY HIGH INCIDENCE OF DIFFICULT
INTUBATION. THE PRESENCE OF CONDITIONS ASSOCIATED WITH
DIFFICULT INTUBATION SHOULD BE ASCERTAINED
THESE CONDITIONS INCLUDE :


CONGENITAL SYNDROMES, INCLUDING DOWN, GOLDNHAR, TREACHER
COLLINS, PIERRE ROBIN AND MUCOPOLYSACCHARIDOSES, AMONG OTHERS
- BONY DISEASES, INCLUDING RHEUMATOID ARTHRITIS,

ANKYLOSING
SPONDYLLITIS, MANDIBULAR FRACTURE OR FIXATION, ANKYLOSIS
OF
THE TEMPOROMANDIBULAR JOINT.
- SOFT TISSUES ABNORMALITIES, INCLUDING OBESITY, TUMORS,
HEMANGIOMAS, ABSCESSES, AIRWAY INFECTIONS SUCH AS
EPIGLOTTITIS, BLEEDING.
- TRAUMA TO FAE OR NECK, BURNS, POSTOPERATIVE CHANGES
INCLUDING SCARRING, RADIATION-INDUCED CHANGES

MANAGEMENT OF THE DIFFICULT AIRWAY



DENTITION



TEMPOROMANDIBULAR JOINT MOBILITY



OROPHARYNGEAL CLASS. THIS IS COMMONLY CALLED MALLAMPATI
CLASS
THE OPENING IN THE PHARYNX IS EVALUATED. SCORES OF 3 OR 4 ARE
ASSOCIATED WITH A GREATER CHANGE OF DIFFICULT INTUBATION.



WIDTH OF THE PALATE



THE TYROMENTAL DISTANCE



COMPLIANCE OF THE MANDIBULAR SPACE



BODY HABITUS



NECK MOBILITY

MANAGEMENT OF THE DIFFICULT AIRWAY

ONE SET OF MANEUVERS WITH SEEMS TO WORK WELL AND ALLOWS,
EVALUATION OF THE SIGNIFICANT FACTORS IS OUTLINED BELOW.
WITH
THE PATIENT IN A SITTING OR SEMI-SITTING POSITION EVALUATE :
 BODY HABITUS, ESPECIALLY THE DISTRIBUTION OF BODY FAT
AROUND THE HEAD AND NECK
 THYROMENTAL DISTANCE, MANDIBULAR COMPLIANCE; I’M GOING
TO PUT MY HAND UNDER YOUR CHIN’
 TEETH, MOUTH OPENING AND ORAL-PHARYNGEAL SPACE; “OPEN
YOUR MOUTH AS WIDE AS YOU CAN;” IF THE MALLAMPATI SCORE IS
NOT 1 OR 2 ASK, FOR PLHONATION.
 TEMPOROMANDIBULAR JOINT MOBILITY; RELAX. NOW STICK YOUR
CHIN OUT TO PUT YOUR LOWER TEETH IN FRONT OF YOUR UPPER
TEETH.
 NECK FLEXION;”PICK YOUR HEAD UP AND GTRY TO TOUCH YOUR
CHIN TO YOUR CHEST”
 HEAD EXTENSION; I’M GOING TO HOLD MY HAND BEHIND YOUR
NECK . TIP YOUR HEAD BACK AS FAR AS YOU CAN, LIKE YOU ARE
TRYING TO LOOK AT THE CEILLING.

PREPARATION
ADEQUATE PREPARATION TO CARE FOR PATIENTS WITH DIFFICULT
AIRWAY ANATOMY REQUIRES ASQUISITION OF KNOWLEDGE AND
EQUIPMENT.
THE KNOWLEDGE NECESSARY FOR SAFE MANAGEMENT OF THESE
PATIENTS IS AN EXTENSION OF THE KNOWLEDGE NEEDED TO
PROVIDE CARE FOR ANY PATIENT BUT WITH ADDITIONAL POINTS.
THE ALGORITHM SUGGESTS THE FOLLOWING STEPS :

A

B

TOOLS FOR MANAGEMENT OF THE DIFFICULT AIRWAY
AIRWAYS
STYLETS, INTUBATION GUIDES AND BOUGIES
AIRWAY EXCHANGE CATHETER
SPECIALIZED FORCEPS
LARYNGOSCOPY
RIGID DIRECT-VISION LARYNGOSCOPES ARE AVAILABLE IN A
WIDE ASSORTMENT OF
BLADE SHAPES AND SIZES.
PATIENTS WITH A LONG, FLOPPY EPIGLOTTIS ARE OFTEN
EASIER TO INTUBATE
USING A STRAIGHT BLADE THAN A
MACHINTOSH BLADE.
RIGID, SEMI-DIRECT LARYNGOSCOPES HAVE A PRISM ON THE BALDE TO ALLOW VISION
OF THE LARYNGEAL STRUCTURES WHEN
THE PATIENT’S ANATOMY DOES’NT ALLOW
DIRECT VISION.
RIGID FIBEROPTIC LARYNGOSCOPES SUCH AS THE BULLARD AND
UPSHER SCOPES
ALLOW VISUALIZATION OF LARYNGEAL STRUCTURES VIA FIBEROPTICS.

LARYNGOSCOPY

THESE SCOPES MAY BE VERY USEFUL IN PATIENTS WITH AN
ANTERIOR
LARYNX.
ADVANTAGES OF THE RIGID FIBEROPTIC INTUBATING SCOPES
INCLUDE :

RIGID SCOPE MORE SIMILAR TO USUAL LARYNGOSCOPES

POSSIBLY SHORTER LEARNING CURVE

POSSIBLY MORE DURABLE THAN FLEXIBLE FIBEROPTIC SCOPES
DISADVANTAGES OF THE RIGID FIBEROPTIC INTUBATING SCOPES
INCLUDE :
 THE ENDOTRACHEAL TUBE IS PASSED INTO THE LARYNX WHILE
WATCHING THROUGH THE FIBEROPTIC EYEPIECE, NOT DIRECTLY
OVER THE SCOPE.
 TECHNIQUE MAY BE DIFFICULT OR AWKWARD
 PATIENT SIZE LIMITS RELATED TO THE RELATIVELY LARGE BLADE
SIZE

FIBEROPTIC BRONCHOSCOPIC INTUBATION
FIBEROPTIC BRONCHOSCOPIC INTUBATION (FBI) USES FLEXIBLE BRONCHOSCOPES TO
INTUBATE THE TRACHEA.
MANY MANUFACTURERS HAVE DEVELOPED SCOPES SPECIFICALLY FOR INTUBATION THAT ARE
TYPICALL LONGER AND OF SMALLER DIAMETER THAN STANDARD DIAGNOSTIC
BRONCHOSCOPES.
THE ADVANTAGES OF FBI INCLUDE :

THE ENDOTRACHEAL TUBE IS PASSED INTO THE TRACHEA DIRECTLY OVER
THE SCOPE
 ACCEPTABLE RANGE OF PATIENT SIZES, SINCE DIFFERENT-SIZED SCOPES
ARE AVAILABLE.
 THERAPEUTIC USES INCLUDE PLACEMENT OF BRONCHIAL BLOCKERS AND
DOUBLE-LUMEN ENDOTGRACHEAL TUBES. ADDITIONALLY, THE
BRONCHOSCOPE MAY BE USEFUL IN REMOVING SECRETIONS FROM THE
BRONCHI.
DISADVANTAGES OF FBI INCLUDE
 THE TECHNIQUE CAN BE DIFFICULT TO LEARN
 THE COST AND FRAGILITY OF THE EQUIPMENT ARE OF CONCERN


PITFALLS OF FBI INCLUDE
 BLOOD / SECRETIONS MAY OBSCURE VIEW
 DISTORTED ANATOMY
 SPECIAL PROBLEMS WITH FBI :




ENDOTRACHEAL TUBE MAY “HANG UP” ON LARYNGEAL STRUCTURES
SCOPE MAY LOOP IN PHARYNX
LENS MAY FOG

ROLE OF THE LARYNGEAL MASK AIRWAY IN DIFFICULT AIRWAY MANAGEMENT
THE LMA CAN BE USED TO CHANGE A “CAN’T VENTILATE” TO A “CAN VENTILATE” SITUATION.
THIS ALLOWS YOU TO CONTINUE THE ANESTHETIC WITH THE LMA AS YOUR AIRWAY DEVICE OR AWAKEN THE PATIENT TO ALLOW A SAFE ALTERNATIVE
INTUBATION OR TRACHEOSTOMY.
HOWEVER, ONCE VENTILATION IS ASSURED THROUGH THE LMA, OTHER TECHNIQUES MAY BE USED TO SECURE THE AIRWAY.
THE INTUBATING LMA (ILMA) ADDS ANOTHER TOOL FOR MANAGEMENT OF PATIENTS WITH DIFFICULT AIRWAY ANATOMY.
THE ILMA SHOULD BE CONSIDERED EARLY IN MANAGEMENT OF PATIENTS WITH UNSUSPECTED DIFFICULT AIRWAY ANATOMY AS IT MAY ALLOW
RAPID CONVERSION OF A DIFFICULT AIRWAY TO A CONTROLLED AIRWAY.
IF AN ILMA IS NOT AVAILABLE, THE LMA MAY STILL BE USED AS A CONDUIT TO INTUBATION, AS A BLIND TECHNIQUE OR WITH AIRWAY
EXCHANGE CATHETERS OR FIBEROPTIC BRONCHOSCOPES.

