Indian J.
PG
336 ISSUE2005;
Anaesth. : AIRWAY
49 (4) : MANAGEMENT
336 - 343
AIRWAY MANAGEMENT IN NEUROSURGICAL PATIENTS
Dr. Umamaheswara Rao G. S.
Indroduction
Special attention to airway is necessary in
neurosurgical patients for many reasons. Procedures used
for airway maintenance may worsen the spinal instability
in patients with traumatic, congenital or degenerative
cervical lesions. The ischemic or injured brain tolerates
hypoxia very poorly. Hypoxia at the time of admission
is associated with a significant decrease in favorable
outcome in traumatic brain injury. Manoeuvres used to
secure airway may aggravate intracranial hypertension
in patients with traumatic brain injury. Routine
intraoperative airway management may be complicated
by the complex requirements of positioning and
preoperative intracranial hypertension. Diseases of the
pituitary gland associated with acromegaly may present
special problems in the airway management.
The current review attempts to discuss the airway
management in neurosurgical patients under the following
headings:
1. Airway management in diseases of the cervical spine
2. Airway management in head injury
3. Airway management in acromegaly
4. Endotracheal intubation for elective craniotomy
Airway management in diseases of the cervical spine
Congenital or acquired lesions associated with
cervical spinal instability may pose challenges in the
airway management. Efforts to secure airway in these
patients may worsen the subluxation leading to
aggravation of the neurological deficits.
Cervical spine trauma
Cervical spinal injuries occur in 2-5% of blunt
trauma. In 7-14% of cases, these lesions are unstable. In
the National Emergency X-Radiography Utilization
Study (NEXUS) that enrolled 34,069 patients of blunt
trauma,1 818 patients sustained 1193 fractures and 231
subluxations. The most common level of the fracture
was C-2 (24% of fractures). Dislocations occurred most
commonly at C-5/6 and C-6/7 levels. The incidence of
Professor of Neuroanaesthesia
National Institute of Mental Health and Neurosciences
Bangalore 560 029
E-mail : gsuma@nimhans.kar.nic.in, gsuma123@yahoo.com
INDIAN JOURNAL OF ANAESTHESIA, AUGUST 2005
336
missed or delayed diagnosis of cervical spine lesions was
1-5%, with up to 30% of such patients developing secondary
neurological damage. In yet another earlier series, secondary
neurological damage occurred in 10.5% of patients with a
missed diagnosis of cervical spine fractures.2
Assessment of cervical spinal stability prior to airway
manoeuvers
Despite liberal use of cervical spine x-rays in
trauma, the majority of them are normal. In order to
avoid unwanted radiographs, five clinical criteria have
been used to clear cervical spine in conscious trauma
patients.3 These criteria are: a) no posterior midline
cervical spine tenderness, (b) no intoxication, (c) alert
patient, (d) no focal neurological deficits and (e) no
painful distracting injuries. The overall sensitivity of
these criteria for identification of any type of cervical
spine injury is 97.6% and 99% for significant injury.
The criteria, however, have a low specificity. Conscious
patients who do not satisfy the above criteria must be
investigated by three cervical radiographs namely, lateral
view including the base of the occiput to first thoracic
vertebra, anteroposterior view and open mouth odontoid
view to rule out injury to the cervical spine. In patients
with altered mental status, there is no consensus on the
criteria for cervical spine clearance. It is a common
practice to rule out injury to cervical spine by a lateral
radiograph. The NEXUS database however has shown
that even screening radiography using three cervical views
can identify only 61% of the injuries.4 Computed
tomography with 3 mm slices using helical scanning and
multiplanar reconstruction has been shown to have a
much higher sensitivity of 97-100%.
Instability of the cervical spine caused by injuries
to ligaments may not be detected by plain radiography.
Ten percent of patients with cervical spine injuries and
0.2% of all patients with blunt trauma have unstable
cervical spine without fractures that are detected by a
combination of plain radiography and selective computed
tomography.5 In conscious patients, ligament injuries
present as neck pain and tenderness. Elimination of
ligament injury is difficult in unconscious patients. The
options that the clinicians may have in unconscious
patients with ligamentous injuries are: a) leave the cervical
spine uncleared and maintain stabilization until the patient
becomes conscious, (b) review three cervical radiographs
UMAMAHESWARA : AIRWAY MANAGEMENT IN NS PATIENTS
supplemented within axial CT images with reconstruction
through the suspicious areas (c) assess the stability of
cervical spine by flexion/extension fluoroscopy, or (d)
perform magnetic resonance imaging of the cervical
