Airway Management

Definition of Airway management

“Airway management
involves ensuring that the patient
has a patent airway through which
effective ventilation can take
place.”
Purpose
 To provide an artificial airway that is
as close to the patient's natural airway
as possible along with a continuous
source of oxygen.
Indications of Airway Management
 Maxillofacial trauma
 Aspiration of foreign body
 Asthma
 Heart failure
 Hypoglycemia
 Overdose reaction
 Anaphylaxis
 Epilepsy
 Diagnosis of Airway Obstruction

 LOOK : Respiratory
movements, gasping,
suprasternal retraction
 LISTEN: Breath sounds
 FEEL : Expired air
Diagnosis of Airway Obstruction

 Abnormal sounds in airway

obstruction
◦ Snoring - due to obstruction of upper
airway by the tongue
◦ Gurgling - due to obstruction of upper
airway by liquids (blood, vomit)
◦ Wheezing - due to narrowing of the
lower airways
◦ Complete airway obstruction is silent.
Anatomy of Respiratory
System
The airways can be divided in to parts namely:
 The upper airway.
 The lower airway
The Upper Airway
A Epiglottis
B Mandible
C Frontal Sinus
D Soft Palate
E Trachea
F Glottis
G Esophagus
H Vocal Cords
The Upper Airway
 Other Structures
◦ Nasopharynx
◦ Oropharynx
◦ Laryngopharynx
◦ Larynx
Functions of the Upper Airway
 Passageway for
air
 Warm
 Filter
 Humidify
 Protection
◦ Gag Reflex
◦ Cough
 Speech
The Lower Airway
Primary Bronchi
A Hyoid Bone
B Right Lung
C Secondary
D Bronchi
E Tracheal
F Ligament
G Trachea
H Larynx
I Esophagus
J Left Lung
Trachea
Lungs
 Structure
 Lobes
 Pleura
Mallampati Grades

Class I Class II Class III Class IV

 Difficulty 

Class I: Uvula/tonsillar pillars visible

Class II: Tip of uvula/pillars hidden by tongue
Class III: Only soft palate visible
Class IV: Only hard palate visible
Airway management procedures
 A. Noninvasive procedures
1. Back Blows
2. Head Tilt Chin lift procedure
3. Heimlich maneuver (Abdominal thrust)
4. Chest thrust
5. Finger sweep
6. Ambu -Bag
 B. Invasive procedures
1. Oropharangeal airway
2. Nasopharangeal airway
3. Cricothyroidectomy
4. Tracheotomy
5. Endotracheal tube
6. Laryngeal Mask Airway
Non Invasive Procedures
Back Blows
Back Blows

◦ Indications:
Infants
◦ Contraindications:
Not recommended for Children and
adults
◦ Advantages
Ease
Back Blows
◦ Disadvantages
1.Not as effective as Heimlich
Maneuver
◦ Procedure
1.Hold the infant in one hand
2.Head lower than trunk
3.Support jaws
4.Blow with heel of hands between
shoulder blades
Heads Tilt Chin lift procedure
Head Tilt Chin lift procedure
 Indications :
◦ To open the airway
 Caution with :
◦ Suspected Neck injury
 Procedure :
◦ One hand on forehead to tilt head
back
◦ With fingers of other hand Lift
mandible upward and outward
Heimlich maneuver
Heimlich maneuver
◦ Indications:
To remove foreign body.
◦ Advantages
Effective procedure
◦ Disadvantages
Injury to intra-abdominal organs
may occur
Heimlich maneuver
◦ Procedure
 Conscious patient :
1.Position behind patient and wrap
arms around waist
2.Grasp one fist with other hand and
position it slightly above umbilicus;
caution- xiphoid process
3. Inward and upward thrusts until
foreign body is out.
Heimlich manuever