BLINDENDOTRACHEAL TUBE INTUBATION VIA LARYNGEAL
MASK
AIRWAY






PLACE LMA AND VERIFY VENTILATION VIA LMA
PASS A WELL-LUBRICATED ENDOTRACHEAL TUBE DOWN THE LMA, ROTATED
900 FROM NORMAL TO EASE PASSAGE THROUGH BARS ON LMA; AT 20 CM,
ROTATE ENDOTRACHEAL TUBE INTO NORMAL POSITION
PASS THE ENDOTRACHEAL TUBE INTO TRACHEA, INFLATE CUFF, VERIFY
VENTILATION
SECURE THE ENDOTRACHEAL TUBE AND LMA IN PLACE OR CUT AND SPLIT
LMA TO ALLOW FOR SECURING OF THE ENDOTRACHEAL TUBE ALONE

LARYNGEAL MASK AIRWAY SIZES AND
CORRESPONDING ENDOTRACHEAL TUBE (ETT)
SIZE
1
1.5
2
2.5
3
4
5

WEIGHT

MAXIMUM
AIR IN CUFF
<5KG
4 ML
5-10KG
7 ML
10-20KG
10 ML
20-30KG
14 ML
30KG TO SMALL ADULT
20 ML
ADULT
30 ML
LARGE ADULT/POOR SEAL WITH 4 40 ML

ETT SIZE THAT WILL PASS
3.0 UNCUFFED
4.5 UNCUFFED
6.0 UNCUFFED
6.0 CUFFED
7.5 CUFFED

FIBEROPTIC INTUBATION VIA LARYNGEAL MASK AIRWAY
 PLACE LMA AND VERIFY VENTILATION VIA LMA
 LUBRICATE ENDOTRACHEAL TUBE WELL, POSITION ON BRONCHOSCOPE
 PASS BRONCHOSCOPE DOWN LMA, INTO TRACHEA, ADVANCE ENDOTRACHEAL TUBE ALONG BRONCHOSCOPE.
 VERIFY POSITION OF ENDOTRACHEAL TUBE VISUALLY, WITHDRAW BRONCHOSCOPE
 SECURE ENDOTRACHEAL TUBE AND LMA IN PLACE OR CUT AND SPLIT LMA TO ALLOW FOR SECURING OF THE ENDOTRACHEAL TUBE ALONE.
PASSAGE OF INTUBATING GUIDE VIA LARYNGEAL MASK AIRWAY
 PLACE LMA AND VERIFY VENTILATION VIA LMA
 PASS VENTILATING OR NONVENTILATING INTUBATION GUIDE VIA LMA – VENTILATING GUIDE ALLOWS VERIFICATION OF POSITION OF GUIDE BY CAPNOMETRY BEFORE ENDOTRACHEAL TUBE
PASSAGE.
 REMOVE LMA, PASS APPROPRIATE-SIZED ENDOTRACHEAL TUBE OVER GUIDE, REMOVE INTUBATING GUIDE
 VERIFY POSITION OF ENDOTRACHEAL TUBE IN TRACHEA BY BRONCHOSCOPY, CAPNOMETRY AND VENTILATION
 SECURE ENDOTRACHEAL TUBE

LARYNGEAL MASK AIRWAYS ALLOW VENTILATION OF PATIENT DURING
OTHER AIRWAY MANAGEMENT TECHNIQUES
 TRACHEOSTOMY
 RETROGRADE WIRE-GUIDED INTUBATION

PITFALLS OF LARYNGEAL MASK AIRWAY IN DIFFICULT AIRWAY
MANAGEMENT
 EPIGLOTTIS MAY FOLD DOWN DURING INSERTION OF THE AIRWAY AND LIMIT THE ABILITY TO PASS OTHER DEVICES INTO THE TRACHEA-THIS MAY HAPPEN EVEN THROUH SOME
VENTILATION IS POSSIBLE.
 BARS ON LMA MAY LIMIT PASSAGE OF OTHER DEVICES
 THE ENDOTRACHEAL TUBE MAY BE TOO SHORT TO COMPLETELY ENTER THE TRACHEA VIA LMA.
 THE LMA / ENDOTRACHEAL TUBE COMBINATION MAY BE DIFFICULT TO SECURE AND MAY SLIP OUT OF TRACHEA.
 RISK OF ASPIRATION OF GASTRIC CONTENTS – PROSEAL MAY DECREASE THIS RISK

ADVANCED AIRWAY TECHNIQUES


RETROGRADE INTUBATION



TRANSTRACHEAL JET VENTILATION



CRICOTHYROIDOTOMY



TRACHEOSTOMY

LARYNGEAL MASK AIRWAY SIZES AND
CORRESPONDING ENDOTRACHEAL TUBE (ETT)

SIZE
1
1.5
2
2.5
3
4
5

WEIGHT

MAXIMUM
AIR IN CUFF
<5KG
4 ML
5-10KG
7 ML
10-20KG
10 ML
20-30KG
14 ML
30KG TO SMALL ADULT
20 ML
ADULT
30 ML
LARGE ADULT/POOR SEAL WITH 4 40 ML

ETT SIZE THAT WILL PASS
3.0 UNCUFFED
4.5 UNCUFFED
6.0 UNCUFFED
6.0 CUFFED
7.5 CUFFED

INTRODUCTION
BEDSIDE ASSESSMENT
MANDIBLE MEASURE MENTAL-TYROID DISTANCE
O PENING OF THE MOUTHS
U VULA VISIBILITY
TEETH PRESENTATION
H EAD MOVEMENT
S ILLOUETTE THE PROFILE OF THE HEAD, NECK AND CHEST

INTRODUCTION
AN INADEQUATE AIRWAY LEADS RAPIDLY TO HYPOXAEMIA AND
UNCORRECTED HYPOXAEMIA WILL RESULT IN BRAIN DAMAGE AND
ULTIMATELY DEATH.
THE GOLD STANDARD FOR A SECURE AIRWAY IS TRACHEAL
INTUBATION.
EVERY AIRWAY ASSESSMENT SHOULD INCLUDE TESTS THAT AIM TO
PREDICT DIFFICULTY WITH TRACHEAL INTUBATION.
NO SINGLE TEST CAN PREDICT AIRWAY OR INTUBATION DIFFICULTY
RELIABLY.
NO SINGLE TEST, OR A COMBINATION OF TESTS, CAN DETECT
DIFFITULTY WITH AIRWAY MANAGEMENT WITH 100% CERTAINTY.

BEDSIDE ASSESSMENT
MOUTHS
THE LETTERS STAND FOR : MANDIBLE, OPENING, UVULA, TEETH, HEAD AN
NECK, SILHOUETTE
MANDIBLE MEASURE MENTAL-TYROID DISTANCE,
JAW THRUST PROTRUSION
- MENTO-TYROID DISTANCE LESS THAN 6 CM A SMALL RECEDING
MANDIBLE
- JAW THRUST PROTRUSION
FULL PROTRUSION :
LOWER INCISORS, ANTERIOR TO UPPER INCISORS IS
CLASSED AS CLASS A,
PART PROTRUSION
UPPER AND LOWER, INCISORS IN LINE AS CLASS B,
NO PROTRUSION
LOWER INCISORS, BEHIND UPPER AS CLASS C

O PENING BE AT LEAST 3 CM
U VULA (INCLUDING THE PALATE AND THE PHARYNGEAL
STRUCTURES)
MALLAMPATI AND MODIFIED BY SAMSOON AN YOUNG. THE TERM
“MALLAMPATI GRADE I TO IV.
EVEN WITH BEST STANDARDISATION (PATIENT SITTING, HEAD IN
NEUTRAL POSITION, MAXIMUM MOUTH OPENING AND TONGUE
PROTRUSION THERE IS INTER-OBSERVER VARIABILITY AND A
RELATIVELY HIGH INCIDENCE OF FALSE NEGATIVES

TEETH
A COMPLETELY EDENTULOUS PATIENT HAS A WIDER GAPE AND THEREFORE IS
RELATIVELY EASY TO INTUBATE
H EAD ALL
ASSESS RANGES OF MOVEMENT OF THE HEAD (ATLANTO-OCCIPITAL JOINT) AND
CERVICAL SPINE. AT LEAST A 900 DIFFRENCE BETWEEN FULL FLEXION (CHIN ON
CHEST) AND EXTENSION (ASK THE PATIENT TO LOOK AT THE CEILING WHILE
SITTING UPRIGHT. THE ABSENCE OF MOVEMENT PARTICULARLY IN THE ATLATOOCCIPITAL JOINT MAY MAKE IT PHYSICALLY IMPOSSIBLE TO OBTAIN A LINE OF
VISION AT ATTEMPTED DIRECT LARYNGOSCOPY.
S ILLOUETTE THE PROFILE OF THE HEAD, NECK AND CHEST
THE COMBINATION OF MALLAMPATI, JAW PROTRUSION AND CRANIOCERVICAL
EXTENSION HAS A SPECIFICITY OF 99% AND POSITIVE PREDICTIVE VALUE OF 93%.
A THROUGH BEDSIDE ASSESSMENT OF THE AIRWAY WILL ALERT THE
ANAESTHETIST TO MOST CASES OF DIFFICULTIES WITH LARYNGOSCOPY AND
INTUBATION. HOWEVER, SOME CASES WILL ONLY DISCOVERED AT INTUBATION

EASY OR HARD?

