Airway Airway ManagementManagement

Tracheal Intubation is useful to deliver anaesthetic gases directly to trachea and allow control of ventilation and oxygenation and no aspiration. The airway device is maintained in situ from the start to the end of anaesthesia.

Airway Anatomy Suggesting Difficult IntubationAirway Anatomy Suggesting Difficult Intubation

Protruding or receding jaw.

Prominent upper incisors.

Short Thick Neck

Disease of pharynx or larynx

Deviation of trachea from midline

Stiff joint syndrome, in the TMJ and cervical spines• About one third of diabetics characterized by short stature,

joint rigidity, and tight waxy skin• Positive prayer sign with an inability to oppose fingers

Prayer Sign

Indications of Tracheal IntubationIndications of Tracheal Intubation

In the operating room• Maintenance of patent airway

- Abnormal intraoperative positions- Airway inaccessible (eg. Head & Neck surgery)- Expected difficulty in use of face mask

• Airway Protection- From contamination by blood, pus, debris, etc.

• Use of controlled ventilation - During anaesthesia

Indications of Tracheal IntubationIndications of Tracheal Intubation

In the operating room• Unconscious patient• Pulmonary toilet• Mechanical ventilation

During CPR

Time to intubate . . . Equipment for intubation

Oxygen source ETT Laryngoscope Airways Magill forceps Suction Stylet

Oral/Nasal AirwaysOral/Nasal Airways

Moulded tubes in different sizes and shaped to curve behind the tongue lifting it away from posterior pharynx.

Oral airways are made of hard plastic

Nasal airways are made of very soft latex and better tolerated in lightly anaesthesised patient.

Uses:•Keep airway patent

•Prevent falling back of tongue in unconsious patients

•Prevents semiconsoius patient from biting and occluding ETT

•Prevent biting of tongue in patient with status epilepticus

Oral/Nasal AirwaysOral/Nasal Airways

OPA

Oropharyngeal Airway

NPA

Nasopharyngeal airway

Laryngoscopes

LaryngoscopeLaryngoscope

Used for direct inspection of larynx

Has 2 separate parts; handlehandle and interchangeable bladesblades

LaryngoscopeLaryngoscope

There are 2 types of laryngoscopes:

Macintosh: for adults, with curved blade

Miller or Magill: for children, with straight blade

LaryngoscopescopeLaryngoscopescope

Made of flexible optical fibres. Used mainly for difficult intubation.

Endotracheal TubesEndotracheal Tubes

ETT for Fastrach LMA

Pediatric uncuffed ETT

ETT for blind nasal

Standard ETT

General features:

•Made of PVC with low-pressure high-volume cuffs

•Sizes from 2.5 to 9.0 mm (internal diameter)

•Radio-opaque incorporated to aid placement

•Distal end is beveled

What Size Endotracheal Tube ?

Adult male 7.5-8 mm

Adult female 7-7.5 mm

Pediatric (16 + AGE)/4

Nasal intubation Size reduced 1-2 mm

Types of ETTsTypes of ETTs

The Robertshaw double-lumen tracheal tube attached to a single-use pediatric pulse oximeter.

1. Portex tubes:Portex tubes: - Semirigid, with little tendency to kink. Most commonly used.

2. Rubber tubes:Rubber tubes: - Soft, easily kinked.

3. Reinforced tubes:Reinforced tubes: - Cuffed or non cuffed. Reinforced with wire to prevent kinking.

4. Special tubes:Special tubes:

- Double lumen (Robertshaw). Used for thoracic surgery to isolate the 2 lungs completely.

TT cuffTT cuff

•Most TTs have cuff inflating system consisting of valve, balloon, inflating tube and cuff.

•Uncuffed tubes used in children to minimise pressure injury

•Purpose of cuff is:

Airtight seal between tube and trachea

Protect from aspiration of blood, mucus or vomitus.

