3AIRWAY ASSESSMENT Cervical spine movement T-M joint movement Mouth openingModified Mallampati gradingThyromental distance
4ARTIFICIAL AIRWAYPurpose of an airway – lift the tongue and epiglottis away from the posterior pharyngeal wall.Advantage of an airway –Cervical spine movement does not occur when airway is inserted.Decreased work of breathing during spontaneous respiration using a face mask.TypesOropharyngeal airwayNasopharyngeal airway
8OROPHARYNGEAL AIRWAYS (contd.) Uses –To maintain open airwayPrevent endotracheal tube occlusionPrevent tongue biteFacilitate suctionConduit for passing devices into oropharynxObtain a better mask fitContraindications –Intact gag reflexOropharyngeal growth
9OROPHARYNGEAL AIRWAY (contd.) Pre requisite for insertionSize estimationMethods of insertionDisadvantages -Due to incorrect sizeLaryngospasm in awake patientAdvantages -1) Simple to use, cheap.2) Not associated with sore throat3) Does not cause bacteremia
10NASOPHARYNGEAL AIRWAY Parts – flange, airway channel, bevel.Size - inside diameter in millimeters.Size determinationMethod of insertionContraindications –1) Anticoagulation2) Basilar skull fracture3) Nasal pathology, sepsis, or deformity of the nose or nasopharynx4) History of epistaxis requiring medical treatment.
11NASOPHARYNGEAL AIRWAY (contd.) Uses of nasopharyngeal airway –To maintain airway in patients with intact gag reflexTo facilitate suctioningAs a guide for a fiberscope or nasogastric tubeTo apply continuous positive airway pressure (CPAP)To dilate the nasal passages in preparation for nasotracheal intubationTo maintain the airway and administer anesthesia during dental surgery.To maintain ventilation during oral fiberoptic endoscopy.
12NASOPHARYNGEAL AIRWAY (contd.) Advantages-1) Nasal airway is better tolerated than an oral airway if the patient has intact airway reflexes.2) Loose or poor dentition.3) Trauma or pathology of the oral cavity.4) It can be used when the mouth cannot be opened.
13COMPLICATIONS OF ARTIFICIAL AIRWAY Airway ObstructionTraumaTissue EdemaUlceration and NecrosisCentral Nervous System TraumaDental DamageLaryngospasm and CoughingRetention, Aspiration, or SwallowingDevices Caught in AirwayEquipment FailureLatex AllergyGastric Distention
14SUPRAGLOTTIC AIRWAY DEVICES Supraglottic devices fill a niche between the face mask and tracheal tube in terms of both anatomical position and degree of invasiveness.These devices sit outside the trachea but provide a handsfree means of achieving a gas-tight airway.
15SUPRAGLOTTIC AIRWAY DEVICES Laryngeal Mask Airway Family –LMA ClassicLMA UniqueLMA FlexibleLMA FastrachLMA CTrachLMA Proseal2) Other supraglottic airways similar to laryngeal mask –Soft seal laryngeal maskAmbu laryngeal maskIntubating laryngeal airway3) Other supraglottic airway devicesLaryngeal tube airwayPerilaryngeal airwayStreamlined pharynx airway liner
17Neonates/infants up to 5 kg 1.5 Infants between 5 and 10 kg cLMA sizePatient size1Neonates/infants up to 5 kg1.5Infants between 5 and 10 kg2Infants/children between 10 and 20 kg2.5Children between 20 and 30 kg3Children 30 to 50 kg4Adults 50 to 70 kg5Adults 70 to 100 kg6Adults over 100 kg.
19LMA-UNIQUE Disposable laryngeal mask airway, DLMA). It is made of polyvinylchlorideThe dimensions are identical to the standard LMA, the tube is stiffer and the cuff less compliant.SizesIt may be a better choice for out-of-hospital or ward use.Insertion and placement of the LMA-Unique is similar to the LMA-Classic.The intracuff pressure increases significantly less in the LMA-Unique when nitrous oxide is used.
20LMA-FLEXIBLEThe LMA-Flexible (wire-reinforced, reinforced LMA, RLMA, FLMA, flexible LMA) has a flexible, wire-reinforced tube.The tube is longer and narrower.Not available in sizes 1 and 1.5Useful for head and neck surgeriesInsertion methodDisadvantages -1) The wire reinforcement does not prevent obstruction from biting.2) The spiral reinforcing wire may become disrupted.3) Only small sizes of tracheal tube or bronchoscope can pass through it.4) Not preferred prolonged spontaneous ventilation.5) Unsuitable for MRI scanning6) Malposition is less easily diagnosed.
21LMA-FASTRACHThe LMA-Fastrach (intubating LMA, ILMA, ILM, intubating laryngeal mask airway) – designed for tracheal intubation.Parts –1) A short, curved stainless steel shaft with a standard 15-mm connector.2) Single, movable epiglottic elevator bar3) A V-shaped guiding ramp built into the floor of the mask.