CLINICAL
ASSESSMENT
OF THE AIRWAY

INTRODUCTION
GLOBAL ASSESSMENT
AIRWAY-COMPROMISING CONDITIONS
OBJECTIVE ASSESSMENT

INTRODUCTION
SAFETY FIRST
THE CLINICAL ANESTHESIOLOGIST, AS A SPECIALIS, PLAYS A UNIQUE
ROLE IN HEALTH CARE, RENDERING PATIENTS FREE FROM PAIN
EITHER IN THE FORM OF REGIONAL ANESTHESIA OR GENERAL
ANESTHESIA TO FACILITATE SURGICAL OPERATIONS.
AS A RESULT OF RAPID-ACTING NEURODEPRESSANTS AND MUSCLE
RELAXANTS CURRENTLY USED IN CLINICAL PRACTICE, THE VARIOUS
PHYSIOLOGIC FORCES, MULTITUDE OF PROTECTIVE REFLEXES, AND
HIGHLY INTRICATE NEUROGENIC MECHANISMS THAT INTERACT WITH
EACH OTHER TO SUPPORT AND MAINTAIN THE VASTLY COMPLEX
BODILY FUNCTIONS (ACID-BASE STATUS, MAINTENANCE OF BODY
TEMPERATURE AND HEMODYNAMIC) ARE SUBDUED OR INTERFERED
WITH FROM MOMENT TO MOMENT. THESE HEMODYNAMIC AND
METABOLIC FUNCTIONS ARE APT TO SUFFER IF OXYGENATION
SHOULD BE COMPROMISED DURING INDUCTION OR MAINTENANCE
OF THE ANESTHETIZED STATE

THESE HEMODYNAMIC AND METABOLIC FUNCTIONS ARE APT TO SUFFER
IF OXYGENATION SHOULD BE COMPROMISED DURING INDUCTION OR
MAINTENANCE OF THE ANESTHETIZED STATE.
AS SUCH, THE PRIMARY RESPONSIBILITY OF THE
ANESTHESIOLOGIST AS A CLINICAL IS TO SAFEGUARD THE
AIRWAY, I.E. TO PRESERVE AND PROTECT IT DURING INDUCTION,
MAINTENANCE, AND RECOVERY FROM THE STATE OF
ANESTHESIA; AND IN THE EVENT OF LOS OF THE AIRWAY, IT
SHOULD BE PROMPTLY RE-ESTABLLISH BY INTRUMENTATION OR
SURGERY BEFORE THE INDIVIDUAL SUFFERS IRREVERSIBLE
INJURY FROM INADEQUATE OR COMPROMISED OXYGENATION.
TECHNOLOGIC INNOVATIONS (PULSE OXIMETRY, CAPNOGRAPHY) ARE
ERTAINLY HELPFUL AS MONITORS TO INDICATE THE STATE OF WELLBEING OF THE PATIENT AND ALERT THE CLINICIAN WHEN THE WELLBEING IS UNSOUND OR TREATENED.
BUT THEY ARE BY NO MEANS A SUBSTITUTE FOR CLINICAL ASSESSMENT
AND ANTICIPATION OF ANY PROBLEM, INCLUDING THE DIFFICULT AIRWAY.

GLOBAL ASSESSMENT
ALTHOUGH AIRWAY ASSESSMENT IS ESSENTIALLY A REGIONAL
ANATOMIC ASSESSMENT A GENERAL ASSESSMENT OF THE
BODY BUILD AND OF THE HEAD AND NECK. TO VIEW THE
HEAD AND NECK FRONTALLY AS WELL AS N PROFILE AND
TAKE INTO CONSIDERATION THE BODY BUILD AS WELL.
THE SHORT, THICK NECK THAT IS OFTEN ASSOCIATED WITH
DIFFICULT INTUBATION IS WELL KNOWN AS IS THE CASE WITH
MORBID OBESITY.
AIRWAYS DIFFICULTIES TEND TO BE ASSOCIATED WITH
SHORT AND STUMPY INDIVIDUALS MORE OFTEN THAN
TALL AND THIN INDIVIDUALS; THIS IS ESPECIALLY TRUE
WITH PREGNANT WOMEN, PERHAPS ALSO AS A REFLECTION OF
FLUID RETENTION DURING PREGNANCY.

ANATOMICALLY, THE AIRWAY MAY BE COMPROMISED BY A
BROAD
ARRAY OF FACTORS THAT MAY BE CLASSIFIED ON THE BASIS
OF
CAUSE.
1.
DISPROPORTION, PARTICULARLY BETWEEN THE BASE OF
TONGUE AND OROPHARYNGEAL SPACE.
2.
DISTORTION
3.
DECREASED MOBILITY OF JOINTS (ATLANTO-OCCIPICAL
AND TEMPOROMANDIBULAR JOINTS)
4.
DENTAL OVERBITE

AIRWAY-COMPROMISING CONDITIONS
CONGENITAL

PIERRE ROBIN SYNDROME
TEACHER COLLINS
SYNDROME
GOLDENHAR’S SYNDROME
DOWN’S SYNDROME
KLIPPEL-FEIL SYNDROME

GOITER

MICROGNETHIA, MACROGLOSSIA, CLEFT SOF
PALATE
AURICULAR AND OCULAR DEFECTS; MALAR
AND MANDIBULAR HYPOPLASIA
AURICULAR AND OCULAR DEFECTS; MALAR
AND MANDIBULAR HYPOPLASIA;
OCCIPITALIZATION OF ATLAS
POORLY DEVELOPED OR ABSENT BRIDGE OF
THE NOSE; MACROGLOSSIA.
CONGENITAL FUSION OF A VARIABLE
NUMBER OF CERVICAL VERTEBRAE;
RESTRICTION OF NECK MOVEMENT
COMPRESSION OF TRACHEA, DEVIATION OF
LARYNX/TRACHEA

AIRWAY-COMPROMISING CONDITIONS
ACQUIRED

INFECTIONS
SUPRAGLOTTITIS
CROUP
ABSCESS (INTRAORAL,
RETROPHARNGEAL)
LUDWIG’S ANGINA
ARTHRITIS
RHEUMATOID ARTHRITIS

ANKYLOSING SPONDYLITIS

BENIGN TUMORS
EXAPLES; CYSTIC HYGROMA,
LIPOMA, ADENOMA, GOITER
MALIGNANT TUMORS
EXAMPLES; CARCINOMA OF
TONGUE, CARCIONAMA OF
LARYNX, CARCINOMA OF
THYROID.
TRAUMA
EXAMLES; FACIAL INJURY,
CERVICAL SPINE INJURY,
LARYNGEAL/TRACHEAL TRAUMA
OBESITY

ACROMEGALY
ACUTE BURNS

LARYNGEAL EDEMA
LARYNGEAL EDEMA
DISTORTION OF THE AIRWAY AND TRISMUS
DISTORTION OF THE AIRWAY AND TRISMUS

TEMPOROMANDIBULAR JOINT ANKYLOSIS,
CRICOARYTENOID ARTHRITIS, DEVIATION OF
LARYNX, RESTRICTED MOBILITY OF CERVICAL
SPINE
ANKYLOSIS OF CERVICAL SPINE; LESS COMMONLY
ANKYLOSIS OF TEMPOROMANDIBULAR OOINTS;
LACK OF MOBILITY OF CERVICAL SPINE.
STENOSIS OR DISTORTION OF THE AIRWAY

STENOSIS OR DISTORTION OF THE AIRWAY;
FIXATION OF LARYNX OR ADJACENT TISSUES
SECONDARY TO INFILTRATION OR FIBROSIS FROM
IRRADIATION.
EDEMA OF THE AIRWAY, HEMATOMA, UNSTABLE
FRACTURES(S) OF THE MAXILLAE, MANDIBLE AND
CERVICAL VERTEBRAE
SHORT, THICK NECK; REDUNDANT TISSUE IN THE
OROPHARYNX; SLEEP APNEA
MACROGLOSSIA; PROGNATHISM
EDEMA OF AIRWAY

OBJECTIVE ASSESSMENT
DIFFICULT LARYNGOSCOPY CAN STILL BE ENCOUNTERED
DURING INDUCTION IN INDIVIDUALS WITH NO OBVIOUS
ANATOMIC VARIATIONS, UNRESTRICTED MOVEMENT OF HEAD
AND NECK, ADEQUATE RELAXATION, OPTIMAL POSITIONING,
AND SOUND TECHNIQUE.
A TOTALLY UNEXPECTED DIFFICULT LARYNGOSCOPY
MIGHT CONTRIBUTE TO SIGNIFICANT MORBIDITY AND
MORTALITY.
THE BASIS OF AIRWAY CLASSIFICATION :
CLASS 1 : UVULA, FAUCIAL PILLARS, SOFT PALATE VISIBEL
CLASS 2 : FAUCIAL PILLARS, SOFT PALATE VISIBLE
CLASS 3 : SOFT PALATE VISIBLE

A

B

C

CORRELATION BETWEEN VISIBILITY OF FAUCIAL PILLARS,
SOFT PALATE AND UVULA AND EXPOSURE OF GLOTTIS BY
DIRECT LARYNGOSCOPY
LARYNGOSCOPY GRADE
VISIBILITY OF
STRUCTURES
NO.OF PTS.
(%)
CLSS 1
155 (73.8%)
CLASS 2
40 (19%)
CLASS 3
15 (7.14%)

GRADE 1
NO.OF PTS
(%)

GRADE 2
NO OF PTS
(%)

GRADE 3
NO.OF PTS
(%)

GRADE 4
NO. OF PTS
(%)