 Procedure
◦ Unconscious patient :
1. Patient positioned supine
2. Open airway by “head tilt technique”
3. Place heel of one hand on abdomen just
above the umbilicus and second hand on
top of that
4. Provide 6-10 thrusts.
Chest Thrust
Chest Thrust
◦ Indications:
1. Infant and child upto 8 years old
2. Pregnant female
3. Extreme obesity
◦ Contraindications:
1. Geriatric patients
◦ Advantages
1. Alternative to Heimlich Maneuver
Chest Thrust
◦ Procedure
 Conscious victim :
1.Stand behind patient encircling
victim’s chest
2.Place same grip on middle of
sternum
3.Perform until foreign body is out
 Chest Thrust
◦ Procedure
 Unconscious victim :
1.Supine position
2.“Head tilt technique”
3.Same hand position on lower half
of sternum
4.6-10 downward thrusts
Jaw Thrust
Jaw Thrust
 Indication :
◦ To open the airway blocked due to
tongue prolapse
 Procedure :
◦ Grasp the angles of the lower jaw, one
hand on each side, and displacing the
mandible forward.
◦ Thumbs opening the mouth
Finger sweep
Finger sweep
◦ Indications:
1. Removal of foreign body in
unconscious patients
◦ Contraindications:
1. Conscious patient
 Finger sweep

◦ Procedure
1.Supine position
2.Grasp tongue and anterior portion
of mandible, pull the tongue
3.Use index finger to dislodge the
foreign body
4.CAUTION: Don’t force the object
deep into airway
Ambu Bag
 Indications:
◦ Unconscious patients
◦ Supplemental oxygen Source
 Advantages :
◦ Can be used directly with
 Endotracheal tube
 Supplemental O2
◦ Allows spontaneous ventilation
Ambu Bag
 Diasdvantages:
◦ Require special training
◦ Does not ensure adequate airway
Ambu Bag
Ambu Bag
Invasive techniques
 Indications:
1. Failure of noninvasive techniques
2. Obstruction due to swelling;
laryngeal edema, epiglottitis
 Contraindications:
1. Inadequate training
2. Lack of proper equipments
Invasive Techniques
 Advantages
1. Higher success rate
 Disadvantages:
1. Need for expertise
2. Equipments
3. Cost
Risks/Protective Measures

 Be prepared for:
◦ Coughing
◦ Spitting
◦ Vomiting
◦ Biting
 Body Substance Isolation
◦ Gloves
◦ Face masks
◦ Eye shields
Oropharyngeal Airway
 Indications :
◦ Unconscious but spontaneously
breathing patients due to tongue
positions
 Advantages :
◦ Seperates tongue from posterior
pharyngeal wall
 Disadvantages :
◦ Activates gag reflex in conscious patients
Oropharyngeal Airway
 Size :
◦ Adult : 100 mm
◦ Small adult : 80 – 90 mm

 Technique :
◦ Position
◦ Use tongue blade
◦ Insert inverted and later rotate
Oropharyngeal Airway
Oropharyngeal Airway
Oropharyngeal Airway
Various Sizes
Oropharyngeal Airway
Nasopharyngeal Airway
 Indications:
◦ Tongue obstruction
◦ Inadequate oral opening
◦ Oral Surgery
 Advantages :
◦ Well tolerated even in conscious
patient
 Sizes : (Internal Diameter)
◦ Large adult :8-9 mm
◦ Small adult : 6-8 mm
Nasopharyngeal Airway
Nasopharyngeal Airway
 Position
 Determine the size of tubes
 Local Anesthesia
 Lubricate
Nasopharyngeal Airway
Nasopharyngeal Airway
Endotracheal Intubation
 Definition :
◦ Endotracheal intubation is the placement of
a tube into the trachea (windpipe) in order
to maintain an open airway in patients who
are unconscious or unable to breathe on
their own.
◦ Oxygen, anesthetics, or other gaseous
medications can be delivered through the
tube.
Endotracheal Intubation
 Indications:
◦ Treatment of symptomatic hypercapnia.
◦ Treatment of symptomatic hypoxemia.
◦ Airway protection against aspiration.
◦ Present or impending respiratory failure
◦ Apnea
◦ Unable to protect own airway
 Contraindications:
◦ Awake patient.
◦ Airway can be managed less invasively
Endotracheal Intubation