spine.
Spinal cord injury may occur without any radiological
abnormality in 2.8-3.8% of all spinal injuries.4,5 MRI is the
investigation of choice to detect this condition.
Airway management in patients with spinal injury
The objective during airway management of patient
with cervical spine injury is to secure the airway rapidly
and efficiently with minimal or no movement of the
neck. Videofluoroscopic studies in anaesthetized patients
and cadaver models of cervical spine injury have improved
our understanding of the movement of spine during
intubation in normal individuals and in patients with
spinal cord injury.
Effect of basic airway manoeuvers on cervical spine
mobility
Chin lift and jaw thrust in an adult cadaver model
of C5-6 ligamentous injury caused a greater than 5 mm
increase in the disc space.6 This widening was not
prevented by a Philadelphia collar. Introduction of an
oesophageal obturator airway caused a 3-4 mm increase
in disc space. Anterior neck pressure to facilitate
nasotracheal intubation caused a posterior subluxation
of more than 5 mm. Head tilt, and insertion of an
oropharyngal or nasopharyngeal airway are not
associated with any significant displacement of the spinal
segments. Cricoid pressure applied during emergency
intubation has been generally believed to displace the
spine. But a recent cadaver study using a lateral cervical
spine x-ray showed negligible spine movement with
cricoid pressure.7
Effect of spinal Immobilisation on techniques of airway
management
Maneuvers used for spinal immobilization may
restrict the exposure of larynx during laryngoscopy.
Immobilisation of neck with collars, straps and sand bags
restricted the mouth opening and caused a poor
laryngoscopic view (grade 3 and 4) in 64% of the
patients.8 Visualisation improved with manual inline
traction but was still poorer compared to the view in the
optimal intubating positioning. Manual inline stabilization
decreases, but does not completely eliminate cervical
spine movement during laryngoscopy.9 Axial traction
applied through weights or by an assistant, as it has been
advocated earlier, can be deleterious. In patients with
337
unstable cervical spine fractures, axial traction has been
shown to cause a mean distraction at the fracture site of
7.75 mm.10 Therefore, the current emphasis during intubation
of a patient with an unstable cervical spine is on manual
inline stabilization and not axial traction.
Techniques of securing airway in patients with
cervical spine injury
Direct Laryngoscopic Intubation: Direct
laryngoscopic orotracheal intubation with manual inline
neck stabilization is the most commonly recommended
technique for securing airway in a patient with cervical
spine injury. During normal direct laryngoscopy and
oral intubation, significant extension occurs between
occipital bone and C1 and also between C-1 and C-2.11,12
Manual inline neck stabilization reduces this head
extension by 50% in anaesthetized patients.13 However,
in a cadaver study of injuries at C4, this type of
stabilisation did not reduce the movement, suggesting
the limitation of this manoeuver in preventing movement
of the spine in patients with cervical spine injury.11 Axial
traction on spine should be avoided during laryngoscopy
and intubation as this could increase the spinal cord
injury. As discussed above, laryngoscopic view is difficult
if a cervical collar is left in place during intubation.8
Gum elastic bougie is an important adjunct for direct
laryngoscopic intubation. By using a bougie, the
laryngoscopist tends to use less pressure, thereby
potentially avoiding a displacement of the fractured
spine.14
Influence of the type of laryngoscope on
cervical movement: The cervical spine movement caused
by McIntosh curved blade or Miller’s straight blade are not
significantly different during direct laryngoscpic intubation.15
In a comparison of McIntosh and McCoy laryngoscopes,
McCoy laryngoscope improved visualization of the larynx
by at least one grade in 49% of cases.16 In another study,
Miller and McIntosh blades were compared with Bullard
laryngoscope.17 Head extension and neck movements were
less and laryngeal visualization better with Bullard
laryngoscope. However, there were problems associated
with Bullard laryngoscope, which included prolonged
time for intubation, fogging, and occasional inability to
pass the tracheal tube through the glottis. Angulated video
intubating laryngoscope significantly improved the laryngeal
view compared with direct laryngoscopy with cricoid
pressure.18
Awake Intubation: Awake intubation is considered
safe in a patient with spinal injury as the normal muscle
tone provides protection and the neurological status of the
patient can be monitored. The various options available for
338 PG ISSUE : AIRWAY MANAGEMENT INDIAN JOURNAL OF ANAESTHESIA, AUGUST 2005