125 (59.5%)

30 (14.3%)

-

-

12 (5.7%)

14 (6.7%)

10 (4.7%)

4 (1.9%)

-

1 (0.5%)

9 (4.3%)

5 (2.4%)

LARYNGOSCOPE
CLINICAL PROBLEM-BASED ASSESSMENT OF
TRADITIONAL LARYNGOSCOPE DESIGN
ANTESTERNAL SPACE RESTRICTION
LIMITED MOUTH OPENING
REDUCED INTRAORAL CAVITY
THE ANTERIOR LARYNX
MANDIBULAR SPACE
UNUSUALLY WIDE, SUCH AS THE
BIZARRI-GUFFRID
NOVEL LARYNGOSCOPE TECHNIQUES
INDIRECT VISUALIZATION OF THE VOCAL CORDS
DIRECT VISUALIZATION OF THE VOCAL CORDS
EPIGLOTTIS POSITIONING
INFANT AND PEDIATRIC REQUIREMENTS

VARIOUS LARYNGOSCOPES HAVE BEEN DESIGNED SINCE WILLIAM MACEWAN
USED HIS FINGERS TO GUIDE TUBE FROM THE MOUTH INTO THE TRACHEA.
A LARYNGOSCOPE CONSISTS OF A HANDLE JOINED TO A BLADE.
THIS JUNCTION USUALLY IS REFERRED TO AS THE FITTING.
THE BLADE CONSISTS OF FIVE PARTS.
1.
THE SPATULA IS THE MAIN SHAFT OF THE BLADE. THE BOTTOM CONTACTS
THE TONGUE AND THE TOP FACES THE ROOF OF THE MOUTH.
2.
THE WEB OR STEP PROJECT UPWARD FROM THE BLADE TOWARD THE
ROFF OF THE MOUTH.
3.
THE FLANGE PROJECTS LATERALLY FROM THE WEB. THE DIRECTION MAY
BE OVER THE BLADE SO THAT A CROSS SECTIONAL AREA IS OPEN
PARTIALLY, OR COMPLETELY ENCLOSED TO FORM A TUBE. ALTERNATIVELY
THE FLANGE BENDS AWAY FROM THE BLADE AND IS REFERRED TO AS A
REVERSED FLANGE.
4.
THE BEAK IS THE TIP OF THE BLADE, PLACED IN THE VALLECULA OR
BEYOND THE EPIGLOTTIS TO ELEVATE IT DIRECTLY.
5.
APPROXIMATING THE BEAK IS A LIGHT SOURCE. THERE MAY BE
ADDITIONAL FEATURES, SUCH AS OXYGEN DELIVERY AND SUCTION

CLINICAL PROBLEM-BASED ASSESSMENT OF
TRADITIONAL LARYNGOSCOPE DESIGN
ANTESTERNAL SPACE RESTRICTION
LIMITED MOUTH OPENING
REDUCED INTRAORAL CAVITY
THE ANTERIOR LARYNX
MANDIBULAR SPACE : TONGUE SIZE DISPROPORTION
ANY BLADE WITH A REVERSED FLANGE, PARTICULARLY IF
UNUSUALLY WIDE, SUCH AS THE BIZARRI-GUFFRIDA.
EPIGLOTTIS POSITIONING

NOVEL LARYNGOSCOPE TECHNIQUES
INDIRECT VISUALIZATION OF THE VOCAL CORDS
THE BELLHOUSE BLADE INCORPORATES A PRISM WHEN
NECESSARY

NOVEL LARYNGOSCOPE TECHNIQUES
DIRECT VISUALIZATION OF THE VOCAL CORDS
THE BILLARD LARYNGOSCOPE HAS A BROAD BLADE
TERMINATING INTUBATION BROAD CURVE. IT IS THIN AND
LACKS A STEP

INFANT AND PEDIATRIC REQUIREMENTS
PREANAESTHESIA ASSESSMENT OF INFANT AND
PEDIATRIC PATIENTS IS SIMILAR TO THAT FOR ADULT.
THE NORMAL ANATOMY DIFFERS FROM THE ADULT IN THE
FOLLOWING DETAILS :
THE TONGUE IS LONGER
THE EPIGLOTTIS IS MORE CEPHALAD AND MORE
ANTERIOR
THE EPIGLOTTIS IS V SHAPED AND NARROWER
THE HYOID CARTILAGE IS MORE RESISTANT TO PRESSURE
THE LARYNX IS AT A HIGHER VERVICAL LEVEL (C3-4)
THE VOCAL CORDS SLOPE UPWARD AND BACKWARDS

SUMMARY OF PROBLEMS PRESENTED BY PAITENTS AND QUESTIONS TO GUIDE
SELCTION OF THE MOST SUITABLE LARYNGOSCOPE BLADE
PROBLEMS PRESENTED BY PATIENT

LARYNGOSCOPE DESIGN CHARACTERISTICS

UPPER CHEST WALL
ANTESTERNAL SPACE RESTRICTION
NECK
CHIN-TYROID NOTCH DISTANCE REDUCED
SCARRING, OTHER SPACE-OCCUPYING
PATHOLOGY
TYROID CARTILAGE IMMOBILITY
SUBMENTAL MASS OR SCARRING
ATLANTO-OCCIPITAL JOINT MOBILITY
REDUCED
CERVICAL SPINE TRAUMATIZED OR REDUCED
MOBILITY
FACE
MICROGNATHIA
MACROGNATHIA
SPLIT LIP
MANDIBULAR / MAXILLARY FRACTURE
NASAL PATHOLOGY OR TRAUMA
ORAL ORIFICE NARROW

BEAK TIP
WILL THIS ATRAUMATICALLY AND SECURELY TILT OR
LIFT
THE EPIGLOTTIS EFFECTIVELY?
BEAK
WILL A TILT FROM AXIS OF THE SPATULA AID
VISUALIZATION/ACCESS FOR VOCAL CORD
APERTURE?
WILL AN EXPOSED CROSS-SECTIONAL AREA BE
PROTECTED FROM PATHOLOGIC OR
ANATOMICALLY ABNORMAL
TISSUES?
WILL THE SIZE OCCUPY SPACE NEEDED TO
MANIPULATE TIP OF ETT?
SPATULA WITH REFERENCE TO THE LENGTH THAT WILL
BE IN THE ORAL CAVITY
APPROACHING BETWEEN THE INCISOR, TEETH WILL ITS
CURVATURE / STRAIGHTNESS AID VISUALIZATION AID
ACCESS TO THE VOCAL
CORDS?
USING A MOLAR OR RETROMOLAR APPROACH, WILL ITS
CURVATURE / STRAIGHTNESS AID VISUALIZATION AID
ACCESS TO THE VOCAL
CORDS?
WILL ITS WIDTH COMPRESS TH E TONGUE
ADWQUATELY?
WILL ITS SIZE HINDER ETT MANIPULATION?

SUMMARY OF PROBLEMS PRESENTED BY PAITENTS AND QUESTIONS TO GUIDE
SELCTION OF THE MOST SUITABLE LARYNGOSCOPE BLADE

PROBLEMS PRESENTED BY PATIENT

LARYNGOSCOPE DESIGN CHARACTERISTICS

MOUTH
RESTRICTED OPENING
DENTAL MISALIGNMENT
TONGUE LARGE
INTRAORAL VOLUME SMALL
PHARYNGEAL SPACE-OCCUPYING PATHOLOGY
MALLAMPATI SIGN II-IV
MOLAR TEETH PRESENT

WITH REFERENCE TO THE LENGTH THAT WILL BE
OUTSIDE THE ORAL CAVITY
WILL ITS SHAPE PROVIDE THE WIDEST FIELD OF
VIEW NECESSARY?
WILL ITS SHAPE HINDER MANIPULATION OF THE
ETT
AND USE OF OTHER AIDS?
FLANGE (MODIFIED / REVERSED)
WILL IT AID TONGUE COMPRESSION?
WILL IT CROSS-SECTIONAL AREA, RELATIVE TO
THAT
OF ENTRY TO MOUTH, HINDER
MANIPULATION OF THE ETT OUTSIDE THE
LUMEN OF SPATULA AND FLANGE?

SUMMARY OF PROBLEMS PRESENTED BY PAITENTS AND QUESTIONS TO GUIDE
SELCTION OF THE MOST SUITABLE LARYNGOSCOPE BLADE (CONTINUED)
PROBLEMS PRESENTED BY PATIENT

LARYNGOSCOPE DESIGN CHARACTERISTICS

UPPER CHEST WALL
ANTESTERNAL SPACE RESTRICTION
NECK
CHIN-THYROID NOTCH DISTANCE REDUCED
SCARRING, OTHER SPACE-OCCUPYING PATHOLOGY
TYROID CARTILAGE IMMOBILITY
SUBMENTAL MASS OR SCARRING
ATLANTO-OCCIPITAL JOINT MOBILITY REDUCED
CERVICAL SPINE TRAUMATIZED OR REDUCED MOBILITY
FACE
MICROGNATHIA
MACROGNATHIA
SPLIT LIP
MANDIBULAR / MAXILLARY FRACTURE
NASAL PATHOLOGY OR TRAUMA
ORAL ORIFICE NARROW
MOUTH
RESTRICTED OPENING
DENTAL MISALIGNMENT
TONGUE LARGE
INTRAORAL VOLUME SMALL
PHARYNGEAL SPACE-OCCUPYING PATHOLOGY
MALLAMPATI SIGN II-IV
MOLAR TEETH PRESENT

STEP
WILL THE HEIGHT PREVENT ENTRY TO THE PATIENT’S
MOUTH ?
WILL ANGULATION OF SPATULA TO THE AXIS OF THE
TRACHEA BE HINDERED?
WILL SHALLOWNESS OR ABSENCE ABOLISH ITS PROP
CAPABILITY IN THAT PATIENT?
FITTING
WILL THE ANGLE BETWEEN HANDLE AND BLADE
PREVENT THE BLADE ENTERING THE MOUTH AND ITS
MANIPULOATION?
WILL VISUALIZATION AND MANIPULATION BE
COMPROMISED UNLESS BLADE IS OFFSET?
HANDLE
IS THE HANDLE TOO LONG TO PERMIT BLADE ENTRY
INTO
THE MOUTH?

