Angkana Lurngnateetape,, MD. Department of Anesthesiology Siriraj Hospital

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1 AIRWAY MANAGEMENT Angkana Lurngnateetape,, MD. Department of Anesthesiology Siriraj Hospital

2 Perhaps the most important responsibility of the anesthesiologist is management of the patient s airway Miller RD s Anesthesia 2000 Barash PG, Cullen BF, Stoelting RK s Clinical Anesthesia 2001

3 What should we know about airway management? Airway anatomy and function Evaluation of airway Clinical management of the airway - Maintenance and ventilation - Intubation and extubation - Difficult airway management

4 Airway anatomy The term airway refers to the upper airway consisting of Nasal and oral cavities Pharynx Larynx Trachea Principle bronchi

5

6 Anterior view of Larynx

7 Lateral view of Larynx Single Cartilage Epiglottis Thyroid Cricoid

8 Posterior of Larynx Double Cartilage Corniculates Arythenoids Cuneiforms

9 Larynx in Laryngoscopic view

10 Nerves

11 Vagus nerve Superior laryngeal n External br (Motor) cricothyroid m Internal br (Sensory) area above cord Recurrent laryngeal n - Motor br intrinsic m Sensory br area below cord

12 Evaluation of the airway History Physical examination Special investigation

13 Evaluation of the airway History Previous history of difficult airway Airway-related untoward events Airway-related symptoms/diseases

14 Evaluation of the airway Physical examination Ease of open airway and maintenance Ease of tracheal intubation Teeth Neck movement Intubation hazards Signs of airway distress

15 Evaluation of the airway Anatomic characteristics associated with difficult airway management Short muscular neck Receding mandible Protruding maxillary incisors Long high-arched palate Inability to visualize uvula Limited temporomandibular joint mobility Limited cervical spine mobility

16 Evaluation of the airway Assessment of airway associated with difficult airway management Mallampati s classification Atlanto-occipital joint extension Hyomental distance Thyromental distance Horizontal length of mandible Sternomental distance > Class III < 35 O < 3 cm or 2 FB < 6 cm or 3 FB < 9 cm < 12 cm

17 Mallampati s classificaton Soft palate Fauces Uvula Pillar Soft palate Fauces Uvula Soft palate Hard palate

18 Laryngoscopic view

19 Signs of upper airway obstruction/airway distress Hoarse voice Decreased air in and out Stridor Retraction of suprasternal / supraclavicular / intercostal space Tracheal tug Restlessness Cyanosis

20 How to open the airway? Non equipment With equipment :- head tilt / chin lift/jaw thrust :- oro/nasopharyngeal airway - endotracheal intubation - laryngeal mask airway (LMA) - combitube

21 Indication for tracheal intubation Airway protection Maintenance of patent airway Pulmonary toilet Application of positive pressure Maintenance of adequate oxygenation

22

23 Face Mask 22 mm orifice Transparent/ black rubber Hook Minimize dead space

24 One-handed face mask technique

25 Two-handed face mask technique

26 Preparation for Rigid Laryngoscopy Suction Airway Laryngoscope ETT Stylet Anesthetic machine / Breathing system / Self-inflating bag Monitoring : Pulse Oximeter, Capnograph Local infiltration, spray

27 Technique of Direct Laryngoscopy & Intubation

28

29 Oral endotracheal tube size guideline Age Int diameter (mm) Length (cm) Full term Child Adult Female Male 4 + Age/ Age/

30 Sign of Tracheal Intubation ETT visualized between cord Fiberoptic visualized of cartilaginious rings of the trachea and tracheal carina

31 Sign of Tracheal Intubation Resp gas moisture disappearing on inhalation and reappearing on exhalation Chest rise & fall No gastric distention ICS filling out during inspiration

32 Sign of Tracheal Intubation Reservoir bag having the appropriate compliance

33 Sign of Tracheal Intubation Breath sound over chest No breath sound over stomach Sound air exit from ETT when chest is compressed Large spontaneous exhaled TV

34 Sign of Tracheal Intubation CO 2 excretion waveform Rapid expansion of an esophageal or tracheal indicator bulb

35 Techniques for routine intubation (Preoxygenation) Administration of induction agent Adequate mask ventilation Administration of rapidly acting neuromuscular blocking agent Intubation Confirm tube in trachea

36 Technique for rapid-sequence (crash) induction and intubation Preoxygenation 5 min Administration of induction and NM blocking agents Cricoid pressure (Sellick maneuver) No mask ventilation Check breath sound Release cricoid pressure

37 Techniques for Difficult Airway Management Techniques for Difficult Ventilation Techniques for Difficult Intubation

38 Techniques for Difficult Ventilation Oral/Nasal Airway Two-person mask ventilation Laryngeal Mask Airway (LMA) Surgical Airway Access Esophageal-tracheal Combitube

39

40 Two person Mask Ventilation

41 Laryngeal Mask Airway

42

43

44 The Esophageal-tracheal Combitube

45 Techniques for Difficult Intubation Stylet Intubating stylet-tube changer Alternative laryngoscope blades (e.g. Mc Coy laryngoscope) Awake intubation Blind intubation (oral or nasal) Fiberoptic intubation Illuminating Stylet / Light wand Retrograde intubation Surgical airway access

46 Stylet

47 Bullard rigid fiberoptic laryngoscope

48

49 Illumination Stylet Light wand

50 Retrograde intubation

51 AWAKE INTUBATION CHOICE * LMA, COMBITUBE, TTJV INTUBATION CHOICE * INTUBATION CHOICE *

52 Complication During Laryngoscopy & Intubation While tube in place Following Extubation

53 Complication: During Laryngoscopy & Intubation Malposition Esophageal Intubation Bronchial Intubation Trauma Tooth damage Lip, tongue, mucosal laceration Dislocated mandible Retropharyngeal dissection Cervical spine Aspiration

54 Complication: During Laryngoscopy & Intubation Physiologic reflexes HT, Arrthymia Intracranial HT Intraocular HT Bronchospasm Tube malfunction Cuff perforation

55 Complication: While tube in place Malpositioning Unintentional Extubation Endobronchial Intubation Laryngeal cuff malposition Airway trauma Mucosal inflammation Excoriation of nose Tube malfunction Ignition Obstruction / Kinking Aspiration

56 Complication: Following Extubation Airway trauma Edema, Stenosis Hoarseness / Sorethroat Laryngeal malfunction Physiologic reflexes Laryngospasm Aspiration

57 Thank you and Good Luck

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