22LMA-FASTRACH Insertion technique Uses To facilitate tracheal intubationIt can also be used as a primary airway device.Tracheal Intubation using LMA Fastrach –Blind,Blind nasalFiberscopic guidedLight guided
23LMA-FASTRACH Disadvantages Pharyngeal pathology or limited mouth opening may make intubation difficult.Cannot be used for intubation in patients below 30 kg.The LMA-Fastrach tracheal tube is expensive & prolonged use is to be avoided.The tracheal tube may be displaced downward or dislodged.It should not be used in the prone positionUnsuitable for use in the MRI unit.Increased incidence of sore throat and difficulty swallowing .In patients with immobilized cervical spine, exerts pressure on the cervical spine.
24LMA-CTrach It has two built-in fiberoptic channels with a monitor. Sizes - 3, 4, and 5Insertion techniqueAdvantages –High first intubation attempt success rate with minimal neck movement.2) Can be used during awake intubation in the presence of an unstable cervical spine.Disadvantages1) Poor image quality2) The view may be obstructed by secretions, lubricant, or blood.3) Cannot be used easily in the patient with a limited mouth opening.
25LMA-ProSealParts - cuff, inflation line with pilot balloon, airway tube, and drain (gastric access) tube.Function of second dorsal cuffInsertion techniques – introducer, guided, digital methodsConfirmation of proper placement
26LMA-ProSeal LMA Size Weight (kg) Max Cuff Inflation Volume (mL) Max. Fiberoptic Scope Size (mm)Max. gastric Tube Size (Fr)Length of Drain Tube (cm)Largest Tracheal Tube (ID in mm)1.55 to 107-1018.24.0 uncuffed210 to 2019.02.520 to 301423.04.5 uncuffed330 to 50201626.55.0 uncuffed450 to 703027.5570 to 100401828.56.0 cuffed
27LMA-ProSealUsesCan be used for both spontaneous and controlled ventilation.Preferred in situations where higher airway pressures are required, better airway protection is desirable, and for surgical procedures in which intraoperative gastric drainage or decompression is neededUseful in cases where it is important to avoid airway trauma.Safe for use in an MRI unit
28LMA-ProSeal Disadvantages - 1) The LMA-ProSeal is less suitable as an intubation device.2) Higher resistance in spontaneously breathing patients than other devices.3) Requires a greater depth of anesthesia for insertion.4) Airway obstruction after insertion.5) Gastric insufflation6) The LMA-ProSeal has a shorter life span.
29LARYNGEAL TUBE AIRWAY Parts – The airway tube is wide, curved, color coded on the connector.single lumen that is closed at the tip.Small (esophageal, distal) cuff near the blind distal tipLarge (oropharyngeal, pharyngeal) cuff near the middle of the tubeLARYNGEAL TUBE AIRWAY
30LARYNGEAL TUBE AIRWAY (Cont.) 5) One inflation tube to inflate both light blue cuffs.6) Two anterior-facing, oval-shaped openings (ventilation holes)7) Side holes lateral to the top of the distal opening.8) A ramp leads from the posterior wall toward the main ventilatory outletReusable silicone or single-use versions made of polyvinylchloride.
32LARYNGEAL TUBE AIRWAY (Cont.) Insertion techniqueAdvantages -1) The LT is relatively easy to insert2) It is well tolerated during emergence3) Because the distal cuff fits over the esophageal inlet, the risk of gastric inflation is low4) Can be used with both spontaneous and controlled ventilation5) High ventilation pressures can be used.
33Laryngeal Tube Airway (Cont.) 6) This device may be especially useful for resuscitation (“cannot intubate, cannot ventilate” situation , obstetrics after failed intubation, edentulous patients).7) The incidence of complications such as sore throat, mouth pain, or dysphagia is low.8) Regurgitated liquid is less likely to be aspirated with the LTDisadvantageFailure to ventilate if tube enters trachea – contrast combitube
34ENDOTRACHEAL TUBE Parts – The machine (proximal) end The tracheal tube (endotracheal tube, intratracheal tube, tracheal catheter) is a device that is inserted through the larynx into the trachea to convey gases and vapors to and from the lungs.Parts –The machine (proximal) endThe patient (tracheal or distal) endBevel.
35ENDOTRACHEAL TUBE 4) Murphy eye 5) A radiopaque marker 6) Cuff Systems - consists of the cuff plus an inflation system, which includes an inflation tube, a pilot balloon, and an inflation valve.