DO THE PROBLEMS PRESENTED DEMAND VISUAL AND ACCESS AIDS SUCH AS PRISMS OR VISUAL
IMAGE TRANSMISSION VIA RIGID OR FLEXIBLE ROUTE?
THE USER WHO DETERMINES THE USEFULNESS OF AN INSTRUMENT. EXAMINE YOUR PATIENT, UNDERSTAND
LARYNGOSCOPES, LEARN HOW TO USE THEM

THE TRIPLE MANOEUVRE
HEAD TILT
CHIN LIFT
JAW THRUST
FACEMASKS
ONE HAND TECHNIQUE
TWO HAND METHOD
THE OROPHARYNGEAL AIRWAY
NASOPHARYNGEAL AIRWAY
THE LARYNGEAL MASK AIRWAY (LMA)
OTHER SUPRAGLOTTIC DEVICES
AIRWAY MANAGEMENT DEVICE, AMD TM.
COMBITUBETM,
CUFFED OROPHARYNGEAL AIRWAY, COPATM,
LARYNGEAL TUBE,LT,
PAXTM OROPHARYNGEAL AIRWAY. PAXPREESSTM

THE FIRST PART OF FOLLOW, DESCRIBES HOW THE AIRWAY IS
MAINTAINED WITHOUT AIRWAY ADJUNCTS AND WITH THE AID OF
SUPRAGLOTTIC DEVICES.
AIRWAY MANAGEMENT WITHOUT INTUBATION (AMWI) IS AN
IMPORTANT SKILL THAT MUST BE MASTERED BY THE MEDICAL
STAFF.
IT MAY BE CARRIED OUT :
 AS A PART OF PRIMARY AIRWAY MANAGEMENT PRIOR TO
EMERGENCY OR ELECTIVE INTUBATION.
 WHEN INTUBATION EEQUIPMENT OR INTUBATION SKILLS ARE
UNAVAILABLE, E.G. ON THE WARDS OR OUT OF HOSPITAL
SCENARIOS.
 WHEN INTUBATION IS DIFFICULT
 WHEN THE PATIENT HAS A PARTIALLY OBSTRUCTED AIRWAY
 AS A PART OF A GENERAL ANAESTHETIC

THE UPPER AIRWAY HAS
A RIGID WALL SUPPORTED BY THE VERTEBRA POSTERIORLY
COLLAPSIBLE ANTERIOR WALL FORMED BY THE TONGUE AND THE
EPIGLOTTIS ANTERIORLY.
THE ANTERIOR WALL OBSTRUCTS THE AIRWAY IF
THERE IS A LOSS OF MUSCLE TONE (UNCONSCIOUSNESS, PARALYSIS)
THE BULK OF THE SOFT TISSUE IS INCREASED (OEDEMA, ABSCESS, TUMOUR)
AMWI MAY CONSIST OF THE USE OF ONE OR MORE OF THE FOLLOWING :
 TRIPLE MANOEUVRE
 FACEMASKS
 OROPHARYNGEAL AIRWAY
 NASOPHARYNGEAL AIRWAY
 LARYNGEAL MASK / OESOPHAGOTGRACEHAL COMBITUBE / AIRWAY
MANAGEMENT DEVICES

(III)
(I)

(II)

THE TRIPLE MANOEUVRE, CLASSICALLY CONSISTS OF :
HEAD TILT
 CHIN LIFT
 JAW THRUST


THE HEAD TILT AND CHIN LIFT IS AVOIDED IN PATIENTS WITH
SUSPECTED HEAD OR CERVICAL SPINE INJURY
FACEMASKS
FACEMASKS ARE DESIGNED SO AS TO FIT SNUGLY OVER THE PATIENT’S
MOUTH AND NOSE.
THE PURPOSE OF THE FACEMASK IS TO DELIVER OXYGEN, PLUS / MINUS
ANAESTHETIC GASES FROM THE BREATHING SYSTEMS TO THE PATIENT.
THE OROPHARYNGEAL AIRWAY
NASOPHARYNGEAL AIRWAY
THE LARYNGEAL MASK AIRWAY (LMA)

LARYNGEAL MASK AIRWAY (LMA)
INDICATIONS
THESE CAN BE CLASSIFIED AS EMERGENCY OR ELECTIVE
CONTRAINDICATIONS
WHERE THERE IS A RISK OF ASPIRATION, SUCH AS
 PATIENTS WITH FULL STOMACH
 HISTORY OF ACTIVE REFLUX OR A HIATUS HERNIA
 MAJOR SURGERY
 MORBIDLY OBESE PATIENTS
 PREGNANCY (ELECTIVE SURGERY FROM 16 WEEKS UP TO 48 H
POST
DELIVERY)

METHOD OF INSERTION
THERE ARE SEVERAL TECHNIQUES THAT HAVE BEEN DESCRIBED FOR
INSERTION OF THE LMA. THE STANDARD TECHNIQUE ID DESCRIBED
BELOW:
1. INFLATE THE CUFF UP TO 50% OF ITS MAXIMUM VOLUME AND CHECK
FOR CUFF LEAKS
2. DEFLATE THE CUFF FULLY OR PARTLY AND APPLY A LUBRICANT JELLY
TO LUBRICATE THE BACK OF THE CUFF (I.E. THE PHARYNGEAL SIDE)
3. ENSURE THAT THE PATIENT IS ADEQUATELY ANAESTHETISED
4. EXTENT THE PATIENT’S NECK AND STABILISE THE OCCIPUT SO THAT
THE JAW FALLS OPEN. THE ASSISTANT MAY HELP BY HOLDING THE
PATIENT’S MOUTH OPEN.
5. GRASP THE LMA LIKE A PEN IN THE DOMINANT HAND AND PRESS THE
DISTALTIP OF THE DFLATED LMA CUFF AGAINST HE HARD PALATE
USING THE INDEX FINGER OF THE NON-DOMINANT HAND TO GUIDE
THE TUBE OVER THE BACK OF THE TONGUE AND INTO THE
OROPHARYNX

METHOD OF INSERTION

6. ADVANCE THE LMA GENTLY UNTIL CHARACTERISTIC RESISTANCE IS
FELT AS IT ENGAGES THE UPPER OESOPHAGEAL SPHINCTER
7. THE CUFF IS THEN GENTLY INFLATED WITH AIR NOT EXCEEDING
THE MAXIMUM RECOMMENDED VOLUME
8. THE LMA MAY “FLOAT OUT” SLIGHTLY THIS MANOEUVRE AS IT
TRIES TO FIT ITSELF IN THE CORRECT POSITION.
9. THE LMA IS THEN CONNECTED TO THE BREATHING SYSTEM
10. CORRECT POSITION IS CHECKED WITH GANTLE POSITIVE
PRESSURE BREATHS SHOWING CHEST EXPANSION, NOTICING THE
MOVEMENTS OF THE RESERVOIR BAG IN A SPONTANEOUSLY
BREATHING PATIENT, AUSCULTATION AND WATCHING THE ENDTIDAL CARBON DIOXIDE TRACE. THE BLACK LINE ON THE TUBE OF
THE LMA LIES DORSALLY IN THE MIDLINE.

WHEN THE LMA IS USED FOR CONTROLLED VENTILATION, IT IS IMPORTANT T
KEEP INFLATION PRESSURES NOT GREATHER THAN 20CM OF WATER,
OTHERWISE IT MAY RESULT IN GASTRIC INSUFFLATION

OTHER SUPRATLOTTIS DEVICES






AIRWAY MANAGEMENT DEVICE, AMD TM. NAGOR LTD, DOUGLAS,
ISLE OF MAN.
COMBITUBETM, TYCO HEALTCARE LTD, GOSPORT, UK
CUFFED OROPHARYNGEAL AIRWAY, COPATM, TYCO HEALTCARE LTD,
GOSPORT, UK
LARYNGEAL TUBE,LT, VBM GMBH, SULZ GERMANY
PAXTM OROPHARYNGEAL AIRWAY. PAXPREESSTM VITAL SIGNS LTD,
BARNHAM UK

combitube

LARYNGEAL TUBE

PAXPRESS

OXYGEN SUPPLEMENTATION


A PATIENT WHO HAS HAD A REGIONAL OR CENTRAL NEURAL
BLOCKADE



A PATIENT WHO HAS HAD INTRAVENOUS SEDATION



WHILE PREPARING FOR OR ATTEMPTING FIBEROPTIC INTUBATION

NASAL CANNULA / NASAL CATHETER
NASAL PRONGS
FACEMASKS

INTRODUCTION
INDICATIONS FOR TRACHEAL INTUBATION
PREPARATION
ASSESSMENT OF THE AIRWAY
EQUIPMENT FOR AIWAY MANAGEMENT
CONDUCT OF ROUTINE INTUBATION
PREPARATION
INDUCTION OF ANESTHESIA
LARYNGOSCOPY
INTUBATION
WARNING

