Airway management
Lukáš Dadák
ARK FNUSA
Desaturation
Benumof, J. L. et al. Critical Hemoglobin Desaturation Will Occur before Return
to an Unparalyzed State following 1 mg/kg Intravenous Succinylcholine.
Anesthesiology. 87(4):979-982, 1997.
Apnoe and CO2
Gentz, B. A., et all. Carbon Dioxide Dynamics During Apneic Oxygenation:: The Effects of Preceding Hypocapnia. Journal of Clinical Anesthesia 10, 189–194 (1998).
Maintaining airway
 Noninvasive
•airway
•laryngeal mask
•combitube
 invasive
•OTI, NTI
•coniotomy
•tracheotomy
vocal
cords
Routine Airway Management
●
Mask 1 2 3 4 5
●
LM 1 1,5 2 2,5 3 4 5
●
OTI 3 3,5 4 4,5 … 7 7,5 8 8,5 9
●
FONA
– Front of Neck Access
– scalpel-bougie-tube
Airway Management
The Vortex Approach & related materials are copyright of Nicholas Chrimes & Peter Fritz. Used
with permission. www.vortexaproach.org
3 + 1 ways
how to keep / improve
oxygenation O2
ventilation CO2
3 + 1 ways
Diferent situations of Airway Management
Goal: Green zone
O2
CO2
Priorities of (D)AM
http://emcrit.org/podcasts/intubation-patient-shock/
Keep airway open
haed tilt, chin lift Esmarch man.
Face mask ventilation
Positive pressure ventilation by bag-valve mask
 correct volume = movement of chest
 f 10/min
 100% O2
 1 hand hold:
 inch + index f.
 3 ff. - chin
 2 hands
Figure 42-4 Technique for holding the mask with one hand. An effort should be made
to avoid excessive pressure on the soft tissues of the neck.
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© 2007 Elsevier
Figure 42-6 Technique for holding the mask with two hands.
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© 2007 Elsevier
3rd year
Airway management
Do NOT
4 Hands Ventilation
(Bag) Mask Ventilation
Improved by
●
OPA
Guedel airway
Oro-Pharyngeal Airway
I: unconsciousness
+ airway obstruction with tongue
Correct size OPA:
 distance angle of mouth --- ear
Risk in mild unconsciousness:
 vomitus + aspiration
Naso-Pharyngeal Airway
(trumpet)
Correct size of NPA:
 distance nostril --- ear
Risk:
 bleeding from nasal cavity
 Use of lubricant is essential
Difficult Airway
difficult mask ventilation
Gastric Volume 
Compliance 
Gastric pressure 
diafragma
cranialy 
intrathoracic
volume 
airway pressure 
distribution of Vt
lungs  abdomen
Unexpected DAM in ORUnexpected DAM in OR
InductionInduction
Facemask ventilation
ImpossibleImpossible
Scenario 1Scenario 1
Ventilation/Oxygenation (V/0)Ventilation/Oxygenation (V/0)
And NOW?
InductionInduction
Facemask ventilation
ImpossibleImpossible
Scenario 1Scenario 1
Ventilation/Oxygenation (V/0)Ventilation/Oxygenation (V/0)
Step 1
Rescue V/ORescue V/O
LMA Supreme, ProSeal ...LMA Supreme, ProSeal ...
Call for HELP
Unexpected DAM in ORUnexpected DAM in OR
3 + 1 ways
Supraglotic devices:
●
LM
●
(( Combitube ))
●
(Laryngeal tubus)
●
I-gel
LM Classic, ProSeal
LMA Flexible
LMA ProSeal
LMA Classic
LMA Fastrach
Single-use
LMA Flexible
Single-use
LMA Unique Single-use
LMA Fastrach
Components of LM
LM
placed against glottis (radix of tongue, recessus
piriformis, esophageal superior sphincter)
I: instead face mask, OTI, difficult airway
CI:
●
full stomach
●
gastro-esophageal reflux,
●
high inspiratory pressure
●
longer operation
LM
●
LMA Classic =
reusable 40 times
●
LMA Unique Single
use
LMA before insertion
●
Vizual control of integrity &pre use checks
●
Preinflation (keep shape and pressure)
●
Deflation
●
Well lubricated – neutral gel
Insertion of the LMA in Neutral Alignment
LMA ProSeal
deflate = flat, thin
Sizes of supraglotic devices
LMA Supreme™
Size of LMA
Supreme
Ideal
weight
Maximal
Volume of Air
Max. size of
G tube
1 Newborn do 5kg 5 ml 6 Fr
1.5 Infant 5-10kg 8 ml 6 Fr
2 Infant 10-20kg 12 ml 10 Fr
2.5 Child 20-30kg 18 ml 10 Fr
3 Adutl/child 30-50kg 30 ml 14 Fr
4 Adult 50-70kg 45 ml 14 Fr
5 Adult 70-100kg 45 ml 14 Fr
Corect placement
Malposition I.
Distální manžeta v oropharyngu - není těsnost s respiračním a GIT.