 Advantages
◦ Secures airway
◦ Route for a few medications
◦ Optimizes ventilation, oxygenation
◦ Allows suctioning of lower airway
 Hazards:
◦ Esophageal intubation
◦ Damage to vocal cords
◦ Damage to teeth (Laryngoscope)
Endotracheal Intubation
 Equipment:
1. Endotracheal tube
Adult female= 7- 8 mm
Adult Male = 8 – 9 mm
child = diameter of little finger
Endotracheal tube
Endotracheal Tube
Endotracheal Tubes
Endotracheal Intubation
 Equipments
1. Laryngoscope blade
1. Stright
1. Adult : size 3 to 4
2. Child : Size 2-3
3. Baby : size 1- 2
2. Curved
1. Adult : size 3 to 4
2. Child : Size 2-3
3. Baby : size 1- 2
Laryngoscope

Curved Laryngoscope

Straight Laryngoscope
Curved Blade (Macintosh)

 Insert from right to

left
 Visualize anatomy
 Blade in vallecula
 Lift up and away
DO NOT PRY ON
TEETH
 Lift epiglottis
indirectly
Straight Blade (Miller)

 Insert from right to

left
 Visualize anatomy
 Blade past vallecula
and over epiglottis
 Lift up and away
DO NOT PRY ON
TEETH
 Lift epiglottis
directly
Intubation Technique
Vocal Cords
Endotracheal Intubation
 Procedure:
 Assess
◦ airway – note landmarks, swelling,
deformities.
◦ Remove dentures. – Assess tongue size,
dental obstruction, visibility of oropharynx,
◦ degree of neck mobility. - Maintain cervical
spine stability as necessary.
 Open airway: suction or manually extract
foreign material. – Chin lift, jaw thrust.
 Heimlich maneuver as needed.
Endotracheal Intubation
 Position patient into “sniffing
position” if possible; restrain as
necessary.
 Standing at the supine patient’s
head, gentle insert laryngoscope
blade with left hand.
Endotracheal Intubation
Endotracheal Intubation
 Visualize glottic opening/vocal
cords.
 Insert the tubes
Endotracheal Intubation

Tip of blade is placed in vallecula, and laryngoscope

is lifted further to expose glottis. The tube is inserted
through the right side of the mouth.
Endotracheal Intubation

Tube is advanced through vocal cords into trachea.

Endotracheal Intubation
 Inflate ETT cuff with 5 – 10 cc air
via syringe.
 Ventilate with bag and oxygen.
Endotracheal Intubation

Tube is positioned so that cuff is below vocal

cords, and laryngoscope is removed.
Endotracheal Intubation
 Confirm tube placement
◦ chest auscultation,
◦ CO2 monitor
◦ chest x-ray.
 Endotracheal Intubation

Complication: Prevention: Management:

Remove loose teeth Check chest x-ray to
Missing/broken prior; avoid using rule out aspiration.
teeth: upper teeth as
fulcrum for
laryngoscope blade.
Clenched teeth: Paralytic
medication.
Air leak: Check cuff prior to Inject more air or
beginning change tube over
procedure. guide wire.
 Endotracheal Intubation
Inability to visualize Proper patient Reposition, choose a
vocal cords: positioning, proper different blade,
laryngoscope blade adequate suction,
size, proper cricoid pressure by
suctioning. assistant.
Esophageal Visualize cords. Remove tube, re-
intubation: oxygenate and
reinsert.
Laryngospasm: Spray vocal cords Benzodiazepine or
with 2% Lidocaine. paralytic
medication.
Failure to intubate: Have alternative
plan prepared:
cricothyrotomy.
Laryngeal Mask Airway
 Indications:
◦ General Anesthesia
◦ Emergency
◦ In patients trapped in sitting position
◦ Unsuccessful intubation
 Disadvantages :
◦ Does not protect lung from aspiration
Laryngeal Mask Airway
Laryngeal Mask Airway
Laryngeal Mask Airway
 Procedure:
◦ Identify correct size
◦ Lubricate
◦ Anesthetize
◦ Extend neck
◦ Insert, follow the curvatures of oropharynx
and rest over pyriform fossa
◦ Inflate cuff
◦ Check position using sthethoscope
◦ Attach to ventilator apparatus
LMA Placement
LMA Placement
References
 Textbook of Medical Emergencies, Malamed.
 Clinician’s Manual of Oral and Maxillofacial
Surgery, Kwon and Laskin
 Performing endotracheal intubation, Cindy
Goodrich
 Tracheostomy and its variants, Dr.Praveen
Kumar
 www.wikipedia.com
 www.medicinenet.org
 www.anesthesiology.org
 www.emtb.com
 www.clarus-medical.com
 www.fotosearch.com
Thank You!
Tracheostomy
 Definition :
“Formation of a fistulas hole
between the skin and trachea”
Tracheostomy
 Classification:
◦ Emergency Tracheostomy
◦ Semi-emergency Tracheostomy
◦ Planned Tracheostomy