Magill ForcepsMagill Forceps

Designed for guiding tip of ETT through larynx during nasal intubation. Also helpful during insertion of nasogastric tubes, removal of foreign body in mouth of putting pharyngeal pack.

Malleable StyletMalleable Stylet

Thin peace of metal of plasticThreaded through lumen of ETTUseful when exposure to larynx is difficultUsed to change curve of ETT.

Local Anaesthesia Spray

Attenuates haemodynamic response to ETT and reduce intensity of cough reflex at light anaesthesia.

Position of Head & Neck Sniffing Position

Flexion of lower cervical spine & extension of A-O joint Long axes of mouth, pharynx and trachea are in straight line

Orotracheal IntubationOrotracheal Intubation

• Place the patient in the correct position.

• Grasp the laryngoscope in the left hand.

• Spread the patient's lips, and insert the blade between the teeth, being careful not to break a tooth.

• Pass the blade to the right of the tongue, and advance the blade into the hypopharynx, pushing the tongue to the left.

• Lift the laryngoscope upward and forward, without changing the angle of the blade, to expose the vocal cords.

Orotracheal IntubationOrotracheal Intubation

• Gently pass the tube next the laryngoscope blade through the vocal cords into trachea, far enough so that the balloon is just beyond the cords.

• Pressing downward on the thyroid cartilage. This helps bring an anteriorly placed larynx into view and facilitate intubation.

• Once in place, inflate the cuff till airtight seal is obtained.• Confirm that the tube is properly positioned. First, listen over the

stomach with a stethoscope while ventilating the patient. If sounds of airflow are heard or if distension of the stomach occurs, the tube is in the esophagus. If the esophagus has been intubated instead of

the trachea, remove the tube and try again.

Orotracheal IntubationOrotracheal Intubation

• Listen to each side of the chest, be sure that breath sounds are equal in both sides of the thorax. If not, reposition the tube. When breath sounds are equal on both sides and the thorax rises equally on both sides with each inspiration, note the position of the tube (mark the tube at patient's mouth).

• Wrap adhesive tape around the tube where it comes out of the mouth. Then carry the tape over the cheek and around the back of the head onto the other cheek. Fasten the end of the tape around the tube.

• Obtain a chest x-ray film immediately to check tube placement, and also obtain arterial blood gas measurements to assess the adequacy of ventilation.

Orotracheal IntubationOrotracheal Intubation

• Gently pass the tube next the laryngoscope blade through the vocal cords into trachea, far enough so that the balloon is just beyond the cords.

• Pressing downward on the thyroid cartilage. This helps bring an anteriorly placed larynx into view and facilitate intubation.

• Once in place, inflate the cuff till airtight seal is obtained.• Confirm that the tube is properly positioned. First, listen over the

stomach with a stethoscope while ventilating the patient. If sounds of airflow are heard or if distension of the stomach occurs, the tube is in the esophagus. If the esophagus has been intubated instead of

the trachea, remove the tube and try again.

Animation of Intubation

Actual Intubation

Nasotracheal IntubationNasotracheal Intubation

Indications1. Oral Surgery2. Faciomaxillary surgery3. If mouth need to be closed after surgery4. Closed mouth5. Difficult oral intubation6. Prolonged mechanical ventilation in ICU

Nasotracheal IntubationNasotracheal Intubation

Contraindications1. Coagulopathy2. Severe intranasal pathology3. Fracture of skull base4. CSF leak

Nasotracheal IntubationNasotracheal Intubation

Technique Apply vasoconstrictor nasal dropsLubricate tube wall. Length should be 2 cm longer and 1-2 mm smaller diameterGuide the tube slowly but firmly into the nasal passage, going up from the nostril (to avoid the large inferior turbinate) and then backward and down into the nasopharynxProceed with the procedure as an orotracheal intubation, guiding the tube through the vocal cords with a Magill’s forceps

Nasotracheal IntubationNasotracheal Intubation

Technique (blind intubation)