INTRODUCTION
PASSING A CUFFED TRACHEAL TUBE CORRECTLY
SECURES THE AIRWAY, PROVIDED NO OBSTRUCTION IS
BELOW THE TIP OF THE TUBE, AND PROTECTS THE
LUNGS AGAINST ASPIRATION OF STOMACH CONTENTS

INDICATIONS FOR TRACHEAL INTUBATION
LIMITED ACCESS TO THE AIRWAY
ABDOMINAL OR THORACIC RELAXATION REQUIRED
PROTECTION FROM ASPIRATION
RESPIRATORY ARREST WITH OR WITHOUT CARDIAC ARREST

PREPARATION
 ASSESSMENT : AIRWAY ASSESSMENT
 EQUIPMENT – LARYNGOSCOPES, BOUGIES MAGILL’S FORCEPS,
PLUS A SELECTION OF FACEMASKS, AIRWAY AND TRACHEAL TUBE
OF VARIOUS SIZES

CONDUCT OF ROUTINE INTUBATION
PREPARATION
 HAVE A SKILLED ANAESTHETIC ASSISTANT PRESENT
 CHECK ALL YOUR EQUIPMENT (MACHINE, SUCTION, AIRWAY
DEVICES, LARYNGOSCOPES) AND DRUGS.
 ATTACH A CAPNOGRAPH TO THE BREATHING SYSTEM
(PREFERABLY A SIDESTREAM ONE TO KEEP BULK OF THE
BREATHING SYSTEM TO THE MINIMUM.
 CHECK THAT RAPID HEAD-DOWN TILT CAN BE ACHIEVED ON
THE TROLLY OR BED.
 ATTACH STANDARD MONITORING – ECG, PULSE OXIMETRY,
NON-INVASIVE BLOOD PRESSURE

INDUCTION OF ANAESTHESIA
LARYNGOSCOPY
CORMACK AND LEHANE HAVE CLASSIFIED THE LARYNGOSCOPIC VIEW
INTO FOUR GRADES.
GRADES I AN DII PROVIDE A FULL OR PARTIAL VIEW OF THE GLOTTIS,
WHILE IN GRADES III AND IV THE EPIGLOTTIS COVERS THE GLOTTIS AND
THEREFORE THESE ARE CONSIDERED DIFFICULT.
A FUTHER FACTOR IS A STRAIGHT LINE OF VISION I.E. ALIGNMENT OF THE
ANTERIOR EDGE OF THE INCISORS, THE BASE OF THE TONGUE AND THE
GLOTTIS, TO DISPLACE THE TONGUE LEFT AND LIFT THE LOWER JAW WITH
TRACTION.

INTUBATION
TO DEPTH SUFFICIENT TO PREVENT ACCIDENTAL EXTUBATION BUT NOT TOO FAR TO
PREVENT ENDOBRONCHIAL INTUBATION.
WHEN THE TUBE IS PASSED,
THE ASSISTANT INFLATES THE CUFF
THE ANAESTHETIST SUPPORTS THE TUBE UNTIL SECURED WITH A TIE OR A TAPE.
SEEING THE TUBE PASS BETWEEN THE VOCAL CORDS IS A GOOD CONFIRMTION OF ITS
PLACEMENT.
IN ALL CASES, CONFIRM THE POSITION OF THE TUBE;
LISTEN OVER BOTH LUNG FIELDS IN THE AXILLAE (BREATH SOUNDS SHOULD BE PRESENT
ON BOTH SIDES EQUALLY) AND OVER THE STOMACH (AIR ENTRY SHOULD BE ABSENT)
WATCH THE CHEST RISE AND FALL
OBSERVE A TYPICAL CAPNOGRAPHIC TRACE-EXPIRATORY WAVES OF EQUAL HEIGHT AND
WITH A PLATEAU, REACHING THE SAME HEIGHT > 3KPA OF END-TIDAL CO2 ON REPEATED
BREATHS

IF THERE IS A PROBLEM AFTER INTUBATION; HIGH AIRWAY PRESSURES, DECREASING
SATURATION, POOR CAPNOGRAPHIC TRACE ,THINK DOPE (WITH OUT THINKING IT,
YOU WOULD BE ONE.
THE TUBE MAY BE AFFECTED BY:
 DISPLACEMENT – TUBE IN THE OESOPHAGUS OR THE RIGHT MAIN BRONCHUS
 OBSTRUCTION – BY SECREATIONS OR FOREIGN BODY
 PNEUMOTHORAX – SUSPECT IF HIGH VENTILATION PRESSURE WERE USED;
DISTINGUISH IT FROM OESOPHAGEAL AND ENDOBRONCHIAL INTUBATION
 EQUIPMENT – ANY PART OF IT MAY MALFUNCTION; GET ANOTHER DEVICE
THAT IS SIMNPLE AND QUICKLY CHECKED
SUSPECT OESOPHAGEAL INTUBATION IN ANY OF THE FOLLOWING :
 CHEST EXPANSION IS POOR, HAND VENTILATION DIFFICULT
 A GUTTURAL SOUND IS HEARD DURING MANUAL VENTILATION
 CAPNOGRAPHIC TRACE SHOWS SMALL BLIPS OR NO EXPIRED CO2
 OXYGEN SATURATION DECREASES
 ABNORMAL BREATH SOUNDS / NO BREATH SOUNDS HEARD ON AUSCULTATION
 INFLATED ABDOMEN / ABDOMINAL SIZE INCREASING – THIS MAY BE A LATE
SIGN

CAPNOGRAPHIC FRACE WITH A. TRACHEAL INTUBATION
B. OESOPHAGEAL INTUBATION

REMEMBER
PATIENTS DO NOT DIE OF DIFFICULT LARYNGOSCOPY BUT THEY DO DIE
OR
GET BRAIN DAMAGED FROM HYPOXIA. SATURATIONS LESS THAN 6070%
LASTING LONGER THAN 3 MIN WOULD BE EXPECTED TI PRODUCE SOME
DETRIMENTAL EFFECTS. TAKE ACTION TO IMPROVE SATURATION

BEFORE THEN

SUMMARY

2.

OPTIMISE CONDITIONS (EQUIPMENT, STAFF, PATIENTS)
IF IN DOUBT, TAKE IT OUT!

3.

OXYGENATE, OXYGENATE, OXYGENATE

1.

INTRODUCTION
DIFFICULTY WITH MASK VENTILATION
DIFFICULTY WITH INTUBATION
DIFFICULTY WITH INTUBATION AND VENTILATION

INTRODUCTION
WE WILL FIRST CONSIDER WHAT CONSTITUTES AIRWAY, DESCRIBE
AN ALOGORITHM AND METHODS FOR DEALING WITH SPECIFIC
DIFFICULTIES, INCLUDING THE SURGICAL AIRWAY AND FINALLY WITH
STRIDOR.
THE JUNIOR TRAINER IS DISCOURAGED FROM ATTEMPTING TO
ANAESTHETISE PATIENTS WHERE A PROBLEM IS IDENTIFIED AT
ASSESSMENT.
THERE IS NO STANDARD DEFINITION OF THE DIFFICULT
AIRWAY.
THE DIFFICULT AIRWAY DEVINES AS THE CLINICAL SITUATION
IN WHICH A CONVENTIONALLY TRAINED ANETHESIOLOGIST
EXPERIENCES DIFFICULTY WITH MASK VENTILATION,
DIFFICULTY WITH TRACHEAL INTUBATION, OR BOTH.

MASK VENTILATION IS DEEMED DIFFICULT WHEN
 IT IS NOT POSSIBLE FOR THE UNASSISTED ANAESTHESIOLOGIST
TO MAINTAIN THE SpO2 > 90% USING 100% OXYGEN AND POSITIVE
PRESSURE MASK VENTILATION IN A PATIENT WHOSE SpO2 WAS >
90% BEFORE ANAESTHETIC INTERVENTION
 IT IS NOT POSSIBLE FOR THE UNASSISTED ANAESTHESIOLOGIST TO
PREVENT OR REVERSE SIGNS OF INADEQUATE VENTILATION
DURING POSITIVE PRESSURE MASK VENTILATION
DIFFICULT TRACHEAL INTUBATION IS SAID TO OCCUR IF
 PROPER PLACEMENT OF THE TRACHEAL TUBE WITH CONVENTIONAL
LARYNGOSCOPY REQUIRES MORE THAN THERE ATTEMPTS
 PROPER INSERTION OF THE TRACHEAL TUBE WITH CONVENTIONAL
LARYNGOSCOPY REQUIRES MORE THAN 10MIN

THIS WOULD BE MOSTLY IN CASES OF DIFFICULT LARYNGOSCOPY, WHEN
IT IS NOT POSSIBLE TO VISUALISE ANY PORTION OF THE VOCAL CORDS
WITH CONVENTIONAL LARYNGOSCOPY.
THIS CORRESPONDS TO GRADES III AND IV OF THE CORMACK AND
LEHANE CLASISIFICATION.
THE TRAINEE MUST BE BEAR IN MIND THAT THE TIME SPENT DURING
INTUBATION ALSO INCLUDES PERIODS OF OXYGENATION BY ALTERNATIVE
MEANS I.E. HAND VENTILATION WITH BAG, MASK AND AIRWAY.
THE INCIDENCE OF FAILED TRACHEAL INTUBATION IS 0.05-0.33%
(DEPENDING ON PATIENT POPULATION, ANAESTHETIC SKILL AND
EQUIPMENT.
THE HIGHER FIGURE REFERS TO DATA FROM OBSTETRIC PATIENTS. THE
INCIDENCE OF FAILED MASK VENTILATION AND TRACHEAL INTUBATION IS
0.01 – 2.0%.