◦ High Level : 1, 2, 3 tracheal rings

◦ Low Level : 2,3,4 tracheal rings

◦ Temporary : for respiratory distress

◦ Permanent :Laryngopharyngectomy
Tracheotomy
◦ Indications:
1. Long term airway maintenance
2. Glottic edema
3. Laryngeal nerve palsy
4. Head injury
5. Tetanus
6. Coma
7. Chest injury
8. Laryngeal infections
Tracheotomy
 Contraindications:
◦ Cervical Spine fracture
◦ Tracheomalecia
◦ Carcinoma of trachea
 Advantages
◦ Bypass upper airway obstruction
◦ Reduces the dead space
◦ Attachment to vetilator is possible
Tracheotomy

◦ Equipments :
1. Blade
2. Tracheal dilator
3. Cats paw retractor
4. Tracheostomy tube
Tracheotomy
 Technique :
◦ Patient position
◦ Hyperextension of neck
◦ Locate the cricoid cartilage
◦ Vertical incision of 2-3 cm
◦ Retract skin using Cat paw retractor
◦ Incise the trachea and dilate it using
tracheal dilator
◦ Apply 2% lignocain gauze ( Reflex)
◦ Insert the tracheotomy tubes
Tracheotomy
 Completed
tracheotomy:
1 - Vocal cords
2 - Thyroid
cartilage
3 - Cricoid
cartilage
4 - Tracheal
cartilages
5 - Balloon cuff
Tracheotomy
◦ Possible Complications
1. Perforation of esophagus
2. Hemorrhage
3. Pnemothorax
4. Tracheal stenosis
5. Loss of speech
6. Chances of infection
Percutaneous Tracheotomy
 Procedure
◦ skin incision along relaxed skin
tension lines
◦ Insert of 14-gauge needle
◦ Tracheal dilatation
◦ Insert tracheostomy tube
◦ Connect ventilator tubing
Percutaneous Tracheotomy
Cricothyrotomy
Cricothyrotomy
 Indications
◦ Absolute need for definitive airway, AND
 unable to perform ETI due to structural or
anatomic reasons, AND
 risk of not securing airway is > than surgical
airway risk
OR
◦ Absolute need for definitive airway AND
 unable to clear an upper airway obstruction,
AND
 multiple unsuccessful attempts at ETT, AND
 other methods of ventilation do not allow for
effective ventilation, respiration
Cricothyrotomy
 Contraindications (relative)
 No real demonstrated indication
 Risks > Benefits
 Age < 8 years (some say 10, some say 12)
 Evidence of fractured larynx or cricoid
cartilage
 Evidence of tracheal transection
 Advantages:
 Less complications
 Less bleeding
 Heals within a few days
 Anatomy

 Thyroid and cricoid

cartilages
 Cricothyroid
membrane
Anatomy
Cricothyrotomy
 Equipments :
1. Scalpel No. 11 Blade
2. Or 13 gauge half inch long needle
Cricothyrotomy
 Technique:
1. Supine position
2. Hyperextension of neck
3. Locate cricothyroid membrane
4. Vertical skin incision
5. Retract with thumb and index finger
6. Horizontal incision as close to cricoid
cartilage as possible
7. Rotate the blade at 90 degrees
8. If available, insert tubes