2. Objectives
• After the presentation, participants will be
able to:
Identify physical assessments for
ventilation and tracheal intubation.
Describe the innervation of the
airway.
State the modalities of anesthetizing
the airway.
7. Closed Claims
Limitations of closed claims
Inaccurate numerator and denominator
Geographical representations
Retrospective studies
8. Closed Claims
Lessons from closed claims
Securing an airway is a team effort
Avoid haste with preparation
(assessment, planning, communication)
Anatomy and physiology,
pharmacological, and equipment
knowledge needs to be current
10. Airway Assessment
Assessment of ability to mask ventilate
M
O
A
N
S
Mask seal
Obese
Age
Nose, no teeth, neck mobility
stiffness
11. Airway Assessment
Assessment of ability to intubate
L
E
M
O
N
Look externally
Evaluate (TMD, RHTTMD, ULBT)
Mallampati
Obstruction
Neck mobility
Multivariate assessment to predict DI
12. Difficulty Airway Algorithm
• ASA Difficult Airway Algorithm
• 1. Assess the likelihood and clinical impact of basic management problems:
• Difficulty with patient cooperation or consent
• Difficult mask ventilation
• Difficult supraglottic airway placement
• Difficult laryngoscopy
• Difficult intubation
• Difficult surgical airway access
• 2. Actively pursue opportunities to deliver supplemental oxygen throughout the
process of difficult airway management.
• 3. Consider the relative merits and feasibility of basic management choices:
• Awake intubation vs. intubation after induction of general anesthesia
• Non-invasive technique vs. invasive techniques for the initial approach to intubation
• Video-assisted laryngoscopy as an initial approach to intubation
• Preservation vs. ablation of spontaneous ventilation
Anesthesiology 2013; 118:251-270
20. Awake Intubation
• Various local anesthetics (LA) can be used
for anesthetizing the airway.
• Lidocaine has an advantage because of:
Availability of different formularies
and preparation.
Wider margin of safety
21. Awake Intubation
Airway innervation
• Nasopharynx- Trigeminal nerve
(opthalmic and maxillary branch)
• Oropharynx- CNIX
(Glossopharyngeal nerve)
• Laryngopharynx- superior
laryngeal nerve
• Larynx and trachea- recurrent
laryngeal nerve
22. Common Methods of Anesthetizing
the Airway
Nasopharynx
• ½ in of lidocaine 5% at each nares (50mg)
OR
• 2 ml Lidocaine 4% aerosol spray (80mg)
23. Common Methods of Anesthetizing
the Airway
Oropharynx
•Apply 2 inches of 5% Lidocaine
ointment on a tongue depressor
(200mg)
OR
• Instruct patient to gurgle 5 ml of
Lidocaine 4% topical solution (may
need to do this twice) (200 mg or
400mg)
24. Common Methods of Anesthetizing
the Airway
Oropharynx
OR
• Place ½ in. of 5% lidocaine at a cotton tip
applicator and apply it at the base of
palatoglossal arch (5 min each side) (100
mg)
OR
• Using a 22g spinal needle, administer 2% of
Lidocaine injection solution to both bases of
the palatoglossal arch (80mg)
25. Common Methods of Anesthetizing
the Airway
Laryngopharynx (Superior Laryngeal Nerve)
•Administer 5 ml of 4% lidocaine injection
solution via nebulization (200 mg)
OR
•Drip 5 ml of 2% lidocaine viscous solution to
the back of the patient’s tongue (1-2 min)
(200mg)
26. Common Methods of Anesthetizing
the Airway
Laryngopharynx (Superior Laryngeal Nerve)
OR
• Using a 23 G needle, administer 3 ml of
2% lidocaine injection solution at both
lateral sides of the neck between the
thyroid cartilage and hyoid bone (120mg).
27. Common Methods of Anesthetizing
the Airway
Recurrent Laryngeal Nerve
• Lidocaine nebulization may suffice
OR
• Using epidural cath through the fiberoptic,
5ml of lidocaine 4% to the trachea (200mg)
OR
• Using a 20 G needle, administer 5 ml of 4%
lidocaine injection solution to the
Cricothyroid membrane (200mg)
28. Awake Intubation
Calculation of lidocaine total
administered dose:
1. Nasopharynx (ointment)= 50mg
2. Glossopharyngeal nerve= 80mg
3. Superior Laryngeal nerve= 120mg
4. Recurrent Laryngeal nerve=200mg
Total without nasopharynx = 400mg
Total with nasopharynx = 450mg
29. Awake Intubation
Lidocaine toxicity
• Legendary: 5mg/kg
• Normal therapeutic range for ventricular
arrythmias: 2-5mcg/ml
• Various pharmacological factors affect
lidocaine plasma level