awake intubation are awake oral or nasal intubation and
awake fibreoptic intubation. Despite the safety claimed for
awake intubation, a number of limitations of these techniques
must be appreciated. Awake intubation is slower compared
to rapid sequence intubation. Cooperation from the
patient is very essential for the success of the procedure.
Considerable expertise of the operator is required to
accomplish awake intubation. Blind nasal intubation is
complicated by epistaxis, laryngospasm and oesophageal
intubation.
In cadavers with a C-5/6 instability, blind nasal
intubation caused least cervical spine movements.19 With
C-1/2 instability both oral and nasal intubations produced
similar cervical spine movement.20 In cadavers with
A plan for airway management in a patient with
cervical spine injury
From the foregoing discussion it follows that a
careful plan for selection of the technique and the devices
is necessary for securing airway in a patient with unstable
cervical spine. Urgency of intubation, presence of other
associated head and facial injuries, presence of basilar
skull fractures, patient cooperation, intoxication of the
patient due to alcohol or drugs and the expertise of the
operator are some of the factors to be considered in the
initial airway management of a patient with cervical spine
injury.
Assess Airway and Oxygenation

C-3 injury, awake fibreoptic technique produced no movement

of unstable segments as assessed by video fluoroscopy.21 Apnea/Respiratory Distress Adequate

Laryngeal Mask Airway: Laryngeal mask airway Emergency Airway Elective Airway

(LMA) is a widely accepted device in cases of difficult Intubation in most efficient manner Cervical spine x-ray series
Inline stabilization without axial traction * CT Scan
intubation. LMA can be easily inserted in a neutral * MRI
* Special views
position and hence considered ideal for use in patients Airway secured
Results

with unstable cervical spine.22 Though there is a risk of Yes No Normal Abnormal

aspiration with LMA, it seems to have been overstated. Radiologic Mask ventilation Cautious oral/nasal Nasal Intubation
* Oral/nasal airway
Intubating LMA has been used successfully for blind spine evaluation intubation Awake fiberoptic
* Avoid jaw thrust/ Surgical airway
neck movement
intubation in patients undergoing cervical spine surgery.23
It has also been used in conjunction with rapid sequence ASA Difficult Airway Algorithm

intubation and also for awake oral intubation with

•Jet vnetilation
•Cricothyrotomy
•LMA
fibreoptic bronchoscope.24 •Tracheostomy

Fig. 1 : An algorithm for airway management in a patient

Both standard LMA and intubating LMA have been
with suspected cervical spine injury
shown to cause a temporary pressure of 250 cm H2O against
the posterior pharyngeal wall during insertion. The pressure
is sufficient to cause up to 2 mm of displacement of C3.25 Abnormal Normal Airway Normal Airway
Airway Cervical Spine Normal Cervical Spine
The cervical spine movement that occurs during insertion of Not Clear
LMA and intubation through LMA is less than that produced
Awake Haemo Possibly Haemo
during direct laryngoscopy.26 Neck stabilization techniques Intubation Dynamically Hypovolemic Dynamically
Stable Unstable
and cricoid pressure may make insertion of LMA more
difficult.27 Cricoid pressure applied after the insertion of Direct Blind Retrograde Same as Reduce ICP Reduce ICP Prevent Cough
intubating LMA makes the passage of the tracheal tube laryngo Technique Intubation
scopy Or Fibreoptic
‘normal
Airway’
Thiopentone
Lignocaine
Etomidate
Lignocaine
Suxameth
Defasciculate
more difficult.28 except
Head held Prevent Cough Prevent Cough
Crocoid press
Ventilate
in neutral Suxameth Suxameth
Augustine Device: Augustine’s device, an Failure position Defasciculate Defasciculate
Crocoid press Crocoid press
accessory to blind oral intubation has been compared with Cricothyrotomy Ventilate Ventilate