THE REPORTED INCIDENCE OF DIFFICULT LARYNGOSCOPY IS 313% A DIFFICULT LARYNGOSCOPY DOES NOT ALWAYS EQUATE
WITH DIFFICULT INTUBATION.
A GRADE III LARYNGOSCOPIC VIEW MAY ENABLE RELATIVELY
EASY INTUBATION WITH A BOUGIE, WHILE A GRADE II WITH AN
ANTERIOR AND DEEP LYING LARYNX MAY BE DIFFICULT TO
INTUBATE

PREVENTION AND PORPER PREPARATION ENABLES THE
ANAESTHETIST TO DEAL WITH THESE SITUATIONS.
ADEQUATE AIRWAY ASSESSMENT IS IMPORTANT BUT BY NO
MEANS GUARANTES AN EASY TIME.
ALWAYS HAVE A PRIMARY AND A SECONDARY PLAN FOR AIRWAY
MANAGEMENT.
THE FIRST PLAN MUST INCLUDE PLANNING FOR THE ALTERNATIVE.
ADMINISTER A H2 BLOCKER TO PATIENTS AT RISK ASPIRATION,
SUCH AS THE MORBIDLY OBESE (BMI>35KG/M 2) OR THOSE WITH
HERNIA.
REMEMBER NOT TO DO ANYTHING BEYOND YOUR COMPETENCE,
HENCE CALL FOR HELP SOONER RATHER THAN LATER.
INITIAL ATTEMPS AT INTUBATION “SHOULD BE INTERPRETED BY
THE JUNIOR TRAINEE AS “CALL FOR HELP.

ASA TASK FORCE
DIFFICULT AIRWAY ALGORITHM

DIFFICULTY WITH MASK VENTILATION
A JUNIOR TRAINEE SHOULD NOT ADMINISTER A LONG ACTING
MUSCLE RELAXANT TO A PATIENT BAFORE ACHIEVING SEVERAL
SATISFACTORY “TEST INFLATIONS” VIA THE MASK AND AIRWAY.
IF VENTILATION IS POSSIBLE WITHOUT MUSCLE PARALYSIS, IT WILL
BE EASIER AFTER THE ADMINISTRATION OF THE MUSCLE RELAXANT.
TRY THE FOLLOWING IF THERE IS A PROBLEM WITH MASK
VENTILATION AT THIS STAGE.
1.
2.
3.
4.

5.

USE THE CORRECT MASK FIT. TRY A DIFFERENT SIZE MASK
TRY ADJUSTING THE TRIPLE MANOEUVER; HEAD TILT, CHIN LIFT AND JAW
THRUST.
INSERT THE CORRECT SIZE OROPHARYNGEAL OR A NASOPHARYNGEAL AIRWAY.
TRY TWO-HAND TECHNIQUE, I.E. THE ASSISTANT SQUEENZES THE BAG WHILE
THE PRACTITIONER HOLDS THE MASK WITH BOTH HANDS (OFTEN NEEDED IN
EDENTULOUS PATIENTS OR PATIENTS OF A LARGE BODY MASS INDEX)
USE SOME FORM OF SUPRAGLOTTIS DEVICE SUCH AS THE LARYNGEAL MASK
AIRWAY (LMA)

DIFFICULTY WITH INTUBATION
VARIOUS ANAESTHETIC ORGANISATIONS HAVE DEVISED THEIR
OWN
ALGORITHMS FOR THE MANAGEMENT OF THE DIFFICULT AIRWAY.
ONE SUCH IS THE ASA ALGORITHM AS DESCRIBED ABOVE.
PREVENTION OF DIFFICULT IS PREFERABLE
 ANTICIPATE BEFORE THE PROCEDURE – MAKE AN ASSESSMENT
 BE PREPARED – MAKE SURE YOU HAVE GOT ALL THE EQUIPMENT
 SPOT THE PROBLEM EARLY
 CALL FOR HELP EARLY
 DO NOT PANIC – MAINTAIN OXYGENATION WITH 100% OXYGEN
 HAVE A BACK-UP PLAN

MAKE SURE THE SURGEON IS AWARE OF THE PROBLEM

IF THE PATIENT IS ANAESTHETISED AND PARALYSED AND THE
INTUBATION IS DIFFICULT (UNABLE TO INTUBATE WITH A
CONVENTIONAL LARYNGOSCOPE IN THE FIRST INSTANCE )
THEN :
1.
CONTINUE WITH EFFECTIVE MASK VENTILATION AS
DECRIBED ABOVE
2.
IDENTIFY THE PROBLEM, E.G. BUCKED TEETH, SMALL
MOUTH, POSITION OF NECK, LARGE BREASTS
3.
TAKE THE NECESSARY ACTION
4.
CALL FOR HELP IF MORE THAN TWO ATTEMPTS AT
INTUBATION ARE REQUIRED.
REMEMBER, THE PATIENT IS SAFE AS LONG AS EFFECTIVE
VENTILATION CAN BE CONTINUED WITH 100% OXYGEN

PROBLEM

ACTION

POOR VIEW (GRADE III-IV)

APPLY OR RELAX PRESSURE
ON THE LARYNX, ALTERNATIVE
BLADE (CURVED/STRAIGHT)

SMALL MOUTH, BUCKEDE
TEETH

SMALL BLADE

LARGE OBESE PATIENT, BIG
BREASTS
ANTERIOR LARYNX, POOR
VIES

SHORT-HANDLE OR POLIO
BLADE
USE A BOUGIE/LARGE BLADE,
LARYNGEAL PRESSURE,
ALTERNATIVE BLADE

VARIOUS LARYNGOSCOPIC BLADES ARE AVAILABLE FOR USE IN DIFFER
SITUATIONS. FOR A DEEP LYING ANTERIOR LARYNX SELECT A LONG AN
OR STRAIGHT BLADE: FOR A LARGE FLOPPY EPIGLOTTIS TRY THE
McCOY LARYNGOSCOPE WITH A TILTING TIP.

IS IN AN EMERGENCY OR LIFE-SAQVING SURGERY?
IN AN EMERGENCY OR LIFE-SAVING SURGERY, ONE HAS NO
OPTION
OTHER THEN KEEPING THE PATIENT ANAESTHETISED, WHILE
MAINTAINING SPONTANEOUS BREATHING OR CONTINUING
EFFECTIVE MASK VENTILATION UNTIL HELP ARRIVES.
IF IT IS A NON-EMERGENCY SURGERY, THE SAFEST OPTION IS
TO
WAKE THE PATIENTS UP AND TAKE STOCK.

TECHNIQUES FOR DIFFICULT INTUBATION








ALTERNATIVE LARYNGOSCOPE – LARGE, McCOY OR POLIO
BLADE, SHORT HANDLE
INTUBATING STLET / GUM ELASTIC BOUGIE
BLIND NASAL
INTUBATING THROUGH A LMA
FIBEROPTIC INTUBATION (AWAKE OR UNDER GENERAL
ANAESTHESIA)
RETROGRADE INBTUBATION
SURGICAL AIRWAY – CRICOTHROIDOTOMY, TRACHEOSTOMY

DIFFICULTY WITH INTUBATION AND VENTILATION
THIS SITUATION MAY ARISE DURING RAPID SEQUENCE
INDUCTION WITH CRICOID PRESSURE, FOLLOWING FAILURE TO
INTUBATE.
OFTEN THE CRICOID PRESSURE APPLIED BY AN
INEXPERIENCED ASSISTANT CONTRIBUTES TO THE DIFFICULTY.
IF LARYNGOSCOPY AND INTUBATION HAVE FAILED USING
STRATEGIES AVAILABLE, MASK VENTILATION OR LMA
VENTILATION IS THE NEXT STEP.

IF ALL POSSIBLE MANEUVRES TO ACHIEVE EFFECTIVE
VENTILATION HAVE FAILED INTUBATION IS UNSUCCESSFUL
AND THE PATIENT IS DESATURATING, THEN IMMEDIATE
OXYGEN DELIVERY TO THE PATIENT IS ABSOLUTELY
NECESSARY. THIS IS A CANNOT INTUBATE, CANNOT
VENTILATE.
IN THIS SITUATION THE ONLY WAY TO ACHIEVE OXYGENATION
QUICKLY IS EITHER A TRANS-TRACHEAL VENTILATION USING
A TRANS-TRACHEAL CANNULA,
NEEDLE CRICOTHYROIDOTOMY.
SURGICAL CRICOTHYROIDOTOMY.

PRECUTANEOUS NEEDLE CRICOTHYROIDOTOMY
THE CRICOTHYROID MEMBRANE IS PUNCTURED VERTICALLY IN THE
MIDLINE USING A LARGE-BORE INTRAVENOUS CANNULA ATTACHED
TO A SYRINGE
1.
2.

3.
4.