Co hrozí: Aspirace, obstrukce - epiglottis v dutině LMA, inflace žaludku
Distální část manžety v glottic inlet.
Totální obstrukce dýchacích cest
Malposition II.
Distální část manžety v nasopharyngu:
Zavádění reversní Guedelovou technikou nebo v poloze chin to chest (ignorace sniffing position).
Může být slučitelná se zachováním průchodnosti dýchacích cest, extremní riziko aspirace - není
ochrana před regurgitací distálním koncem manžety.
Malposition III.
Figure 42-11 Intubating laryngeal mask airway (ILMA), illustrating the rigid curve and handle. Notice the different window compared with a standard LMA. (Courtesy of LMA North America, Inc.,
San Diego, CA.)
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© 2007 Elsevier
Intubating laryngeal mask airway
(ILMA)
Supraglotic devices:
●
LM
●
Combitube
●
Laryngeal tubus
●
I-gel
Combitube
●
emergency situations instead OTI
●
I: difficult airway
●
CI: stenosing process in pharynx / trachea
Figure 42-13 Insertion of the Combitube. A, The tongue and mandible are lifted with one hand, and the Combitube is inserted in the direction of the natural curvature of
the pharynx with the other hand. The printed ring is aligned with the teeth. B, The pharyngeal cuff is inflated with 100 mL of air, and the distal cuff is inflated with 15 mL. C,
Ventilation is begun through the longer no. 1 tube because placement is usually in the esophagus. D, If ventilation is absent and the stomach is being insufflated, begin
ventilation through the no. 2 connecting tube. (Courtesy of Sheridan Catheter Corp., Argyle, NY.)
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© 2007 Elsevier
Figure 42-13 Insertion of the Combitube. A, The tongue and mandible are lifted with one hand, and the Combitube is inserted in the direction of the natural curvature of
the pharynx with the other hand. The printed ring is aligned with the teeth. B, The pharyngeal cuff is inflated with 100 mL of air, and the distal cuff is inflated with 15 mL. C,
Ventilation is begun through the longer no. 1 tube because placement is usually in the esophagus. D, If ventilation is absent and the stomach is being insufflated, begin
ventilation through the no. 2 connecting tube. (Courtesy of Sheridan Catheter Corp., Argyle, NY.)
Downloaded from: Miller's Anesthesia (on 12 March 2009 09:47 PM)
© 2007 Elsevier
Figure 42-13 Insertion of the Combitube. A, The tongue and mandible are lifted with one hand, and the Combitube is inserted in the direction of the natural curvature of
the pharynx with the other hand. The printed ring is aligned with the teeth. B, The pharyngeal cuff is inflated with 100 mL of air, and the distal cuff is inflated with 15 mL. C,
Ventilation is begun through the longer no. 1 tube because placement is usually in the esophagus. D, If ventilation is absent and the stomach is being insufflated, begin
ventilation through the no. 2 connecting tube. (Courtesy of Sheridan Catheter Corp., Argyle, NY.)
Downloaded from: Miller's Anesthesia (on 12 March 2009 09:47 PM)
© 2007 Elsevier
Figure 42-13 Insertion of the Combitube. A, The tongue and mandible are lifted with one hand, and the Combitube is inserted in the direction of the natural curvature of
the pharynx with the other hand. The printed ring is aligned with the teeth. B, The pharyngeal cuff is inflated with 100 mL of air, and the distal cuff is inflated with 15 mL. C,
Ventilation is begun through the longer no. 1 tube because placement is usually in the esophagus. D, If ventilation is absent and the stomach is being insufflated, begin
ventilation through the no. 2 connecting tube. (Courtesy of Sheridan Catheter Corp., Argyle, NY.)
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© 2007 Elsevier
Video Laryngoscopy
Tracheal intubation
Def: Placing tube to trachea through mouth/nose
and larynx.
I:
●
maintain open airway (GCS < 8)
●
toilet (no cough)
●
maintain ventilation (shock, hypoventilation)
narrowest place in airway – vocal cords
– subglotic space (<8years)
OTI, NTI - aids:
●
laryngoscope
●
Magill tongs
●
tracheal tubes
●
syringe
●
lead, bougie
●
bronchoscope
How to:
●
prepare all aids, (ventilate)
●
position of p.
●
LA, GA, coma
●
direct laryngoscopy
●
placing tube
●
inflate cuff
●
ensure position
Figure 42-3 Schematic diagram demonstrating the head position for endotracheal intubation. A, Successful direct laryngoscopy for exposure of the glottic opening
requires alignment of the oral, pharyngeal, and laryngeal axes. B, Elevation of the head about 10 cm with pads below the occiput and with the shoulders remaining on the
table aligns the laryngeal and pharyngeal axes. C, Subsequent head extension at the atlanto-occipital joint creates the shortest distance and most nearly straight line
from the incisor teeth to glottic opening.