direct laryngoscopy in 16 patients. Augustine’s device caused Prevent Hyperten.

Narcotics
a 17° less extension from occiput to C-3.29 Esmolol
Labetalol

Surgical Airway : Cricothyroidotomy, which is
attempted when non-surgical techniques of securing
airway have failed may be associated with movement of
cervical spine. In a cadaver model of C-5/6 transection,
cricothyriodotomy resulted in 1-2 mm anteroposterior
displacement and 1 mm axial compression of the spinal
cord.30
Fig. 2 : An algorithm for airway management in a patient with head injury
In a retrospective analysis of 393 patients with
cervical spinal injury, 104 required intubation; the techniques
of intubation used in these patients comprised of oral or
nasal intubation with direct laryngoscopy under general or
local anaesthesia in 93 patients and intubation with a
UMAMAHESWARA : AIRWAY MANAGEMENT IN NS PATIENTS
fibreoptic scope in 11 patients. Irrespective of the technique
used, there were no instances of neurological deterioration
attributable to endotracheal intubations.31 Absence of a major
effect of the technique of intubation on neurological outcome
has also been documented in another study of 150 patients
undergoing elective spinal stabilization. Intubation was
carried out in an awake state or under general anaesthesia.
The techniques of intubation consisted of direct laryngoscopy,
blind nasal intubation, fibreoptic intubation or intubation
with the aid of lighted stylet in both the groups.32
As can be inferred from the above evidence,
emphasis during the airway care of a patient with cervical
spinal injury is not on the specific technique of
management, but on operator–experience and case-specific
management. No single technique of airway management
has been shown to be superior to others.33,34 Bag–mask
ventilation, introduction of oral or nasal airway, chin
lift, jaw thrust and oral or nasal intubation may be
required based on the needs of the individual patients.
Despite the fact that all these maneuvers have the
potential to move the cervical spine, excessive attention
to immobilization techniques is undesirable as it may
delay the airway management or make intubation difficult;
eventually it may lead to inadequate ventilation. There
is no evidence for an association between the technique
of intubation and neurological deterioration when
manual inline stabilization is ensured. Therefore, the fear
of inflicting cord damage should not prevent securing
the airway with the technique that the operator is
conversant with.
A practical approach for airway management in a
patient with suspected cervical spine/ injury is shown in
figure 1. If the patient is apneic, rapid orotracheal
intubation by direct laryngoscopy must be achieved while
manual inline stabilization is maintained. If this approach
is impossible due to extensive faciomaxillary injuries,
surgical airway must be attempted. If no immediate need
for airway exists, a detailed radiological evaluation can
be carried out. If the evaluation is positive/possible for
cervical spine injury, and the patient is cooperative and
requires a non-emergent intubation, awake fibreoptic
intubation under local anaesthesia may be carried out. Awake
nasotracheal intubation or surgical airway are the other
alternative choices.
Congenital anomalies of the cervical spine
Failure of fusion of the bony structures, laxity of
the ligamentous structures or excess ossification of the
spine are the causes of congenital spinal anomalies that
may interfere with safe tracheal intubation. Hypoplasia of
the odontoid may occur in isolation or as a part of many
339
clinical syndromes such as Morquio’s syndrome, Klippel-
Feil syndrome, Down’s syndrome, and Osteogenesis
imperfecta. In these patients, hyperextension of the atlanto-
axial joint during tracheal intubation may cause subluxation
of atlas over axis thereby reducing the spinal canal space
and compression of the cervical cord.
Laxity of transverse ligament is seen in 14-22% of
children with Down’s syndrome.35 Extension of head in
these patients may cause subluxation of atlas over axis with
resultant compression of the spinal cord by the odontoid
process. Rotatory subluxation of the atlanto-axial joint and
posterior subluxation of the axis have been reported in the
postoperative period in patients with Down’s syndrome.
36,37
Increased prevalence of lower cervical spondylosis and