THE PATIENT’S HEAD IS EXTENDED
THE CANNULA IS ADVANCED IN THE MIDLINE VERTICALLY
DOWN UNTIL AIR IS ASPIRATED AND IT IS THEN DIRECTED
CAUDALLY SO THAT THE CANNULA SLIDES INTO THE TRACHEA
AND THE NEEDLE IS REMOVED.
ASPIRATION OF AIR CONFIRMS CORRECT PLACEMENT
THE CANNULA IS THEN CONNECTED TO A HIGH PRESSURE
OXYGEN SOURCE (4 BAR) DELIVERING OXYGEN AT 12-15L/MIN
VIA A SANDARS JET INJECTOR (NEWER DEVICES ALLOW
PRESURE REGULATION), OR USING SOME OTHER DEVICE.

ADVANTAGES
1.
RAPID ACCESS TO THE AIRWAY IN ACUTE UPPER AIRWAY
OBSTRUCTION OR THE CANNOT INTUBATE, CANNOT
VENTILATE SITUATION.
2.
BUYS TIME TO PREPARE FOR A MORE DEFINITIVE FORM OF
AIRWAY USING ADVANCED TECHNIQUES.
DISADVANTAGES
1.
TRAUMA TO SURROUNDING STRUCTURES, ESPECIALLY THE
OESOPHAGUS
2.
HAEMORRHAGE
3.
SURGICAL EMPHYSEMA
4.
PULMONARY BAROTRAUMA

SURGICAL CRICOTHYROIDOTOMY (LARYNGOTOMY)
A SCALPEL US USED TO PIERCE THE CRICOTHYROID
MEMBRANE. IT IS POSSIBLE TO INSERT A SMALL-CUFFED
TRACHEAL TUBE OR A SPECIFICALLY DESIGNED 4 MM
CANNULA.
TRANS-TRACHEAL JET VENTILATION
IT USES THE VENTURI PRINCIPLE WHEREBY A JET OF OXYGEN
UNDER HIGH PRESSURE (4BAR) ENTRAINS A LARGER VOLUME
OF AIR, RESULTING IN CHEST INFLATION.
IT IS A POTENTIALLY DANGEROUS TECHNIQUES THAT CAN
EASILY RESULT IN BAROTRAUMA.
OTHERWISE USE A SURGICAL CRICOTHYRODOTOMY AND A
MINIMUM 4 MM INTERNAL DIAMETER EMERGENCY AIRWAY.

STRIDOR
IF STRIDOR IS PRESENT, IT MEANS A MAJOR UPPER AIRWAY
OBSTRUCTION / COMPRESSION.
STRIDOR IS A CLEAR WARNING OF EXPECTED DIFFICULTY WITH
MASK VENTILATION AND QUITE LIKELY DIFFICULTY WITH
LARYNGOSCOPY AND INTUBATION.
PARTIAL AIRWAY OBSTRUCTION WHEN THE PATIENT IS CONSCIOUS
MAY RAPIDLY PROGRESS TO COMPLETE AIRWAY OBSTRUCTION
WHEN CONSCIOUSNESS IS LOST
THE FAILED MASK VENTILATION AND FAILED INTUBATION
ALGORITHM IS OF LITTLE USE IN THIS SITUATION.
DO !
PRE-OPERATIVE ASSESSMENT
OPTIMISING BREATHING

STRATEGIES FOR INTUBATION
THIS CAN BE ACHIEVED IN EXPERT HANDS WITH AWAKE FIBEROPTIC
INTUBATION.
MANY THEREFORE PREFER INHALATIONAL INDUCTION OF ANAESTHESIA
WITH OXYGEN AND A VOLATILE AGENT, MAINTAINING SPONTANEOUS
RESPIRATION UNTIL A SUFFICIENTLY DEEP LEVEL OF ANAESTHESIA IS
ACHIEVED TO ALLOW LARYNGOSCOPY
THE TRAINEE ANAESTHETIST SHOULD AVOIDE ANAESTHETISING PATIENTS
WITH STIDOR

SUMMARY






AVOID DIFFICULTY – BE PREPARED
OPTIMISE YOUR CONDITIONS (STAFF, EQUIPMENT, PATIENT
PREPARATION)
USE ALTERNATIVE MEANS IF PRIMARY STRATEGY FAILS
OXYGENATE

THE DIFFICULT AIRWAY
DIFFICULT BMV – MOANS
DIFFICULT LARYNGOSCOPY -AND INTUBATION - LEMONS
DIFFICULT EGD - RODS
DIFFICULT CRICOTHYROTOMY – SHORT
AIRWAY ALGORITHM
THE UNIVERSAL EMERGENCY AIRWAY ALGORITHM
MAIN EMERGENCY AIRWAY MANAGEMENT ALRORITHM
THE CRASH AIRWAY ALGORITHM
THE DIFFICULT AIRWAY ALGORITHM
THE FAILED AIRWAY ALGORITHM

THE DIFFICULT AIRWAY
IN CLINICAL
:
1. DIFFICULT
2. DIFFICULT
3. DIFFICULT
4. DIFFICULT
5. DIFFICULT

PACTICE, THE DIFFICULT AIRWAY HAS FIVE DIMENSIONS
BMV
LARYNGOSCOPY
INTUBATION
EGD
CRICOTHYROTOMY

THESE FIVE DIMENSIONS CAN BE REDUCED TO FOUR TECHNICAL
OPEATIONS :
1. DIFFICULT BMV
2. DIFFICULT LARYNGOSCOPY AND INTUBATION
3. DIFFICULT EGD
4. DIFFICULT CRICOTHYROTOMY

DIFFICULT BAG – MASK VENTILATION : MOANS
MASK SEAL
OBESITY / OBSTRUCTION
AGE
NO TEETH
STIFF
DIFFICULT LARYNGOSCOPY AND INTUBATION : LEMON
LOOK EXTERNALLY
EVALUATE THE 3-3-2 RULE
MALLAMPATI SCORE
OBSTRUCTION / OBESITY
NECK MOBILITY

DIFFICULT EXTRAGLOTTIC DEVICES : RODS
RESTRICTED MOUTH OPENING
OBSTRUCTION
DISRUPTED OR DISTORTED AIRWAY
STIFF LUNGS OR CERVICAL SPINE
DIFFICULT CRICOTHYROTOMNY : SHORT
SURGERY (OR OTHER AIRWAY DISRUPTION)
HERMATOMA (INCLUDES INFECTION / ABSCESS)
OBESITY (INCLUDES ANY ACCESS PROBLEM)
RADIATION DISTORTION (AND OTHER DEFORMITY)
TUMOR

THE UNIVERSAL EMERGENCY AIRWAY ALGORITHM
UNCONSCIOUS
UNREACTIVE
NEAR DEATH

YES

CRASH
AIRWAY
ALGORITHM

YES

DIFFICUT
AIRWAY ?
ALGORITHM

FAILS

NO

DIFFICUT
AIRWAY ?
NO

RSI

FAILS

FAILS

FAILED
AIRWAY
ALGORITHM

MAIN EMERGENCY AIRWAY
MANAGEMENT ALRORITHM

NEEDS
INTUBATION
UNRESPONSIVE
NEAR DEATH

YES

CRASH
AIRWAY

YES

DIFFICULT
AIRWAY

NO
PREDICT DIFFICULT
AIRWAY
FROM DIFFICULT
AIRWAY

NO
RSI

ATTEMPT
INTUBATION
SUCCESSFUL ?
NO
FAILURE TO MAINTAIN
OXYGENATION ?
NO
2-3 ATTEMPTS AT OTI BY
EXPERIENCED OPERATOR ?
NO

YES POST INTUBATION
MANAGEMENT
YES

YES

FAILED
AIRWAY

THE CRASH AIRWAY
ALGORITHM

CRASH
AIRWAY

MAINTAIN OXYGENATION
INTUBATION ATTEMPT
SUCCESSFUL ?

YES POST INTUBATION
MANAGEMENT

NO
UNABLE TO BAG VENTILATE ?

YES

FAILED
AIRWAY

NO
SUCCINYCHOLINE 2 MG/KG IVP

ATTEMPT INTUBATION
NO
SUCCESSFUL ?
NO
FAILURE TO MAINTAIN
OXYGENATION ?

YES POST INTUBATION
MANAGEMENT
YES

NO
> 3 ATTEPTS BY
EXPERIENCED OPERATOR ?

YES

FAILED
AIRWAY

THE DIFFICULT AIRWAY
ALGORITHM
DIFFICULT AIRWAY
PREDICTED

FAILURE TO MAINTAIN
OXYGENATION ?

CALL FOR ASSISTANCE

YES

FAILED
AIRWAY

NO
BMV OR EGD
PREDICTED TO BE
SUCCESSFUL ?

YES

NO

INTUBATION PREDICTED
TO BE SUCCESSCUL ?

YES

RSI

NO

AWAKE DL, FO, OR
VL SUCCESSFUL ?

NO
ILMA
FO OR VL+
CRICOTHYROTOMY
BNTI LIGHTED STYLET

YES

FAILED
AIRWAY
FAILED
AIRWAY

FAILED
AIRWAY CRITERIA

CALL FOR ASSISTANCE

EXTRA-GLOTTIC DEVICE
MAY BE ATTEMPTED

FAILURE TO MAINTAIN
OXYGENATION ?

YES

CRITOTHYROTOMY

NO
CHOOSE ONE AT
-FIBEROPTIC METHOD
-VIDEO LARYNGOSCOPY
-EXTRA GLOTTIC DEVICE
-LIGHTED STYLET
-CRICOTYROTOMY

CUFFED ETT PLACED

NO
ARRAGE FOR
DEFINITIVE AIRWAY
MANAGEMENT

YES

POST INTUBATION
MANAGEMENT

THE FAILED AIRWAY
ALGORITHM

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