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© 2007 Elsevier
Figure 42-3 Schematic diagram demonstrating the head position for endotracheal intubation. A, Successful direct laryngoscopy for exposure of the glottic opening
requires alignment of the oral, pharyngeal, and laryngeal axes. B, Elevation of the head about 10 cm with pads below the occiput and with the shoulders remaining on the
table aligns the laryngeal and pharyngeal axes. C, Subsequent head extension at the atlanto-occipital joint creates the shortest distance and most nearly straight line
from the incisor teeth to glottic opening.
Downloaded from: Miller's Anesthesia (on 12 March 2009 09:47 PM)
© 2007 Elsevier
Figure 42-3 Schematic diagram demonstrating the head position for endotracheal intubation. A, Successful direct laryngoscopy for exposure of the glottic opening
requires alignment of the oral, pharyngeal, and laryngeal axes. B, Elevation of the head about 10 cm with pads below the occiput and with the shoulders remaining on the
table aligns the laryngeal and pharyngeal axes. C, Subsequent head extension at the atlanto-occipital joint creates the shortest distance and most nearly straight line
from the incisor teeth to glottic opening.
Downloaded from: Miller's Anesthesia (on 12 March 2009 09:47 PM)
© 2007 Elsevier
Positioning of ob. Patient.
Size of TT
Age
Premature 2,5 3,3 10 10
Term newborn 3 4.0-4.2 12 11
1-6 mo 3,5 4.7-4.8 14 11
6-12 mo 4 5.3-5.6 16 12
2 yr 4,5 6.0-6.3 18 13
4 yr 5 6.7-7.0 20 14
6 yr 5,5 7.3-7.6 22 15-16
8 yr 6 8.0-8.2 24 16-17
10 yr 6,5 8.7-9.3 26 17-18
12 yr 7,0 9.3.2010 28-30 18-22
≥14 yr 7.0 (females) 9.3.2010 28-30 20-24
8.0 (males) 32-34
Internal
Diameter (mm)
External
Diamete
r (mm)*
French
Unit
Distance Inserted from Lips for
Tip Placement in the
Midtrachea (cm)†
  10.7-
11.3
 crooked spoon - Macintosh
 straight spoon - Miller
Laryngoscope:
Laryngoscopic view
Laryngoscopic view:
radix of tongue
epiglottis
vocal cords
trachea
interarytenoid notch
Always easy? (Cormac & Lehane)
Improvement of View
●
pressure over larynx
●
BURP
– backward, upward, and rightward pressure on the
larynx
Verify placing of the tube
 auscultation
 End tidal CO2
 fibroskopic view
Complications of TI - early:
 trauma of teeth, soft
tissue
 placed to esophagus /
endobronchialy
 aspiration
 cardiovascular P,
f, arrhythmia

 ICP
 laryngospasmus,
bronchospasmus
Complication of TI - later:
 damage of vocal cords, trachea
 sinusitis, otitis,
 decubitus – lip, nose
 obturation of tracheal tube by secret, blood
How to do NTI:
●
LA
anemisation of
nose
●
tube through
nose
●
placing tube
under visual
control
CAVE:
deviation of septum
nasi
Check your neck
●
Mallanpati
●
3-3-2
Bougie
Intubation via Bougie
RSI
●
Rapid Sequence of Intubation
●
Rapid Sequence of Induction
RSI indication
I: increased risk of aspiration
●
full stomach
– unknown time of starving
– gastroparesis
– analgetics
– diabetes
●
GE reflux
RSI - sequence
●
Preox + i.v. line, working suction
●
induction = propofol, SchJ
●
Sellick maneuver + OTI
●
confirmation
●
fixation by tape
●
be ready for 2 l of gastric content
●
Sellick maneuver continues until tube is in place
and balloon is cuffed
Difficult Airway
●
Anticipated
– awake intubation – bronchoscope
– (TS)
●
Unanticipated
– spont. vent. / paralyzed
Time of Airway Events
Alternative Equipment
Better view: → intubation
●
VideoLaryngoscopy
●
Fastrach LMA
●
fibroscope
What to do for survival?
●
O2, ventilation
●
call for help early + have a plan
Cannot intubate, can ventilate
●
call for help
●
keep ventilation
Can not ventilate, can not intubate
●
Call for Help
●
try 3 nonsurgical techniques
●
awake as soon as possible (no more drugs ..
awakening)
●
perform surgical airway
Coniotomy
●
urgent access to airway
●
lig. cricothyreoideum
(lig. conicum)
Coniotomy
 First try OTI
 find the ligament
 DO it.
Minitrach
BACT
Mind in a stressful event
●
When you do the same thing twice,
it usually leads to the same result
Na 2. pokus něco změň
Only 3+1 ways of A.M.
Summary – Difficult Airway
●
Preop exam – allways
●
History
●
ready to awake intubation = fibroscopic OTI
●
Have a plan
●
Surgical access takes max 90 s
Extubation:
●
contact [open eye, mouth...]
●
clear oropharynx
(secretions, stopped bleeding)
●
Patient keeps head 5s above bed / hand grip
●
good pain control
●
minimal ET concentration of anaesthetic
agents