cervical myelopathy are known to occur in adults with
Down’s syndrome. Other spinal anomalies with specific
relevance to airway management seen in patients with
Down’s syndrome include spina bifida of the atlas, vertebral
occipitalisation, congenital nonunion of the odontoid process
and Klippel-Feil syndrome. The importance of all the above
anomalies lies in the fact that tracheal intubation may be
rendered difficult in these patients. Also, cervical spinal
movements during intubation may worsen the spinal cord
compression. Awake fibreoptic intubation under regional
anaesthesia is preferred in these patients. Anaesthetic drugs
should not be administered until the trachea is intubated,
patient is positioned for surgery and neurological examination
carried out.
Airway management in head injury
Patients with severe traumatic brain injury require
endotracheal intubation in the emergency room.
Uncooperative head injured patients may require sedation
for computed tomographic scanning and sedatives cannot
be administered without an endotracheal tube in place
and institution of controlled ventilation. All head-injured
patients should be assumed to have an unstable spine
until proven otherwise and precautions described in the
section on cervical spinal injuries should be followed
meticulously.
The major goals during intubation of a brain-
injured patient are to prevent an increase in intracranial
pressure (ICP), prevent pulmonary aspiration and avoid
aggravation of a coexisting spinal injury. All these
objectives are satisfied by a rapid sequence induction
with thiopentone or propofol and suxamethonium and
intubation while maintaining cricoid pressure and manual
inline axial stabilization. But a number of limitations of
this approach need to be appreciated. If the airway is
difficult, hypnotics and muscle relaxants are contraindicated
unless the ability to ventilate with a bag and mask has been
340 PG ISSUE : AIRWAY MANAGEMENT
established. Administration of thiopentone or propofol in
a hypovolemic patient may decrease the systemic arterial
pressure and thereby the cerebral perfusion pressure
(CPP). A profound decrease in CPP caused by the anaesthetic
agents may be more detrimental to cerebral oxygenation
than a transient increase in ICP caused by intubation.
It is very well established now that cerebral blood flow
in a patient with traumatic brain injury is lowest duirng
the first 24 after injury, which is precisely the time when
he is most likely to require emergency endotracheal
intubation.
There is no consensus on the choice of agent for
reducing ICP during tracheal intubation in a patient with
traumatic brain injury. Based on the evidence from studies
on tracheal suctioning, it is generally believed that
lignocaine is effective in preventing a rise in ICP. There
is however, no substantial evidence to support this belief.
In fact, even in studies on tracheal suction, prevention
of cough by a muscle relaxant seems to be more effective
in decreasing the ICP than administering other adjuvants
such as thiopentone, fentanyl or Lidocaine.38 Barbiturates
and lidocaine were, however, effective in attenuating
ICP increase caused by tracheal suctioning in patients
who have already received muscle relaxants.
Choice of relaxant for intubation also remains
somewhat controversial. Suxamethonium causes a transient
increase in ICP by stimulating the brain through muscle
fasciculation. Defasciculation with a small dose of non-
depolariser muscle relaxant appears to prevent an increase
in ICP. Agents such as thiopentone, propofol or lignocaine
may also minimize the effect of suxamethonium.
Rocuronium, which has an onset of action that is close
to that of suxamethonium could have been an ideal non-
depolariser muscle relaxant for rapid sequence intubation.
But its long duration of action makes it unsuitable and
positively risky in patients with difficult airway. Inability
to intubate rapidly or ventilate adequately after
administration of the relaxant may aggravate the cerebral
injury. Thus, despite its potential to increase ICP
transiently, suxamethonium remains the relaxant of choice
for rapid intubation and institution of mechanical ventilation
in a head injured patient. Hyperkalemic response to
suxamethonium may be expected from 48 hours onwards
with peaks between 4 weeks and 5 months.
A practical approach to endotracheal intubation
