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Airway Management

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Airway Management Augusto Torres, MD Department of Anesthesiology MetroHealth Medical Center Outline Review of airway anatomy Airway evaluation Mask ventilation ... – PowerPoint PPT presentation

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Title: Airway Management


1
Airway Management
  • Augusto Torres, MD
  • Department of Anesthesiology
  • MetroHealth Medical Center

2
Outline
  • Review of airway anatomy
  • Airway evaluation
  • Mask ventilation
  • Endotracheal intubation
  • The difficult airway

3
Airway Anatomy
  • Ab-ductor
  • Posterior cricoarytenoid
  • Tensor
  • Cricothyroid
  • Ad-ductors
  • All the rest

4
Airway Anatomy
  • Innervation
  • Vagus n.
  • Superior laryngeal n.
  • External branch motor to cricothyroid m.
  • Internal branch sensory larynx above TVCs
  • Recurrent laryngeal n.
  • Right subclavian
  • Left Aortic arch (board question)
  • Motor to all other muscles, Sensory to TVCs and
    trachea

5
Airway Anatomy
  • Innervation of oropharynx
  • Glossopharyngeal n. innervates tongue base and
    oropharynx

6
Airway Anatomy
  • Membranes
  • Thyrohyoid
  • Cricothryoid
  • Cartilages
  • Hyoid
  • Thyroid
  • Cricoid

7
(No Transcript)
8
Airway Evaluation
  • Take very seriously history of prior difficulty
  • Head and neck movement (extension)
  • Alignment of oral, pharyngeal, laryngeal axes
  • Cervical spine arthritis or trauma, burn,
    radiation, tumor, infection, scleroderma, short
    and thick neck

9
Airway Evaluation
  • Jaw Movement
  • Both inter-incisor gap and anterior subluxation
  • lt3.5cm inter-incisor gap concerning
  • Inability to sublux lower incisors beyond upper
    incisors
  • Receding mandible
  • Protruding Maxillary Incisors (buck teeth)

10
Airway Evaluation
  • Obesity
  • Distribution, i. e. short, thick neck more
    concerning
  • Neck circumference

11
Airway Evaluation
  • Thyromental distance bony point on mentum
    (mandible) to thyroid notch
  • If short (lt3FBs or 6cm), pharyngeal and
    laryngeal axis off

12
Airway Evaluation
  • Oropharyngeal visualization
  • Mallampati Score
  • Sitting position, protrude tongue, dont say AHH

13
Airway Evaluation
  • Difficulty ventilating
  • Age gt55
  • Beard
  • History of snoring
  • Lack of teeth
  • BMI gt26

14
Preoxygenation
  • Replaces the nitrogen volume of the lungs (69 of
    FRC) with oxygen
  • Functional residual capacity (residual volume and
    expiratory reserve volume)
  • Preoxygenation with 100 oxygen via tight-fitting
    mask for 5 minutes ? up to 10 min of oxygen
    reserve following apnea
  • Four vital capacity breaths over 30 seconds (time
    to desaturation quicker)

15
Patient Positioning
  • Sniffing position
  • Lower neck flexion
  • Upper neck extension
  • Important in obesity

16
Mask Ventilation
  • Induction of anesthesia produces upper airway
    relaxation and possible collapse
  • Downward displacement of mask with thumb and
    index finger

www.aic.cuhk.edu.hk
17
Mask Ventilation
  • Upward traction of remaining fingers upward
  • Fingers on bony mandible
  • Fifth digit at angle displacing mandible
    anteriorly

www.aic.cuhk.edu.hk
18
Mask Ventilation
  • Oral airway
  • Two-handed technique

www.aic.cuhk.edu.hk
www.haworth21.karoo.net
19
LMA Placement
  • Carries prominent position in ASA algorithm
  • May be held like a pencil
  • Balloon partially inflated
  • Directed posteriorly and upwards towards the
    palate
  • Jaw thrust and sniffing position may help
    placement

www.brandianestesia.it/Images/LMA-ins.jpg
20
LMA Placement
  • Verify placement by ventilating
  • Check for good chest rise, ETCO2, and adequate
    tidal volumes
  • Check for leak if significant leak at around
    10cm H2O problematic
  • May try size larger or smaller
  • May try to inflate/deflate cuff to obtain better
    seal
  • If difficulty passing may try inserting upside
    down and then flipping around

21
Endotracheal Intubation
  • Open the mouth with right hand
  • Scissor technique
  • Gently insert laryngoscope into right side of
    mouth pushing tongue to the left
  • Careful with insertion not to hit teeth
  • Advance laryngoscope further into oropharynx with
    applied traction 45 degrees

22
Endotracheal Intubation
  • Look for epiglottis
  • If initially not found insert laryngoscope
    further
  • If this maneuver does not work slowly pull
    laryngoscope back
  • Once epiglottis visualized, push laryngoscope
    into vallecula and apply traction at 45 degree
    angle to push epiglottis up and out of the way

www.int-med.uiowa.edu/Research/TLIRP/Bronchos
23
Endotracheal Intubation
  • Look for vocal cords or arytenoid cartilages and
    try to optimize view
  • (i.e. lift head, apply more traction at 45 degree
    angle if necessary)
  • Do not move once view is optimized!
  • Assistant will hand you ETT
  • Insert ETT into far right aspect of mouth
  • Traction of laryngoscope slightly to left may
    assist
  • Traction of laryngoscope at 45 degrees will also
    help keep mouth open

24
Endotracheal Intubation
  • Insert ETT above and between arytenoids and
    through vocal cords
  • Try to visualize the ETT passing between the
    vocal cords
  • If this is not possible, then you must visualize
    the ETT passing above and between the arytenoids

25
Endotracheal Intubation
  • Common problems
  • I cant see anything!
  • Make sure tongue is swept to the left
  • You are probably too shallow or too deep. Even
    with difficult intubations the epiglottis can be
    visualized
  • Insert laryngoscope in further looking for
    epiglottis
  • Pull laryngoscope back if this fails

26
Endotracheal Intubation
  • Common problems
  • I cant see the cords!
  • Epiglottis is visualized, vocal cords are not
  • Removing the epiglottis partly from view is
    necessary to visualize the vocal cords below
  • Push the end of the laryngoscope blade further
    into the vallecula and toe up
  • Lifting the patients head with your other hand
    may improve the sniffing position and bring the
    vocal cords into view

27
Endotracheal Intubation
  • Common problems
  • I can see the cords. But I cant get the tube
    there!
  • You may not be giving yourself adequate room in
    the oral cavity
  • Push up and to the left with the laryngoscope to
    make sure the mouth is still fully opened and the
    tongue adequately swept away
  • Slide the ETT in the mouth all the way to the
    right side, perhaps even sideways

28
Difficult Intubation
  • ASA Difficult Airway Algorithm
  • www.metrohealthanesthesia.com

29
Fiberoptic Intubation
  • Oral or nasal routes
  • Topicalization is key
  • Aerosolized lidocaine 4
  • Airway blocks
  • Thin bronchoscope inserted into trachea

30
Other airway options
  • GlideScope
  • Needle cricothyroidotomy

31
Conclusion
  • Airway management is an extremely important
    aspect of the practice of anesthesiology and
    critical care
  • A firm basis in airway anatomy is needed
  • Skills such as mask ventilation, endotracheal
    intubation, LMA placement are necessary
  • In the case of a difficult airway, a logical
    algorithm and airway equipment assist the
    physician in safely managing the situation
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