Blind nasal intubation is tried if laryngoscopy isn’t feasibleThe patient is allowed to breathe during induction of anaesthesia to facilitate intubationTube is inserted till maximun breath sounds are heardTube is then blindly inserted into glottis during inspiration

Methods of Anaesthesia for TI

1. General Anaesthesia (GA) by rapid IV agent2. In children, induction is done by inhalational

agent3. ETI can be done without muscle relaxant under

deep anaesthesia4. Intubation through tracheal stoma can be done

without GA, muscle relaxant or laryngoscope5. Awake intubation using only topical anaesthesia.

Indicated in patients whom induction is unsafe unless airway is secured first

6. ETI can be done without anaesthesia in comatose patients or during CPR

Extubation

1. Muscle relaxant fully reversed2. Patient awake & responsive, sable vital signs3. 100% oxygen at high flow 2-3 min4. Remove secretion in trachea or pharynx5. Turn patient to lateral position6. Defkate cuff and remove ETT during inspiration7. Continue 100% oxygen by facemask8. Extubation in semiconscious patient can provoke laryngospasm

Complications of Laryngoscopy & ETI

A) During Intubation• Prologned attempt: hypoxia – hypercapnia – risk of aspiration • With inadequate anesthesia: Coughing – Laryngospasm - Bronchospasm• Trauma

• Bruising lips,tongue,pharynx• Fracture,chipping,dislogement of teeth• Perforation trachea,esophagus• Fracture or dislocation cervical spine• Dislocation arytenoid cartilages or mandible

• Endobronchial intubation• Oesophageal intubation• Nasal Intubation

• Epistaxis• Mucosal damage• Displaced polyp or adenoid• Bacteraemia from nasal obstruction

• Haemodynamic response to laryngoscopy * Hypertension, tachycardia, arrhythmia (bradycardia in children) * Common at light anesthesia, dangerous to cardiacs

* Minimized by deep anesthsia, propofol induction

Complications of Laryngoscopy & ETI

B) With tube in situ -Accidental extubation

-Endobronchial intubation-Tube malfunction

• Obstruction / kinking• Ignition of tube by laser device • Cuff perforation

-Bronchospasm-Aspiration-Sinusitis-Excoriation of nose or mouth

Complications of Laryngoscopy & ETI

C) After extubation• Haemodynamic response• Hypoxia• Laryngospasm

• Common in semiconscious• Better extubate in deep anesthesia or awake patient• Treated with giving oxygen via facemask

• Pulmonary Oedema: dt. Prolonged powerful inspiratory effort against closed epiglottis – require re-intubation

• Stridor or croup due to oedema in subglottic region in children.

• Hoarsness and sore throat• VC paralysis – Granuloma of cords – Laryngeal or

tracheal Stenosis

Watch demo

The Laryngeal Mask Airway (LMA)The Laryngeal Mask Airway (LMA)

The Laryngeal Mask Airway (LMA)The Laryngeal Mask Airway (LMA)

•New device to maintain airway during anesthesia when TI is not desired.

•It’s easier in insertion and has high rate of success

•It’s made in 8 sizes to suite neonates, children and adults.

•Better inserted with propofol (that depresses laryngeal reflex) or deep inhalation anesthesia.

•After adequate anesthesia, LMA is inserted to mouth blindly without laryngoscope and pushed downward till resistance is felt. The cough is then inflated.

The Laryngeal Mask Airway (LMA)The Laryngeal Mask Airway (LMA)

•Video of insertion of an LMA

Laryngeal Mask Airway

Uses In short procedures Life-saving difficult intubation Conduit for smooth emergence Way of intubation in difficult cases

Contraindications Increased risk of aspiration Full stomach

Laryngeal Mask Airway

Use of LMA avoids occurrence of most TI complication

The major disadvantage is lack of mechanical protection from regurgitation and aspiration. Other problems are laryngospasm, coughing and sore throat.