based on an assessment of airway and haemodynamic
status of the patient is shown in figure 2.
In a patient with head injury, the decision to
extubate or decannuate the trachea must take into
account the Glasgow coma score of the patient and his
INDIAN JOURNAL OF ANAESTHESIA, AUGUST 2005
ability to maintain an unobstructed airway. The patient
must be capable of clearing his airway secretions before
extubation is attempted. Patients with a Glasgow coma
score of eight or less are unlikely to tolerate extubation.
Postextubation monitoring in these patients should include
the level of consciousness in addition to the routine
cardiorespiratory variables. Any neurological deterioration
during weaning which is otherwise unexplained, should be
considered an indication for reintubation.
Problems may be encountered during extubation or
decannulation of head injured patients who have required an
artificial airway for a prolonged period of time. The ideal
time for tracheostomy in such patients remains debatable.
Endotracheal tubes made of polyvinyl chloride may be
generally left in situ for upto two weeks. Repeated coughing
on the endotracheal tube could lead to significant laryngeal
injury and postextubation laryngeal oedema. Stenosis at the
glottic and subglottic levels may occur in such patients, if
a tracheostomy is performed after a prolonged period of
intubation. This, in turn, may lead to difficulties in
decannulating the trachea. Therefore, early tracheostomy
at the end of the first week should be considered in a
patient whose trachea is unlikely to be extubated by two
weeks and the patient’s airway reflexes are active. These
problems are even more accentuated in children in whom
the airway is already narrow.
Airway management in acromegaly
Airway management may be difficult in a patient
with acromegaly due to hypertrophy of facial bones and
mandible, large bulbous nose, thick tongue and lips,
and hypertrophy of the nasal turbinates, soft palate,
tonsils, epiglottis and larynx. Mask fit and laryngeal
visualization may be difficult in these patients. Glottic
stenosis due to tissue overgrowth may predispose to
preoperative hoarseness and dyspnoea; it may also cause
post-extubation oedema. Unusual cases of pituitary
adenomas with nasal and nasopharyngeal extension that
caused airway problems have been reported.39,40 Vocal cord
paralysis may result from stretching of recurrent laryngeal
nerve, impaired mobility of cricoarytenoid joints, or
compression of recurrent laryngeal nerve by thyroid
enlargement.
Acromegalic patients also have a higher incidence
of preoperative hypertension and cardiomegaly. The
combination of a difficult airway with cardiac disease
may predispose these patients to major haemodynamic
disturbances at intubation.
Sleep-disordered breathing, either central or
obstructive in nature, is common in patients with
UMAMAHESWARA : AIRWAY MANAGEMENT IN NS PATIENTS
acromegaly. The pharyngeal airway of acromegalic
patients with sleep-disordered breathing is highly
collapsible. The etiology of sleep-disordered breathing in
acromegaly appears to differ from that of ordinary sleep
apnea. Anatomic abnormality, especially at the base of the
tongue, appears to play a significant role in development of
this problem.41
A thorough preoperative airway evaluation is
mandatory in these patients. Patients without hoarseness,
dyspnea or other acromegalic stigmata may be managed
in a routine manner. Those with glottic anomalies should
be intubated with a fibreoptic laryngoscope, awake or
anaesthetized depending on the degree of laryngeal
involvement evaluated by indirect laryngoscopy. Nasal
intubation cannot be considered for transphenoidal
surgery as it would obstruct the surgical field.
In a study of 28 patients with acromegaly compared
with 28 matched controls, difficult intubation was
encountered in 12 patients in the acromegalic group and
1 patient in the control group; 19 patients in the
acromegalic group had enlarged tongue; three patients
in the acromegalic group and none in the control group
required fiberoptic intubation.42 Intubating laryngeal
mask airway has been used as a primary tool for
ventilation and intubation in acromegalic patients. In
one study of 23 patients with acromegaly, intubating
laryngeal mask airway was successful as a primary airway
for oxygenation and ventilation before attempting
intubation. Intubating laryngeal mask airway could be