36Latex coated red rubber tubes ENDOTRACHEAL TUBELatex coated red rubber tubesPVC tubesReused multiple timesDisposableNot transparentTransparentHarden and become sticky with age, poor resistance to kinking, become clogged by dried secretionsLess likely to kink than rubber tubes. They are stiff enough for intubation at room temperature but soften at body temperature, so they tend to conform to the patient's upper airway.Latex allergy in susceptible patientsNo latex allergy
38EXTUBATIONThe tracheal tube (extubation) is removed when it is no longer needed for airway protection.Extubation may be performed at different depths of anesthesia - “awake,” “light,” and “deep”Preparation for ExtubationInitial PlanPatient position planBite block in placeThroat pack removedPreoxygenationSecretions aspirated from the pharynx (the trachea also if indicated)
39EXTUBATION Complications at Extubation Hypoventilation (residual effect of anesthetic drugs and neuromuscular blockade)Upper airway obstructionLaryngospasm and bronchospasmCoughing (wound disruption)Impaired laryngeal competence and pulmonary aspirationHypertension, tachycardia, dysrhythmias, myocardial ischemia
40FLEXIBLE FIBEROPTIC BRONCHOSCOPY Indications –Difficult intubation predictedCongenital airway abnormalitiesAcquired airway abnormalitiesTraumaContraindications-Lack of timeBlood & secretions in oral cavityEdema of pharynx or tongueTechnique – oral or nasal (awake or GA)
41COMBITUBE Device for difficult airway PARTS – 1) Two separate lumens (pharyngeal & tracheoesophageal) that are fused longitudinally2) Two inflatable cuffs.3) Each lumen is linked by a short tube to a standard 15-mm connector at the breathing system end.4) Pharyngeal lumen - occluded distal end and eight oval-shaped perforations (ventilating eyes) between the cuffs, coloured blue.
42COMBITUBE5) Tracheoesophageal lumen - patent distal end and a clear tube.6) The smaller distal cuff serves to seal either the esophagus or trachea, depending on its placement.7) The larger (pharyngeal) cuff (balloon) is above the perforations.8) The pilot balloon for the pharyngeal cuff is colored blue.
43COMBITUBE Sizes: Regular (41 [Fr]) SA (37 Fr) Recommended for patients with a height greater than 5 feet (152 cm).Not recommended for patients younger than 12 years of age.METHOD OF INSERTION
44COMBITUBE Indications Airway management in the difficult-to-intubate patientMassive airway bleeding or regurgitation.Limited access to the airway and limited mouth openingCervical spine injury.Useful in entertainers in whom it is important to avoid vocal cord damage.In cardiopulmonary resuscitation in both prehospital and in-hospital settings.“Cannot ventilate, cannot intubate” situation.Can be used during percutaneous dilatational tracheostomy or tracheotomy
45COMBITUBE Contraindications Active pharyngeal or laryngeal reflexes Oesophageal trauma or pathologyingestion of corrosive agentsOropharyngeal, pharyngeal, or hypopharyngeal mass.
46COMBITUBEAdvantagesTime needed for insertion is short and less skill is requiredCan be inserted in presence of blood or secretions in the oropharynx.Provides comparable ventilation and improved oxygenation to that of tracheal intubationIt can be used by an anesthesia provider having limited use of the left arm .It is well tolerated by the patient during emergence from anesthesia.Its use is not associated with high levels of trace gases.Decreased risk of accidental extubation.The Combitube provides good but not complete protection from aspiration
47COMBITUBE Disadvantages Tracheal suctioning or fiberoptic bronchoscopy is not possible through the Combitube in the esophageal positionHigh airflow resistanceInsertion and removal of the Combitube is associated with a higher stress responseTrauma to the airway and esophagusSore throat and dysphagia.Unsuitable for use in a patient with latex allergy .The Combitube is expensive compared to other single use devices.
48RETROGRADE INTUBATION Retrograde (translaryngeal-guided, guided blind) intubation is an elective or emergency technique for securing a difficult airway, either alone or in conjunction with other techniques.Retrograde intubation is a useful option in patients who cannot be intubated by using traditional techniques.Procedure can be expected to take 5 minutes or more for completion.
55RETROGRADE INTUBATION ComplicationsSore throatTraumaBarotraumaPretracheal abscessThe tracheal tube may inadvertently slip out as it is advanced
56CRICOTHYROTOMYPlacing a device through the cricothyroid membrane to gain control of the airway.It is part of the ASA and Difficult Airway Society difficult airway algorithms.Anatomical considerationsTechniquesNeedle CricothyrotomyPercutaneous Dilatational CricothyrotomySurgical Cricothyrotomy
57NEEDLE CRICOTHYROTOMY Ventilation Techniques - Jet VentilationDevicesA number of jet ventilation devices are commercially available.Automatic VentilatorManual Jet Ventilation DeviceFlowmeterOxygen FlushAnesthesia Breathing SystemManual Resuscitation Bag
59CRICOTHYROTOMY Indications Upper Airway Obstruction with Inability to Ventilate or IntubateAnticipated Difficult Intubation - Cricothyrotomy may be used as an adjunct to fiberoptic or other intubation techniques where it is anticipated that intubation may be difficult to perform.Procedures Involving the AirwayCervical Spine Injury
60CRICOTHYROTOMY Contraindications Intrathoracic Airway Obstruction Inability to Locate the Cricothyroid MembraneComplete Airway ObstructionPaediatric patientsLaryngeal pathologyDecreased compliance
61CRICOTHYROTOMY Advantages – Simple, quick, easy to perform Prevents tracheal collapseDisadvantage-Does not provide definitive airway