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  • Airway Management

  • OutlineReview of airway anatomyAirway evaluationMask ventilationEndotracheal intubationThe difficult airway

  • Airway AnatomyAb-ductorPosterior cricoarytenoidTensorCricothyroidAd-ductorsAll the rest

  • Airway AnatomyInnervationVagus n.Superior laryngeal n.External branch motor to cricothyroid m.Internal branch sensory larynx above TVCsRecurrent laryngeal n.Right subclavianLeft Aortic arch (board question)Motor to all other muscles, Sensory to TVCs and trachea

  • Airway AnatomyInnervation of oropharynxGlossopharyngeal n. innervates tongue base and oropharynx

  • Airway AnatomyMembranesThyrohyoidCricothryoidCartilagesHyoidThyroidCricoid

  • Airway EvaluationTake very seriously history of prior difficultyHead and neck movement (extension)Alignment of oral, pharyngeal, laryngeal axesCervical spine arthritis or trauma, burn, radiation, tumor, infection, scleroderma, short and thick neck

  • Airway EvaluationJaw MovementBoth inter-incisor gap and anterior subluxation
  • Airway EvaluationObesityDistribution, i. e. short, thick neck more concerningNeck circumference

  • Airway EvaluationThyromental distance: bony point on mentum (mandible) to thyroid notchIf short (
  • Airway EvaluationOropharyngeal visualizationMallampati ScoreSitting position, protrude tongue, dont say AHH

  • Airway EvaluationDifficulty ventilatingAge >55BeardHistory of snoringLack of teethBMI >26

  • PreoxygenationReplaces the nitrogen volume of the lungs (69% of FRC) with oxygenFunctional residual capacity (residual volume and expiratory reserve volume)Preoxygenation with 100% oxygen via tight-fitting mask for 5 minutes up to 10 min of oxygen reserve following apneaFour vital capacity breaths over 30 seconds (time to desaturation quicker)

  • Patient PositioningSniffing positionLower neck flexionUpper neck extensionImportant in obesity

  • Mask VentilationInduction of anesthesia produces upper airway relaxation and possible collapseDownward displacement of mask with thumb and index finger

  • Mask VentilationUpward traction of remaining fingers upwardFingers on bony mandibleFifth digit at angle displacing mandible

  • Mask VentilationOral airwayTwo-handed technique

  • LMA PlacementCarries prominent position in ASA algorithmMay be held like a pencilBalloon partially inflatedDirected posteriorly and upwards towards the palateJaw thrust and sniffing position may help

  • LMA PlacementVerify placement by ventilatingCheck for good chest rise, ETCO2, and adequate tidal volumesCheck for leak if significant leak at around 10cm H2O problematicMay try size larger or smallerMay try to inflate/deflate cuff to obtain better sealIf difficulty passing may try inserting upside down and then flipping around

  • Endotracheal IntubationOpen the mouth with right handScissor techniqueGently insert laryngoscope into right side of mouth pushing tongue to the leftCareful with insertion not to hit teethAdvance laryngoscope further into oropharynx with applied traction 45 degrees

  • Endotracheal IntubationLook for epiglottisIf initially not found insert laryngoscope furtherIf this maneuver does not work slowly pull laryngoscope backOnce epiglottis visualized, push laryngoscope into vallecula and apply traction at 45 degree angle to push epiglottis up and out of the

  • Endotracheal IntubationLook for vocal cords or arytenoid cartilages and try to optimize view(i.e. lift head, apply more traction at 45 degree angle if necessary)Do not move once view is optimized!Assistant will hand you ETTInsert ETT into far right aspect of mouthTraction of laryngoscope slightly to left may assistTraction of laryngoscope at 45 degrees will also help keep mouth open

  • Endotracheal IntubationInsert ETT above and between arytenoids and through vocal cordsTry to visualize the ETT passing between the vocal cordsIf this is not possible, then you must visualize the ETT passing above and between the arytenoids

  • Endotracheal IntubationCommon problems:I cant see anything!Make sure tongue is swept to the leftYou are probably too shallow or too deep. Even with difficult intubations the epiglottis can be visualizedInsert laryngoscope in further looking for epiglottisPull laryngoscope back if this fails

  • Endotracheal IntubationCommon problemsI cant see the cords!Epiglottis is visualized, vocal cords are notRemoving the epiglottis partly from view is necessary to visualize the vocal cords belowPush the end of the laryngoscope blade further into the vallecula and toe upLifting the patients head with your other hand may improve the sniffing position and bring the vocal cords into view

  • Endotracheal IntubationCommon problemsI can see the cords. But I cant get the tube there!You may not be giving yourself adequate room in the oral cavityPush up and to the left with the laryngoscope to make sure the mouth is still fully opened and the tongue adequately swept awaySlide the ETT in the mouth all the way to the right side, perhaps even sideways

  • Difficult IntubationASA Difficult Airway Algorithm

  • Fiberoptic IntubationOral or nasal routesTopicalization is keyAerosolized lidocaine 4%Airway blocksThin bronchoscope inserted into trachea

  • Other airway optionsGlideScopeNeedle cricothyroidotomy

  • ConclusionAirway management is an extremely important aspect of the practice of anesthesiology and critical careA firm basis in airway anatomy is neededSkills such as mask ventilation, endotracheal intubation, LMA placement are necessaryIn the case of a difficult airway, a logical algorithm and airway equipment assist the physician in safely managing the situation

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