successfully placed at the first attempt in 91% of patients
and in the second attempt in the rest. An attempt at
tracheal intubation through the intubating laryngeal
mask airway was successful only in 82% of the patients.
The study concluded that intubating laryngeal mask
airway can be used as a primary airway for oxygenation
in acromegalic patients but the rate of failed blind
intubation through the intubating laryngeal mask airway
precludes its use as a first choice for elective airway
management.43
Rhinological problems may occur after a trans-septal
transphenoidal surgery for pituitary tumors. Endoscopic
observation of the nasal cavity after a transphenoidal surgery
may reveal the presence of crust formation, hypertrophy of
the inferior turbinate, or synaechiae. All the above changes
have been shown to increase the resistance to airflow
following transphenoidal surgery.44
Endotracheal intubation for elective craniotomy
Surgical position and aggravation of intracranial
hypertension are two major considerations in the airway
management for an elective craniotomy.
341
Surgical position and airway
Airway compromise may be expected in some of
the positions used for neurosurgery. Flexion of the neck is
generally required for approach to lesions in the infratentorial
compartment and high parietal region. Lateral position
or park bench position are required for lateral cerebellar
and cerebellopontine angle lesions. Prone position is
generally used for surgery on cerebellar lesions and
spinal lesions. There is a risk of kinking of the endotracheal
tube or inadvertent extubation in all these positions. Flexion
of the neck after intubation may lead to endobronchial
migration of the tube. In all these patients, adequacy of
ventilation must be confirmed after surgical positioning.
Reinforced endotracheal tubes should be used where there
is a risk of kinking of the endotracheal tube. There are
reports of obstruction of a reinforced endotracheal tube
through a valve-like mechanism caused by a partial
detachment of the inner coating from the embedded spiral
of the ETT. The detachment was most likely caused by
reuse of a single-use product after autoclaving.45 Continuous
soaking of the tapes used for tracheal tube fixation by
saliva might increase the risk of self-extubation. Massive
oedema of the tongue and face requiring postoperative
tracheal intubation for many days has been reported
following posterior fossa surgery in sitting as well as lateral
positions. The exact mechanism of the complication remains
ill-understood.46
Pressure on endotracheal tube might be caused
by the instruments used in anterior surgical approaches
on the cervical spine. An armored endotracheal tube prevents
airway compromise in these situations. Postoperative airway
oedema may occur following high cervical spine surgery or
skull base surgery requiring extensive dissection.
Intracranial hypertension and airway management for
craniotomy
No specific measures other than those required
for any routine endotracheal intubation are necessary in
patients without evidence of raised ICP. In patients with
evidence of raised ICP, acute exacerbation of intracranial
hypertension should be avoided. A smooth and unhurried
intubation is very essential. The dosage of the hypnotic
used for induction should ensure adequate depth of
anaesthesia at intubation. Profound muscle relaxation must
be achieved with a non-deplorising muscle relaxant before
intubation. An additional dose of thiopentone or propofol
may be given just prior to intubation. Lignocaine in a dose
of 1-2 mgkg-1 is administered intravenously to prevent a
rise in ICP. Mild hyperventilation by mask before intubation
and also after intubation may also help to reduce ICP.
Hypercapnia at this stage may be meticulously avoided by
continuous capnographic monitoring.
342 PG ISSUE : AIRWAY MANAGEMENT
In summary, airway management plays a critical
role in the acute management of neurosurgical patients.
The primary neurological problem may pose limitations
on the techniques used for establishing an unobstructed
airway. At the same time, inadequate airway management
may adversely affect the neurological outcome of the
patient. A clear understanding of this interaction in a
given patient helps to determine the choice of appropriate
airway maintenance technique in that patient.
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